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Physical activity during inpatient spinal cord injury rehabilitation Zbogar, Dominik 2015

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Physical Activity During Inpatient Spinal Cord Injury Rehabilitation by  Dominik Zbogar  M.Sc., The University of British Columbia, 2009  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Rehabilitation Sciences)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  October 2015  © Dominik Zbogar, 2015 ii  Abstract Introduction Engaging in rehabilitation activities of a sufficient intensity is necessary for optimal recovery in individuals with spinal cord injury (SCI). Optimizing rehabilitation and activity prescription requires quantification of physical activity and its predictors during this time.  Purpose To determine, during inpatient rehabilitation, the: 1) reliability and validity of measures of physical activity (Chapter 2). 2) number of active movement repetitions occurring during PT and OT (Chapter 3). 3) level of physical activity using objective and self-report measures (Chapter 4). 4) level of cardiovascular stress experienced during PT and OT (Chapter 5).  Methods Design: A test retest design was used to determine the reliability of physical activity measures (Chapter 2). A longitudinal observation design was used to determine movement repetitions (Chapter 3) and physical activity levels (Chapter 4). A cross-sectional observational design was used to determine the level of cardiovascular stress (Chapter 5).  Subjects: Participants (n=108) were recruited from consecutive admissions to rehabilitation.   Results Chapter 2: Good reliability for accelerometry and step counts, and moderate reliability for self-report, was demonstrated. Validity was demonstrated for wrist accelerometry and step counts but not self-report physical activity.  iii  Chapter 3: Average repetitions did not exceed 300 for the upper or lower extremity. Most repetition variables remained unchanged over the inpatient rehabilitation stay while clinical outcomes improved significantly.  Chapter 4: For most groups and variables, no changes occurred during therapy time from admission to discharge. Outside of therapy all groups increased from admission to discharge in activity kilocounts but not PARA-SCI minutes, where the majority of time was spent in leisure time sedentary activity (~4.5 hours).  Chapter 5: The average time spent at a heart rate within the cardiovascular training zone was 6.0±9.0 minutes in PT and lower in OT. Lower spasticity, higher exercise self-efficacy, and better orthostatic tolerance correlated with a greater amount of time within a cardiovascular training zone.  Conclusions Individuals indicate a large amount of time is spent engaged in higher intensity activities. Measurement of heart rate during therapy sessions shows little time is spent at intensities sufficient to accrue cardiovascular benefits. Repetitions in therapy are low compared to the animal literature.    iv  Preface All the work presented herein was conducted at GF Strong Rehabilitation Centre, Vancouver and Lyndhurst Centre, Toronto. All projects and associated methods were approved by the University of British Columbia’s Research Ethics Board (certificate number: H09-02633) and Toronto Rehabilitation Institute-University Health Network’s Research Ethics Board (certificate number: 10-033).  Versions of Chapters 2 through 5 will be submitted for publication. For all Chapters, I was responsible for all data collection, analysis, and manuscript composition. JW Noble was responsible for computer coding and data processing for Chapter 5. JJ Eng was the supervisory author on this project and was responsible for concept formation and was involved throughout the project in interpretation of results and was the key editor of all manuscripts. My committee members (AV Krassioukov, WC Miller, M Verrier) provided ongoing feedback and contributed to manuscript edits.  v  Table of Contents  Abstract .......................................................................................................................... ii Preface .......................................................................................................................... iv Table of Contents .......................................................................................................... v List of Tables ................................................................................................................. x List of Figures .............................................................................................................. xi List of Abbreviations ................................................................................................... xii Glossary ...................................................................................................................... xiii Acknowledgements .................................................................................................... xiv Dedication .................................................................................................................... xv Chapter 1: Introduction ................................................................................................. 1 1.1 Statement of the problem .................................................................................... 1 1.1.1 Epidemiology of spinal cord injury ................................................................... 2 1.2 Measuring physical activity.................................................................................. 4 1.2.1 Content of inpatient PT and OT ...................................................................... 4 1.2.2 Movement repetitions during inpatient PT and OT .......................................... 7 1.2.2.1 Movement repetitions and theoretical perspectives of motor learning ... 7 1.2.3 Accelerometry ................................................................................................. 9 1.2.3.1 Wrist accelerometry ............................................................................... 9 1.2.3.2 Step counts ............................................................................................ 9 1.2.4 Heart rate monitoring .................................................................................... 10 1.2.5 Self-reported physical activity ....................................................................... 12 1.2.6 Summary ....................................................................................................... 12 1.3 Determinants of physical activity ....................................................................... 13 1.3.1 Determinants of physical activity in the community ....................................... 13 1.3.2 Determinants of physical activity during inpatient rehabilitation .................... 15 1.3.3 Summary ....................................................................................................... 17 1.4 Purpose, objectives, and hypotheses ................................................................ 18 1.4.1 Objectives ..................................................................................................... 18 vi  1.4.2 Hypotheses ................................................................................................... 19 Chapter 2: Reliability and validity of wrist accelerometry and step counts during inpatient SCI rehabilitation ......................................................................................... 20 2.1 Introduction ....................................................................................................... 20 2.2 Methods ............................................................................................................ 22 2.2.1 Participants ................................................................................................... 22 2.2.2 Data collection .............................................................................................. 22 2.2.3 Physical activity measures ............................................................................ 23 2.2.4 Validation measures ..................................................................................... 24 2.2.5 Descriptive measures ................................................................................... 25 2.2.6 Data analyses ............................................................................................... 25 2.3 Results .............................................................................................................. 26 2.3.1 Test-retest reliability of accelerometry counts, step counts, and self-reported physical activity ...................................................................................................... 27 2.3.2 Validity of accelerometry counts, step counts, and self-reported physical activity  ................................................................................................................... 27 2.4 Discussion ......................................................................................................... 32 2.4.1 Test-retest reliability ...................................................................................... 32 2.4.2 Validity .......................................................................................................... 33 2.4.3 Limitations ..................................................................................................... 35 2.5 Conclusion ........................................................................................................ 35 Bridging Statement I ................................................................................................... 36 Chapter 3: Movement repetitions in physical and occupational therapy during inpatient spinal cord injury rehabilitation ................................................................. 37 3.1 Introduction ....................................................................................................... 37 3.2 Methods ............................................................................................................ 38 3.2.1 Participants ................................................................................................... 38 3.2.2 Observed therapy sessions ........................................................................... 39 3.2.3 Therapy observation procedure .................................................................... 40 3.2.4 Clinical outcome measures ........................................................................... 41 vii  3.2.5 Data analysis ................................................................................................ 42 3.3 Results .............................................................................................................. 43 3.3.1 Patient demographics and clinical outcomes ................................................ 43 3.3.2 Changes in therapy time ............................................................................... 43 3.3.3 Changes in upper extremity repetitions ......................................................... 44 3.3.4 Changes in lower extremity repetitions ......................................................... 44 3.3.5 Participation in group classes ....................................................................... 44 3.4 Discussion ......................................................................................................... 53 3.4.1 Amount of movement repetitions .................................................................. 53 3.4.2 Changes in movement repetitions ................................................................. 53 3.4.3 Therapeutic versus non-therapeutic time ...................................................... 54 3.4.4 Changes in clinical outcomes ........................................................................ 54 3.4.5 Limitations ..................................................................................................... 54 3.5 Conclusion ........................................................................................................ 55 Bridging Statement II .................................................................................................. 56 Chapter 4: Self-reported physical activity and accelerometry in individuals with spinal cord injury during inpatient rehabilitation ..................................................... 57 4.1 Introduction ....................................................................................................... 57 4.2 Research methods ............................................................................................ 58 4.2.1 Participants ................................................................................................... 58 4.2.2 Physical activity measures ............................................................................ 59 4.2.3 Clinical outcome measures ........................................................................... 60 4.2.4 Data analyses ............................................................................................... 61 4.3 Results .............................................................................................................. 62 4.3.1 Physical activity during PT and OT ............................................................... 63 4.3.2 Physical activity outside of PT and OT .......................................................... 63 4.4 Discussion ......................................................................................................... 71 4.4.1 Physical activity during PT and OT ............................................................... 71 4.4.2 Physical activity outside of PT and OT .......................................................... 72 4.4.3 Physical activity guidelines ............................................................................ 73 viii  4.4.4 Limitations ..................................................................................................... 74 4.5 Conclusion ........................................................................................................ 75 Bridging Statement III ................................................................................................. 76 Chapter 5: Cardiovascular stress during inpatient spinal cord injury physical and occupational therapy .................................................................................................. 77 5.1 Introduction ....................................................................................................... 77 5.2 Research methods ............................................................................................ 79 5.2.1 Participants ................................................................................................... 79 5.2.2 Heart rate and therapy content data collection .............................................. 79 5.2.3 Questionnaire and assessment data collection ............................................. 80 5.2.4 Data analysis ................................................................................................ 82 5.3 Results .............................................................................................................. 83 5.3.1 Heart rate characteristics during PT and OT ................................................. 84 5.3.2 Aerobic activities during PT and OT .............................................................. 84 5.3.3 Correlates associated with amount of time at moderate/vigorous intensity ... 85 5.4 Discussion ......................................................................................................... 91 5.4.1 Which activities elicited the highest heart rates? ........................................... 93 5.4.2 Correlates of heart rate intensity ................................................................... 94 5.4.3 Limitations ..................................................................................................... 96 5.5 Conclusion ........................................................................................................ 96 Chapter 6: Overall discussion, synthesis, and future directions ............................ 97 6.1 Overview ........................................................................................................... 97 6.2 Strengths of this research ................................................................................. 97 6.3 Results .............................................................................................................. 97 6.4 New findings...................................................................................................... 99 6.5 Limitations of this research ............................................................................. 101 6.6 Future Directions ............................................................................................. 102 References ................................................................................................................. 105 Appendices ................................................................................................................ 118 Appendix A Questionnaires and Assessments ........................................................ 118 ix  A.1 PARA-SCI ................................................................................................... 119 A.2 SCIM- Spinal Cord Independence Measure (version III) ............................. 121 A.3 Hand Grip Strength Assessment ................................................................. 123 A.4 Walking Index for Spinal Cord Injury (WISCI II) .......................................... 124 A.5 10m-walk test .............................................................................................. 126 A.6 GRASSP Hand Capacity Tests and Scoring ............................................... 127 A.7 CES-D10 ..................................................................................................... 140 A.8 The Chronic Pain Grade Questionnaire (modified) ..................................... 141 A.9 Fatigue Severity Scale Questionnaire ......................................................... 142 A.10 Penn Spasm Frequency and Severity Scale ............................................... 143 A.11 Exercise Self Efficacy Scale (SCI-ESES) .................................................... 144 A.12 Sit-up Test for Orthostatic Tolerance .......................................................... 145 Appendix B Data Collection Sheets ......................................................................... 147 B.1 PARA-SCI Data Collection Sheet ................................................................ 148 B.2 Therapy Observation Data Collection Sheet ............................................... 150 Appendix C Demographic Information ..................................................................... 153 C.1 Data completeness ..................................................................................... 154 C.2 Inter-site comparison .................................................................................. 155 Appendix D Consent Forms ..................................................................................... 158 D.1 Letter of initial contact ................................................................................. 159 D.2 Therapist consent ....................................................................................... 160 D.3 Subject information and informed consent .................................................. 163  x  List of Tables Table 2.1  Participant Characteristics and Clinical Measures ........................................ 28 Table 2.2  Reliability statistics for wrist accelerometry and steps .................................. 29 Table 2.3  Spearman correlation matrix for physical activity measures ......................... 30 Table 2.4  Spearman correlations of physical activity measures versus clinical measures ...................................................................................................................................... 31 Table 3.1  Definitions of movements, units of repetition, and examples for categories and subcategories. ........................................................................................................ 45 Table 3.2  Demographic and SCI information for all patients and subgroups of paraplegia and tetraplegia and ambulatory patients ...................................................... 46 Table 3.3  Patients with tetraplegia: therapy time, repetitions, and assessments at admission and discharge. .............................................................................................. 47 Table 3.4  Patients with paraplegia: therapy time, repetitions, and assessments at admission and discharge. .............................................................................................. 48 Table 3.5  Patients with tetraplegia: mean times and repetitions separating for motor complete and motor incomplete injury. .......................................................................... 49 Table 3.6  Ambulatory patients: therapy time, repetitions, and assessments at admission and discharge. .............................................................................................. 50 Table 4.1  Demographic and SCI information for all participants and subgroups of paraplegia and tetraplegia ............................................................................................. 65 Table 4.2  Wrist accelerometry and hand function ........................................................ 66 Table 4.3  Step counts and walking assessments for ambulatory participants .............. 67 Table 4.4  PARA-SCI stratified by intensity for time inside and outside therapy ........... 68 Table 4.5  Subcomponents of time outside therapy ...................................................... 69 Table 5.1  Demographic and clinical information for all participants and subgroups of paraplegia and tetraplegia. ............................................................................................ 86 Table 5.2  Heart rate variables for different subgroups. ................................................ 87 Table 5.3  Characteristics of participants who accumulated ≥20 minutes of activity at ≥40% HRR in PT or OT ................................................................................................. 88 Table 5.4  Spearman correlation for minutes in PT at ≥ 40% HRR versus correlates ... 89 xi  List of Figures Figure 1.1  International Classification of Functioning, Disability, and Health for potential barriers and facilitators of physical activity during inpatient rehabilitation...................... 17 Figure 3.1  Flow diagram of recruitment to the study .................................................... 51 Figure 3.2  Daily repetitions for PT and OT combined................................................... 52 Figure 4.1  Flow diagram of recruitment to the study .................................................... 70 Figure 5.1  Minutes in therapy at various heart rate intensities. .................................... 90  xii  List of Abbreviations 10MWT = 10 Meter Walk Test ADL= Activity of Daily Living AIS= ASIA Impairment Scale ASIA= American Spinal Injury Association CI = Confidence Interval GRASP = Graded Repetitive Arm Supplementary Program  GRASSP = Graded Redefined Assessment of Strength, Sensibility and Prehension HRmax = Maximal Heart Rate HRrest = Resting Heart Rate HRR = Heart Rate Reserve ICC = Intraclass Correlation Coefficient ICF = International Classification of Functioning, Disability, and Health LTPA = Leisure Time Physical Activity MDC = Minimal Detectable Change OT = Occupational Therapy PARA-SCI = Physical Activity Recall Assessment for People with Spinal Cord Injury PT = Physical Therapy SCI = Spinal Cord Injury SCI-ICS = Spinal Cord Injury-Interventions Classification System SCIM III = Spinal Cord Independence Measure III SEM = Standard Error of Measurement TBI = Traumatic Brain Injury WISCI II = Walking Index for Spinal Cord Injury II  xiii  Glossary  HRR = HRtarget= [% intensity (HRmax-HRrest)]+HRrest MDC95 = SEM * 1.96 * √2 SEM = SD * (√1-ICC) xiv  Acknowledgements I would like to recognize Dr. Janice Eng, my supervisor. Janice, thank you for believing in me and becoming my supervisor. I am very fortunate to have the opportunity to learn from you. I admire not only your expertise as a researcher, but also your ability to bring out the best in each of your students; you certainly inspired me as I worked on my research.   To my thesis committee members, Dr. Bill Miller, Dr. Andrei Krassioukov, and Prof. Molly Verrier, thank you for your unique insights, perspectives, and critiques. I am a better researcher and my thesis is stronger for it. I must also thank Molly for her contribution to the study in facilitating data collection at Lyndhurst Centre in Toronto.  Through the years a number of people have worked diligently on this research. I would like to express my appreciation especially to the Research Assistants Erica Brown and Jenna Homer, and the GF Strong Rehabilitation Research Lab coordinator, Chihya Hung, whom I was privileged to work with.   A special thanks to the graduate students and fellows of GFS Research Laboratory I shared my PhD years with. You made the Lab a great place to work.  I would like to acknowledge the clients and physical and occupational therapists at GF Strong and Lyndhurst Centre who participated in this project. Without their help, this research would not have been possible.  Finally, I would like to acknowledge the Canadian Institutes of Health Research (Frederick Banting and Charles Best Canada Graduate Doctoral Scholarship), The University of British Columbia (Four Year Doctoral Fellowship), and Dr. Janice Eng for providing personal financial support. xv  Dedication     To my mother and father, sisters and brothers.  ~and~  To everyone who supported me during this journey, especially Joella.  1  Chapter 1: Introduction 1.1 Statement of the problem Physical activity early after a spinal cord injury (SCI) is important for the benefits of optimizing recovery from acute SCI, as well as the ability to improve secondary complications like physical deconditioning resulting from bed rest, cardiovascular disease and autonomic disorders (Jacobs and Nash, 2004). Indeed, a delay in starting appropriate and intensive activities may negatively influence a patient’s ultimate functional capability since the degree of post-SCI deconditioning will increase with a longer delay in starting an exercise program (Sumida et al., 2001; Scivoletto et al., 2005).  While the optimal time window for therapy in humans remains unknown, evidence suggests the initial months following a SCI are a crucial time for optimizing recovery (Norrie et al., 2005; Winchester et al., 2009; Harkema et al., 2011; Battistuzzo et al., 2012). This time corresponds to sub-acute inpatient rehabilitation stay that begins, on average, 44±44 days after injury and lasts 96±46 days (See Table 3.2). In their investigation of 123 individuals with traumatic SCI, Sumida et al. (2001) found that SCI patients without effective rehabilitation in the six months following injury had a notably lower percent increase in motor recovery from admission to discharge as well as a significantly longer length of stay in rehabilitation. Additionally, it has been shown that early rehabilitation is effective in accelerating and promoting improvement in activities of daily living (ADL) (Janssen et al., 1994; Sumida et al., 2001; Scivoletto et al., 2005). Exercise rehabilitation as soon as possible after injury may prepare individuals with SCI to engage in exercise programs once they return home after inpatient rehabilitation and potentially counteract the significant decrease in physical activity that follows discharge (van den Berg-Emons et al., 2008). Knowing the current repetitions of activities during therapy sessions, the amount of physical activity experienced during the day, and how they progress over time will provide a baseline of activity levels and set the stage for clinical trials aimed at developing interventions to enhance neuroplasticity, functional capacity and rehabilitation outcomes. 2   1.1.1 Epidemiology of spinal cord injury Worldwide, incidence rates for traumatic spinal cord injury (SCI) vary from 12.1 per million in The Netherlands to 57.8 per million in Portugal (van den Berg et al., 2010). Research in the last decade shows that in Canada incidence rates vary from 37.2 per million (Pickett et al., 2003) to 52.5 per million (Dryden et al., 2003). In terms of prevalence, approximately 86,000 Canadians live with SCI with 44,000 resulting from traumatic causes (Krueger, 2010).   In a study of spinal cord injury across the world, it was reported that the mean age of individuals when a SCI occurs is 33, and the ratio of males to females is 3.8/1 (Wyndaele and Wyndaele, 2006). However, the picture is more complex. Most studies of traumatic SCI show a bimodal age distribution with a peak in young adults (15-29 years) and again in older individuals (≥65 years) (van den Berg et al., 2010). Canadian research reflects this trend and shows that those individuals who are 65 years and older constitute a growing proportion of those with traumatic SCI (Pickett et al., 2006). In this older cohort, falls account for 63% of traumatic SCI. In individuals below 65 years of age, falls account for 24% of injuries. In this group, motor vehicle accidents are the most frequent causes of SCI with 43% occurring in young adults and 33% in middle-aged adults (Pickett et al., 2006).  The worldwide literature study mentioned earlier shows that two-thirds of those with SCI are paraplegic and one-third is tetraplegic (Wyndaele and Wyndaele, 2006). Individuals with paraplegia are those with a spinal cord lesion at the thoracic or lumbar level (≤ T1). Individuals with tetraplegia are defined as those with a lesion at the cervical level (C1-C7). US data from the SCI Model Systems indicates that the most frequent injury is incomplete tetraplegia (45%) followed by incomplete paraplegia (21%) (NSCISC, 2015). Complete paraplegia and complete tetraplegia compose 20% and 14% of those affected by SCI in the United States, respectively (NSCISC, 2015). Canadian data for traumatic SCI indicates that tetraplegia is more common, ranging from 62 (Dryden et al., 2003) to 3  75% (Pickett et al., 2006). Rates for thoracic injury are around 17% (Dryden et al., 2003; Pickett et al., 2006) and lumbar injury rates range from 10 (Pickett et al., 2006) to 17% (Dryden et al., 2003).  Individuals with non-traumatic SCI represent a significant proportion of admissions to rehabilitation centres (McKinley et al., 1999). In Canada, 42,000 individuals are living with a SCI of non-traumatic causes; these individuals represent a significant 49% of those living with SCI of all causes (Krueger, 2010). A recent Canadian study involving 553 patients found that the incidence of non-traumatic SCI was 39.5% (McCammon and Ethans, 2011). Data of 220 individuals admitted to SCI rehabilitation over a 5-year period in the USA yielded a very similar result with 39% of the sample comprised of those with non-traumatic SCI (McKinley et al., 1999). This group differs from individuals whose SCI is of traumatic origin in that they are significantly older, have an equal amount of men and women, and are more likely to be married and retired. The aetiology of most non-traumatic SCI, spinal stenosis and tumorous invasion, which occurs later in life, is invoked as a major reason for demographic differences between traumatic and non-traumatic SCI (McKinley et al., 1999).  Completeness and level of injury for non-traumatic SCI differs from that mentioned earlier for traumatic SCI. An Australian study, which used consecutive sampling of 70 non-traumatic individuals, did not encounter any individuals with complete tetraplegia (New, 2005). The most common were incomplete injuries, with 58.6% being incomplete paraplegics and 32.9% affected by incomplete tetraplegia. Complete paraplegia composed 8.6% of the sample.  Substantial improvement has occurred over the last 30 years in reducing mortality rates in the first 2 years following SCI (Strauss et al., 2006). This has increased life expectancy and consequently presents a significant financial burden over a disabled lifetime. In Canada the costs associated with living with SCI are believed to vary from $1.47 million for low thoracic paraplegia to $3 million for tetraplegia (Krueger et al., 4  2013). Unfortunately, half of traumatic SCIs result in tetraplegia (Krueger, 2010). Undoubtedly, a portion of these costs is incurred from the increased prevalence and earlier onset of the medical complications of a sedentary lifestyle, namely cardiovascular disease (Orakzai et al., 2007; Wilt et al., 2008).  1.2 Measuring physical activity There is debate as to whether the level of activity during the rehabilitation stay is adequate for optimizing recovery or for achieving sufficient physical capacity for returning to the community (Janssen et al., 1994; Dallmeijer et al., 1999). Though time in physical therapy (PT) and occupational therapy (OT) is a central part of a patient’s day, it makes up only a small proportion, and so it is also important to develop an understanding of physical activity levels outside of rehabilitation therapy sessions in order to assess the overall daily physical activity that the patient is experiencing. While some studies have evaluated content during structured therapy ((van den Berg-Emons et al., 2008; Foy et al., 2011; Taylor-Schroeder et al., 2011; van Langeveld et al., 2011b; Nooijen et al., 2012; Koopman et al., 2013; Zbogar et al., 2014), this thesis is unique in its inclusion of the content of physical activity outside of the structured rehabilitation sessions, in addition to objective measures of activity during structured therapy sessions.    1.2.1 Content of inpatient PT and OT Over the past several years, quantifying therapy content in SCI rehabilitation has received increasing attention in order to better understand current practice. The SCIRehab project is a notable comprehensive and recent example (Whiteneck et al., 2011a) where therapists recorded the number of sessions, minutes, activity-specific details, and the extent of patient participation in PT (Teeter et al., 2012) and OT (Ozelie et al., 2012) sessions in inpatient rehabilitation. This large multicenter trial, that involved 6 SCI rehabilitation facilities in the US, sought to identify which of the interventions that comprise SCI inpatient rehabilitation are associated with positive outcomes a year after injury (Whiteneck et al., 2011b). The investigators (Whiteneck et al., 2011a) noted that 5  of the various therapies engaged in by patients with SCI, PT and OT accounted for 60% of total therapy time. Two papers, one focused on OT (Foy et al., 2011) and the other on PT, (Taylor-Schroeder et al., 2011) describe the nature and distribution of activities in the respective discipline and discuss predictors of treatment time in 600 individuals with traumatic SCI. They are highlighted next.   Taylor-Schroeder et al. (2011) employed a taxonomy of 20 PT activities to assess content of individual and group therapy sessions. The sample was divided into 4 groups for analysis: 1) AIS D, 2) Paraplegia AIS A, B, C, 3) Tetraplegia C5-C8 AIS A, B, C, 4) Tetraplegia C1-C4 AIS A, B, C. While the authors found that there was significant variation in time spent on activities within groups, they did note significant differences in the amount of time spent on activities between groups. They noted that in individuals with high tetraplegia the most common activities were range of motion/stretching, strengthening and transfers. Those with low tetraplegia spent more time on transfers than strengthening. Individuals with paraplegia spent most time in therapy on transfers, ROM/stretching, and strengthening. Individuals with AIS D differed significantly with dominant activities including gait training, strengthening, and balance exercises.   Taylor-Schroeder et al. (2011) also employed a regression model to identify patient and injury characteristics that affected time spent on different therapy activities. The most noticeable findings were that those with paraplegia AIS A, B, C experienced 47 (R2= 0.15) and 49 (R2= 0.31) more minutes of therapy time over the rehabilitation stay compared to the other injury groups in the areas of manual wheelchair mobility and transfers, respectively.  The investigation of OT (Foy et al., 2011) followed the same methodology with respect to grouping of patients and statistical analyses. There were 23 activities included for assessing therapy content. The activities of strengthening/endurance and ROM/stretching exercises consumed the most time. When examining therapy provided in individual settings only, ADL work consumed the most time. The most common ADL 6  component was lower body dressing. Significant differences were seen between groups for all activities. The regression model showed that patient and injury characteristics were associated with time in OT activities. Most notably, individuals with C1-C4 AIS A, B, C experienced 48 more minutes of therapy time in ROM/stretching (R2= 0.41) and 42 fewer minutes working on ADLs (R2= 0.27) over the rehabilitation stay.  In an study of 140 individuals with TBI and 106 with SCI, Heinemann et al., (1995) explored the relationship between the Functional Independence Measure and therapy intensity and found, after controlling for a number of factors in multiple regression, that intensity of PT and OT were not predicitive of outcomes in either group. Intensity was calculated as billed time in each type of therapy divided by length of stay.   A study by van Langeveld et al., (2011b) investigated the content of PT, OT, and sports therapy of individuals with SCI in three Dutch rehabilitation centres. In this study, 1640 therapy sessions of 48 subjects were recorded by therapists over 4 weeks. The Spinal Cord Injury-Interventions Classification System (SCI-ICS), which covers 25 categories with a total of 139 different interventions, was developed by the authors and was used to classify patient activities in therapy. The authors found that the largest proportion of time was spent on interventions to improve muscle power, walking and hand rim wheelchair propulsion. Unfortunately a small sample size limited the ability to divide the subjects by lesion level. This study was also specific to what was observed by therapists during therapy and does not investigate the content of activities outside of these sessions. Importantly, it appears that there was notable variability between and within sites regarding when during rehabilitation stay individuals were measured.   A similar study by the same group (2011a) differed in that there were 79 subjects and also included rehabilitation centres in several countries. Here, 2526 therapy sessions were observed using the same classification system. The authors found that therapy in inpatient SCI rehabilitation in all 3 countries focused on mobility and self-care exercises at body function and a basic activity level. While the authors stated that data collection 7  took place during a 4-week period, again there was notable variability of when during their inpatient rehabilitation stay individuals were measured.   1.2.2 Movement repetitions during inpatient PT and OT While studies of content and time spent on activities (Heinemann et al., 1995; Foy et al., 2011; Taylor-Schroeder et al., 2011; van Langeveld et al., 2011a; 2011b) provide a key component to unraveling the relationship between therapeutic intervention and outcomes, they do not provide an indication of the amount of movement repetitions during that time, which are important for optimizing neuroplasticity.  Research studies in animals and humans have found that retraining after SCI using the activity-dependent plasticity properties of the nervous system facilitates the recovery of locomotor function (Edgerton et al., 2004) and reaching (Girgis et al., 2007). In patients with incomplete SCI, rehabilitation therapies such as repetitive upper extremity movements (massed practice) improve hand function (Beekhuizen and Field-Fote, 2005; Hoffman and Field-Fote, 2010), while locomotor training promotes ambulatory recovery (Behrman et al., 2006). However, positive findings for hind-limb stepping after SCI in the animal literature involve several hundred to over a thousand repetitions (Lovely et al., 1986; de Leon et al., 1998) with higher doses resulting in improved outcomes. Study of the content of stroke rehabilitation has shown that the amount of movement practice in PT and OT sessions are substantially smaller than doses used in animal models (Lang et al., 2009). Further investigation indicated that increasing repetitions during therapy time was feasible and that this increased volume may be beneficial for individuals with stroke (Birkenmeier et al., 2010).  1.2.2.1 Movement repetitions and theoretical perspectives of motor learning The concept of hierarchical control suggests that as people engage in movement repetitions and learn a task, a shift occurs from “higher” to “lower” levels of motor control in the nervous system (Schmidt and Lee, 2011). The higher level in the system is responsible for decision making while the lower level carries out decisions. This speaks 8  to the concepts of a “cognitive phase” where performers discover what to do and concludes with “automaticity” of movements that occurs with learning where skilled performers are able to perform a complex but routine motor task with minimal attention cost and minimal interference from other cognitive information processing activities (Edgerton et al., 2004). This automaticity may result from the creation of motor programs by the central pattern generator, descending brain control, and peripheral inputs where the numerous complex actions required to complete a task are merged and actions become more consistent, smoother, and require less effort (Edgerton et al., 2004; Schmidt and Lee, 2011).   The motor patterns that the spinal cord generates after an injury are a consequence of the specific sensorimotor stimuli applied. This specificity means that training to stand improves standing ability while training to step improves stepping ability. This training is associated with motor-pool specific biomechanical changes (Edgerton et al., 2004). Spinal cord injury can result in upregulation of inhibitory neurotransmitter systems, and this effect is reversed by performing movement repetitions such as stepping. This shows that the physiological and biochemical milieu of the spinal cord will affect how it responds to therapeutic interventions (Edgerton et al., 2004).   While aerobic exercise is critical for improving a patient’s tolerance for physical activity and improving cardiovascular parameters, such exercise of sufficient intensity is associated with increased neurogenesis and angiogenesis, as well as the production of neurotrophic molecules such as brain-derived neurotrophic factor and other growth factors involved in neuroprotection and the promotion of cell survival, neurite outgrowth and synaptic plasticity (Cramer et al., 2011). Such changes have implications for optimizing motor outcomes during inpatient SCI rehabilitation and explains why we investigated both repetitions during therapy as well as the amount of cardiovascular stress experienced during therapy.  9  1.2.3 Accelerometry 1.2.3.1 Wrist accelerometry Wrist accelerometry is shown to be a valid indicator of physical activity for wheelchair users in laboratory and free-living conditions (Warms and Belza, 2004). Recent research has shown that wrist accelerometry is linearly related to energy expenditure during manual wheelchair propulsion (Learmonth et al., 2015). While wrist accelerometry appears to be a useful tool for quantifying physical activity, we have found no research using simple wrist accelerometers in field-based research during subacute SCI.   An upper limb activity monitor consisting of a system of interconnected accelerometers on body parts including the wrist, sternum and thighs, has been used to objectively quantify everyday behaviour during SCI rehabilitation (van den Berg-Emons et al., 2008). Using this whole body accelerometry system, the authors reported that physical activity increased from admission to discharge from inpatient rehabilitation and that those with tetraplegia and complete injuries were the most sedentary. Notably, this research included activity for the entire day, not only including time in PT and OT sessions. We are not, however, provided with information about subsections of the day (inside therapy vs. outside therapy) or quantification of how much activity was, for example, leisure time activity or ADLs.   In more recent research, the same group (Nooijen et al., 2012) has used the upper limb activity monitor to show that during inpatient rehabilitation, an increase in physical activity is related to increases in peak aerobic power and peak power output measured via a graded exercise test using wheelchair ergometry as well as improved blood lipid profile.  1.2.3.2 Step counts For those with SCI who are ambulatory, ankle step counters/accelerometers provide a reliable option used much in able-bodied research but have also demonstrated reliability 10  in community-dwelling individuals with chronic incomplete SCI (Bowden and Behrman, 2007; Ishikawa et al., 2011). Guidelines indicate that individuals accumulating less than 5,000 steps/day are classified as sedentary and that individuals living with disability and/or chronic illness accumulate an average of 1200-8800 steps/day (Tudor-Locke et al., 2011) which is in keeping with the values (1,281±1594 steps) seen in community-dwelling individuals with incomplete SCI (Ishikawa et al., 2011).   1.2.4 Heart rate monitoring It is well known that physical activity of a sufficiently high intensity confers cardiovascular benefits not obtained by lighter activity, (Lee et al., 1995) and the importance of this fact is accounted for in physical activity recommendations by various organizations. For example, the World Health Organization (WHO, 2010) recommends that, throughout the week, one obtains at least 150 minutes of moderate-intensity, 75 minutes of vigorous-intensity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity in bouts of no less than 10 minutes. The U.S. Department of Health and Human Services (Office of Disease Prevention and Health Promotion, 2008) recommends these same guidelines for individuals with disabilities. More recently, SCI specific guidelines suggest individuals accrue, at a minimum, two bouts of 20 minutes of moderate to vigorous intensity aerobic activity per week (Martin Ginis et al., 2011a). Unfortunately it appears most individuals with chronic SCI do not meet these guidelines at one year following discharge from rehabilitation (van den Berg-Emons et al., 2008).   Research shows that individuals with stroke spend a negligible amount of time at a heart rate of appropriate intensity for cardiovascular adaptations (MacKay-Lyons and Makrides, 2002; Kuys et al., 2006) and individuals with SCI are less active over a 24-hour period than their counterparts with stroke (van den Berg-Emons et al., 2008), suggesting that cardiovascular stress during rehabilitation is even lower in individuals with SCI than that seen in individuals with stroke. However, one study (Koopman et al., 2013) assessed 8 individuals with paraplegia and 3 with tetraplegia over a typical rehabilitation day and concluded that there was sufficient strain to improve aerobic 11  fitness. The authors included time for the entire day, noting that half of the time where the heart rate was at a sufficient intensity occurred in therapy and the other half outside of therapy time. The study showed there was notable variability in cardiorespiratory strain and that the subjective measure of intensity (Borg scale) was moderately correlated (r=0.56) with heart rate suggesting limited value for evaluating activity as an alternative to heart rate monitoring. However these results must be interpreted with caution for, aside from the small sample size, the authors did not indicate the injury severity of their participants. They did report on the walking ability of participants using the Walking Index for Spinal Cord Injury, but these results are binned into tertiles and the status of another 2 patients is unknown. Thus we are left to assume anywhere between 4-11 (36-100%) of their participants had some level of ambulatory ability which would suggest less impairments and a greater ability to increase the heart rate.  Individuals with paraplegia exhibit the same relationship between heart rate and oxygen uptake as for able bodied individuals, indicating that already established exercise guidelines do not need to be modified for these persons and that heart rate can be used as indicator of exercise intensity (Hooker et al., 1993). However, individuals with a spinal cord lesion above T6 may experience disruption of sympathetically driven cardiac control, resulting in bradycardia at rest (Krassioukov et al., 2007) and a blunted chronotropic response to exercise (Teasell et al., 2000; Jacobs and Nash, 2004). The severity of autonomic impairment is associated with the level and severity of injury, however autonomic pathways may be damaged or spared independent of motor and sensory pathway status (Krassioukov et al., 2007; West et al., 2013). The use of typical prediction equations for estimating maximal heart rate (HRmax) in individuals with SCI whose sympathetic innervation of the heart is damaged is therefore inappropriate because the new true HRmax of these individuals may depend solely on parasympathetic withdrawal, resulting in an achievable HRmax approximating only 120bpm (Teasell et al., 2000; Jacobs and Nash, 2004).   12  Accurately assessing exercise intensity and the creation of exercise guidelines for individuals with a lack of sympathetic innervation to the heart remains an issue. As stated above, gauging effort via heart rate may not be appropriate. Subjective indicators of exercise intensity may also not be the ideal tool for use with individuals with SCI in the case of the Borg Scale (Lewis et al., 2007; Koopman et al., 2013), yet self-reported physical activity and intensity gauged via the Physical Activity Recall Assessment for SCI (PARA-SCI), described below, has successfully been used to determine physical activity in community dwelling individuals with SCI (Martin Ginis et al., 2005; 2012b).  1.2.5 Self-reported physical activity Perhaps because no equipment is required, self-report is the most widely used method for measuring physical activity (Warms, 2006). However, the subjective nature of self-reported physical activity renders it prone to recall error and social desirability bias (Prince et al., 2008). On the other hand, information not available from objective measures can be obtained from self-report. For example, accelerometry may measure when and how much an individual lifts an arm, while self-report captures information on how difficult this activity was. A self-report questionnaire developed for use in the SCI population, the PARA-SCI, allows respondents to indicate time and intensity of physical activities performed during the day. The reliability and validity of this questionnaire has been established in community dwelling individuals with SCI where they also showed that individuals with SCI reported over 85 minutes/day of time was spent performing activities of a moderate and heavy intensity (Martin Ginis et al., 2005; Latimer et al., 2006).  1.2.6 Summary Research has catalogued both volume and content of PT and OT. Some claim to measure intensity when they actually provide a measure of time in therapy; none indicate actual repetitions that occur during inpatient PT and OT sessions and none have measured cardiovascular stress during this time. Moreover, it is important to note when inpatient rehabilitation measures are taken as the content and volume of patient 13  activities are not static over this time. Additionally, little information exists that provides an indication of how time outside of therapy is spent. Literature review yielded one 27 year old study that used a spot-checking approach to monitor patient activities outside of therapy (Kennedy et al., 1988). The authors found that much time was spent on the ward in solitary, disengaged behaviours. An updated assessment is required, and no one has measured physical activity during this time via self-report.  1.3 Determinants of physical activity Identifying the factors that impact physical activity participation in individuals, whether in the community or in rehabilitation, is a necessary step in removing barriers and promoting facilitators of physical activity. Understanding which factors have the greatest impact would provide justification for how to allocate resources to promote physical activity. Furthermore, such knowledge may identify those who need more assistance to optimize their engagement in physical activity.   1.3.1 Determinants of physical activity in the community The topic of determinants of physical activity in individuals with chronic SCI has, in more recent years, received attention (Levins et al., 2004; Whiteneck et al., 2004; Vissers et al., 2008; Kehn and Kroll, 2009; Martin Ginis et al., 2011b; Fekete and Rauch, 2012; Martin Ginis et al., 2012a; Williams et al., 2014) with research in the past decade showing that, for those with chronic SCI, barriers to being physically active include a complex combination of personal, physical, attitudinal, and policy factors (Levins et al., 2004; Whiteneck et al., 2004; Kehn and Kroll, 2009).  In a cross-sectional survey of 72 individuals with SCI, Skelza et al. (2005) found that less than half were physically active. Their most frequently cited factors affecting physical activity participation were intrinsic (e.g., lack of motivation, energy, and/or interest), resource (e.g., cost of an exercise program, not knowing where to exercise), and, structural factors (e.g., accessibility of facilities and knowledgeable instructors).   14  Semi-structured phone interviews with 15 exercising individuals and 11 non-exercising individuals with SCI (Kehn and Kroll, 2009) revealed motivational and socio-economic factors impacted exercise participation. Specifically, non-exercising individuals indicated a perceived low return on investment, resource issues (cost), and structural factors (lack of accessibility of facilities and knowledgeable instructors) were barriers. Exercisers indicated that facilitators included motivation, independence, structural factors (in this case the presence of accessible facilities and knowledgeable instructors), fear of health complications, and weight management.  Levins et al. (2004) in semi-structured phone interviews with 8 individuals with SCI identified two themes that impacted physical activity: (1) individual influences, defined as a period of loss of “able identity” and subsequent process of rediscovering and redefining self, facilitated by participation in physical activity and, (2) societal influences (environmental and attitudinal barriers).  The construct of Social Cognitive Theory posits that self-efficacy is a direct determinant of behavior and has indirect effects on behavior through its influence on outcome expectations and self-regulatory strategies. Using this construct, Martin Ginis et al., (2011b) found that self-regulation was the only direct predictor of the variance in physical activity in a sample of 106 individuals with SCI.  In a telephone survey of 695 individuals with SCI, the same research group (Martin Ginis et al., 2010) showed that sex, age, years post-injury, injury severity, and primary mode of mobility were unique predictors of leisure time physical activity (LTPA) using multiple regression.   A useful model to organize the numerous factors that act as barriers and facilitators of physical activity is the International Classification of Functioning, Disability, and Health (ICF). It has been used previously (Rimmer, 2006) to identify key factors associated with participation in community-based physical activity and rehabilitation and is 15  comprehensive in that it identifies the level of functioning at the level of the body, the person, as well as their interaction in society. Additionally, it acknowledges the influence of personal and environmental factors that can impede or enhance participation) (WHO, 2001). Recently Martin Ginis et al. (2012a) investigated LTPA in this sample using the ICF. Their investigation revealed that Personal Factors (intentions and fewer years post-injury) and Activities and Participation (greater social integration) were associated with a greater likelihood of being active. Counterintuitively, motor and physical independence were negatively related to minutes per day of LTPA. Overall, the models explained 19%–25% of the variance (Martin Ginis et al., 2012a).  In a review of correlates and determinants of physical activity in individuals with SCI, Fekete & Rauch (2012) employed the ICF to show that Environmental Factors were consistently found as correlates of physical activity, whereas Personal Factors (socio-demographics and psychological constructs) were weakly associated with physical activity. The authors also noted that associations with Body Functions, Body Structures, Activities and Participation and Health Conditions were less frequently studied.   A meta-analysis by Williams (2014) identified 8 interrelated concepts as barriers, benefits and/or facilitators of LTPA: (1) well-being; (2) environment; (3) physical body; (4) body–self relationship; (5) physically active identity; (6) knowledge; (7) restitution narrative; and (8) perceived absences.   1.3.2 Determinants of physical activity during inpatient rehabilitation  The determinants of physical activity are expected to be different during inpatient rehabilitation as individuals are at an earlier stage post-injury and not yet reintegrated with the community. The ICF will serve as a conceptual framework for this study to understand how physical activity is impacted by body structure and functions, activities, personal factors and environmental factors (see figure 1). Of importance, note that we list physical activity measures (measures of heart rate, accelerometry and self-report PARA-SCI) in the participation domain. The ICF is also helpful to organize the 16  questionnaires and assessments (see Appendix A & B) that measure factors believed to be important in impacting participation in physical activity/rehabilitation in the inpatient setting. In research investigating factors that may affect physical fitness (assessed using peak oxygen uptake and peak power output), Haisma et al., (2007) has shown that spasticity, complications (such as urinary tract infection and pressure sores), and bed rest slow the recovery of physical fitness during inpatient rehabilitation, and that longer rehabilitation stay does not result in higher physical fitness. The authors (Haisma et al., 2006) have also shown that the characteristics of younger age, male sex, and higer level of and presence of complete injury were related to a greater amount of improvement in physical capacity over rehabilitation.  Certainly, the determinants of physical capacity during rehabilitation are important and require further study. Physical capacity is expected to have an effect on how active individuals with SCI are during inpatient rehabilitation (Nooijen et al., 2012). However, very little information exists on factors that affect activity levels in therapy, specifically during rehabilitation.  We do know that orthostatic intolerance can significantly delay the physical rehabilitation of individuals with SCI (Illman et al., 2000). Orthostatic manoeuvres performed during PT and mobilization induce blood pressure decreases diagnostic of orthostatic hypotension in 74% of SCI patients, and symptoms of orthostatic hypotension (such as lightheadedness or dizziness) in 59% of SCI individuals (Illman et al., 2000). Usually affecting those with lesions above T6 where cardiac and splanchnic autonomic outflow emerges, orthostatic hypotension occurs due to pooling of blood in the lower body when upright, leading to decreased venous return and reduced blood pressure. If the blood pressure fall is pronounced, cerebral hypoperfusion occurs, causing the typical symptoms of orthostatic hypotension which include nausea, fatigue, and dizziness and can lead to syncope (Claydon et al., 2006).    17  Figure 1.1  International Classification of Functioning, Disability, and Health for potential barriers and facilitators of physical activity during inpatient rehabilitation   1.3.3 Summary The determinants of physical activity for individuals with SCI living in the community are multifactorial. Because of the different environment in inpatient rehabilitation and the shorter time since injury, compared to the community, it is possible that the determinants of physical activity, which have not been researched, are different. More specifically, the determinants of physical activity during therapy sessions are expected to be different from what is seen in community dwelling individuals with SCI.   Spinal Cord Injury Personal Factors SCI-ESES  Age Gender Body Functions     and Structure     ASIA AIS Orthostatic Tolerance Test Grip strength Spasm freq/severity scale Chronic Pain Grade Q Fatigue Severity Scale CES-D 10 Environmental Factors Physical Activity and Social Support Questionnaire Participation PARA-SCI Heart rate time ≥40%HRR Wrist accelerometry Step counts  Activities WISCII 10m Walk Test SCIM III  Contextual Factors Functioning and Disability 18  1.4 Purpose, objectives, and hypotheses The purpose of this research is to investigate physical activity (measured by accelerometry, self-report, and heart rate), and the determinants thereof, during inpatient SCI rehabilitation.   1.4.1 Objectives 1) To determine the day-to-day (test-retest) reliability of wrist accelerometry, step count measures, and self-report physical activity measures during inpatient SCI rehabilitation.   2) To determine the relationship of step count and wrist accelerometry measures with self-reported physical activity, as well as with relevant clinical outcome measures.   3) To quantify the amount of movement repetitions that patients experience for the upper extremity and lower extremity during inpatient SCI PT and OT therapy.  4) To quantify changes in the amount of movement repetitions that patients with SCI undertake during PT and OT therapy sessions over their recovery.   5) To quantify physical activity during inpatient rehabilitation, specifically during structured therapy (PT and OT) and outside of structured therapy as measured by wrist and hip accelerometry and patient self-report.   6) To examine how or if physical activity (as measured by wrist and hip accelerometry and patient self-report) changes over time from admission to discharge.   7) To measure the amount of cardiovascular stress experienced by individuals with SCI during PT and OT therapy sessions at the end of inpatient rehabilitation stay.   8) To investigate which factors were associated with higher amounts of cardiovascular stress during PT therapy sessions near discharge from inpatient rehabilitation.  19   1.4.2 Hypotheses 1) We hypothesized that because of the regimented nature of patient schedules during inpatient stay that test-retest reliability of physical activity measures would be high between two separate days.   2) We postulated that objective physical activity measures would be moderately related to self-report measures and clinical outcomes.  3) We expected that movement repetitions for both the upper and lower extremity would be low during PT and OT sessions (e.g., under 100 reps/day)   4) We expected that movement repetitions would increase for PT and OT sessions over the SCI inpatient rehabilitation stay.  5) We hypothesized that physical activity as measured by wrist and hip accelerometry and patient self-report would be low.  6) We hypothesized that physical activity measured by wrist and hip accelerometry and patient self-report would increase from admission to discharge.  7) We hypothesized that the amount of time spent in PT and OT at an intensity sufficient to achieve a cardiovascular training effect (≥ 40% heart rate reserve) would be low (not meeting the recommendations of SCI physical activity guidelines).  8) We hypothesized that less severe injury and higher functional ability would be correlated with more time spent within a cardiovascular training zone during PT.    20  Chapter 2: Reliability and validity of wrist accelerometry and step counts during inpatient SCI rehabilitation 2.1 Introduction For individuals with spinal cord injury (SCI), physical activity plays a vital role in countering an often profoundly sedentary lifestyle and the consequent higher incidence and earlier onset of secondary complications such as cardiovascular disease, dyslipidemia, and diabetes (Frankel et al., 1998; Jacobs and Nash, 2004; Hitzig et al., 2011). Following a SCI, physical activity can optimize recovery and decrease or prevent the degree of post-SCI deconditioning that occurs after weeks of bed rest. This is important because physical activity during this time can affect an individual’s ultimate functional capacity (Sumida et al., 2001; Scivoletto et al., 2005). Inpatient rehabilitation provides opportunities for increasing physical activity after a SCI, both within formal therapy sessions, as well as during the rest of the day. To accurately characterize physical activity and optimize activity prescription, it is necessary to establish the reliability and validity of measures that quantify physical activity as it occurs over the day.   Variations in physical activity from day to day present a challenge for reliable assessment (Baranowski and de Moor, 2000; Nicolai et al., 2010; Hart et al., 2011) and there are several options for assessing physical activity, each with strengths and weaknesses. The gold standard in physical activity measurement includes use of doubly labeled water, calorimetry, and direct observation (Warms, 2006). However, these options are resource intensive, precluding their viability as convenient options for measurement during inpatient SCI rehabilitation stay, though direct observation has been used to observe small portions of the day during physical and occupational therapy during inpatient rehabilitation (Zbogar et al., 2014).   Non-invasive, low-cost options for measuring physical activity include accelerometry and self-report. For those who are ambulatory, hip step counters provide a reliable option used much in able-bodied research but have also demonstrated reliability in 21  community-dwelling individuals with chronic incomplete SCI (Ishikawa et al., 2011). Wrist accelerometry is shown to be a valid indicator of physical activity for wheelchair-users in laboratory and community-dwelling environments (Warms and Belza, 2004). For wheelchair users, wrist accelerometry is well-tolerated, does not interfere with regular activity, and detects activity such as wheeling that would otherwise not be detected by hip accelerometry (Warms, 2006).   Perhaps because no equipment is required, self-report is the most widely used method for measuring physical activity (Warms, 2006). However, the subjective nature of self-reported physical activity renders it prone to recall error and social desirability bias (Prince et al., 2008). On the other hand, information not available from objective measures can be obtained from self-report. For example, accelerometry may measure when and how much an individual moves an arm, while self-report captures information on how difficult this activity was and the purpose of the activity (i.e. leisure, activity of daily living (ADL), etc.). A self-report questionnaire developed for use in the SCI population, the Physical Activity Recall Assessment for SCI (PARA-SCI), allows respondents to indicate time and intensity of physical activities performed during the day. The reliability and validity of this questionnaire has been established in community dwelling individuals with SCI (Martin Ginis et al., 2005; Latimer et al., 2006).   There are many contextual differences between the inpatient SCI rehabilitation setting compared to the community setting. The inpatient setting provides a semi-structured environment for supporting therapeutic activities. Importantly, the inpatient’s physical and psychological status may be changing rapidly over recovery, which may impact the reliability and validity of physical activity measures. Being able to estimate the daily physical activity during inpatient rehabilitation is critical as greater activity during this time results in greater motor recovery, shorter inpatient stay (Sumida et al., 2001), quicker improvement in ADL performance (Janssen et al., 1994; Scivoletto et al., 2005), and may counteract the significant decrease in physical activity that follows discharge (van den Berg-Emons et al., 2008) 22   To date no research has investigated whether physical activity measures are reliable or valid during inpatient rehabilitation. Therefore, our purpose was to determine 1) the day-to-day (test-retest) reliability of accelerometry and self-report physical activity measures during inpatient SCI rehabilitation and 2) the relationship of accelerometry measures with self-reported physical activity, as well as with relevant clinical outcome measures (convergent validity). We hypothesized that because of the semi-structured nature of participant schedules during inpatient rehabilitation that test-retest reliability of physical activity measures would be high between two separate days. In addition, we postulated that objective physical activity measures would show good correlation with self-report measures and clinical outcomes.   2.2 Methods 2.2.1 Participants Participants were a consecutive sample of traumatic and non-traumatic SCI admissions to inpatient subacute care at two Canadian rehabilitation centres in two provinces. Nontraumatic SCI was defined as SCI resulting from spinal stenosis, tumour, ischemia, transverse myelitis, and infection (New and Marshall, 2014). Participants were excluded if they had a traumatic brain injury that significantly affected the content and delivery of therapy, consent could not be obtained within the first week of admission, or their length of stay in rehabilitation was projected to be less than 4 weeks as the short length of stay precluded the ability to collect admission and discharge data.  2.2.2 Data collection Data were collected over a single week at a time-point when participants would have likely reached their maximal physical activity, and when bias from discharge planning activities would not be occurring. Thus, we collected data over two separate weekdays in the second week before discharge. On each data collection day, a research assistant met the participant in their room in the morning, prior to breakfast, before participants had transferred from bed. At this time the participant donned the accelerometers and 23  was reminded that they would be required to recall the events of their day that evening. In the evening of each day, when participants had transferred to bed, the research assistant returned to collect the accelerometers and to administer the self-report physical activity questionnaire. Clinical outcome measures were collected on a separate day within the same week period.  Approval for this study was obtained from the local university and health ethics boards and health authority and all participants provided informed consent before study enrolment.   2.2.3 Physical activity measures Physical activity over an entire day was assessed by three different measures. First, all participants wore an Actical accelerometer (Actical; Mini Mitter Co., Bend, OR) on the dominant wrist like a wrist watch to quantify the amount and intensity of upper extremity activity using mean activity kilocounts per day. The Actical accelerometer is a small device with a frequency range of 0.3–3 Hz. The unit is sensitive to 0.05–2.0 G-force and samples data at 32 Hz. Acceleration is detected in all three planes, although more sensitivity is present in the vertical plane. The accelerometer record is rectified and integrated over 15 seconds as activity counts. Higher activity counts may indicate longer use, more movement, and/or greater intensity of movement.   Second, participants who were ambulatory (i.e., could walk independently with or without assistive devices at the time of their assessment) wore an accelerometer on the right hip secured with a waist strap to detect the number of steps using the step-count function of the accelerometer.   Third, participants completed the PARA-SCI (See Appendix A.1 and B.1), a questionnaire that measures the amount of physical activity individuals with SCI accumulate over a day (Martin Ginis et al., 2005). This semi-structured interview 24  provides an estimate of time (in minutes) spent participating in mild, moderate and heavy intensity physical activities, as well as activities with no intensity (“nothing at all”).  2.2.4 Validation measures The following clinical outcome measures were chosen to assess convergent validity: grip strength with wrist accelerometry, a test of ambulatory function with step counts, and overall functional independence with accelerometry, step counts, and self-reported physical activity. Convergent validity indicates that two measures believed to reflect the same phenomenon will be highly correlated (Portney and Watkins, 2000).  The physical activity measures of accelerometry, step counts, and self-reported physical activity capture activities being perfomed during the day, a significant part of which is composed of ADLs. Thus, we investigated the relationship between our physical activity measures and the Spinal Cord Independence Measure (See Appendix A.2) which measures the ability of SCI participants to accomplish ADLs in the area of self-care, respiration, sphincter management, and mobility (Catz et al., 2007), with higher scores (0-100) indicating better functional independence. This measure has excellent validity and reliability (Itzkovich et al., 2007).   The upper extremities contribute significantly to physical activity in individuals with SCI, especially during wrist accelerometry measures of physical activity. The arms are relied on more heavily for ADLs and leisure time activities as they take on activities that previously involved the lower body. Upper extremity function has implications for how much activity is engaged in by the upper extremities (for example, using a manual versus a power wheelchair) and thus, measures of upper extremity function were validated against wrist accelerometry measures. Grip strength (See Appendix A.3) was tested using a hand held Jamar Dynamometer (Nicholas MMT, Lafayette Instrument, Lafayette, IN). For the dominant hand, participants performed 3 maximal voluntary contractions, with at least 30 seconds of rest between trials. The 3 trials were averaged to obtain a mean score in kilograms. All measurements were taken with the participant 25  seated, with the elbow at 90 degrees and the hand in a neutral position. This test has proven reliable and valid for assessing manual grip in both healthy and hand-injured populations (Mathiowetz et al., 1984; Bohannon and Schaubert, 2005).   Participants with SCI who take more steps during rehabilitation are expected to perform better at assessments of ambulatory ability. Thus, step count measures in patients with ambulatory ability were validated against the Walking Index for Spinal Cord Injury (WISCI II), which gauges locomotor performance on a 0 to 20 hierarchical scale and accounts for the requirement of devices, braces, and physical assistance used to complete a 10-meter distance (See Appendix A.4). Higher scores indicate better ambulatory ability. The WISCI II is reliable and valid in the SCI population (Burns et al., 2011).   Step count measures were also validated against the 10 Meter Walk Test (10MWT), which is a measure of functional walking capacity (See Appendix A.5). For this test, ambulatory participants walk 14-meters while being timed at their comfortable pace. The first and last 2 meters are eliminated from the speed calculation to negate acceleration/deceleration effects (Jackson et al., 2008). The 10MWT has been shown to have excellent reliability and validity in incomplete SCI (Scivoletto et al., 2011).   2.2.5 Descriptive measures Demographic information was collected for age, sex, plegia type (paraplegia/tetraplegia), aetiology (traumatic or nontraumatic), American Spinal Injury Association Impairment Scale (AIS) score (Kirshblum et al., 2011), length of stay in acute care and length of stay in rehabilitation.  2.2.6 Data analyses For the purpose of this study, the four intensities of the PARA-SCI were binned into two categories: ‘lower intensity’ comprising nothing and mild intensity and ‘higher intensity’ comprising moderate and heavy intensity. Moderate and heavy physical activity are 26  intensities recommended by exercise guidelines for accruing health benefits (Garber et al., 2011; Martin Ginis et al., 2011a).   We analyzed data for the total sample and by ambulation status. Intraclass correlation coefficients (ICC2,1) with 95% confidence intervals (CI) were used to assess the reliability of wrist accelerometry counts, step counts, and self-report physical activity on Day 1 versus Day 2 of measurement. Poor reliability was indicated by ICC coefficients below 0.50, moderate reliability between 0.50 and 0.75, and good reliability ≥ 0.75 (Portney and Watkins, 2000). Agreement was quantified by the standard error of measurement (SEM), and minimal detectable change (MDC95). Exploration of scatterplots indicated the presence homoscedasticity. Spearman’s ρ correlation coefficients were used to quantify the relationship between the physical activity measures of wrist accelerometry counts, step counts, and self-report physical activity. Correlations were also assessed between wrist accelerometry and hand function measures, and between number of walking steps and ambulatory ability. Lastly, all measures of physical activity were correlated with functional independence. A ρ value ≤ 0.25 indicated a weak correlation, a ρ between 0.26 and 0.49 a low correlation, a ρ between 0.5 and 0.69 moderate correlation, and a ρ value was ≥ 0.7 was considered a high correlation (Dumholdt, 2000).   Our sample of 108 individuals provides the ability to detect hypothesized correlations of at least 0.30 between measures at a power of 80% and an alpha of p≤0.05. Statistical software, SPSS 17 (SPSS Inc, Chicago, IL USA), was used for the analysis.   2.3 Results A total of 387 participants were admitted to SCI rehabilitation over the course of 2 years. Of the 387 participants, 277 were excluded because they did not meet study criteria or did not agree to participate. The remaining 127 participants entered into the study and we obtained an evaluation for 108 (85%) in the second week prior to discharge. While we could not attain an evaluation for 19 participants because they were discharged with 27  insufficient notice, demographic variables for these participants were not notably different from those included for analyses. Descriptive statistics (means, standard deviations, frequencies) for participant demographics and clinical outcome measures for the 108 participants in this study are included in Table 2.1.  2.3.1 Test-retest reliability of accelerometry counts, step counts, and self-reported physical activity Reliability data with the ICC, 95% CI, SEM, and MDC95 is found in Table 2.2. The average time between testing days was 2.2±1.9 days. Both wrist accelerometry and step counts showed good test-retest reliability (ICC > 0.8). For self-reported physical activity, the ICC indicated moderate test-retest reliability (0.59, CI 0.45-0.70).  2.3.2 Validity of accelerometry counts, step counts, and self-reported physical activity  Descriptive values for clinical assessments are found in Table 2.1. Correlations for physical activity measures (self-report, wrist accelerometry and step count) are displayed in Table 2.3. The three physical activity measures were not significantly correlated to one another.  Correlations of physical activity measures with clinical measures are provided in Table 2.4. Wrist accelerometry showed moderate correlation with grip strength (ρ =0.51) and functional independence (ρ =0.53).  In ambulatory participants, step counts exhibited moderate correlation with functional independence (ρ =0.55) and measures of ambulation (ρ =0.61 to 0.62). Self-reported physical activity was weakly correlated with functional independence.   28  Table 2.1  Participant Characteristics and Clinical Measures Variable           All Participants    Ambulatory Participants††   n             108        37 Age, mean (SD), years      49.2 (18.0)      51.2 (15.7) Sex (M/F), n(%)        77/31 (71/29)     28/9 (76/24) Traumatic/nontraumatic, n(%)    71/37 (66/34)     26/11 (70/30) Paraplegia/tetraplegia, n(%)     58/50 (54/46 )     24/13 (65/35) AIS score (A/B/C/D), n(%)†     25/10/14/56 (23/9/13/52)  1/2/0/34 (3/5/0/92) LOS in rehabilitation, mean (SD), days 93.8 (45.3)      71.6 (43.2) LOS in acute care, mean (SD), days  38.5 (37.3)      19.7 (12.9) SCIM III, mean (SD)       60.1 (23.9)      79.4 (12.9) Grip strength, mean (SD), kg    23.8 (18.0)      ~ 10MWT, mean (SD), m/s      ~         0.76 (0.38) WISCI II, mean (SD)       ~         15.6 (5.6)       † While the AIS is valid for traumatic SCI, it has not been validated in non-traumatic SCI. †† The Ambulatory group is composed of a subset of individuals with paraplegia and tetraplegia who were able to ambulate by the time of the assessment.     n= number of participants; ASIA= American Spinal Injury Association; AIS= ASIA Impairment Scale; LOS= Length Of Stay; SCIM= Spinal Cord Independence Measure- Total (0-100); 10MWT= 10 Meter Walk Test- comfortable speed; WISCI II= Walking Index for Spinal Cord Injury (0-20).    29  Table 2.2  Reliability statistics for wrist accelerometry and steps            Day 1     Day 2    ICC  95% CI   SEM  MDC95 Wrist Accelerometry (n=108)  188.7 (124.7)  190.7 (128.0) 0.82  0.75 to 0.87  52.9  146.6 Step Counts (n=28)     2374.5 (2866.2) 2377.0 (3701.3) 0.83  0.66 to 0.92  1195.6 3314.0 PARA-SCI (n=105)     109.4 (91.3)   111.4 (85.0)  0.59  0.45 to 0.70  58.6  162.5 Day 1 and Day 2 values are means (SD); wrist accelerometry values are kilocounts; step count values are for ambulatory participants only; PARA-SCI= Physical Activity Recall Assessment for People with Spinal Cord Injury, values in minutes. ICC= intraclass correlation coefficient; 95% CI= confidence interval; SEM= standard error of measurement; MDC95= minimal detectable change.  30  Table 2.3  Spearman correlation matrix for physical activity measures          PARA-SCI     Wrist Accelerometry Wrist Accelerometry   0.10 (-0.10 to 0.29)            n=106        Step Counts     0.22 (-0.12 to 0.51)  0.16 (-0.18 to 0.46)          n=36       n=36       Values are ρ (95%CI); *p≤ 0.05 (2-tailed), **p≤ 0.01 (2-tailed); n= number of participants; PARA-SCI= Physical Activity Recall Assessment for People with Spinal Cord Injury.              31  Table 2.4  Spearman correlations of physical activity measures versus clinical measures       ρ (95% CI)       Wrist Accelerometry      SCIM III (n=102)  0.53 (0.40 to 0.67)**  Grip strength (n=101) 0.51 (0.35 to 0.65)**     Step Counts†      SCIM III (n=36)   0.55 (0.27 to 0.72)**  10MWT (n=33)   0.62 (0.35 to 0.80)**  WISCI II (n=32)  0.61 (0.33 to 0.79)**     PARA-SCI     SCIM III (n=102)  0.25 (-0.056 to 0.42)*     *p≤ 0.05 (2-tailed), **p≤ 0.01 (2-tailed); CI= Confidence interval; SCIM III= Spinal Cord Independence Measure III, Total Score; † Values reported are for ambulatory individuals only; 10MWT= 10 Meter Walk Test; WISCI II= Walking Index for Spinal Cord Injury II; PARA-SCI= Physical Activity Recall Assessment for People with Spinal Cord Injury.      32   2.4 Discussion The average amount of wrist accelerometry counts observed in this study was 189±125 kilocounts. Normative values for wrist accelerometry counts do not exist for SCI. However, able-bodied older adults have been shown to accumulate between 164 to 224 daily kilocounts using the same instrument (Rand and Eng, 2010), and our value falls within this range albeit with a large amount of variability. Individuals with paraplegia who use their arms to propel a manual wheelchair likely have higher wrist accelerometry counts, while individuals with tetraplegia who have arm impairment and use a power wheelchair may have relatively fewer wrist accelerometry counts. Ambulatory individuals in this study accrued approximately 2400 steps during a weekday which is typical of individuals living with disability and/or chronic illness who have been shown to accumulate an average of 1200-8800 steps/day (Tudor-Locke et al., 2011).   Values for self-reported moderate and high intensity minutes amounted to 1.8 hours while previous research reported lower amounts with approximately 1.4 hours in community-dwelling SCI (Martin Ginis et al., 2005; Latimer et al., 2006). However, the variability of the measure across our rehabilitation participants was high, as was the case also in the community-dwelling SCI.  2.4.1 Test-retest reliability The good test re-test reliability for wrist accelerometry and step counts indicates that accelerometry is a reliable measure in the inpatient setting and also that physical activity is similar from one day to the next during inpatient rehabilitation. This is likely due to the consistent nature of the participant schedules. During inpatient rehabilitation a participant will usually be woken at the same time every day, have a regularly scheduled bowel/bladder and medication routine, meals, and therapy sessions, and such activities will all generally occur in the same locations and take the same amount of time every day. Thus, while research with able-bodied adults has shown that 2 to 6 days are required to characterize daily physical activity (Gretebeck & Montoye, 1992; 33  Hart et al., 2011; Kang et al., 2009; Matthews, Ainsworth, Thompson, & Bassett, 2002; van Schooten et al., 2015), it appears that the consistent nature of activities during inpatient SCI rehabilitation could require 1 day to capture habitual physical activity patterns.  The reliability of the PARA-SCI was lower than the other physical activity measures. The fact that self-reported physical activity did not show the same reliability as seen with accelerometry may indicate poorer reliability of the PARA-SCI or it may indicate the heterogeneous nature of self-reported physical activity. We acquired the responses to the PARA-SCI at the end of each day which would minimize recall bias, while the original questionnaire followed up after 3-days of activity (Martin Ginis et al., 2005). Our reliability (ICC=0.59) was lower than values (0.79) reported previously for the PARA-SCI in chronic SCI (Martin Ginis et al., 2005). While our follow-up after a single day may have contributed to more accurate recall, perhaps more days are required to capture the variability in activities.  2.4.2 Validity The lack of correlation between physical activity measures in the inpatient rehabilitation setting suggests that these 3 measures are capturing different aspects of physical activity. This contrasts with studies in individuals living in the community where the PARA-SCI has been shown to relate to indirect calorimetry in individuals living in the community (Martin Ginis et al., 2005; Latimer et al., 2006), accelerometry derived step counts have been shown to relate to observed steps community-dwelling persons with incomplete SCI (Bowden and Behrman, 2007), and wrist accelerometry has also been shown to relate to indirect calorimetry and heart rate in community-dwelling wheelchair users (Warms and Belza, 2004; Washburn and Copay, 2010).  One expects the physical activity of an able-bodied ambulatory person to manifest itself in accelerometry counts regardless of whether activity is measured at the hip or wrist. However, it is likely that ambulatory individuals with SCI still use a wheelchair for part of 34  the day. Thus, high wrist accelerometry counts may occur during wheeling in the presence of no step counts, while step counts while using an assistive device like a wheeled walker may result in minimal wrist accelerometry counts, and hence contribute to the lack of correlation between wrist accelerometry counts and step counts.  Hip mounted accelerometry/pedometer measures of physical activity have correlated weakly or not at all to self-reported physical activity in other sedentary or chronic-disease populations (Shephard, 2003). The lack of a relationship between self-report physical activity (PARA-SCI) and wrist accelerometry/step counts may occur because these subjective and objective assessments may be quantifying different facets of physical activity. Perhaps the PARA-SCI captures more ADLs and leisure time physical activities in the rehabilitation setting; ADLs make up a large portion of the day and may be done relatively slowly and thus substantial wrist accelerometry counts are not generated. Likewise, ADLs and leisure time physical activity measured by the PARA-SCI may not correlate with step counts because much of an ambulatory participant’s time will be spent on challenging activities such as working on stabilization or specific leg muscles that do not involve taking steps.   Our measures of physical activity are performance measures, assessing actual activity during a participant’s day, while the clinical assessments are measures of capacity. While these are different constructs, they are expected to correlate highly in the same way that manual wheelchair skills correlate highly with performance (Inkpen et al., 2012), and in doing so offer insight as to the validity of the physical activity measures. Grip strength was significantly moderately correlated with wrist accelerometry, providing validity that wrist accelerometry is capturing constructs requiring hand strength. The moderate correlation between step counts and the 10MWT and WISCI II also provides validity, in this case, that the step counts are capturing constructs of ambulation.    Our results demonstrated that wrist accelerometry counts and step counts do relate to constructs of ADLs since our functional independence measure (SCIM III) is a strong 35  indicator of the ability to complete ADLs. Given that ADLs make up a substantial portion of the physical activities within the rehabilitation day, this provides additional validity to the measures of wrist accelerometry and step counts.  The low correlation with functional independence and self-reported physical activity is noteworthy and may exist because we report time spent at higher intensity physical activities using the PARA-SCI whereas higher scores on the SCIM III may result from activities that do not involve physical activity per se (such as respiration or sphincter management) and that do not involve physical activities of a more intense nature.   2.4.3 Limitations We did not include weekends as part of this analysis. It is expected that activity patterns would be significantly lower during weekends as compared to weekdays since therapy sessions, group classes, and most other appointments do not occur during this time.  2.5 Conclusion We have shown that wrist accelerometry counts and step counts provide good test-retest reliability, and that self-reported physical activity provides moderate test-retest reliability, within the inpatient SCI rehabilitation setting. Furthermore, we have shown that wrist accelerometry and step counts are validated against clinical measures of the upper and lower extremity, respectively, as well as functional independence in general. Self-reported physical activity requires further investigation within the rehabilitation setting.   36  Bridging Statement I The accurate portrayal of content and changes in physical activity over time requires outcome measures of adequate reliability and validity. Reliability estimates from Chapter 2 indicate that wrist accelerometry and step counts, and the PARA-SCI are appropriate measures for characterizing physical activity during inpatient SCI rehabilitation. Thus, these measures are utilized in Chapter 4 and discussed in Chapter 6.  37  Chapter 3: Movement repetitions in physical and occupational therapy during inpatient spinal cord injury rehabilitation 3.1 Introduction Occupational therapy (OT) and physical therapy (PT) play a central role in the rehabilitation of individuals who have experienced a spinal cord injury (SCI). Over the past several years, quantifying therapy content in SCI rehabilitation has received increasing attention in order to better understand current practice. The SCIRehab project is a notable comprehensive and recent example (Whiteneck et al., 2011a) where therapists recorded the number of sessions, minutes, activity-specific details, and the extent of patient participation in PT (Teeter et al., 2012) and OT (Ozelie et al., 2012) sessions in inpatient rehabilitation. While studies of content and time spent on activities (Heinemann et al., 1995; Foy et al., 2011; Taylor-Schroeder et al., 2011; van Langeveld et al., 2011a; 2011b) provide a key component to unraveling the relationship between therapeutic intervention and outcomes, they do not provide an indication of the amount of movement repetitions during that time, which are important for optimizing neuroplasticity.  Research studies in animals and humans have found that retraining after SCI using the activity-dependent plasticity properties of the nervous system facilitates the recovery of locomotor function (Edgerton et al., 2004) and reaching (Girgis et al., 2007). In patients with incomplete SCI, rehabilitation therapies such as repetitive upper extremity movements (massed practice) improve hand function (Beekhuizen and Field-Fote, 2005; Hoffman and Field-Fote, 2010), while locomotor training promotes ambulatory recovery (Behrman et al., 2006). However, positive findings for hind-limb stepping after SCI in the animal literature involve several hundred to over a thousand repetitions (Lovely et al., 1986; de Leon et al., 1998) with higher doses resulting in improved outcomes. No inventory of repetitions has been taken within the SCI population. Furthermore, no studies have investigated how repetitions change over inpatient SCI rehabilitation.  38  While the optimal time window for therapy in humans remains unknown, evidence in animal and human research suggests the initial months following a SCI are a crucial time for optimizing recovery (Norrie et al., 2005; Winchester et al., 2009; Harkema et al., 2011; Battistuzzo et al., 2012) which corresponds to sub-acute inpatient rehabilitation stay. Thus, knowing the current repetitions of activities during this period of rehabilitation and how they progress over time will provide a baseline of activity levels and set the stage for clinical trials aimed at developing interventions to enhance motor learning and improve rehabilitation outcomes. Optimizing recovery during this time is expected to positively impact long-term function.  Our purposes were to 1) quantify the amount of movement repetitions that patients experience for the upper extremity and lower extremity during inpatient SCI rehabilitation, and 2) quantify changes in the amount of movement repetitions that patients with SCI undertake over their recovery. To investigate our questions we observed PT and OT sessions and collected information on the amount of repetitions, type of activity, and time spent on activities. We expected that: 1) movement repetitions for both the upper and lower extremity would be low during PT and OT sessions (e.g., under 100 reps/day), and 2) movement repetitions would increase for PT and OT sessions over the SCI inpatient rehabilitation stay.  3.2 Methods 3.2.1 Participants Participants were consecutive traumatic and non-traumatic SCI admissions to inpatient subacute care at two stand-alone rehabilitation centres, recruited over two years. Non-traumatic SCI was defined as that resulting from spinal stenosis, tumor, ischemia, transverse myelitis, and infection (McKinley et al., 1999). Ambulatory participants were defined as those who were independently ambulatory (with or without assistive devices) at the time of the discharge assessment. Participants were excluded if they had a traumatic brain injury that significantly affected content and delivery of therapy or if their 39  length of stay in rehabilitation was projected to be less than four weeks as it precluded the ability to collect admission and discharge data.  Approval for this study was obtained from the university research ethics boards. All observed participants and therapists provided informed consent prior to therapy observation.   3.2.2 Observed therapy sessions A trained observer recorded all activities occurring under the direction of a physical therapist, occupational therapist, or rehabilitation assistant. This most often included PT and OT sessions, but also included supplementary sessions with rehabilitation assistants occurring in the rehabilitation area and on the ward. As we wanted to measure typical active therapy sessions, the first measurement occurred in the second week after admission to avoid observation of sessions involving assessments. Observers recorded all PT and OT therapy activities that occurred on two days within that week period. The final measurement took place in the second-last week before discharge to avoid discharge planning and re-assessment activities. Again, two days within that week were observed. If a session did not occur on a scheduled day or did not meet the criteria indicated below, an additional day of therapy was observed if it occurred within one-week of the first day of data collection.   Therapy sessions were included for observation if more than 50% of therapeutic time was comprised of physical rehabilitation. Therapeutic time was defined as any activity undertaken by the therapist with the goal of treating the patient and included physical rehabilitation, education, assessments, and interventions designed to improve functional independence. Sessions were excluded if more than 50% of therapeutic time was comprised of admission or discharge assessments, equipment fitting, or non-motor issues (e.g. discharge planning, education). Thus, our criteria allowed us to assess therapeutic repetitions under a best-case scenario, omitting sessions not representative of the majority of therapy sessions. Non-therapeutic time was defined as any activity 40  that occurred but was not for treating the patient’s condition, such as talking, resting, changing location, or setting up for the next activity.  Standardization between trained and new observers was accomplished by an orientation where new observers were familiarized with the data collection protocol and then recorded sessions with an experienced observer. The lead investigator and the observers compared therapy observation data sheets following therapy sessions, feedback was provided, and further sessions were recorded under supervision until the data recorded were in complete agreement. There were 4 observers at one rehabilitation centre and 3 at the other.   3.2.3 Therapy observation procedure During observed therapy sessions, the observer situated themselves such that they were able to clearly see and hear the therapy session while being a distance away such that their presence did not interfere with therapy delivery. Moreover, observers did not engage the therapist or patient during the session.  To record information, the observer used a stopwatch and data collection sheets (See Appendix B.2) to document the type of therapy (PT or OT), repetitions, movement classification, and duration of activity. Movements were classified via a taxonomy (Table 3.1) modified from others (Lang et al., 2009; Natale et al., 2009; Ozelie et al., 2009). The categories used in this study included: upper extremity (including all arm and hand movements), hand (a subset including only repetitions of the hand/wrist), lower extremity (including all lower extremity activity), and stepping (a subset of lower extremity including only stepping on flat surfaces or ascending/descending stairs). As we wished to include only those repetitions that contributed most to motor and functional recovery (Table 3.3-3.5), we excluded passive movements.  On the occasion that the patient was undergoing two therapeutic activities at the same time (e.g., simultaneous upper and lower extremity repetitions), both movements were 41  recorded and included as therapeutic activities. In calculating therapeutic time in a session, we subtracted non-therapeutic time (e.g., resting) from total therapy time to avoid the possibility of therapeutic time being longer than the actual session time.  Outside of therapy observation, patients were asked how many minutes of structured group classes they attended that day. These classes were not observed as patients were not followed outside of individual PT and OT therapy sessions. Group classes included wheelchair skills, pulleys (upper body), and hand function.  3.2.4 Clinical outcome measures Clinical outcome measures were collected on a separate day within the admission and discharge data collection periods.  The Spinal Cord Independence Measure (See Appendix A.2) measures the ability of SCI patients to accomplish activities of daily living (ADLs) in the area of self-care, respiration and sphincter management, and mobility (Catz et al., 2007), with higher scores (0-100) indicating better functional independence. The measure has excellent validity and reliability (Itzkovich et al., 2007).   Ambulatory patients were assessed with the Walking Index for SCI II (See Appendix A.4), designed to gauge ambulation over a 10-meter distance with ambulation aids and physical assistance. Locomotor ability is assessed on a 0 to 20 hierarchical scale where a lower number indicates higher impairment. This assessment shows excellent reliability and validity (Burns et al., 2011).   Grip strength (See Appendix A.3) was tested using a hand-held Jamar Dynamometer (Nicholas MMT, Lafayette Instrument, Lafayette, IN). Patients performed three maximal voluntary contractions, with at least 30 seconds of rest between trials. The trials were averaged to obtain a mean score in kilograms. Measurements were taken with the patient seated, the elbow bent at 90 degrees, and hand in a neutral position. This test is 42  reliable and valid for assessing grip in healthy and hand-injured populations (Mathiowetz et al., 1984; Bohannon and Schaubert, 2005).   The Graded Redefined Assessment of Strength, Sensibility and Prehension (See Appendix A.6) was used with patients with tetraplegia to evaluate muscle, sensory, and grasping function. This assessment involves scoring six functional tasks and assessing upper extremity strength and sensibility of the hands; scores for each hand are summed (0 to116) with higher scores indicating better hand function (Rudhe and Van Hedel, 2009). The assessment has excellent reliability and adequate to excellent validity in the SCI population (Kalsi-Ryan et al., 2012).   Demographic information was collected for age, gender, injury level (paraplegia/tetraplegia), ASIA Impairment Scale score, aetiology (traumatic or non-traumatic), and length of stay in acute care and rehabilitation.  3.2.5 Data analysis For OT and PT, therapy time and repetitions were calculated by averaging sessions occurring over two days to obtain a daily therapy value. Descriptive statistics (means, standard deviations, frequencies) for patient demographics are included in Table 3.2. We present the therapeutic time and movement repetition data separating patients with tetraplegia and paraplegia (Table 3.3 and 3.4). We also provide descriptive data for the tetraplegia group separated by complete and incomplete SCI status (Table 3.5), but this data is not assessed statistically due to the small size of these subsets and overlap with other analyses. Additionally, we present data for those patients able to ambulate by the time of their discharge assessment because it is likely that their therapy sessions involved ambulatory goals and activities (Table 3.6). Paired-samples T-tests determined whether therapy times (total time, therapeutic time), movement repetitions (total upper extremity, hand, total lower extremity, steps), and clinical outcome measures changed from admission to discharge.  A minimum sample size of 43 was calculated a priori using G*Power version 3.1 (available at http://www.gpower.hhu.de) using a moderate 43  effect size (d=0.5), an alpha of 0.01, and power of 0.80, for T-tests comparing two dependent means with a directional hypothesis.   Statistical software, SPSS 17 (SPSS Inc., Chicago, IL USA) was used for the analysis. Given that a number of T-tests were employed, an alpha of 0.01 was used to minimize type I error.  3.3 Results 3.3.1 Patient demographics and clinical outcomes A total of 117 patients entered the study from November 2010 to December 2012 (Recruitment information provided in Figure 3.1). Of these, we attained a discharge evaluation for 105 (90%). While we could not attain a discharge evaluation for 12 patients because they were discharged with insufficient notice, demographic variables for these patients (not reported) were similar to those included for analyses. Demographic information is provided in Table 3.2. From the 105 patients in this study, we observed 561 PT sessions and 347 OT sessions. Some patients did not engage in any sessions over the observed week that were focused on physical activities and were assigned a value of zero repetitions. This occurred for four patients at discharge from PT, for 22 patients at OT admission, and 42 patients at OT discharge.   There were significant and clinically meaningful improvements for all clinical outcome measures (Tables 3.3, 3.4, 3.6) from admission to discharge (p<0.001) except grip strength for individuals with paraplegia (Table 3.4).  3.3.2 Changes in therapy time Total therapy session time and therapeutic time did not change during PT or OT sessions from admission to discharge, except for individuals with paraplegia who experienced a reduction in both these variables during OT (Table 3.4). Therapeutic time for both PT and OT sessions comprised, on average, 62% of total therapy time.  44  3.3.3 Changes in upper extremity repetitions Total daily upper extremity repetitions can be found in Figure 3.2. Upper extremity repetitions were primarily undertaken in OT. More specifically, for patients with tetraplegia, upper extremity repetitions decreased significantly from 112.8 to 57.7 in OT (Table 3.3). Hand repetitions (Table 3.3), a subset of upper extremity repetitions, were low in OT sessions (69.6) but did not change.   In the subset of individuals with paraplegia (Table 3.4), upper extremity repetitions were low at admission (~40 in PT sessions and negligible in OT sessions) and did not change over time.  3.3.4 Changes in lower extremity repetitions Total daily lower extremity repetitions can be found in Figure 3.2. Lower extremity repetitions were primarily undertaken in PT. For patients with tetraplegia and paraplegia, lower extremity repetitions were ~100 at admission in PT but did not change significantly over time (Table 3.3, 3.4), and were higher for motor incomplete individuals compared to motor complete (Table 3.5).  For patients who were ambulating by the time of their discharge assessment (Table 3.6), the values for lower extremity repetitions (214.6) and steps (128.3) were moderate at admission in PT sessions and did not change significantly over time.   3.3.5 Participation in group classes The average time spent in group classes was 12 minutes at admission and 15 minutes at discharge.   45  Table 3.1  Definitions of movements, units of repetition, and examples for categories and subcategories.  Category     Definition   Definition of a single repetition   Examples Upper Extremity                Total   Any movement in which the patient attempted to or moved the upper limb through a specific motion or attempted or accomplished a functional task   One movement of 1 limb from initial position and back again OR one movement from initial position to desired position OR One movement from one surface to another using the arms.   Dumbbell exercises, pulley exercises using the arm, transfers, mobility     Hand   Any movement in which the patient attempted or moved the finger(s) or wrist through a specific motion   One movement from initial position and back again    Working on grip/dexterity, wrist roller, squeezing ball, pegboard Lower Extremity                 Total   Any movement in which the patient attempted or moved the lower limb through a specific motion   One movement of 1 limb from initial position and back again   Hip abduction; knee extension; hamstring curl, balance training     Gait   Walking overground or on a treadmill; going up and/or down stairs   Each step of each foot   walking 46  Table 3.2  Demographic and SCI information for all patients and subgroups of paraplegia and tetraplegia and ambulatory patients Variable           All Patients   Paraplegia   Tetraplegia   Ambulatory† n             105     55      50      47 Age, mean (SD), years      49 (17)    48 (18)    50 (17)    50 (16) Gender (M/F), n (%)       76/29 (72/28)  38/17 (69/31)   38/12 (76/24)  34/13 (72/27) AIS, (A/B/C/D), n (%)‡       23/12/12/56   12/6/9/28   11/6/3/28   1/2/0/42  (22/11/11/53)  (22/11/16/51)  (22/12/6/56)   (2/4/0/89) Traumatic/non-traumatic, n (%)    68/37 (65/35)  32/23 (58/42)  36/14 (72/28)  28/19 (60/40) LOS in rehabilitation, mean (SD), days 96 (46)    85 (38)    108 (52)    76 (43) LOS in acute care, mean (SD), days  44 (44)    31 (30)    46 (43)    23 (27)   n= number of patients; AIS= ASIA Impairment Scale; LOS= Length Of Stay.  † The Ambulatory group is composed of a subset of individuals from the Paraplegia and Tetraplegia groups who were able to ambulate by the time of the discharge assessment. ‡ 2 patients had Guillian Barré syndrome and therefore do not have an AIS score. They are classified as motor incomplete tetraplegia. 47  Table 3.3  Patients with tetraplegia: therapy time, repetitions, and assessments at admission and discharge. Variable       Admission  Discharge  p    95%CI   eta2 Physical Therapy (n=50)                     Total time (min)    53.7 (16.3)  52.1 (25.6)  0.65  -5.5 to 8.8  0.00 Therapeutic time (min) 31.4 (10.7)  34.4 (17.7)  0.20  -7.8 to 1.7  0.03 Upper extremity (reps) 31.9 (44.6)  46.7 (70.2)  0.13  -34.1 to 4.5  0.05 Hand (reps)     0.4 (1.5)   1.3 (9.1)   0.48  -3.3 to 1.6  0.01 Lower extremity (reps) 100.9 (174.0) 153.7 (291.4) 0.21  -136.6 to 31.1 0.03 Occupational Therapy (n=45)                   Total time (min)    40.7 (18.4)  33.0 (27.4)  0.089  -1.2 to 16.5  0.06 Therapeutic time (min) 27.1 (14.8)  22.2 (20.6)  0.10  -1.0 to 10.8  0.06 Upper extremity (reps) 112.8 (170.1) 57.7 (127.0)     0.003* 19.1 to 91.0  0.18 Hand (reps)     69.6 (122.3)  31.9 (82.0)  0.011  8.9 to 66.4  0.14 Lower extremity (reps) 3.4 (18.0)  7.8 (34.3)  0.46  -16.2 to 7.4  0.01 Assessments                        Grip strength, (kg)   6.3 (10.5)  9.7 (10.8)  0.001** -5.3 to -1.4  0.21 GRASSP     66.4 (36.0)  79.8 (34.7)  0.0001** -18.5 to -8.2  0.48 SCIM III- Total    34.1 (24.3)  53.5 (27.8)  0.0001** -24.2 to -14.5 0.59 All values are means (SD); *p≤ 0.01, **p≤ 0.001; CI= confidence interval; n= number of patients; GRASSP= Graded Redefined Assessment of Strength, Sensibility and Prehension; SCIM III= Spinal Cord Independence Measure III.  48  Table 3.4  Patients with paraplegia: therapy time, repetitions, and assessments at admission and discharge. Variable       Admission  Discharge  p     95%CI   eta2 Physical Therapy (n=55)                       Total time (min)    53.3 (15.2)  51.8 (23.0)  0.64  -5.0 to 8.0  0.00 Therapeutic time (min) 32.0 (11.6)  32.9 (15.5)  0.71  -5.4 to 3.7  0.00 Upper extremity (reps) 40.3 (67.0)  38.3 (78.2)  0.85  -19.5 to 23.4 0.00 Lower extremity (reps) 110.1 (175.6) 140.7 (194.7) 0.31  -90.7 to 29.3 0.02         Occupational Therapy (n=49)                   Total time (min)    27.8 (19.7)  15.1 (19.9)  0.0001** 6.4 to 19.1  0.25 Therapeutic time (min) 15.5 (11.5)  8.7 (12.4)  0.001** 2.9 to 10.5  0.21 Upper extremity (reps) 6.2 (15.6)  3.9 (17.7)  0.28  -1.9 to 6.5  0.02 Lower extremity (reps) 9.0 (38.6)  32.5 (124.8)  0.20  -59.9 to 12.8 0.03            Assessments                        Grip strength, (kg)   34.8 (13.5)  35.3 (13.5)  0.58  -2.3 to 1.3  0.01 SCIM III- Total    50.7 (17.0)  66.6 (17.1)  0.0001** -19.2 to -12.6 0.63 All values are means (SD); p≤ 0.01=*, p≤ 0.001**; CI= confidence interval; n= number of patients; SCIM III= Spinal Cord Independence Measure III.                       49  Table 3.5  Patients with tetraplegia: mean times and repetitions separating for motor complete and motor incomplete injury. Variable      Admission          Discharge                  Motor Complete Motor Incomplete  Motor Complete Motor Incomplete  Physical Therapy                             n        17      33       17      33 Upper extremity (reps) 48.7 (52.9)   23.2 (37.6)    68.6 (86.3)   35.5 (58.6) Hand (reps)     0.3 (1.2)    0.5 (1.6)     3.8 (15.5)   0.0 (0.0) Lower extremity (reps) 0.1 (0.4)    152.8 (195.3)   3.7 (10.4)   230.9 (334.5)   Occupational Therapy                           n        16      29       16      29 Upper extremity (reps) 16.5 (37.4)   165.9 (191.0)   8.1 (18.0)   85.1 (151.7) Hand (reps)     5.2 (18.4)   105.1 (140.2)   2.0 (5.7)    48.5 (98.7) Lower extremity (reps) 0.0 (0.0)    5.3 (22.4)    0.0 (0.0)    12.2 (42.3)    All values are means (SD); n= number of patients.50  Table 3.6  Ambulatory patients: therapy time, repetitions, and assessments at admission and discharge. Variable        Admission  Discharge  p        95%CI    eta2  Physical Therapy (n=47)                          Total time (min)     55.2 (15.5)  54.8 (27.1)  0.91  -7.2 to 8.1   0.00 Therapeutic time (min)  34.6 (10.8)  39.4 (18.8)  0.082  -10.3 to 0.6   0.06 Lower extremity (reps)  214.6 (211.6) 291.7 (303.8) 0.17  -188.6 to 34.4  0.04 Steps (reps)      128.3 (188.2) 197.4 (285.9) 0.21  -177.1 to 39.0  0.03          Occupational Therapy (n=41)                      Total time (min)     33.5 (21.1)  26.9 (26.5)  0.077  -0.7 to 14.0   0.08 Therapeutic time (min)  23.3 (17.0)  18.8 (20.6)  0.076  -0.5 to 9.5   0.08 Lower extremity (reps)  14.0 (45.2)  37.3 (136.2)  0.29  -67.6 to 21.0  0.03 Steps (reps)      8.8 (26.9)  28.3 (128.6)  0.33  -59.6 to 20.7  0.02  Assessments                           WISCI II       6.8 (7.8)   15.4 (5.2)  0.0001** -11.0 to -6.3   0.58 SCIM III- Total     57.4 (20.6)  78.7 (12.5)  0.0001** -26.3 to -8.6   0.63  All values are means (SD); *p≤ 0.01, **p≤ 0.001; CI= confidence interval; n= number of patients; WISCI II= Walking Index for Spinal Cord Injury II; SCIM III= Spinal Cord Independence Measure III. 51  Figure 3.1  Flow diagram of recruitment to the study     12/117 (10%) individuals missed discharge data collection due to early discharge 387 individuals were admitted to rehabilitation due to SCI during November 2010 – December 2012  270/387 (70%) individuals were omitted because they did not meet inclusion criteria, refused to participate, or were unavailable at admission 117/387 (30%) individuals entered the study 105/117 (90%) individuals were included for data analysis 52  Figure 3.2  Daily repetitions for PT and OT combined. a. Individuals with tetraplegia. b. Individuals with paraplegia.      050100150200250Admission DischargeRepetitions a. Upper ExtremityLower Extremity050100150200250Admission DischargeRepetitions b. 53  3.4 Discussion 3.4.1 Amount of movement repetitions The repetitions experienced by individuals are noteworthy. Summing repetitions from OT and PT sessions, we found that repetitions were markedly lower than that what has been reported to be necessary for optimizing neuroplastic changes (Lovely et al., 1986; de Leon et al., 1998; Cha et al., 2007). These repetitions are not only low for optimizing neuroplastic changes, but also for musculoskeletal or endurance functions. For example, a typical wheeling push frequency is one push per second (Cowan et al., 2008) and the 47 repetitions (total for PT and OT) measured in our patients with paraplegia would hypothetically allow one to wheel less than a minute. These repetition levels would not be sufficient to strengthen the upper extremities to prevent overuse injuries or develop upper extremity endurance for wheeling. Similarly, for ambulatory patients, the 226 steps (total for PT and OT) that we observed at the discharge gait speed (0.76 m/s) with a typical short step length (0.5 m) would hypothetically result in only 2.5 minutes of walking practice over 113 metres, which is not sufficient for any community ambulation activity.   We counted all active movements, but not all repetitions were undertaken with the intention of reducing impairment of an affected limb. The goals in SCI rehabilitation also include activities such as strengthening unaffected muscles and teaching compensatory strategies to accomplish ADLs. Thus, repetitions undertaken for the purpose of eliciting neuroplastic change is likely even lower.  3.4.2 Changes in movement repetitions For the most part, little change in repetitions occurred over time. This may be attributed to patients who met their therapeutic goals earlier in their stay and then focused on non-motor activities as they approached discharge time. However, given that 61% of patients had motor incomplete injuries, it would appear that patients could have benefited from further motor training, but other priorities left little time for these activities.   54  3.4.3 Therapeutic versus non-therapeutic time It is common for clinical research to use hours of therapy as an independent variable when evaluating outcomes (Heinemann et al., 1995; Foy et al., 2011; Taylor-Schroeder et al., 2011; van Langeveld et al., 2011a; 2011b; Ozelie et al., 2012; Teeter et al., 2012), and health-care guidelines often use this metric (Centers for Medicare and Services, 2014). However, we found that non-therapeutic time (e.g., setting up the next activity) made up approximately 1/3 of a session. If appropriate therapeutic guidelines are to be made for public policy decisions, the actual patient time spent engaged in the therapeutic interventions needs to be quantified.  3.4.4 Changes in clinical outcomes Despite repetitions being notably below what may be optimal as described in the literature, patients improved significantly on all clinical outcome measures. It is likely that repetitions improve functional improvements through a combination of neural plasticity and compensation, with greater neuroplasticity in incomplete SCI (Curt et al., 2008). However, the finding that therapy repetitions are vastly lower than recommended task-specific training protocols suggests that methods are required to increase repetitions. Therapy time cannot be solely dedicated to task-specific training for gait or reaching as we found that a multitude of other therapeutic goals take up the patient’s time, such as assessments, orthotic/splint/wheelchair fitting, discharge planning, and education. Furthermore, approximately one-third of sessions is spent on activities such as sling transfers and preparing for an exercise, activities not therapeutic in themselves but necessary for delivering therapy. One alternative which has been successful in the stroke population (Harris et al., 2009; Birkenmeier et al., 2010; Connell et al., 2014) is to accumulate repetitions outside of therapy time.  3.4.5 Limitations We did not capture whether repetitions were progressed beyond the number of repetitions. For example, 30 repetitions may have been done with 2kg near admission and with 5kg at discharge. Furthermore, in the animal literature, movement repetitions 55  are acutely challenged where success rates of only 60% are experienced for reaching tasks (Girgis et al., 2007) and likely contribute to the positive effects of task-specific training (Girgis et al., 2007; Weishaupt et al., 2013). We know from observation that the large majority of patients were able to complete all repetitions prescribed. It is possible that individuals with SCI could perform more difficult exercises to improve recovery. However it is likely that therapists prescribe exercise that is challenging yet at the same time meets with successful execution since failed repetitions could be demotivating to a patient, and in some activities, potentially injurious.  We did not monitor repetitions that occurred outside of PT and OT directed activities, for example during group classes and ADLs. However, group class time was small, not exceeding an average of 15 minutes for the entire study sample. Also, while repetitions occur during ADLs, these are likely low as they are typically done once or twice and not repeatedly practiced as in therapy sessions.  We did not capture repetitions around the midpoint of their stay and it is possible that some patients reached their goals earlier and switched to non-motor tasks during the latter half of their stay.   3.5 Conclusion The amount of movement practice that occurs during inpatient SCI therapy is notably smaller than that recommended in motor learning literature, and does not appear to progress over time. The implication is that the stimuli applied during inpatient stay may not be adequate to maximize the neural changes needed to promote optimal function after SCI.   To provide more insight into the content and amount of repetitions over time, we recommend that future research investigate activity during outpatient rehabilitation. An investigation of patient perception of physical activity intensity during rehabilitation is also recommended.  56  Bridging Statement II Report of active movement repetitions that occur during PT and OT sessions provided in Chapter 3 provides information on what has been a missing component in understanding therapy content. While time during therapy is understandably a focus for most research endeavours to understand inpatient rehabilitation, it is also important to develop an understanding of physical activity levels outside of therapy sessions. To develop appropriate rehabilitation programs to increase physical activity in individuals with SCI, research is needed on the amount and change in physical activity level during inpatient stay when individuals are not engaged in rehabilitation. Structured rehabilitation therapy sessions only account for a small percentage of an individual’s day leaving a significant amount of time that other rehabilitation activities could be pursued. While observing repetitions is possible for short therapeutic activities, other measures may be more appropriate to elucidate information about physical activity over the course of a day. Thus Chapter 4 investigates physical activity during the course of the day using accelerometry and self-report.  57  Chapter 4: Self-reported physical activity and accelerometry in individuals with spinal cord injury during inpatient rehabilitation 4.1 Introduction Physical activity early after a spinal cord injury (SCI) is important for the benefits of optimizing recovery from acute SCI, as well as the ability to improve secondary complications like physical deconditioning resulting from bed rest, cardiovascular disease and autonomic disorders (Jacobs and Nash, 2004). Indeed, a delay in starting appropriate and intensive activities may negatively influence a patient’s ultimate functional capability since the degree of post-SCI deconditioning will increase with a longer delay in starting an exercise program (Sumida et al., 2001; Scivoletto et al., 2005).   In their investigation of 123 individuals with traumatic SCI, Sumida et al. (2001) found that SCI patients without effective rehabilitation in the six months following injury had a notably lower percent increase in motor recovery from admission to discharge as well as a significantly longer length of stay in rehabilitation. Additionally, it has been shown that early rehabilitation is effective in accelerating and promoting improvement in activities of daily living (ADLs) (Janssen et al., 1994; Sumida et al., 2001; Scivoletto et al., 2005). Exercise rehabilitation as soon as possible after injury may prepare individuals with SCI to engage in exercise programs once they return home after inpatient rehabilitation and potentially counteract the significant decrease in physical activity that follows discharge (van den Berg-Emons et al., 2008).   There is some debate as to whether the level of activity during rehabilitation stay is adequate for optimizing recovery or for achieving sufficient physical capacity for returning to the community (Janssen et al., 1994; Dallmeijer et al., 1999). As time in therapy makes up only a small proportion of a patient’s day, it is also important to develop an understanding of physical activity levels outside of rehabilitation therapy sessions in order to assess the overall daily physical activity that the patient is experiencing. While some studies have evaluated therapy intensity or content during 58  structured therapy (van den Berg-Emons et al., 2008; Foy et al., 2011; Taylor-Schroeder et al., 2011; van Langeveld et al., 2011b; Nooijen et al., 2012; Koopman et al., 2013; Zbogar et al., 2014), this study is unique in its inclusion of the content of physical activity outside of the structured rehabilitation sessions, in addition to the activity during structured therapy sessions.    This study had two objectives. Objective 1: To quantify physical activity during inpatient rehabilitation, specifically during structured therapy (physical therapy (PT) and occupational therapy (OT)) and outside of structured therapy. Objective 2: To examine how or if physical activity changes over time from admission to discharge. We hypothesized that physical activity would be low, but would increase from admission to discharge.   We used both a self-report interview and a real-time, objective measure (accelerometry) to capture physical activity.   4.2 Research methods 4.2.1 Participants Participants were a consecutive sample of traumatic and non-traumatic SCI admissions to inpatient subacute care at two Canadian rehabilitation centres in two provinces following SCI. Nontraumatic SCI was defined as SCI resulting from spinal stenosis, tumour, ischemia, transverse myelitis, and infection (New and Marshall, 2014). Ambulatory participants were defined as those who were independently ambulatory (with or without assistive devices) at the time of the discharge assessment. Participants were excluded if they had a traumatic brain injury that significantly affected the content and delivery of therapy, if consent could not be obtained within the first week of admission, or if their length of stay in rehabilitation was projected to be less than 4 weeks as it precluded the ability to collect admission and discharge data.  Data were collected over two weekdays in the second week after admission and over 59  two weekdays in the second-last week before discharge to minimize bias from admission and discharge assessments and discharge planning activities. On each data collection day, a research assistant met the participant in their room in the morning prior to breakfast, before participants had transferred from bed. At this time the participant donned the accelerometers and was reminded that they would be required to recall the events of their day that evening. In the evening of each day, when participants had transferred to bed, the research assistant returned to collect the accelerometers and to administer the self-report physical activity questionnaire. In addition, information on the time of day when PT and OT sessions occurred was collected.  Approval for this study was obtained from the local university and health ethics boards and all participants provided informed consent before study enrolment.   4.2.2 Physical activity measures Actical accelerometers (Actical; Mini Mitter Co., Bend, OR) worn on the dominant wrist like a wrist watch quantified the amount and intensity of upper extremity activity using mean total activity kilocounts per day. The Actical accelerometer is a small device with a frequency range of 0.3–3 Hz. The unit is sensitive to 0.05–2.0 G-force and samples data at 32 Hz. Acceleration is detected in all three planes, although more sensitivity is present in the vertical plane. The accelerometer record is rectified and integrated over 15 seconds as activity counts. Higher activity counts may indicate longer use, more movement, and/or greater intensity of movement. Ambulatory individuals also wore an accelerometer on the right hip secured with a waist strap to detect the number of steps using the step-count function of the accelerometer.   Participants also completed the Physical Activity Recall Assessment for SCI (PARA-SCI), found valid and reliable in community dwelling individuals with SCI (See Appendix A.1 and B.1). This questionnaire measures the amount of physical activity individuals with SCI accumulate over a day. This semi-structured interview provides an estimate of time (in minutes) spent participating in mild, moderate and heavy intensity physical 60  activities, as well as activities with no intensity (“nothing at all”) (Martin Ginis et al., 2005).   For the purpose of this study, the four intensities of the PARA-SCI were binned into two categories: ‘lower intensity’ comprising nothing or mild intensity and ‘higher intensity’ comprising moderate or heavy intensity. Moderate and heavy physical activity are intensities recommended by exercise guidelines for accruing health benefits (Garber et al., 2011; Martin Ginis et al., 2011a). We also categorized activities reported in the PARA-SCI into six areas: 1) PT, 2) OT, 3) ADLs (i.e., tasks which included feeding, transfers, toileting, bathing, dressing, walking or propelling a wheelchair), 4) active group classes (organized classes including wheelchair skills, pulley, swimming pool, and hand classes), 5) leisure-time physical activity (any physical activity intentionally engaged in by the participant outside of formal therapy times that is not an ADL) and 6) sedentary leisure-time (e.g., watching TV, playing board games, talking to friends/family, etc.).  4.2.3 Clinical outcome measures Clinical outcome measures were collected on a separate day within the admission and discharge data collection periods.  Participants with ambulatory ability were assessed with the Walking Index for Spinal Cord Injury (WISCI II), which gauges locomotor performance on a 0 to 20 hierarchical scale where higher scores indicate better ambulatory ability and accounts for the requirement of devices, braces, and physical assistance used to complete a 10-meter distance (See Appendix A.4). The WISCI II is reliable and valid in the SCI population (Burns et al., 2011).   The 10 Meter Walk Test (10MWT) is a measure of functional capacity (See Appendix A.5). For this test, ambulatory participants walk 14-meters while being timed at their comfortable pace. The first and last 2 meters are eliminated from the speed calculation 61  to negate acceleration/deceleration effects (Jackson et al., 2008). The 10MWT has been shown to have excellent reliability and validity in incomplete SCI (Scivoletto et al., 2011).   Grip strength (See Appendix A.3) was tested using a hand held Jamar Dynamometer (Nicholas MMT, Lafayette Instrument, Lafayette, IN). Participants performed 3 maximal voluntary contractions, with at least 30 seconds of rest between trials. The 3 trials were averaged to obtain a mean score in kilograms. All measurements were taken with the participant seated, with the elbow bent at 90 degrees and the hand in a neutral position. This test has proven reliable and valid for assessing manual grip in both healthy and hand-injured populations (Mathiowetz et al., 1984; Bohannon and Schaubert, 2005).   The Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) was used with participants with tetraplegia to evaluate the muscle, sensory, and grasping function (See Appendix A.6). The GRASSP involves scoring 6 functional tasks, assessing upper extremity strength via muscle testing, and assessing sensibility of the hands using monofilaments. Test scores are summed for a total score for each hand (ranging from 0 to 116) with higher scores indicating better hand function (Rudhe and Van Hedel, 2009). The GRASSP has excellent reliability and adequate to excellent validity in the SCI population (Kalsi-Ryan et al., 2012).   Also, demographic information was collected for age, gender, plegia type (paraplegia/tetraplegia), aetiology (traumatic or nontraumatic), ASIA Impairment Scale score (Kirshblum et al., 2011), length of stay in acute care and length of stay in rehabilitation.  4.2.4 Data analyses Descriptive statistics (means, standard deviations, frequencies) for participant demographics are included in Table 4.1. Activity counts, number of steps and PARA-SCI values were calculated by averaging measures collected over two days to obtain 62  more representative values of daily inpatient rehabilitation stay and separated into time in OT, PT, and time outside of therapy. We also analyzed data by plegia type (tetraplegia and paraplegia) and ambulation status (participants who were able to ambulate by the time of their discharge assessment). For the PARA-SCI we also provide descriptive data for the category of Time Outside Therapy separated into: ADLs, physically active group classes, leisure time physical activity, sedentary leisure activity, and appointments/sedentary classes.  To test our second hypothesis, for the PARA-SCI and accelerometry, paired-samples T-tests were used to quantify changes from admission to discharge from inpatient SCI rehabilitation for OT, PT, and time outside of therapy. Paired-samples T-tests were also performed for clinical outcome measures at admission and discharge.   Statistical software, SPSS 17 (SPSS Inc, Chicago, IL USA) was used for the analysis. Due to the number of analyses, a Benjamini-Hochberg p-value correction was employed to minimize the chance of type I error.  4.3 Results Recruitment of participants is described in Figure 4.1. Demographic information is presented in Table 4.1. Briefly, the 95 participants in this study were 50±18 years of age. Average time in rehabilitation was 97±46 days. Half of the group (n=53/95) had paraplegia and approximately two-thirds had traumatic injuries. Thirty-three participants were ambulatory at discharge.  There were statistically significant and clinically meaningful improvements for all clinical outcome measures (Tables 4.2 and 4.3) from admission to discharge (p<0.007) except grip strength for individuals with paraplegia (Table 4.2).  63  4.3.1 Physical activity during PT and OT In general, activity counts for individuals with paraplegia were 1.5 to 2 times that of individuals with tetraplegia, except for at discharge from OT, where counts were higher for individuals with tetraplegia (Table 4.2). In addition, activity counts during PT were 1.3 to 4 times that OT across data collection time points. No statistically significant changes in activity counts were found between admission and discharge except in individuals with paraplegia, who significantly decreased activity counts by half during OT (Table 4.2).  For ambulatory individuals (Table 4.3), steps in PT were relatively low with a significant increase from 147±235 at admission to 377±477 at discharge (p=0.03). Steps taken in OT were minimal with 13±41 at admission and 30±119 at discharge.  Self-reported physical activity from the PARA-SCI (Table 4.4) was not different between admission and discharge for either individuals with paraplegia or tetraplegia during PT sessions. Participants perceived that the majority of the session was spent in higher intensity activity (~50 minutes) while time spent at lower intensity activity did not exceed 13.5±22.1 minutes. In OT, for individuals with paraplegia, there was a significant decrease in higher intensity minutes from admission (18.8±21.1) to discharge (6.5±11.0, p=0.002), while lower intensity activity did not change significantly from admission (16.1±18.1). For individuals with tetraplegia in OT at admission, higher intensity activity made up approximately two-thirds of the ~40 minute session and lower intensity activity the remaining third. While this trend was reversed at discharge, changes were not significant.  4.3.2 Physical activity outside of PT and OT For wrist accelerometry outside of therapy time (Table 4.2), individuals with paraplegia accrued 2 to 3 times the activity counts of individuals with tetraplegia. Activity counts outside of therapy for individuals with paraplegia increased from admission (174.4±114.2 kilocounts) to discharge (200.8±108.3 kilocounts, p=0.049). Similarly, 64  individuals with tetraplegia experienced a significant increase from admission (59.8±50.7 kilocounts) to discharge (97.6±84.2 kilocounts, p=0.002).   For the subset of individuals who were ambulatory (Table 4.3), steps increased significantly during time outside of therapy (admission=464±985 vs. discharge=2008±2700 steps, p=0.002).  For the PARA-SCI, there was no statistically significant change over time in physical activity minutes outside therapy for both individuals with tetraplegia and paraplegia. Between 36.5±38.8 and 55.3±73.3 minutes of the overall waking hours outside of therapy were perceived by participants to be higher intensity activity (Table 4.4).    When we look at the subcomponents of time spent outside of PT and OT sessions (Table 4.5) we find that half of all time was spent engaged in leisure time sedentary activity with no change from admission (271.1±111.4 minutes). ADLs accounted for a further 36.5% of time, with no change from admission (201.1±65.7 minutes). Appointments and sedentary classes composed 8.5% of time, also with no change from admission (46.8±126.1 minutes); individuals with tetraplegia account for the large amount of variability in time at admission. A small amount of time was spent in leisure time physical activity (20.3±35.3 to 30.6±46.6 minutes, average 4.5% of time) and in physically active group classes (11.5±18.8 to 17.0±25.6 minutes, average 2.6%).65  Table 4.1  Demographic and SCI information for all participants and subgroups of paraplegia and tetraplegia Variable            All Participants  Paraplegia    Tetraplegia    Ambulatory†  n             95      53      42      33 Age, mean (SD), years      49.5 (17.6)   48.0 (17.9)   51.3 (17.2)   50.9 (16.5) Gender (M/F), n(%)       68/27 (72/28)  37/16 (70/30)  31/11 (74/26)  24/9 (73/27) Traumatic/nontraumatic, n(%)    66/29 (70/30)  32/21 (60/40)  34/8 (81/19)   23/10 (70/30) Discharge AIS (A/B/C/D), n(%)‡    23/12/12/48   13/6/9/25   10/6/3/23   1/2/0/30  (24/13/13/50)   (25/11/17/47)   (24/14/7/55)   (3/6/0/91) LOS in rehabilitation, mean (SD), days 97.4 (46.3)   85.6 (38.4)   112.3 (51.4)   74.8 (44.1) LOS in acute care, mean (SD), days  39.2 (39.0)   32.4 (32.8)   47.6 (44.6)   20.1 (13.4)   n= number of participants; AIS= American Spinal Injury Association Impairment Scale; LOS= Length Of Stay.   † The Ambulatory group is composed of a subset of individuals from the Paraplegia and Tetraplegia who were able to ambulate by the time of the discharge assessment. ‡ While the AIS is valid for traumatic SCI, it has not been validated in non-traumatic SCI.  66  Table 4.2  Wrist accelerometry and hand function Paraplegia           Tetraplegia          Day segment    Admission  Discharge  p    Admission  Discharge  p   Outside Therapy   174.4 (114.2) 200.8 (108.3) 0.049   59.8 (50.7)  97.6 (84.2)  0.002 Physiotherapy    19.1 (14.9)  20.6 (14.0)  0.65   8.8 (9.9)   11.5 (12.1)  0.14 Occupational Therapy  10.1 (10.0)  5.3 (7.0)   0.009   6.1 (6.7)   8.1 (12.0)  0.36              Upper Extremity Assessments                          Grip strength, (kg)   36.4 (13.2)  36.4 (13.6)  0.93   5.6 (9.4)   8.7 (10.3)  0.007 GRASSP     ~     ~     ~    63.7 (36.9)  76.9 (35.9)  0.002  All values are means (SD); *p≤ 0.05 (Benjamini-Hochberg corrected values); GRASSP= Graded Redefined Assessment of Strength, Sensibility and Prehension.  67  Table 4.3  Step counts and walking assessments for ambulatory participants Hip Accelerometry, (Steps) Admission  Discharge  p   Outside Therapy     464 (985)  2008 (2700)  0.002 Physiotherapy      147 (235)  377 (477)  0.030 Occupational Therapy    13 (41)   30 (119)   0.59        Walking Assessments                 10MWT- comfortable, (m/s)  0.30 (0.40)  0.73 (0.38)  0.002 WISCI II        7 (8)    15 (6)    0.002   All values are means (SD); *p≤ 0.05 (Benjamini-Hochberg corrected values); 10MWT= 10 Meter Walk Test; WISCI II= Walking Index for Spinal Cord Injury II.  68  Table 4.4  PARA-SCI stratified by intensity for time inside and outside therapy Outside Therapy      Physiotherapy      Occupational Therapy     Paraplegia  Admission  Discharge  p  Admission Discharge p  Admission Discharge p   Lower Intensity 519.0 (138.4) 555.9 (123.5) 0.10 8.6 (16.4) 13.5 (22.1) 0.35 16.1 (18.1) 15.7 (22.5) 0.93 Higher Intensity 36.5 (38.8)  40.2 (48.5)  0.67 52.6 (25.2) 49.4 (31.2) 0.65 18.8 (21.1) 6.5 (11.0) 0.002 Tetraplegia                    Lower Intensity 502.2 (215.7) 499.2 (124.4) 0.93 10.6 (15.0) 12.7 (22.3) 0.73 16.5 (19.4) 26.7 (27.7) 0.068 Higher Intensity 42.6 (52.7)  55.3 (73.3)  0.43 47.1 (20.1) 48.1 (31.3) 0.93 24.0 (24.3) 17.2 (21.2) 0.28  All values are means (SD) reported in minutes; *p≤ 0.05 (Benjamini-Hochberg corrected values).                           69               Table 4.5  Subcomponents of time outside therapy            Admission           Discharge          Variable         Total     %  Higher Intensity  Total        %    Higher Intensity Time outside PT and OT    550.7 (172.4)          577.7 (118.7)      Leisure time sedentary activity 271.1 (111.4) 49.2 0.0 (0.0)     269.6 (115.9)   46.7 0.0 (0.0)  Activities of daily living   201.1 (65.7)  36.5 19.8 (30.4)    219.9 (81.6)     38.1 17.1 (26.6)  Appts, sedentary classes, etc. 46.8 (126.1)  8.5 0.0 (0.0)     39.4 (42.4)     6.8 0.0 (0.0)  Leisure time physical activity 20.3 (35.3)  3.7 9.1 (21.9)    30.6 (46.6)     5.3 18.9 (36.1)  Physically active group classes 11.5 (18.8)  2.1 7.4 (16.4)    17.0 (25.6)     2.9 6.9 (17.7)   All means (SD) reported in minutes; % values are subcomponents of Time outside PT and OT; PT= physical therapy; OT= occupational therapy; Appts= appointments.                            70   Figure 4.1  Flow diagram of recruitment to the study    15/110 (14%) individuals missed discharge data collection due to early discharge 387 individuals were admitted to rehabilitation due to SCI during November 2010 – December 2012  277/387 (72%) individuals were omitted because they did not meet inclusion criteria, refused to participate, or were unavailable at admission 110/387 (28%) individuals entered the study 95/110 (86%) individuals were included for data analysis 71  4.4 Discussion 4.4.1 Physical activity during PT and OT For the most part, there were no changes in self-reported physical activity during structured therapy from admission to discharge, and in some instances, there was a decline. Limited therapy time and numerous therapeutic goals in addition to those involving physical activity may explain why upper extremity activity kilocounts, steps, and self-reported physical activity did not significantly increase during therapy time. It is possible that participants are working harder over time in therapy but with increased recovery, their perception of effort does not change. However, this was not corroborated by the upper extremity activity counts, or the step data, which did not change. It is also possible that participants have met the physical goals in therapy and are focusing on other important goals, yet, half of participants were AIS D who were likely experiencing neurological recovery through this entire rehabilitation phase.   Notably, participants perceived that their PT sessions were physically challenging (~50 higher intensity minutes). A number of factors may contribute to the higher intensity experienced by the participants: the taxing PT sessions may be a result of the greater reliance on the arms which have relatively small mass compared to the legs for most functional tasks; the extreme deconditioning of participants following their acute stay; or perhaps the exercise bouts are truly challenging in repetitions and motor control. However, we have previously shown (Zbogar et al., 2014) that the number of repetitions during SCI inpatient rehabilitation is very low, and thus, there appears to be a discrepancy in the exertion that individuals with paraplegia and tetraplegia are experiencing and the actual activity performed.  It is concerning that the participants who were ambulatory by discharge practiced so few steps during therapy sessions. Assuming a short step length (0.5m), individuals are walking for 204 meters at discharge during PT and OT combined. It is important that capable patients take as many steps as possible during rehabilitation as practicing locomotion improves motor recovery (Behrman et al., 2006). While the optimal number 72  of steps in humans is unknown, steps taken during therapy (few hundred) are very low compared to the doses that elicit positive neuro-plastic changes and outcomes in the animal literature (Lovely et al., 1986; de Leon et al., 1998) (few thousand) and are also insufficient for producing a cardiovascular training effect (Garber et al., 2011).   4.4.2 Physical activity outside of PT and OT Time outside therapy constitutes the majority of a patient’s waking hours and it is here where the greatest opportunity for increasing physical activity lies. ADLs and appointments and sedentary classes, together, account for over 35% of time that is a necessary and unchangeable part of the day. Time spent engaged in physical activity (as leisure time physical activity and physically active group classes) accounts for eight percent (~48 minutes) of a patient’s day; most often these minutes were accumulated in small bouts (a few minutes at a time) and current guidelines indicate that bouts must be ≥10 minutes to confer cardiovascular benefit (Garber et al., 2011). On the other hand, leisure time sedentary activity (watching television, reading, playing games, socializing, etc.) makes up 271 minutes or 50% of time. In other words, there are about 4.5 hours in a day available for patients to engage in further physical activity.   From our data, we found an average 31 minutes of time near discharge was spent on leisure time physical activity at discharge with over half of participants reporting no leisure time physical activity whatsoever. Our findings reflect those of Ginis et al (2010) who showed that community dwelling individuals with chronic SCI reported an average 27 minutes of daily leisure time physical activity with half reporting no leisure time physical activity. Thus we show that leisure time physical activity levels are very low in individuals with SCI during inpatient rehabilitation and also that levels do not appear to increase after the conclusion of inpatient rehabilitation. It is not surprising then, that most individuals do not go on to have active lives. This underlies the importance of using time in rehabilitation to promote habits that lead to a physically active lifestyle.    73  4.4.3 Physical activity guidelines  While it is recognized that inpatient rehabilitation provides an opportunity to gradually increase physical activity levels in a supervised setting, one goal could be to reach SCI specific physical activity guidelines that recommend individuals accumulate at a minimum, 20 minutes of moderate to vigorous intensity aerobic activity two times per week (Martin Ginis et al., 2011a). Notably, our data shows that individuals perceive that they are engaged in moderate and heavy activity for most of an hour during PT, and an additional 43 minutes outside of therapy. However, even though participants report 17.1 minutes of higher intensity ADLs, previous research shows that ADLs do not adequately challenge cardiovascular fitness in persons with SCI (Figoni, 1990; Janssen et al., 1994; Vidal et al., 2003). This is likely due to the nature of ADLs, they occur most often in very short bouts. Even for the higher intensity time spent in leisure time physical activity and physically active group classes, much time was accrued in bouts of below 10 minutes, which is currently the minimum bout time recommended by exercise guidelines (Office of Disease Prevention and Health Promotion, 2008). An investigation of heart rate during activities both inside and outside of therapy would provide insight into how much cardiovascular activity is really accrued during inpatient rehabilitation stay.  Other physical activity guidelines measure the number of daily walking steps. Individuals accumulating less than 5,000 steps/day are classified as sedentary (Tudor-Locke and Bassett, 2004; Tudor-Locke et al., 2008). Further research by the same group has shown that individuals living with disability and/or chronic illness accumulate an average of 1200-8800 steps/day (Tudor-Locke et al., 2011) which is in keeping with the values we see in our study group (average just over 2000 steps per day by discharge). Measuring walking steps during structured therapy or outside of therapy is not part of usual practice. We would argue that adding such a non-obtrusive measure would enable clinicians to monitor and progress patients on physical activity, and compare with targets, as well as with existing physical activity guidelines. Such values will also serve as baseline activity from which to build novel clinical trials to increase physical activity within the rehabilitation setting. 74   Whereas we earlier noted that steps taken during PT and OT sessions were of insufficient volume to maximize locomotor recovery, if we assume a minimum of 500 steps is required to optimize locomotor recovery (Lovely et al., 1986; de Leon et al., 1998; Cha et al., 2007), the combination of steps taken inside and outside of therapy result in 21 ambulatory participants (64 percent) exceeding this value. The 1/3 of individuals with fewer than 500 may not be accumulating sufficient repetitions to optimize locomotor recovery. Furthermore, 12 individuals who were taking steps in therapy but were not ambulatory outside of therapy (thus not included in the ambulatory group) were not accruing sufficient repetitions to optimize locomotor recovery. In summary, of 45 individuals participating in locomotor activities, 24 (over 50 percent) were accruing below 500 repetitions.  4.4.4 Limitations Accelerometry may underestimate the number of steps particularly near admission for individuals with SCI who are learning to walk again and steps are very slow (Martin et al., 2012). On the other hand, some movements that are recorded via accelerometry can give a ‘false positive’ of the participant doing activity (e.g., passive range of motion exercises, assisted transfer).  It has been shown that a ‘wear effect’ may occur when wearing accelerometers such that individuals are more active when the monitors are worn (MacMillan and Kirk, 2010). We believe this potential was minimized in our study due to the regimented nature of participant’s days.  Individuals tend to overrate their physical activity participation during recall questionnaires (Adams et al., 2005). Furthermore self-report can be unreliable due to poor memory and limited insight. We believe that by administering the PARA-SCI at the end of each day and having a trained researcher administer the interview, helping the individual in recollecting the events of the day, we minimized issues with recall. 75   4.5 Conclusion Half of time outside of therapy is spent on sedentary leisure activities. This provides a significant opportunity for patients to engage in further physical activity, beyond that accrued during PT and OT sessions. Patient self-report suggests that increased time spent being physically active could be accommodated since individuals do not report increased intensity of physical activity during the inpatient stay.   76  Bridging Statement III In Chapter 4 we showed that, compared to time outside of therapy, the greatest number of high-intensity minutes occur during PT and OT sessions. The data also allows us to determine that for a given amount of time, accelerometry counts are higher during PT and OT sessions than outside therapy. While the data in Chapter 4 suggests that participants perceive therapy sessions to be moderate or heavy in intensity, a physiological measure of exertion would provide complementary evidence towards these findings.  Thus in Chapter 5, we investigate heart rate during this most active period of PT and OT, so we can make conclusions on whether individuals are spending enough time at exercise intensities of intensity to raise the heart rate to levels sufficient for obtaining cardiovascular benefits during therapy. Furthermore, assessing physical activity using heart rate overcomes potential social-desirability bias and recall issues with self-reported physical activity and provides another facet in the assessment of activities occurring during inpatient PT and OT session, facilitating the accurate portrayal of physical activity.       77  Chapter 5: Cardiovascular stress during inpatient spinal cord injury physical and occupational therapy 5.1 Introduction Cardiovascular disease is a leading cause of death in persons with spinal cord injury (SCI) (Garshick et al., 2005; Cragg et al., 2013) and has a higher prevalence, earlier onset, and occurs at an accelerated rate after SCI compared to the general population (Jacobs and Nash, 2004; Hitzig et al., 2011). Exercise training in individuals with SCI has the potential to improve cardiovascular health and alleviate numerous medical complications associated with being physically inactive (Glaser, 1989; Tawashy et al., 2009), which underscores the importance of participating in an exercise program after SCI (Haisma et al., 2007).   Early after SCI, a large amount of bed rest contributes to very low levels of physical activity and cardiovascular fitness (Haisma et al., 2007). Physical capacity, defined as the combined ability of the cardiovascular and musculoskeletal systems to perform at a given level of activity, is extremely low in individuals with acute SCI (Stewart et al., 2000) and improves over time (Haisma et al., 2006), likely due to a number of factors including improvements in neurological status, recuperation from trauma, and training effects of the rehabilitation program. However, little information exists on how much, if at all, conventional clinical protocols in SCI challenge cardiovascular fitness.   It is well known that physical activity of a sufficiently high intensity confers cardiovascular benefits not obtained by lighter activity (Lee et al., 1995), and the importance of this fact is accounted for in physical activity recommendations by various organizations. The World Health Organization (WHO, 2010) recommends that, throughout the week, one obtains at least 150 minutes of moderate-intensity, 75 minutes of vigorous-intensity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity in bouts of no less than 10 minutes. The U.S. Department of Health and Human Services (Office of Disease Prevention and Health Promotion, 2008) recommends these same guidelines for individuals with disabilities. More recently, SCI 78  specific guidelines suggest individuals accrue, at a minimum, two bouts of 20 minutes of moderate to vigorous intensity aerobic activity per week (Martin Ginis et al., 2011a). Unfortunately it appears most individuals with chronic SCI do not meet these guidelines at one year following discharge from rehabilitation (van den Berg-Emons et al., 2008). Indeed, individuals with SCI have been shown to have the lowest physical activity levels when compared to persons with different chronic diseases (van den Berg-Emons et al., 2008). One might assume that the cardiovascular stress experienced after SCI injury would be equally low. However, one study (Koopman et al., 2013) assessed 8 individuals with paraplegia and 3 with tetraplegia over a typical rehabilitation day and concluded that there was sufficient strain to improve aerobic fitness, but there was large heterogeneity of the subjects (participants with paraplegia/tetraplegia/walking ability combined), and subsequently large variability in the data. Clearly more research is required.  The primary goals of physical therapy (PT) and occupational therapy (OT) include motor and functional recovery, however SCI rehabilitation should also purposefully involve the reversal of the cycle of reduced cardiovascular fitness that leads to reduced activity and functioning, which in turn results in a further reduction of physical capacity (Haisma et al., 2006). Cardiovascular stress can improve physical capacity, and in turn contribute to better performance of activities of daily living (ADLs) (Haisma et al., 2006). Furthermore, awareness of the demands placed on the cardiovascular system by rehabilitation interventions is important for both patient safety and for optimizing activity prescription.   The topic of determinants of physical activity in individuals with chronic SCI has, in more recent years, received attention (Levins et al., 2004; Whiteneck et al., 2004; Kehn and Kroll, 2009; Martin Ginis et al., 2011b; Fekete and Rauch, 2012; Martin Ginis et al., 2012a) with research showing that barriers to being physically active include a complex combination of personal, physical, attitudinal, and policy factors (Levins et al., 2004; Whiteneck et al., 2004; Kehn and Kroll, 2009). However, determinants of physical activity are expected to be different during inpatient rehabilitation as individuals are at 79  an earlier stage post-injury and not yet reintegrated with the community. The determinants of physical activity intensity during therapy sessions remain unknown.  Therefore, our purpose was 1) to measure the amount of cardiovascular stress experienced by individuals with SCI during inpatient rehabilitation, and 2) to investigate which factors were associated with higher amounts of cardiovascular stress at discharge from inpatient rehabilitation. We hypothesized that the amount of time spent in PT and OT at an intensity sufficient to achieve a cardiovascular training effect (≥ 40% heart rate reserve) would be low (not meeting the recommendations of SCI physical activity guidelines), and that less severe injury and higher functional ability would be correlated with more time spent within a cardiovascular training zone during OT and PT.  5.2 Research methods 5.2.1 Participants Participants were recruited as part of a larger study examining consecutive traumatic and non-traumatic SCI admissions to inpatient subacute care at two stand-alone rehabilitation centres. Non-traumatic SCI was defined as SCI resulting from spinal stenosis, tumour, ischemia, transverse myelitis, and infection (McKinley et al., 1999). Participants were excluded if they had a traumatic brain injury that notably affected the content and delivery of therapy (as determined by their health care team), if consent could not be obtained within the first week of admission, or if their length of stay in rehabilitation was projected to be less than four weeks as it precluded the ability to potentially progress their rehabilitation activities prior to discharge.  Approval for this study was obtained from the university and hospital ethics boards and all participants provided informed consent prior to measurement.   5.2.2 Heart rate and therapy content data collection Heart rate data were collected during therapy sessions over two weekdays in the second-last week of inpatient rehabilitation stay as it was expected that at this point in 80  time patients would be near their peak inpatient recovery and would be able to maximally participate in rehabilitation activities. A research assistant fitted the participant with a Holter monitor (Nasiff CardioCard, Nasiff Associates Inc., New York) to record and store continuous heart rate data. This device provides 3 channel ECG and consists of 5 electrodes on the chest and abdomen attached via leads to a small recorder that was worn around the waist, around the neck, or on the wheelchair depending on participant preference.  Research assistants were present for all PT and OT sessions and collected information on the beginning, end times, and content of sessions occurring that day. Therapy sessions were included for analysis if ≥ 50% of therapeutic time was comprised of physical rehabilitation. Therapeutic time was defined as any activity undertaken by the therapist with the goal of treating the patient and included physical rehabilitation, education, assessments, and interventions designed to improve functional independence. Sessions were excluded if more than 50% of therapeutic time was comprised of admission or discharge assessments, equipment fitting, or non-motor issues (discharge planning, education). If a session did not occur on a scheduled day or did not meet the criteria indicated above, an additional day was collected if it occurred during the 1-week data collection window. Thus, our criteria allowed us to collect therapy sessions under a best-case scenario.   During each therapy observation, the research assistant situated themselves such that they were able to clearly observe the therapy session while being at a distance away such that their presence did not interfere with therapy delivery. Moreover, research assistants did not engage the therapist or participant during the therapy session.  5.2.3 Questionnaire and assessment data collection On another day during the data collection week, participants were administered outcome measures that had the potential to impact the amount of physical activity, and therefore, potential correlates of heart rate. In chronic SCI, physical activity has been 81  shown to correlate with depression, pain, fatigue, and self-efficacy (Tawashy et al. 2009) and, during rehabilitation, spasm (Haisma et al., 2007) and orthostatic hypotension (Illman et al., 2000). The measures were:  The Centre for Epidemiological Studies Depression Scale (See Appendix A.7), a 10-item questionnaire developed to identify current depressive symptomatology related to major or clinical depression developed for the general population but used extensively in individuals with SCI and reliable and valid in this population (Miller et al., 2008).   The Chronic Pain Grade Questionnaire (See Appendix A.8) which asks three questions about pain intensity, interference with ADLs, and interference with recreational activities (Korff et al., 1992). It is reliable and valid in people with SCI (Raichle et al., 2006).   The Fatigue Severity Scale (See Appendix A.9), a nine-item questionnaire designed to capture an individual’s experience of mental or psychological fatigue and how it interferes with performing certain activities such as exercise, work, and family life (Krupp et al., 1989). It has acceptable reliability and validity in individuals with SCI (Anton et al., 2008).   The Penn Spasm Frequency Scale (See Appendix A.10), a self-report measure with larger values indicating greater frequency and intensity of reported muscle spasms (Penn et al., 1989). The scale has adequate validity (Benz et al., 2005).  The Spinal Cord Injury Exercise Self-Efficacy Scale (See Appendix A.11), which consists of 10 self-efficacy items that require individuals to indicate, on a four-point Likert scale, how confident they are with regard to carrying out regular physical activities and exercise. This scale is reliable with high internal consistency, scale integrity, and has satisfactory content validity (Kroll et al., 2007).   82  The Spinal Cord Independence Measure III (SCIM III) (See Appendix A.2), which measures the ability of SCI patients to accomplish ADLs in the area of self-care, respiration and sphincter management and mobility (Catz et al., 2007).   Orthostatic tolerance, assessed via a ‘sit-up test’ (See Appendix A.12 and B.3). This test involves passively moving a person from the supine position to an upright seated position. The largest change in blood pressure during the 3 minutes following the maneuvre is recorded.  The Walking Index for Spinal Cord Injury II (See Appendix A.4), designed to gauge ambulation with ambulation aids and physical assistance. Locomotor ability is assessed on a 0 to 20 hierarchical scale where a lower number indicates higher impairment. This assessment shows excellent reliability and validity (Burns et al., 2011).   Demographic information was collected for age, sex, aetiology (traumatic or nontraumatic), American Spinal Injury Association Impairment Scale (AIS), β-blocker status, and length of stay in acute care and rehabilitation.  5.2.4 Data analysis Heart rate data for all therapy sessions was downloaded to a computer. The ECG waveform was investigated and any artefacts were corrected. Data were entered into MATLAB (MathWorks Inc, Natick, MA USA) where the waveform was converted to beat-by-beat heart rate by identifying RR-intervals across the analysis period. The heart rate data was re-sampled to a time series with a sampling frequency of 10Hz, such that the heart rate could be determined at any point throughout the therapy sessions. Maximal heart rate was calculated using the formula HRmax= 208 - 0.7 x age (Tanaka et al., 2001). A modified formula was used for those individuals on β-blocker medications: HRmax= 164 - 0.72 x age (Brawner et al., 2004). Resting heart rate was obtained during a 10-minute period of supine rest prior to the orthostatic tolerance test, on the day outcome measures were administered. Heart rates were binned into deciles ranging 83  from 0 to 100% of predicted maximal heart rate, calculated using the Heart Rate Reserve (HRR) method: HRtarget= [% intensity (HRmax-HRrest)]+HRrest and the time spent in each decile was output to a spreadsheet. Each decile was averaged over the two observation days for PT and for OT sessions. The number of minutes spent at ≥ 40% HRR was calculated and used to represent the time spent in a cardiovascular training zone (Garber et al., 2011). Participants who met SCI specific physical activity guidelines (Martin Ginis et al., 2011a) of ≥ 20 minutes within this intensity were noted. As per American College of Sports Medicine guidelines, moderate intensity was defined as ≥ 40-60% HRR and vigorous intensity as ≥ 60-90% HRR (Garber et al., 2011). Subanalysis was done to compare heart rate parameters (resting, mean, and peak heart rate, and time in cardiovascular training zone) between paraplegia/tetraplegia, as well within PT and OT sessions using students T-tests.   Investigation of scatterplots showed presence of outliers, homoscedasticity and some non-linear relationships. Spearman correlations were performed between relevant covariates and the amount of time spent at moderate or higher intensity during PT sessions as it was assumed that these sessions would have substantial focus on exercise, and because a number of participants (usually those high functioning who had met their OT goals) were no longer attending OT sessions near discharge. The correlated variables were age, AIS motor score, pain, fatigue, depressive symptoms, spasm, ADLs (SCIM III), walking ability, exercise self-efficacy, and orthostatic tolerance. Longitudinal data show that the recovery of physical fitness over time is associated with severity of injury (Haisma et al., 2006, Janssen et al., 1996) and thus, the AIS motor score was also correlated. Alpha was set at p < 0.05. Statistical analyses were performed using SPSS 20 (SPSS Inc, Chicago, IL USA).   5.3 Results A total of 387 patients were admitted to SCI rehabilitation over the course of 2 years. Of the 387 patients (see Figure 5.1), 272 were excluded because the patient did not agree to participate or did not meet study criteria. The remaining 115 patients were entered 84  into the study. Of these 115 participants, we attained a discharge evaluation for 89 (77%). While we could not attain a discharge evaluation for 12 participants because they were discharged with insufficient notice, and a further 14 because of unusable data, demographic variables for these participants were not notably different from those included for analyses. Demographic information for the 89 participants in this study is found in Table 5.1. Thirty-seven participants were ambulatory at discharge. From the 89 participants included, we observed 218 PT sessions and 122 OT sessions. On occasion more than one PT or OT session occurred on an observation day. The number of valid OT sessions was less than PT as many OT sessions did not involve physical activity, and thus, were not included in the final analyses.  5.3.1 Heart rate characteristics during PT and OT Heart rate variables are reported in Table 5.2. The resting heart rate for the entire group was 68±13bpm. During therapy sessions the mean heart rate was 92±15bpm and reached a peak heart rate of 145±21bpm. Resting and mean heart rate were approximately 10bpm higher in individuals with paraplegia than individuals with tetraplegia.   During PT sessions, the average time spent at an intensity ≥ 40% HRR was 6.0±9.0 minutes and in OT sessions it was 4.6±8.5 minutes (Table 5.2). Eleven individuals met or exceeded 20 minutes of time at an intensity of ≥ 40% HRR in PT or OT (Table 5.4). Only two participants met the exercise guidelines during both OT and PT sessions.   The amount of time below 40% HRR amounted to over 80% of OT or PT sessions with the majority of time spent between 0-20% HRR except in the case of individuals with paraplegia in PT where the most time was spent between 20-40% HRR (Figure 5.1).  5.3.2 Aerobic activities during PT and OT Data from therapy session observations of those participants who met physical activity guidelines (Table 5.3) showed that typical activities resulting in higher heart rate 85  included walking (with/without various supports), leg exercises in standing, jumping, leg cycle ergometry, shuttle leg press for high repetitions, and ADLs including dressing (seated), repetitive transfers and bed mobility movements.   5.3.3 Correlates associated with amount of time at moderate/vigorous intensity Spearman correlations between minutes of time spent at ≥ 40% HRR during PT and the hypothesized covariates are shown in table 5.4 with their 95th percent confidence intervals. Correlates that were significantly related to time spent at ≥ 40% HRR included age, exercise self-efficacy, orthostatic tolerance, ADL performance, spasticity intensity, and walking ability.  86   Table 5.1  Demographic and clinical information for all participants and subgroups of paraplegia and tetraplegia. Variable           All Participants    Paraplegia     Tetraplegia   n             89         51        38 Age, mean (SD), years      49.4 (16.5)      48.6 (16.8)     50.4 (16.4) Sex (M/F), n(%)        65/24 (73/27)     37/14 (73/27)    28/10 (74/26) Traumatic/nontraumatic, n(%)    62/27 (70/30)     33/18 (65/35)    29/9 (76/24) AIS score (A,B,C,D), n(%)†     21/10/12/46 (24/11/13/52) 11/6/10/24 (21/12/20/47) 10/4/2/22 (26/11/5/58) LOS in acute care, mean (SD), days  38.2 (39.2)      32.4 (33.1)     46.1 (45.4) LOS in rehabilitation, mean (SD), days 96.5 (48.0)      85.7 (39.6)     111.1 (54.5) β-blocking medication (Y/N), n(%)   8/81 (9/91)      8/43 (16/84)     0/38 (0/100) Duration of PT (minutes/day)    44.2 (16.7)      41.1 (14.8)     48.5 (18.3) Duration of OT (minutes/day)    41.3 (17.8)      36.5 (17.6)     45.5 (17.1)   n= number of participants; M/F= male/female; AIS= American Spinal Injury Association Impairment Scale; LOS= Length of Stay.        † While the AIS is valid for traumatic SCI, it has not been validated in non-traumatic SCI.        87  Table 5.2  Heart rate variables for different subgroups. Variable        All participants Paraplegia Tetraplegia  p   PT    OT   p  n          89      51    38        67    67  Resting HR (beats/min)    68.3 (12.5)   72.2 (11.3) 63.2 (12.3)  0.007  68.6 (13.0) 68.6 (13.0) ~ Mean HR (beats/min)     92.1 (15.0)   96.3 (14.5) 86.5 (14.0)  0.007  91.6 (16.0) 90.5 (15.9) 0.38 Peak HR (beats/min)     144.9 (21.3)   148.5 (22.7) 139.9 (18.4)  0.14  143.3 (22.0) 140.5 (23.2) 0.38 Time in Target HR Zone (min) 9.8 (13.9)   10.2 (13.7) 9.2 (14.4)  0.75  6.0 (9.0)  4.6 (8.5)  0.38 All values are means or percent (SD); independent-samples T-tests performed between paraplegia and tetraplegia; paired-samples T-tests performed between PT and OT; *p≤ 0.05 (Benjamini-Hochberg corrected values); n= number of participants; HR= heart rate; PT= physical therapy; OT= occupational therapy. 88  Table 5.3  Characteristics of participants who accumulated ≥20 minutes of activity at ≥40% HRR in PT or OT ID Age Aetiology   Ambulatory? AIS score Lesion level Minutes ≥ 40% HRR  Session type   1 54  Traumatic   No     D    C5     39.6      OT 2 21  Traumatic   Yes    D    T11    37.8 & 30.0    PT & OT 3 62  Nontraumatic  Yes    D    missing   35.7      PT 4 27  Traumatic   Yes    D    T10    34.4      PT 5 53  Traumatic   Yes    D    L4     33.8      PT 6 58  Nontraumatic  No     C    T10    33.0      OT 7 22  Traumatic   Yes    D    C7     31.2 & 20.8    OT & PT 8 48  Traumatic   Yes    B    L3     25.2      PT 9 53  Traumatic   Yes    D    C5     25.0      PT 10 45  Traumatic   Yes    B    L3     24.3      PT 11 55  Traumatic   Yes    D    C4     23.7      PT      AIS= American Spinal Injury Association Impairment Scale; HRR= heart rate reserve; PT= physical therapy; OT= occupational therapy.         89  Table 5.4  Spearman correlation for minutes in PT at ≥ 40% HRR versus correlates Correlate      ρ    95% CI     (1) Age       -0.271*  -0.453 to -0.067 (2) AIS Motor Score   0.18   -0.05 to 0.392 (3) Chronic pain    -0.107  -0.308 to 0.103 (4) Depression symptoms -0.04   -0.246 to 0.169 (5) Exercise self efficacy  0.240*  0.034 to 0.426 (6) Fatigue      -0.036  -0.242 to 0.173 (7) Orthostatic tolerance  -0.232*  -0.427 to -0.016 (8) SCIM-total     0.357**  0.161 to 0.526 (9) Spasm intensity   -0.370**  -0.536 to -0.176 (10) Walking Index    0.328**  0.124 to 0.505    *p≤ 0.05 (2-tailed), **p≤ 0.01 (2-tailed); PT= physical therapy; HRR= heart rate reserve; AIS= American Spinal Injury Association Impairment Scale; SCIM= Spinal Cord Independence Measure.          90    Figure 5.1  Minutes in therapy at various heart rate intensities.  PT= physical therapy; OT= occupational therapy.   24.7 17.2 4.6 0.7 0.1 0-20% 20-40% 40-60% 60-80% 80-100% 25.3 16.5 4.9 0.2 0.0 19.6 14.1 3.7 0.5 0.1 15.0 18.9 6.2 1.2 0.2 A. Individuals with tetraplegia in PT D. Individuals with paraplegia in OT B. Individuals with tetraplegia in OT C. Individuals with paraplegia in PT Intensity 91  5.4 Discussion Our findings indicate that individuals with SCI are spending very little time during PT and OT sessions at a heart rate of sufficient intensity to confer cardiovascular benefits. The time spent at a sufficient intensity during PT or OT is a quarter of that recommended by SCI specific aerobic guidelines (Martin Ginis et al., 2011a). Only 11 of 89 individuals (12%) met the required guidelines of 20 minutes at moderate to vigorous intensity. In fact, over three quarters of time in OT and PT sessions was spent at a heart rate under 40% HRR, with the largest portion under 20%. We believe our results are optimistic as we observed only active therapy sessions, accounted for β-blocker status, did not require consecutive minutes at the target heart rate, and included all time up to 100% HRR in addition to that within recommended intensity guidelines (i.e. 40-90% HRR).  The SCIRehab project, a multi-centre account of numerous facets of SCI rehabilitation in the United States shows that in PT, about half of patients are engaging in endurance activities (e.g. ergometry, walking, using gym machines (Natale et al., 2009)) and these patients average 7.5±13.3 minutes of time in these activities (Taylor-Schroeder et al., 2011) while no endurance activities occurred in OT (Foy et al., 2011). Our research in two Canadian rehabilitation centres extends these findings with objective, continuous heart rate data showing that individuals with SCI spent ~5 minutes per session during PT and OT in moderate/vigorous activities.  The expectation that PT elicits more time at higher heart rates compared to OT (MacKay-Lyons and Makrides, 2002) is not supported by our findings in individuals with SCI. Perhaps because minutes of time in the training zone were so low, no significant differences were extant. Indeed, the participant with the most minutes at a high heart rate accrued these minutes in OT.  Vigorous aerobic exercise confers more benefit than moderate aerobic exercise (Swain and Franklin, 2006). However, there is evidence to suggest that deconditioned 92  individuals can incur cardiovascular benefit from activities below 40% HRR. Swain et al. (2002), noted that deconditioned persons improved VO2max at intensities equivalent to 30% HRR (Swain and Leutholtz, 1997). Thus the American College of Sports Medicine indicates that while ≥ 40% HRR is sufficient for most adults, deconditioned persons may benefit as well from intensities between 30 to <40% HRR as well. Also, it is accepted that meeting recommended exercise volume in ≥10 minute bouts of exercise is beneficial (Garber et al., 2011) and it is plausible that even bouts of exercise <10 minutes may be beneficial for sedentary individuals, however more research is required (Lee et al., 2000; Garber et al., 2011). If we include any intensity from 30% to 100% HRR for at least 10 minutes as sufficient for obtaining cardiovascular benefit in this population, this more lenient intensity guideline applied to our study sample would result in 41 of 89 participants meeting the requirement. Or in other words, ~55% of participants are not meeting even these most lenient activity guidelines.  The majority of an inpatient’s day is not spent in PT and OT sessions. It is conceivable, that outside of therapy time, patients are accruing a significant amount of time in activities that elicit a sufficiently intense heart rate response to derive cardiovascular benefits. We have previously shown that individuals with SCI are not participating in much physical activity outside of therapy time (Chapter 3) and, we infer that the amount of cardiovascular stress is accordingly low. However one study, involving 11 individuals with SCI, indicated that patients do experience sufficient strain to improve aerobic fitness (Koopman et al., 2013). These authors included heart rate for the entire day, noting that half of the time when the heart rate was at a sufficient intensity occurred within therapy time and the other half outside of therapy time. These results must be interpreted with caution for, aside from the small sample size, the authors include several other groups with disability in their statement and do not indicate the injury severity of their participants. Indeed, the most active individuals in our study were often ambulatory. Further investigation, measuring heart rate during time outside of therapy in a larger, representative, and well-defined sample of individuals in inpatient SCI rehabilitation is required.  93   5.4.1 Which activities elicited the highest heart rates? Eleven participants accrued a minimum of 20 minutes at an intensity 40% HRR. Of the 11 participants who met this standard, 80 percent were able to ambulate at the time of measurement and for these participants, activities responsible for high heart rates involved leg exercises whereas for those who did not ambulate, activities included ADLs requiring moving the body (transfers and changing position). These results show that in individuals with SCI, activities garnering heart rates in the target zone usually involved ambulation and ADLs suggesting that both types of activities can be utilized in an intervention designed to stimulate cardiovascular fitness. We note that the ADLs were repeatedly performed during therapy. ADLs performed as a part of one’s day in a typical fashion (i.e. not repeatedly and not for a significant amount of time), are insufficient for providing fitness gains (Hoffman, 1986).  The highest exercising heart rates were seen in participants with AIS D injury or those with low lesion levels. This suggests that completeness of injury is a more important player in determining physical activity except when the level of injury is low. These participants have a greater ability to perform exercise that will create sufficient stimulus for cardiovascular adaptations (Glaser, 1989; Figoni, 1990; Jacobs and Nash, 2004). This is due to a relatively larger active muscle mass available and less impaired sympathetic reflexes in those with AIS D injury and those with low lesion level. More specifically, there is a significant elevation of resting and exercising heart rate in partial compensation for a decreased stroke volume in individuals with SCI to maintain cardiac output (Jacobs and Nash, 2004). Decreased stroke volume is due to a decreased venous return, resulting in reduced filling pressure and end-diastolic volumes (Jacobs and Nash, 2004) caused by impaired blood redistribution during exercise resulting from absence of the muscle pump in paralyzed legs and centrally mediated sympathetic control (Hopman et al., 1992, Hopman et al., 2004).  94  Sympathetic control plays a part in that normal sympathetic reflexes increase blood flow to metabolically active skeletal muscles to increase oxygen and fuel substrate provision and metabolite removal (Glaser, 1985, Myers et al., 2007). This process involves vasoconstriction of relatively inactive tissues (e.g. viscera, skin, and non-exercising muscle), venoconstriction, vasodilation of arterioles in exercising muscle, increased heart rate and contractility and cardiac output. The loss of active muscle and sympathetic contributions in exercise can result in high fatigability of exercising muscle due to smaller mass, inadequate blood flow, more anaerobic contribution and increased accumulation of metabolites in muscles (Glaser, 1989).  For individuals with lesions above T6, interruption of sympathetically driven cardiac acceleration results in severely decreased cardiac output. This will negatively impact oxygen delivery to exercising musculature and limit the ability to exercise at higher intensities. The blunted chronotropic response to exercise in these individuals usually yields peak heart rates in the range of 120 beats per minute (Jacobs and Nash, 2004).  Small active muscle mass, compromised sympathetic reflexes to exercise, and interruption of sympathetic innervation to the heart all result in lower levels of time spent at a heart rate of sufficient intensity to obtain cardiovascular benefits. For some patients with lesions above T6, it is impossible to attain levels of physical activity at a higher intensity corresponding to ≥ 40 percent of HRR pre-injury maximal heart rate.  5.4.2 Correlates of heart rate intensity  As expected, ambulatory ability and ADL performance were positively correlated with time at moderate to vigorous intensity during PT and OT. Exercise self-efficacy was also positively correlated whereas age, orthostatic tolerance, and spasm intensity were negatively correlated with time at moderate to vigorous intensity. Interestingly, chronic pain, fatigue, and depression symptoms were not significantly correlated. Investigation of variable distribution shows that there was a tendency for positive skewness in the data distribution for chronic pain and depression symptoms, which could reduce the 95  strength of a correlation. It is also possible that because we explored correlates of higher intensity physical activity during PT, some questions from the questionnaires may not be relevant to this specific setting (e.g. see Appendix A.7, question 9: “I felt lonely.” and Appendix A.9, question 9: “Fatigue interferes with my work, family, or social life.”). On the other hand a patient’s mood and fatigue are both factors that can arguably be modified by a therapist’s presence such that one will be motivated by the therapist, mitigating the impact from poor mood or fatigue. Even pain was not significantly correlated with time at moderate/vigorous exercise intensity. Individuals often take their pain medication prior to therapy, which would decrease the impact of pain during the therapy session. The fact that exercise-self efficacy is significant was unexpected. One would anticipate it would fall in the category of correlates that could arguably be modified by therapist presence and that its level would not impact time within the training zone. Orthostatic hypotension has previously been shown to delay rehabilitation (Illman et al., 2000). It may result in decreased heart rate intensity because when it occurs during therapy time, patients are not able to participate in a given activity and are usually required to recline to allow symptoms to abate. Also, orthostatic hypotension is more prevalent in persons with tetraplegia and high paraplegia (Illman et al., 2000). Such individuals are also at increased likelihood of having compromised sympathetic innervation to the heart, which would result in a failure to experience heart rates at intensities above 40%HRR. Spasticity, which has been shown to slow the recovery of physical fitness during inpatient rehabilitation (Haisma et al., 2007) had a significant negative correlation with time in the training zone. As with orthostatic tolerance, we speculate that this may have been because spasm, when it occurs in therapy, prevents patients from engaging in exercises that could promote cardiovascular stress regardless of therapist input or patient intention. That orthostatic hypotension and spasticity could impact therapy, indicates that identifying individuals with these issues and addressing them may increase time at higher heart rate intensities. The use of non-pharmacological interventions (e.g., functional electrical stimulation, abdominal binders, and lower extremity compression bandages, and increasing dietary salt intake) may improve orthostatic hypotension (Krassioukov et al., 2009; Mills et al., 2015). Optimizing the 96  dose and timing (relative to therapy) of pharmaceutical interventions such as midodrine for addressing orthostatic hypotension is an apparent step. The use of oral or intrathecal Baclofen, Botox injections, and surgery have been shown to provide effective management of spasticity (Burchiel and Hsu, 2001; Elbasiouny et al., 2010). Identifying diurnal patterns and triggers of these conditions in patients may also allow therapists to optimally time therapy sessions.   5.4.3 Limitations Individuals with paraplegia exhibit cardiovascular responses similar to able-bodied individuals, suggesting that already established exercise guidelines are appropriate for for persons with paraplegia and that heart rate can be used as indicator of exercise intensity (Hooker et al., 1993). However, individuals with a spinal cord injury above T6 may experience disruption of sympathetically driven cardiac control, resulting in bradycardia at rest (Krassioukov et al., 2007) and a blunted chronotropic response to exercise, with a maximal heart rate in the range of 120bpm (Teasell et al., 2000; Jacobs and Nash, 2004). Thus, using heart rate as an indicator of intensity may underestimate the response for individuals with SCI above the T5 level. Nevertheless, regardless of the status of sympathetic innervation to the heart, the fact remains that individuals were experiencing nowhere near the amount of time required to accrue cardiovascular benefits.  5.5 Conclusion The cardiovascular stress incurred by individuals with SCI during PT and OT sessions is not enough to obtain a cardiovascular training effect; on average, individuals spent only six minutes within a cardiovascular training zone. That individuals with less severe injury tended to accrue more time in the training zone suggests that solutions for more severely injured individuals to engage in physical activity of a sufficient duration and intensity are required. Near discharge from inpatient therapy, improving spasticity and orthostatic hypotension may improve time spent at higher heart rates during inpatient therapy.  97  Chapter 6: Overall discussion, synthesis, and future directions 6.1 Overview Individuals with SCI are among the most sedentary individuals in society (van den Berg-Emons et al., 2008). Consequently, they are at increased risk for chronic diseases (Jacobs and Nash, 2004; Hitzig et al., 2011) that can be ameliorated by engaging in physical activity (Tawashy et al., 2009). Optimizing physical activity participation during inpatient rehabilitation has the potential to improve long-term outcomes (Sumida et al., 2001; Scivoletto et al., 2005). Therefore, we performed this research to gain understanding of physical activity during inpatient SCI rehabilitation.  6.2 Strengths of this research This dissertation is the first study to characterize physical activity during inpatient SCI rehabilitation using a combination of physiological (heart rate), motion capture (accelerometry), and self-report (PARA-SCI) measures. This diverse approach provides a robust characterization of physical activity and allows for a clearer picture of who experiences the most and least physical activity, what activities are engaged in, when these activities occur, and how physical activity is experienced; we have shown that self-report may not reflect physical activity as measured by accelerometry or heart rate. The results provide new knowledge that serves as a foundation for increasing physical activity during inpatient SCI rehabilitation.  Clinical research in SCI often suffers from small sample size. Through 2 years of data collection, a wide acceptance criteria, and recruitment at GF Strong in Vancouver and Lyndhurst Centre in Toronto, we have a large sample from consecutive sampling that increases generalizability of results.  6.3 Results Before discussing new findings in detail below, we present here the results of the 8 hypotheses presented at the end of Chapter 1. 98  1) We hypothesized that because of the regimented nature of patient schedules during inpatient stay that test-retest reliability of physical activity measures would be high between two separate days. We found that test-retest reliability was good for wrist accelerometry and steps and was moderate for self-reported physical activity.  2) We postulated that objective physical activity measures would be moderately related to self-report measures and clinical outcomes. Wrist Accelerometry and steps were indeed moderately correlated with relevant clinical outcomes. However, self-report physical activity was weakly correlated with functional independence.  3) We expected that movement repetitions for both the upper and lower extremity would be low during PT and OT sessions (e.g., under 100 reps/day). We found that average repetitions did not exceed 300 for the upper or lower extremity.  4) We expected that movement repetitions would increase for PT and OT sessions over the SCI inpatient rehabilitation stay. We found that most repetition variables remained unchanged over the inpatient rehabilitation stay.  5) We hypothesized that physical activity as measured by wrist and hip accelerometry and patient self-report would be low. We found that self-reported physical activity minutes spent at higher intensity were high, as it averaged just over 100 minutes at admission and discharge. Accelerometry measures were consistent with values seen in the literature for other disabled populations.  6) We hypothesized that physical activity measured by wrist and hip accelerometry and patient self-report would increase from admission to discharge. We found that, for most groups and variables, no changes occurred during therapy time from admission to discharge. Outside of therapy all groups increased from admission to discharge in activity kilocounts but not self-reported higher-intensity physical activity minutes.  99  7) We hypothesized that the amount of time spent in PT and OT at an intensity sufficient to achieve a cardiovascular training effect (≥ 40% heart rate reserve) would be low (not meeting the recommendations of SCI physical activity guidelines). We found that no more than 6 minutes of time in PT or OT was spent at a heart rate ≥ 40% heart rate reserve.  8) We hypothesized that less severe injury and higher functional ability would be correlated with more time spent within a cardiovascular training zone during PT. We found that the individuals who spent the most time at higher intensity were AIS D or had low lesions. We found that spasticity, orthostatic hypotension, and self-efficacy were modifiable factors that were correlated with time spent at a heart rate ≥ 40% heart rate reserve.  6.4 New findings Over the course of this research we established the reliability of accelerometry and self-reported physical activity during inpatient rehabilitation (Chapter 2). We continued by embarking on characterizing physical activity through measuring active movement repetitions (Chapter 3) and heart rate (Chapter 5) during PT and OT sessions, and by measuring physical activity outside of therapy sessions using self-reported physical activity and wrist and hip accelerometry (Chapter 4). We showed how movement repetitions in therapy (Chapter 3) and physical activity (Chapter 4) changed between admission and discharge from inpatient rehabilitation and provided insight on factors that act as facilitators and limitations to higher intensity physical activity in the inpatient SCI rehabilitation setting (Chapter 5).  One of the overarching themes that emerges from this dissertation is that physical activity differs depending on the method of measurement. In Chapter 2 we showed that accelerometry counts measured at the wrist or waist do not correlate well with self-reported minutes of higher intensity physical activity. In Chapter 4 we reported that in 100  time outside of therapy accelerometry counts increased between admission and discharge while self-reported physical activity did not.   We have shown that individuals with SCI report that the intensity of PT and OT sessions is often of a moderate or high intensity. However our observation of the number of repetitions during therapy shows that compared to the animal literature, values are low for both the upper and lower extremity, not exceeding 300 repetitions. It is possible that participants were so challenged that only a low number of repetitions could be performed, explaining why most time was spent at moderate and heavy intensities while repetitions were low. However, in Chapter 5 we reported that a minimal amount of time was spent at a heart rate of moderate to heavy intensity and additionally, participants were almost always able to complete prescribed sets and repetitions. An alternative explanation could be that heart rate data reports on the physiological variable directly, while self-report incorporates how individuals feel with respect to a number of domains from breathing frequency, presence of warmth/sweating, and muscle fatigue. In the end these findings indicate that in PT and OT, repetitions are low, time spent at intensities high enough to derive cardiovascular stress is low, and both need to be addressed.  Self-reported physical activity minutes (Chapter 4) did not change between admission and discharge during time outside of therapy, despite increases in accelerometry counts during this time, suggesting that individuals’ capacity improved commensurate with increased activity. We also reported that there were approximately 4 hours outside of therapy time where individuals were engaged in leisure time sedentary activity. In the previous paragraph, we indicated the need, and here we show that individuals may have the capacity to engage in further activity, and also the available time, after accounting for PT, OT, other therapy, appointments, and activities of daily living (ADLs), to engage in additional physical activity.  The factors that were correlated with time spent at higher intensity heart rate in PT and OT sessions (Chapter 5) indicate that those receiving the lowest amount of 101  cardiovascular stress are not ambulatory and negatively impacted by factors such as spasm and orthostatic hypotension. Finding alternative exercise modalities, and minimizing spasm and orthostatic hypotension may offer individuals the ability to engage in higher intensity activities not only during PT and OT, but also outside of therapy during the available sedentary leisure time.  6.5 Limitations of this research We have shown that physical activity generally increases between admission to and discharge from rehabilitation. However, we cannot offer insight into how this progress occurs; for example, it may be a linear increase, it may increase and plateau, or even decrease near discharge. Characterizing the improvement would offer information that could be used to further improve physical activity during rehabilitation.  The issue of impaired sympathetic nervous system innervation to the heart and inappropriate use of heart rate as a gauge of physical activity intensity in affected individuals remains. We do not know if working at or above 60%HRR provides cardiovascular benefit for those whose HR does not exceed 120 bpm as normative values do not exist.  To optimize participant recruitment to the study we increased enrolment by recruiting from GF Strong Rehabilitation Centre in Vancouver and Lyndhurst Centre in Toronto. However, multi-site research projects may introduce differences between study sites that could be problematic for pooling data. In this study, recruitment at Lyndhurst Centre involved patients speaking with a recruiter who provided information on all available studies one could participate in, after which, if consent was given, the researcher from our study could approach the patient. At GF Strong, the researcher approached the patient directly. This is a major reason for the notably higher recruitment at GF Strong Rehab Centre (n=86) versus Lyndurst Centre (n=43) (see Appendix C.1). Also, a certain amount of leisure time activity and therapy sessions occur outdoors. Snow and other winter conditions that occur in Toronto but not Vancouver may cause differences in 102  physical activity. Furthermore, there may be differences demographically between sites for variables not measured. For example, differences in ethno-cultural backgrounds may have an impact on physical activity participation. For known differences between sites, please see Appendix C.2. While some significant differences were present in select physical activity measures, the resultant low number of participants from Lyndhurst Centre (Appendix C.1) did not alter the findings of this research when combined with the main dataset from G.F. Strong.  We are confident that our training method of new observers (see Section 3.2.2), similar to that of Lang et al., (2009) produced good inter-rater reliability between observers at GF Strong, and between observers at Lyndhurst Centre. However, reliability of our measures was not assessed and is a limitation of the study. Still, observers recorded only the description and the amount of time spent on activities with clear instructions on how to count repetitions and only one researcher performed all categorization of movements from the therapy observation data.  6.6 Future Directions This dissertation has thoroughly quantified the physical activity that occurs during inpatient SCI rehabilitation and shows that repetitions are low compared to what is seen as optimal in the animal literature. Additionally we have shown that the amount of cardiovascular stress experienced by individuals with SCI during inpatient PT and OT session is very small and does not meet established guidelines (WHO, 2010; Martin Ginis et al., 2011a). However, we cannot indicate a minimum threshold amount that needs to be met to optimize outcomes. Studies that manipulate the amount of physical activity or repetitions are needed to determine what the optimal threshold for a given patient would be.   Translation of these findings into practice is the necessary next step. Our findings indicate that participants could engage in more activity inside and outside of PT and OT sessions. Increasing repetitions to optimize motor recovery may be feasible during 103  therapy time for some individuals. Indeed, a proof-of-concept study in persons with stroke showed that it is possible to deliver ≥300 repetitions of task-specific training to people with stroke in one-hour sessions without inducing pain or substantial fatigue (Birkenmeier et al., 2010).   The other option is to accumulate repetitions outside of therapy time as we have shown that over 4 hours of time is spent in sedentary leisure time. This may be especially useful when therapy time is used for other rehabilitation priorities such as patient education and orthotic or wheelchair fitting, for example. Ideally, a program such as the Graded Repetitive Arm Supplementary Program (GRASP) utilized in the stroke population could be modified for individuals with SCI. The GRASP is a self-directed arm and hand exercise program taught and monitored by a therapist but carried out independently by the patient and their family if possible (Harris et al., 2009), and results in over 300 additional repetitions (Connell et al., 2014).  The high prevalence and earlier incidence of cardiovascular disease in individuals with SCI indicates that cardiac rehabilitation programs created for those who have cardiovascular disease would be appropriate for the SCI population. Cardiac rehabilitation programs involve retraining the cardiorespiratory system through 20 to 60 minutes of carefully monitored aerobic exercise on most days of the week at an intensity determined by a target heart rate (Wenger et al., 1995; Leon, 2000). Such a program that challenges the cardiovascular system (minimum 40% HRR) could be engaged in outside of PT and OT sessions.   We have also found that there is a large disconnect between patient reported higher intensity physical activity and actual higher intensity physical activity. This study also showed that it is possible to measure accelerometry and heart rate outside of therapy and during PT and OT sessions without interfering with therapy; we recommend that incorporating the use of technology such as heart rate monitors and accelerometers as part of standard practice would provide therapists with important information on 104  optimizing patient therapy through creating baseline assessments and allowing the tracking of intensity and ensuring progression.  To successfully implement the recommendations suggested above and uncover other solutions it is necessary to engage the therapists and discuss their impressions of whether patients could engage in more activity and how this would be accomplished. Involving therapists so that they understand in more detail what patients are doing outside of therapy sessions will help to inform therapy. 105  References Adams SA, Matthews CE, Ebbeling CB, Moore CG, Cunningham JE, Fulton J, Hebert JR. The effect of social desirability and social approval on self-reports of physical activity. Am J Epidemiol 161: 389–398, 2005. Anton HA, Miller WC, Townson AF. Measuring fatigue in persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation 89: 538–542, 2008. Baranowski T, de Moor C. How many days was that? Intra-individual variability and physical activity assessment. Res Q Exerc Sport 71: S74–8, 2000. Battistuzzo CR, Callister RJ, Callister R, Galea MP. A Systematic Review of Exercise Training To Promote Locomotor Recovery in Animal Models of Spinal Cord Injury. Journal of Neurotrauma 29: 1600–1613, 2012. Beekhuizen KS, Field-Fote EC. Massed practice versus massed practice with stimulation: effects on upper extremity function and cortical plasticity in individuals with incomplete cervical spinal cord injury. Neurorehabilitation and Neural Repair 19: 33–45, 2005. Behrman AL, Bowden MG, Nair PM. Neuroplasticity After Spinal Cord Injury and Training: An Emerging Paradigm Shift in Rehabilitation and Walking Recovery. Physical Therapy 86: 1406–1425, 2006. Benz EN, Hornby TG, Bode RK, Scheidt RA, Schmit BD. A physiologically based clinical measure for spastic reflexes in spinal cord injury. Archives of Physical Medicine and Rehabilitation 86: 52–59, 2005. Birkenmeier RL, Prager EM, Lang CE. Translating Animal Doses of Task-Specific Training to People With Chronic Stroke in 1-Hour Therapy Sessions: A Proof-of-Concept Study. Neurorehabilitation and Neural Repair 24: 620–635, 2010. Bohannon RW, Schaubert KL. Test-retest reliability of grip-strength measures obtained over a 12-week interval from community-dwelling elders. J Hand Ther 18: 426–7– quiz 428, 2005. Bowden MG, Behrman AL. Step Activity Monitor: accuracy and test-retest reliability in persons with incomplete spinal cord injury. J Rehabil Res Dev 44: 355–362, 2007. Brawner CA, Ehrman JK, Schairer JR, Cao JJ, Keteyian SJ. Predicting maximum heart rate among patients with coronary heart disease receiving β-adrenergic blockade therapy. American Heart Journal 148: 910–914, 2004. Burchiel KJ, Hsu FP. Pain and spasticity after spinal cord injury: mechanisms and treatment. Spine 26: S146–60, 2001. 106  Burns AS, Delparte JJ, Patrick M, Marino RJ, Ditunno JF. The reproducibility and convergent validity of the walking index for spinal cord injury (WISCI) in chronic spinal cord injury. Neurorehabilitation and Neural Repair 25: 149–157, 2011. Catz A, Itzkovich M, Tesio L, Biering-Sorensen F, Weeks C, Laramee MT, Craven BC, Tonack M, Hitzig SL, Glaser E, Zeilig G, Aito S, Scivoletto G, Mecci M, Chadwick RJ, Masry El WS, Osman A, Glass CA, Silva P, Soni BM, Gardner BP, Savic G, Bergström EM, Bluvshtein V, Ronen J. A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation. Spinal Cord 45: 275–291, 2007. Centers for Medicare, Services M. Medicare Benefit Policy Manual [Online]. www.cms.gov www.cms.gov2014. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c01.pdf [7 Mar. 2014]. Cha J, Heng C, Reinkensmeyer DJ, Roy RR, Edgerton VR, de Leon RD. Locomotor Ability in Spinal Rats Is Dependent on the Amount of Activity Imposed on the Hindlimbs during Treadmill Training. Journal of Neurotrauma 24: 1000–1012, 2007. Claydon VE, Elliott SLS, Sheel AWA, Krassioukov AV. Cardiovascular responses to vibrostimulation for sperm retrieval in men with spinal cord injury. J Spinal Cord Med 29: 207–216, 2006. Connell LA, McMahon NE, Simpson LA, Watkins CL, Eng JJ. Investigating measures of intensity during a structured upper limb exercise program in stroke rehabilitation: an exploratory study. Archives of Physical Medicine and Rehabilitation 95: 2410–2419, 2014. Cowan RE, Boninger ML, Sawatzky BJ, Mazoyer BD, Cooper RA. Preliminary outcomes of the SmartWheel Users' Group database: a proposed framework for clinicians to objectively evaluate manual wheelchair propulsion. Archives of Physical Medicine and Rehabilitation 89: 260–268, 2008. Cragg JJ, Noonan VK, Krassioukov AV, Borisoff J. Cardiovascular disease and spinal cord injury: results from a national population health survey. Neurology 81: 723–728, 2013. Cramer SC, Sur M, Dobkin BH, O'Brien C, Sanger TD, Trojanowski JQ, Rumsey JM, Hicks R, Cameron J, Chen D, Chen WG, Cohen LG, deCharms C, Duffy CJ, Eden GF, Fetz EE, Filart R, Freund M, Grant SJ, Haber S, Kalivas PW, Kolb B, Kramer AF, Lynch M, Mayberg HS, McQuillen PS, Nitkin R, Pascual-Leone A, Reuter-Lorenz P, Schiff N, Sharma A, Shekim L, Stryker M, Sullivan EV, Vinogradov S. Harnessing neuroplasticity for clinical applications. Brain 134: 1591–1609, 2011. Curt A, Van Hedel HJA, Klaus D, Dietz V. Recovery from a Spinal Cord Injury: Significance of Compensation, Neural Plasticity, and Repair. Journal of Neurotrauma 107  25: 677–685, 2008. Dallmeijer AJ, van der Woude LH, Hollander AP, van As HH. Physical performance during rehabilitation in persons with spinal cord injuries. Medicine & Science in Sports & Exercise 31: 1330–1335, 1999. de Leon RD, Hodgson JA, Roy RR, Edgerton VR. Locomotor capacity attributable to step training versus spontaneous recovery after spinalization in adult cats. J Neurophysiol 79: 1329–1340, 1998. Dryden DM, Saunders LD, Rowe BH, May LA, Yiannakoulias N, Svenson LW, Schopflocher DP, Voaklander DC. The epidemiology of traumatic spinal cord injury in Alberta, Canada. Can J Neurol Sci 30: 113–121, 2003. Dumholdt E. Physical therapy reserach: Principles and applications. 2nd ed. Philadelphia: 2000. Edgerton VR, Tillakaratne NJK, Bigbee AJ, de Leon RD, Roy RR. Plasticity of the spinal neural circuitry after injury*. Annu Rev Neurosci 27: 145–167, 2004. Elbasiouny SM, Moroz D, Bakr MM, Mushahwar VK. Management of spasticity after spinal cord injury: current techniques and future directions. Neurorehabilitation and Neural Repair 24: 23–33, 2010. Fekete C, Rauch A. Correlates and determinants of physical activity in persons with spinal cord injury: A review using the International Classification of Functioning, Disability and Health as reference framework. Disabil Health J 5: 140–150, 2012. Figoni SF. Perspectives on cardiovascular fitness and SCI. J Am Paraplegia Soc 13: 63–71, 1990. Foy T, Perritt G, Thimmaiah D, Heisler L, Offutt JL, Cantoni K, Hseih C-H, Gassaway J, Ozelie R, Backus DD. The SCIRehab project: treatment time spent in SCI rehabilitation. Occupational therapy treatment time during inpatient spinal cord injury rehabilitation. J Spinal Cord Med 34: 162–175, 2011. Frankel HL, Coll JR, Charlifue SW, Whiteneck GG, Gardner BP, Jamous MA, Krishnan KR, Nuseibeh I, Savic G, Sett P. Long-term survival in spinal cord injury: a fifty year investigation. Spinal Cord 36: 266–274, 1998. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee I-M, Nieman DC, Swain DP, American College of Sports Medicine. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Medicine & Science in Sports & Exercise 43: 1334–1359, 2011. 108  Garshick E, Kelley A, Cohen SA, Garrison A, Tun CG, Gagnon D, Brown R. A prospective assessment of mortality in chronic spinal cord injury. Spinal Cord 43: 408–416, 2005. Girgis J, Merrett D, Kirkland S, Metz GAS, Verge V, Fouad K. Reaching training in rats with spinal cord injury promotes plasticity and task specific recovery. Brain 130: 2993–3003, 2007. Glaser RM. Arm exercise training for wheelchair users. Medicine & Science in Sports & Exercise 21: S149–57, 1989. Haisma JA, Bussmann JB, Stam HJ, Sluis TA, Bergen MP, Dallmeijer AJ, de Groot S, van der Woude LH. Changes in Physical Capacity During and After Inpatient Rehabilitation in Subjects With a Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation 87: 741–748, 2006. Haisma JA, Bussmann JBJ, Stam HJ, Sluis TAR, Bergen MP, Post MWM, Dallmeijer AJ, van der Woude LHV. Physical fitness in people with a spinal cord injury: the association with complications and duration of rehabilitation. Clinical Rehabilitation 21: 932–940, 2007. Harkema S, Gerasimenko Y, Hodes J, Burdick J, Angeli C, Chen Y, Ferreira C, Willhite A, Rejc E, Grossman RG, Edgerton VR. Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: a case study. Lancet 377: 1938–1947, 2011. Harris JE, Eng JJ, Miller WC, Dawson AS. A self-administered Graded Repetitive Arm Supplementary Program (GRASP) improves arm function during inpatient stroke rehabilitation: a multi-site randomized controlled trial. Stroke 40: 2123–2128, 2009. Hart TL, Swartz AM, Cashin SE, Strath SJ. How many days of monitoring predict physical activity and sedentary behaviour in older adults? Int J Behav Nutr Phys Act 8: 62, 2011. Heinemann AW, Hamilton B, Linacre JM, Wright BD, Granger C. Functional Status and Therapeutic Intensity During Inpatient Rehabilitation. American Journal of Physical Medicine & Rehabilitation 74: 315–326, 1995. Hitzig SL, Eng JJ, Miller WC, Sakakibara BM, SCIRE Research Team. An evidence-based review of aging of the body systems following spinal cord injury. Spinal Cord 49: 684–701, 2011. Hoffman LR, Field-Fote EC. Functional and corticomotor changes in individuals with tetraplegia following unimanual or bimanual massed practice training with somatosensory stimulation: a pilot study. J Neurol Phys Ther 34: 193–201, 2010. Hoffman MD. Cardiorespiratory fitness and training in quadriplegics and paraplegics. 109  Sports Medicine 3: 312–330, 1986. Hooker SP, Greenwood JD, Hatae DT, Husson RP, Matthiesen TL, Waters AR. Oxygen uptake and heart rate relationship in persons with spinal cord injury. Medicine & Science in Sports & Exercise 25: 1115–1119, 1993. Illman A, Stiller K, Williams M. The prevalence of orthostatic hypotension during physiotherapy treatment in patients with an acute spinal cord injury. Spinal Cord 38: 741–747, 2000. Inkpen P, Parker K, Kirby RL. Manual wheelchair skills capacity versus performance. Archives of Physical Medicine and Rehabilitation 93: 1009–1013, 2012. Ishikawa S, Stevens SL, Kang M, Morgan DW. Reliability of daily step activity monitoring in adults with incomplete spinal cord injury. J Rehabil Res Dev 48: 1187–1194, 2011. Itzkovich M, Gelernter I, Biering-Sorensen F, Weeks C, Laramee MT, Craven BC, Tonack M, Hitzig SL, Glaser E, Zeilig G, Aito S, Scivoletto G, Mecci M, Chadwick RJ, Masry El WS, Osman A, Glass CA, Silva P, Soni BM, Gardner BP, Savic G, Bergström EM, Bluvshtein V, Ronen J, Catz A. The Spinal Cord Independence Measure (SCIM) version III: Reliability and validity in a multi-center international study. Disabil Rehabil 29: 1926–1933, 2007. Jackson AB, Carnel CT, Ditunno JF, Read MS, Boninger ML, Schmeler MR, Williams SR, Donovan WH, Gait and Ambulation Subcommittee. Outcome measures for gait and ambulation in the spinal cord injury population. J Spinal Cord Med 31: 487–499, 2008. Jacobs PL, Nash MS. Exercise recommendations for individuals with spinal cord injury. Sports Medicine 34: 727–751, 2004. Janssen TW, van Oers CA, van der Woude LH, Hollander AP. Physical strain in daily life of wheelchair users with spinal cord injuries. Medicine & Science in Sports & Exercise 26: 661–670, 1994. Kalsi-Ryan S, Beaton D, Curt A, Duff S, Popovic MR, Rudhe C, Fehlings MG, Verrier MC. The Graded Redefined Assessment of Strength Sensibility and Prehension: Reliability and Validity. Journal of Neurotrauma 29: 905–914, 2012. Kehn M, Kroll T. Staying physically active after spinal cord injury: a qualitative exploration of barriers and facilitators to exercise participation. BMC Public Health 9: 168, 2009. Kennedy P, Fisher K, Pearson E. Ecological evaluation of a rehabilitative environment for spinal cord injured people: behavioural mapping and feedback. Br J Clin Psychol 27 ( Pt 3): 239–246, 1988. 110  Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov AV, Mulcahey MJ, Schmidt-Read M, Waring W. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med 34: 535–546, 2011. Koopman A, Eken M, Bezeij T, Valent L, Houdijk H. Does clinical rehabilitation impose sufficient cardiorespiratory strain to improve aerobic fitness? Journal of Rehabilitation Medicine 45: 92–98, 2013. Korff Von M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 50: 133–149, 1992. Krassioukov AV, Eng JJ, Warburton DE, Teasell R, Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of the management of orthostatic hypotension after spinal cord injury. Archives of Physical Medicine and Rehabilitation 90: 876–885, 2009. Krassioukov AV, Karlsson A-K, Wecht JM, Wuermser L-A, Mathias CJ, Marino RJ. Assessment of autonomic dysfunction following spinal cord injury: Rationale for additions to International Standards for Neurological Assessment. JRRD 44: 103, 2007. Kroll T, Kehn M, Ho P-S, Groah S. The SCI Exercise Self-Efficacy Scale (ESES): development and psychometric properties. Int J Behav Nutr Phys Act 4: 34, 2007. Krueger H, Noonan VK, Trenaman LM, Joshi P, Rivers CS. The economic burden of traumatic spinal cord injury in Canada. Chronic Dis Inj Can 33: 113–122, 2013. Krueger H. The economic burden of spinal cord injury: A literature review and analysis [Online]. www.krueger.ca 2010. http://scia.intersearch.com.au/sciajspui/bitstream/1/247/1/H%20Krueger%20Economic%20burden%20of%20spinal%20cord%20injury.pdf [5 Jul. 2015]. Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol 46: 1121–1123, 1989. Kuys S, Brauer S, Ada L. Routine physiotherapy does not induce a cardiorespiratory training effect post-stroke, regardless of walking ability. Physiother Res Int 11: 219–227, 2006. Lang CE, MacDonald JR, Reisman DS, Boyd L, Kimberley TJ, Schindler-Ivens SM, Hornby TG, Ross SA, Scheets PL. Observation of Amounts of Movement Practice Provided During Stroke Rehabilitation. YAPMR 90: 1692–1698, 2009. Latimer AE, Martin Ginis KA, Craven BC, Hicks AL. The physical activity recall assessment for people with spinal cord injury: validity. Medicine & Science in Sports & Exercise 38: 208–216, 2006. 111  Learmonth YC, Kinnett-Hopkins D, Rice IM, Dysterheft JL, Motl RW. Accelerometer output and its association with energy expenditure during manual wheelchair propulsion. Spinal Cord (March 17, 2015). doi: 10.1038/sc.2015.33. Lee IM, Hsieh CC, Paffenbarger RS. Exercise intensity and longevity in men. The Harvard Alumni Health Study. JAMA 273: 1179–1184, 1995. Lee IM, Sesso HD, Paffenbarger RS. Physical activity and coronary heart disease risk in men: does the duration of exercise episodes predict risk? Circulation 102: 981–986, 2000. Leon AS. Exercise following myocardial infarction. Current recommendations. Sports Medicine 29: 301–311, 2000. Levins SM, Redenbach DM, Dyck I. Individual and societal influences on participation in physical activity following spinal cord injury: A qualitative study. Physical Therapy 84: 496–509, 2004. Lewis JE, Nash MS, Hamm LF, Martins SC, Groah SL. The relationship between perceived exertion and physiologic indicators of stress during graded arm exercise in persons with spinal cord injuries. YAPMR 88: 1205–1211, 2007. Lovely RG, Gregor RJ, Roy RR, Edgerton VR. Effects of training on the recovery of full-weight-bearing stepping in the adult spinal cat. Exp Neurol 92: 421–435, 1986. MacKay-Lyons MJ, Makrides L. Cardiovascular stress during a contemporary stroke rehabilitation program: Is the intensity adequate to induce a training effect? Archives of Physical Medicine and Rehabilitation 83: 1378–1383, 2002. MacMillan F, Kirk A. Patterns of physical activity and the effect of accelerometer wear on physical activity participation in people with Type 2 diabetes. [Online]. CARE A Scholary Journal for Nursing Midwifery Allied Community Health 3: 6–22, 2010. http://www.gcu.ac.uk/care/currentissue/. Martin Ginis KA, Arbour-Nicitopoulos KP, Latimer-Cheung AE, Buchholz AC, Bray SR, Craven BC, Hayes KC, McColl MA, Potter PJ, Smith K, Wolfe DL, Goy R, Horrocks J. Predictors of leisure time physical activity among people with spinal cord injury. ann behav med 44: 104–118, 2012a. Martin Ginis KA, Hicks AL, Latimer AE, Warburton DER, Bourne C, Ditor DS, Goodwin DL, Hayes KC, McCartney N, McIlraith A, Pomerleau P, Smith K, Stone JA, Wolfe DL. The development of evidence-informed physical activity guidelines for adults with spinal cord injury. Spinal Cord 49: 1088–1096, 2011a. Martin Ginis KA, Latimer AE, Arbour-Nicitopoulos KP, Bassett RL, Wolfe DL, Hanna SE. Determinants of physical activity among people with spinal cord injury: a test of social cognitive theory. ann behav med 42: 127–133, 2011b. 112  Martin Ginis KA, Latimer AE, Arbour-Nicitopoulos KP, Buchholz AC, Bray SR, Craven BC, Hayes KC, Hicks AL, McColl MA, Potter PJ, Smith K, Wolfe DL. Leisure Time Physical Activity in a Population-Based Sample of People With Spinal Cord Injury Part I: Demographic and Injury-Related Correlates. YAPMR 91: 722–728, 2010. Martin Ginis KA, Latimer AE, Hicks AL, Craven BC. Development and evaluation of an activity measure for people with spinal cord injury. Medicine & Science in Sports & Exercise 37: 1099–1111, 2005. Martin Ginis KA, Phang SH, Latimer AE, Arbour-Nicitopoulos KP. Reliability and validity tests of the leisure time physical activity questionnaire for people with spinal cord injury. Archives of Physical Medicine and Rehabilitation 93: 677–682, 2012b. Martin JB, Krč KM, Mitchell EA, Eng JJ, Noble JW. Pedometer accuracy in slow walking older adults. Int J Ther Rehabil 19: 387–393, 2012. Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg Am 9: 222–226, 1984. McCammon JR, Ethans K. Spinal cord injury in Manitoba: a provincial epidemiological study. J Spinal Cord Med 34: 6–10, 2011. McKinley WO, Seel RT, Hardman JT. Nontraumatic spinal cord injury: Incidence, epidemiology, and functional outcome. YAPMR 80: 619–623, 1999. Miller WC, Anton HA, Townson AF. Measurement properties of the CESD scale among individuals with spinal cord injury. Spinal Cord 46: 287–292, 2008. Mills PB, Fung CK, Travlos A, Krassioukov AV. Nonpharmacologic management of orthostatic hypotension: a systematic review. Archives of Physical Medicine and Rehabilitation 96: 366–375.e6, 2015. Natale A, Taylor S, LaBarbera J, Bensimon L, McDowell S, Mumma SL, Backus DD, Zanca JM, Gassaway J. SCIRehab Project series: the physical therapy taxonomy. J Spinal Cord Med 32: 270–282, 2009. New PW, Marshall R. International Spinal Cord Injury Data Sets for non-traumatic spinal cord injury. Spinal Cord 52: 123–132, 2014. New PW. Functional outcomes and disability after nontraumatic spinal cord injury rehabilitation: Results from a retrospective study. Archives of Physical Medicine and Rehabilitation 86: 250–261, 2005. Nicolai S, Benzinger P, Skelton DA, Aminian K, Becker C, Lindemann U. Day-to-day variability of physical activity of older adults living in the community. J Aging Phys Act 18: 75–86, 2010. 113  Nooijen CFJ, de Groot S, Postma K, Bergen MP, Stam HJ, Bussmann JBJ, van den Berg-Emons RJ. A more active lifestyle in persons with a recent spinal cord injury benefits physical fitness and health. Spinal Cord 50: 320–323, 2012. Norrie BA, Nevett-Duchcherer JM, Gorassini MA. Reduced functional recovery by delaying motor training after spinal cord injury. J Neurophysiol 94: 255–264, 2005. NSCISC. Spinal cord injury (SCI) facts and figures at a glance [Online]. httpswww.nscisc.uab.edu 2015. https://www.nscisc.uab.edu/Public/Facts%202015.pdf [5 Jul. 2015]. Office of Disease Prevention and Health Promotion. Physical Activity Guidelines For Americans [Online]. httpwww.health.govpaguidelinesguidelineschapter.aspx 2008. http://www.health.gov/paguidelines/guidelines/chapter7.aspx [9 Mar. 2015]. Orakzai SH, Orakzai RH, Ahmadi N, Agrawal N, Bauman WA, Yee F, Adkins RH, Waters RL, Budoff MJ. Measurement of coronary artery calcification by electron beam computerized tomography in persons with chronic spinal cord injury: evidence for increased atherosclerotic burden. Spinal Cord 45: 775–779, 2007. Ozelie R, Gassaway J, Buchman E, Thimmaiah D, Heisler L, Cantoni K, Foy T, Hsieh C-HJ, Smout RJ, Kreider SED, Whiteneck G. Relationship of occupational therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab Project. The Journal of Spinal Cord Medicine 35: 527–546, 2012. Ozelie RR, Sipple CC, Foy TT, Cantoni KK, Kellogg KK, Lookingbill JJ, Backus DD, Gassaway JJ. SCIRehab Project series: the occupational therapy taxonomy. J Spinal Cord Med 32: 283–297, 2009. Penn RD, Savoy SM, Corcos D, Latash M, Gottlieb G, Parke B, Kroin JS. Intrathecal baclofen for severe spinal spasticity. N Engl J Med 320: 1517–1521, 1989. Pickett GE, Campos-Benitez M, Keller JL, Duggal N. Epidemiology of traumatic spinal cord injury in Canada. Spine 31: 799–805, 2006. Pickett W, Simpson K, Walker J, Brison RJ. Traumatic Spinal Cord Injury in Ontario, Canada. The Journal of Trauma: Injury, Infection, and Critical Care 55: 1070–1076, 2003. Portney LG, Watkins MP. Foundations of clinical reserach: Applications to practice. 2nd ed. Upper Saddle River, New Jersey: Prentice Hall Health, 2000. Prince SA, Adamo KB, Hamel ME, Hardt J, Connor Gorber S, Tremblay M. A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review. Int J Behav Nutr Phys Act 5: 56, 2008. 114  Raichle KA, Osborne TL, Jensen MP, Cardenas D. The reliability and validity of pain interference measures in persons with spinal cord injury. J Pain 7: 179–186, 2006. Rand D, Eng JJ. Arm-hand use in healthy older adults. Am J Occup Ther 64: 877–885, 2010. Rudhe C, Van Hedel HJA. Upper extremity function in persons with tetraplegia: relationships between strength, capacity, and the spinal cord independence measure. Neurorehabilitation and Neural Repair 23: 413–421, 2009. Scelza WM, Kalpakjian CZ, Zemper ED, Tate DG. Perceived Barriers to Exercise in People with Spinal Cord Injury. American Journal of Physical Medicine & Rehabilitation 84: 576–583, 2005. Schmidt RA, Lee TD. Motor Control and Learning. Fifth Edition. Champaign: Human Kinetics, 2011. Scivoletto G, Morganti B, Molinari M. Early versus delayed inpatient spinal cord injury rehabilitation: an Italian study. YAPMR 86: 512–516, 2005. Scivoletto G, Tamburella F, Laurenza L, Foti C, Ditunno JF, Molinari M. Validity and reliability of the 10-m walk test and the 6-min walk test in spinal cord injury patients. Spinal Cord 49: 736–740, 2011. Shephard RJ. Limits to the measurement of habitual physical activity by questionnaires. Br J Sports Med 37: 197–206– discussion 206, 2003. Stewart MW, Melton-Rogers SL, Morrison S, Figoni SF. The measurement properties of fitness measures and health status for persons with spinal cord injuries. Archives of Physical Medicine and Rehabilitation 81: 394–400, 2000. Strauss DJ, Devivo MJ, Paculdo DR, Shavelle RM. Trends in life expectancy after spinal cord injury. YAPMR 87: 1079–1085, 2006. Sumida M, Fujimoto M, Tokuhiro A, Tominaga T, Magara A, Uchida R. Early rehabilitation effect for traumatic spinal cord injury. Archives of Physical Medicine and Rehabilitation 82: 391–395, 2001. Swain DP, Franklin BA. VO(2) reserve and the minimal intensity for improving cardiorespiratory fitness. Medicine & Science in Sports & Exercise 34: 152–157, 2002. Swain DP, Franklin BA. Comparison of cardioprotective benefits of vigorous versus moderate intensity aerobic exercise. Am J Cardiol 97: 141–147, 2006. Swain DP, Leutholtz BC. Heart rate reserve is equivalent to %VO2 reserve, not to %VO2max. Medicine & Science in Sports & Exercise 29: 410–414, 1997. 115  Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol 37: 153–156, 2001. Tawashy AE, Eng JJ, Lin KH, Tang PF, Hung C. Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: a correlational study. Spinal Cord 47: 301–306, 2009. Taylor-Schroeder S, LaBarbera J, McDowell S, Zanca JM, Natale A, Mumma S, Gassaway J, Backus DD. The SCIRehab project: treatment time spent in SCI rehabilitation. Physical therapy treatment time during inpatient spinal cord injury rehabilitation. J Spinal Cord Med 34: 149–161, 2011. Teasell RW, Arnold JMO, Krassioukov AV, Delaney GA. Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury. Archives of Physical Medicine and Rehabilitation 81: 506–516, 2000. Teeter L, Gassaway J, Taylor S, LaBarbera J, McDowell S, Backus DD, Zanca JM, Natale A, Cabrera J, Smout RJ, Kreider SED, Whiteneck G. Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project. The Journal of Spinal Cord Medicine 35: 503–526, 2012. Tudor-Locke C, Bassett DR. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Medicine 34: 1–8, 2004. Tudor-Locke C, Craig CL, Aoyagi Y, Bell RC, Croteau KA, De Bourdeaudhuij I, Ewald B, Gardner AW, Hatano Y, Lutes LD, Matsudo SM, Ramirez-Marrero FA, Rogers LQ, Rowe DA, Schmidt MD, Tully MA, Blair SN. How many steps/day are enough? For older adults and special populations. Int J Behav Nutr Phys Act 8: 80, 2011. Tudor-Locke C, Hatano Y, Pangrazi RP, Kang M. Revisiting “How Many Steps Are Enough?.” Medicine & Science in Sports & Exercise 40: S537–S543, 2008. van den Berg MEL, Castellote JM, Mahillo-Fernandez I, de Pedro-Cuesta J. Incidence of Spinal Cord Injury Worldwide: A Systematic Review. Neuroepidemiology 34: 184–192, 2010. van den Berg-Emons RJ, Bussmann JB, Haisma JA, Sluis TA, van der Woude LH, Bergen MP, Stam HJ. A Prospective Study on Physical Activity Levels After Spinal Cord Injury During Inpatient Rehabilitation and the Year After Discharge. Archives of Physical Medicine and Rehabilitation 89: 2094–2101, 2008. van Langeveld SA, Post MW, van Asbeck FW, Gregory M, Halvorsen A, Rijken H, Leenders J, Postma K, Lindeman E. Comparing Content of Therapy for People With a Spinal Cord Injury in Postacute Inpatient Rehabilitation in Australia, Norway, and the Netherlands. Physical Therapy 91: 210–224, 2011a. 116  van Langeveld SA, Post MW, van Asbeck FW, Horst ter P, Leenders J, Postma K, Rijken H, Lindeman E. Contents of physical therapy, occupational therapy, and sports therapy sessions for patients with a spinal cord injury in three Dutch rehabilitation centres. Disabil Rehabil 33: 412–422, 2011b. Vidal J, Javierre C, Segura R, Lizarraga A, Barbany JR, Pérez A. Physiological adaptations to exercise in people with spinal cord injury. J Physiol Biochem 59: 11–18, 2003. Vissers M, van den Berg-Emons R, Sluis T, Bergen M, Stam H, Bussmann H. Barriers to and facilitators of everyday physical activity in persons with a spinal cord injury after discharge from the rehabilitation centre. Journal of Rehabilitation Medicine 40: 461–467, 2008. Warms C. Physical activity measurement in persons with chronic and disabling conditions: methods, strategies, and issues. Fam Community Health 29: 78S–88S, 2006. Warms CA, Belza BL. Actigraphy as a measure of physical activity for wheelchair users with spinal cord injury. Nurs Res 53: 136–143, 2004. Washburn RA, Copay AG. Assessing physical activity during wheelchair pushing: validity of a portable accelerometer. APAQ. Weishaupt N, Li S, Di Pardo A, Sipione S, Fouad K. Synergistic effects of BDNF and rehabilitative training on recovery after cervical spinal cord injury. Behav Brain Res 239: 31–42, 2013. Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA, Certo CM, Dattilo AM, Davis D, DeBusk RF. Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute. Clin Pract Guidel Quick Ref Guide Clin : 1–23, 1995. West CR, Romer LM, Krassioukov AV. Autonomic function and exercise performance in elite athletes with cervical spinal cord injury. Medicine & Science in Sports & Exercise 45: 261–267, 2013. Whiteneck G, Gassaway J, Dijkers M, Backus DD, Charlifue S, Chen D, Hammond F, Hsieh C-H, Smout RJ. Inpatient treatment time across disciplines in spinal cord injury rehabilitation. J Spinal Cord Med 34: 133–148, 2011a. Whiteneck G, Gassaway J, Dijkers MP, Hammond FM, Lammertse DP. The SCIRehab project: analyzing multidisciplinary inpatient spinal cord injury rehabilitation treatment--second phase. J Spinal Cord Med 34: 131–132, 2011b. Whiteneck GG, Harrison-Felix CL, Mellick DC, Brooks CA, Charlifue SB, Gerhart KA. Quantifying environmental factors: A measure of physical, attitudinal, service, 117  productivity, and policy barriers. Archives of Physical Medicine and Rehabilitation 85: 1324–1335, 2004. WHO. International Classification of Functioning, Disability and Health (ICF) [Online]. httpwww.who.intclassificationsicfen 2001. http://www.who.int/classifications/icf/en/ [2015]. WHO. Global recommendations on physical activity for health [Online]. httpwww.who.intdietphysicalactivityfactsheetrecommendationsen 2010. http://whqlibdoc.who.int/publications/2010/9789241599979_eng.pdf [6 Mar. 2015]. Williams TL, Smith B, Papathomas A. The barriers, benefits and facilitators of leisure time physical activity among people with spinal cord injury: a meta-synthesis of qualitative findings. Health Psychol Rev 8: 404–425, 2014. Wilt TJ, Carlson KF, Goldish GD, MacDonald R, Niewoehner C, Rutks I, Shamliyan T, Tacklind J, Taylor BC, Kane RL. Carbohydrate and lipid disorders and relevant considerations in persons with spinal cord injury. Evid Rep Technol Assess (Full Rep) : 1–95, 2008. Winchester P, Smith P, Foreman N, Mosby JM, Pacheco F, Querry R, Tansey K. A prediction model for determining over ground walking speed after locomotor training in persons with motor incomplete spinal cord injury. J Spinal Cord Med 32: 63–71, 2009. Wyndaele M, Wyndaele J-J. Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Spinal Cord 44: 523–529, 2006. Zbogar D, Eng JJ, Krassioukov AV, Miller WC, Verrier MC. Repetitions in Physical and Occupational Therapy During Spinal Cord Injury Rehabilitation. Archives of Physical Medicine and Rehabilitation 95: e80, 2014.    118  Appendices Appendix A    Questionnaires and Assessments   119  A.1 PARA-SCI  Activity Intensity Classification For all subjects: This assessment is administered via a semistructured interview, providing an estimate of time (in minutes) spent participating in mild-, moderate- and heavy-intensity physical activities. During the PARA-SCI interview, participants are asked to recall activities done over the past 3 days, starting with yesterday. The interview is structured by dividing each recalled day into eight periods: Morning Routine, Breakfast, Morning, Lunch, Afternoon, Dinner, Evening, and Evening Routine. The Morning and Evening Routines are further subdivided into transferring, bowel and bladder management, bathing, personal hygiene, and dressing. Table 1. PARA-SCI activity intensity classification                 Nothing at all    Mild      Moderate      Heavy   How hard are you working? Includes activities that even when you are doing them, you do not feel like you are working at all  Includes physical activities that require you to do very light work. You should feel like you are working a little bit but overall you should not find yourself working too hard  Includes physical activities that require some physical effort. You should feel like you are working somewhat hard but can maintain the effort for a long time  Includes physical activities that require a lot of physical effort. You should feel like you are working really hard (almost at your maximum) and can only do the activity for a short time before getting tired. These activities can be exhausting How does your body feel?            Breathing and heart rate Normal    Stays normal or is only a little bit harder and/or faster than normal  Noticeable harder and faster than normal but not extremely hard or fast  Fairly hard and much faster than normal               Muscles   Normal    Feel loose, warmed up and relaxed. Feel normal temperature or a little bit warmer and not tired at all  Feel pumped and worked. Feel warmer than normal and starting to get tired after a while  Burn and feel tight and tense. Feel a lot warmer than normal and feel tired               Skin    Normal    Normal temperature is only a little bit warmer and not sweaty  A little bit warmer than normal and might be a little sweaty  Much warmer than normal and might be sweaty               Mind     Normal      You might feel very alert. Has no effect on concentration   Requires some concentration to complete   Requires a lot of concentration (almost full) to complete Abbreviation: PARA-SCI, physical activity recall assessment for patients with spinal cord injury. NOTE: activities that the subject indicates as moderate/heavy for the ‘mind’ must have a corresponding moderate/high score in ≥1 other domains to be considered physical activity. Modified from Ginis et al. 120  PARA-SCI: Interview Script  I would like you to tell me about the physical activities you have engaged in during the day.   Please remember, this is a recall of actual activities for today, not a history of what you usually do.     Also, keep in mind that physical activity includes any activity that required physical effort.  That means that I am interested in all of the activities you did in a day including the activities you did getting ready in the morning, in therapy, around the rehab centre, and during your leisure time.   For example, your day might include activities such as transferring, getting dressed, eating, or going to therapy.     I will also ask you to categorize the intensity of each physical activity you did into one of four groups, mild, moderate, heavy or nothing at all.     Each of these intensities is described on this sheet (show participant the sheet (previous page)).  I will explain them to you. Notice that this sheet also provides a description of how you might feel at each intensity of activity.  DAY 1  What time did you wake up?  What was the first thing that you did?  What other activities did you do in the morning that required physical exertion?  What did you do after your morning dressing routine?    Tell me about your afternoon. What did you do for lunch?  What did you do after lunch?   What did you do for dinner?  What did you do after dinner?  Think about what you usually do?  Tell me about your evening routine?    Now, using our chart, how would you rate the intensity of each activity?   How long did you work at that intensity?   Are there any physical activities that you might have forgotten?  Did you have to take any trips to the bathroom during your day?  Any other recreational activities?    DAY 2 Compared with day 1, were there any differences in your morning routine?  Afternoon routine?  Evening routine?   121  A.2 SCIM- Spinal Cord Independence Measure (version III) Obtain information from patient chart, observation in therapy, and finally, by asking the patient.  Examiner Initials:_____ (Enter the score for each functionin the adjacent square below the date. The form may be used for up to 6 examinations.)              1    2    3   4    5   6 122    123  A.3 Hand Grip Strength Assessment For all subjects except those with splinting or no voluntary hand function.  Procedure  All measurements will be taken with the subject seated in their wheelchair, with the shoulder in 0° abduction and neutral rotation, the elbow in 90° of flexion, and the forearm in neutral pronation/supination (in accordance with American Society of Hand Therapy recommendations).    Illustrate the use of the dynamometer to the participant prior to testing.   Have the patient hold the dynamometer to establish if the grip is too small or large. Ideally, the base of the dynamometer handle will be against the thenar eminence and the fingers will curl around the handle at the 2nd phalanges. Adjust grip if necessary. Record the setting of the grip (below) as it must be consistent across testing times.   Subjects will perform three maximal voluntary contractions, alternating the left and right hands with at least 30 seconds of rest between trials. The evaluator will stabilize the dynamometer and provide verbal encouragement during all trials. The three trials will be averaged to obtain a mean score.    Ask the participant to squeeze the dynamometer with as much force as possible, being careful to squeeze only once for each measurement.   Record the result of each trial to the nearest kilogram. If the difference in scores is within 3 kg (6.6 lbs), the test is complete. If the difference between any two measures is more than 3 kg, then repeat the test once more after a rest period. Use the best 3 measurements (i.e. the highest three) in your data report.   When any of the 3 measurements are 3 kg apart a 4th measurement is taken.   There are 5 width settings for the grip. The smallest grip is to be labeled ‘1’ and so on.   Grip strength (kg)     Left Right Width setting Trial 1     Trial 2      Trial 3      (Trial 4)       124  A.4 Walking Index for Spinal Cord Injury (WISCI II) Descriptors  For subjects who obtain a score of ≥3 on Q12 in the SCIM. If a subject scores below 3 they are excluded from the test and receive a score of 0 on the WISCI.  NOTE: In addition to your observation of the patient during therapy, answers on the SCIM (questions 12 and 13) are to be used for determination of the approximate level at which the patient will perform the WISCI.   About: Physical limitation for walking secondary to impairment is defined at the person level and indicates the ability of a person to walk after spinal cord injury. The development of this assessment index required a rank ordering along a dimension of impairment, from the level of most severe impairment (0) to least severe impairment (20) based on the use of devices, braces and physical assistance of one or more persons. The order of the levels suggests each successive level is a less impaired level than the former. The ranking of severity is based on the severity of the impairment and not on functional independence in the environment. The following definitions standardize the terms used in each item:  Physical assistance:  `Physical assistance of two persons' is moderate to maximum assistance. `Physical assistance of one person' is minimal assistance.          Braces:  `Braces' means one or two braces, either short or long leg. (Splinting of lower extremities for standing is considered long leg bracing). `No braces' means no braces on either leg.          Walker:  `Walker' is a conventional rigid walker without wheels.       Crutches:  `Crutches' can be Lofstrand (Canadian) or axillary.             Cane:  `Cane' is a conventional straight cane.   125  Scoring Sheet Subject ID: __________         Date: DD/MM/YYYY      126   A.5 10m-walk test For subjects who obtain a score of ≥3 on Q12 in the SCIM (i.e. subjects must be able to ambulate the required 14 meters with or without assistive devices to participate in the test).  About The 10m-walk test is a measure of functional capacity rather than physical disability, and following an incomplete SCI, alterations in gait mechanics, strength, and proprioception will have a direct effect on walking speed.   Procedure  Use measuring tape to mark the course (10 meters) along with 2 additional meters at the beginning and the end for acceleration and deceleration. Place 2 pylons at the beginning and the end (14 meters apart).    A sitting rest period will precede the test.   The patient should initiate the test.  The patient is instructed to walk the 14m at their preferred speed and then as quickly as possible.  Walking time will be calculated by timing subjects during 10 meters of ambulation.  A ‘‘flying start’’ is used where the subject may accelerate 2 meters before entering the timed 10-meter distance and 2 meters to decelerate afterwards.  Press “Start” on the stopwatch when the subject’s first foot crosses the start line of the 10-meter course, and when the first foot crosses the stop line of the 10-meter course, press “Stop”, though the subject continues to walk 2 extra meters.   The tester may ‘shadow’ the subject however no physical assistance is allowed. The tester is responsible for the safety of the participants and may artificially limit walking speed.   Though no numerical adjustment is made in scoring, the patients may walk with supervision, braces, or any ambulation aids needed to complete the 10-meter distance. Make note of any assistance used below.  No distinction is made between subjects using reciprocal or swing-through gait.  Instructions to patient: The goal of this test is to measure the amount of time it takes you to walk 10 meters. Please walk in a straight line without stopping until you reach the endpoint. Preferred speed: “I am going to measure your comfortable walking speed.  When I say “GO”, walk in a straight line at a pace which is safe and comfortable for you, until you reach the second pylon”. Maximum speed: ” I am now going to measure your maximum walking speed. Perform this test at your maximal safe speed, but don’t run. I will be close by to prevent you from falling.”           _______________________________________________            Comfortable Speed: ________ seconds Maximum Speed: ________ seconds Assistance:  ☐braces    ☐walker    ☐crutches    ☐cane     ☐parallel bars 10 Meters 2 Meters 2 Meters Stopwatch Start Start walking here Stopwatch Stop 127   A.6 GRASSP Hand Capacity Tests and Scoring For subjects for whom addressing the upper extremity is a goal of therapy.  MODULES The GRASSP is comprised of three separate modules, Strength, Sensibility, and Prehension. Multiple modules allow for a comprehensive assessment at multiple time points in the post-injury continuum. Each module can be tested according to the scheduled timeline provided by a trial protocol.  INSTRUCTIONS FOR IMPLEMENTATION OF THE GRASSP: Positioning the Patient: In the acute period the patient is lying supine with both arms exposed to the shoulders and should be tested in this position. During other test sessions the subject should be seated in his/her own seating system with his/her appropriate supports. During all testing, the entire upper extremity should be exposed (up to the shoulder). An adjustable table which can move in and out of wheelchair space will be required to perform the assessment. The subject’s hands should be positioned on the table, with approximately 30 degrees of shoulder flexion, 65 degrees of elbow flexion and the hands and distal half of the forearms supported on the table. This position can be modified slightly to ensure comfort for the individual being tested. The room where the testing will be done should be well lit. Length of the Testing: The time required to complete all of the tests in one session is approximately 30 - 45 minutes (depending on patient ability). It is not recommended to break the testing up into two sessions over two days as an individual’s response can vary and recovery can potentially affect the results. For the best outcome it is recommended to complete the testing in one session, however, between sub-tests the individual and the examiner can break and stretch. In the early phases of injury (0-21 days) it is recommended to only perform the partial GRASSP which consists of the sensory, strength and qualitative prehension portions (15-20 minutes) of the test. After the early phase the full GRASSP is recommended.  STRENGTH Muscles specific to the upper limb and hand were added to the ASIA (Marino et al. 2004) repertoire of testing to establish greater sensitivity to potential change post-injury. Strength will be assessed with Manual Muscle Testing (MMT) (Daniels & Worthington, 1995). An isotonic muscle contraction will be required by the subject to grade muscle strength. Specifically, resistance should be given at the distal end of the moving bone while the subject moves the limb through the specific range (Daniels and Worthingham, 1995). The following table defines the scaling for the muscle testing and the instructions for testing each muscle.  Muscle Testing Prior to beginning muscle testing the subject should be oriented to the test by demonstration on an active body part. If the testing will be done in supine the examiner should stand comfortably at the bedside. If the subject is seated, the examiner may choose to stand next to the wheelchair or sit next to/across from them. During assessment of the distal arm musculature the subjects’ forearm should rest on an adjustable table. Begin by testing the muscle for a grade three (range against gravity), ensuring the joints are isolated. If the individual is able to move through full range of motion (ROM) against gravity then the same movement 128  should be tested with resistance for a grade 4 or 5 through full ROM. The examiner will grade the individual according to the scoring key. Resistance is given at the distal end of the moving bone during an isotonic contraction. Table 1 defines the muscles to be tested, the starting position, the stabilization and resistance required for testing these muscles and the scoring key to be used. Remember that for finger muscles gravity does not have an effect, which defines grade 2 as: movement of the corresponding body part but not through the full range of motion and grade 3 as: movement through full ROM. All MMT scoring should be recorded in the scoring sheets section.  Note: 1) Full range of motion for anterior deltoid should be established and then measured based on available range (available should be considered full range). 2) For elbow extension if the starting position (full elevation) is not feasible then elbow extension can be tested in 90 degrees of shoulder elevation.  Table1: Strength Testing and Instructions 129   ASIA Muscles in Italics and framed in red box. If possible refer to the results of the ASIA assessment instead of repeating the test (Daniels and Worthingham, 1995; Kendall, McCleary and Provance, 1993).     130  Table 2: Scoring for Manual Muscle Testing   SENSIBILITY Sensory testing should always be conducted in a room that is at a comfortable temperature (as close to room temperature as possible). When applying the stimulus to the hands the examiner must ensure that he/she does not touch the hand as this can alter the individual’s ability to sensate accurately. Prior to beginning the testing the subject should be oriented to the test by demonstration on an area of intact sensation such as the face. The examiner will be standing beside the bed or seated across from the subject. The test is performed with the subjects eyes closed or occluded. The forearm and hand should be supported in supination or pronation with a towel or a pillow (not with the examiners hands). A circumferential 2 inch Velcro strap may be used to secure the hand to the pillow allowing for access to the palm and finger tips during the testing.  Semmes Weinstein Monofilament Testing (SWM) The monofilaments should be applied to all 6 points (test points 1 to 6 in Figure 1). The filament should be applied until it bends: applying for 1.5 seconds, holding for 1.5 seconds, and removing for 1.5 seconds. Filament 3.61 is to be applied three times at all test locations, 2/3 positive responses indicates intact sensibility of that force. The assessor should determine if the participant has sensation by asking “do you feel a touch?” and following by “where do you feel the touch?” If the patient is not able to adequately localize the stimulus then he/she is not feeling the applied stimulus. The remaining three filaments are applied once. The test is started on the dorsal side of the hand. The first filament (3.61) is applied three times; all dorsal test locations (points 1-3) can be tested before moving to the palmar test locations (4-6). Delayed responses of more than three seconds are abnormal. If the patient feels the first filament in all areas the examination is complete. It will not be necessary to use the other filaments. If the patient does not respond to the 3.61 filament the next heavier filament is used. Only test locations which do not respond to the previous filament need to be tested with the next filament. The exam continues until the patient recognizes a force in all test locations or until it is established that he/she does not feel even the heaviest filament. When the response is positive for a particular filament a check can be put in the associated box. When all the test locations have been tested the filament force should be scored appropriately into the final box score. Table 3 defines the score associated to the log label of the monofilament (Mackin et al. 2002).        131   Figure 1: Diagram for Sensibility Test Locations    PREHENSION Prehension is assessed both qualitatively and quantitatively. A. Qualitative Prehension Testing The aim of this sub-section is to ensure that the early movement is captured before an individual may be ready for a seated assessment. No specific positioning of the patient is required, but appropriate positioning of the hand for movement should be ensured. The patient is asked to form three prehension patterns with each hand separately. The requested movement and grasp patterns can be demonstrated by the examiner. The purpose of this testing is to establish which components of the finger-hand-forearm can be actively or passively positioned and directed to allow a grasp function and if the movement is wrist dominant. The intent is to establish whether the participant can perform a limited movement that does or does not include the components to develop an active grasp. The assessor should be looking to isolate, wrist, fingers and thumb. The basic pattern for grasping might be visible although the patient yet can not quite grasp. In the very early stages a patient will require the assessor to support the hand so that the patient can see it. This may require providing the neutral position of the wrist as well. Table 4 defines the three grips to be tested and the associated scoring.   132   Table 4: A. Qualitative Prehension, Instructions and Scoring    B. Quantitative Prehension Testing The patient is positioned in a sitting position symmetrically in front of a table. Additional support for trunk stability is allowed. This includes for example the use of a belt but also sitting in bed supported by the back rest or using the bed side table to set up the test. · A change in position, concerning the person’s angle to the table, is not allowed during the standardised test administration. · The test is conducted twice, once for the right hand and then once for the left hand. · The stabilisation of the objects/test board, if necessary, is done by the examiner. · The test board is placed parallel to the edge of the table, in front of the patient. Moving the board in a parallel line to the table’s edge is permitted. Turning or rotating of the board is not permitted (see picture). · All other items are placed on the table in front of the patient.  Procedure The required material for the different tasks is placed on the table in front of the patient just prior to the performance of each task. Prior to the first test administration, the patient is allowed to perform each task once as a rehearsal, without being scored. This will allow familiarization with the task and reduce the learning effect. The rehearsal time is limited to 1 minute for each task. The precise administration procedure for each task can be found in the table below. The examiner times each task. The timing starts at a clear signal “start” by the 133  examiner and ends when the task is fully completed. The material can only be touched or grasped after the “start” signal by the examiner. Table 5 defines the instructions to the examiner and the patient. The initiation of each task is defined by clear activity, such as moving pegs, lifting up coins, manipulating the bottle of water in the hand. To score a 1 at least one part of the task must be done (i.e. lifting up a coin, grasping and/or moving a coin, holding/lifting the bottle). Moving the hand alone is not regarded as "done part of the activity"; neither is placing the hand on the test equipment. The examiner observes task performance focusing on the form of the grasp. The time required for task performance is recorded on the score sheet and the task is scored according to the scoring key in Table 6. Quantitative prehension performance leads to a score with an associated time that is recorded separately. The maximum score for each task is 5 points with a maximal total score of 30 points per hand. To judge the quality of the performance, the examiner must refer to the description of the “expected performance”. This description defines the typical form of grasp used and performance with an unaffected hand (see Table 5). One minute and 15 seconds is allowed for the completion of each task, if the individual is unable to complete the task within 1 minute and 15 seconds score accordingly and move on to the next task (Sollerman and Ejeskar, 1995). There is no specific order to the tasks and they appear in order of simplicity (least difficult to more difficult). Dropping of objects: If a patient drops an object and it falls onto the table, still reachable for the patient to retrieve, the task is continued without stopping the clock the drops are counted and the number is entered in the # of drops column. If the object falls onto the floor or the lap of the patient and cannot be reached by the patient, the clock is stopped. The examiner can pick the object up and the task may be repeated. If the drop lands on the floor or lap of the patient again, during the repeated execution, the task is judged as “not conducted" (0 points) and comments are noted.    134  Table 5: Quantitative Prehension, Instructions and Scoring    135  Table 6: Scoring for the Quantitative Prehension 136  SCORING SHEETS FOR GRASSP 1- Demographics    Subject ID:       Examiner       Assessment Number 1. Admission 2. Midpoint 3. Discharge Date of Assessment DD/MM/YYYY     Hand Dominance       Pre-injury       Post-injury       Comments              * Note these muscles are tested for strength in section 2. ASIA Motor and Sensory Assessment.    * * * * * 137  3 – Sensibility     138  4 - Prehension A - Qualitative Prehension   B - Quantitative Prehension     139  5 – Summary and Total Scores    140  A.7 CES-D10  Below is a list of the ways you might have felt or behaved.  Please tell me how often you have felt this way during the past week.  During the past week:   Rarely or None of the Time  (Less than 1 day) Some or Little of the Time (1-2 days) Occasionally or a Moderate Amount of Time  (3-4 days) Most or All of the Time   (5-7 days) 1. I was bothered by things that usually don’t bother me. 1 2 3 4 2. I had trouble keeping my mind on what I was doing. 1 2 3 4 3. I felt depressed 1 2 3 4 4. I felt that everything I did was an effort. 1 2 3 4 5. I felt hopeful about the future 1 2 3 4 6. I felt fearful. 1 2 3 4 7. My sleep was restless. 1 2 3 4 8. I was happy. 1 2 3 4 9. I felt lonely. 1 2 3 4 10. I could not get “going”. 1 2 3 4    141  A.8 The Chronic Pain Grade Questionnaire (modified)  (von Korff et al., 1992) For the following questions with a scale of 1-10 please circle one number only  1. In the past week, on average, how intense was your worst pain rated on a 0-10 scale where 0 is “no pain” and 10 is “pain as bad as could be”? (That is your usual pain at times you were experiencing pain.)  No               Pain as bad pain              as could be  0 1 2 3 4 5 6 7 8 9 10   2. In the past week, how much has this pain interfered with your daily activities rated on a 0-10 scale where 0 is “no interference” and 10 is “unable to carry on activities”?  No               Unable to carry Interference             on activities  0 1 2 3 4 5 6 7 8 9 10   3.  In the past week, how much has this pain changed your ability to take part in recreational, social and family activities where 0 is “no change” and 10 is “extreme change”?  No                 Extreme change                     change  0 1 2 3 4 5 6 7 8 9 10   142  A.9 Fatigue Severity Scale Questionnaire Please read each statement and circle a number from 1 to 7, depending on how appropriate you feel the statement applies to you over the past week.  A low value indicates that the statement is not very appropriate whereas a high value indicates agreement: 1---------------2---------------3---------------4---------------5---------------6---------------7 Strongly Disagree                                                                                       Strongly Agree During the past week, I have found that: Score  1. My motivation is lower when I am fatigued.  1 2 3 4 5 6 7  2. Exercise brings on my fatigue.  1 2 3 4 5 6 7  3. I am easily fatigued.  1 2 3 4 5 6 7  4. Fatigue interferes with my physical functioning.  1 2 3 4 5 6 7  5. Fatigue causes frequent problems for me.  1 2 3 4 5 6 7      6. My fatigue prevents sustained physical functioning.  1 2 3 4 5 6 7      7. Fatigue interferes with carrying out certain dutie10-s and responsibilities.  1 2 3 4 5 6 7      8. Fatigue is among my three most disabling symptoms.  1 2 3 4 5 6 7      9. Fatigue interferes with my work, family, or social life.  1 2 3 4 5 6 7    143  A.10 Penn Spasm Frequency and Severity Scale  SPASM FREQUENCY 0= No Spasm 1= Spasm induced only by stimulation 2= Infrequent spontaneous spasms occurring less than once per hour 3= Spontaneous spasms occurring more than once per hour 4= Spontaneous spasms occurring more than ten times per hour Right Left 0   1   2   3   4 Arm 0   1   2   3   4 0   1   2   3   4 Leg 0   1   2   3   4 0   1   2   3   4 Trunk 0   1   2   3   4 SPASM SEVERITY 1= Weak 2= Moderate 3= Strong Right Left 1   2   3 Arm 1   2   3 1   2   3 Leg 1   2   3 1   2   3 Trunk 1   2   3    144  A.11 Exercise Self Efficacy Scale (SCI-ESES) The 10 self-efficacy items require individuals to indicate, on a 4-point Likert scale (1=not at all true, 4=always true), how confident they are with regard to carrying out regular physical activities and exercise. The total score is derived by summing the scores for the individual items; possible scores range from 10 to 40.   Please tell us how confident you are with regard to carrying out regular physical activities and exercise. (Please check only one box for each question)            ______ + ______ + _______ + ______                    Total= ______   I am confident that:  Not at All True Rarely True Moderately True Always True I can overcome barriers and challenges with regard to physical activity and exercise if I try hard enough 1 2 3 4 I can find means and ways to be physically active and exercise 1 2 3 4 I can accomplish the physical activity and exercise goals that I set 1 2 3 4 when I am confronted with a barrier to physical activity or exercise I can find several solutions to overcome this barrier 1 2 3 4 I can be physically active or exercise even when I am tired 1 2 3 4 I can be physically active or exercise even when I am feeling depressed 1 2 3 4 I can be physically active or exercise even without the support of my family and friends 1 2 3 4 I can be physically active or exercise without the help of a therapist or trainer 1 2 3 4 I can motivate myself to start being physically active or exercising again after I’ve stopped for a while 1 2 3 4 I can be physically active or exercise even if I had no access to a gym, exercise training, or rehabilitation facility 1 2 3 4 145  A.12 Sit-up Test for Orthostatic Tolerance For all subjects  Required apparatus:  2 people are required for the test    Plinth  Holter monitor (including battery, electrodes, tape)  Foot stool  automated BP cuff   1. All measures will be performed in a quiet temperature-controlled room. 2. On arrival at the laboratory, each subject will be asked to empty their bladder to minimize the influence of reflex sympathetic activation on peripheral vascular tone.  3. Have subject lie supine on the adjustable bed. Ten minutes of rest begins at this time. 4. Equip the subject with the Holter monitor. 5. If the patient is wearing an abdominal binder or compression stockings these must be loosened. 6. Equip the subject with an appropriately sized blood pressure cuff for BP measurement on the left arm. For arm circumference size of: Cuff size should be: 22 to 26 cm "small adult" size: 12x2 2 cm 27 to 34 cm "adult" size: 16x30 cm 35 to 44 cm "large adult" size: 16x36 cm 45 to 52 cm "adult thigh" size: 16x42 cm  7. Position arm on a pillow so that the cuff is at the level of the right atrium. The right atrium is approximately halfway between the bed and the level of the sternum. 8. Instruct the participant to keep the arm relaxed during the measurement. 9. Following 10 minutes of rest begin collecting HR data. (HR will continue to be collected during the entire test). Note: HR data will only begin to be collected once the time is displayed and not the ECG wave pattern. Ensure you press and hold down the ‘event’ button to begin recording. 10. Measure BP every minute and record the measurement on the data collection form.  11. After resting BP data is collected (ensure that BP values are similar- if there is fluctuation, extend the resting period and take another measurement), passively (instruct the subject not to flex or move any muscles (if able) in an attempt to assist during the sit-up manoeuvre) move the subject to an upright seated position by raising the head of the bed to 90 degrees and dropping the base of the bed so that the feet point downwards. If the bed does this or do it manually by moving the patient yourself. Ensure that feet are supported and not dangling.  12. Make note of sit up time for HR by pressing the ‘event’ button on the Holter monitor and writing the time down on the data collection sheet. 13. After the sit-up continue measurement for 10 minutes. 14. Note any symptoms that are observed or reported by the participant on the data collection form. Orthostatic hypotension is defined by The Consensus Committee of the American Autonomic Society and the American Academy of Neurology (1996) as a drop in SBP > 20 mmHg or in DBP by > 10 mmHg.    146  NOTE: BP readings must be stable (within 5mmHg) of previous value to continue to sit-up. If not, do another reading until BP is stable, then proceed with the sit-up. Time BP mmHg Comments, Symptoms Supine [   ] R   [   ] L  00:05 – 06:00   06:00 – 07:00   07:00 – 08:00   08:00 – 09:00   09:00 – 10:00   **   **    ENSURE YOU PRESS THE EVENT BUTTON ON THE HOLTER UPON SITUP  Sitting  D LH SOB V Other, specify 10:00 – 11:00       11:00 – 12:00       12:00 – 13:00       13:00 – 14:00       14:00 – 15:00       15:00 – 16:00       16:00 – 17:00       17:00 – 18:00       18:00 – 19:00       19:00 – 20:00       Legend: D= Dizzy, LH= lightheaded, SOB= shortness of breath, V= blurred vision/other visual changes.  Make note of start and sit up time for HR by pressing the ‘event’ button on the Holter monitor and writing the time down below: Holter monitor start time: _______      Holter monitor sit-up time: _______ Check if worn during the test: ☐abdominal binder   ☐full compression stockings   ☐1/2 compression stockings   147  Appendix B    Data Collection Sheets   148  B.1 PARA-SCI Data Collection Sheet  PARA-SCI Data Collection Sheet       page 1 method of mobility: ___________________  method of transfer: ____________________  Activity Intensity Duration Type Morning Routine wake up☐ (or)  holter on☐  Note holter on time if it is not 1st thing the patient has done that day Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy   Activity- activity that individual was engaged in; Intensity- circle appropriate intensity after showing the patient the intensity table; Duration- length of time (mins/hrs) activity was done;  Items to inquire about in the morning include:  Transfers/getting around (ask how they get from bed to wheelchair to toilet to therapy to EVERYTHING)  Leisure activities (friends, family, TV, games, reading, etc)   - Breakfast  Bladder mgmt (how many? There very likely will me more than 1)   - Lunch  Bathing (may or may not occur during observation day)  - Bowel mgmt  Personal hygiene (brushing teeth, combing hair, washing face, shaving, etc) - Physiotherapy Dressing lower body - Dressing upper body   - Occupational Therapy 149  PARA-SCI Data Collection Sheet                page 2 Activity Intensity Duration Type  Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy   Evening Routine  Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy    Nothing / Mild / Mod / Heavy   Items to inquire about in the evening include:  Transfers (ask how they get from bed to wheelchair to toilet to therapy to EVERYTHING)  Leisure activities (friends, family, TV, games, reading, etc) Lunch  Physiotherapy  Occupational Therapy  Dinner Bowel mgmt  Bladder mgmt (how many? There very likely will me more than 1)  Bathing (may or may not occur during observation day)  Personal hygiene (brushing teeth, combing hair, washing face, shaving, etc)  Dressing lower body  Dressing upper body   150  B.2 Therapy Observation Data Collection Sheet Information Sheet  Observer: ___________     Start time: _____:_____         End time: _____:_____ Type of therapist:  ☐PT     ☐OT    Break (duration): ______           ☐PT Assistant     ☐OT Assistant Therapist ID: _____________       Frequency of PT: ____times/day; ____days/week Frequency of OT: ____times/day; ____days/week   Overt signs/symptoms of exertion: Activity: ___________  Time: __________   RPE (average): _______ RPE (maximal): _______ Activity at maximal RPE: ___________   Factors Impacting Session:  (obtain from chart &/or observation)☐ Pain ☐Spasticity ☐Involuntary bowel/bladder ☐Orthostasis ☐Autonomic dysreflexia ☐Heterotopic ossification ☐Fatigue ☐Contracture/deformity ☐Respiratory status ☐Wound/wound vacs ☐Bed rest ☐Weight-bearing status ☐Surgical precautions ☐Orthoses ☐Halo ☐Behavioral issue ☐Cognitive issue ☐Visual/hearing impairment ☐Cultural issues ☐Refused ☐Equipment malfunction  (from Natale et al., 2009)   NOTE: Consider that what you observe during therapy may be helpful in answering some of the questions in the SCIM and the WISCI. *Please ensure you bring at least 4 copies of the Data Collection Sheet to observation sessions.   151  Data Collection Sheet Page#: ____   Session:  ☐PT   ☐OT Activity Observed† LOA* Written Description Tally of Repetitions Total Reps Time of day (hh:mm:ss)                                                                                                                                                                                                                                                                                                          † Refer to Therapy Observation Taxonomy Sheet  (if time permits during observation, enter numeric value/phrase) *LOA= level of assistance where: 1= Total assistance of 1 person 2= Maximum assist  3= Moderate assist 4= Minimal assist 5= Supervision or setup 6= Modified independent 7= Independent 8= patient education only 9=family/caregiver educ only 10= pt/fam/caregiver edu152  Therapy Observation Taxonomy To be used to fill in the ‘activity observed’ section of the “Therapy Observation: Data Collection Sheets:  # Activity- PHYSIOTHERAPY 01 Strengthening lower body 02 Strengthening upper body 03 Transfers 04 ROM/Stretching- lower body 05 ROM/Stretching- upper body 06 WC mobility- manual 07 WC mobility- power 08 Pre-gait   09 Gait    10 Bed Mobility   11 Balance   12 Assessment   13 Endurance   14 Upright   15 Musculoskeletal Tx/Modality 16 Skin management   17 Wound care   18 Equipment Eval/Provision/Education 19 Airway/respiratory mgmt 20 Complementary approaches 21 Aquatic exercises   22 Education           # Activity- OCCUPATIONAL THERAPY 23 Strength/Endurance- lower body  24 Strength/Endurance- upper body  25 ROM/Stretching- lower body 26 ROM/Stretching- upper body 27 Dressing- lower body 28 Dressing- upper body 29 Bathing  30 Self-Feeding  31 Grooming  32 Bladder management 33 Bowel management 34 Toileting for clothing mgmt & hygiene 35 Bed mobility  36 WC mobility- manual 37 WC mobility- power 38 Transfers  39 Assessment/Evaluation 40 Home management skills 41 Therapeutic activities 42 Modalities  43 Balance  44 Assistive technology 45 Communication  46 Equipment evaluation 47 Skin management  48 Splint/cast fabrication 49 Airway respiratory management 50 Community reintegration outing 51 Education not covered by other activities   153   Appendix C  Demographic Information   154   C.1 Data completeness GF Strong Rehab Centre: Vancouver        Lyndhurst Centre: Toronto     Admission &         Admission &        Admission Discharge Discharge   Admission Discharge Discharge   PARA-SCI    79/86   79/86   75/86    33/43   30/43   23/43 Accelerometry   78/86   81/86   74/86    33/43   28/43   19/43 Hip accelerometry  16/17   33/40   31/40    5/9   9/23   1/23 Step count data  15/17   35/40   33/40    2/9   5/23   6/23 Holter monitoring  82/86   76/86   71/86    30/43   26/43   16/43 Therapy observation 120/131  115/131  108/131   31/43   29/43   22/43     Questionnaires   68/86   84/86   71/86    31/43   31/43   23/43 Assessments   66/86   73/86   59/86    10/43   15/43   6/43 Sit-up test    75/86   76/86   74/86    28/43   13/43   7/43     All values are numbers of participants with available data over total possible participants; PARA-SCI= Physical Activity Recall Assessment for People with Spinal Cord Injury.    155   C.2 Inter-site comparison                      Vancouver    Toronto    p   n                     84       43      ~ Age, mean (SD), years              50.06 (16.6)    46.49 (18.81)  0.28 Sex (M/F), n(%)                64/20 (76/24)   30/13 (70/30)  0.44 Traumatic/nontraumatic, n(%)            60/24 (71/29)   19/24 (44/56)  0.003* Paraplegia/tetraplegia, n(%)             48/36 (57/43)   18/25 (42/58)  0.10 AIS score (A/B/C/D), n(%)†             21/10/12/41    4/3/5/25    0.19                      (25/12/14/49)   (11/8/14/68) LOS in acute care, mean (SD), days          34.82 (33.7)    50.05 (51.77)  0.10 LOS in rehabilitation, mean (SD), days         99.57 (50.74)   77.28 (34.74)  0.011 Chronic pain, mean (SD)              9.01 (7.51)    7.06 (6.95)   0.20 Fatigue, mean (SD)               30.95 (12.9)    28.21 (11.04)  0.29 Exercise self efficacy, mean (SD)           32.04 (4.69)    30.33 (5.9)   0.11 Spasm frequency, mean (SD)            4.44 (4.61)    3.82 (5.32)   0.53 SCIM III, mean (SD)               60.82 (22.72)   61.1 (26.04)   0.96 Grip strength, mean (SD), kg            26.93 (18.71)   18.67 (15.82)  0.036 10MWT, mean (SD), m/s              0.29 (0.43)    0.37 (0.46)   0.37 WISCI II, mean (SD)               6.19 (8.15)    7.54 (9)    0.43 GRASSP, mean (SD)               78.31 (36.62)   83.89 (25.12)  0.61 156   Inter-site comparison: continued                      Vancouver    Toronto    p   Orthosatstic hypotension (Y/N), n(%)          17/61 (22/88)   10/10 (50/50)  0.025 Heart rate: Rest, mean (SD), bpm           67.92 (12)    71.17 (16.05)  0.42 Heart rate: Average, mean (SD), bpm          92.11 (15.27)   92.06 (13.72)  0.99 Heart rate: Peak, mean (SD), bpm           144.7 (21.25)   145.98 (22.62)  0.85 Heart rate: time in CV zone, mean (SD), min        10.34 (14.33)   5.89 (10.34)   0.32 Accelerometry: wrist at admission, mean (SD), kilocounts    167.62 (127.80)  126.30 (89.87)  0.098 Accelerometry: wrist at discharge mean (SD), kilocounts    200.04 (123.25)  156.44 (100.28) 0.085 Accelerometry: steps at admission, mean (SD), steps     267.3 (878.76)   46.54 (200.78)  0.037 Accelerometry: steps at discharge, mean (SD), steps     1092.37 (2348.64)  246.92 (715.74) 0.005* PARA-SCI: PT at admission, mean (SD), min††       53.19 (22.77)   38.82 (19.89)  0.002* PARA-SCI: OT at admission, mean (SD), min       25.75 (22.46)   6.32 (14.35)   0.000* PARA-SCI: PT at discharge, mean (SD), min       50.55 (32.41)   43.02 (27.6)   0.268 PARA-SCI: OT at discharge, mean (SD), min       13.98 (20.04)   5.69 (11.63)   0.009* PARA-SCI: Time outside therapy at admission, mean (SD), min  44.12 (54.55)   33.11 (30.91)  0.182 PARA-SCI: Time outside therapy at discharge, mean (SD), min  43.3 (61.69)    56.1 (52.85)   0.323 *p≤ 0.0065 (Benjamini-Hochberg corrected significance level); †While the AIS is valid for traumatic SCI, it has not been validated in non-traumatic SCI; ††All PARA-SCI values are higher intensity minutes; n= number of participants; AIS= American Spinal Injury Association Impairment Scale; LOS= Length Of Stay. SCIM= Spinal Cord Independence Measure; 157   Inter-site comparison: continued 10MWT= 10 Meter Walk Test; WISCI II= Walking Index for Spinal Cord Injury II; GRASSP= Graded Redefined Assessment of Strength, Sensibility and Prehension; PARA-SCI= Physical Activity Recall Assessment for People with Spinal Cord Injury; PT= Physical therapy; OT= Occupational therapy.158   Appendix D  Consent Forms 159   D.1 Letter of initial contact *** RESEARCH STUDY ***  Physical Activity and Cardiovascular Outcomes  During Spinal Cord Injury Rehabilitation  Principal Investigator:                                            Janice Eng, PhD PT/OT, Department of Physical Therapy, UBC                   GF Strong Rehab Centre, 4255 Laurel Street, Vancouver, B.C.  V5Z 2G9         To the participant, We would like to invite you to participate in an investigation that is focused on the discovery of new information about the amount and type of physical activity experienced by individuals with spinal cord injury (SCI) during inpatient rehabilitation at GF Strong Rehab Centre. It is important to know the amount and type of physical activity during rehabilitation as these factors can influence the gains in recovery and aerobic function.  This will be the first study to investigate the content of rehabilitation therapy in SCI and how the intensity of physical activities changes during inpatient rehabilitation. We are interested in observing you during up to four of your regular rehabilitation therapy sessions. During these sessions you would be asked to wear a heart rate and blood pressure monitor.   In addition, there will also be 3 measurement sessions scheduled outside of your regular therapy sessions; one at admission, another at the midpoint, and a final session at discharge from your in-patient stay at GF Strong Rehab Centre. During each session measures taken will include: (1) tests measuring cardiovascular fitness and function, (2) measures of muscle strength and sensory status, and (3) a questionnaire asking about your ability to perform daily tasks. After each of these measurement sessions, you will be asked to wear a heart rate/ blood pressure monitor and accelerometers for 3 days.  The time commitment for the measurements in which you are asked to take time out of your day will amount to approximately 6 hours.  In addition, we will observe you during therapy for up to 4 hours. Lastly you will wear the heart rate monitor and accelerometers for a total of 9 days while going about your normal routine.  You are eligible to participate in this study if you meet the following criteria:  Are an in-patient at GF Strong Rehab Centre  Have had a spinal cord injury   Are between the ages of 16-60  Are able to push an arm crank cycle  160   D.2 Therapist consent For more information or to participate in this study, contact Mrs. Chihya Hung  at GF Strong Rehab Centre at: 604-714-4109  T H E   U N I V E R S I T Y   O F   B R I T I S H    C O L U M B I A  Therapist Information and Informed Consent Form  Observation of physical and occupational therapy  treatment during spinal cord injury rehabilitation  Principal Investigator:  Study Coordinator: Dr. Janice Eng, PhD PT/OT Dominik Zbogar, MSc Department of Physical Therapy, UBC Department of Physical Therapy, UBC Rehab Research Lab, GF Strong Rehab Centre Rehab Research Lab, GF Strong Rehab Phone: (604) XXX-XXXX Phone: (604) XXX-XXXX  Contact number for study information and questions: 604-XXX-XXXX  Introduction: We are investigating the amount and type of activities experienced by individuals with spinal cord injury (SCI) during rehabilitation and outside rehabilitation therapy. The purpose of this study is to gain a better understanding of what occurs during physical and occupational therapy sessions during inpatient stay for individuals with spinal cord injury. You have been invited to participate in this study because you are currently a therapist who provides rehabilitation services to individuals with spinal cord injury in the rehabilitation program at GF Strong Rehab Centre.  Your participation is voluntary:  Your participation is voluntary; it is up to you to decide whether or not to take part in this study.  This consent form will tell you about the study, why the research is being done, and what will happen during the study.     If you wish to participate, you will be asked to sign this form.  If you decide to take part in this study, you are still free to withdraw at any time and without giving any reason.   Your choice will not at any time affect the commitment of your health care providers to administer care. There will be no penalty or loss of benefits to which you are otherwise entitled.   Inclusion and exclusion criteria: You are able to participate in this study if you are a licensed physical therapist, physical therapy assistant, occupational therapist, or certified occupational therapy assistant. If you are an aide or technician providing treatment, you are not eligible to participate.   161   Time commitment for the study: We will be observing patients who you may be treating. Any one patient may be observed up to 4 times. Patients will be recruited into the study over the next two years.  What does the study involve? The study will take place at GF Strong Rehab Centre. One hundred people with spinal cord injury will be recruited for this study.    You are being asked to allow us to observe your therapy sessions as you treat patients with SCI. An observer will write down the types and amount of activities you do with the patient during therapy sessions. Observers will position themselves so that they are not intruding on the session yet can hear and see what takes place. During these sessions, patients will be asked to wear a heart rate and blood pressure monitor.   For your information, participants in this study may also be involved in other measurements that do not involve rehabilitation therapy, including assessment of cardiovascular fitness via arm ergometry, measures of orthostatic tolerance, and a health questionnaire.  What are the possible risks of participating? This study involves no additional risks to the therapists beyond everyday risks of providing physical and occupational therapy. As observers, research team members will not be interacting with either you or with the patient during the treatment session.  Benefits: This study will not directly benefit you. If you are interested, we can provide you with a summary of your own data at the conclusion of the study. This data may be useful for you when you consider the type of activities and the amount of activities you do with patients during therapy. Overall, the knowledge gained from this study will provide insight into current rehabilitation practices for therapists and individuals with SCI. It will also help address the development of rehabilitation practices in the future.  New Information Available that May Affect Your Decision to Participate: If there is new information that may affect your willingness to be in the study, you will be advised of this information.    If You Withdraw Your Consent to Participate:  Your participation in this research is entirely voluntary. You can decide to withdraw at any time without providing any reason. If you decide to enter the study and withdraw, there will be no penalty and your medical care will not be affected.  The study investigators may decide to stop the study, or withdraw you from the study if they feel that it is in your best interest.  If you choose to withdraw, all data collected about you will be retained for analysis.    Confidentiality: Your confidentiality will be respected.  No information that shows your identity will be released or published without your specific consent. Your identity will not be revealed in any publication that may result from this study. Research and medical records identifying you may be inspected 162   in the presence of the investigator or his or her designate by representatives of Health Canada and the UBC Research Ethics Board for the purpose of monitoring the research. No records that identify you by name or initial will be allowed to leave the investigators’ office.   Contact:  If you have any questions with respect to this study or during participation, you can contact Dr. Janice Eng or one of her associates at (604) XXX-XXXX. If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, contact the Research Subject Information Line in the University of British Columbia Office of Research Services at 604-822-XXXX.  Consent to Participate: This is not a contract and I understand that I do not give up any legal rights by signing it. By signing the form I am indicating that:  I have read and understood the subject information and consent form.  I have had the opportunity to ask questions and have had satisfactory responses.  I understand that all the information collected will be kept confidential and that the results will only be used for scientific objectives.  I understand that my participation in this study is voluntary and I am free to refuse to participate or withdraw at any time without changing the quality of care that I receive.  I understand I am not waiving any legal rights as a result of signing this consent form.  I have read this form and I freely consent to participate in this study.  I have been told that I will receive a dated and signed copy of this form.     Printed Name of Subject  Subject Signature    Date   Printed Name of Witness  Witness Signature    Date   Printed Name of Principal     Signature of Principal      Date Investigator/Designated       Investigator/Designated Representative     Representative     163   D.3 Subject information and informed consent T H E   U N I V E R S I T Y   O F   B R I T I S H    C O L U M B I A  Subject Information and Informed Consent Form  Physical Activity and Cardiovascular Outcomes During Spinal Cord Injury Rehabilitation  Principal Investigator:  Study Coordinator: Dr. Janice Eng, PhD PT/OT Dominik Zbogar, MSc Department of Physical Therapy, UBC Department of Physical Therapy, UBC Rehab Research Lab, GF Strong Rehab Centre Rehab Research Lab, GF Strong Rehab Phone: (604) XXX-XXXX Phone: (604) XXX-XXXX  Contact number for study information and questions: 604-XXX-XXXX  Introduction: We are investigating the amount and type of physical activity experienced by individuals with spinal cord injury (SCI) during rehabilitation and outside rehabilitation therapy.  You have been invited to participate in this study because you are currently participating in the spinal cord injury rehabilitation program at GF Strong Rehab Centre.  Your participation is voluntary:  Your participation is voluntary; it is up to you to decide whether or not to take part in this study.  This consent form will tell you about the study, why the research is being done, what will happen to you during the study and the possible benefits and risks.     If you wish to participate, you will be asked to sign this form.  If you decide to take part in this study, you are still free to withdraw at any time and without giving any reason.   If you do not wish to participate you will not lose the benefit of any medical care to which you are entitled or are presently receiving.  Background and purpose: Little is known about the amount of physical activity experienced by individuals with SCI during and outside of rehabilitation therapy sessions. It is important to know the amount and type of physical activity during rehabilitation as these factors can influence the gains in recovery and aerobic function.  This will be the first study to investigate the content of rehabilitation therapy in SCI and how intensity of the physical activities changes during inpatient rehabilitation.   Who can participate in this study?     If you meet the following criteria you are eligible to participate in this study:  Are an in-patient at GF Strong Rehab Centre  Have had a spinal cord injury   Are between the ages of 16-60  Able to push an arm crank cycle  164   Who should not participate in this study?    If you have any of the following conditions you are not eligible to participate in this study:  Any known serious heart disease (e.g., congestive heart failure, uncontrolled atrial fibrillation, left ventricular failure) Have a brain injury which stops you from understanding the instructions that will be given during the research study  Time commitment for the study: We will observe you during up to four of your regular rehabilitation therapy sessions. During these sessions you will be asked to wear a heart rate and blood pressure monitor.   In addition, there will also be 3 functional measurement sessions scheduled outside of your regular therapy sessions; one at admission, another at the midpoint, and a final session at discharge from your in-patient stay at GF Strong Rehab Centre. After each of these measurement sessions, you will be asked to wear a heart rate monitor and accelerometers (one on your waistband and one on a wrist band) for 3 days.  The time commitment for the measurements in which you are asked to take time out of your day will amount to approximately 6 hours.  In addition, we will observe you during therapy for up to 4 hours. Lastly you will wear the heart rate monitor and accelerometers for a total of 9 days while going about your normal routine.  What does the study involve? The study will take place at GF Strong Rehab Centre.  One hundred people with spinal cord injury will be recruited for this study.    Medical Information: The following information will be taken from your medical records: date of injury and impairment scores.   Functional Measurements: During the functional measurement sessions, we will measure your muscle strength by how well you move your arm or leg (if able), sensory ability (whether your skin can feel a light touch or pin prick), spasticity (by bending your joints while you are relaxed), grip strength, hand dexterity, walking ability (if able), cardiovascular fitness and blood pressure regulation. We will also ask questions about your general health.  Measurement of activity during rehabilitation:  We will measure  your physical activity and cardiovascular stress during physiotherapy and occupational therapy through blood pressure and heart rate monitoring which consists of a sensor/transmitter strapped to the chest and the receiver worn on the wrist in addition to a blood pressure cuff.  In addition, an accelerometer (3 X 3 cm) will be attached to the waistband and wristband to measure movement. We will also obtain a rating of how hard you feel you were working during the therapy session.    165   Cardiovascular fitness: This measure of cardiovascular fitness (how well your heart works) will be performed on an arm crank cycle. You will begin to cycle with your arms at a very light intensity, and as the test progresses, the intensity will gradually increase until your arms are tired. The intensity refers to how challenging the arm cycling will be; it will be very easy when you begin and gradually become more difficult. You will have 12 electrodes attached to your chest (they stick to your skin similar to a band-aid, and are painless when on your skin) to measure how well your heart is handling the exercise. You will also be fitted with a face mask to measure the amount of oxygen that you are breathing in. The test will be stopped if any abnormal signals arise from the electrodes monitoring your heart, if you feel chest discomfort, if you feel dizzy or lightheaded, or if your blood pressure gets too high.  Blood pressure regulation: We will measure your heart rate and blood pressure while you are lying down.  Then, you will be assisted to move to a sit up position and we will measure your heart rate and blood pressure again.  In addition, the nervous system will controls blood pressure will be evaluated by a noninvasive assessment which applies 10 short, painless, low intensity electrical pulses to your leg.  Health questionnaire: You will be given a questionnaire regarding your health and ability to complete activities of daily living.  You do not have to respond to any questions you do not feel comfortable answering.    What are the possible risks of participating? There is a chance you may feel tired or have some muscle soreness following the cardiovascular fitness measure. This is usually gone in a few days. Problems have been few during exercise tests, as they usually clear quickly with little or no treatment.  You are asked to report any unusual symptoms during any of the exercise tests. You may stop or rest whenever you wish because of feelings of fatigue or discomfort. During and immediate following the cardiovascular fitness measure, you may experience some discomfort (i.e. dry mouth, dizziness from breathing too heavily, muscle soreness). These symptoms can be minimized by drinking 2 cups of water prior to testing, and deep breathing and stretching following the test. In addition, there is a slight chance that the electrodes used to monitor your heart and lung function during the test may cause skin irritation. During any activities which involve exercise, there is a low risk that you may experience a cardiac event (less than 0.001%). Some of the questions you will be asked will determine if you are more likely to experience a cardiac event, and if you are, you will not be able to participate in the study.   If you experience any adverse events, you will receive immediate care from a physician at no cost.  If you feel that you are experiencing any side effects as a result of any procedures you should immediately report this to the principal investigator.  In addition, there is a slight chance that the electrodes used to monitor your heart during the stress test may cause skin irritation.     166   Benefits: This study will provide participants with information about their cardiovascular fitness, which can help promote physical activity as part of a healthy lifestyle. Furthermore, this research will help to define the intensity and content of SCI rehabilitation therapy, which will help to optimize in-patient rehabilitation in individuals with SCI.  New Information Available that May Affect Your Decision to Participate: If there is new information that may affect your willingness to be in the study, you will be advised of this information.    If You Withdraw Your Consent to Participate:  Your participation in this research is entirely voluntary. You can decide to withdraw at any time without providing any reason. If you decide to enter the study and withdraw, there will be no penalty and your medical care will not be affected.  The study investigators may decide to stop the study, or withdraw you from the study if they feel that it is in your best interest.  If you choose to withdraw, all data collected about you will be retained for analysis.    Alternatives to the study program:  During the study you will be participating in usual care spinal cord injury rehabilitation.  If something goes wrong: In case of an emergency, please report to it to the medical staff on your unit.  You do not waive your legal rights by signing the consent form.    After the study is completed: Once the study is completed and the data are analyzed, you will be sent a report on your aerobic fitness. You may be contacted in the future for related studies. At that time you can refuse to participate and your name will be removed from future correspondence.  If you decide to participate in future studies, you will be asked to sign another consent form specific to that study.  Confidentiality: Your confidentiality will be respected.  No information that shows your identity will be released or published without your specific consent. Research and medical records identifying you may be inspected in the presence of the Investigator or his or her designate by representatives of Health Canada and the UBC Research Ethics Board for the purpose of monitoring the research.  No records that identify you by name or initial will be allowed to leave the Investigators’ offices.  Contact:  If you have any questions with respect to this study or during participation, you can contact Dr. Janice Eng or one of her associates at (604) XXX-XXXX. If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, contact the Research Subject Information Line in the University of British Columbia Office of Research Services at 604-822-XXXX.  167   Consent to Participate: This is not a contract and I understand that I do not give up any legal rights by signing it. By signing the form I am indicating that:  I have read and understood the subject information and consent form.  I have had the opportunity to ask questions and have had satisfactory responses.  I understand that all the information collected will be kept confidential and that the results will only be used for scientific objectives.  I understand that my participation in this study is voluntary and I am free to refuse to participate or withdraw at any time without changing the quality of care that I receive.  I understand I am not waiving any legal rights as a result of signing this consent form.  I have read this form and I freely consent to participate in this study.  I have been told that I will receive a dated and signed copy of this form.    Yes, I would like to be contacted for future studies.     No, I would not like to be contacted for future studies.        Printed Name of Subject  Subject Signature     Date   Printed Name of Witness  Witness Signature     Date   Printed Name of Principal   Signature of Principal            Date Investigator/Designated         Investigator/Designated Representative     Representative    

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