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Research in Action

With so much exciting research going on, it’s critical that results are put into practice. At Toronto Rehab, we translate key scientific evidence into action in many ways. Some examples:

Sharing space, sharing ideas: the Balance, Falls and Mobility Clinic

Toronto Rehab’s new Balance, Falls and Mobility Clinic is a place where clinicians and researchers work side by side with patients. The goal: to improve mobility and reduce the risk of falling among stroke survivors, whose ability to get around is often compromised.

Each new stroke inpatient is tested in the clinic using the latest technology. Some is so new that it has only been used in research labs until now. For example, sophisticated instrumentation measures how an individual – strapped into a harness – reacts to simulated trips and controlled falls. An electronic mat gauges how well a patient walks.

“Some of these things are difficult to objectively measure without the benefit of this kind of equipment,” says physiotherapist Liz Inness, who helped develop and now oversees the clinic in conjunction with Toronto Rehab scientists Drs. Mark Bayley and William McIlroy. Exposing a patient’s underlying problems with mobility helps to guide treatment decisions and to reveal how the individual is responding to treatment.

The stakes are high. “This is a safety and quality of life issue,” says Dr. Bayley, Medical Director of Toronto Rehab’s Brain and Spinal Cord Rehab Program. “If we can improve people’s gait, they will be less likely to fall and more likely to engage in activities in the community, which is ultimately the goal of rehabilitation.”

The new clinic is also a place of active research where scientists are enhancing methods to assess and treat balance and mobility problems. They are also turning promising new treatments into standard clinical practice.

Brain injury screening

Homeless people face numerous daily challenges such as finding food, shelter and safety. It turns out they often contend with another challenge too – brain injury. Over half of Toronto’s homeless population has had a traumatic brain injury. That 2008 finding was published in a headline-grabbing study authored by researchers at St. Michael’s Hospital in Toronto and Toronto Rehab.

“The study is the first to show that the roots of homelessness may sometimes lie in serious head injury that occurred in the person’s past,” says principal author Dr. Stephen Hwang, a physician and researcher at St. Michael’s.

The study’s co-author, Toronto Rehab senior scientist Dr. Angela Colantonio, says the study underscores the need for clinicians to routine screen for brain injury among the homeless.

Now, work is underway at a Toronto shelter to determine how best to screen for brain injury among the homeless. “It’s a significant step towards routine early identification, which can lead to rehabilitation,” says Dr. Colantonio, who is co-supervisor of the project with Dr. Jane Topolovec-Vranic of St. Michael’s.

If physicians and frontline workers were to screen vulnerable populations more routinely for prior head trauma, it might also help to prevent homelessness in the first place, says Dr. Colantonio.

Traumatic brain injury most commonly results from falls, car crashes and assaults. Cognitive skills, memory, language and behaviour can all be severely affected. Survivors of serious brain injury face an increased risk of premature death.

A wireless system for tracking health, independence

A partnership between Toronto Rehab’s Mobility Team and the Schlegel-UW Research Institute for Aging (RIA) has produced a novel system for tracking the health and independence of long-term care residents.

The assessment system can be used a regular intervals to identify changes in a person’s health and independence, guide interventions and target exercise programs – helping people to stay upright and out of hospital.

It was born out of a common frustration: in the lab, scientists have sensitive research tools, like force plates, that can assess people’s ability to get around and do daily activities. But such lab instruments can be big, expensive and complicated to use. What if these tools could be portable, cheaper and easier to use, so that clinicians could assess patients in long-term care settings and doctors’ offices?

“We’ve been looking for a way to better blend what research tools have been successful in telling us with practical implementation in a clinical setting,” explains Dr. William McIlroy, a University of Waterloo (UW) researchers and leader of Toronto Rehab’s Mobility Team. “Now, the development of very low-cost technology has actually made this possible.”

The result is the Schlegel Functional Fitness Assessment (FFA), a wireless system that has been merged with a clinical assessment developed through the Schlegel-UW RIA partnership involving a team led by Dr. Mike Sharratt of the RIA, Dr. McIlroy and Dr. Karen Van Ooteghem. Software developer Simon Jones of Toronto Rehab’s Mobility Team assisted with the development of data-collection software.

The system is comprised of several measures that assess mobility and functional fitness (ability to do activities of daily living). A Nintendo Wii balance board (force plate), ordinarily used for gaming or exercising, is used to measure a person’s ‘sway’ while standing. Wireless sensors are attached to a person’s ankles, where they record information about step variability and other aspects of walking. Performance reports are generated immediately.

The system offers valuable insights into a person’s fall risk and ability to get around. “It looks at the most important components of mobility: ability to stand and maintain your balance; ability to sit and stand; and ability to walk independently,” says Dr. McIlroy.

Already, several long-term care facilities operated by Schlegel are routinely using the tool and it will be introduced at Schlegel’s other sites in Ontario. “We would love to roll this out as a toolkit that could be used in clinical offices, and even people’s homes,” says Dr. McIlroy.

A new approach for hip-fracture patients with cognitive problems

Usually, hip-fracture patients who have dementia-like symptoms are moved directly from acute care to a nursing home. The reason? A belief that these patients can’t endure or benefit from an active rehab setting. But Toronto Rehab researchers challenged that assumption. Senior scientist Dr. Kathy McGilton and colleagues developed a new model of care for hip fracture patients with cognitive impairment. The results show that, with a creative, sensitive and personally tailored approach, these patients can do just as well in active rehab as those who are cognitively intact. The key is to provide staff with a greater understanding of cognitive impairments— and the skills, knowledge and support needed to relate to patients with these conditions.

A fascinating study shows that, with the new approach, cognitively-impaired patients made comparable gains in functional independence after breaking a hip. What’s more, they did not require extra days in hospital to make those gains. “Our study found that these patients were just as likely to walk out of the hospital on their own steam―and to live in the community after discharge,” says Dr. McGilton.

An evaluation of the model of care focused on long-term patient outcomes was recently conducted at two hospitals outside of the GTA. Results of the evaluation, led by Dr. McGilton, are expected to be published soon.

An estimated 17% of people who are living in the community and break a hip have a diagnosis of cognitive impairment―and the numbers are expected to increase.

Enhancing client-centred care

Client-centred care is a term often used but not always well understood, even by the very people who care for patients. A recent survey of Ontario long-term care homes identified a need for greater support to make this philosophy part of everyday practice. Dr. Pia Kontos, a Toronto Rehab scientist, is known for her research with people with dementia and how they continue to express their individual identity, or ‘selfhood,’ through actions and gesture, even when words fail. Her pilot research shows that when caregivers respond to residents’ expressions of selfhood, interactions between them improve, and the use of psychotropic medications and other forms of restraint declines. Dr. Kontos decided to communicate her findings by developing a series of vignettes about practitioner-client interactions to show caregivers what client-centred care actually looks like.

The vignettes have burst into cyberspace where they are reaching practitioners through an e-learning course developed by the Registered Nurses Association of Ontario, with funding from the Ministry of Health and Long-Term Care. Launched in 2009, the online course is available to nurses and personal support workers in Ontario’s 400 long-term care facilities. “This has enormous potential to change attitudes and practice by increasing understanding of client-centred care,” says Dr. Kontos, a CIHR New Investigator.

Preventing injury on the job

August may be the cruellest month for brain injuries in Ontario's construction industry, but October is not far behind, according to a 2009 study by Dr. Angela Colantonio, a senior scientist at Toronto Rehab. Few academic studies have looked at brain injury among construction workers. Yet the construction industry—with approximately 400,000 workers in Ontario alone—is known to have a high rate of serious brain injury.

The authors didn't expect to find a second peak of injuries in October. This may reflect a surge in work to complete projects prior to the winter months. Contributing factors, they speculate, could be shorter days to work, less light, and more adverse weather conditions. Their study also begins to raise questions about the time of day when many construction–related brain injuries occur. It identifies two peaks during the day: the hour before and the hours after lunch.

Doug McVittie, assistant general manager and director of operations for the Construction Safety Association of Ontario (CSAO), says his group will circulate the findings to construction companies across the province, as well as labour and management health and safety committees. The results will also be shared with CSAO staff members who provide training and safety seminars for construction workers.

An award-winning program for people living with heart disease

Cardiac rehabilitation saves lives. But despite the proven benefits, studies show that only 30 per cent of people who would benefit from taking part in a cardiac rehab program actually enrol in one. Toronto Rehab set out to change that. Scientists and clinicians at the hospital used their experience with Toronto Rehab’s successful on-site cardiac rehab program to create a home-based cardiac rehab program. Launched in 2007, the program has already reached hundreds of patients.

Here’s how it works: participants undergo a fitness assessment at the hospital and are given an individualized exercise plan. They work out from home, e-mailing exercise logs to a case manager who follows up with weekly prescheduled phone calls. Patients also learn about nutrition, psychosocial and other heart-related issues using a workbook and videotaped Internet lectures.

Preliminary findings are encouraging. Eighty per cent of participants complete the program. Their heart and lungs show an average 21 per cent improvement, compared to 17 per cent for on-site patients. Satisfaction levels with the program are high. Most encouraging is that the service is reaching people who would otherwise have no access to cardiac rehab.

The research-based program is quickly gaining recognition. It won an Innovation in Health Care Award from the Ontario government for outstanding innovation in improving quality and patient safety. The $20,000 award is being used to develop materials to help other facilities run home programs.

Addressing a brain-injury information gap

Brain injury is a leading cause of death and disability, yet there has never been a centralized dataset to assist in planning and evaluating services for brain injury survivors. Dr. Angela Colantonio, a senior scientist at Toronto Rehab, led an ambitious project to create a registry with information on Ontarians living with traumatic and non-traumatic brain injuries.

The dataset gives service providers an accurate picture of brain injury in their geographic region, including incidence and prevalence, and information on survivors such as age, gender, type of brain injury, and which services they use and where.

Launched in mid-2009, the registry is being used by planners at some of Ontario’s local health integration networks (LHINs). “Providers are using this vital data for planning, placement and budgeting, and ensuring the right services are provided,” says Dr. Colantonio.

Using drama to improve care

Survivors of brain injury need compassion, choice and control to recover; caregivers need strategies to help people with these serious injuries. So Toronto Rehab scientists are using the dramatic medium of theatre to train health professionals to provide better care for patients with brain injury.

Drs. Pia Kontos and Angela Colantonio worked with playwright Julia Gray to develop After the Crash, a play based on their research. The remarkable play follows a patient and his wife through the healthcare system as he struggles to recover from brain injury.
Findings of an evaluation study, funded by the Canadian Institutes of Health Research (CIHR), suggested that the drama positively affected reflexivity, empathy, and practice change to facilitate a client-centered culture of practice.

Between September 2006 and September 2012, After the Crash was publicly performed 35 times in cities across Canada (in rehabilitation hospitals and at conferences). Approximately 3,000 people have seen it, including health professionals, hospital volunteers, survivors and their families. Response has been overwhelmingly positive. The play also resonated with the public and media when it was featured at the Toronto Fringe Festival.

Shared Home Ownership for Independent Aging: 100 Perry Street

Dr. Geoff Fernie (Institute Director) and Catharine Hancharek (Business Development Leader, Research) reviewed the architectural plans for 100 Perry Street with the developer and two of the buyers.   Both of those buyers intend to “age in place” – remaining in the 100 Perry Street house as long as possible.  

Geoff and Catharine offered valuable advice on several important safety and accessibility features.  Geoff kicked off the discussion by pointing out that, if all five residents grow old in the house, “at least one of you will be in a wheelchair or scooter”.  That provided the framework for the discussion.

The following is a partial list of the recommendations that have been incorporated:

  • Ramping of the front entrance, porch at the same level as the first floor of the house, wider than normal front door, railing on the side porch for safety
  • Sizing the elevator to handle a scooter or wheelchair with attendant
  • Wider than normal stair treads to reduce the risk of falls
  • Permanently “on” lighting on all stairways – safety and an automatic “night light”
  • Generator for emergency power
  • Bathroom design – including fixtures and handrails
  • Design of hallway railings (install when needed) 
  • Fire sprinkler systems and “smart” fire and CO2 alarms
  • Advice on flooring styles,  type and placement of furniture