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Craven BC, Souza WH, Jaglal S, Gibbs J, Wiest MJ, Sweet SN, Athanasopoulos P, Lamontagne ME, Boag L, Patsakos E, Wolfe D, Hicks A, Maltais DB, Best KL, Gagnon D. Reducing endocrine metabolic disease risk in adults with chronic spinal cord injury: strategic activities conducted by the Ontario-Quebec RIISC team. Disabil Rehabil 2024; 46:4835-4847. [PMID: 38018518 DOI: 10.1080/09638288.2023.2284223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/17/2023] [Accepted: 11/10/2023] [Indexed: 11/30/2023]
Abstract
PURPOSE The Rehabilitation Interventions for Individuals with a Spinal Cord Injury in the Community (RIISC) team aimed to develop and evaluate innovative rehabilitation interventions to identify endocrine metabolic disease (EMD) risk, intending to reduce the frequency and severity of EMD related morbidity and mortality among adults living with chronic spinal cord injury or disease (SCI/D). MATERIALS AND METHODS An interprovincial team from Ontario and Quebec reviewed available EMD literature and evidence syntheses and completed an inventory of health services, policies and practices in SCI/D care. The review outcomes were combined with expert opinion to create an EMD risk model to inform health service transformation. RESULTS EMD risk and mortality are highly prevalent among adults with chronic SCI/D. In stark contrast, few rehabilitation interventions target EMD outcomes. The modelled solution proposes: 1) abandoning single-disease paradigms and examining a holistic perspective of the individual's EMD risk, and 2) developing and disseminating practice-based research approaches in outpatient community settings. CONCLUSIONS RIISC model adoption could accelerate EMD care optimization, and ultimately inform the design of large-scale longitudinal pragmatic trials likely to improve health outcomes. Linking the RIISC team activities to economic evaluations and policy deliverables will strengthen the relevance and impact among policymakers, health care providers and patients.
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Affiliation(s)
- Beverley Catharine Craven
- Toronto Rehabilitation Institute, Lyndhurst Centre, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Wagner Henrique Souza
- Kite Research Institute, University Health Network, Lyndhurst Centre, Toronto, Canada
| | - Susan Jaglal
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Jenna Gibbs
- Department of Kinesiology and Physical Education, McGill University, Montreal, Canada
| | | | - Shane N Sweet
- Department of Kinesiology & Physical Education, McGill University, Montreal, Canada
| | - Peter Athanasopoulos
- Senior Manager Public Policy and Government Relations, Spinal Cord Injury Ontario, Toronto, Canada
| | | | - Lynn Boag
- University of Guelph, Guelph, Canada
| | - Eleni Patsakos
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | - Dalton Wolfe
- Department of Physical Medicine and Rehabilitation, Western University, Parkwood Institute Research, London, Canada
| | - Audrey Hicks
- Department of Kinesiology, McMaster University, Hamilton, Canada
| | - Désirée B Maltais
- Department of Rehabilitation, Physiotherapy Program, Laval University, Quebec City, Canada
| | - Krista Lynn Best
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec City, Canada
| | - Dany Gagnon
- School of Rehabilitation, Université de Montréal, Montréal, Canada
- Centre for Interdisciplinary Research in Rehabilitation, Institut Universitaire sur la Réadaptation en Déficience Physique de Montréal (IURDPM), Montréal, Canada
- Rehabilitation, Université de Montréal, École de Réadaptation, Montréal, Canada
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Amiri M, Kangatharan S, Brisbois L, Farahani F, Khasiyeva N, Burley M, Craven BC. Developing and Evaluating Data Infrastructure and Implementation Tools to Support Cardiometabolic Disease Indicator Data Collection. Top Spinal Cord Inj Rehabil 2023; 29:124-141. [PMID: 38174138 PMCID: PMC10759866 DOI: 10.46292/sci23-00018s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Background Assessment of aerobic exercise (AE) and lipid profiles among individuals with spinal cord injury or disease (SCI/D) is critical for cardiometabolic disease (CMD) risk estimation. Objectives To utilize an artificial intelligence (AI) tool for extracting indicator data and education tools to enable routine CMD indicator data collection in inpatient/outpatient settings, and to describe and evaluate the recall of AE levels and lipid profile assessment completion rates across care settings among adults with subacute and chronic SCI/D. Methods A cross-sectional convenience sample of patients affiliated with University Health Network's SCI/D rehabilitation program and outpatients affiliated with SCI Ontario participated. The SCI-HIGH CMD intermediary outcome (IO) and final outcome (FO) indicator surveys were administered, using an AI tool to extract responses. Practice gaps were prospectively identified, and implementation tools were created to address gaps. Univariate and bivariate descriptive analyses were used. Results The AI tool had <2% error rate for data extraction. Adults with SCI/D (n = 251; 124 IO, mean age 61; 127 FO, mean age 55; p = .004) completed the surveys. Fourteen percent of inpatients versus 48% of outpatients reported being taught AE. Fifteen percent of inpatients and 51% of outpatients recalled a lipid assessment (p < .01). Algorithms and education tools were developed to address identified knowledge gaps in patient AE and lipid assessments. Conclusion Compelling CMD health service gaps warrant immediate attention to achieve AE and lipid assessment guideline adherence. AI indicator extraction paired with implementation tools may facilitate indicator deployment and modify CMD risk.
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Affiliation(s)
- Mohammadreza Amiri
- KITE Research Institute, University Health Network, Toronto, ON, Canada
- ICON plc, Burlington, ON, Canada
| | - Suban Kangatharan
- KITE Research Institute, University Health Network, Toronto, ON, Canada
| | - Louise Brisbois
- KITE Research Institute, University Health Network, Toronto, ON, Canada
| | - Farnoosh Farahani
- KITE Research Institute, University Health Network, Toronto, ON, Canada
| | | | | | - B. Catharine Craven
- KITE Research Institute, University Health Network, Toronto, ON, Canada
- Department of Medicine, Temerty Faculty of Medicine, Toronto, ON, Canada
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Garabiles MR, Shen ZZ, Yang L, Chu Q, Hannam K, Hall BJ. Investigating the Physical and Mental Health Nexus: a Network Analysis of Depression, Cardiometabolic Health, Bone Mass, and Perceived Health Status Among Filipino Domestic Workers. Int J Behav Med 2023; 30:234-249. [PMID: 35578098 DOI: 10.1007/s12529-022-10087-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Migrant domestic workers are vulnerable to physical and mental health problems given the many challenges they experience while working abroad. Using network analysis, this study examined the structure of depression, cardiometabolic health indicators (BMI, waist-hip ratio (WHR), blood pressure, and heart rate), bone mass, and perceived health status in this population. The network model allowed for an examination of central symptoms or symptoms with the most direct connections with other symptoms; bridge symptoms, or symptoms that link two or more communities; and edges, or relationships among symptoms. METHOD Cross-sectional data were gathered from 1375 Filipino domestic workers in Macao (SAR), China. Data from a subsample of 510 participants who met a cutoff indicating depression were analyzed. Anthropometric measurements and surveys were used to collect data, which was analyzed using R statistical software. RESULTS Results showed four community clusters: three communities consisted of at least two depression symptoms each and the fourth community included physical health indicators. Strong edges were formed between BMI-bone mass, psychomotor-concentration, BMI-WHR, and sad mood-anhedonia. The node with the highest expected influence was BMI. There were three bridges: worthlessness, psychomotor difficulties, and concentration difficulties. CONCLUSION The link between depression, cardiometabolic indicators, bone mass, and poor perceived health reinforces the need to address multimorbidity within migrant populations. Health promotion interventions that address mental and physical health may improve the health of this population.
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Affiliation(s)
- Melissa R Garabiles
- Department of Psychology, Ateneo de Manila University, Quezon City, NCR, Philippines
- UGAT Foundation Inc, Ateneo de Manila University, Quezon City, NCR, Philippines
- Psychology Department, De La Salle University, Manila, NCR, Philippines
- Scalabrini Migration Center, Quezon City, NCR, Philippines
| | - Zhuo Zhuo Shen
- School of Psychology, South China Normal University, Guangzhou City, Guangdong, People's Republic of China
| | - Lawrence Yang
- New York University School of Global Public Health, New York, NY, USA
| | - Qian Chu
- Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Kevin Hannam
- University of St. Joseph, Macao SAR, People's Republic of China
| | - Brian J Hall
- New York University School of Global Public Health, New York, NY, USA.
- Center for Global Health Equity, New York University Shanghai, Pudong, Shanghai, People's Republic of China.
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Ghodsi Z, Jazayeri SB, Pourrashidi A, Sadeghi-Naeini M, Azadmanjir Z, Baigi V, Maroufi SF, Azarhomayoun A, Faghih-Jouybari M, Amirjamshidi A, Naghdi K, Habibi Arejan R, Shabani M, Sepahdoost A, Dehghanbanadaki H, Habibi R, Mohammadzadeh M, Bahreini M, O'Reilly GM, Vaccaro AR, Harrop JS, Davies BM, Yi L, Ghodsi SM, Rahimi-Movaghar V. Development of a comprehensive assessment tool to measure the quality of care for individuals with traumatic spinal cord injuries. Spinal Cord Ser Cases 2023; 9:12. [PMID: 37005413 PMCID: PMC10067818 DOI: 10.1038/s41394-023-00569-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/11/2023] [Accepted: 03/20/2023] [Indexed: 04/04/2023] Open
Abstract
OBJECTIVE To develop a comprehensive assessment tool to evaluate the Quality of Care (QoC) in managing individuals with traumatic spinal cord injuries (TSCI). METHOD At first, the concepts of QoC for TSCI were identified by conducting a qualitative interview along with re-evaluation of the results of a published scoping review (conceptualization). After operationalization of indicators, they were valued by using the expert panel method. Afterward, the content validity index (CVI) and content validity ratio (CVR) were calculated and served as cut-offs for indicator selection. Then specific questions were developed for each indicator and classified into three categories: pre-hospital, in-hospital, and post-hospital. Data availability of the National Spinal Cord Injury Registry of Iran (NSCIR-IR) was subsequently used to design questions that represent indicators in an assessment tool format. The comprehensiveness of the tool was evaluated using a 4-item Likert scale by the expert panel. RESULT Twelve experts participated in conceptualization and 11 experts participated in operationalization phase. Overall, 94 concepts for QoC were identified from published scoping review (87 items) and qualitative interviews (7 items). The process of operationalization and indicator selection led to the development of 27 indicators with acceptable content validity. Finally, the assessment tool contained three pre-hospital, twelve in-hospital, nine post-hospital, and three mixed indicators. Ninety-one percent of experts evaluated the entire tool as comprehensive. CONCLUSION Our study presents a health-related QoC tool that contains a comprehensive set of indicators to assess the QoC for individuals with TSCI. However, this tool should be used in various situations to establish construct validity further.
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Affiliation(s)
- Zahra Ghodsi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Behnam Jazayeri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Pourrashidi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Sadeghi-Naeini
- Department of Neurosurgery, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Azadmanjir
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Health Information Management Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Vali Baigi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Farzad Maroufi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Azarhomayoun
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Morteza Faghih-Jouybari
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Amirjamshidi
- Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Khatereh Naghdi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Maryam Shabani
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hojat Dehghanbanadaki
- Metabolic Disorders Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Habibi
- Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Maryam Bahreini
- Emergency Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Gerard Michael O'Reilly
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Emergency and Trauma Centre, The Alfred, Melbourne, VIC, Australia
- National Trauma Research Institute, The Alfred, Melbourne, VIC, Australia
| | - Alexander R Vaccaro
- Department of Orthopedics and Neurosurgery, Thomas Jefferson University and the Rothman Institute, Philadelphia, PA, USA
| | - James S Harrop
- Department of Neurological and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Benjamin M Davies
- Department of Academic Neurosurgery, University of Cambridge, Cambridge, UK
| | - Lu Yi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Seyed Mohammad Ghodsi
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - Vafa Rahimi-Movaghar
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
- Universal Scientific Education and Research Network (USERN), Tehran, Iran.
- Institute of Biochemistry and Biophysics, University of Tehran, Tehran, Iran.
- Visiting Professor, Spine Program, University of Toronto, Toronto, ON, Canada.
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Hitzig SL, Jeyathevan G, Farahani F, Noonan VK, Linassi G, Routhier F, Jetha A, McCauley D, Alavinia SM, Omidvar M, Craven BC. Development of community participation indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project. J Spinal Cord Med 2021; 44:S79-S93. [PMID: 34779731 PMCID: PMC8604477 DOI: 10.1080/10790268.2021.1955204] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Community participation following spinal cord injury/disease (SCI/D) can be challenging due to associated primary impairments and secondary health conditions as well as difficulties navigating both the built and social-emotional environment. To improve the quality of SCI/D rehabilitation care to optimize community participation, the SCI-High Project developed a set of structure, process and outcome indicators for adults with SCI/D in the first 18 months after rehabilitation admission. A pan-Canadian Working Group of diverse stakeholders: (1) defined the community participation construct; (2) conducted a systematic review of available outcomes and their psychometric properties; (3) constructed a Driver diagram summarizing available evidence associated with community participation; and (4) prepared a process map. Facilitated meetings allowed selection and review of a set of structure, process and outcome indicators. The structure indicator is the proportion of SCI/D rehabilitation programs with availability of transition living setting/independent living unit. The process indicators are the proportion of SCI/D rehabilitation inpatients who experienced: (a) a therapeutic community outing prior to rehabilitation discharge; and, (b) those who received a pass to go home for the weekend. The intermediary and final outcome measures are the Moorong Self-Efficacy Scale and the Reintegration to Normal Living Index. The proposed indicators have the potential to inform whether inpatient rehabilitation for persons with SCI/D can improve self-efficacy and lead to high levels of community participation post-rehabilitation discharge.
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Affiliation(s)
- Sander L. Hitzig
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gaya Jeyathevan
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Farnoosh Farahani
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | | | - Gary Linassi
- Department of Physical Medicine and Rehabilitation, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - François Routhier
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Quebec City, Québec, Canada
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Québec City, Québec, Canada
| | - Arif Jetha
- Institute for Work & Health, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - S. Mohammad Alavinia
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - Maryam Omidvar
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - B. Catharine Craven
- KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
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Craven BC, Alavinia SM, Wiest MJ, Farahani F, Hitzig SL, Flett H, Jeyathevan G, Omidvar M, Bayley MT. Methods for development of structure, process and outcome indicators for prioritized spinal cord injury rehabilitation Domains: SCI-High Project. J Spinal Cord Med 2019; 42:51-67. [PMID: 31573444 PMCID: PMC6781197 DOI: 10.1080/10790268.2019.1647386] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: High-quality rehabilitation care following spinal cord injury or disease (SCI/D) is critical for optimizing neurorecovery and long-term health outcomes. This manuscript describes the methods used for developing, refining, and implementing a framework of structure, process, and outcome indicators that reflect high-quality rehabilitation among adults with SCI/D in Canada. Methods: This quality improvement initiative was comprised of the following processes: (1) prioritization of care Domains by key stakeholders (scientists, clinicians, therapists, patients and stakeholder organizations); (2) assembly of 11 Domain-specific Working Groups including 69 content experts; (3) conduct of literature searches, guideline and best practice reviews, and outcome synthesis by the Project Team; (4) refinement of Domain aim and construct definitions; (5) conduct of cause and effect analysis using Driver diagrams; (6) selection and development of structure, process and outcome indicators; (7) piloting and feasibility analysis of indicators and associated evaluation tools; and, (8) dissemination of the proposed indicators. Result: The Project Team established aims, constructs and related structure, process, and outcome indicators to facilitate uniform measurement and benchmarking across 11 Domains of rehabilitation, at admission and for 18 months thereafter, among adult Canadians by 2020. Conclusion: These processes led to the selection of a feasible set of indicators that once implemented should ensure that adults with SCI/D receive timely, safe, and effective rehabilitation services. These indicators can be used to assess health system performance, monitor the quality of care within and across rehabilitation settings, and evaluate the rehabilitation outcomes of the population to ultimately enhance healthcare quality and equity.
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Affiliation(s)
- B. Catharine Craven
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
| | - S. Mohammad Alavinia
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Matheus J. Wiest
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
| | - Farnoosh Farahani
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
| | - Sander L. Hitzig
- St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Heather Flett
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Departmenet of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Gaya Jeyathevan
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
| | - Maryam Omidvar
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
| | - Mark T. Bayley
- KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
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