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Background: Exoskeletons are used in rehabilitation centers for people with spinal cord injuries (SCI) due to the potential benefits they offer for locomotor rehabilitation. The acceptability of exoskeletons is crucial to promote rehabilitation and to ensure a successful implementation of this technology. The objective was to explore the acceptability of overground wearable powered exoskeleton used in rehabilitation among people with SCI. Methods : Fourteen individuals with SCI (9 men, mean [SD] age 47 years [14.8], a majority with traumatic and thoracic lesion (T6-T12)) who had utilized an exoskeleton in Canada or in France during their rehabilitation participated in a semi-structured interview. A thematic analysis using the theoretical framework of acceptability was carried out. Results : Participants were motivated to use an exoskeleton during their rehabilitation. They reported several perceived benefits to its use, including better walking pattern, increased endurance, and greater muscle mass. They also experienced mild pain, notable concentration demands, and fatigue. Most participants reported that using exoskeletons in their rehabilitation process was appropriate and relevant to them. Conclusions : Exoskeletons are generally well accepted by participants in this study. Adjustments in their use, such as conducting training sessions in obstacle-free environment and technological improvements to address the device's restrictive characteristics, heaviness, and massiveness are however still needed.

Background: In Canada, primary care reforms led to the implementation of various team-based care models to improve access and provide more comprehensive care for patients. Despite these advances, ongoing challenges remain. The aim of this scoping review is to explore current understanding of the functioning of these care models as well as the contexts in which they have emerged and their impact on the population, providers and healthcare costs., Methods: The Medline and CINAHL databases were consulted. To be included, team-based care models had to be co-located, involve a family physician, specify the other professionals included, and provide information about their organization, their relevance and their impact within a primary care context. Models based on inter-professional intervention programs were excluded. The organization and coordination of services, the emerging contexts and the impact on the population, providers and healthcare costs were analysed., Results: A total of 5952 studies were screened after removing duplicates; 15 articles were selected for final analysis. There was considerable variation in the information available as well as the terms used to describe the models. They are operationalized in various ways, generally consistent with the Patient's Medical Home vision. Except for nurses, the inclusion of other types of professionals is variable and tends to be associated with the specific nature of the services offered. The models primarily focus on individuals with mental health conditions and chronic diseases. They appear to generally satisfy the expectations of the overarching framework of a high-performing team-based primary care model at patient and provider levels. However, economic factors are seldom integrated in their evaluations., Conclusions: The studies rarely provide an overarching view that permits an understanding of the specific contexts, service organization, their impacts, and the broader context of implementation, making it difficult to establish universal guidelines for the operationalization of effective models. Negotiating the inherent complexity associated with implementing models requires a collaborative approach between various stakeholders, including patients, to tailor the models to the specific needs and characteristics of populations in given areas, and reflection about the professionals to be included in delivering these services., (© 2024. The Author(s).)

Purpose: Multiple healthcare professionals fit walking aids (WA) and train individuals on their use. The purpose of this investigation was to describe curricula on WA fitting and training in Canadian entry-to-practice professional programs., Materials and Methods: An online survey was administered to leads from all accredited programs ( n  = 199). Seventeen questions asked about the importance of WA education, instructional methods and time dedicated to WA fitting and skills training, and how the pandemic had affected WA curriculum delivery., Results: Responses were received from 97 programs. While most occupational therapy (OT, 8/15), physiatry (PM&R, 5/9), and physical therapy (PT, 12/19) trainees received more than 3 h of instruction on WA fitting, most nursing (29/40) and pharmacy (7/8) programs spent less than 3 h on this topic. Most OT (9/15) and PT (15/19) programs spent more than 3 h on WA skills training whereas most nursing (25/40), pharmacy (4/8), and PM&R (5/9) programs spent less than 3 h on this subject. Across all programs, 52% educated students on adapting activities of daily living for WA while 18% provided education on WA maintenance and repair. Only 19/89 programs consulted a formal WA skills training resource for curriculum development. Seventeen of 55 programs modified their WA curricula due to the pandemic., Conclusions: There is a wide range in curricular approaches to WA education in Canadian professional programs. This highlights the need for a standardised WA education program to guide curricular development to ultimately improve safe WA use for clients with short- and long-term mobility impairments.IMPLICATIONS FOR REHABILITATIONCurricula on walking aids is extremely variable within and between programs.Navigating terrains, adapting activities of daily living, and maintenance are poorly taught.There is a need for a national standardized curriculum on walking aids.This curriculum should be modular and designed for practitioners, students, and patients.

Background: Wearable powered exoskeletons represent a promising rehabilitation tool for locomotor training in various populations, including in individuals with a spinal cord injury. The lack of clear evidence on how to implement a locomotor powered exoskeleton training program raises many challenges for patients, clinicians and organizations., Objective: To report determinants of implementation in clinical practice of an overground powered exoskeleton locomotor training program for persons with a spinal cord injury., Data Sources: Medline, CINAHL, Web of Science., Study Selection: Studies were included if they documented determinants of implementation of an overground powered exoskeleton locomotor training program for individuals with spinal cord injury., Data Extraction: Eligible studies were identified by two independent reviewers. Data were extracted by one reviewer, based on constructs of the Consolidated Framework for Implementation Research, and validated by a second reviewer., Results: Sixty-three articles were included. 49.4% of all determinants identified were related to the intervention characteristics, 29.6% to the individuals' characteristic and 13.5% to the inner setting. Recurrent barriers identified were the high prevalence of adverse events (e.g., skin issues, falls) and device malfunctions. Adequate training for clinicians, time and resource available, as well as discussion about patients' expectations were identified as facilitators., Conclusions: Powered exoskeleton training is a complex intervention. The limited information on the context and the implementation process domains may represent a barrier to a successful transition from knowledge to action.

Despite decades of research establishing the importance of breastfeeding, skin-to-skin contact and mother-infant closeness, the response to the coronavirus disease 2019 (COVID-19) pandemic has underscored the hidden assumption that these practices can be dispensed with no consequences to mother or child. This article aims to support shared decision-making process for infant feeding and care with parents and health care providers during the unprecedented times of the pandemic. It proposes a structure and rationale to guide the process that includes (1) discussing with parents evidence-based information and the different options to feed and care for an infant and young child in the context of the pandemic as well as their potential benefits, risks and scientific uncertainties; (2) helping parents to recognize the sensitive nature of the decisions and to clarify the value they place on the different options to feed and care for their infant or young child; and (3) providing guidance and support needed to make and implement their decisions. A shared decision-making process will help parents navigate complex feeding and care decisions for their child as we face the different stages of the COVID-19 pandemic., (© 2021 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world., (© 2021 Author(s).)

Background: Older adults are at greater risk of falls while descending stairs. Cognitive deficits can further influence one's ability and mild cognitive impairments (MCI) specifically affect visual attention and dual tasking behavior. The present study aimed at comparing the attentional costs at different points during the approach to and descent of a staircase between older adults with and without MCI., Methods: Eleven older adults with MCI and twenty-three healthy older individuals without cognitive impairments were recruited. Neuropsychological tests were carried out. In addition, participants approached and descended a 5-step staircase while a simultaneous visual Stroop dual-task was randomly introduced during the approach, transition or steady state descent phases across trials. Three-dimensional kinematics and accuracy on the Stroop task were analyzed and dual task costs were calculated., Results: The MCI group showed deficits for visuo-spatial attention, memory and multi-tasking abilities, as well as balance and decreased confidence for falls efficacy, but not for daily activity scores. Despite such changes, this group of community-dwelling individuals with MCI presented a functional capacity to descend stairs even during divided visual attention. However, there were subtle, but significant, group differences for movement fluidity and performance on the simultaneous cognitive task, particularly during the approach and transition to descent phases. The MCI group also tended to descend slower while using the handrails more than healthy older adults., Conclusion: The present cohort of community-dwelling older adults with MCI were functional, but appeared to prioritize locomotor demands over the simultaneous cognitive task in a possible "posture first" strategy to descend stairs. The present findings should be considered for developing more ecologically based clinical assessments of mobility deficits following cognitive impairments, with the approach and transition phases during stair descent as key points of focus., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To determine the possible relationship between pain experienced by mothers with breastfeeding and musculoskeletal impairment commonly seen in physiotherapy practice. Evidence-based principles of the evaluation and treatment of musculoskeletal impairment used in physiotherapy practice were applied and adapted to manage pain experienced by mothers with breastfeeding. Subjects and Methods: This report describes 11 mothers referred to a breastfeeding clinic for pain with breastfeeding. Mothers were initially assessed by a physician and a nurse clinician, both International Board-Certified Lactation Consultants, to rule out causes of breast or nipple pain. When the cause remained unexplained, it was deemed musculoskeletal, and mothers were referred to a physiotherapist for assessment and treatment with manual orthopedic therapy and mobilization of the myofascial system. Results: The physiotherapist's objective musculoskeletal assessment and mothers' impression showed an improvement in the overall clinical picture after the first appointment in most mothers. Pain was resolved or alleviated by 80% in five mothers after 1-3 weekly treatments. The most useful therapeutic approach was to make afflicted mothers aware of their posture to maintain spinal alignment and avoid shear posture (lateral displacement of the trunk). Shear posture is a consequence of sitting leaning to one side. This posture is exacerbated by thoracic rotation and flexion, for example, when turning the trunk and bending over the baby while giving the breast. Conclusion: Treating musculoskeletal impairment referred pain to the breast or nipple with physiotherapy practices used in a nonbreastfeeding clientele can help alleviate or resolve pain with breastfeeding.

Objective: To understand family physicians' perceptions of Manitoba's strategies for primary care renewal or reform (PCR)., Design: Qualitative substudy of an explanatory case study., Setting: Rural and urban Manitoba., Participants: A total of 60 family physicians (31 fee-for-service physicians, 26 alternate-funded physicians, and 3 physicians representing provincial physician organizations)., Methods: Semistructured interviews and focus groups., Main Findings: Many physicians were hesitant to participate in PCR initiatives, perceiving clear risks but uncertain benefits to patients and providers. Additional barriers to participation included concerns about the adequacy and import of communication about PCR, the meaningfulness of opportunities for physician "voice," and the trustworthiness of decision makers. There was an appetite for tailored, clinic-level support in addressing concrete, physician-identified problems; however, the initiatives on offer were not widely viewed as providing such support., Conclusion: Although some of the observed barriers might fade over time, concentrating PCR efforts on the everyday realities of family physician practice might be the best way to build a primary care system that works for patients and providers., (Copyright© the College of Family Physicians of Canada.)

Primary care reform cannot succeed without substantive change on the part of providers. In Canada, these are mostly fee-for-service physicians, who tend to regard themselves as independent professionals and not under managerial sway. Hence, policymakers must balance two conflicting imperatives: ensuring the acceptability of renewal efforts to these physicians while enforcing their accountability for defined actions or outcomes. In its 2011-15 strategy to improve access to primary care, the province of Manitoba introduced several linked initiatives, each striving to blend acceptability- and accountability-promoting elements. Clearly delimited initiatives that directly promoted a specific observable behaviour (accountability) through financial or non-financial support (acceptability) were most successfully implemented. System-wide initiatives with complicated designs (notably a primary care network model that established formal partnership among clinics and regional health authorities) encountered greater difficulties in recruiting and sustaining physician participation. Although such initiatives offered physicians considerable decision-making latitude (acceptability), many physicians questioned the meaningfulness of opportunities for voice within a predetermined structure (accountability). Moreover, policymakers struggled to enhance the acceptability of such initiatives without sacrificing strong accountability mechanisms. Policymakers must carefully consider how acceptability and accountability elements may interact, and design them in such a way as to minimize the risk of mutual interference., (Copyright © 2019. Published by Elsevier B.V.)

Purpose: Healthcare policymakers and managers struggle to engage private physicians, who tend to view themselves as independent of the system, in new models of primary care. The purpose of this paper is to examine this issue through a social identity lens., Design/methodology/approach: Through in-depth interviews with 33 decision-makers and 31 fee-for-service family physicians, supplemented by document review and participant observation, the authors studied a Canadian province's early efforts to engage physicians in primary care renewal initiatives., Findings: Recognizing that the existing physician-system relationship was generally distant, decision-makers invested effort in relationship-building. However, decision-makers' rhetoric, as well as the design of their flagship initiative, evinced an attempt to proceed directly from interpersonal relationship-building to the establishment of formal intergroup partnership, with no intervening phase of supporting physicians' group identity and empowering them to assume equal partnership. The invitation to partnership did not resonate with most physicians: many viewed it as an inauthentic offer from an out-group ("bureaucrats") with discordant values; others interpreted partnership as a mere transactional exchange. Such perceptions posed barriers to physician participation in renewal activities., Practical Implications: The pursuit of a premature degree of intergroup closeness can be counterproductive, heightening physician resistance., Originality/value: This study revealed that even a relatively subtle misalignment between a particular social identity management strategy and its intergroup context can have highly problematic ramifications. Findings advance the literature on social identity management and may facilitate the development of more effective engagement strategies.

We explored the particularities of the Healthy Baby Prenatal Benefit (HBPB), an unconditional cash transfer program for low-income pregnant women in Manitoba, Canada, which aims to connect recipients with prenatal care and community support programs, and help them access healthy foods during pregnancy. While previous studies have shown associations between HBPB and improved birth outcomes, here we focus on how the intervention contributed to positive outcomes. Using a case study design, we collected data from government and program documents and interviews with policy makers, academics, program staff, and recipients of HBPB. Key informants identified using evidence and aligning with government priorities as key facilitators to the implementation of HBPB. Program recipients described how HBPB helped them improve their nutrition, prepare for baby, and engage in self-care to moderate the effect of stressful life events. This study provides important contextualized evidence to support government decision making on healthy child development policies.

Two crucial, multi-articular strategies for anticipatory locomotor adjustments (ALA) are knee flexor generation to step over obstacles and hip flexor generation to step up. While lower limb control can be adapted online to modify an already planned obstacle avoidance, or to avoid the sudden appearance of an obstacle, it is not known whether a planned ALA can be substituted by different one online. The present objective was to study such ALA substitutions at two specific timepoints: the final planning stage and the initiation of ALA execution. Ten healthy, young adults (22.0 ± 1.7 years; 5 males) walked in a Virtual Environment (VE) representing the laboratory within a head mounted display. Two blocks of trials, one involving an initial VE with an obstacle (OB) and the other an initial VE with a platform (PL) (heights of 15% of lower limb length for both), were presented, where the initial VE could remain unchanged or be randomly switched between them at one of the two timepoints. The final VE always corresponded to the real environment. Lead limb kinematics, joint kinetics and energetics, as well as electromyography were measured. Repeated measures ANOVAs were used to compare across conditions. Foot clearance, knee flexor generation, and hip flexor generation all changed in the expected directions for the final VEs when requiring early substitution, but not when switched late. These findings show that volitional, locomotor strategies may be substituted at the end of the ALA planning phase, but not once execution is initiated.

Background: Mobility limitations represent the third most prevalent cause of disability, affecting more than 1.9 million community-dwelling Canadians. Walking aids are often prescribed to reduce the impacts of mobility impairments. There are limited data on walking aids since 2004., Objective: The objectives of this study were to investigate the prevalence of walking aid use in Canada and to explore demographic characteristics among users of walking aids., Design: The design used was a secondary analysis of a cross-sectional national survey., Methods: Data were obtained from the 2012 Canadian Survey on Disability from community-dwelling individuals who were 15 years old or older, had a self-identified activity limitation, and indicated that they used at least 1 walking aid (cane/walking stick/crutches or walker). Prevalence estimates were calculated as weighted frequencies. Analytic variables included walking aid type, sex, age, province/territory of residence, and main cause of activity limitation., Results: Approximately 1,125,000 community-dwelling individuals who were 15 years old or older used walking aids, representing 4.1% of the Canadian population. Of these individuals, 962,290 used canes/walking sticks/crutches, and 465,340 used a walker. Users of walking aids were predominantly female, with a mean age of 68 years., Limitations: Self-reported results reflect only the perceptions of individuals living in Canadian communities. Analyses excluded individuals in residential or long-term care settings and individuals living on First Nations reserves., Conclusions: Since 2004, there has been a 2% increase in the prevalence of walking aid use by the Canadian population, which is likely related to the aging of the population. The high prevalence of walking aid use highlights the need for better use of existing resources to ensure that individuals are receiving the correct devices. Results of this study suggest a need to evaluate the impact of device use to better understand how resources should be allocated for prescription and maintenance of walking aids and training of users.

Many individuals, such as persons with spinal cord injury (SCI), rely on wheeled locomotion involving manual (MWC) or power (PWC) wheelchairs to navigate their environments. Yet, visuo-locomotor control underlying WC navigation in experienced users is not well understood. The objective of this study was to compare the visuo-locomotor control between MWC and PWC in individuals with SCI while changing direction and circumventing an obstacle. Participants with SCI using a MWC (n = 12, 38.5 ± 10.7 years) or a PWC (n = 10, 47.8 ± 8.6 years) were asked to maneuver their chair straight ahead, while changing direction 45° to the right, and while circumventing an obstacle to the right, all at self-selected speeds. Speed, minimal clearance, point of deviation, temporal body and WC coordination, relative timing of segment rotations and visual behavior were analyzed. There was no main effect of group for speed, clearance and point of deviation. During direction change, the head always led body and wheelchair reorientation while an "en bloc" strategy was used for circumventing obstacle for both groups. In straight-ahead locomotion, participants predominantly fixed their gaze on the end target. During direction change and obstacle circumvention, participants fixated more on the future path and the obstacle for both WC modes. Overall, specific gaze behavior depended on environmental demands. While MWC and PWC users adopt similar navigational strategies and visuo-locomotor coordination while changing direction and circumventing obstacle, there were some differences in the amount of head rotation that could be related to a counter-movement used more by PWC users.

Background: In Manitoba, Canada, school-based clinics providing sexual and reproductive health services for adolescents have been implemented to address high rates of sexually transmitted infections (STIs) and pregnancies., Methods: The objectives of this population-based study were to compare pregnancy and STI rates between adolescents enrolled in schools with school-based clinics, those in schools without clinics, and those not enrolled in school. Data were from the PATHS Data Resource held in the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy. Adolescents aged 14 to 19 between 2003 and 2009 were included in the study. Annualized rates of pregnancies and positive STI tests were estimated and Poisson regression models were used to test for differences in rates amongst the three groups., Results: As a proportion, pregnancies among non-enrolled female adolescents accounted for 55 % of all pregnancies in this age group during the study period. Pregnancy rates were 2-3 times as high among non-enrolled female adolescents. Compared to adolescents enrolled in schools without school-based clinics, age-adjusted STI rates were 3.5 times (p < .001) higher in non-enrolled males and 2.3 times (p < .001) higher in non-enrolled females., Conclusions: The highest rates for pregnancies and STIs were observed among non-enrolled adolescents. Although provision of reproductive and health services to in-school adolescents should remain a priority, program planning and design should consider optimal strategies to engage out of school youth.

Essential fatty acids (EFAs) are primarily generated by phytoplankton in aquatic ecosystems, and can limit the growth, development, and reproduction of higher consumers. Among the most critical of the EFAs are highly unsaturated fatty acids (HUFAs), which are only produced by certain groups of phytoplankton. Changing environmental conditions can alter phytoplankton community and fatty acid composition and affect the HUFA content of higher trophic levels. Almost no research has addressed intraspecific variation in HUFAs in zooplankton, nor intraspecific relationships of HUFAs with body size and fecundity. This is despite that intraspecific variation in HUFAs can exceed interspecific variation and that intraspecific trait variation in body size and fecundity is increasingly recognized to have an important role in food web ecology (effect traits). Our study addressed the relative influences of abiotic selection and food web effects associated with climate change on intraspecific differences and interrelationships between HUFA content, body size, and fecundity of freshwater copepods. We applied structural equation modeling and regression analyses to intraspecific variation in a dominant calanoid copepod, Leptodiatomus minutus, among a series of shallow north-temperate ponds. Climate-driven diurnal temperature fluctuations favored the coexistence of diversity of phytoplankton groups with different temperature optima and nutritive quality. This resulted in unexpected positive relationships between temperature, copepod DHA content and body size. Temperature correlated positively with diatom biovolume, and mediated relationships between copepod HUFA content and body size, and between copepod body size and fecundity. The presence of brook trout further accentuated these positive effects in warm ponds, likely through nutrient cycling and stimulation of phytoplankton resources. Climate change may have previously unrecognized positive effects on freshwater copepod DHA content, body size, and fecundity in the small, shallow bodies of inland waters that are commonly found in north-temperate landscapes.