The main objective of my dissertation was to evaluate the biomedical and psychosocial factors associated with pain and disability in patients following traumatic upper extremity nerve injuries. This was approached by conducting 3 studies. The first study surveyed peripheral nerve surgeons regarding the assessment of pain in patients with nerve injury. The results showed that only 52% of surgeons always evaluate pain in patients referred for motor/sensory dysfunction. Pain assessment frequently includes verbal response and assessment of psychosocial factors is infrequent. The second study was a retrospective review to assess disability, as measured by the Disabilities of the Arm, Shoulder and Hand (DASH), in patients with chronic nerve injury. Results showed substantial disability (mean DASH 52 + 22) and a significantly lower health status (p < 0.001) compared with well-established norms. In the regression model, the factors associated with the DASH (R2 = 44.5%) were pain, older age and nerve injured. The third study was a cross-sectional evaluation of the biomedical and psychosocial factors associated with pain and disability after upper extremity nerve injury in 158 patients. DASH scores were significantly higher in patients with workers’ compensation or litigation (p = 0.03), brachial plexus injuries (p < 0.001) and unemployed patients (p < 0.001). In the multivariable regression analysis, the final model explained 52.7% of the variance with these predictors; pain intensity (Beta = .230, p = 0.006), nerve injured (Beta = -.220, p = 0.000), time since injury (Beta = -.198, p = 0.002), pain catastrophizing (Beta = .192, p = 0.025), age (Beta = .187, p = 0.002), work status (Beta = .179, p = 0.008), cold sensitivity (Beta = .171, p = 0.015), depression score (Beta = .133, p = 0.066), workers’ compensation/litigation (Beta = .116, p = 0.049) and gender (Beta = -.104, p = 0.09). Future investigation regarding treatments of the factors that are associated with disability and chronic pain will assist to improve health related quality of life in patients with traumatic nerve injury.

Cardiovascular disease (CVD) continues to be the leading cause of death of Canadian women and while treatment for CVD has improved dramatically, women typically fare worse than men with regards to morbidity following cardiac event. Cardiac rehabilitation (CR) is well established as a key intervention in the treatment of coronary artery disease and has been shown to be effective in both men and women. CR remains largely underutilized, especially in women who comprise only 12 – 24% of contemporary CR programs, even though the prevalence of CVD in men and women is similar. The objectives of this pilot trial were to test the feasibility of all procedures, specifically to determine: 1) an estimate of patient recruitment rates, 2) acceptability and feasibility of the intervention and 3) barriers to CR attendance and resources required. Additionally, exploratory research questions were used to determine the effects of telephone coaching on women’s attendance at CR intake appointment, self-efficacy for cardiac exercise and self-efficacy to attend CR. A RCT design enrolled women with CVD referred for CR at a single site in Ontario. Patients were randomized, stratified for age, to either a usual care group or an intervention group. Participants allocated to usual care received a referral to CR. In addition to usual care, women assigned to the intervention group received individualized telephone coaching, designed to support self-management prior to CR intake. Eighty-three patients were approached and 70 consented to participate (usual care n = 36, intervention n = 34). Participants in the intervention group were significantly more likely to attend CR intake (p = 0.048). Participants were highly satisfied with their coaching experience; they found the information provided to be helpful with goal setting, action planning and assisted them in their interactions with their health care providers. Barriers to attendance identified included transportation, health concerns, timing and lack of physician endorsement. Most common resources identified included problem solving support, assistance with communication with physicians and information concerning CR. The evidence obtained from this pilot trial suggests that a telephone coaching intervention designed to enhance self-management is feasible and may improve attendance at CR intake for women following hospital discharge with a cardiac event.

Brain-computer interface (BCI) technologies allow users to control external devices through brain activity alone, circumventing the somatic nervous system and the need for overt physical movement. BCIs may potentially benefit individuals with severe neuromuscular disorders who experience significant, and often total, loss of voluntary muscle control (e.g. amyotrophic lateral sclerosis, multiple sclerosis, brainstem stroke). Though a majority of BCI research to date has focused on electroencephalography (EEG) for brain signal acquisition, recently researchers have noted the potential of an optical imaging technology called near-infrared spectroscopy (NIRS) for BCI applications. This thesis investigates the feasibility of a practical, online optical BCI based on conscious modulation of prefrontal cortex activity through the performance of different cognitive tasks, specifically mental arithmetic (MA) and mental singing (MS). The thesis comprises five studies, each representing a step toward the realization of a practical optical BCI. The first study demonstrates the feasibility of a two-choice synchronized optical BCI based on intentional control states corresponding to MA and MS. The second study explores a more user-friendly alternative - a two-choice system-paced BCI supporting a single intentional control state (either MA or MS) and a natural baseline, or "no-control (NC)", state. The third study investigates the feasibility of a three-choice system-paced BCI supporting both MA and MS, as well as the NC state. The fourth study examines the consistency with which the relevant mental states can be differentiated over multiple sessions. The first four studies involve healthy adult participants; in the final study, the feasibility of optical BCI use by a user with Duchenne muscular dystrophy is explored. In the first study, MA and MS were classified with an average accuracy of 77.2% (n=10), while in the second, MA and MS were differentiated individually from the NC state with average accuracies of 71.2% and 62.7%, respectively (n=7). In the third study, an average accuracy of 62.5% was obtained for the MA vs. MS vs. NC problem (n=4). The fourth study demonstrated that the ability to classify mental states (specifically MA vs. NC) remains consistent across multiple sessions (p=0.67), but that there is intersession variability in the spatiotemporal characteristics that best discriminate the states. In the final study, a two-session average accuracy of 71.1% was achieved in the MA vs. NC classification problem for the participant with Duchenne muscular dystrophy.

FACILITATORS AND BARRIERS OF PHYSICAL ACTIVITY IN OLDER PERSONS WHO HAVE EXPERIENCED A FALL Edwin Yoshiyuki Hanada, Master's of Science Degree, Institute of Medical Science, University of Toronto, 2008 ABSTRACT A systematic review and four focus groups were conducted to determine the facilitators and barriers of physical activity in older adults who have experienced a fall. Results from the systematic review demonstrated facilitators and barriers of purposeful and non-purposeful physical activity for older adults, but not specifically fallers. Facilitators identified in the systematic review and elaborated upon in the focus groups involving older fallers included: deriving benefits from physical activity in the physical, psychological, or functional realms; and social support providing encouragement for participation in physical activity, or acting as a distraction from negative physical symptoms during participation in group physical activity. Conversely, barriers to purposeful and non-purposeful physical activity included: symptoms of chronic illnesses, such as cardiac chest pain, arthritic pain, poor balance or poor eyesight; a fear of falling; and adverse physical environmental conditions, such as cold or warm, humid weather. The focus groups identified disinclination to activity as an important barrier to purposeful physical activity. When placed in a theoretical context such as Bandura’s Social Cognitive Theory and Marcus and Owen’s Readiness for Change model, the results of this study can help inform the design of physical activity interventions to prevent falls in older adults with a history of falls.

Stroke is the primary cause of adult disability. To support this large population in recovery, robotic technologies are being developed to assist in the delivery of rehabilitation. A partially observable Markov decision process (POMDP) system was designed for a rehabilitation robotic device that guides stroke patients through an upper-limb reaching task. The performance of the POMDP system was evaluated by comparing the decisions made by the POMDP system with those of a human therapist. Overall, the therapist agreed with the POMDP decisions approximately 65% of the time. The therapist thought the POMDP decisions were believable and could envision this system being used in both the clinic and home. The patient would use this system as the primary method of rehabilitation. Limitations of the current system have been identified which require improvement in future research stages. This research has shown that POMDPs have promising potential to facilitate upper extremity rehabilitation.

Objectives: To describe the relationship between sensorimotor function and walking in incomplete SCI. Methods: 25 subjects were assessed using Lower Extremity Motor (LEMS) and Pinprick (LEPS) scores, and 7 walking measures: FIM-Locomotor Score, Assistive Device Score, Walking Index for SCI, 10-metre Walk Test (10mWT), Timed Up and Go (TUG), Six-Minute Walk Test (6MWT) and Walking Mobility Scale. Results: Walking and sensorimotor function varied between subjects. Walking measures significantly correlated with LEMS and individual leg muscles but not LEPS. 21/22 ambulatory subjects had LEMS threshold>20. Non-ambulatory subjects didn’t achieve threshold. Not all subjects completed all walking measures: 10mWT: n=19; TUG: n=14, 6MWT: n=13. Most walking measures were significantly related. 10mWT and 6MWT were highly correlated. Subjects walking0.95 m/s didn’t reach predicted 6MWT. Conclusion: Lower extremity strength is important for walking and should be further examined with other factors in a range of subjects across different measures to fully understand these relationships.

The benefits of brief-duration, early exercise programs in stroke have been shown, but the effects of longer-duration aerobic training early after stroke have not been examined. The purpose of this study was to determine the effects of an early aerobic exercise program that extended beyond inpatient into outpatient rehabilitation on aerobic capacity, walking parameters (walking distance, speed, and symmetry), health-related quality of life, and balance. Patients in the subacute phase after stroke (n = 15) with mild to moderate impairment received aerobic exercise in addition to conventional rehabilitation. The study participants demonstrated significant improvement in aerobic and walking capacity, peak work rate, quality of life, balance, and gait velocity from baseline to midpoint. However, no difference was found between midpoint and final. This early aerobic exercise program following stroke significantly improved aerobic capacity, walking ability, quality of life and balance during the inpatient period although no further improvement was observed during the outpatient period.

Introduction: This study explored the health behaviour of older adults with COPD. Objectives included: 1) to explore the process of successfully managing COPD; 2) to identify health behaviour strategies utilized; 3) to identify factors influencing health behaviour change; 4) to understand the impact of pulmonary rehabilitation (PR). Methods: Eleven community-dwelling older adults were interviewed following PR. Interviews were coded and analyzed using constant comparative analysis, comparing and contrasting incoming data with emerging theory. Findings: Two distinct models were developed representing participants’ experience with COPD and health behaviour change: Struggling with Living: Life with COPD before Pulmonary Rehabilitation; and Carrying on with Living: Life with COPD following Pulmonary Rehabilitation. Conclusions: Older adults with COPD engaged in a limited repertoire of health behaviour strategies which were relatively ineffectual prior to participation in PR. PR had a major impact on health behaviour strategies, and on the external and personal factors influencing health behaviour.

Post-stroke fatigue (PSF) is a common yet under-diagnosed and undertreated phenomenon. The unresolved debate over what is PSF has hampered the ability of clinicians to study and develop treatments for this condition. Patients with stroke (n=70) seeking neurorehabilitation at Toronto Rehabilitation Institute completed self-report ratings of fatigue, depressive and anxiety symptoms, and sleepiness. Data were collected from objective measures of stroke topography, sleep disorders, physical fatigability and comorbid medical conditions. A Principal-Components Analysis was performed. Factor 1, the “Distress” factor, was comprised of the all of the self-reported scales i.e. depression, anxiety, fatigue and sleepiness. Factor 2, the “Physical State” factor, was comprised of a diagnosis of Obstructive Sleep Apnea, stroke territory and total medical burden. Factor 3, the “Performance” factor, was comprised by the 6 Minute Walk Test. An orthogonal rotation was the most parsimonious fit to the data, suggesting that the three factors are uncorrelated to each other.

The strength of time-dependent correlations known as stride interval (SI) dynamics have been proposed as an indicator of neurologically healthy gait. Most recently, it has been hypothesized that these dynamics may be necessary for gait efficiency although the supporting evidence to date is limited. To gain a better understanding of this relationship, this study investigated stride interval dynamics, the energy cost of walking, and physical activity in a pediatric population. The findings indicate that differences in energy cost are not reflected in the stride interval dynamics of able-bodied children. Interestingly, increasing physical activity levels were associated with decreasing variance in stride interval dynamics between subjects, though this finding only approached significance (p=0.054). Lastly, this study found that stride interval dynamics in children as young as nine years were comparable to stride interval dynamics found in healthy young adults.