Exploring knowledge and implementation gaps of activity-based therapy in centers lacking specialized spinal cord injury services: understanding therapists' perspectives

Spinal cord injury or disease (SCI) affects more than 85,000 Canadians and can lead to profound sensory, motor, and autonomic impairments that reduce mobility and independence and increase risks of secondary health conditions. Advances in neuroplasticity have shifted neurorehabilitation from compensatory to restorative approaches. Activity-based therapy (ABT)—intensive, task-specific activation of neuromuscular systems below the level of injury—has evidence for promoting neurological improvements and reducing risks of secondary complications, with benefits for cardiovascular/metabolic health and bowel/bladder outcomes. ABT commonly includes treadmill training, muscle strengthening below the level of injury, overground walking, ergometer training, and load-bearing, delivered with high intensity, frequency, massed practice, sensory stimulation, and mental effort. In Canada, SCI-specialized centers have implemented ABT across the continuum of care, and a Canadian community of practice (CoP) has been formed to improve access. However, many individuals, particularly those in rural communities, face reduced access to specialized services, travel burdens, and associated financial and psychosocial strains. Prior work on access for people with SCI has focused largely on specialized physicians, with less attention to rehabilitation therapies such as ABT. This study explores the extent of knowledge, perceptions, and implementation of ABT among physical and occupational therapists working in non-SCI-specialized centers.

The paper situates ABT within a restorative neurorehabilitation paradigm supported by evidence showing task-specific, intensive, repetitive training can enhance neurological recovery and reduce secondary complications in SCI. ABT characteristics include massed, task-specific practice, sensory stimulation, and mental effort; reported benefits include improved mobility, neurological status, and quality of life. In Canada, ABT has been variably implemented in SCI-specialized centers and supported by a national community of practice. Access disparities persist, especially in rural areas where individuals may have limited healthcare resources and must travel to specialized centers, leading to financial and psychosocial burdens. Existing literature has emphasized access to specialized physicians, with less focus on rehabilitation services such as ABT. The current study addresses this gap by examining how ABT is understood and implemented in non-SCI-specialized settings.

Design: Interpretive descriptive qualitative study. Framework: Interview development guided by the Theoretical Domains Framework (TDF) to capture factors influencing therapists’ knowledge, behavior, and decision-making regarding SCI rehabilitation and ABT. Eligibility: Licensed Canadian physical therapists (PTs) and occupational therapists (OTs) working at non-SCI-specialized centers with experience treating at least one person with SCI in the past 18 months. Sampling and recruitment: Target sample size 7–10 based on information power considerations (aim, sample specificity, theory use, dialogue quality, analysis strategy) and alignment with prior ABT studies. Recruitment via snowball sampling through the Canadian ABT Community of Practice networks. Data collection: Semi-structured phone interviews (June–December 2022), 26–45 minutes each, conducted in English by a single researcher using a guide adapted from prior studies in SCI-specialized centers. At interview start, ABT was defined as repetitive neuromuscular activation below the level of spinal injury achieved through intensive, task-specific movement practice. A total of seven interviews were completed with four PTs and three OTs; all were individual except one joint PT/OT interview from the same facility. Data analysis: Interpretive descriptive approach. Two researchers independently reviewed transcripts, developed a preliminary codebook from the first two transcripts, jointly coded the third to refine the codebook, and applied it to remaining interviews. Iterative analysis examined relationships among ideas and themes. Member checking occurred throughout. Consensus on final themes/subthemes was reached by the team; NVivo 12 was used for data management.

Participants: Seven therapists (4 PTs, 3 OTs) from Ontario (n=3) and Alberta (n=4) across acute care, inpatient rehabilitation, long-term care, outpatient neurorehabilitation, and a rural outpatient clinic. Themes: 1) Available knowledge, resources, and therapy time in non-SCI-specialized centers challenge ABT implementation. Subthemes: (a) Gaps in specialized knowledge related to SCI and ABT—limited familiarity and comfort treating SCI; infrequent exposure requiring refreshers; uncertainty with SCI-specific equipment. (b) Lack of access to resources for SCI rehab and ABT—equipment often unavailable or borrowed; fewer community resources and education compared with specialized centers. (c) Limited time for therapy and ABT—high caseloads and setup time reduce capacity for intensive, repetitive ABT. 2) How current therapy practices in non-SCI-specialized centers align with ABT. Subthemes: (a) Unconscious incorporation of ABT principles—therapists reported using weight-bearing and recovery-oriented activities without labeling them as ABT. (b) Emphasis on function and independence—focus on functional tasks (transfers, toileting, dressing, grooming, IADLs) often without the intensity/massed practice typical of ABT. 3) Desire for ABT knowledge. Subthemes: (a) Strong interest in learning more about ABT to expand clinical tools. (b) Preference for accessible, tailored education—online modules and virtual learning; materials adapted to specific settings (e.g., acute care). Overall, participants were largely unfamiliar with the ABT term but recognized integrating components in practice and expressed keenness for additional training.

Findings indicate therapists in non-SCI-specialized settings are generally unfamiliar with the ABT label yet often apply elements of ABT in practice. Implementation is hampered by three key constraints: limited specialized SCI/ABT knowledge, insufficient equipment and community resources, and time pressures due to large caseloads and setup demands. Addressing these barriers could expand ABT access for individuals with SCI who frequently receive care outside specialized centers, especially those living closer to non-specialized services or in rural areas. The study suggests improving distribution of ABT expertise across more centers and leveraging virtual modalities to extend specialized support and training to remote or underserved areas—a strategy aligned with the broader uptake of tele-rehabilitation during COVID-19. Given the rising incidence of non-traumatic SCI with aging populations and the likelihood that such patients receive care in non-specialized settings, strengthening SCI-specific rehabilitation capacity in these environments is increasingly important.

Knowledge and implementation of ABT in non-SCI-specialized centers are limited. Therapists often, albeit unknowingly, incorporate aspects of ABT while prioritizing functional independence within constrained time and resource environments. There is clear interest in accessible, tailored ABT education to fit diverse non-specialized contexts (e.g., acute care, rural outpatient). The findings can inform targeted training and implementation strategies, including virtual education and support, to improve ABT access and quality across the continuum of care.

All interviews were conducted by phone, limiting the ability to capture non-verbal cues. The sample was confined to two Canadian provinces, which may limit transferability. Small sample size typical of qualitative work and recruitment via professional networks may also introduce selection bias.