Providing Insights into the Challenges of Implementing Activity-Based Therapy in Canada: A Comparative Analysis Using Focus Group Interviews with Key Interest Groups

Neurorehabilitation has evolved over recent years with the introduction of therapies that target neuromuscular activation below the level of injury. These therapies, known as activity-based therapies (ABT),¹  involve intensive practice of task-specific movements with the goals of promoting neurorecovery, reducing secondary complications, and improving emotional well-being and overall quality of life for persons living with spinal cord injury or disease (SCI/D).^2-7  ABT may be practiced with or without the aid of technology in various settings across the continuum of care and injury trajectory.^7-10  Despite the versatility and potential health benefits of ABT, implementation in Canada has proved challenging.^7-9 

With 86,000 Canadians living with SCI/D and nearly 1400 new cases each year, the staggering $2.7 billion in annual healthcare costs creates a toll on the Canadian healthcare system.¹¹  The need for rehabilitation, like ABT, to be available to all individuals with SCI/D, in all settings, at any point in their life course is paramount not only to reducing the burden on the healthcare system¹²  but also to improving the lives of persons living with SCI/D. In response to the state of SCI/D in Canada, a diverse group of 39 individuals from across Canada with an interest in ABT met in 2019 to understand the current situation of ABT in this country and to outline priorities going forward to advance research and clinical care over the next 5 years.¹³  The group included researchers, healthcare administrators, frontline clinicians, funders of SCI research, health policy experts, and persons with SCI/D. Together they formed the Canadian ABT Community of Practice (ABT CoP) with a goal to increase the access to and quality of ABT in Canada for individuals living with SCI/D.

This study allowed us to follow-up on the priorities identified by the ABT CoP by having an in-depth discussion that was focused on key challenges with specific groups of people who have an interest in ABT. Using a comparative analysis approach with multiple perspectives allows researchers to investigate different viewpoints of a specific phenomenon, in this case ABT.¹⁴  The advantage to using this approach is the ability to highlight differences within and between groups, identify existing barriers specific to only one group, or identify challenges that exist between groups.¹⁴  Successful strategies toward the implementation of ABT in Canada requires the input of all applicable members to identify existing challenges. As such, the purpose of this study was to understand and compare the perspectives of key interest groups on the challenges of implementing ABT in Canada for people living with SCI/D.

This descriptive qualitative study employed focus group meetings with key interest groups. These focus group meetings also explored participants’ perspectives on tracking ABT activities and parameters, with these results summarized in Kaiser et al.¹⁵  The study received ethical approval from the Research Ethics Board of the University Health Network (REB Protocol #19-6154). Reporting of study details was guided by the Standards for Reporting Qualitative Research (SRQR).¹⁶ 

Individuals from six different groups were recruited through a national poster campaign, the ABT CoP, and snowball sampling.¹⁷  The groups were (1) researchers, (2) hospital-based physical and occupational therapists, (3) community-based exercise trainers, (4) administrators of rehabilitation hospitals and community ABT clinics, (5) individuals living with SCI/D, and (6) advocates, funders, and policy experts. Purposive sampling¹⁸  was used to recruit a representative sample of six to seven males and three to four females with SCI/D.^11,19,20 

A screening questionnaire that queried the nature and duration of experience with ABT was used to determine eligibility to participate in the study. Participants were Canadian, English speaking, and either participated in, supervised, or had knowledge of ABT and SCI/D. There were no restrictions placed on years of experience with SCI/D and ABT. Written and verbal consent were obtained prior to participation in the study.

Information power, as described by Malterud et al.,²¹  was used to determine the sample size (see Table 1). Other literature suggests sample sizes of up to 60 participants when intergroup heterogeneity and intragroup homogeneity of focus groups exist.^22,23  As such, we aimed to carry out 12 separate focus group meetings, two for each interest group, with four to five participants per group.²² 

Three separate semi-structured focus group guides were developed for this study: (1) for community-based exercise trainers and hospital physical and occupational therapists, (2) for community and hospital administrators, researchers, advocates, funders, and policy experts, and (3) for individuals living with SCI/D. The focus group guides were developed a priori based on previous work through the ABT CoP^7-9,13  and discussions with the diverse research team representing different interest groups. Each guide contained open-ended questions that probed reasons for participating in or practicing ABT, the types of exercises and equipment they used, and the barriers and facilitators to practicing ABT (see Table 2).

Focus group meetings occurred between June and November 2020 over web conferencing (Zoom Video Communications) due to the COVID-19 pandemic and geographic spread of participants. Focus group meetings with each interest group lasted 30 to 80 minutes and were led by A.K., a female who identifies as a woman with 25 years of experience living with SCI/D, 7 years of experience participating in ABT, and 10 years of experience in qualitative research methods. A team member belonging to one of the interest groups (J.Z., I.M., S.M., P.A., C.R., J.L., or S.F.) also helped facilitate the focus group meetings. Following the focus group meetings, reflexivity was used to capture main ideas, impressions, and personal biases.²⁴  Team meetings were held weekly to discuss completed focus group discussions, and minor revisions were made to all three focus group guides. Focus group meetings were audio-recorded, de-identified, and transcribed verbatim manually into Microsoft Word (2016).

A conventional content analysis, as outlined by Hsieh and Shannon,²⁵  followed by a comparative analysis of multiple perspectives of the same phenomenon (i.e., ABT), described by Lindsay,¹⁴  were utilized to derive meaning from the transcript data. Team members A.K. and J.S. initially read through the transcripts multiple times to immerse themselves in the data. They then proceeded to separately code three transcripts from three different interest groups using an inductive approach. A third team member (K.E.M.) met with A.K. and J.S. to discuss the initial coding list and group codes into categories of information. The remaining transcripts were then separately coded by A.K. and J.S. with additional codes added as new information emerged. Team meetings were held to discuss the coding list and organize codes into categories and preliminary themes. Microsoft Excel (2016) was used to sort codes by category and interest group for further analysis. Once all transcripts were coded, team members A.K. and K.E.M. compared transcripts within and between groups and reached consensus on emerging themes.

Trustworthiness, a measure of validity and reliability, as outlined by Shenton²⁶  was accomplished in several ways. First, the expertise of team members who performed the data collection and analysis ranged from novice to expert in ABT, SCI/D, and qualitative methods, which helped to reduce any potential bias during data interpretation. Second, investigator triangulation was established through the use of multiple team members to carry out the data collection and analysis. An audit trail was used to document this process. Third, data triangulation was achieved through the use of verbatim accounts, reflexive notes, and previous work.^7-9,13  Finally, study findings were verified with team leads of each interest group who were part of the study team and facilitated a focus group meeting. Verbatim quotes were used to support identified themes.

Forty-eight individuals representing six key interest groups participated. The key interest groups ranged from 5 to 12 participants, with three groups (researchers, hospital therapists, and advocates, funders, and policy experts) not reaching the minimum target of eight participants. A representative sample of seven males and three females with SCI/D participated in the study. Expertise in ABT and SCI/D ranged from 0.25 to 33 years. Details of participant characteristics are presented in Table 3. Ten focus group meetings ranging from two to six participants were conducted along with two one-on-one interviews due to scheduling conflicts.

Six themes reflecting the challenges related to ABT practice in Canada were identified: (1) challenge of gaps in knowledge and training, (2) challenge of standardizing ABT, (3) challenge of determining the optimal timing of ABT, (4) challenge of defining, characterizing, and achieving high dosage and intensity, (5) challenge of funding ABT, and (6) challenge of measuring participation and performance in ABT. See Table 4 for quotes by theme with Q1, Q2, etc. linking the text to the supporting quotes.

Although all groups reported challenges across each theme, the comparative analysis revealed that some challenges were emphasized by one or a few groups. Hospital and community clinicians described the lack of quality education and training (theme 1) and achieving a high dosage and intensity in ABT as key challenges (theme 4). Researchers and advocates, funders, and policy experts emphasized the challenge of developing standardized guidelines (theme 2) and performing economic analyses to measure the impact of ABT programs (theme 6). With respect to developing guidelines (theme 2), groups also expressed contrasting views on the benefits of some high-technology equipment, with clinicians and people living with SCI/D favouring them over researchers. Persons with SCI/D specifically struggled with the high cost and lack of access to ABT programs and equipment, whereas hospital and community administrators were similarly challenged with securing the funding needed to support the high demands of an ABT program (theme 5).

Participants across all groups acknowledged that there was a general lack of knowledge and understanding about ABT within their peer groups. Some participant groups (people with SCI/D, community administrators, and trainers) demonstrated a clear understanding of ABT and its principles when describing ABT practice or engaging in ABT by using key terminology such as targeting muscles “below level of injury,” “repetition,” and “task-specific movement” (Q1). A few hospital therapists pointed out that once they learned about the definition of ABT they recognized that they actually practiced ABT to a much greater extent than they realized (Q2). Individuals with SCI/D did mention, however, that many of their peers were unfamiliar with ABT when they spoke to them about it (Q3). Advocates, funders, and policy experts, researchers, and hospital administrators agreed, believing that many of their colleagues lacked clarity on how ABT was defined, what it encompassed, and how it differed from conventional therapy (Q4).

Community trainers spoke about how their postsecondary learnings about SCI/D, its prognosis, and therapies were inaccurate and opposite to what they observed in practice (Q5). Hospital therapists described being inadequately trained with specific types of equipment, like electrical stimulation devices, which led to fears and lack of use in practice (Q6). Researchers, community trainers, and hospital and community administrators likewise talked about the importance of training on the appropriate use of equipment and adapting the way equipment is used to maximize the potential benefits to people with SCI/D who participate in ABT.

Researchers and advocates, funders, and policy experts discussed the benefit of learning about ABT practice from other populations, such as stroke, in order to apply learnings to SCI/D (Q7). All groups stressed the importance of collaboration and knowledge sharing—between research and clinical practice, and across community and rehab centres—as a key to optimizing and advancing practice (Q8).

According to researchers and advocates, funders, and policy experts, there are currently no standardized guidelines for ABT (Q9), and the need for developing an evidence-based, standardized approach to ABT practice was emphasized. Standardized guidelines could provide information for clinicians regarding the types of ABT activities, exercises, and techniques that are most effective in promoting recovery based on injury characteristics. Some groups (advocates, funders, and policy experts, researchers, hospital therapists, and hospital administrators) reported a dearth of evidence in this area (Q10), which limits the ability to develop standardized guidelines. Researchers also described the challenge of standardizing ABT due to the variety of activities and exercises available and ways of characterizing them.

Researchers and hospital administrators pointed out that without consensus on the definition and parameters of ABT, we may not be speaking the same language when we talk about ABT (Q11). Advocates, funders, and policy experts further questioned the relevance of defining the therapy provided as being ABT or conventional therapy and suggested the focus should instead be on determining the ideal mix of therapies needed to optimize recovery.

Equipment and technology were discussed at great length by the various groups suggesting standardized guidelines should include recommendations on appropriate use of technology in ABT (Q12). Researchers explained that although a great amount of research has focused on high-tech, costly robotics like the Lokomat, the equipment has not demonstrated superior benefits to justify their costs and reflected that further research should consider exploring the benefits of other exercises that don't require high-tech devices (Q13). Interestingly, hospital and community administrators, therapists, and trainers agreed that certain high-tech equipment was a disappointment, but it may be valued because it reduces the strain of manual labour and preserves the health of therapists and trainers (Q14). Individuals with SCI/D also tended to be enamored by the high-tech equipment they heard about or used; this was something researchers also recognized through their clinical trials (Q15). The diverse views expressed across groups highlight the challenge of developing standardized guidelines to ABT practice and technology use.

Participants indicated that little was known about the optimal timing for engagement in ABT. For example, one advocate questioned if and how time since injury influenced the potential to benefit from ABT (Q16). Although evidence on the optimal timing of ABT is lacking, participants identified numerous factors that impacted readiness to engage in ABT. Advocates, funders, and policy experts, researchers, and hospital and community administrators spoke about motivation being a key factor to participation in ABT. Levels of motivation may be influenced by age at the time of injury, time postinjury, psychosocial, cultural, and personal factors, and the need to focus on other goals of rehabilitation (Q17).

Aside from level of motivation, hospital administrators were concerned that individuals with SCI/D were not physically capable or emotionally ready to participate in intensive therapy early postinjury as they were still coming to terms with their injury. Unfortunately, they often found that the timing was misaligned; readiness to participate often coincided with discharge from inpatient rehab.

An advocate with a background in physical therapy also expressed concerns regarding the safety of participating in ABT in the acute stages of injury while the body was still healing from the initial trauma (Q18). However, most participants with SCI/D, including a few advocates with SCI/D, stated that they would have appreciated the opportunity to experience ABT earlier postinjury (Q19). One hospital therapist agreed stating that early rehabilitation was the perfect time to introduce ABT because of the resources and therapy time available to them (Q20).

Participants identified a lack of clarity concerning the dosage and intensity of ABT as a challenge. In hospital-based rehabilitation, the dosage (i.e., frequency and duration of sessions) is defined by the structure of service delivery, whereas in the community, dosage can vary (Q21). Individuals with SCI/D spoke about initially adjusting their ABT program until they found their optimal dosage (Q22). Regardless, advocates, funders, and policy experts, researchers, and community administrators stated that there is a lack of, and need for, evidence on optimal dosing (Q23); however, higher dosages were perceived to lead to better outcomes (Q24).

Achieving a high dosage is challenging in both the hospital and community settings for several reasons. Hospitals are challenged with trying to provide equitable access to care for all individuals who experience SCI/D. Compared to the past, this translates to more individuals receiving some therapy rather than a few individuals receiving a high amount of therapy (Q25). Researchers and hospital therapists and administrators described the pressures of trying to balance neurorecovery with functional independence and readiness for discharge within the limited time they have with their patients (Q26).

Community administrators acknowledged that due to constraints within a publicly funded healthcare system, hospital therapists would be unable to offer their patients a higher dosage; this is something the community is able to provide to clients who desire it (Q27). Nonetheless, there are still a number of challenges that prevent individuals with SCI/D from reaching a high dosage in community. Cost of therapy and lack of third-party coverage are main reasons for individuals not participating in ABT more often (Q28). Other factors reported by community trainers and persons with SCI/D that may affect an individual's ability to sustain a high dosage of ABT are other competing interests such as work, family obligations, or other therapies. The necessity of support staff, trainees, students, and volunteers were voiced strongly by hospital therapists, community trainers, hospital and community administrators, and persons with SCI/D without whom they wouldn't be able to provide ABT to the number of individuals with SCI/D to the extent that they do (Q29). Similar to timing and readiness, motivation ties in here as well since individuals need to not only be willing to participate in ABT but also be willing to exercise at an intensity needed to achieve neurorecovery.

Participants often used the words “dosage” and “intensity” interchangeably, suggesting a lack of clarity on the differences between the two terms. Participants, even within the same group, had differing views on how intensity is gauged, characterized, and measured when describing ABT. A researcher and an advocate with a physical therapy background suggested focusing on the cardiovascular system as a way to measure exercise intensity, while another advocate suggested including other parameters, such as distance, number of repetitions, and weight (Q30). In contrast, another researcher thought the emphasis should be on the nervous system (Q31).

Hospital- and community-based rehabilitation settings are challenged with acquiring the necessary funds to provide ABT to people with SCI/D. One hospital therapist identified funding as one of the top three challenges they faced (Q32). An advocate believed the funding challenge to be a systemic issue reaching across the continuum of care (Q33). Existing differences in funding structures across provinces, as mentioned by another therapist, pose additional challenges and create inequities in access to ABT (Q34). In addition, there is the challenge of accessing beneficial technology due to complex funding models (Q35). Hospital administrators consider financial barriers to implementing ABT as a component of a larger issue that looks at the process as a whole and considers elements such as space to accommodate new equipment (Q36).

Unlike hospitals, which are publicly funded, community-based ABT clinics are privately owned and rely on fee for service to operate. Community trainers and administrators describe the struggle of accessing funds for equipment (Q37). Hospital therapists and advocates, funders, and policy experts acknowledge the importance of having ABT available in the community for individuals postrehabilitation and believe the clinics should be able to access supports through the government (Q38). In response, community clinics have applied for charity status in order to receive donations, host fundraising events, apply for grants, and maintain affordability for clients (Q39). Some community clinics received equipment donations, which was helpful to some extent but not necessarily ideal.

Researchers and advocates, funders, and policy experts stressed the need to conduct economic evaluations to determine the cost-benefit analysis, attract government funding, and support implementation of ABT in various settings (Q40). However, they also recognized the challenges associated with these types of evaluations in relation to ABT as it may be difficult to demonstrate an improvement in health-related quality of life or longevity of life—the accepted gold standards (Q41). Particularly when evaluating cost-effectiveness of high-technology equipment, research evidence in this area is poor (Q42).

Participants across all groups discussed the importance of having tools that can measure participation in and outcomes of ABT (Q43). Researchers and advocates, funders, and policy experts reported that currently there are no suitable tools to measure ABT dose (Q44) and no standardized approach to the collection of outcomes (Q45). Researchers, hospital and community administrators, hospital therapists, and community trainers all expressed varying degrees of dissatisfaction with some of the existing standardized tools they used to track performance in ABT. One advocate questioned whether some of the standardized tools used in rehabilitation to measure performance would be applicable to ABT (Q46). Hospital therapists confirmed that there were validated tools to measure function that were not being used consistently by clinicians. In addition, hospital therapists stressed the need to track therapy occurring outside of their one-on-one sessions to get a full understanding of an individual's activity (Q47). One community administrator explained that some improvements individuals make don't get captured on any tools they use (Q48). Researchers, hospital therapists, community administrators, and trainers all criticized the lack of sensitivity of existing tools, which they felt were incapable of measuring small increments of change in function over time.

In addition to measures of function, researchers and advocates, funders, and policy experts mentioned a few other outcomes they thought were important, yet challenging, to consider, such as secondary health complications to determine whether ABT prevents bowel, bladder, pain, or skin-related issues (Q49). Advocates, funders, and policy experts also suggested tracking long-term quality of life outcomes such as return to work, mobility device use, independence in activities of daily living, reliance on support providers, and community participation (Q50).

This study explored the challenges related to ABT practice and implementation in Canada from the perspective of researchers, hospital-based physical and occupational therapists, community-based exercise trainers, administrators of rehabilitation hospitals and community ABT clinics, individuals living with SCI/D, and advocates, funders, and policy experts. Although there was agreement among groups regarding challenges to ABT practice, there were challenges that were emphasized by one or a few groups. Individuals with SCI/D highlighted the cost and access to ABT and equipment as particular challenges. The minimal and sometimes inaccurate education and training in ABT and associated technologies were identified as challenges for hospital and community clinicians. Researchers, hospital and community administrators, and advocates, funders, and policy experts emphasized the lack of evidence to develop guidelines, optimize dosing, and determine cost-benefit analysis in ABT as key challenges.

The challenges identified in this study validate and coincide with four of the eight priorities for ABT research and care identified by the Canadian ABT CoP: (1) track engagement in ABT activities across the continuum of care, (2) develop and implement best practice recommendations for ABT, (3) study optimal timing, methods, and dose of ABT to promote desired outcomes, and (4) educate clinicians from across the continuum of care about ABT.^13,27  The evaluation of challenges or barriers to ABT practice mark a key step in the process of translating knowledge into practice as described by the Knowledge to Action Framework.²⁸  Most groups in this study identified the lack of knowledge and clarity in how ABT is defined and characterized as a significant challenge to ABT practice. At least four definitions have been reported in the literature.^1,4,29,30  Definitions of ABT vary in their focus (i.e., function vs. neurorecovery) and target (above and below level of injury vs. only below level of injury). Reaching international consensus on the definition of ABT may facilitate communication across disciplines and settings (e.g., research, health administration, hospital-based rehabilitation, community clinics) and prevent confusion about which therapeutic activities are and are not considered ABT. Lack of knowledge, education, and training in ABT among therapists and exercise trainers suggests that teachings should be incorporated into entry-to-practice and postgraduate curriculums. On-the-job training in ABT through in-services and mentorship by experienced colleagues may also increase knowledge and competence in delivering ABT.

Developing standardized ABT guidelines is essential in order to guide clinicians in optimizing neurorecovery for their patients and clients. To accomplish this, we need to know the best time to provide ABT, the effectiveness of ABT activities and technologies, and the optimal dosing and intensity.³¹  Preclinical data suggest there is a small window of opportunity early post-SCI to maximize recovery, provided inflammatory responses are controlled, after which time there is no effect.³²  However, studies have demonstrated improvements in trunk, upper and lower extremity motor function, cardiovascular fitness, and thermoregulation in individuals with complete and incomplete chronic SCI using transcutaneous electrical spinal cord stimulation alone or combined with overground gait training or pharmacological treatment, or a multimodal ABT program.^6,33-39  The Neurorecovery Network has developed guidelines specific to locomotor training that have been implemented across several centers in the United States,⁴⁰  yet no such guidelines exist for other interventions, such as functional electrical stimulation ergometer training. Jones et al.⁴¹  reports on a set of guidelines developed by a community-based ABT clinic in the United States where individuals transition through five phases of recovery; each phase is associated with specific interventions and techniques to promote neurorecovery. The authors acknowledge the lack of clarity pertaining to optimal dosing and intensity, yet they maintain that a higher dosage and intensity of therapy is needed than what is currently available. The literature reports a dosage of ABT ranging from 90 minutes to 3 hours per day, three to five days per week.^4,41-43 

Hospital and community settings are both uniquely challenged with striving to achieve a high dosage and intensity of therapy among their patients and clients. Studies in two Canadian inpatient rehabilitation centres found the intensity of cardiovascular training and number of movement repetitions in the upper and lower extremities per therapy session to be insufficient to result in neurological improvements.^44,45  Cost-effective ways to address these challenges are needed. One study demonstrated how the use of technology (i.e., a treadmill) increased the number of steps taken in a 1-hour locomotor training session in comparison to gait training performed overground, which led to greater improvements in walking ability.⁴⁶  Another study found inpatients had potentially 4 hours of time available outside of their regular therapy sessions to participate in additional therapy.⁴⁷  Where the nontherapy time is currently spent in sedentary leisure activities, individuals could instead use it to focus on independent muscle strengthening exercises above the level of injury and cardiovascular training, which would allow session times with their therapist to be devoted to ABT-related activities targeting muscles below the level of injury.

Appropriate tools that are capable of tracking the details of an ABT session, and sensitive enough to measure change in function over time, are needed and will allow us to collect the necessary data to answer many of the questions posed above. Ongoing work with the ABT CoP has explored the types of ABT activities and parameters to include in an ABT tracking tool.^15,48  The Neuromuscular Recovery Scale, developed by the Neurorecovery Network for their locomotor training program, is a discriminative tool that has demonstrated responsiveness.^42,49,50  Further research should consider evaluating existing outcome measures to determine suitability for ABT and developing a standardized approach to collecting outcome data.

Funding appears to be a chronic and systemic issue that all groups identified in ways that were applicable to them. Suitable ABT tracking tools and outcome measures will facilitate economic evaluations that may support an increase in government funding and insurance coverage for ABT across the continuum of care after SCI/D. Unfortunately, few economic evaluations of ABT for SCI/D rehabilitation have been produced. One study explored the economic benefits of locomotor training and found it reduced long-term healthcare costs associated with rehospitalization.¹²  Another study evaluated the cost-effectiveness of overground robotic locomotor training in comparison to conventional locomotor training for people with SCI; it found overground robotic locomotor training to be more cost-effective for people with complete injuries, whereas conventional locomotor training was more cost-effective for people with incomplete injuries.⁵¹  A recent environmental scan of studies targeting neurorecovery in people with SCI found only two of the 73 studies reported on economic factors.¹  Inclusion of economic evaluations in future ABT research and clinical projects is needed.

Biases inherent in qualitative research and focus group meetings were considered in this study, and measures were taken to reduce these through efforts to ensure trustworthiness. As these meetings occurred early in the COVID-19 pandemic, web conferencing was used, which permitted geographic diversity of participants yet may have compromised the quality of data collected due to participants’ lack of comfort and familiarity with virtual platforms. Interviewer bias,⁵²  social desirability bias,⁵³  and conformity bias⁵⁴  were lessened due to the experience of the interviewer (A.K.) in creating a rapport with study participants and allowing each to voice their opinion freely. Three participant groups (researchers, hospital-based physical and occupational therapists, and advocates, funders, and policy experts) failed to reach their recruitment target. There are few individuals in Canada who identify with one of these three groups and have experience with ABT and SCI/D; hence, it was not surprising to find recruitment of these three groups challenging. In addition, the COVID-19 pandemic posed a strain on the hospital system, with many staff being redeployed to other areas and researchers having to manage labs and projects that were put on hold. This made it particularly challenging to recruit hospital therapists and researchers. Nevertheless, we believe that within group diversity of participants provided sufficient variance in perspectives to minimize the impact.

We are recognizing that rehabilitation is no longer a short-term venture for individuals who sustain SCI/D. ABT may provide individuals with the opportunity to continually improve function, independence, and overall quality of life. Establishing a system that can ensure all individuals with SCI/D have the ability to access and participate in ongoing therapy once they are discharged from rehabilitation is needed. This study identified challenges that currently limit ABT practice and implementation in Canada. Future research should explore strategies to address these challenges to ABT practice to support successful implementation of ABT in Canada.

The authors would like to thank the participants for their time and involvement in this study.