Research Day

STUDENTS: Francis-Bignall, D; Lin, F; Meloche, K

SUPERVISORS: Woo, K

BACKGROUD: Virtual wound care occurs remotely with the use of different types of communication media, and interaction between patients, their caregivers, and their healthcare providers. A growing body of literature highlights the role of virtual care in the management of wounds, however the lived experience of participants in virtual wound care is unknown.

PURPOSE: To critically appraise and synthesize the findings of qualitative studies regarding the experience of virtual wound care for patients, their caregivers and health care providers in home care and community settings.

METHODS: We searched six electronic databases – MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS and PROQUEST - for relevant studies published in English from 2001 to 2021. Fifty-six studies were assessed by two independent reviewers for relevance and methodological quality using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI). Discrepancies were resolved in consultation with a third reviewer. Ten studies met the criteria for thematic synthesis and were included in the review.

RESULTS: Meta-synthesis resulted in five syntheses: perceptions of virtual wound care; quality of care delivery; pathways for delivering virtual wound care; interdisciplinary collaboration; and satisfactoriness with virtual wound care.

CONCLUSION: Our findings provide important information about the perceptions and lived experiences of the delivery of virtual wound care. Likewise, they support virtual wound care as a satisfactory adjunct to usual wound care practices, and can influence decision-making, future directions, and research in virtual wound care.

KEY WORDS: virtual wound care, home care, community care, qualitative research, evidence synthesis.

STUDENTS: Darlington, K; Mazerolle, K

SUPERVISORS: Babenko-Mould, Y; Kennedy, E

BACKGROUD: A noticeable shift to the use of virtual wound care has occurred since the COVID-19 pandemic. Social determinants of health create barriers or facilitators to achieving wound goals. It is unknown if virtual wound care will support the reduction of health inequalities.

PURPOSE: This scoping review aims to identify how social determinants of health have related to virtual wound care. Highlighting approaches to increasing inclusivity.

METHODS: The authors’ scoping review followed the Arksey and O’Malley methodological framework. Keywords were searched in MEDLINE, Embase, Scopus, and CINAHL for English language studies published between 2019 and May 26, 2022. Relevant studies were selected; data was extracted, charted, collated, and summarized.

RESULTS: Thematic analysis revealed exclusion criteria corresponding to known health inequalities. Income my limit access to needed smartphones and rural regions may not have equivalent internet access. Limited social supports impact ability to take suitable photographs on areas such as the foot.

DISCUSSION: Virtual care has capacity to care for less accessible individuals however, despite time and cost savings this was not found in the literature.

CLINICAL RELEVANCE: Underserved individuals deserve equitable wound expertise. Gaps within the literature include infrequent sustainable solutions for clients and clinicians to access virtual care.

KEY WORDS: social determinants, wound, virtual care, Covid-19

STUDENTS: Brooks, J; Forbes, SG; Lindsay, J; Stephens, M

SUPERVISORS: Houghton, P

BACKGROUD: Numerous clinical trials and systemic reviews have examined the effect of E-Stim on healing of chronic wounds including pressure injuries.

PURPOSE: The objective of this systematic review was to identify clinical studies that evaluated the effect of E-Stim on healing outcomes in lower limb ulcers (LLU) resulting from vascular disease.

METHODS: A systematic search of PubMed, CINHAL, Scopus databases and a manual search of journals and references included in previous systematic reviews was conducted. Paired consensus was used to select articles that met predetermined inclusion/exclusion criteria.

RESULTS: Nine articles involving three hundred and eighty-one participants and four hundred and four LLU’s were selected from forty-five full articles. Eight included studies were controlled clinical trials of moderate-high methodological quality (mean PEDro score=7.25/10). Most research published to date focused on leg ulcers due to venous insufficiency and used monophasic pulsed current applied directly to the wound. Eight of nine (88.9%) included studies concluded E-Stim improved healing outcomes compared to placebo or standard care in LLU’s. Different healing outcomes prevented a meta-analysis.

CONCLUSION: E-Stim has been shown to stimulate healing in LLU’s in several small, moderate quality, controlled clinical trials.

KEY WORDS: electrical stimulation, venous leg ulcers, arterial ulcer, mixed ulcer, wound healing, wound size reduction

STUDENTS: Cowan, J; Dresser, J; Hayle-Hope, L; Holtz, G.

SUPERVISORS: LeBlanc, K.

BACKGROUD: The COVID-19 pandemic altered the delivery of health care throughout the world. Historically, diabetic foot ulcer (DFU) management required regular in person visits and thus restrictions to in person visits caused by the pandemic, impacted DFU care delivery.

PURPOSE: The objective of this scoping review was to identify key concepts from the literature that highlight the impact the pandemic has had on the delivery of wound care to persons experiencing diabetic foot ulcers.

METHODS: A scoping literature search was conducted for publications from 2019-2022. After the relevant articles were identified the key concepts were synthesized into relevant themes.

RESULTS: Based on our exclusion criteria; 42 articles were chosen for inclusion. Four themes emerged from the review: Communication, prioritization, self-management, and health care utilization.

CONCLUSION: The volatile and unpredictable course of the COVID-19 pandemic brought challenges to the delivery of care of the diabetic foot. Several lessons can be learned from the evaluation of the themes that were identified by this scoping review. Within each of these themes, there were positive innovations in care and negative implications. Further studies are required to learn how diabetic foot care will evolve in the future.

CLINICAL RELEVANCE: Health care systems must adapt to lessons learned from within the themes identified.

KEY WORDS: COVID-19, “wound care delivery”, “diabetic foot ulcer”

STUDENTS: North, Megan

SUPERVISORS: Lee, J.

BACKGROUD: Strength training is commonly used to treat chronic bilateral knee pain. However, there is some controversy about the appropriate knee flexion to elicit optimal results.

PURPOSE: To evaluate the function and range of motion of a client after four weeks of consistent strength training focusing on complete knee flexion movements.

METHODS: Over four weeks, a general strength training approach was used in addition to the Knees Over Toes Method created by Ben Patrick to recruit the vastus medialis oblique (VMO). Patient-reported outcomes were given, including the Brief Pain Inventory, Brief Illness Perception Questionnaire, the Tampa Scale for Kinesiophobia and the Patient Health Questionnaire 9, and baseline functional fitness testing included but was not limited to a push, pull, hinge, squat and core.

RESULTS: This client experience overall improvements in all functional movement patterns, excluding the core. Most significantly improving in pushing pattern and squatting pattern. At the end of four weeks, this client improved in each patient-reported outcome, but most significantly, the Brief Pain Inventory.

CONCLUSION: Full knee flexion movements paired with a strength training regimen can significantly improve chronic knee pain, self-efficacy, and functional strength, leading to an improved quality of life.

KEY WORDS: knees over toes, knee flexion, vastus medialis oblique, chronic bilateral knee pain, patient-reported outcomes

STUDENTS: Patel, C

SUPERVISORS: Wideman, T

BACKGROUD: This case presents a patient with many multimorbid & biopsychosocial challenges that influence complex pain management.

SYMPTOMS: The patient experiences worsening lower back pain, complicated with bilateral leg ulcers that significantly interfere with her ability to complete daily activities. As a result, she has experienced ongoing frustration with her rehabilitation progress, due to her complex medical history, alongside a decline in her psychosocial wellbeing, due to a lack of financial and social support.

CLINICAL FINDINGS/INTERVENTIONS: The patient had paraspinal muscle spasms on L4-S2 bilaterally, diffuse tenderness across the spine, and background history of lumbar lordosis. She had a loss of sensation to light touch, temperature, and pinprick below the knees bilaterally, because of diabetic neuropathy. She sustained a left ankle fracture from a fall that lead to a stage 3 calcaneal ulcer on the left side, furthermore impairing ambulation. As a result of her ongoing difficulties ambulating, her depression worsened, and there was an increasing lack of interest as manifested by her reluctance to engage in physiotherapy. Poor adherence to a diabetic regimen, due to complex financial, social, and familial factors, also predisposed her to a poor prognosis prior to her admission to LTC. Upon her arrival to an LTC, she was managed through a biopsychosocial framework. A radar plot was used to identify her primary drivers of pain experience and was rated highly on emotional/ affective, socioenvironmental and nociceptive factors. For her physiotherapy needs, she was recommended modifications to her back-rest on the power chair and was offered intermediate use of hot packs for pain management. She also received 1-on-1 strengthening exercises for her upper extremities and assisted exercises for her lower extremities and she was put on a repositioning schedule every two hours. To manage her diabetic complications, she was referred to a specialized wound clinic, however, due to geographical limitations, a nurse was deployed to the LTC to provide care instead. The Ontario Disability Program was re-instigated after a functional cognitive assessment was conducted, and was also referred to a social worker to address her diagnosis of depressive disorder.

CONCLUSION: Multimorbid patients require an interdependent focus of care that addresses biological, psychological, and social needs in order to promote rehabilitation and recovery.

KEY WORDS: Diabetes, Comorbidity, back pain, foot ulcer, psychosocial needs, prognosis, poor rehabilitation.

STUDENTS: Hibi-Galbraith, N

BACKGROUD: Calcinosis cutis occurs when calcium salts are deposited into the skin and subcutaneous tissue. It is classified into five main types: dystrophic, metastatic, idiopathic, iatrogenic, and calciphylaxis. Dystrophic calcification is the most common cause of calcinosis cutis. Dystrophic calcification is typically associated with a systemic disease such as dermatomyositis. Dermatomyositis is a rare acquired immune-mediated muscle disease characterized by muscle weakness and skin rash. It is classified as one of the idiopathic inflammatory myopathies. Treatment for calcinosis cutis can be challenging. Dermatomyositis with severe calcinosis cutis is a condition with very few studies of high-level evidenced treatment options. Sodium thiosulfate is one of the treatments used to improve function, promote independence, and pain management.

CASE PRESENTATION: A pleasant 54-year-old woman presented with dermatomyositis with extensive calcinosis and associated interstitial lung disease who has been intermittently bedbound for a year. About 2 years ago, she started developing calcinosis cutis in her upper and lower extremities, resulting in repeated Emergency Department visits for skin infections due to subcutaneous calcinosis, as well as immobilization due to calcinotic lesions in various tendons and joints. She has a positive ANA and a positive PM/Scl75/100. The patient has previously trialed methotrexate and Imuran. The treatment used intralesional sodium thiosulfate in hopes to improve her mobility, maintain her ability to perform activities of daily living, and decrease her pain.

OUTCOMES: The patient received a total of 7 intralesional injections of sodium thiosulfate over a three-year span in various areas of concern. There was a noted softening of lesions with improved function, increased range of motion and decrease in pain. Patient had multiple hospital admissions for various falls and fractures as well as other complications. Sadly, patient passed away in 2021.

CONCLUSION: This case report is presented to encourage more high-level evidenced studies on effective treatment of dermatomyositis with sever calcinosis cutis. The patient reported functional gains and a decrease in pain from the proposed treatment. She was hopeful, remained positive in regaining some independence and improved pain control.

KEY WORDS: intralesional sodium thiosulfate; dermatomyositis; calcinosis cutis, improved patient function; promote independence; pain management; case report

STUDENTS: Obljubek, T.

SUPERVISORS: Birnie, K.

BACKGROUD: Axillary web syndrome (AWS) is a painful and functionally debilitating condition that has been described in the literature as prevalent but under-reported. It generally occurs after breast cancer surgery following lymph node removal. To date, there is a lack of evidence-based research to guide physical therapists in the treatment of AWS. Person-centered care has been shown to increase health outcomes and quality of care by engaging a patient in their care. For this reason, a co-operatively designed care approach to physical therapy treatment for those with AWS may optimize outcomes better aligned with what matters most to patients.

CASE PRESENTATION: A 54-year-old woman presented with pain-limited right shoulder movement and palpable cords in the axilla, arm, elbow, and forearm three weeks post lumpectomy and sentinel lymph node dissection. Outcome scores reveal mild to moderate anxiety and decreased function. The patient valued her family and health and wanted to return to functional activities, walking, and yoga practice. After seven sessions of physical therapy care over five weeks, there was a resolution of pain, normalization of shoulder movement and functional outcome scores, and a return to activities important to the patient. Using a person-centered approach, treatment included specialized education, soft tissue mobilization, manual lymphatic drainage, mindfulness, and home-based progressive exercise prescription to work towards mutually developed goals.

CONCLUSION: This case provides preliminary evidence that early diagnosis and treatment of AWS using a person-centered approach to physical therapy can support a patient in mediating pain and functional disability in the short term. Future research needs to review the impact of this approach to empower patients with the knowledge and resources to prevent long-term pain and disability due to cancer treatments such as AWS that are underrecognized and undertreated.

KEY WORDS: Axillary web syndrome, person-centered care, pain, breast cancer, case study

STUDENTS: Reaume, J

SUPERVISORS: Nash, J

BACKGROUD: Chronic pain is a complex condition requiring interprofessional collaborative interventions to optimize treatment. Here, a clinical reasoning framework is used to identify drivers of chronic pain in a patient with a remote history of spinal injury. These chronic pain drivers were used to guide multimodal interventions by a pharmacist and a social worker working in a primary care setting.

CASE PRESENTATION: The case is of a 61-year-old male who had a serious workplace accident in 1997 resulting in a crush injury to his lumbosacral spine. After spinal surgery, physiotherapy, decades of opioid and adjuvant pain medication use, and implantation of a spinal cord stimulator, the patient remained in significant pain and felt he had poor quality of life. He sought to reduce his dependence on opioids and learn new ways of coping with his chronic pain.

CONCLUSION: This case highlights how the identification of drivers of chronic pain during assessment can guide clinicians to targeted interventions that yield not only improvements in scores on multiple validated pain measures, but also improve a patient’s self-reported quality of life.

KEY WORDS: chronic pain, interprofessional, opioids, primary care, case report

STUDENTS: Dennis, A

BACKGROUD: Primary synovial chondromatosis (PSC) is a rare, benign condition where multiple loose bodies are formed within a joint capsule. It most commonly occurs in adult males; it is extremely rare in children. Signs and symptoms are a painful swollen joint with possible locking or catching sensations.

CASE: A 16-year-old female hockey player presented for chiropractic care with a painful, swollen elbow and complaints of locking. Radiographic examination confirmed the presence of primary synovial chondromatosis. Treatment took the form of surgical excision and was successful for the patient.

CONCLUSION: A rare case of PSC is presented in this study. Pediatric cases of PSC are very limited in the literature.

STUDENTS: Cuconato, A.

SUPERVISORS: Lukacs, M.

BACKGROUD: There is a growing movement towards individualization of treatment approaches for people experiencing pain. Those who are involved in a motor vehicle crash (MVC) have an increased likelihood of developing chronic pain compared to the general population, further necessitating the need to understand how to identify appropriate personalized treatment plans.

PURPOSE: A case study report is presented outlining how an interdisciplinary team used the radar plot for pain assessment to guide individualized pain treatment for a client experiencing chronic pain following a MVC.

METHODS: This patient was assessed by an Occupational Therapist, Physiotherapist, Kinesiologist and Registered Clinical Counsellor, and the clinicians met with the client as a team to review the findings using the Radar Plot. This plot was used to influence the treatment plans and the client was re-assessed 8 weeks later and re-plotted.

RESULTS: At the time of the assessment the radar plot was used and the domains which were rated the highest were central nocioplastic (very high), cognitive beliefs (very high) and emotional affective (high). Following 8 weeks of individualized treatment the radar plot was reapplied and those domains were rated as central nocioplastic (moderate), cognitive beliefs (moderate) and emotional affective (moderate).

DISCUSSION: Interdisciplinary, personalized care is emerging as best practice for chronic pain management and the radar plot offers an assessment tool to inform the evaluation and treatment of painful conditions.

CONCLUSION: Individualized interprofessional pain treatments influenced by the radar plot contributed to decreased global ratings, as well as improvements in subjective pain, function and mood as well as objective measures at 8 week follow up.

KEY WORDS: case report, radar plot, chronic pain, interdisciplinary

STUDENTS: Nelson, F.

SUPERVISORS: Leyland, Z.

BACKGROUD: The cause of overactive bladder remains unknown. It is theorized that it is a result of central mechanisms, similar to the nociplastic changes that occur with chronic pain.

PURPOSE: To explore the relationship between the occurrence of both OAB and chronic pain in a patient’s subjective and clinical exam. To address the central drivers through pelvic and physiotherapy as concurrent treatment for both conditions.

METHODS: The patient was evaluated by a pelvic physiotherapist and diagnosed with both OAB and chronic low back pain. A comparison of central vs peripheral mediators of pain and a radar plot were done regarding the low back pain. Distress questionnaires including CSI, DASS, ACE Q, PCS and FreBAQ were completed.

DISCUSSION: There is little evidence available to confirm that OAB is caused by changes within the central nervous system. There are multiple theories as to the neuroplastic changes that may take place. These all relate to the same central pain mechanisms that occur with chronic pain. Unfortunately, patient compliance and treatment timelines limited the possibility of evaluating the effectiveness of therapy for both conditions by addressing the central drivers of pain.

CONCLUSION: Given the commonalities between chronic pain and OAB, it is worth screening patients with OAB for central nervous system changes. It is also worth asking patients with chronic pain about their bladder function. This would be part of a true biopsychosocial approach to treatment.

KEY WORDS: case report, overactive bladder, low back pain, urgency, central pain mechanisms, chronic pain

STUDENTS: Carrie, P

SUPERVISORS: Walton, D

BACKGROUD: Prognostic indicators and risk factors are commonly used in clinical practice to help determine a patient’s anticipated recovery and response to treatment. One tool used in this assessment is the Brief Illness Perceptions Questionnaire (BIPQ). A high score in the BIPQ is suggestive of delayed recovery and/or poor prognosis. In this case study, a patient with an acute work related low back injury made a full recovery despite several risk factors for low back chronicity and a
BIPQ score indicating poor recovery.

CASE INFORMATION: A 39 year old female patient suffered an acute low back injury at work from lifting. Examination ruled out red flags and neurological injury. BIPQ was administered to help evaluate prognosis and give insight into the patient’s condition. Initial BIPQ scores suggested this patient was high risk for delayed or poor recovery. The Brief Pain Inventory (BPI) was used to monitor the patient’s response to treatment. Chiropractic treatment including manipulation, myofascial release and education was initiated. Brief Pain Inventory (BPI) scores indicated a full or nearfull recovery, from 7.9/10 to 0.4/10 on the pain interference scale over the six weeks of treatment.

CONCLUSION: The patient in this case had multiple risk factors and a BIPQ score suggestive of poor or delayed recovery and high risk of chronicity. Despite these risk factors, she returned to work within one month of injury.