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Aisha K Lofters,1–3,* Sara JT Guilcher,1,3,4,* Lauren Webster,1 Richard H Glazier,1–3 Susan B Jaglal,1 Ahmed M Bayoumi,1,3 1Institute for Clinical Evaluative Sciences, 2Department of Family and Community Medicine, St Michael’s Hospital, University of Toronto, 3Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, 4Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada *These authors contributed equally to this work Purpose: Despite more frequent use of health services by people living with disability, the quality of preventive care received may be suboptimal. In this retrospective cohort study, we used administrative data to examine the relationship between cholesterol testing and levels of disability and morbidity among women and men in Ontario, Canada. Methods: We linked multiple provincial-level databases in this study. In stratified analyses for women and men, we used multivariable logistic regression to examine differences in cholesterol testing, and we tested for an interaction effect between disability and morbidity. In a secondary analysis, we tested for a three-way interaction between sex, disability, and morbidity on the entire cohort. Results: There was an interaction between morbidity and disability for both women and men. Women and men with no chronic conditions appeared to be least likely to be up-to-date on cholesterol testing, and among this group, those with moderate disability were more likely to be up-to-date on cholesterol testing than those with no disability (adjusted odds ratio [AOR] =1.51; 95% confidence interval [CI] 1.20–1.90 for women; AOR =1.16; 95% CI 1.00–1.34 for men). Among women and men who had one chronic condition, having severe disability put them at significant disadvantage versus those with no disability. Only 58.5% of men with no disability and no chronic conditions were up-to-date on cholesterol testing. Conclusion: An intermediate level of health care need (reflected in this study as level of disability and level of morbidity) may provide a benefit for cholesterol testing, and conversely, health care needs that are too few or too great may negatively affect testing. Public health and practice-based interventions need to be explored to address these findings. Keywords: primary care, preventative care, cholesterol testing, disability, morbidity

Background/objective: The purpose of this study was to investigate the impact of the COVID-19 pandemic on mortality rates in a community-dwelling spinal cord injury (SCI) population in Ontario., Methods: Using health administrative databases, monthly mortality rates were evaluated pre-pandemic, during the pandemic, and post-pandemic from March 2014 to May 2024. Data were stratified by sex, injury etiology, and mental health status. Group differences were evaluated using t -tests. Autoregressive integrated moving average (ARIMA) models evaluated the pandemic's impact on mortality rates., Results: A significant increase of 21.4% in mortality rates during the pandemic was found for the SCI cohort. With the exception of the traumatic group, all subgroups also experienced a significant increase in mortality rates (males: 13.9%, females: 31.9%, non-traumatic: 32.3%, mental health diagnoses: 19.6%, and mental health diagnoses: 29.4%). During the pandemic, females had a significantly higher mortality rate than males. The non-traumatic group had higher mortality rates than the traumatic group at all time periods. Individuals with mental health diagnoses had higher mortality rates than those without at the pre-pandemic and pandemic periods., Conclusions: The variation in mortality rates across groups highlights inequitable access to medical care in the SCI population, with further research and interventions needed.

Persons with disabilities experience numerous barriers to healthcare access including vaccine accessibility. The purpose of this study was to determine COVID-19 vaccine uptake in the spinal cord injury and disease (SCI/D) population of Ontario and identify potential factors influencing C OVID-19 vaccine uptake. This was a retrospective closed-cohort study using administrative health data on individuals with SCI/D of traumatic and non-traumatic causes to examine the monthly number of COVID-19 vaccine doses received between December 2020 and December 2023. Logistic regression analysis was used to examine the potential association between socio-demographic, clinical, and neighbourhood characteristics with initial COVID-19 vaccine receipt and booster dose uptake. By the end of the observation period in December 2023, 82.9% received the full two-dose coverage and 65.6% received at least one additional booster dose in a cohort of 3574 individuals with SCI/D. SCI/D individuals showed a comparable COVID-19 vaccine uptake percentage to the general population. Sociodemographic, clinical, and neighbourhood characteristics were associated with COVID-19 vaccine uptake in the SCI/D population, including age, type of injury, number of comorbidities, mental health history, and neighbourhood characteristics such as income. Further investigation is necessary to determine the causation effects of these relationships with vaccine uptake to address health equity concerns.

Purpose: To explore how healthcare partners in community-based exercise programs for people with balance and mobility limitations perceive and enact referral in the context of their role., Materials and Methods: We conducted a descriptive, qualitative study involving semi-structured interviews and reflexive thematic analysis., Results: Twelve healthcare partners from the Together In Movement and Exercise (TIME TM ) program completed interviews. Seven (58%) participants were clinicians and 5 (42%) held non-clinical roles. The most common professional background of participants was physical therapy ( n  = 9, 75%). Clinicians made direct referrals while non-clinical participants facilitated referral by promoting the program. The main theme was healthcare partners perceive their role in referrals as secondary to their role as educators and trainers. Subthemes were: (1) healthcare partners fulfill educator and trainer roles when conducting formal training of instructors, educating instructors during program visits, and fielding questions; (2) almost all healthcare partners facilitate referral by sharing program information formally and informally; and (3) healthcare partners in clinical practice make direct referrals depending on the clientele., Conclusions: Healthcare partners perceive their roles as educators and trainers as taking precedence over their role in referrals. Findings can be used to guide selection and training of healthcare partners, design of clinical education programs, and research on competencies.

Study Design: Descriptive repeated-cross sectional retrospective longitudinal cohort study., Objective: To investigate the impact of the COVID-19 pandemic on homecare services in individuals with traumatic or non-traumatic Spinal Cord Injury (SCI)., Setting: Health administrative database in Ontario, Canada., Methods: A repeated cross-sectional study using linked health administrative databases from March 2015 to June 2022. Monthly homecare utilization was assessed in 3381 adults with SCI using Autoregressive Integrated Moving Average (ARIMA) models., Results: Compared to pre-pandemic levels, between March 2020 to June 2022, the traumatic group experienced a decrease in personal and/or homemaking services, as well as an increase in nursing visits from April 2020-March 2022 and June 2022. Case management increased at various times for the traumatic group, however therapies decreased in May 2020 only. The non-traumatic group experienced a decrease in personal and/or homemaking services in July 2020, as well as an increase in nursing visits from March 2020 to February 2021 and sporadically throughout 2020. Case management also increased at certain points for the non-traumatic group, but therapies decreased in April 2020, July 2020, and September 2021., Conclusion: The traumatic group had decreases in personal and/or homemaking services. Both groups had increases in nursing services, increases in case management, and minimal decreases in therapies at varying times during the pandemic. Investigation is warranted to understand the root cause of these changes, and if they resulted in adverse outcomes., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Introduction: For individuals with mobility limitations, virtual exercise programmes can address the challenges of in-person participation in community exercise programmes. A synthesis of studies of virtual exercise programmes targeting mobility limitations provided outside of conventional rehabilitation services and strategies used to optimise equitable access and inclusivity in these programmes is lacking. We aim to characterise evaluations of virtual exercise programmes for adults with mobility limitations, and the nature of and extent to which equity, diversity and inclusion considerations are integrated in the research process., Methods and Analysis: A scoping review following a six-stage methodological framework, including a consultation exercise, is proposed. A comprehensive strategy will be used to search Medline, Embase, PEDro, CINAHL and Scopus to identify peer-reviewed studies evaluating virtual exercise programmes for adults with mobility limitations living in the community. Three trained reviewers will select studies independently. Data (eg, study methodology, programme structure and content, participant characteristics) will be extracted using a standardised form, and collated and summarised using quantitative and qualitative methods. The PROGRESS-Plus and International Classification of Functioning, Disability and Health frameworks will be used to classify participant characteristics and study outcomes, respectively. During the consultation exercise, key knowledge users, including exercise participants, programme providers and coordinators, and members of community organisations for persons living with disabilities and under-represented groups, will be asked to provide insights regarding the applicability of review findings. A directed content analysis of data from the consultation exercise will be performed., Ethics and Dissemination: The research ethics board at the University of Toronto approved the consultation exercise. Findings will be disseminated through peer-reviewed publications and conference presentations. Findings will enhance understanding of current research evaluating virtual exercise programmes and inform future research and strategies for promoting equitable access and outcomes for individuals with mobility limitations., Registration Details: https://doi.org/10.17605/OSF.IO/X5JMA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Pelvic health physiotherapy is an emerging and sensitive area of practice that offers effective conservative treatment for pelvic health conditions. Canadian entry-to-practice curriculum guidelines accord programs considerable flexibility regarding incorporating pelvic health content, which may lead to differences between programs and diverse levels of competence among new graduates. The purpose of this study was to determine the nature and extent to which pelvic health content is incorporated in entry-to-practice physiotherapy programs in Canada., Method: We conducted a descriptive cross-sectional e-survey of representatives from Canadian entry-to-practice physiotherapy programs., Results: Ten out of 15 Canadian programs participated. Programs incorporated pelvic health content throughout the required curriculum ( n = 9) and in optional courses ( n = 6). All participating programs covered musculoskeletal-related conditions, urinary incontinence, and pelvic pain conditions, and included anatomy and physiology, clinical reasoning, subjective assessment and pelvic floor muscle training topics. Three programs trained students in internal pelvic floor techniques in elective courses. All programs covered cisgender women populations, however, transgender populations were seldom covered., Conclusions: This study provides an understanding of pelvic health curricular content that can serve as a first step towards standardizing and improving entry-level pelvic health training in Canada., Competing Interests: Competing Interests: The authors declare that there is no conflict of interest. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors., (© Canadian Physiotherapy Association, 2024.)

Background: Individuals with spinal cord injuries or disease (SCI/D) require frequent healthcare services. The COVID-19 pandemic may have impacted healthcare. Furthermore, due to secondary health conditions and comorbidities persons with SCI/D are at increased risk of experiencing severe symptoms or outcomes if infected with the COVID-19 virus. It is unclear to what extent research has investigated the pandemic and virus impacts on the SCI/D population., Objective: To identify and summarize what is reported in the literature on the impact the COVID-19 virus and pandemic had on healthcare, health outcomes, and experiences in the adult SCI/D population., Methods: Electronic databases and grey literature were searched for articles that included an adult population with a SCI/D and investigated the impact the COVID-19 virus and pandemic had on healthcare-related outcomes and experiences. Articles were double screened, and data were extracted, and synthesized to provide a descriptive summary of the findings., Results: Twenty-four studies were included in this review with eight qualitative, fifteen quantitative, and one mixed methods study. Sixteen studies investigated healthcare utilization/access; nine investigated care delivery, nine investigated patient outcomes, and eight investigated patient experiences, with multiple studies spanning different categories of investigation. The pandemic was detrimental to healthcare utilization, access, and outcomes, but no studies quantified these changes. Virtual care was well-received by the SCI/D population to maintain continuity of care. The SCI/D population had issues with maintaining caregiving support. It was unclear if the COVID-19 virus infection impacted individuals with SCI/D differently than the general population., Conclusions: This scoping review found the pandemic negatively impacted multiple aspects of healthcare in individuals with SCI/D, however further investigation on health outcomes is required. More research, particularly large-scale quantitative studies, investigating healthcare access, utilization, and delivery, as well as patient outcomes and experiences is needed to improve care in the SCI/D population post-pandemic onset., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Senthinathan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Study Design: A retrospective cross-sectional study., Objective: To identify who prescribes outpatient antibiotics among a primary care spinal cord injury (SCI) cohort., Setting: ICES databases in Ontario, Canada., Methods: A cohort of individuals with SCI were retrospectively identified using a tested-algorithm and chart reviews in a primary care electronic medical records database. The cohort was linked to a drug dispensing database to obtain outpatient antibiotic prescribing information, and prescriber details were obtained from a physician database., Results: Final cohort included three hundred and twenty individuals with SCI. The average annual number of antibiotic courses dispensed for the SCI cohort was 2.0 ± 6.2. For dispensed antibiotics, 58.9% were prescribed by rostered-primary care practice physicians, compared to 17.9% by emergency and non-rostered primary care physicians, 17.4% by specialists and 6.1% by non-physician prescribers. Those who lived in urban areas and rural areas, compared to those who lived in suburban areas, were more likely to receive antibiotics from emergency and non-rostered primary care physicians than from rostered-primary care practice physicians., Conclusion: Although individuals with SCI received outpatient antibiotic prescriptions from multiple sources, physicians from an individual's rostered-primary care practice were the main antibiotic prescribers. As such, interventions to optimize antibiotics use in the SCI population should target the primary care practice., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Competing Interests: Intérêts concurrents : Lora Giangregorio déclare avoir reçu des honoraires d’Amgen Inc. pour une conférence donnée sur l’exercice physique, hors du cadre du présent manuscrit, sans mention de médicaments. La Dre Giangregorio est également membre du conseil consultatif scientifique d’Ostéoporose Canada et coresponsable du Groupe d’intérêt spécial sur la fracture vertébrale du Fragility Fracture Network. Sandra Kim déclare qu’Ostéoporose Canada lui a offert le soutien d’une personne spécialiste de la méthodologie GRADE (Grading of Recommendations, Assessment, Development and Evaluations) à l’Université McMaster au cours de l’étude. De 2017 à 2020, la Dre Kim a aussi été membre bénévole du conseil d’administration d’Ostéoporose Canada. Nancy Santesso déclare avoir reçu une rémunération versée à son établissement (Université McMaster) afin d’apporter son expertise de l’outil GRADE à l’élaboration des lignes directrices et à la préparation de contenus au cours de l’étude. La Dre Santesso a aussi reçu du soutien d’Ostéoporose Canada pour se rendre aux réunions sur les lignes directrices. Heather McDonald-Blumer déclare avoir reçu des honoraires de consultation d’Eli Lilly et de Novartis pour sa présence à des conseils consultatifs, sans lien avec les présents travaux. Rowena Ridout est membre du conseil d’administration d’Ostéoporose Canada depuis 2020 (aucune rémunération perçue). Neil Binkley déclare avoir reçu une subvention de recherche (versée à son établissement) de Radius, ainsi que des frais de consultation et des honoraires d’Amgen. Angela Cheung a reçu des honoraires d’Amgen et des Laboratoires Paladin à titre de consultante. La Dre Cheung a aussi été membre du comité des lignes directrices cliniques de l’Endocrine Society, coprésidente du programme de santé postménopause de l’American College of Obstetrics and Gynecology et vice-présidente et coresponsable de la Conférence de prise de position 2023 de la Société internationale de densitométrie clinique. Robert Josse déclare avoir reçu des frais de consultation d’Amgen Canada, des Laboratoires Paladin et d’Alexion, ainsi que des honoraires d’Amgen et d’Alexion. Le Dr Josse a aussi participé à des comités consultatifs pour Amgen, Paladin, Alexion et Ultragenyx. Aliya Khan a reçu des subventions de recherche d’Alexion, d’Amgen Canada, de Takeda, d’Ascendis, de Chugai, de Radius, d’Amolyt et d’Ultragenyx, ainsi que des honoraires de conférencière d’Amgen, d’Alexion, d’Ascendis, de Takeda et d’Ultragenyx. La Dre Khan a également participé à des comités consultatifs pour Amgen Canada, Alexion, Amolyt, Ascendis et Takeda. E. Lynn Izumi Nash déclare que le Collège des médecins de famille de l’Ontario lui a versé des honoraires pour la conception d’ateliers de formation médicale continue sur l’ostéoporose. La Dre Nash est aussi membre du conseil consultatif scientifique d’Ostéoporose Canada (à titre bénévole). Zahra Bardai déclare avoir reçu des honoraires en tant que membre du comité de planification scientifique de Pri-Med Canada depuis 2011 et en tant que créatrice du Programme d’apprentissage basé sur la pratique en petit groupe de la Fondation pour l’éducation médicale continue, à l’Université McMaster. La Dre Bardai est aussi membre bénévole du conseil consultatif scientifique d’Ostéoporose Canada. Suzanne Cadarette déclare avoir reçu des subventions de recherche (versées à son établissement) en tant que cochercheuse principale pour des projets financés par les Instituts de recherche en santé du Canada et les National Institutes of Health. Heather Frame a siégé au conseil d’administration d’Ostéoporose Canada jusqu’en novembre 2020. Kaleen Hayes déclare avoir reçu des subventions de recherche à l’initiative des chercheurs du National Institute on Aging, d’Insight Therapeutics, de Genentech et de Sanofi (versées directement à son établissement), et des honoraires de consultation de l’Agence canadienne des médicaments et des technologies de la santé. Alexandra Papaioannou a fait partie d’un comité consultatif et de services de conférenciers et conférencières et a reçu des honoraires d’Amgen Canada. Christine Thomas a été membre du conseil d’administration d’Ostéoporose Canada à différentes périodes.

Background: In Canada, more than 2 million people live with osteoporosis, a disease that increases the risk for fractures, which result in excess mortality and morbidity, decreased quality of life and loss of autonomy. This guideline update is intended to assist Canadian health care professionals in the delivery of care to optimize skeletal health and prevent fractures in postmenopausal females and in males aged 50 years and older., Methods: This guideline is an update of the 2010 Osteoporosis Canada clinical practice guideline on the diagnosis and management of osteoporosis in Canada. We followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and quality assurance as per Appraisal of Guidelines for Research and Evaluation (AGREE II) quality and reporting standards. Primary care physicians and patient partners were represented at all levels of the guideline committees and groups, and participated throughout the entire process to ensure relevance to target users. The process for managing competing interests was developed before and continued throughout the guideline development, informed by the Guideline International Network principles. We considered benefits and harms, patient values and preferences, resources, equity, acceptability and feasibility when developing recommendations; the strength of each recommendation was assigned according to the GRADE framework., Recommendations: The 25 recommendations and 10 good practice statements are grouped under the sections of exercise, nutrition, fracture risk assessment and treatment initiation, pharmacologic interventions, duration and sequence of therapy, and monitoring. The management of osteoporosis should be guided by the patient's risk of fracture, based on clinical assessment and using a validated fracture risk assessment tool. Exercise, nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized., Interpretation: The aim of this guideline is to empower health care professionals and patients to have meaningful discussions on the importance of skeletal health and fracture risk throughout older adulthood. Identification and appropriate management of skeletal fragility can reduce fractures, and preserve mobility, autonomy and quality of life., Competing Interests: Competing interests: Lora Giangregorio reports receiving an honorarium from Amgen Inc. for a lecture on exercise with no mention of medications, outside the current manuscript. Dr. Giangregorio is also a member of the Scientific Advisory Council of Osteoporosis Canada and co-lead of the Vertebral Fracture Special Interest Group, Fragility Fracture Network. Sandra Kim reports receiving support from Osteoporosis Canada for a Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodologist at McMaster University, during the conduct of the study. Dr. Kim was also a volunteer member of the Osteoporosis Canada Board of Directors from 2017 to 2020. Nancy Santesso reports receiving payment to provide GRADE expertise for guideline development and preparation of materials paid to institution (McMaster University), during the conduct of the study. Dr. Santesso has also received support from Osteoporosis Canada for travel to guideline-related meetings. Heather McDonald-Blumer reports receiving consulting fees from Eli Lilly and Novartis, for attendance on advisory boards, outside the submitted work. Rowena Ridout has been a member of the Osteoporosis Canada Board of Directors since 2020 (no payment received). Neil Binkley reports receiving a research grant (paid to institution) from Radius, and consulting fees and honoraria from Amgen. Angela Cheung has received honoraria for consultancy work from Amgen and Paladin Laboratories. Dr. Cheung has also held the following roles: member of the Clinical Guidelines Committee of the Endocrine Society; co-chair of the postmenopausal health pathway, American College of Obstetrics and Gynecology; and vice-president and co-chair of the 2023 Position Development Conference, International Society for Clinical Densitometry. Robert Josse reports receiving consulting fees from Amgen Canada, Paladin Laboratories and Alexion, and honoraria from Amgen and Alexion. Dr. Josse has also participated on advisory boards for Amgen, Paladin, Alexion and Ultragenyx. Aliya Khan has received research grants from Alexion, Amgen Canada, Takeda, Ascendis, Chugai, Radius, Amolyt and Ultragenyx, and speaker honoraria from Amgen, Alexion, Ascendis, Takeda and Ultragenyx. Dr. Khan has also participated on advisory boards for Amgen Canada, Alexion, Amolyt, Ascendis and Takeda. E. Lynn Izumi Nash reports receivin an honorarium from the Ontario College of Family Physicians for designing continuing medical education workshops on osteoporosis. Dr. Nash is also a member of the Scientific Advisory Council for Osteoporosis Canada (voluntary unpaid position). Zahra Bardai reports receiving honoraria as a member of the Pri-Med Canada Scientific Planning Committee (2011–present) and as an author of the Foundation for Medical Practice Education Small Group Practice–Based Learning Program, at McMaster University. Dr. Bardai is also a volunteer member of the Osteoporosis Canada Scientific Advisory Council. Suzanne Cadarette reports receiving research funds (paid to institution) as co–principal investigator on Canadian Institutes of Health Research and National Institutes of Health project grants. Heather Frame is a former member of the Osteoporosis Canada Board of Directors (term ended November 2020). Kaleen Hayes reports receiving researcher-initiated grants from the National Institute on Aging, Insight Therapeutics, Genentech and Sanofi (all paid directly to institution), and consulting fees from the Canadian Agency for Drugs and Technologies in Health. Alexandra Papaioannou has participated on an advisory board and in speakers’ bureaus and received honoraria from Amgen Canada. Christine Thomas has been a member of the Osteoporosis Canada Board of Directors at various time points. Conflict-of-Interest Oversight Committee: Heather McDonald-Blumer (Chair), Larry Funnell, Rowena Ridout., (© 2023 CMA Impact Inc. or its licensors.)

Study Design: A retrospective longitudinal cohort time-series analysis study., Objectives: To examine healthcare utilization and delivery during the COVID-19 pandemic in individuals with spinal cord injury/dysfunction (SCI/D)., Setting: Health administrative database in Ontario, Canada., Methods: In 5754 individuals with SCI/D diagnosed from 2004-2014 and living in the community, healthcare utilization (physician visits, primary care visits, specialist visits, urologist visits, physiatrist visits, emergency department (ED) visits, and hospital admissions) and delivery (total, in-person, virtual) were determined at the (1) pre-pandemic period (March 2015 to February 2020), (2) initial pandemic onset period (March 2020-May 2020), and (3) pandemic period (June 2020 to March 2022). Autoregressive integrated moving average (ARIMA) modelling was conducted to determine the impact of the pandemic on monthly healthcare utilization and delivery., Results: The initial pandemic onset period had a significant reduction of 24% in physicians (p = 0.0081), 35% in specialists (p < 0.0001), and 30% in urologist (p < 0.0001) visits, compared to pre-pandemic levels, with a partial recovery as the pandemic progressed. In April 2020, compared to the pre-pandemic period, a significant increase (p < 0.0001) in virtual visits for physicians, specialists, urologists, and primary care was found. The initial pandemic onset period had a 58% decrease in hospital admissions (p = 0.0011), compared to the pre-pandemic period., Conclusion: Healthcare utilization dropped in the initial pandemic onset period as physicians, specialists, and urologists, as well as hospitalization visits decreased significantly (p < 0.05) versus pre-pandemic levels. Virtual visit increases compensated for in-person visit decreases as the pandemic progressed to allow for total visits to partially recover., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)

Background: Individuals with a spinal cord injury (SCI) are considered higher users of antibiotics. However, to date there have been no detailed studies investigating outpatient antibiotic use in this population., Objectives: (1) To describe primary care antibiotic prescribing patterns in adults with SCI rostered to a primary care physician (PCP), and (2) to identify patient or PCP factors associated with number of antibiotics prescribed and antibiotic prescription duration., Methods: A retrospective cohort study using linked health administrative and electronic medical records (EMR) databases from January 1, 2013 to December 31, 2015 among 432 adults with SCI in Ontario, Canada. Negative binomial regression analyses were conducted to identify patient or physician factors associated with number of antibiotics prescribed and prescription duration., Results: During the study period, 61.1% of the SCI cohort received an antibiotic prescription from their PCP. There were 59.8% of prescriptions for urinary tract infections (UTI) and 24.6% of prescriptions for fluoroquinolones. Regression analysis found catheter use was associated with increased number of antibiotics prescribed (relative risk [RR] = 3.1; 95% CI, 2.3-4.1; p < .001) and late career PCPs, compared to early-career PCPs, prescribed a significantly longer duration (RR = 1.8; 95% CI, 1.1-3.1; p = .02)., Conclusion: UTIs were the number one prescription indication, and fluoroquinolones were the most prescribed antibiotic. Catheter use was associated with number of antibiotics, and PCP's years of practice was associated with duration. The study provided important information about primary care antibiotic prescribing in the SCI population and found that not all individuals received frequent antibiotics prescriptions., Competing Interests: Conflicts of Interest The authors declare no conflicts of interest., (© 2023 American Spinal Injury Association.)

Background: Community-based exercise programs integrating a healthcare-community partnership (CBEP-HCP) can facilitate lifelong exercise participation for people post-stroke. Understanding the process of implementation from multiple perspectives can inform strategies to promote program sustainability., Purpose: To explore stakeholders' experiences with undertaking first-time implementation of a group, task-oriented CBEP-HCP for people post-stroke and describe associated personnel and travel costs., Methods: We conducted a descriptive qualitative study within a pilot randomized controlled trial. In three cities, trained fitness instructors delivered a 12-week CBEP-HCP targeting balance and mobility limitations to people post-stroke at a recreation centre with support from a healthcare partner. Healthcare and recreation managers and personnel at each site participated in semi-structured interviews or focus groups by telephone post-intervention. Interviews and data analysis were guided by the Consolidated Framework of Implementation Research and Theoretical Domains Framework, for managers and program providers, respectively. We estimated personnel and travel costs associated with implementing the program., Results: Twenty individuals from three sites (4 recreation and 3 healthcare managers, 7 fitness instructors, 3 healthcare partners, and 3 volunteers) participated. We identified two themes related to the decision to partner and implement the program: (1) Program quality and packaging, and cost-benefit comparisons influenced managers' decisions to partner and implement the CBEP-HCP, and (2) Previous experiences and beliefs about program benefits influenced staff decisions to become instructors. We identified two additional themes related to experiences with training and program delivery: (1) Program staff with previous experience and training faced initial role-based challenges that resolved with program delivery, and (2) Organizational capacity to manage program resource requirements influenced managers' decisions to continue the program. Participants identified recommendations related to partnership formation, staff/volunteer selection, training, and delivery of program activities. Costs (in CAD) for first-time program implementation were: healthcare partner ($680); fitness coordinators and instructors ($3,153); and participant transportation (personal vehicle: $283; public transit: $110)., Conclusion: During first-time implementation of a CBEP-HCP, healthcare and hospital managers focused on cost, resource requirements, and the added-value of the program, while instructors and healthcare partners focused on their preparedness for the role and their ability to manage individuals with balance and mobility limitations. Trial Registration: ClinicalTrials.gov, NCT03122626. Registered April 17, 2017-Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03122626., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Aravind, Bashir, Cameron, Bayley, Teasell, Howe, Tee, Jaglal, Hunter and Salbach.)

Study Design: A retrospective cohort study., Objectives: To describe antibiotic prescribing and urine culture testing patterns for urinary tract infections (UTIs) in a primary care Spinal Cord Injury (SCI) cohort., Setting: A primary care electronic medical records (EMR) database in Ontario., Methods: Using linked EMR health administrative databases to identify urine culture and antibiotic prescriptions ordered in primary care for 432 individuals with SCI from January 1, 2013 to December 31, 2015. Descriptive statistics were conducted to describe the SCI cohort, and physicians. Regression analyses were conducted to determine patient and physician factors associated with conducting a urine culture and class of antibiotic prescription., Results: The average annual number of antibiotic prescriptions for UTI for the SCI cohort during study period was 1.9. Urine cultures were conducted for 58.1% of antibiotic prescriptions. Fluroquinolones and nitrofurantoin were the most frequently prescribed antibiotics. Male physicians and international medical graduates were more likely to prescribe fluroquinolones than nitrofurantoin for UTIs. Early-career physicians were more likely to order a urine culture when prescribing an antibiotic. No patient characteristics were associated with obtaining a urine culture or antibiotic class prescription., Conclusion: Nearly 60% of antibiotic prescriptions for UTIs in the SCI population were associated with a urine culture. Only physician characteristics, not patient characteristics, were associated with whether or not a urine culture was conducted, and the class of antibiotic prescribed. Future research should aim to further understand physician factors with antibiotic prescribing and urine culture testing for UTIs in the SCI population., (© 2023. The Author(s), under exclusive licence to International Spinal Cord Society.)

Objective: To obtain expert consensus on the parameters and etiologic conditions required to retrospectively identify cases of non-traumatic spinal cord injury (NTSCI) in health administrative and electronic medical record (EMR) databases based on the rating of clinical vignettes., Design: A modified Delphi process included 2 survey rounds and 1 remote consensus panel. The surveys required the rating of clinical vignettes, developed after chart reviews and expert consultation. Experts who participated in survey rounds were invited to participate in the Delphi Consensus Panel., Setting: An international collaboration using an online meeting platform., Participants: Thirty-one expert physicians and/or clinical researchers in the field of spinal cord injury (SCI)., Main Outcome Measure(s): Agreement on clinical vignettes as NTSCI. Parameters to classify cases of NTSCI in health administrative and EMR databases., Results: In health administrative and EMR databases, cauda equina syndromes should be considered SCI and classified as a NTSCI or TSCI based on the mechanism of injury. A traumatic event needs to be listed for injury to be considered TSCI. To be classified as NTSCI, neurologic sufficient impairments (motor, sensory, bowel, and bladder) are required, in addition to an etiology. It is possible to have both a NTSCI and a TSCI, as well as a recovered NTSCI. If information is unavailable or missing in health administrative and EMR databases, the case may be listed as "unclassifiable" depending on the purpose of the research study., Conclusion: The Delphi panel provided guidelines to appropriately classify cases of NTSCI in health administrative and EMR databases., (Copyright © 2022 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Community-based programmes can support healthcare systems by delivering preventive services and health promotion. This study aimed to determine the nature, range, and extent of theoretical models that guide the development of linkages between healthcare settings and community programmes. A scoping review guided by the Joanna Briggs Institute methodology and the PRISMA-ScR was conducted. Four databases (MEDLINE, EMBASE, CINAHL and PsycINFO) were searched on August 8, 2020. Two reviewers independently screened articles by title and abstract and divided the remaining articles for full-text screening. Articles that described the development of a theoretical model to guide the establishment of linkages between healthcare settings and community programmes, were peer-reviewed, and in English, were included. Articles that solely applied linkage models were excluded. One reviewer extracted data on study and model characteristics (e.g. model purpose, model components and relationships between components from the included articles). Categorical data were summarised using frequencies and percentages. Conventional content analysis was used for variables that had lengthier descriptions and variable terminology. The search identified 8926 records. Six articles describing six unique models were included in the review. Of the four models that described intended users, three (75%) identified primary care. Healthcare settings were identified in all models, with three (50%) focusing on primary care. Models used two or more linkage strategies: (1) agreeing on sharing resources, staff, and information, (2) coordinating services and referral processes, (3) planning and evaluation, (4) leadership, policies, and funding, (5) boundary spanning and (6) brokering. All models used the linkage strategy of agreeing on sharing resources, staff, and information. Findings provide important considerations for healthcare and community programme providers planning linkages. Future research should investigate the role and characteristics of community programmes in linkages, and linkages with other types of healthcare settings., (© 2022 John Wiley & Sons Ltd.)

Purpose: Therapists play a key role in delivering fall prevention/management education to individuals with spinal cord injury/disease, yet their perspectives on this topic remain understudied. Here, we described the perspectives of physical and occupational therapists who routinely provided rehabilitation to patients with spinal cord injury/disease on: (1) how fall risk was assessed, (2) what fall prevention education, interventions or strategies were provided, and (3) opportunities to improve fall risk assessment and the delivery of fall prevention education, strategies and interventions., Materials and Methods: Twenty-one therapists completed an individual interview or focus group that was analyzed using an inductive thematic analysis., Results: Four main themes were identified: (1) policy and procedures impact practice (i.e., policy and procedures positively and negatively impact practice), (2) assessing and managing fall risk/falls in patients with spinal cord injury/disease (i.e., discipline-specific roles in fall risk assessments and fall management processes in rehabilitation), (3) fall prevention and management education (i.e., helicopter therapists and challenges with fall prevention and management education), (4) building insight into fall risk and management (e.g., building insight into fall risk for patients and therapists)., Conclusions: This study revealed opportunities to improve the delivery of fall prevention education and training to individuals with spinal cord injury/disease.IMPLICATIONS FOR REHABILITATIONFall prevention education should be initiated in spinal cord injury rehabilitation and then reinforced in community rehabilitation.Barriers and challenges faced by therapists when delivering fall prevention and management education/training in spinal cord injury rehabilitation include their perceptions of a patient's readiness to receive fall prevention education, short length of stay in rehabilitation, organization's expectations of zero falls and a lack of spinal cord injury-specific fall prevention resources.Therapists who work in spinal cord injury rehabilitation may benefit from information about fall risk factors encountered by individuals with spinal cord injury/disease in the community.

Introduction: Several differences have been reported between male and female patients with stroke in clinical and sociodemographic features, treatment, and outcomes. Potential effects in the inpatient rehabilitation population are unclear., Objective: To evaluate the differences between male and female patients in discharge functional status, length of stay, and discharge home after inpatient rehabilitation for stroke., Design: Retrospective, population-based cohort study., Setting: Inpatient rehabilitation centers in Ontario, Canada., Participants: Male (N = 10,684) and female (N = 9459) patients discharged from acute care between September 1, 2012 and August 31, 2017, with a diagnosis of stroke and subsequently admitted to inpatient rehabilitation., Exposure Variable: Female sex., Main Outcome Measures: Discharge Functional Independence Measure (FIM) score, length of stay, and discharge home., Results: Female patients had a lower functional status at discharge (mean FIM score 94.1 vs. 97.8, p < .001) and a lower proportion were discharged home (81.1% vs. 82.9%, p = .001). Female and male patients had similar rehabilitation length of stay (mean 31.8 vs. 31.7 days, p = .90). In the adjusted analyses, there was no difference in discharge functional status between male and female patients (FIM score β -.20 [95% confidence interval [CI] -0.64 to 0.25]). Female patients had a mean length of stay 2% shorter (0.98 [95% CI 0.96-0.99]) and a higher odds of discharge home (odds ratio [OR] 1.14 [95% CI 1.05-1.24])., Conclusions: There were no clinically significant sex differences in outcomes after inpatient rehabilitation for stroke. Observed sex disparities in the general stroke population may not be directly applicable to individuals undergoing inpatient rehabilitation., (© 2021 American Academy of Physical Medicine and Rehabilitation.)

Background: Despite the potential for community-based exercise programs supported through healthcare-community partnerships (CBEP-HCPs) to improve function post-stroke, insufficient trial evidence limits widespread program implementation and funding. We evaluated the feasibility and acceptability of a CBEP-HCP compared to a waitlist control group to improve everyday function among people post-stroke., Methods: We conducted a 3-site, pilot randomized trial with blinded follow-up evaluations at 3, 6, and 10 months. Community-dwelling adults able to walk 10 m were stratified by site and gait speed and randomized (1:1) to a CBEP-HCP or waitlist control group. The CBEP-HCP involved a 1-h, group exercise class, with repetitive and progressive practice of functional balance and mobility tasks, twice a week for 12 weeks. We offered the exercise program to the waitlist group at 10 months. We interviewed 13 participants and 9 caregivers post-intervention and triangulated quantitative and qualitative results. Study outcomes included feasibility of recruitment, interventions, retention, and data collection, and potential effect on everyday function., Results: Thirty-three people with stroke were randomized to the intervention (n = 16) or waitlist group (n = 17). We recruited 1-2 participants/month at each site. Participants preferred being recruited by a familiar healthcare professional. Participants described a 10- or 12-month wait in the control group as too long. The exercise program was implemented per protocol across sites. Five participants (31%) in the intervention group attended fewer than 50% of classes for health reasons. In the intervention and waitlist group, retention was 88% and 82%, respectively, and attendance at 10-month evaluations was 63% and 71%, respectively. Participants described inclement weather, availability of transportation, and long commutes as barriers to attending exercise classes and evaluations. Among participants in the CBEP-HCP who attended ≥ 50% of classes, quantitative and qualitative results suggested an immediate effect of the intervention on balance, balance self-efficacy, lower limb strength, everyday function, and overall health., Conclusion: The CBEP-HCP appears feasible and potentially beneficial. Findings will inform protocol revisions to optimize recruitment, and program and evaluation attendance in a future trial., Trial Registration: ClinicalTrials.gov , NCT03122626 . Registered April 21, 2017 - retrospectively registered., (© 2022. The Author(s).)

Background: Low socioeconomic status is associated with increased risk of stroke and worse poststroke functional status. The aim of this study was to determine whether socioeconomic status, as measured by material deprivation, is associated with direct discharge to long-term care or length of stay after inpatient stroke rehabilitation., Methods: We performed a retrospective, population-based cohort study of people admitted to inpatient rehabilitation in Ontario, Canada, after stroke. Community-dwelling adults (aged 19-100 yr) discharged from acute care with a most responsible diagnosis of stroke between Sept. 1, 2012, and Aug. 31, 2017, and subsequently admitted to an inpatient rehabilitation bed were included. We used a multivariable logistic regression model to examine the association between material deprivation quintile (from the Ontario Marginalization Index) and discharge to long-term care, and a multivariable negative binomial regression model to examine the association between material deprivation quintile and rehabilitation length of stay., Results: A total of 18 736 people were included. There was no association between material deprivation and direct discharge to long-term care (most v. least deprived: odds ratio [OR] 1.07, 95% confidence interval [CI] 0.89-1.28); however, people living in the most deprived areas had a mean length of stay 1.7 days longer than that of people in the least deprived areas ( p = 0.004). This difference was not significant after adjustment for other baseline differences (relative change in mean 1.02, 95% CI 0.99-1.04)., Interpretation: People admitted to inpatient stroke rehabilitation in Ontario had similar discharge destinations and lengths of stay regardless of their socioeconomic status. In future studies, investigators should consider further examining the associations of material deprivation with upstream factors as well as potential mitigation strategies., Competing Interests: Competing interests: Shannon MacDonald is chair or cochair of Toronto Stroke Network committees, a surveyor for Accreditation Canada’s Stroke Distinction program (paid position) and a member of the Heart and Stroke Foundation of Canada Health Systems Quality Committee. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Physiotherapy competencies inform the education and regulation of the profession. Many different methods appear to be used to identify competencies and there is no consensus on optimal methods to identify competencies. The purpose of this review is to synthesize the methodological approaches used to identify competencies for the physiotherapy profession and summarize the nature of those competencies. We searched MEDLINE, EMBASE, CINAHL, and the grey literature from inception to June 2020. Two independent reviewers screened for empirical peer-reviewed articles that aimed to identify professional physiotherapy competencies. General study characteristics, competency characteristics (e.g., target practice area), and methodological characteristics (e.g., study population, data collection and analysis method for each methodological step) were extracted. Descriptive statistics and narrative synthesis were performed. Of the 9529 references screened, 38 articles describing 35 studies published between 1980 and 2020 were included. Orthopaedics (20.0%) was the most commonly targeted area of practice. Studies used one to eight methodological steps whose objective was to generate (16 studies), validate (18 studies), assign value (21 studies), refine (10 studies), or triangulate (3 studies) competencies, or to address multiple objectives (10 studies). The most commonly used methods were surveys to assign value (n = 20, 95%), and group techniques to refine competencies (n = 7, 70%). Physiotherapists with experience in the area of competence was the most commonly consulted stakeholder group (80% of studies). This review can provide methodological guidance to stakeholders such as educators and regulators that aim to identify professional competencies in the future., Supplementary Information: The online version contains supplementary material available at 10.1007/s44217-022-00008-9., Competing Interests: Competing interestOn behalf of all authors, the corresponding author states that there is no conflict of interest., (© The Author(s) 2022.)

Purpose: While the physical consequences of falls among wheelchair users with spinal cord injury have previously been examined, the psychosocial impacts remain understudied. Here, we explored the psychosocial impacts of falls and risk of falling from the perspectives of wheelchair users with spinal cord injury., Materials and Methods: Twelve wheelchair users (aged 41.8 ± 12.5 years; median 17.5 (range 3-44) years post-spinal cord injury) with traumatic spinal cord injury captured photographs of how falls and the risk of falling impacted their recreation/leisure and paid/volunteer work activities. Participants then engaged in photo-elicitation interviews to discuss the content depicted in the photographs. Interviews were analyzed using a thematic analysis., Results: Two main themes emerged: (1) The varying concern about falling: While some participants experienced a high concern, others were not concerned about falling in their daily activities. The level of concern about falling varied among participants over time and across situations. (2) Fear, falling, and limitations: Falls could impact daily activities, parenting, work, leisure/recreation, and lead participants to want a life without a constant risk of falling., Conclusions: Falls have a significant psychosocial impact for some, but not all participants. Clinicians should explore whether and to what extent falls/fall risk have a lasting psychosocial impact, and work with individuals to create strategies that may reduce negative psychosocial impacts.IMPLICATIONS FOR REHABILITATIONThis study highlighted that falls can have a significant psychosocial impact on the lives of some wheelchair users with spinal cord injury.Since a wheelchair user's concern of falls may change overtime, clinicians are encouraged to have ongoing dialogue about every wheelchair user's level of concern about falls.If a wheelchair user expresses a high concern of falls, clinicians are encouraged to provide appropriate supports and resources for individuals to continue engaging in meaningful activities.

Introduction: Traumatic brain injury (TBI) is estimated to affect 10 million people annually, making it a leading cause of morbidity and mortality worldwide. One cost-effective intervention that has been shown to minimize some of the negative sequelae after TBI is peer support. However, the evidence supporting the benefits of peer support for individuals with TBI is sparse and of low quality. Integrated knowledge translation (iKT) may be one approach to optimizing the evaluation of peer support programs among individuals with TBI. Therefore, the objectives are: (1) To understand key informants' perspectives of the barriers and facilitators of participating in peer support research and programs among individuals with TBI; (2) to understand key informants' perspectives on the perceived impacts of peer support programs on individuals with TBI; and, (3) to demonstrate how an iKT approach can inform the development and implementation of a pilot feasibility randomized controlled trial (RCT)., Methods: A qualitative descriptive approach using one-on-one semi-structured interviews was used. Purposive sampling of 22 key informants included 8 peer support mentors, 4 individuals with TBI who received peer support, 3 caregivers of individuals with TBI, 4 peer support program staff, and 3 academics in peer support and/or TBI., Results: There were five main themes related to the barriers and facilitators to participating in peer support research and programs: knowledge, awareness, and communication; logistics of participating; readiness and motivation to participate; need for clear expectations; and matching. There were three main themes related to the perceived impact of peer support: acceptance, community, social experiences; vicarious experience/learning through others: shared experiences, role-modelling, encouragement; and "I feel better." Discussions with our Research Partner led to several significant adaptations to our trial protocol, including removing the twice/week intervention arm, shortening of the length of trial, and changing the measure for the community integration outcome., Discussion/conclusion: This is the first study to use an iKT approach to inform a trial protocol and the first to assess the barriers and facilitators to participating in peer support research., Competing Interests: The authors have declared that no competing interests exist.

Background: The long-term consequences of traumatic brain injury can create major barriers to community integration. Peer support represents a sustainable model of support across this transition. The objective of the current study was to determine the feasibility of conducting a randomized controlled trial on the Ontario Brain Injury Association Peer Support Program and the preliminary effectiveness of the program on community integration, mood, health-related quality of life, and self-efficacy; Methods: A pilot feasibility randomized controlled trial with an embedded qualitative component was conducted. Mentees with moderate-to-severe traumatic brain injury (n = 13) were randomized to a weekly intervention or waitlist control group. Interviews were conducted with a subset of mentees and peer mentors (n = 10). Integration of the quantitative and qualitative data was completed using a joint display approach; Results: No statistically significant results were found for community integration, mood, or self-efficacy; however, changes in these outcomes were accompanied by moderate-to-large effect sizes. Within health-related quality of life, the mean pain score of the intervention group was significantly lower than that of the control group at the two-month timepoint but not at completion. Interviews revealed proximal improvements in knowledge, skills, and goals, and identified two domains related to trial acceptability: (1) environmental context and resources, and (2) reinforcement; Conclusions: Given the conceivable importance of proximal improvements in domains such as knowledge, skills, and/or goals for the attainment of more distal outcomes, modifications to the existing Peer Support Program may be warranted. The introduction of program recommendations which promote discussion around particular domains may help facilitate long-term improvements in health outcomes.

Background: Globally, 1 in 3 adults live with multiple chronic conditions. Thus, effective interventions are needed to prevent and manage these chronic conditions and to reduce the associated health care costs. Teaching effective self-management practices to people with chronic diseases is one strategy to address the burden of chronic conditions. With the increasing availability of and access to the internet, the implementation of web-based peer support programs has become increasingly common., Objective: The purpose of this scoping review is to synthesize existing literature and key characteristics of web-based peer support programs for persons with chronic conditions., Methods: This scoping review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews guidelines. Studies were identified by searching MEDLINE, CINAHL, Embase, PsycINFO, and the Physiotherapy Evidence Database. Chronic diseases identified by the Public Health Agency of Canada were included. Our review was limited to peer support interventions delivered on the web. Peers providing support had to have the chronic condition that they were providing support for. The information abstracted included the year of publication, country of study, purpose of the study, participant population, key characteristics of the intervention, outcome measures, and results., Results: After duplicates were removed, 12,641 articles were screened. Data abstraction was completed for 41 articles. There was a lack of participant diversity in the included studies, specifically with respect to the conditions studied. There was a lack of studies with older participants aged ≥70 years. There was inconsistency in how the interventions were described in terms of the duration and frequency of the interventions. Informational, emotional, and appraisal support were implemented in the studied interventions. Few studies used a randomized controlled trial design. A total of 4 of the 6 randomized controlled trials reported positive and significant results, including decreased emotional distress and increased health service navigation, self-efficacy, social participation, and constructive attitudes and approaches. Among the qualitative studies included in this review, there were several positive experiences related to participating in a web-based peer support intervention, including increased compassion and improved attitudes toward the individual's chronic condition, access to information, and empowerment., Conclusions: There is limited recent, high-level evidence on web-based peer support interventions. Where evidence exists, significant improvements in social participation, self-efficacy, and health-directed activity were demonstrated. Some studies incorporated a theoretical framework, and all forms of peer support-emotional, informational, and appraisal support-were identified in the studies included in this review. We recommend further research on web-based peer support in more diverse patient groups (eg, for older adults and chronic conditions outside of cancer, cardiovascular disease, and HIV or AIDS). Key gaps in the area of web-based peer support will serve to inform the development and implementation of future programs., (©Saima N Hossain, Susan B Jaglal, John Shepherd, Laure Perrier, Jennifer R Tomasone, Shane N Sweet, Dorothy Luong, Sonya Allin, Michelle L A Nelson, Sara J T Guilcher, Sarah E P Munce. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 25.05.2021.)

Purpose: Family caregivers provide essential support to individuals recovering after experiencing a stroke. Although clinical guidelines recommend the provision of caregiver education and support, these guidelines have not been implemented into standard clinical practice. The objective of this study was to gain insight from key informants-affiliates of a regional stroke system-to identify organization and system level barriers and facilitators associated with implementing stroke caregiver programs., Methods: Twelve key informants were interviewed. Informants discussed their experiences with and perceptions of caregiver programs. They also identified barriers and facilitators to implementing caregiver programs. Interview data were analyzed using inductive thematic analysis., Results: Three themes were generated: (1) lack of consensus on the need for caregiver education and support programs as part of the health care system; (2) a collaborative process is needed to engage stakeholders and identify champions (3) stakeholders need different types of evidence in support of implementation., Conclusions: This study provides initial insight into the potential barriers and facilitators needed to develop and implement stroke caregiver programs. Further exploration of these topics can inform caregiver program development and their implementation into stroke systems of care.IMPLICATIONS FOR REHABILITATIONRehabilitation research needs to demonstrate that caregivers are a unique group in need of support from the health care system.Rehabilitation research needs to contribute to the evidence that caregiver programs can improve patient, caregiver, and health system outcomes.Researchers can enhance caregiver program implementation through collaboration between researchers, stakeholders, and system change champions starting with program development.

Background: Systematic reviews have established that exercise reduces falls in older adults, however the most effective types of exercise are not known. This secondary analysis determined the comparative effectiveness of fall prevention exercise approaches., Method: All fall prevention exercise interventions for older adults were identified from an existing search from inception until April 2017. Interventions were coded using a framework of 25 exercise types. Two reviewers independently screened studies, extracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis (NMA) were conducted. P-scores were used to rank exercise combinations., Results: One hundred and sixty-nine studies were included. NMA was conducted on 73 studies (30,697 participants) for the outcome of number of fallers. The exercise combination ranked with the greatest likelihood of being most effective relative to no exercise was: anticipatory control, dynamic stability, functional stability limits, reactive control and flexibility (p-score = 0.95). This exercise combination also significantly reduced number of fallers compared to 16 other combinations. No exercise combination had a significantly greater effect on reducing number of fallers more than this combination., Conclusion: This analysis identified components of effective fall prevention exercise. The results can inform evidence-informed exercise recommendations and be used to design effective programs., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Context: Although self-management is linked to reduced secondary health complications (SHCs) and enhanced overall quality of life post-spinal cord injury or disease (SCI/D), it is poorly integrated into the current rehabilitation process. Promoting self-management and assuring equity in care delivery is critical. Herein, we describe the selection of Self-Management structure, process and outcome indicators for adults with SCI/D in the first 18 months after rehabilitation admission., Methods: Experts in self-management across Canada completed the following tasks: (1) defined the Self-Management construct; (2) conducted a systematic search of available outcomes and their psychometric properties; and (3) created a Driver diagram summarizing available evidence related to Self-Management. Facilitated meetings allowed development and selection following rapid-cycle evaluations of proposed structure, process and outcome indicators., Results: The structure indicator is the proportion of staff with appropriate education and training in self-management principles. The process indicator is the proportion of SCI/D inpatients who have received a self-management assessment related to specific patient self-management goal(s) within 30 days of admission. The outcome indicator is the Skill and Technique Acquisition, and Self-Monitoring and Insight subscores of the modified Health Education Impact Questionnaire., Conclusion: The structure indicator will heighten awareness among administrators and policy makers regarding the need to provide staff with ongoing training related to promoting self-management skill acquisition. Successful implementation of the Self-Management process and outcome indicators will promote self-management education and skill acquisition as a rehabilitation priority, allow for personalization of skills related to the individual's self-management goal(s), and empower individuals with SCI/D to manage their health and daily activities while successfully integrating into the community.

Introduction: Wheelchair users with spinal cord injury are at a high risk of falls. However, the perspectives of wheelchair users with spinal cord injury on their fall circumstances and their preferences for fall prevention strategies/interventions remain understudied. Therefore, we aimed to: a) describe the circumstances of falls experienced by wheelchair users with spinal cord injury over a six-month period, b) explore their perspectives of why falls occurred in certain situations, and c) explore their perspectives on recommended content/structure of fall prevention strategies/interventions., Methods: This sequential explanatory mixed methods study had two phases. Phase I involved tracking of falls experienced by wheelchair users with spinal cord injury over six months, in which participants completed a survey after experiencing a fall to track the number/circumstance of each fall. Data from the surveys were descriptively reported. Phase II involved a photovoice focus group discussion of the survey findings and their preferences for fall prevention strategies/interventions. Data from the focus group discussion were analyzed using a thematic analysis., Results: Thirty-two participants completed phase I. More than half of the participants fell at least once in six months. Falls commonly occurred in the afternoon during a transfer, or when participants were wheeling over uneven ground. One-third of the falls caused an injury. Eleven participants that fell during phase I participated in the focus group. Two main themes were identified from the discussion: 1) "circumstances surrounding the falls" (e.g. when falls occurred, the home is a 'safe space') and 2) "suggestions and preferences for fall prevention strategies/interventions" (e.g. fall prevention involves all, fall prevention training available as needed)., Conclusion: Fall prevention strategies/interventions should be an integral component of rehabilitation practices across the lifespan. Participants recommend customizing fall prevention strategies/interventions to their specific needs to guide the structure, content, and delivery of targeted fall prevention programs., Competing Interests: The authors have declared that no competing interests exist.

Purpose : Family members make an important contribution to informal and formal care, as well as the overall health and wellbeing of individuals with spinal cord injury. Caregiving often results in negative outcomes which, if not addressed, threaten the sustainability of these critical supports. We sought to explore the perceptions of individuals with spinal cord injury and their family caregivers regarding the facilitators and barriers to undertaking and sustaining the caregiving role in the community. Methods: A qualitative descriptive approach with semi-structured interviews. Thematic analysis was employed to determine key themes arising from individuals with spinal cord injury ( n  = 19) and their family members' ( n  = 16) experiences. Results: The following four facilitators to caregiving were identified: access to community support services, positive coping in relationship, social support, and mastery of caregiving roles. Conversely, the following six barriers to caregiving were identified: lack of access to community resources, lack of knowledge about resources and formal training, fragmented continuity of care, negative coping in relationship, role strain, and caregiver injury or illness. Conclusions: The current study demonstrated that positive coping, social support, skills training, access to community services and continuity of care contribute significantly to the sustainability of the spinal cord injury family caregiving role. As such, the development of future caregiver interventions should consider these facilitators.Implications for RehabilitationFamily caregivers make an important contribution to the care processes and overall quality of life of individuals with spinal cord injury post-discharge into the community.The potential negative effects of caregiving could threaten the sustainability of these critical supports.Positive coping, social support, skills training, access to community services, and continuity of care contribute significantly to the sustainability of the spinal cord injury family caregiving role.This study shows the need for better integration of family members during the rehabilitation and discharge process to better prepare them for the caregiving role.

Background: Preventing patient falls is a priority in tertiary spinal cord injury (SCI) rehabilitation. Falls can result in patient or staff injury, delayed rehabilitation, and hospital liability. A comprehensive overview of fall prevention/management policies and procedures in Canadian SCI rehabilitation is currently lacking. We describe and compare the fall prevention/management policies and procedures implemented in Canadian tertiary hospitals that provide SCI rehabilitation., Methods: Fall prevention/management documents implemented in SCI rehabilitation at six Canadian tertiary rehabilitation hospitals across five provinces were analyzed using a document analysis. Analysis involved multiple readings of the documents followed by a content and thematic document analysis., Results: Fall prevention/management policies and procedures in SCI rehabilitation were organized into three main categories: 1) pre-fall policies and procedures; 2) post-fall policies and procedures; and, 3) communication between and amongst staff, patients, and families. Pre-fall policies and procedures encompassed: a) the definition of a fall; b) fall risk assessments in SCI rehabilitation; and, c) fall prevention strategies. The post-fall policies and procedures included: a) recovery from a fall; b) incident reporting process; and, c) fall classification. Components of fall prevention/management policies and practices that differed between hospitals included the fall risk assessments, post-fall huddles, and fall classifications., Conclusions: Fall prevention/management is a required organizational practice for all hospitals. Although Canadian tertiary hospitals that provide SCI rehabilitation have similar components of fall prevention/management policies and procedures, the specific requirements differ at each site. There is a need for evidence-informed, consensus-driven implementation of SCI-specific fall prevention and management procedures across Canadian SCI rehabilitation settings.

The objectives of this study were to describe home care utilization and costs in community-dwelling individuals 2 years post-spinal cord injury (SCI) in Ontario, Canada. This retrospective incident cohort study uses administrative health care data to identify individuals with traumatic SCI (tSCI). Time to service delivery and frequency of service delivery and costs were calculated. A total of 798 individuals with tSCI comprised the cohort. In the first 2 years, personal support/homemaking was the most utilized service. Median cumulative home care 2 years post-discharge was $7,200 ($1,240-35,410 25-75% interquartile range). This study highlights the importance of home care to individuals with SCI.

Background: Knee osteoarthritis (OA) is a leading cause of disability. There is increasing emphasis on initiating treatment earlier in the disease. Physical therapists are central to the management of OA through the delivery of exercise programs. There is a paucity of research on physical therapists' perceptions and clinical behaviors related to early knee OA management., Objective: The study aimed to explore how physical therapists approached management of early knee OA, with a focus on evidence-based strategies. This is an important first step to begin to optimize care by physical therapists for this population., Design: We used a qualitative, descriptive research design., Methods: Semistructured interviews were conducted with 33 physical therapists working with people with knee symptoms and/or diagnosed knee OA in community or outpatient settings in Canada. Data were analyzed using thematic analysis., Results: Five main themes were constructed: (1) Physical therapists' experience and training: clinical experiences and continuing professional development informed clinical decision-making. (2) Tailoring treatment from the physical therapist "toolbox:" participants described their toolbox of therapeutic interventions, highlighting the importance of tailoring treatments to people. (3) The central role of exercise and physical activity in management: exercise was consistently recommended by participants. (4) Variability in support for weight management: there was variation related to how participants addressed weight management. (5) Facilitating "buy-in" to management: physical therapists used a range of strategies to gain "buy-in.", Limitations: Participants were recruited through a professional association specializing in orthopedic physical therapy and worked an average of 21 years., Conclusions: Participants' accounts emphasized tailoring of interventions, particularly exercises, which is an evidence-based strategy for OA. Findings illuminated variations in management that warrant further exploration to optimize early intervention (eg, weight management, behavior change techniques)., (© 2019 American Physical Therapy Association.)

This study sought to understand patient experiences, benefits, and challenges to osteoporosis care delivered virtually by telemedicine. Telemedicine bridges the access gap to specialized osteoporosis care in remote areas. Improving coordination of investigations, access to allied health members, and future initiatives may improve osteoporosis-related morbidity and mortality in this population., Introduction: There is limited research on the role of telemedicine (TM) in the management of osteoporosis (OP). We previously reported that OP patients assessed by TM had a higher prevalence of fragility fractures, co-morbidities, and need for allied health resources than those serviced by the outpatient clinic. The purpose of this study is to understand the experiences, benefits, and challenges associated with receiving OP care by TM from the patient perspective., Methods: We adopted a convergent, mixed methods study design whereby both a quantitative component (mailed survey) and qualitative component (30-min telephone interviews) were conducted simultaneously. In addition to reporting survey data, thematic analysis was applied to interview data., Results: Participants were comfortable with virtual technology and perceived that their quality of care by TM was comparable to in-person visits. Expressed benefits included the convenience of timely care close to home, reduced burden of travel and costs, and enhanced sense of confidence with being assessed by an osteoporosis specialist. Perceived barriers included poor follow-up with allied health professionals in the TM program (e.g., physiotherapist) and coordination of tests and investigations. Many participants indicated interest in an OP self-management program, with content focusing on diet and lifestyle factors., Conclusion: The TM program bridges the access gap for those living with OP in underserviced and remote areas. However, we identified the need to improve the existing processes to better coordinate access to allied health team members and arrangements for investigations. Participants also expressed interest for a virtual osteoporosis self-management program.

Background: To optimize traumatic spinal cord injury (tSCI) care, administrative and clinical linked data are required to describe the patient's journey., Objectives: To describe the methods and progress to deterministically link SCI data from multiple databases across the SCI continuum in British Columbia (BC) and Ontario (ON) to answer epidemiological and health service research questions., Methods: Patients with tSCI will be identified from the administrative Hospital Discharge Abstract Database using International Classification of Diseases (ICD) codes from Population Data BC and ICES data repositories in BC and ON, respectively. Admissions for tSCI will range between 1995-2017 for BC and 2009-2017 for ON. Linkage will occur with multiple administrative data holdings from Population Data BC and ICES to create the "Admin SCI Cohorts." Clinical data from the Rick Hansen SCI Registry (and VerteBase in BC) will be transferred to Population Data BC and ICES. Linkage of the clinical data with the incident cases and administrative data at Population Data BC and ICES will create subsets of patients referred to as the "Clinical SCI Cohorts" for BC and ON. Deidentified patient-level linked data sets will be uploaded to a secure research environment for analysis. Data validation will include several steps, and data analysis plans will be created for each research question., Discussion: The creation of provincially linked tSCI data sets is unique; both clinical and administrative data are included to inform the optimization of care across the SCI continuum. Methods and lessons learned will inform future data-linking projects and care initiatives., Competing Interests: Conflicts of Interest Dr. Noonan is an employee of the Praxis Spinal Cord Institute and is paid from a grant administered by the University of British Columbia. The other authors report no conflicts of interest., (© 2020 American Spinal Injury Association.)

Background and Purpose- Family caregivers play a central role in the recovery of people with stroke. They need support to optimize the care they provide and their own health and well-being. Despite support from the literature and best practice recommendations, healthcare systems are not formally adopting caregiver programs. This study aimed to describe system-level facilitators and barriers to caregiver support program implementation in a regional stroke system. Methods- Using a qualitative descriptive study design, focus groups were conducted with regional rehabilitation specialists, education coordinators, community and long-term care specialists, and regional/district program directors. Semi-structured interviews were conducted with regional medical directors, health professionals providing stroke care in acute care, rehabilitation and community settings, regional health executives, and primary care leaders. Data were analyzed using inductive thematic analysis. Results- Four focus groups (n=43) and 29 interviews were conducted. We identified 4 themes related to caregiver program implementation: (1) establishing the need for caregiver education and support in an integrated healthcare system; (2) incorporating caregiver programs into the system of care across the care continuum; (3) uncertainty regarding ownership and responsibility for implementation; and (4) addressing regional variations related to access, availability, and culture. Conclusions- This study provides a comprehensive understanding of organization and system-level considerations for implementing caregiver programs in a regional stroke system. Program implementation requires evidence to establish the need for caregiver programs, practical strategies, and establishing ownership to incorporate programs into existing healthcare systems, and consideration of regional variations across healthcare systems. Ultimately, adopting programs to support caregivers will improve recovery in people with stroke and caregiver well-being.

Context: Spinal cord injury (SCI) presents numerous physiological, psychosocial, and environmental complexities resulting in significant healthcare system resource demands. Objective: To describe the current health system surveillance mechanisms in Ontario, Canada and highlight gaps in health surveillance among adults with SCI across their lifespan. Methods: A review of administrative data sources capturing SCI-specific information took place via internet searching and networking among SCI rehabilitation and health services experts with emphasis on functionality, health service utilization, and quality of life data. Results: The review identified a distinct paucity of data elements specific to the health surveillance needs of individuals with SCI living in the community. The gaps identified are: (1) a lack of data usability; (2) inadequate linkage between available datasets; (3) inadequate/infrequent reporting of outcomes; (4) a lack of relevant content/patient-reported outcomes; and, (5) failure to incorporate additional data sources ( e.g. Insurance datasets). Conclusion: Currently, SCI-specific health data is disproportionately weighted towards the first 3-6 months post injury with detailed data regarding pre-hospital care, acute management and rehabilitation, but little existing infrastructure supporting community-based health surveillance. Given this reality, the bolstering of meaningful community health surveillance of this population across the lifespan is needed. Addressing the identified gaps in health surveillance must inform the creation of a comprehensive community health dataset incorporating patient-reported outcome measures and enabling linkage with existing administrative and/or clinical databases. A future harmonized data surveillance strategy would, in turn, positively impact function, health services, resource utilization and health-related quality of life surveillance.

Background: Due to the earlier discharge of individuals with spinal cord injury (SCI), family caregivers are often left with limited time for learning caregiving skills, and they usually feel unprepared to undertake the caregiver role. Objective: Considering the key role of family caregivers in maintaining the overall health and well-being of the individual with SCI, the objective of this study was to determine the breadth of skills needed by family caregivers to enhance their competency in caring for individuals with SCI living in the community. Methods: A qualitative descriptive approach was used with semi-structured interviews. Thematic analysis was used to determine key themes arising from the experiences of individuals with SCI ( n = 19) and their family members ( n = 15). Results: Twenty-nine SCI family caregiving skills were identified and grouped into six caregiving processes signifying the multiple dimensions of the SCI caregiving role. These include monitoring and managing physical health and secondary health conditions, providing for psychosocial needs, decision making, time management, being flexible, and navigating the health and social services system. Conclusion : The current study demonstrated that development of multiple caregiving skills is crucial to enhance family members' competency in caregiving. These findings should further alert health care professionals that assessment of caregiving skills at regular intervals is necessary to help caregivers achieve mastery in situations where they are facing caregiving difficulties. Future programs need to be designed to include the skills that family caregivers need and use in real-life caregiving situations., Competing Interests: Dr. Craven reports personal fees from Rick Hansen Institute outside the submitted work. Drs. Cameron and Jaglal report no conflicts of interest., (© 2019 Thomas Land Publishers, Inc.)

Background: Fall prevention is a priority in Canadian tertiary rehabilitation hospitals. We aimed to understand the perspectives of hospital administrators on the challenges experienced when implementing fall prevention policies/procedures for patients with spinal cord injury (SCI) in tertiary rehabilitation hospitals., Methods: Semi-structured interviews were conducted with 10 administrators employed in six Canadian tertiary rehabilitation hospitals. Guided by an interpretive description framework, interviews were analyzed using a constant comparison approach., Results: Challenges with fall prevention experienced by administrators fell into the three categories: 1) fall prevention policy and procedural challenges (e.g. fall prevention policy not SCI-specific, expectation of zero falls, determining contributing factors, learning from falls, and overall effectiveness of the fall prevention policy), 2) clinician-related challenges (e.g. variable staff adherence with the organizations' fall prevention procedures, inconsistent delivery of fall prevention education, and integrating individualized fall risks to guide clinical practice), and 3) patient-related challenges (e.g. balancing risk vs independence and rehabilitation progress, responsibility for fall prevention, and non-preventable falls)., Conclusions: Fall prevention policies/procedures required by the hospitals were insufficient for clinical practice in SCI rehabilitation.