Abstract Background. Physical therapists report inconsistent use of valid and reliable measures of walking post-stroke. Objective. To describe the methods physical therapists use to evaluate walking, reasons for selecting these methods, and the use of the evaluation results in clinical practice along the continuum of an organized system of stroke care. Methods. A qualitative descriptive study involving semi-structured telephone interviews of physical therapists in Ontario was conducted. A thematic analysis was performed. Results. Participants (n=28) used both standardized and non-standardized methods to assess walking. A hierarchy of factors influencing use of both methods was observed. Assessment results were commonly used for communication with other healthcare professionals or education of the patient. Conclusions. A variety of factors influence physical therapists to use standardized assessment tools. Future knowledge translation interventions should focus on these factors to improve the standardized assessment of walking post-stroke.

Whole-body vibration (WBV) was recently introduced as a potential modality for strengthening bones, and this thesis was set out to investigate whether it plays a role in the prevention of postmenopausal bone loss. First, effects of WBV on bone mineral density (BMD) were systematically evaluated in previous randomized controlled trials (RCTs) in postmenopausal women. Second, a RCT of 202 postmenopausal women with primary osteopenia not on bone medications was conducted to investigate the effects of WBV at 0.3g and 90 Hz versus 0.3g and 30 Hz versus controls on various bone outcomes, as measured by dual-energy x-ray absorptiometry (DXA), high-resolution peripheral quantitative computed tomography (HR-pQCT), and quantitative ultrasound (QUS). In the systematic evaluation of previous RCTs, statistically significant increase in areal BMD (aBMD) at the hip was found in postmenopausal women receiving WBV versus controls, but the effect was small and may have been due to study bias. Also, WBV was not found to influence aBMD at the lumbar spine or volumetric BMD (vBMD) at the distal tibia in the systematic evaluation. In the RCT conducted in this thesis, no statistically significant effects of WBV were found on aBMD at the femoral neck, total hip or lumbar spine, as measured by DXA, or on vBMD or bone structure parameters at the distal tibia or distal radius, as measured by HR-pQCT. Further in this RCT, a statistically significant decrease was observed in QUS attenuation at the calcaneus in women receiving 90 Hz or 30 Hz WBV compared to controls. This may have been due to heel bone or soft tissue damage, although the effect was small and may not be clinically important. In conclusion, this investigation of postmenopausal women did not find clinically relevant benefits of WBV on osteoporotic-prone skeletal sites, including the hip, spine, tibia or radius, while potentially harmful effects on heel bone and/or soft tissue was observed in response to WBV. Thus based on this thesis, WBV is currently not recommended for the prevention of bone loss in community-dwelling postmenopausal women with primary osteopenia.

Abstract Background. Physical therapists report inconsistent use of valid and reliable measures of walking post-stroke. Objective. To describe the methods physical therapists use to evaluate walking, reasons for selecting these methods, and the use of the evaluation results in clinical practice along the continuum of an organized system of stroke care. Methods. A qualitative descriptive study involving semi-structured telephone interviews of physical therapists in Ontario was conducted. A thematic analysis was performed. Results. Participants (n=28) used both standardized and non-standardized methods to assess walking. A hierarchy of factors influencing use of both methods was observed. Assessment results were commonly used for communication with other healthcare professionals or education of the patient. Conclusions. A variety of factors influence physical therapists to use standardized assessment tools. Future knowledge translation interventions should focus on these factors to improve the standardized assessment of walking post-stroke.

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.

Executive dysfunction can affect community integration in adults with traumatic brain injury (TBI). The Cognitive Orientation to daily Occupational Performance (CO-OP) approach has shown some promise in promoting functional improvements in adults with executive dysfunctions post TBI. However, access to rehabilitation is often limited especially in rural communities. This study aimed to (1) investigate the feasibility of administering the CO-OP approach in a tele-rehabilitation format and (2) examine its impact on community integration and executive dysfunction. A pilot series of 3 case studies was conducted. Participants identified 5 goals; 3 were trained and 2 were untrained to allow examination of transfer. Outcome measures included the Canadian Occupational Performance Measure, the Mayo-Portland Adaptability Inventory-4 Participation Index, and the Dysexecutive Questionnaire. Descriptive analyses demonstrated goal achievement and transfer, suggesting it is feasible to implement the CO-OP approach in a tele-rehabilitation format. Community integration and executive dysfunction behaviours also showed trends towards improvement.

Many patients do not maintain physical activity (PA) post cardiac rehabilitation (CR),however few studies examine a large enough sample over the long-term. Thus, a retrospective cross-sectional study was carried out to examine PA and its correlates 2-6 years post CR; 584 graduates completed a mailed survey (mean+SD age: 69.8+9.8 years, BMI: 27+5.0 kg/m2, 80% male, 41.4+11.6 months since graduation, 36% response rate). PA was assessed using the Physical Activity Scale for the Elderly (PASE, mean+SD: 122.3+75.9). Seventy five percent of participants met Canadian PA guidelines. Greater PA was significantly associated with male sex, younger age, fear of falling, cholesterol control, self-controlled transportation, marital status, full-time work, rural location, higher VO2max, more comorbid conditions, greater perceived health, PA enjoyment, quality of life (QOL), social support, income, and CR staff support. Age,PA enjoyment, QOL, work status, cholesterol control and CR staff were significant in a multivariate model (R2=0.22, F=18.7, p<0.001).

The purpose of this prospective cohort study was to determine the relationships between changes in coping strategies and community integration at 6 and 12 months post traumatic brain injury (TBI). Seventy-one participants were adult significant others (SOs) (family members/friends) of people with TBI. SOs, proxies for TBI patients, completed coping and community integration questionnaire to describe TBI patients’pre-injury status immediately post-injury as baseline information. Followed-up interviewed were completed at 6 and 12 months. Results showed that increased emotional preoccupation coping from baseline to 6 months were significantly associated with decreased productive activities and decreased social integration at 6 months and 12 months and modestly associated with decreased home integration at 12 months. Multivariable regressions showed that changes in emotional preoccupation coping from baseline to 6 months contributed significantly to social integration and productive activities above and beyond demographic factors and injury severity. Implications for cognitive rehabilitation are discussed.

Objectives: Research literature points to a range of “factors” that are associated with return to work outcomes but little understanding of the experience of workers, the strategies used to adapt, how work shapes and influences adjustment, and the trajectories that describe their return to work experience. The aim of this qualitative, workplace-based study was to characterize workers readaptation to the workplace and develop a substantive framework for return to work following disabling cardiac illness. Methods: The study used a concurrent, nested, mixed methods approach, using grounded theory to inform the sampling and analysis framework. Participant workers were 12 males having suffered occupational disability owing to cardiac illness and returning to work at a large auto manufacturing plant. Participants were purposefully sampled for a range of disease and disability experiences as well as a range of work roles in the plant. Data were derived from semi-structured in-depth interviews, standardized questionnaire measures of health-related quality of life and work limitations, observations within the plant, and extensive field notes and memos. Longitudinal information was obtained through follow-up interviews over a two to ten month period. Results: Participants had a range of illness impacts and representations and fulfilled diverse roles in the plant including assembly jobs and trade work. Thematic analysis revealed that participants used adaptive strategies including changing mindset in relation to work, building physical capacity and efficiency, managing relationships and work schedules, and using supports in the plant. Thematic analysis highlighted the importance of the nature of work, the quality of work relationships, organizational practices around accommodation and supports in the workplace including occupational health support. Conclusions: Worker adaptation following disabling cardiac illness involved a process of self-regulation including elements of illness and work representations, deployment of adaptive strategies to compensate for ongoing impairments, self-monitoring, goal setting and adaptive selection of work activities. Work demands, relationships and structures provide a range of possibility for self-regulation and quality of life. Implications for practice for work and health researchers and professionals as well as potential linkages to theory are discussed.

The rollator is a mobility aid commonly used to facilitate balance and mobility for individuals with cardiorespiratory, musculoskeletal, or neurological deficits. Despite its popularity, there are also reports of adverse effects related to walker use linked to increased fall risks. Studies examining the effectiveness and consequences of rollator use have employed standard laboratory-based measurement methods that rely on performing specific tasks within a short time period and under controlled conditions, potentially limiting generalization to mobility in the everyday context. An instrumented rolling walker (iWalker) was developed as an ambulatory measurement tool applicable to the assessment of balance outside of the lab or clinic for assistive device users. The iWalker autonomously collects measurements of the upper and lower limb behaviour related to balance, walker kinematics, and video of the immediate spatial environment. The design and development of the iWalker is first described, followed by two studies characterizing the involvement of the upper limbs for balance in standing and walking that served to address gaps in the literature and evaluate the utility of the upper limb measures. Overall, the upper limbs can become the primary effectors of balancing forces when lower limb capabilities are compromised. When lower limb involvement was experimentally constrained, the upper limbs became the primary effectors of balance control in healthy, young adults. In older adults, individuals demonstrating the highest upper limb usage during walking were associated with the largest reduction in frontal plane stepping parameters (i.e., step width). A third study evaluated the applicability of the iWalker to assess everyday mobility in a series of in-patients recovering from neurological injury (i.e., stroke, traumatic brain injury). Patients demonstrated significantly different upper limb balancing behaviour in everyday situations compared to in-laboratory assessments. Furthermore, the iWalker captured behaviours that may be precursors to falling, such as collisions, stumbling and lifting the assistive device. The implications of these studies on assessing the effectiveness of rollators and feasibility of using the iWalker in follow-up efforts are discussed.

This dissertation examines the impact of exercise rehabilitation and the components of exercise prescriptions on optimizing health outcomes for people with diabetes (DM). Exercise is an accepted part of the diabetes management regime to help prevent or slow the progression of the disease. A combined aerobic and resistance training protocol is the recommended exercise regime for people with DM, but the question remains as to what the optimal dose may be for glycemic control and reduction of cardiovascular risk. This thesis aims to address three objectives surrounding optimal exercise prescriptions for diabetes: 1) To investigate aerobic exercise prescription efficacy in people with DM, coronary artery disease (CAD) and both CAD and DM to determine if there are population-specific VO2peak responses to exercise prescription; 2) To determine the optimal volume and intensity of resistance training exercise, in combination with aerobic training, that may improve glucose control, cardiovascular risk factors and body composition in people with type 2 DM (T2DM); and 3) To study the relationship between exercise performance, physiological changes and depressive mood in people with T2DM participating in a supervised, exercise program. Encouraging participation in an appropriately prescribed aerobic and resistance training program may help to improve adherence to exercise and elicit optimal health outcomes in people with T2DM. Tailoring the exercise prescription to suit the patient’s lifestyle, history and capacity is the utmost challenge for health care providers who hope to provide a complementary, non-pharmacologic therapeutic option for their patients.