Step Number and Aerobic Minute Exercise Prescription and Progression in Stroke: A Roadmap

Background: While higher therapeutic intensity improves motor recovery after stroke, translating findings from successful studies is challenging without clear exercise intensity targets. We show in the DOSE trial1 more than double the steps and aerobic minutes within a session can be achieved compared with usual care and translates to improved long-term walking outcomes. Objective: We modeled data from this successful higher intensity multi-site RCT to develop targets for prescribing and progressing exercise for varying levels of walking impairment after stroke. Methods: In twenty-five individuals in inpatient rehabilitation, twenty sessions were monitored for a total of 500 one-hour physical therapy sessions. For the 500 sessions, step number and aerobic minute progression were modeled using linear mixed effects regression. Using formulas from the linear mixed effects regression, targets were calculated. Results: The model for step number included session number and baseline walking speed, and for aerobic minutes, session number and age. For steps, there was an increase of 73 steps per session. With baseline walking speed, for every 0.1 m/s increase, a corresponding increase of 302 steps was predicted. For aerobic minutes, there was an increase of.56 minutes of aerobic activity (ie, 34 seconds) per session. For every year increase in age, a decrease of.39 minutes (ie, 23 seconds) was predicted. Conclusions: Using data associated with better walking outcomes, we provide step number and aerobic minute targets that future studies can cross-validate. As walking speed and age are collected at admission, these models allow for uptake of routine measurement of therapeutic intensity. Registration: www.clinicaltrials.gov; NCT01915368

Differences in Peak Impact Accelerations Among Foot Strike Patterns in Recreational Runners

Introduction: Running-related injuries (RRIs) occur from a combination of training load errors and aberrant biomechanics. Impact loading, measured by peak acceleration, is an important measure of running biomechanics that is related to RRI. Foot strike patterns may moderate the magnitude of impact load in runners. The effect of foot strike pattern on peak acceleration has been measured using tibia-mounted inertial measurement units (IMUs), but not commercially available insole-embedded IMUs. The aim of this study was to compare the peak acceleration signal associated with rearfoot (RFS), midfoot (MFS), and forefoot (FFS) strike patterns when measured with an insole-embedded IMU. Materials and Methods: Healthy runners ran on a treadmill for 1 min at three different speeds with their habitual foot strike pattern. An insole-embedded IMU was placed inside standardized neutral cushioned shoes to measure the peak resultant, vertical, and anteroposterior accelerations at impact. The Foot strike pattern was determined by two experienced observers and evaluated using high-speed video. Linear effect mixed-effect models were used to quantify the relationship between foot strike pattern and peak resultant, vertical, and anteroposterior acceleration. Results: A total of 81% of the 187 participants exhibited an RFS pattern. An RFS pattern was associated with a higher peak resultant (0.29 SDs; p = 0.029) and vertical (1.19 SD; p < 0.001) acceleration when compared with an FFS running pattern, when controlling for speed and limb, respectively. However, an MFS was associated with the highest peak accelerations in the resultant direction (0.91 SD vs. FFS; p = 0.002 and 0.17 SD vs. RFS; p = 0.091). An FFS pattern was associated with the lowest peak accelerations in both the resultant and vertical directions. An RFS was also associated with a significantly greater peak acceleration in the anteroposterior direction (0.28 SD; p = 0.033) than an FFS pattern, while there was no difference between MFS and FFS patterns. Conclusion: Our findings indicate that runners should be grouped by RFS, MFS, and FFS when comparing peak acceleration, rather than the common practice of grouping MFS and FFS together as non-RFS runners. Future studies should aim to determine the risk of RRI associated with peak accelerations from an insole-embedded IMU to understand whether the small observed differences in this study are clinically meaningful

Blood pressure trajectory of inpatient stroke rehabilitation patients from the Determining Optimal Post-Stroke Exercise (DOSE) trial over the first 12 months post-stroke

BackgroundHigh blood pressure (BP) is the primary risk factor for recurrent strokes. Despite established clinical guidelines, some stroke survivors exhibit uncontrolled BP over the first 12 months post-stroke. Furthermore, research on BP trajectories in stroke survivors admitted to inpatient rehabilitation hospitals is limited. Exercise is recommended to reduce BP after stroke. However, the effect of high repetition gait training at aerobic intensities (>40% heart rate reserve; HRR) during inpatient rehabilitation on BP is unclear. We aimed to determine the effect of an aerobic gait training intervention on BP trajectory over the first 12 months post-stroke.MethodsThis is a secondary analysis of the Determining Optimal Post-Stroke Exercise (DOSE) trial. Participants with stroke admitted to inpatient rehabilitation hospitals were recruited and randomized to usual care (n = 24), DOSE1 (n = 25; >2,000 steps, 40–60% HRR for >30 min/session, 20 sessions over 4 weeks), or DOSE2 (n = 25; additional DOSE1 session/day) groups. Resting BP [systolic (SBP) and diastolic (DBP)] was measured at baseline (inpatient rehabilitation admission), post-intervention (near inpatient discharge), 6- and 12-month post-stroke. Linear mixed-effects models were used to examine the effects of group and time (weeks post-stroke) on SBP, DBP and hypertension (≥140/90 mmHg; ≥130/80 mmHg, if diabetic), controlling for age, stroke type, and baseline history of hypertension.ResultsNo effect of intervention group on SBP, DBP, or hypertension was observed. BP increased from baseline to 12-month post-stroke for SBP (from [mean ± standard deviation] 121.8 ± 15.0 to 131.8 ± 17.8 mmHg) and for DBP (74.4 ± 9.8 to 78.5 ± 10.1 mmHg). The proportion of hypertensive participants increased from 20.8% (n = 15/72) to 32.8% (n = 19/58). These increases in BP were statistically significant: an effect [estimation (95%CI), value of p] of time was observed on SBP [0.19 (0.12–0.26) mmHg/week, p < 0.001], DBP [0.09 (0.05–0.14) mmHg/week, p < 0.001], and hypertension [OR (95%CI): 1.03 (1.01–1.05), p = 0.010]. A baseline history of hypertension was associated with higher SBP by 13.45 (8.73–18.17) mmHg, higher DBP by 5.57 (2.02–9.12) mmHg, and 42.22 (6.60–270.08) times the odds of being hypertensive at each timepoint, compared to those without.ConclusionBlood pressure increased after inpatient rehabilitation over the first 12 months post-stroke, especially among those with a history of hypertension. The 4-week aerobic gait training intervention did not influence this trajectory

Measuring the long-term impact of childhood injury : a longitudinal study of health related quality of life

In Canada, unintentional injuries are a leading cause of hospitalization for children aged 5-19 years old. The need for longitudinal studies examining the impact of non-fatal childhood injuries across age groups and injury types has been identified internationally. Health related quality of life (HRQoL) measures assess functional limitations in multiple health domains making HRQoL an interesting and appropriate outcome to measure the impact of injury. The overarching goal of this dissertation was to advance the understanding of HRQoL among children following injury and the appropriate analysis of longitudinal HRQoL data. A systematic review was performed to summarize the findings of research on HRQoL following pediatric injury, and to examine the methods used to measure and analyze HRQoL data in the childhood injury context. In addition, primary research was conducted with 365 children 0-16 years old and their parents who presented with an injury at a tertiary care pediatric hospital in Vancouver, British Columbia. Children aged between 5-16 years old and all parents completed questionnaire measures at the time of presentation for the injury and again at one-, four- and 12-months post-injury. How childhood injury and the process of recovery impacts children’s HRQoL from both the child’s and parent’s perspective was investigated. Four different longitudinal models were explored to determine the model that best fit the data. Analyses revealed that injuries among older children, children requiring hospitalization and children with lower extremity fractures had more significant impact on HRQoL at one-month post-injury. By four-months post-injury differences in HRQoL were minimal. On average, parents rated their children’s HRQoL lower at one-month post-injury relative to the children’s self-perceived HRQoL. Most injured children regained HRQoL baseline status by four-months post-injury. Non-linear quantile regression provided the best fitting model as it is robust to skewness and outliers and free from any assumptions regarding the distribution of errors. Older children, those hospitalized, and children with lower extremity fractures were at higher risk of having lower HRQoL in the early part of recovery relative to younger children, those seen in the ED and children with other types of injuries.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat

Construct validity and impact of mode of administration of the PedsQL™ among a pediatric injury population

The purpose of this study was to determine the construct validity of the PedsQL™ health related quality of life (HRQoL) instrument for use among injured children and to examine the impact of using different modes of administration, including paper and pencil, online and telephone. Results: rANOVA showed significant differences in PedsQL™ total score between baseline and one month post injury (p < .001), and differences in mean total score at one month post injury by category of injury severity (p < .001). There was also significant interaction by category of injury severity for the change in PedsQL™ total score from baseline to one month (p < .001). Pearson’s correlations were highly significant across three modalities of survey administration: paper and pencil, computer and telephone administration (range: .92 to .97, p < .001). Bland-Altman plots showed strong consistency. Conclusion: The PedsQL™ instrument is able to discriminate between pre and post injury HRQoL, as well as HRQoL post injury for injuries of varying severity. These findings are an indication that this instrument has good construct validity for the purpose of evaluating HRQoL of injured children. Data collected via paper-pencil, online and telephone administration were highly consistent. This is important as depending on the setting, clinical or research, different modalities of completing this instrument may be more appropriate.Medicine, Faculty ofOther UBCNon UBCPediatrics, Department ofPopulation and Public Health (SPPH), School ofReviewedFacultyResearcherGraduat

'Do as we say, not as we do:' a cross-sectional survey of injuries in injury prevention professionals

Background: As the leading cause of death and among the top causes of hospitalisation in Canadians aged 1–44 years, injury is a major public health concern. Little is known about whether knowledge, training and understanding of the underlying causes and mechanisms of injury would help with one's own prevention efforts. Based on the Theory of Planned Behaviour, we hypothesised that injury prevention professionals would experience fewer injuries than the general population. Methods: An online cross-sectional survey was distributed to Canadian injury prevention practitioners, researchers and policy makers to collect information on medically attended injuries. Relative risk of injury in the past 12 months was calculated by comparing the survey data with injury incidence reported by a comparable subgroup of adults from the (Canadian Community Health Survey (CCHS)) from 2009 to 2010. Results: We had 408 injury prevention professionals complete the survey: 344 (84.5%) women and 63 (15.5%) men. In the previous 12 months, 86 individuals reported experiencing at least one medically attended injury (21 235 people per 100 000 people); with sports being the most common mechanism (41, 33.6%). Fully 84.8% individuals from our sample believed that working in the field had made them more careful. After accounting for age distribution, education level and employment status, injury prevention professionals were 1.69 (95% CI 1.41 to 2.03) times more likely to be injured in the past year. Interpretation: Despite their convictions of increasing their own safety behaviour and that of others, injury prevention professionals’ knowledge and training did not help them prevent their own injuries

Pediatric Canadian Triage and Acuity Scale (PaedsCTAS) as a Measure of Injury Severity

This research explored whether the pediatric version of the Canadian Triage Acuity Scale (PaedsCTAS) represented a valid alternative indicator for surveillance of injury severity. Every patient presenting in a Canadian emergency department is assigned a CTAS or PaedsCTAS score in order to prioritize access to care and to predict the nature and scope of care that is likely to be required. The five-level PaedsCTAS score ranges from I (resuscitation) to V (non-urgent). A total of 256 children, 0 to 17-years-old, who attended a pediatric hospital for an injury were followed longitudinally. Of these children, 32.4% (n = 83) were hospitalized and 67.6% (n = 173) were treated in the emergency department and released. They completed the PedsQLTM, a validated measure of health related quality of life, at baseline (pre-injury status), one-month, four- to six-months, and 12-months post-injury. In this secondary data analysis, PaedsCTAS was found to be significantly associated with hospitalization and length of stay, sensitive to the differences between PaedsCTAS II and III, and related to physical but not psychosocial HRQoL. The findings suggest that PaedsCTAS may be a useful proxy measure of injury severity to supplement or replace hospitalization status and/or length of stay, currently proxy measures.Medicine, Faculty ofPediatrics, Department ofPopulation and Public Health (SPPH), School ofReviewedFacultyGraduat

Efficacy of an exoskeleton-based physical therapy program for non-ambulatory patients during subacute stroke rehabilitation: a randomized controlled trial

Background Individuals requiring greater physical assistance to practice walking complete fewer steps in physical therapy during subacute stroke rehabilitation. Powered exoskeletons have been developed to allow repetitious overground gait training for individuals with lower limb weakness. The objective of this study was to determine the efficacy of exoskeleton-based physical therapy training during subacute rehabilitation for walking recovery in non-ambulatory patients with stroke. Methods An assessor-blinded randomized controlled trial was conducted at 3 inpatient rehabilitation hospitals. Patients with subacute stroke (< 3 months) who were unable to walk without substantial assistance (Functional Ambulation Category rating of 0 or 1) were randomly assigned to receive exoskeleton-based or standard physical therapy during rehabilitation, until discharge or a maximum of 8 weeks. The experimental protocol replaced 75% of standard physical therapy sessions with individualized exoskeleton-based sessions to increase standing and stepping repetition, with the possibility of weaning off the device. The primary outcome was walking ability, measured using the Functional Ambulation Category. Secondary outcomes were gait speed, distance walked on the 6-Minute Walk Test, days to achieve unassisted gait, lower extremity motor function (Fugl-Meyer Assessment), Berg Balance Scale, Patient Health Questionnaire, Montreal Cognitive Assessment, and 36-Item Short Form Survey, measured post-intervention and after 6 months. Results Thirty-six patients with stroke (mean 39 days post-stroke) were randomized (Exoskeleton = 19, Usual Care = 17). On intention-to-treat analysis, no significant between-group differences were found in the primary or secondary outcomes at post-intervention or after 6 months. Five participants randomized to the Exoskeleton group did not receive the protocol as planned and thus exploratory as-treated and per-protocol analyses were undertaken. The as-treated analysis found that those adhering to exoskeleton-based physical therapy regained independent walking earlier (p = 0.03) and had greater gait speed (p = 0.04) and 6MWT (p = 0.03) at 6 months; however, these differences were not significant in the per-protocol analysis. No serious adverse events were reported. Conclusions This study found that exoskeleton-based physical therapy does not result in greater improvements in walking independence than standard care but can be safely administered at no detriment to patient outcomes. Clinical Trial Registration The Exoskeleton for post-Stroke Recovery of Ambulation (ExStRA) trial was registered at ClinicalTrials.gov (NCT02995265, first registered: December 16, 2016)Medicine, Faculty ofNon UBCMedicine, Department ofOccupational Science and Occupational Therapy, Department ofPhysical Medicine and Rehabilitation, Division ofReviewedFacultyResearche

A longitudinal study on quality of life after injury in children

Background: In high income countries, injuries account for 40 % of all child deaths, representing the leading cause of child mortality and a major source of morbidity. The need for studies across age groups, and use of health related quality of life measures that assess functional limitations in multiple health domains, with sampling at specific post-injury time points has been identified. The objective of this study was to describe the impact of childhood injury and recovery on health related quality of life (HRQoL) for the 12 months after injury. Methods: In this prospective cohort study parents of children 0-16 years old attending British Columbia Children’s Hospital for an injury were surveyed over 12 months post-injury. Surveys assessed HRQoL at four points: baseline (pre-injury), one month, four to six months and 12 months post injury. Generalized estimating equation models identified factors associated with changes in HRQoL over time. Results: A total of 256 baseline surveys were completed. Response rates for follow-ups at one, four and twelve months were 74 % (186), 67 % (169) and 64 % (161), respectively. The mean age of participants was 7.9 years and 30 % were admitted to the hospital. At baseline, a retrospective measure of pre-injury health, the mean HRQoL score was 90.7. Mean HRQoL ratings at one, four and 12 months post injury were 77.8, 90.3 and 91.3, respectively. Both being older and being hospitalized were associated with a steeper slope to recovery. Conclusions: Although injuries are prevalent, the long term impacts of most childhood injuries are limited. Regardless of injury severity, most injured children recuperated quickly, and had regained total baseline status by four month post-injury. However, although hospitalization did not appear to impact long term psychosocial recovery, at four and 12 months post injury a greater proportion of hospitalized children continued to have depressed physical HRQoL scores. Both older and hospitalized children reported greater impact to HRQoL at one month post injury, and both had a steeper slope to recovery and were on par with their peers by four month.Medicine, Faculty ofOther UBCNon UBCPediatrics, Department ofPopulation and Public Health (SPPH), School ofReviewedFacultyGraduat

A Web-Based Risk-Reframing Intervention to Influence Early Childhood Educators’ Attitudes and Supportive Behaviors Toward Outdoor Play : Protocol for the OutsidePlay Study Randomized Controlled Trial

Early learning and childcare centers (ELCCs) can offer young children critical opportunities for quality outdoor play. There are multiple actual and perceived barriers to outdoor play in ELCCs, ranging from safety fears and lack of familiarity with supporting play outdoors to challenges around diverse perspectives on outdoor play among colleagues, administrators, licensing officers and parents. Results: The primary outcome is increased tolerance of risk in children’s play, as measured by the Teacher Tolerance of Risk in Play Scale. The secondary outcome is self-reported attainment of a self-developed behavior change goal. We will test the hypothesis that there will be a difference between the intervention and control groups with respect to tolerance of risk in children’s play using mixed-effects models. Differences in goal attainment will be tested using logistic regression. Conclusion: The OutsidePlay web-based intervention guides users through a personalized journey that is split into three chapters. An effective intervention that addresses the barriers to outdoor play in ELCC settings has the potential to improve children’s access to outdoor play and support high quality early childhood education.Medicine, Faculty ofPediatrics, Department ofPopulation and Public Health (SPPH), School ofEducation, Faculty ofNon UBCReviewedFacultyResearche