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.

This thesis reports on a multi-phased research project conducted to evaluate the use of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach with adults with stroke. Current approaches to motor recovery, called systems approaches, suggest that movement arises from a dynamic interaction among several different systems, including perception, cognition, and action, all within the context of the individual and his or her environment. CO-OP is an established treatment approach for children with motor-based performance problems that takes into account interactions among several systems, as well as individual needs and environmental factors. CO-OP is a client-centred, problem solving approach based on the theoretical foundations of learning and motor learning theory. The objectives of this project were: to examine the efficacy of CO-OP to improve motor skill acquisition and performance in adults living with chronic stroke; to explore other benefits of the approach; and to identify adaptations for use with adults with stroke. Two series of single case experimental studies were conducted, with three participants completing each. In addition, semi-structured interviews were conducted. Findings from the single case experiments provide evidence that CO-OP is associated with performance improvements in both trained and untrained self-selected goals in adults more than one year post stroke. As well, pre-post measures suggest there may be changes in performance satisfaction, motor control, generalized use of the affected upper extremity, and self-efficacy. Interview findings provided valuable information about the experiences of participants with the approach; the interview respondents enjoyed the increased sense of responsibility that came with problem solving on their own, but expressed a desire to have ongoing professional support. Suggestions for modifications to CO-OP for use adults with stroke are made. CO-OP is a promising approach to improve functional independence in adults with stroke. Future research is warranted.

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.

Upper limb function is important for individuals with tetraplegia because upper limb function supports global function for these individuals. As a result, a great deal of time and effort has been devoted to the restoration of upper limb function. Appropriate outcome measures that can be used to characterize the neurological status of the upper limb have been one of the current barriers in substantiating the efficacy of interventions. Techniques and protocols to evaluate changes in upper limb neurological status have not been applied to the SCI population adequately. The objectives of this thesis were to develop a measure; which is called the Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP). Development of the scoring approach, testing for reliability and construct validity, and determining impairment and function relationships specific to the upper limb neurological were established. The GRASSP is a clinical measure of upper limb impairment which incorporates the construct of “sensorimotor upper limb function”; comprised of three domains which include five subtests. The GRASSP was designed to capture information on upper limb neurological impairment for individuals with tetraplegia. The GRASSP defines neurological status with numerical values, which represent the deficits in a predictive pattern, is reliable and valid as an assessment technique, and the scores can be used to determine relationships between impairment and functional capability of the upper limb. The GRASSP is recommended for use in the very early acute phases after injury to approximately one year post injury. Use of the GRASSP is recommended when a change in neurological status is being assessed.

Violence and traumatic brain injury (TBI) are two major public health concerns. This thesis is comprised of three different research topics; the epidemiology of intentional TBI in Ontario, discharge against medical advice (DAMA) as an undesirable outcome of acute stage, and functional changes after receiving rehabilitation care. To study these areas, three different datasets from the Canadian Institute for Health Information (CIHI) were used. The first epidemiological study on intentional TBI identified 1,409 (8.0%) intentional TBIs and 16,211 (92.0%) unintentional TBIs. Of the intentional TBIs, 389 (27.6%) were self-inflicted TBI (Si-TBI) and 1,020 (72.4%) were other-inflicted TBI (Oi-TBI). The most common causes of Si-TBI were “jumping from high places” and “firearms”. Major causes of Oi-TBI were ‘fight and brawl” and “struck by objects”. Si-TBI was associated with younger age, female gender, and having a history of alcohol/drug abuse. Oi-TBI was also associated with younger age and having an alcohol/drug abuse history and also with male gender. The second study on discharge against medical advice found that 446 (2.84%) TBI patients left hospitals without medical advice. DAMA was significantly associated with intentional injuries in those with self-inflicted TBI and other-inflicted TBI. DAMA was also associated with younger age and a history of alcohol/drug abuse. Using univariate analyses, the third study found that people with intentional TBI had significantly lower FIM gains in the motor area and significantly lower relative function gains (as measured by Montebello Rehabilitation Factor Score) in the cognitive area. Multivariate analyses of the same data showed that intentional TBI was also associated with lower cognitive relative gains, while controlling for age, gender, alcohol/abuse history, and other demographic and clinical variables. Persons with intentional TBI were found to be less likely to be discharged home, controlling for other relevant confounders. In conclusion, a person who has been injured due to assault or suicidal attempt may need more individualized care as they may be at greater risk for adverse rehabilitation outcomes. These findings regarding people with intentional TBI provide a basis for enhancing efforts on prevention of violence-related TBI and DAMA, and also for improving rehabilitation programs and discharge plans for this vulnerable population.

The ability to respond rapidly with spatial precision is required in a number of facets of everyday life, whether catching a falling object, reacting to other drivers on a busy freeway or recovering one’s balance following an unexpected perturbation. The sophisticated central nervous system (CNS) control of these reactions is often overlooked until the speed of such reactions becomes delayed, either due to ageing or brain injury, wherein the individual becomes at risk of injury. Surprisingly, little is known regarding the control of these ‘temporally urgent’ movements. Therefore, the primary objectives of this dissertation were to develop an understanding of the control of these movements by exploring the factors that may be involved in the generation of temporally urgent movements in the healthy CNS, locating the areas within the CNS that such modulation occurs and identifying the relative weighted importance of those modulators based on the initial conditions of stimulus delivery. Specific characteristics of stimulus properties, such as intensity and modality were particularly influential in the latency of motor reactions and physiological electrodermal skin responses fluctuated in accordance with input stimulus parameters. Importantly, outcomes from this dissertation identified that rapid reactions likely utilize a CNS network that includes higher cortical regions such as somatosensory cortex and primary motor cortex, which may be modulated by physiological arousal, rather than the solitary involvement of subcortical structures. The findings from this dissertation have important implications for individuals with disordered speed of processing and indicate the potential modifiability of factors that influence reaction time.

Despite the evident advantages of assistive technologies, many are still abandoned within the first few months of use. The key to changing this may lie in the assessment process, which has been described as the most consequential phase in the provision of assistive technology [14]. The purpose of this research was to create a protocol for the assessment and delivery of individualized access technologies based on the concepts of response efficiency theory. The protocol was applied with three children, ages 12 to 14, who were seeking new access technologies. The results suggest that a protocol based on this theory will result in a technology that is appropriate to the user, and as a result will be less likely to be abandoned and will contribute to goal achievement and potentially improve participation.

The ability to respond rapidly with spatial precision is required in a number of facets of everyday life, whether catching a falling object, reacting to other drivers on a busy freeway or recovering one’s balance following an unexpected perturbation. The sophisticated central nervous system (CNS) control of these reactions is often overlooked until the speed of such reactions becomes delayed, either due to ageing or brain injury, wherein the individual becomes at risk of injury. Surprisingly, little is known regarding the control of these ‘temporally urgent’ movements. Therefore, the primary objectives of this dissertation were to develop an understanding of the control of these movements by exploring the factors that may be involved in the generation of temporally urgent movements in the healthy CNS, locating the areas within the CNS that such modulation occurs and identifying the relative weighted importance of those modulators based on the initial conditions of stimulus delivery. Specific characteristics of stimulus properties, such as intensity and modality were particularly influential in the latency of motor reactions and physiological electrodermal skin responses fluctuated in accordance with input stimulus parameters. Importantly, outcomes from this dissertation identified that rapid reactions likely utilize a CNS network that includes higher cortical regions such as somatosensory cortex and primary motor cortex, which may be modulated by physiological arousal, rather than the solitary involvement of subcortical structures. The findings from this dissertation have important implications for individuals with disordered speed of processing and indicate the potential modifiability of factors that influence reaction time.