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Doctoral Student Supervision (Jan 2008 - April 2022)
Stroke is a leading cause of adult disability, typically resulting in mental and physical impairments that can affect functional abilities such as walking. Recovering the ability to walk is an important goal for stroke survivors, having implications for long-term health and functional outcomes. Population trends and new medical interventions have resulted in changes in mortality and disablement, warranting an update of the prevalence of leg and walking impairment after stroke; interventions to optimize walking recovery after stroke also remain a key priority for research. Powered robotic exoskeletons, a new generation of electromechanical devices that can support and move the lower limbs to walk overground, may be a novel intervention to achieve higher-intensity walking practice and rehabilitation gains for patients after stroke.The aims of this dissertation were to characterize the current state of leg and walking impairment after stroke, as well as to investigate the role of exoskeletons, both their efficacy and acceptability, in stroke rehabilitation. A cohort study first established that approximately half of patients surviving a first-ever stroke are unable to walk, affecting their discharge disposition after acute hospitalization. The second study, a scoping review, mapped the existing research surrounding the use of powered exoskeletons for overground gait retraining and highlighted a need for more rigorous trials in the subacute stroke population. The third and fourth studies were conducted concurrently as a mixed methods trial to investigate the use of powered exoskeletons for gait retraining with non-ambulatory patients during subacute stroke rehabilitation. In the randomized controlled trial, no greater benefit was achieved by using a powered exoskeleton for walking recovery compared to standard physical therapy care. However, the qualitative component, an interview-based study exploring how patients and therapists react to using an exoskeleton for intensive rehabilitation, revealed that the technology is viewed highly favorably. In summary, these studies, which focused on non-ambulatory patients, indicate an ongoing need to target walking recovery after stroke and suggest that powered exoskeletons are a welcome option to achieve repetitive walking practice. Further work is needed to clarify which patients will truly benefit, and to what extent, from this intervention.
Background: Recurrent strokes, which may comprise up to a fifth of all stroke, are more severe than first events. Optimal secondary stroke prevention may require changes to health-related behaviours and improved vascular risk factor control. While patients’ knowledge regarding stroke, health-related behaviours, and cardiovascular risk may improve with secondary prevention strategies, there is little information available to guide programs for patient and family education for stroke prevention. Purpose: First, to assess the knowledge of individuals with a recent stroke about stroke symptoms, risk factors, and prevention. Second, to explore the association between stroke knowledge and health behaviours and cardiovascular risk factor control. Last, to explore perceived barriers and facilitators for participation in secondary prevention programs for stroke survivors and their caregivers, and to examine the effectiveness of nursing interventions on modification of stroke risk factors among stroke survivors. Methods: A prospective cross-sectional study was conducted to assess the knowledge of individuals with recent stroke and its relation to health-related behaviours and cardiovascular disease risk. Then, a longitudinal qualitative study was conducted using individual interviews with stroke survivors and their caregivers to understand changes in their perceptions regarding secondary stroke prevention in the stroke recovery period. Lastly, a meta-analysis of randomized controlled trials was conducted investigating the role of nurses in secondary stroke prevention. Results: The cross-sectional study revealed that stroke patients lacked knowledge about stroke, and those who had better stroke knowledge had better health-related behaviours. Those who were physically active prior to their stroke had better cardiovascular risk factor control. In the qualitative study, stroke was perceived as a soul-searching experience by stroke survivors and their caregivers, motivating them to consider its causes. Despite experiencing some barriers, stroke survivors made lifestyle adjustments, transitioning through different stages of change. The meta-analysis found that nursing interventions were associated with improvements in blood pressure control, diet, physical activity, medication adherence, and knowledge of stroke risk factors. Conclusions: The findings demonstrate the importance of strengthening current programs for secondary stroke prevention. Further, the findings suggest that developing patient- and family-centered programs may improve the knowledge and health-related behaviours to optimize secondary stroke prevention.
Background: Stroke is a serious health concern and a leading cause of disability worldwide. Up to two-thirds of stroke survivors will experience physical and/or cognitive deficits thus requiring ongoing rehabilitation. Determining the appropriate exercise intensity and dose to optimize recovery is one of the top priorities in stroke rehabilitation research.Purpose: To determine the feasibility and efficacy of higher exercise intensity and dose on walking and functional recovery, cognition, and quality of life in the early phase after stroke.Methods: Multiple studies were conducted to examine how exercise intensity and dose may influence recovery early after stroke. Two studies were completed to identify and assess the precision of a readily available monitoring device to accurately record step count, a measure of walking dose. The results of these studies contributed to the design and implementation of an ongoing national, multi-site, randomized clinical trial occurring during inpatient stroke rehabilitation, to investigate how higher exercise intensity and dose impact walking and functional recovery, cognition, and quality of life. Results: From the two studies examining measurement of walking dose, The Fitbit One was identified as a monitoring device that could accurately assess step count (
Introduction Rehabilitation activities of a sufficient intensity are necessary for optimal recovery in individuals with spinal cord injury (SCI). Optimizing rehabilitation and activity prescription requires quantification of physical activity and its predictors during this time. Purpose To determine, during inpatient rehabilitation, the: 1) reliability and validity of measures of physical activity. 2) level of physical activity using objective and self-report measures. 3) level of cardiovascular stress experienced during physical therapy (PT) and occupational therapy (OT). 4) variables associated with greater time spent at higher heart rate during PT.5) number of active movement repetitions occurring during PT and OT.Methods Design: A test retest design was used to determine the reliability of physical activity measures. A longitudinal observation design was used to determine movement repetitions and physical activity levels. A cross-sectional observational design was used to determine the level of cardiovascular stress. Subjects: Participants (n=108) were recruited from consecutive admissions to rehabilitation. Results Good reliability for accelerometry and step counts, and moderate reliability for self-report, was demonstrated. Validity was demonstrated for wrist accelerometry and step counts but not self-report physical activity. For most groups and variables, no changes occurred during therapy time from admission to discharge. Outside of therapy all groups increased from admission to discharge in accelerometer measured activity kilocounts but not self-report minutes, where the majority of time was spent in leisure time sedentary activity (~4.5 hours). The average time spent at a heart rate within the cardiovascular training zone was 6.0±9.0 minutes in PT and lower in OT. Lower spasticity, higher exercise self-efficacy, and better orthostatic tolerance correlated with a greater amount of time within a cardiovascular training zone. Average repetitions for PT and OT combined did not exceed 300 for the upper or lower extremity. Most repetition variables remained unchanged over the inpatient rehabilitation stay while clinical outcomes improved significantly. Conclusions Individuals report that a large amount of time is spent engaged in higher intensity activities. Measurement of heart rate during therapy sessions shows little time is spent at intensities sufficient to accrue cardiovascular benefits. Repetitions in therapy are low compared to the motor learning literature.
Introduction: Anterior cruciate ligament (ACL) injury remains one of the most common and debilitating knee injuries in sport. Neuromuscular training programs show promise in improving biomechanical risk factors but we do not know which aspects of these programs are effective. There is a need to investigate the effect of specific movement strategies in reducing biomechanical risk factors for ACL injury. Purpose: 1) To evaluate the reproducibility of biomechanical variables at the knee during threesoccer-specific tasks (Chapter 2). 2) To determine the feasibility of implementing a novel movement strategy (Core-PAC) into a soccer team warm-up (Chapter 3). 3) To determine whether the Core-PAC would improve biomechanical variables during thethree tasks after immediate instruction and after a four-week training program (Chapter 3). 4) To conduct a randomized controlled trial (RCT) to compare a Core-PAC trained group to a control group for biomechanical variables during the three tasks after a six-week training program (Chapter 4). Methods: Design: A test-retest design was used for the reliability study (Chapter 2). A single group pretest-posttest design was used for the feasibility study (Chapter 3). An RCT was used inChapter 4. Subjects: A cohort of female soccer players (n = 10) participated in the reliability study (Chapter 2) and the feasibility study (Chapter 3). A different cohort of female soccer players participated in the RCT (n = 20) (Chapter 4). Results: Chapter 2: Adequate reproducibility (flexion angles (ICC=0.88-0.95; SEM=1.0-1.9°); abduction moments (ICC=0.62-0.84; SEM=0.1-0.5 Nm/kg) were demonstrated during the three tasks.Chapter 3: Feasibility of implementing the Core-PAC into a soccer warm-up was demonstrated. After immediate instruction, there were significant increases in peak flexion angles (3.5-6.4°) and decreases in abduction moments (0.17-0.27 Nm/kg) during the three tasks. After the training program, some individuals showed improvement. Chapter 4: The Core-PAC group improved (P
Introduction Approximately 70% of individuals with stroke have upper limb impairment. Inability to use the upper limb can lead to difficulties in activities of daily living. Increased time spent in therapy improves outcome of the upper limb post stroke however, length of stay in rehabilitation has decreased. Innovative ways of increasing therapy intensity need to be explored. Purpose1) To undertake a meta-analysis to determine the treatment effect of upper limb strengthening on strength, function and activities of daily living.2) To determine the effectiveness of a four week self-administered in-patient homework exercise program (GRASP) on upper limb function and depressive symptoms in individuals in the sub-acute stage of stroke recovery.3) To determine modifiable predictors of upper limb function in individuals in the sub-acute stage of stroke recovery. MethodsDesign: Chapter 2 is a meta-analysis of upper limb strength training in individuals with stroke. Electronic databases were searched from 1950-September 2008. 14 articles were reviewed.Chapter 3-5 involved a four week multi-site single blind randomized controlled trial of a self-administered upper limb exercise program (GRASP) compared to control. Subjects: 103 individuals with stroke were recruited from four rehabilitation units. ResultsChapter 2: The meta-analysis showed strength training is effective in increasing paretic upper limb strength and function but not performance in activities of daily living. Chapters 3-5: The GRASP program improved upper limb function significantly more than the control group (p
Master's Student Supervision (2010 - 2021)
Introduction and PurposeUnderstanding upper extremity functional recovery following stroke requires knowledge of how individuals use their upper extremity in the home and community settings. Currently, there are no measures that provide a rich description about the types of activities and manner in which they are performed by the affected upper extremity. This study aimed to develop and validate a classification scale that captures UE use following stroke. Objectives1. To conduct a systematic review of existing research on the ability of UE function and UE use measures following stroke to capture important, observed and detectable change.2. To develop a new classification tool, Rating of Everyday Arm-use in the Community and Home (REACH) scale, that captures UE use and to assess the interrater reliability and validity of the new tool. MethodsDesign: This study used multiple methods to achieve the stated objectives. A systematic review methodology that reviewed 68 articles covering 14 measures was employed. Development of the REACH scale utilized focus groups to acquire client, clinician, and caregiver perspectives. Evaluation of interrater reliability involved a test-retest design with different raters. Hypothesis testing was used to assess the validity of the REACH scale. Participants: Focus groups included clinicians (n=13), participants with stroke (n=16), and caregivers (n=4). Individuals with stroke living in the community participated in the evaluation of the REACH scale (n=96). Measures: Responsiveness indices were extracted and calculated from the included articles for the systematic review. The following measures were used to evaluate the REACH scale: Motor Activity Log, activity counts captured by accelerometers, Action Research Arm Test, Stroke Impact Scale – hand subscale, Chedoke-McMaster Stroke Assessment (Arm Recovery, Hand Recovery, and Shoulder pain scales).ResultsThe REACH scale, informed by literature and user consultation, takes 5 minutes to administer. The intraclass correlation coefficient and weighted kappa for interrater reliability was 0.96 and 0.91 respectively. Strong relationships were observed between the REACH scores and external measures of UE use, UE function and UE impairment (ρ=0.91-0.94). ConclusionsThe REACH scale provides an accessible and efficient tool for measuring UE use following stroke.