Individuals with stroke often demonstrate impaired ankle-foot function, commonly termed dropped foot that affects their ability to walk safely at home and within their community. While interventions are available to improve gait function, they have inconsistency demonstrated positive effects due to the lack of evidence-based practice guidelines and a limited understanding of the mechanisms leading to dropped foot. The aim of this dissertation was to 1) determine the relationship between dropped foot gait deviations and impaired sensorimotor control, 2) compare gait biomechanics between stroke survivors with and without dropped foot impairment, and 3) evaluate the immediate effects of an ankle-foot orthotic (AFO) and functional electrical stimulation (FES) device among stroke survivors with dropped foot impairment. Our evaluation combined standardized clinical measures of ankle-foot function (i.e. sensorimotor control, strength, spasticity and range of motion) and gait analysis using advanced laboratory techniques (i.e. electromyography and electrical goniometers) to quantify mechanisms of dropped foot impairment. Fifty-five stroke survivors completed the assessment prior to discharge from inpatient rehabilitation. Individuals with poor generation of isometric dorsiflexor force and reduced passive ankle range of motion were likely to demonstrate greater plantarflexion in swing and limited stance phase ankle joint excursion, respectively. Results from the gait analysis revealed a delayed onset and reduced activation time of the ankle dorsiflexors, and decreased co-activation time in the stance phase as possible mechanisms leading to dropped foot. A detailed case series was performed with four stroke survivors with dropped foot currently using an AFO. Application of an AFO immediately improved peak dorsiflexion in the swing phase and limited ankle range of motion during stance. When walking with the FES device, individuals with moderate dorsiflexor muscle weakness improved their ankle position at initial contact and increased peak dorsiflexion during stance, while no significant changes were observed among individuals with greater impairment. Overall, the results highlighted individual differences in response to interventions aimed at improving dropped foot gait deviations. These findings contribute to a greater understanding of gait dysfunction post stroke, and may lead to the development of a more effective clinical assessment and intervention strategies to improve dropped foot impairment.

Preliminary evidence suggests that balance deficits constitute an important secondary impairment in individuals with chronic obstructive pulmonary disease (COPD). The main objective of this thesis was to describe balance impairment and fall risk in individuals with COPD and to examine interventions for improving balance and reducing fall risk in the context of pulmonary rehabilitation. The first study of this thesis showed that falls are common in patients with COPD and that fallers are characterized by impairments in standard clinical balance measures, such as the Berg Balance Scale and Timed Up and Go. In the second study, we found that the exercise component of conventional pulmonary rehabilitation has only modest effects on balance and fall risk in COPD, highlighting the need to examine the role of balance-specific training for these patients. The third study of this thesis identified the postural control subsystems most responsible for the observed balance deficits in COPD. Compared with age-matched controls, individuals with COPD demonstrated reductions in all balance control subsystems and slower reaction times in response to external perturbations. In this study, we also showed that deficits in balance in patients with COPD were associated with peripheral muscle weakness and reduced physical activity levels. These results informed the design of the final study of this thesis, a randomized controlled trial evaluating the addition of specific balance training to pulmonary rehabilitation for improving balance in patients with COPD. Preliminary results from this study suggest that the addition of thrice weekly balance exercises to a conventional pulmonary rehabilitation program is effective for optimizing gains in measures of functional balance and fall risk. The findings from the four studies included in this thesis support the need for incorporating balance assessment and treatment for at-risk patients with COPD, as part of their comprehensive management.

Background: For children with developmental coordination disorder (DCD), the acquisition and performance of everyday visual-motor activities such as buttoning, shoe tying, cutting with scissors or writing, presents a major challenge. Regardless of the activity considered, children with DCD are typically slower and less accurate than their peers. Given the well-acknowledged difficulties of children with DCD, it is surprising to find very few research studies systematically exploring visual-motor skill acquisition and performance in children with DCD. Objective: The overall objective of this study was to systematically describe visual-motor skill acquisition and task performance in children with DCD. Methods: Twenty-four children (8 years 11 months to 12 years 11 months) were recruited for this study; 12 children with DCD, 12 children developing typically with regards to their motor skills. A computer-based aiming task completed with three different cursor controls of increasing levels of difficulty (mouse, joystick, novel controller) was designed for this study. Mixed-effect modelling and visual graph analyses were performed to describe the influence of motor ability and task difficulty on visual-motor skill acquisition and task performance. Results: Motor ability modulated the impact of task difficulty on visual-motor skill acquisition and task performance. Children with DCD were as fast and as accurate as their peers in their initial performance of the simple, well-learned task (mouse). However, they were slower and less accurate when performing the complex and novel visual-motor task. Over repeated trials, the visual-motor task performance of children with DCD improved on all tasks, even for the simple. With regard to the complex, novel task, once children with DCD understood the features of the task, their performance also improved and approached that of their peers. Conclusion: While children with DCD can generally be characterized as less accurate and slower than their peers, this characterization needs to be specified and qualified; it is probably best not applied to a well-learned task.

Cardiovascular disease (CVD) is the leading cause of death among Canadian women, and accounts for up to 30% of deaths among women worldwide. Women with CVD are typically older than their male counterparts, experience worse functional status, are more likely to experience non-CVD health conditions such as diabetes or arthritis, and will live with these health conditions for more years than men. Physical activity (PA) and cardiac rehabilitation (CR) participation is lower among women compared to men, but little is known about the PA and health promotion experiences, priorities and practices of older women living with CVD. Guided by a socioenvironmental approach to health promotion, a mixed method design involving a mail survey (N=127) and qualitative interviews (N=15) was employed to describe and explore the PA and health promotion practices, preferences and priorities of older women (≥65 years) living with CVD in the Champlain health region of Ontario. Nearly 60% of survey respondents were referred to CR. Logistic regression analysis revealed urban residence as a predictor of CR referral (p<0.01, OR=3.24; 95% CI: 1.44-7.30). Nearly 55% of respondents attended CR, which was predicted by CR referral (p<0.01, OR=32.26; 95% CI: 9.26-111.11), availability of transportation (p<0.05, OR=9.96; 95% CI: 1.22-81.41), and a history of structured PA (p<0.05, OR=3.64; 95% CI: 1.16-11.36). Respondents were more active than their peers, but received little support from their physician for PA. Older women’s incidental PA (walking six or more hours/week for transportation) was predicted by their sense of community belonging (p<0.05, OR=2.6; 95% CI: 1.05-6.29) and having energy for PA (p<0.05, OR=5.8; 95% CI: 1.21-27.92). Interview participants (including four who had attended CR) described health as a resource that enables them to lead busy, active lives. Most participants attributed CVD to genetics or stress, but still engaged in health-promoting activities, including structured and incidental PA. Participants engaged in ‘incidental’ activities such as walking, gardening, and housekeeping tasks purposefully, with the intention of maintaining or improving their health. This research can inform public health initiatives and health care services (including CR) to better meet the needs and preferences of the growing population of older women with CVD.

The stride interval of typical human gait is correlated over thousands of strides. This statistical persistence diminishes with age, disease, and pace-constrained walking. Considering the widespread use of treadmills in rehabilitation and research, it is important to understand the effect of this speed-constrained locomotor modality on stride interval dynamics. To this end, and given that the dynamics of children have been largely unexplored, this study investigated the impact of treadmill walking, both with and without handrail use, on paediatric stride interval dynamics. An initial stationarity analysis of stride interval time series identified both non-stationary and stationary signals during all walking conditions. Subsequent scaling analysis revealed diminished stride interval persistence during unsupported treadmill walking compared to overground walking. Finally, while the correlation between stride interval dynamics and gross energy expenditure was investigated in an effort to elucidate the clinical meaning of persistence, no simple linear correlation was found.

Objectives: To demonstrate that at 6-months post-cessation of cognitive behaviour therapy (CBT) adapted for acquired brain injury (ABI), (1) patients maintain psychological benefits, (2) coping strategy selection improves, (3) community integration is enhanced, and (4) benefits are observed in both face-to-face and telephone administrations. Methods: Participants. Seventeen ABI patients with elevated psychological distress. Outcome Measures. Pre-treatment, post-treatment and 6-month follow-up performance on the Symptom Checklist-90-revised (SCL-90-R), Depression, Anxiety Stress Scales (DASS-21), Community Integration Questionnaire (CIQ) and the Ways of Coping-Revised Questionnaire (WOC-R). Procedures. Eleven CBT sessions provided in group, face-to-face format or individually by telephone. Results: For face-to-face and telephone groups, psychological distress was significantly reduced from pre-treatment to 6-months follow-up: DASS-21 (t16= 7.32, p <.000); SCL-90-R (t16= 6.22, p <.000). Community integration (t16= -6.15 p<.000) and problem-focused coping (t16= -3.67, p<.01) were also significantly enhanced. Conclusion: CBT adapted for patients with ABI carries robust benefits even 6-months after treatment.

Background: The current study investigated the efficacy of a novel virtual reality-cognitive rehabilitation (VR-CR) intervention to improve contextual processing of objects in children with autism. Contextual processing is a cognitive ability thought to underlie the social and communication deficits of autism. Previous research supports that children with autism show deficits in contextual processing, as well as deficits in its basic component abilities: abstraction and cognitive flexibility. Methods: Four children with autism participated in a multiple baseline single-subject study. The children were taught how to see objects in context by reinforcing attention to pivotal contextual information. One-on-one teaching sessions occurred three times per week for approximately two weeks. Results: All children demonstrated significant improvements in contextual processing and cognitive flexibility. Mixed results were found on the control test. Changes in context-related behaviours were reported. Conclusions: Further studies using virtual reality to target specific cognitive impairments in children with autism are warranted.

This study investigated the extent to which occupational therapists (OT) use the Internet as a clinical resource and as a tool for communication with clients. It also identified barriers and facilitators associated with Internet use. A survey was mailed to all occupational therapists registered with the College of Occupational Therapists of Ontario. Our findings based on 1382 respondents show that a large percentage of occupational therapists currently use the Internet for clinical purposes. A majority of respondents reported using the Internet to meet their practice needs, primarily for looking up relevant clinical information, and less commonly as a communication tool with their clients. Greater Internet use was associated with younger age and fewer years of practice. Having a computer station, a work culture fostering Internet use, accessible technical support, paid time and credible ratings of websites were five most influential factors on Internet use in OTs’ clinical practice.

Orthostatic hypotension (OH) is a prevalent condition among individuals with spinal cord injury (SCI). After an injury, OH often reduces the benefit of neurorehabilitation and also prolongs periods of inactivity that lead to secondary complications. This study investigated whether the cardiovascular response to head-up tilting can be improved using functional electrical stimulation (FES) and rhythmic passive movements of the lower extremities. Participants with high thoracic and cervical SCI were recruited. While the participants were tilted head-up to 70 degrees, four conditions were applied in a random sequence: 1) no intervention, 2) rhythmic passive leg movements, 3) isometric FES, and 4) a combination of FES and passive leg movements. The measured cardiovascular parameters indicated that a combination of FES and passive leg movements induced the most desirable response to head-up tilting. The proposed intervention will enable more individuals with SCI to participate in beneficial neurorehabilitation that uses a novel tilt table.

Hospital stays have grown increasingly shorter with a corresponding increase in the use of homecare services. However, we have a limited understanding of how homecare services are allocated in Ontario, particularly homecare rehabilitation services. The primary objective of this research is to explore the current decision-making processes for the allocation of occupational and physical therapy services in homecare for the long stay clients. To address this objective a exploratory study using key informant interviews was conducted. The results indicate that the process of decision making for the allocation of therapy services is comprised of a series of stages called intake, assessment, referral to service provider and reassessment. Amongst these the process of determining the volume of therapy services varies widely across different region. These variations are primarily due to the regional contextual (e.g. financial constraints) factors of the individual CCACs.