Toronto Rehabilitation Institute

Background Youth with disabilities often experience disability‐related discrimination (ableism). Those with multiple minoritised identities, such as along the axes of disability and gender, arguably encounter more complex forms of discrimination; however, little is known about their experiences. Exploring the experiences of sex/gender minoritised youth with disabilities is important because they often face many challenges within education, health and social services, including discrimination, which could perpetuate inequalities. The purpose of this study was to understand the ways in which discrimination influenced the experiences of sex/gender minoritised youth with disabilities and how they coped with the discrimination they encountered. Methods This study involved a qualitative interview design using a purposive sample of 10 sex/gender minoritised youth with disabilities aged 17–25 years (mean age 21.5 years). An interpretive inductive thematic analysis was applied to the interview data. Results Our findings identified the following themes: (1) intersectional forms of discrimination, (2) negative impacts on physical and mental health, (3) hiding minoritised identities while avoiding unsafe spaces and situations and (4) inadequate social support and opportunities. We found that some youth demonstrated several positive coping strategies for dealing with ableism (Theme 5), which included (1) finding safe spaces through support‐seeking and community involvement and (2) self‐acceptance and self‐advocacy. Conclusions The results highlight the pervasive negative impact that ableism has for sex/gender minoritised youth with a disability. Although most youth demonstrated some coping and resilience skills, much further work is needed at a societal and institutional level to address and reduce discrimination while optimising social inclusion.

Neurotechnological interfaces have the potential to create new forms of human-machine interactions, by allowing devices to interact directly with neurological signals instead of via intermediates such as keystrokes. Surface electromyography (sEMG) has been used extensively in myoelectric control systems, which use bioelectric activity recorded from muscles during contractions to classify actions. This technology has been used primarily for rehabilitation applications. In order to support the development of myoelectric interfaces for a broader range of human-machine interactions, we present an sEMG dataset obtained during key presses in a typing task. This fine-grained classification dataset consists of 16-channel bilateral sEMG recordings and key logs, collected from 19 individuals in two sessions on different days. We report baseline results on intra-session, inter-session and inter-subject evaluations. Our baseline results show that within-session accuracy is relatively high, even with simple learning models. However, the results on between-session and between-participant are much lower, showing that generalizing between sessions and individuals is an open challenge.

Aims To examine the risk of perinatal mental illness, including new diagnoses and recurrent use of mental healthcare, comparing women with and without traumatic brain injury (TBI), and to identify injury-related factors associated with these outcomes among women with TBI. Methods We conducted a population-based cohort study in Ontario, Canada, of all obstetrical deliveries to women in 2012–2021, excluding those with mental healthcare use in the year before conception. The cohort was stratified into women with no remote mental illness history (to identify new mental illness diagnoses between conception and 365 days postpartum) and those with a remote mental illness history (to identify recurrent illnesses). Modified Poisson regression generated adjusted relative risks (aRRs) (1) comparing women with and without TBI and (2) according to injury-related variables (i.e., number, severity, timing, mechanism and intent) among women with TBI. Results There were n = 12,724 women with a history of TBI (mean age: 27.6 years [SD, 5.5]) and n = 786,317 without a history of TBI (mean age: 30.6 years [SD, 5.0]). Women with TBI were at elevated risk of a new mental illness diagnosis in the perinatal period compared to women without TBI (18.5% vs. 12.7%; aRR: 1.31, 95% confidence interval [CI]: 1.24–1.39), including mood and anxiety disorders. Women with a TBI were also at elevated risk for recurrent use of mental healthcare perinatally (35.5% vs. 27.8%; aRR: 1.18, 95% CI: 1.14–1.22), including mood and anxiety, psychotic, substance use and other mental health disorders. Among women with a history of TBI, the number of TBI-related healthcare encounters was positively associated with an elevated risk of new-onset mental illness. Conclusions These findings demonstrate the need for providers to be attentive to the risk for perinatal mental illness in women with a TBI. This population may benefit from screening and tailored mental health supports and treatment options.

A 79‐year‐old former professional football player presented with language deficits and cognitive changes. A year later, he had difficulty completing sentences, and 3 years after onset, was reduced to one‐word answers. He developed severe apathy and agitation, and became more impulsive. He eventually became mute and had difficulty with walking and balance. The patient had mild repetitive head injury while playing football and three concussions. Magnetic resonance imaging revealed left > right frontotemporal atrophy. Duration of illness was 6 years. Neuropathology revealed an unexpected number and diversity of degenerative pathologies, including chronic traumatic encephalopathy (CTE, high level), high level Alzheimer's disease neuropathologic change (A3B3C3), limbic Lewy body disease, cerebral amyloid angiopathy (type 2), argyrophilic grain disease (Stage 2), and neuronal intranuclear hyaline inclusion body disease. In addition, there was selective and asymmetric involvement of the corticospinal tract with globular oligodendroglial tau pathology corresponding to globular glial tauopathy (Type II). The patchy and irregular accentuation of cortical tau pathology, particularly in the depths of sulci and accumulation around blood vessels, allows the diagnosis of CTE‐neuropathologic change. This diagnosis correlated with the past medical history of multiple concussions. In addition, the patient had an unprecedented number and combination of additional degenerative pathologies, including those that are rare, and how they contributed to the clinical symptoms is difficult to interpret. Globular glial tauopathy Type II is a rare disorder that has been mostly reported in association with progressive supranuclear gaze palsy, and these observations support the notion that globular glial tauopathy Type II is an independent entity with isolated corticospinal tract involvement. These observations highlight that rare disorders can occur in the same individual and be overlooked, especially when there is more obvious pathology. It is essential for neuropathologists to consider an extensive array of neuropathological examinations when assessing patients with neurodegenerative disorders.

Objective The Getting Older Adults Outdoors (GO-OUT) randomized trial showed that a 10-week outdoor walk group (OWG) program was not superior to 10 weekly phone reminders in increasing physical and mental health; however, OWG attendance varied. This study examined whether dose-response relationships existed between OWG attendance and improvement in physical and mental health among older adults with mobility limitations. Methods We analyzed data from 76 OWG participants with pre- and post-intervention scores on at least one of seven measures of health outcomes (walking endurance, comfortable and fast walking speed, balance, lower extremity strength, walking self-efficacy, and emotional well-being). Participants were classified as attending 0–9, 10–15, and 16–20 OWG sessions based on attendance tertiles. We adjusted for participant sex and study site in regression analyses. Results Among the 76 participants, mean age was 74.9 ± 6.6 years and 72% were female. Compared to those attending 0–9 OWG sessions, participants attending 16–20 sessions exhibited a 56.3-meter greater improvement in walking endurance (95% CI: 17.3, 95.4, p = 0.005); 0.15-meter/second greater improvement in comfortable walking speed (95% CI: 0.01, 0.29, p = 0.034); and 0.18-meter/second greater improvement in fast walking speed (95% CI: 0.03, 0.34, p = 0.020). Higher attendance was associated with greater odds of improvement in comfortable walking speed (OR = 7.1; 95% CI: 1.1, 57.8, p = 0.047) and fast walking speed (OR = 10.1, 95% CI: 1.8, 72.0, p = 0.014). No significant dose-response relationships for the remaining outcomes were observed. Conclusions Higher attendance in a park-based, supervised, task-oriented and progressive OWG program is associated with greater improvement in walking endurance and walking speed among older adults with mobility limitations. Attendance likely impacted walking capacity and not balance, lower extremity strength, walking self-efficacy or emotional well-being due to task-specificity of training. This study highlights the importance of attendance when designing and implementing OWG programs to enhance walking endurance and speed among older adults.

Background With the explosion of techniques for recording electrical brain activity, our recognition of neurodiversity has expanded significantly. Yet, uncertainty exists regarding sex differences in electrical activity during sleep and whether these differences, if any, are associated with social parameters. We synthesised existing evidence applying the PROGRESS-Plus framework, which captures social parameters that may influence brain activity and function. Methods We searched five databases from inception to December 2024, and included English language peer-reviewed research examining sex differences in electrical activity during sleep in healthy participants. We performed risk of bias assessment following recommended criteria for observational studies. We reported results on sex differences by wave frequency (delta, theta, alpha, sigma, beta, and gamma) and waveforms (spindle and sawtooth), positioning results across age-related developmental stages. We created visualizations of results linking study quality and consideration of PROGRESS-Plus parameters, which facilitated certainty assessment. Results Of the 2,783 unique citations identified, 28 studies with a total of 3,374 participants (47% male, age range 4–5 months to 101 years) were included in data synthesis. Evidence of high certainty reported no sex differences in alpha and delta relative power among participants in middle-to-late adulthood. Findings of moderate certainty suggest no sex differences in alpha power; and theta, sigma and beta relative power; and delta density. There is evidence of moderate certainty suggesting that female participants had a steeper delta wave slope and male participants had greater normalized delta power. Evidence that female participants have higher spindle power density is of low certainty. All other findings were regarded as very low in certainty. The PROGRESS-Plus parameters were rarely integrated into the methodology of studies included in this review. Conclusion Evidence on the topic of sex differences in sleep wave parameters is variable. It is possible that the reported results reflect unmeasured social parameters, instead of biological sex. Future research on sex differences in sleep should be discussed in relevance to functional or clinical outcomes. Development of uniform testing procedures across research settings is timely. PROSPERO: CRD42022327644. Funding: Canada Research Chairs (Neurological Disorders and Brain Health, CRC-2021-00074); UK Pilot Award for Global Brain Health Leaders (GBHI ALZ UK-23-971123).

Introduction Normal pressure hydrocephalus (NPH) is a syndrome characterized by the buildup of cerebrospinal fluid that results in the clinic triad of gait impairment, urinary incontinence, and cognitive impairment. NPH can be categorized as secondary, idiopathic, or familial. Here, we report a comparison of sporadic to familial types from clinical, radiological, and surgery response aspects as well as a novel gene mutation as a cause of familial NPH. Method We analyzed 139 patients evaluated for NPH at our center from 2010 to 2022. Ninety-five patients diagnosed with probable (n = 26) or definite (n = 69) iNPH were included. Clinical, radiological, and gait data were retrospectively collected. In patients with a positive familial history of NPH, we defined the inheritance pattern when possible. The results of performed genetic tests were reported. Result Nine patients (9.5%) had a familial history of NPH. Familial and sporadic groups were largely comparable in age, sex, and disease duration. However, familial cases had better cognitive scores (p = 0.022) and a higher prevalence of upper-limb action tremor (56% vs. 14%; p = 0.008). No significant differences were noted in radiological markers, and both groups showed a positive response to ventriculoperitoneal shunting (VPS). Whole exome sequencing identified a novel pathogenic NEIL1 variant in twin patients with familial NPH. Conclusions Familial NPH occurred in roughly 1 in 10 reviewed iNPH cases and demonstrates better cognition and increased tremor incidence compared to sporadic cases but otherwise similar characteristics. The genetic underpinning of these cases is heterogeneous and NEIL1 might represent another associated gene.

Background Traumatic brain injury is a chronic disease with lifelong consequences. In children, it can affect developmental milestones. Longitudinal data on brain injury and long-term healthcare use is limited, with lack of clarity on social determinants of health and its effects on healthcare use. This study explores rates of healthcare use, from birth, and up to 10 years after a childhood traumatic brain injury-related healthcare visit. Methods and findings This study uses a population-based birth cohort of individuals born between April 1, 2002 and March 31, 2020 from Ontario, Canada. A case cohort (TBI cohort) was created using a sample of individuals who had at least one traumatic brain injury-related healthcare visit between the ages of 0 and 4 years, inclusive (n = 26,988). Controls were generated from a sample of individuals who did not have any traumatic brain injury-related healthcare visit during the study period (n = 193,253 for emergency department visits and hospitalizations, and n = 19,313 for primary care physician visits). The primary outcome is rates of primary care physician visits, emergency department visits, and hospitalizations for each year prior to and up to 10 years after the index traumatic brain injury-related healthcare visit, calculated using standard life table methods. Rates and 95% confidence intervals were further calculated and stratified by rurality of residence, and the following Ontario Marginalization Index metrics: neighbourhood income quintile and neighbourhood racialized and newcomer populations. Rates of healthcare use remained consistently higher in the TBI cohort compared to controls both prior to and after the index TBI-related healthcare visit. Rates also varied across social determinants of health. Overall, rates were higher in males compared to females across all healthcare settings. Rates of primary care physician visits were higher among those living in urban (vs. rural) settings. However, rates of emergency department visits were higher among those living in rural (vs. urban) settings. Rates of emergency department visits and hospitalizations were higher among those living in the lowest (vs. highest) income quintile neighbourhoods. Rates of primary care physician visits were higher among those living in areas with the most (vs. least) racialized and newcomer populations. However, rates of emergency department and hospitalizations were higher among those living in areas with the least (vs. most) racialized and newcomer populations. This study is limited to change in rates of healthcare use over time and does not quantify the magnitude of these changes. Conclusions Research on longitudinal healthcare use is needed to explore the causes of sustained and increased healthcare use post-injury, to inform opportunities for targeted health and social care interventions. Findings also suggest that a lifespan perspective is critical to understand how early life events can impact post-injury outcome.

Background Rhythm-based rehabilitation interventions are gaining attention and measuring their effects is critical. With more clinical care and research being conducted online, it is important to determine the feasibility of measuring rhythm abilities online. However, some tools used to measure rhythm abilities, in particular the beat alignment test (BAT), have not been validated for online delivery. This study aims to determine the feasibility, reliability, and learning effects for online delivery of the BAT in adults with and without stroke. Methods Neurotypical adults and adults with chronic stroke completed the BAT online three times, with testing sessions separated by 2 to 4 days. The BAT includes a perception task (identifying whether tones overlayed on music matched the beat of the music) and a production task (tapping to the beat of music). Feasibility was evaluated with completion rates, technical challenges and resolutions, participant experience via exit questionnaire, and test duration. Reliability was measured using inter-class correlations and standard error of measurement, and learning effects were determined using a repeated-measures ANOVA. Results Thirty-nine neurotypical adults and 23 adults with stroke participated in this study. More a priori feasibility criteria for the online BAT were met with neurotypical adults than people with stroke. Most components of the online BAT were considered reliable based on an ICC = 0.60 cut-off, except for perception in the neurotypical group, and production asynchrony in the stroke group. There was notable variability in performance, but no learning effects in either group. Conclusions Online administration of the BAT is more feasible for neurotypical adults than people with stroke. Challenges with online administration for people with stroke may be partly related to the delivery platform. The BAT is a reliable tool with no learning effects and therefore is a promising way to assess for rhythm abilities online with careful consideration of user interface for people with stroke.

Importance: Cultural humility may improve the quality of occupational therapy services, but how occupational therapy practitioners apply this approach in their practice contexts has not been clearly described in the literature. Objective: To describe peer-reviewed rehabilitation literature on the practice of cultural humility and align the findings with occupational therapy practice using the Canadian Practice Process Framework (CPPF). Data Sources: Nine databases were searched, using the term cultural humility to identify relevant peer-reviewed rehabilitation literature. Google Scholar and six journals were hand-searched to identify additional studies. Study Selection and Data Collection: This substudy of a larger knowledge synthesis was guided by Arksey and O’Malley’s (2005) scoping review methodology. Titles, abstracts, and full texts of studies were screened using Covidence. Study descriptors, context, population, and cultural humility elements defined by Tervalon and Murray-García (1998), and recommendations were extracted, analyzed, and mapped onto the CPPF. Findings: In total, 11 studies were included. Cultural humility elements of self-reflection and critique (n = 7; 63.6%), self-awareness and egolessness (n = 8; 72.7%), and supportive interaction (n = 5; 45.4%) were identified. Most cultural humility elements aligned with the societal (n = 11; 100%) and practice (n = 10; 90.9%) contexts of the CPPF. Conclusions and Relevance: Findings highlight how occupational therapists could integrate cultural humility at each stage and in each context of their practice. Additionally, these insights can inform occupational therapy education on integrating cultural humility into training programs and guiding practitioners in applying cultural humility principles to enhance their practice. Plain-Language Summary: Cultural humility may improve the quality of occupational therapy services. How occupational therapy practitioners apply cultural humility has not been clearly described in the literature. This review describes literature on the practice of cultural humility. The findings were aligned with occupational therapy practice using the Canadian Practice Process Framework. The findings highlight how occupational therapists could integrate a cultural humility approach at each stage, in each practice process and context, and into training programs. The findings also provide a foundation for future research on how to apply cultural humility principles to improve occupational therapy services.

While deep learning methods have shown great promise in improving the effectiveness of prostate cancer (PCa) diagnosis by detecting suspicious lesions from trans-rectal ultrasound (TRUS), they must overcome multiple simultaneous challenges. There is high heterogeneity in tissue appearance, significant class imbalance in favor of benign examples, and scarcity in the number and quality of ground truth annotations available to train models. Failure to address even a single one of these problems can result in unacceptable clinical outcomes. We propose TRUSWorthy, a carefully designed, tuned, and integrated system for reliable PCa detection. Our pipeline integrates self-supervised learning, multiple-instance learning aggregation using transformers, random-undersampled boosting and ensembling: These address label scarcity, weak labels, class imbalance, and overconfidence, respectively. We train and rigorously evaluate our method using a large, multi-center dataset of micro-ultrasound data. Our method outperforms previous state-of-the-art deep learning methods in terms of accuracy and uncertainty calibration, with AUROC and balanced accuracy scores of 79.9% and 71.5%, respectively. On the top 20% of predictions with the highest confidence, we can achieve a balanced accuracy of up to 91%. The success of TRUSWorthy demonstrates the potential of integrated deep learning solutions to meet clinical needs in a highly challenging deployment setting, and is a significant step toward creating a trustworthy system for computer-assisted PCa diagnosis.

As Artificial Intelligence (AI) technologies become more integrated into clinical settings to optimize care, healthcare professionals (HCPs) will need to become more adept in responsibly using these novel technologies to augment patient care. A qualitative study, consisting of semi-structured interviews was conducted to explore the informational needs of HCPs and gaps in current AI education. Participants, consisting of educators and learners, were recruited from AI programs. The interview data were analyzed using inductive thematic analysis. Three themes were identified, addressing the need for (1) developing a longitudinal AI curriculum to transform the mindset, skillset, and toolset of providers, (2) cultivating an active learning approach to foster knowledge mobilization and optimize the use of AI tools in the provision of care, and (3) fostering a multidisciplinary approach to AI curriculum design is essential to promote collaborative efforts among HCPs in implementing AI tools. This study identified five key recommendations to prepare HCPs with the knowledge and skills necessary for an AI-driven future.

The present study aimed to test the accuracy of applying machine learning to a novel contactless video-based approach in detecting task-related concentration. Evaluations of concentration on-task have relied on laboratory methodologies, which encounter difficulties when applied to real work scenarios. Video photoplethysmography (VPPG) can present a solution to these difficulties by extracting physiological changes from videos captured by any conventional camera. Applying machine learning to physiological signals from VPPG can enable contactless detection of task-related concentration. Thirty adults completed a simulated task. Physiological changes were recorded via electrocardiogram (ECG) and VPPG. Pre-trained VGG, support vector machine, and XGBoost were performed on ECG and VPPG signals to detect when participants were on- or off-task. The ensemble method, which combined three machine-learning methods, applied to VPPG signals proved to be highly accurate (∼97%). Among individual machine-learning methods, pre-trained VGG applied to VPPG signals performed the best, comparable to the ensembled method. All analyses showed detection based on VPPG signals to significantly outperform ECG signals. Results establish a proof-of-concept that VPPG and machine learning can be used to detect task-related concentration in a contactless, convenient, and inexpensive fashion. VPPG can enable the detection of task-related concentration in natural work settings.

Obstructive sleep apnea (OSA) represents a prevalent condition impacting over 9% of the general adult population. Various treatment options have been clinically proposed and utilized, with a particular focus on continuous positive airway pressure (CPAP) and oral appliances due to their overall effectiveness and higher adherence rates. CPAP therapy has demonstrated greater effectiveness but lower adherence compared to oral appliances. However, treatment success of oral appliances is not always guaranteed, hence sleep physicians are more cautious in their prescriptions unless they can reasonably estimate the chance of responding to oral appliance therapy. Prior studies often rely on invasive or inconvenient methodologies such as drug-induced sleep endoscopy (DISE), cephalometry, multisensor catheters, or full polysomnography (PSG). In this prospective study, we collected data with a home sleep apnea test (HSAT) device from 50 participants (38 using mandibular advancement devices [MADs] and 12 using tongue stabilizing devices [TSDs]). We used a simple yet informative data source: snoring vibrations extracted from a nasal pressure sensor with a low sampling frequency (125 Hz). Using spectro-temporal analysis of the snoring signal, we successfully predicted therapy efficacy with accuracies of 88% for MAD and 91% for TSD. Our proposed methodology presents a promising approach that can be utilized without further need for PSG or integrated within PSG testing for accurate prediction of oral appliance efficacy.

Objective In this cross-sectional analysis, we explored how return-to-work (RTW) experiences and postinjury pain are associated with opioid use after a workplace injury/illness. Methods Workers with accepted lost-time claims, compensated by the workers’ compensation board in Ontario, Canada were interviewed by telephone 18 months following a work-related physical injury/illness. Participants were asked about their past-year opioid use, current pain, RTW timing and workplace accommodations. Separate logistic regression analyses were conducted to estimate the association between two independent variables and opioid use: one combining the presence of pain with workplace accommodation and a second combining the presence of pain with RTW timing, adjusted for sociodemographic, work, injury and health covariates. Results Of 1793 participants included in the analysis, 35.6% used opioids more than once in the past 12 months. Compared with those who did not return to work too soon and had no/mild pain, odds of opioid use were higher among those with severe pain, both those who returned too soon (OR 2.90, 95% CI 2.11 to 3.99) and those who did not return too soon (OR 3.01, 95% CI 2.16 to 4.19). Compared with those who had an offer of accommodation and no/mild pain, workers with severe pain and an accommodation offer (OR 2.78, 95% CI 2.16 to 3.57) or without an offer (OR 2.69, 95% CI 1.90 to 3.81) had increased odds of reporting use of opioids. Conclusions Findings suggest pain is the main factor associated with opioid use after a work-related injury, irrespective of RTW experiences. However, due to the limitations of this exploratory analysis, longitudinal research examining this issue is warranted.

Purpose Immigrant youth face both unique and disproportionate barriers to sexual health. Targeted sexual health education to redress these disparities requires creative and inclusive approaches that consider personal and community challenges and strengths. This study piloted a novel intervention: SExT: Sex Education by Theatre, a theatre-based, culturally-relevant, participatory action research programme delivered in an immigration destination neighbourhood in Toronto, Canada. Design/methodology/approach Nineteen youth were trained as peer educators. They participated in theatre-based workshops on sexual health topics which culminated in a performance for local peers. Mixed methods evaluation included surveys which investigated changes in personal and social development over three time-points (pre, post, 4-month follow-up). The impact of the intervention on peer educators was explored in greater depth using qualitative peer interviews and focus groups. Findings Quantitative study findings indicated that peer educators experienced significant improvements in personal growth, social inclusion and social engagement after participating in SExT and these improvements were maintained at follow-up. Thematic qualitative analysis further indicates that meaningful involvement in a sex education theatre intervention may protect against adverse outcomes and promote self-actualization, connection and active citizenship. Originality/value This research stands out for its innovative approach to addressing sexual health disparities among immigrant youth in Toronto using culturally relevant theatre-based peer education. SExT may serve as a model for sexual health interventions for newcomer youth and other priority groups in diverse contexts.

This article describes the development of priorities and actions to improve the state of research, policy, and practice related to accessible housing in Canada for persons with disability or with accessible housing needs. A modified Delphi approach with an expert cross-sectoral panel was used to gain convergence on a set of priorities for advancing the accessible housing field in Canada. This included circulating an anonymous pre-meeting survey (N = 49) followed by an in-person planning meeting (N = 45). The expert panel at the in-person meeting identified three clusters of priorities from an initial list of 21 priorities, which included: 1) engaging with all levels of government to support accessible housing efforts; 2) developing educational resources to raise awareness about accessible housing, and creating services to facilitate locating and acquiring accessible housing; and 3) fostering meaningful engagement across key interest groups and sectors to find solutions to enact positive change in this space. The findings provide an initial roadmap for bringing greater cohesion to the accessible housing field, which will enable cross-sectoral partnerships and collective action towards informing the next generation of accessible housing standards, regulations and practices for people with accessible housing needs.

The purpose of our study was to develop a toolkit to facilitate the implementation of functional electrical stimulation (FES) cycling for persons with a newly acquired spinal cord injury (SCI) in the acute care inpatient hospital setting. The researchers and community members used participatory action as a research approach to co-create the toolkit. We held two focus groups to develop drafts, with a third meeting to provide feedback, and a fourth meeting to evaluate the toolkit and determine dissemination strategies. Toolkit development followed the Planning, Action, Reflection, Evaluation cycle. We used an iterative design informed by focus group and toolkit consultant (SC) feedback. In focus group discussions, we included FES cycling champions (JK, DW) who led acute care implementation. Focus group members, recruited through purposive sampling, had to 1) have an understanding about FES cycling in acute care for SCI and 2) represent one of these groups: individual living with SCI, social support, hospital manager, clinician, therapist, researcher, and/or acute care FES cycling champion. Twelve individuals took part in four focus groups to develop a toolkit designed to facilitate implementation of FES cycling in SCI acute care in Edmonton, Alberta. Group members included an individual with lived experience, three acute-care occupational or physical therapists, three acute-care hospital managers, and five researchers. Two physical therapists also identified as clinical FES cycling champions. Following an inductive content analysis, we identified four main themes: 1) Health care provider toolkit content and categories, 2) Health care provider toolkit end product, 3) Collaborations between groups and institutions and 4) Infrastructure. Interested parties who utilize FES cycling in acute care for SCI rehabilitation agree that toolkits should target the appropriate group, be acute care setting-specific, and provide information for a smooth transition in care.

Background Improving hand and arm function is an important goal for individuals with cervical spinal cord injury (cSCI). Activity Based Therapy (ABT) is a neurorestorative approach that incorporates a high intensity, long duration and effortful engagement to garner sensory‐motor improvements. Spinal cord stimulation is a neuromodulation modality that can restore sensory‐motor function. Spinal cord stimulation can elevate the excitability of the spinal neural network and potentially enhance the neurorestorative benefits of ABT. However, there is scarce evidence on the combined effects of ABT and spinal cord stimulation on UL recovery after cSCI. Objective This report aims to describe how theory informed the design and development of a Phase 1 study on a new UL intervention combining ABT and transcutaneous cervical spinal cord stimulation (tCSCS) (short form:ABT‐tCSCS) delivered simultaneously for individuals with cSCI. Method The design of the ABT‐tCSCS was guided by theory‐based frameworks such as the Rehabilitation treatment specification system and the Template for Intervention Description and Replication guide. The ABT‐TCSCS aimed to improve somatosensory‐motor deficits and function in the UL after cSCI. The ABT‐tCSCS intervention was developed through the following stages: (a) Description of the active ingredients, mechanism of action, and targets of the ABT‐tCSCS; (b) Tailoring of ABT‐tCSCS; and (c) Development of treatment regimen guidelines for the delivery of the ABT‐tCSCS. Results ABT constitutes 4 types of exercises, including cardio‐fitness, resistance, postural/weightbearing, and functional exercises, for activation of the neuromuscular system below the level of lesion to target somatosensory‐motor impairments. In tCSCS, electrical stimulation is delivered at a frequency of 30–50 Hz at 500–1000 μs between C3‐C7. The spinal neural networks of the cervical region are stimulated to neuromodulate the descending motor commands which control the muscles. ABT‐tCSCS will be delivered simultaneously over 28 sessions (1 h/session, 3x/week over 9–10 weeks). Conclusions Combined ABT‐tCSCS is a new intervention for neurorestoration of the upper limbs after cSCI. Trail Registration ClinicalTrials.gov ID: NCT06472986