PRE-COURSE WORKSHOP ABSTRACTS #PreW 1–PreW4 6th National Spinal Cord Injury Conference: Bioinformatics Inform SCI Rehabilitation October 2–4, 2014 Allstream Centre, Toronto, Ontario Workshop #: PreW1
FUTURE DIRECTIONS IN CLINICAL GAIT AND POSTURAL BALANCE ANALYSIS AFTER SPINAL CORD INJURY – MOVING TOWARDS NOVEL GAIT TRAINING OPPORTUNITIES Hossein Rouhani 1,2, Daniel Schließmann 3, Matthias Schneiders 3, Norbert Weidner 3, Rüdiger Rupp3, Christian Schuld 3 1
Toronto Rehabilitation Institute – UHN; 2University of Toronto; 3Heidelberg University Hospital
Background/Objective: Gait and postural balance analysis provides objective information about improvements after spinal cord injury (SCI) rehabilitation and thus is widely applied for research and clinical evaluations. External feedback is an important component of motor learning and can be used in gait rehabilitation after incomplete SCI. In addition, ambulatory movement monitoring using wearable sensors has provided inexpensive and practical tools for gait and postural balance analysis. This technology can be used for both gait and postural balance training and health monitoring during daily life. Technical progress in the last years has made the following feasible: (1) real-time movement analysis systems allowing for novel feedbackassisted gait and balance therapies and (2) wearable systems for movement analysis including mobile health monitoring. This workshop provides an overview about the state-of-the-art of clinical movement analysis in SCI (including typical examples of common SCI gait patterns) and will demonstrate two currently running projects among the emerging fields in gait and postural balance training: gait therapy systems based on real-time feedback and applications of wearable systems for this purpose. Methods/Overview: (a) Feedback system: A commercial real-time motion analysis system (consisting of eight cameras and a custom-made treadmill) streams marker trajectories, analogue data, and model-based joint angles into the local area network with low latency. The new feedback system performs online low latency gait event detection to provide time–distance parameters as well as step cycle normalized joint angles as selectable feedback parameters. These parameters can be fed back visually (line graphs, absolute values, etc.), acoustically (mapping to auditory pitch, timbre or rhythm scales) or haptically (electrical simulation). The feasibility of this novel feedback-assisted gait training was demonstrated in a pilot study where individuals with chronic, incomplete SCI showed short-term performance increases and also mid-term learning effects. (b) Body-worn systems: The following steps for clinical implementation of body-worn systems in long-term (virtually unlimited) gait and postural balance analysis for SCI patients will be demonstrated: (1) configuration and calibration of wearable inertial sensor modules for gait and postural balance analysis, (2) design of clinical protocols to evaluate long-term gait and postural balance performance of individuals with SCI, (3) calculation of gait and postural balance parameters using inertial sensors, and (4) application of obtained parameters for clinical evaluations during daily life and for gait and postural balance therapy system based on real-time feedback.
608
© The Academy of Spinal Cord Injury Professionals, Inc. 2014 DOI 10.1179/1079026814Z.000000000342
The Journal of Spinal Cord Medicine
2014
VOL.
37
NO.
5
Abstracts
Results: N/A. Conclusions: Feedback-assisted gait training is a promising option for improving gait function. Application of wearable sensor technology for this purpose offers a convenient alternative compared to traditional gait laboratory instruments. Future work will combine both technologies to allow for a mobile and affordable gait analysis and gait feedback therapy device not only for SCI but also for other neurological and orthopaedic gait disorders.
Workshop #: PreW2
CLINICAL GUIDELINES FOR USE AND IMPLEMENTATION FOR THE GRADED REDEFINED ASSESSMENT OF STRENGTH SENSIBILITY AND PREHENSION (GRASSP) Sukhvinder Kalsi-Ryan1,2, Stephanie Hadi2, Sylvia Haycock 1,3, Jennifer Holmes 1,2 University Health Network; 2University of Toronto, Toronto Rehabilitation Institute – UHN; 3Galit Liffshiz & Associates Inc. 1
Background/Objective: GRASSP Version 1.0 is a clinical impairment measure designed specifically to assess the upper limb after traumatic cervical spinal cord injury. The Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP) consists of five subtest scores that characterize the upper limb; it captures subtle changes in neurological impairment during the acute, sub-acute, and chronic phases of recovery. Psychometric properties of reliability (inter/test retest), validity, responsiveness, and minimally detectable difference (MDD) have been established. Methods/Overview: A number of staged studies have been conducted to develop and validate the GRASSP. Studies include a multi-centre cross-sectional study for reliability and validity; a multi-centre longitudinal study to establish responsiveness, sensitivity, minimally clinical important difference, and MDD. Furthermore, with the iterative process of development and validation a standardized teaching/training module has been established. Results: Psychometric properties of the staged development of GRASSP will be presented and include reliability, validity, responsiveness, and MDD. The teaching and training will be conducted using a standardized teaching method. Conclusions: At the end of the session participants will be able to: • • • •
Administer the GRASSP independently, accurately score patient outcomes, and interpret the results; Evaluate and document the results, and determine the optimal use of longitudinal assessment; Identify the benefits of utilizing the GRASSP and indicate how the GRASSP can be applied in their clinical settings; Recommend how to enhance use and uptake of the GRASSP in their own clinical environments.
The GRASSP is a well-established method of assessment specific to the upper limb in tetraplegia. Enhancing the ways in which the tool can be applied clinically and within research related work is the current application of our efforts.
Workshop #: PreW3
ENHANCING INTER-PROFESSIONAL COLLABORATION DURING TEAM ROUNDS IN SPINAL CORD INJURY REHABILITATION THROUGH THE IMPLEMENTATION OF A DOMAIN-BASED, PATIENT-FOCUSED STRUCTURE Kristina Guy1, Sandra Mills 1, Carol Y. Scovil 1,2, Tess Devji 1,2, Heather M. Flett1,2 Toronto Rehabilitation Institute – UHN; 2University of Toronto
1
Background/Objective: The Spinal Cord Rehab Program (SCRP) at Toronto Rehabilitation Institute-UHN established an operating initiative aimed at creating an integrated approach to goal setting, patient and
The Journal of Spinal Cord Medicine
2014
VOL.
37
NO.
5
609
Abstracts
family education, and transition planning. Using Toronto Rehabilitation Institute’s Clinical Best Practice Process, a working group established the following objectives: to identify educational barriers, and enhance opportunities/exchanges; to enhance team communication and collaboration; to place patient and family securely within team processes; to reduce barriers and integrate transition of care through rehab into the community. Methods/Overview: Inter-professional team rounds provide a formal opportunity for team members to plan patient care and discuss transition plans. In the past, these meetings have been structured such that the information was sequentially presented from a discipline-specific perspective and focus. The working group developed a list of topic areas or domains which were introduced as a means of structuring the discussion during team rounds. Any team member may contribute to the domain-specific discussion as they are not aligned with any individual profession. These domains are also introduced to patients during the admission process to: (1) engage the patient in learning about all of the areas that may be impacted by a spinal cord injury, and (2) identify for the team which of the domains are most important to the patient. A panel consisting of representatives from the working group will present the implementation of the above-described approach. Following an overview of the project as a whole, the panel will specifically focus on the approach taken to develop and create the tools which have supported the evolution of team rounds towards a more inter-professional, “patient-as-partners” model. Results: The introduction of a domain-based structure to team rounds has resulted in discussions which are more collaborative with multiple team members contributing to the discussion about any one domain. The structure helps not only to ensure that the team’s care planning is comprehensive, but also that the patient’s priorities are the central focus. Conclusions: Participants in this workshop will achieve an understanding of the strategies undertaken by the SCRP team to enhance inter-professional collaboration and patient-centred focus during team rounds. We anticipate that the discussion will allow leaders to evaluate whether this approach would be beneficial in their setting and provide them with a framework for achieving similar results with their teams. Acknowledgements: Supported by the Toronto Rehabilitation Institute-UHN Brain and Spinal Cord Rehabilitation Program.
Workshop #: PreW4
IMPROVING VOLUNTARY GRASPING FUNCTION IN INCOMPLETE CERVICAL SPINE INJURY PATIENTS USING FUNCTIONAL ELECTRICAL STIMULATION THERAPY Milos R Popovic1,2, Naaz Kapadia Desai 2,3, Sylvia Daniel 1 1
University of Toronto; 2Toronto Rehabilitation Institute – UHN; 3William Osler Health System
Background/Objective: The aim of this workshop is to illustrate the application of functional electrical stimulation (FES) therapy for retraining upper extremity function, in particular grasping, in individuals with cervical level spinal cord injury (SCI). One of the most promising approaches to improve motor function in individuals with neurological ailments is FES. FES is a methodology that uses bursts of short electrical pulses to generate muscle contraction. In the last 15+ years, our team has explored the use of FES as a means to restore voluntary function in cervical level patients with SCI. In this therapeutic approach, patients consciously attempt to perform a predefined grasping tasks (e.g. opening a hand, palamar grasp, pinch grasp), and after a few seconds of trying, a therapist triggers a coordinated sequence of FES-induced muscle contractions in the forearm to produce the intended synergistic movement in the arm and hand. We have shown in various clinical trials that this FES therapy promotes changes in the neuronal circuitry by combining the patients’ intention to move and the sensory information resulting from the artificially produced movement. In this workshop, we will focus on explaining how this therapy works, how it should be administered, and what type of outcomes one can expect following the therapy completion.
610
The Journal of Spinal Cord Medicine
2014
VOL.
37
NO.
5
FUTURE DIRECTIONS IN CLINICAL GAIT AND POSTURAL BALANCE ANALYSIS AFTER SPINAL CORD INJURY – MOVING TOWARDS NOVEL GAIT TRAINING OPPORTUNITIES Hossein Rouhani 1,2, Daniel Schließmann 3, Matthias Schneiders 3, Norbert Weidner 3, Rüdiger Rupp3, Christian Schuld 3 1
Toronto Rehabilitation Institute – UHN; 2University of Toronto; 3Heidelberg University Hospital
Background/Objective: Gait and postural balance analysis provides objective information about improvements after spinal cord injury (SCI) rehabilitation and thus is widely applied for research and clinical evaluations. External feedback is an important component of motor learning and can be used in gait rehabilitation after incomplete SCI. In addition, ambulatory movement monitoring using wearable sensors has provided inexpensive and practical tools for gait and postural balance analysis. This technology can be used for both gait and postural balance training and health monitoring during daily life. Technical progress in the last years has made the following feasible: (1) real-time movement analysis systems allowing for novel feedbackassisted gait and balance therapies and (2) wearable systems for movement analysis including mobile health monitoring. This workshop provides an overview about the state-of-the-art of clinical movement analysis in SCI (including typical examples of common SCI gait patterns) and will demonstrate two currently running projects among the emerging fields in gait and postural balance training: gait therapy systems based on real-time feedback and applications of wearable systems for this purpose. Methods/Overview: (a) Feedback system: A commercial real-time motion analysis system (consisting of eight cameras and a custom-made treadmill) streams marker trajectories, analogue data, and model-based joint angles into the local area network with low latency. The new feedback system performs online low latency gait event detection to provide time–distance parameters as well as step cycle normalized joint angles as selectable feedback parameters. These parameters can be fed back visually (line graphs, absolute values, etc.), acoustically (mapping to auditory pitch, timbre or rhythm scales) or haptically (electrical simulation). The feasibility of this novel feedback-assisted gait training was demonstrated in a pilot study where individuals with chronic, incomplete SCI showed short-term performance increases and also mid-term learning effects. (b) Body-worn systems: The following steps for clinical implementation of body-worn systems in long-term (virtually unlimited) gait and postural balance analysis for SCI patients will be demonstrated: (1) configuration and calibration of wearable inertial sensor modules for gait and postural balance analysis, (2) design of clinical protocols to evaluate long-term gait and postural balance performance of individuals with SCI, (3) calculation of gait and postural balance parameters using inertial sensors, and (4) application of obtained parameters for clinical evaluations during daily life and for gait and postural balance therapy system based on real-time feedback.
608
© The Academy of Spinal Cord Injury Professionals, Inc. 2014 DOI 10.1179/1079026814Z.000000000342
The Journal of Spinal Cord Medicine
2014
VOL.
37
NO.
5
Abstracts
Results: N/A. Conclusions: Feedback-assisted gait training is a promising option for improving gait function. Application of wearable sensor technology for this purpose offers a convenient alternative compared to traditional gait laboratory instruments. Future work will combine both technologies to allow for a mobile and affordable gait analysis and gait feedback therapy device not only for SCI but also for other neurological and orthopaedic gait disorders.
Workshop #: PreW2
CLINICAL GUIDELINES FOR USE AND IMPLEMENTATION FOR THE GRADED REDEFINED ASSESSMENT OF STRENGTH SENSIBILITY AND PREHENSION (GRASSP) Sukhvinder Kalsi-Ryan1,2, Stephanie Hadi2, Sylvia Haycock 1,3, Jennifer Holmes 1,2 University Health Network; 2University of Toronto, Toronto Rehabilitation Institute – UHN; 3Galit Liffshiz & Associates Inc. 1
Background/Objective: GRASSP Version 1.0 is a clinical impairment measure designed specifically to assess the upper limb after traumatic cervical spinal cord injury. The Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP) consists of five subtest scores that characterize the upper limb; it captures subtle changes in neurological impairment during the acute, sub-acute, and chronic phases of recovery. Psychometric properties of reliability (inter/test retest), validity, responsiveness, and minimally detectable difference (MDD) have been established. Methods/Overview: A number of staged studies have been conducted to develop and validate the GRASSP. Studies include a multi-centre cross-sectional study for reliability and validity; a multi-centre longitudinal study to establish responsiveness, sensitivity, minimally clinical important difference, and MDD. Furthermore, with the iterative process of development and validation a standardized teaching/training module has been established. Results: Psychometric properties of the staged development of GRASSP will be presented and include reliability, validity, responsiveness, and MDD. The teaching and training will be conducted using a standardized teaching method. Conclusions: At the end of the session participants will be able to: • • • •
Administer the GRASSP independently, accurately score patient outcomes, and interpret the results; Evaluate and document the results, and determine the optimal use of longitudinal assessment; Identify the benefits of utilizing the GRASSP and indicate how the GRASSP can be applied in their clinical settings; Recommend how to enhance use and uptake of the GRASSP in their own clinical environments.
The GRASSP is a well-established method of assessment specific to the upper limb in tetraplegia. Enhancing the ways in which the tool can be applied clinically and within research related work is the current application of our efforts.
Workshop #: PreW3
ENHANCING INTER-PROFESSIONAL COLLABORATION DURING TEAM ROUNDS IN SPINAL CORD INJURY REHABILITATION THROUGH THE IMPLEMENTATION OF A DOMAIN-BASED, PATIENT-FOCUSED STRUCTURE Kristina Guy1, Sandra Mills 1, Carol Y. Scovil 1,2, Tess Devji 1,2, Heather M. Flett1,2 Toronto Rehabilitation Institute – UHN; 2University of Toronto
1
Background/Objective: The Spinal Cord Rehab Program (SCRP) at Toronto Rehabilitation Institute-UHN established an operating initiative aimed at creating an integrated approach to goal setting, patient and
The Journal of Spinal Cord Medicine
2014
VOL.
37
NO.
5
609
Abstracts
family education, and transition planning. Using Toronto Rehabilitation Institute’s Clinical Best Practice Process, a working group established the following objectives: to identify educational barriers, and enhance opportunities/exchanges; to enhance team communication and collaboration; to place patient and family securely within team processes; to reduce barriers and integrate transition of care through rehab into the community. Methods/Overview: Inter-professional team rounds provide a formal opportunity for team members to plan patient care and discuss transition plans. In the past, these meetings have been structured such that the information was sequentially presented from a discipline-specific perspective and focus. The working group developed a list of topic areas or domains which were introduced as a means of structuring the discussion during team rounds. Any team member may contribute to the domain-specific discussion as they are not aligned with any individual profession. These domains are also introduced to patients during the admission process to: (1) engage the patient in learning about all of the areas that may be impacted by a spinal cord injury, and (2) identify for the team which of the domains are most important to the patient. A panel consisting of representatives from the working group will present the implementation of the above-described approach. Following an overview of the project as a whole, the panel will specifically focus on the approach taken to develop and create the tools which have supported the evolution of team rounds towards a more inter-professional, “patient-as-partners” model. Results: The introduction of a domain-based structure to team rounds has resulted in discussions which are more collaborative with multiple team members contributing to the discussion about any one domain. The structure helps not only to ensure that the team’s care planning is comprehensive, but also that the patient’s priorities are the central focus. Conclusions: Participants in this workshop will achieve an understanding of the strategies undertaken by the SCRP team to enhance inter-professional collaboration and patient-centred focus during team rounds. We anticipate that the discussion will allow leaders to evaluate whether this approach would be beneficial in their setting and provide them with a framework for achieving similar results with their teams. Acknowledgements: Supported by the Toronto Rehabilitation Institute-UHN Brain and Spinal Cord Rehabilitation Program.
Workshop #: PreW4
IMPROVING VOLUNTARY GRASPING FUNCTION IN INCOMPLETE CERVICAL SPINE INJURY PATIENTS USING FUNCTIONAL ELECTRICAL STIMULATION THERAPY Milos R Popovic1,2, Naaz Kapadia Desai 2,3, Sylvia Daniel 1 1
University of Toronto; 2Toronto Rehabilitation Institute – UHN; 3William Osler Health System
Background/Objective: The aim of this workshop is to illustrate the application of functional electrical stimulation (FES) therapy for retraining upper extremity function, in particular grasping, in individuals with cervical level spinal cord injury (SCI). One of the most promising approaches to improve motor function in individuals with neurological ailments is FES. FES is a methodology that uses bursts of short electrical pulses to generate muscle contraction. In the last 15+ years, our team has explored the use of FES as a means to restore voluntary function in cervical level patients with SCI. In this therapeutic approach, patients consciously attempt to perform a predefined grasping tasks (e.g. opening a hand, palamar grasp, pinch grasp), and after a few seconds of trying, a therapist triggers a coordinated sequence of FES-induced muscle contractions in the forearm to produce the intended synergistic movement in the arm and hand. We have shown in various clinical trials that this FES therapy promotes changes in the neuronal circuitry by combining the patients’ intention to move and the sensory information resulting from the artificially produced movement. In this workshop, we will focus on explaining how this therapy works, how it should be administered, and what type of outcomes one can expect following the therapy completion.
610
The Journal of Spinal Cord Medicine
2014
VOL.
37
NO.
5
