Abstract
Objective
To explore physiotherapists’ experiences with and perspectives on providing care to acute mechanically ventilated spinal cord injury patients in intensive care units to better understand physiotherapy practice with this patient population.
Design
Qualitative descriptive study.
Setting
Level 1 intensive care units in hospitals across Ontario.
Participants
Eleven physiotherapists working in level 1 intensive care units who had experience treating at least one mechanically ventilated spinal cord injury patients within the year prior to recruitment.
Methods
Semistructured interviews were conducted with participants. Interviews lasted approximately 60 minutes, were transcribed verbatim and anonymised. Interview transcripts were analyzed using an inductive thematic analysis approach.
Results
Three overarching themes with several subthemes were identified: (1) spinal cord injury care provision is improved by physiotherapist presence and collaboration with patients’ circle of care in the intensive care unit; (2) increased access to resources, specialized education and training could address challenges in physiotherapist treatments and assessments; and (3) physiotherapist involvement in acute spinal cord injury patients’ care can optimize safety.
Conclusions
Our findings suggest that integrating physiotherapist into intensive care unit spinal cord injury care may support early mobilization and improved patient outcomes. Physiotherapist presence enhanced interprofessional collaboration and communication. Physiotherapists faced challenges such as training gaps and limited autonomy, but informal mentorship improved physiotherapist integration. This qualitative study of 11 intensive care unit physiotherapists from one region suggests that greater physiotherapist involvement may improve care processes and warrants larger multisite studies.
Keywords
Background
Spinal cord injury is a life-changing event that results from damage to the spinal cord either traumatically (e.g. motor vehicle accident) or nontraumatically (e.g. tumor). This damage can lead to varying levels of significant temporary or permanent impairment of motor, sensory, and autonomic functions.1,2 Between 250,000 and 500,000 people suffer from spinal cord injury yearly around the world, with up to 90% of these cases being due to trauma. 3 , 2 In Canada, it is estimated that there are approximately 86,000 individuals currently living with traumatic spinal cord injuries, with 4300 new cases reported each year (80% male; most aged 20–29). 4 Physiotherapists play a crucial role in spinal cord injury care, addressing range of motion/stretching, strengthening exercises, bed mobility, balance, upright tolerance, endurance, skin management, airway clearance, transfer/gait training, and patient and family education.5–7 They also help prevent chronic secondary complications, including respiratory compromise, bladder dysfunction, Charcot joints, and pressure injuries. 5 Physiotherapy for mechanically ventilated spinal cord injury patients in the intensive care unit is complex (e.g. high acuity) and requires close coordination with the interprofessional team and adherence to medical parameters. Even when patients remain sedated, on vasoactive medication, or mechanically ventilated, it is advisable for physiotherapy to begin within the first week postinjury, once medically stable. 7 Despite early involvement, the optimal physiotherapy care for acute spinal cord injury has yet to be established. This is a pressing issue as systematic reviews in the past have consistently demonstrated the absence of high-quality evidence for physiotherapy intervention not only in acute care settings, but in general. 6 8–10 Studies have also placed greater emphasis on physiotherapy within rehabilitation or chronic care contexts for this patient population.9–12 In a systematic review performed by Hicks et al., out of the 82 studies, only 13 studies were relevant for the acute spinal cord injury (< 1 year postinjury; and only one within the first month, limited to ambulating incomplete injuries). 10 Existing guidelines offer broad recommendations across all phases of care but omit physiotherapy specifics in the early acute period.13–15 The lack of physiotherapy-specific recommendations across resources and guidelines is a significant gap. To the best of our knowledge, there are no studies that have explored the role and influence of physiotherapy in the early days to few weeks following a spinal cord injury when the patient is still under mechanical ventilation.6–12 The practices and interventions physiotherapists are employing for acute spinal cord injury patients remain unclear, thereby limiting our knowledge on how the acute spinal cord injury population is being treated by physiotherapists and how this care could potentially be improved in the future. To address this, our study explores physiotherapists’ experiences with and perspectives on providing care to acute mechanically ventilated spinal cord injury patients in intensive care units in Ontario. This study will begin elucidating the overall understanding of physiotherapy practice with mechanically ventilated spinal cord injury patients in an intensive care unit setting.
Methods
Study design
This study was approved by the Research Ethics Board at Sunnybrook Health Sciences Centre (REB# 5025). A qualitative descriptive approach was used to describe the current practice of Ontario physiotherapists and their perspectives on the care of acute mechanically ventilated patients. The report produced using qualitative description is descriptively rich and adequately reflects the viewpoints of the participants, thereby making it easier to adopt for the type of real-world change that this project aims to achieve.16,17
Participants and recruitment
General hospitals classified under group A as defined by the Ministry were included in the list of hospitals in Ontario that were established through the website of the Ministry of Long Term Care and Health. Hospitals with intensive care units were confirmed through hospital websites, telephone contact, and email addresses. A list of level I intensive care unit physiotherapists was assembled at the included group A general hospitals described above. We used a targeted recruitment approach to invite level I intensive care unit physiotherapists to participate by contacting them via telephone and email and informing them about the study objectives and providing general study information. Interested respondents received an email with a detailed information package and the informed consent form. Upon emailing back the signed consent forms, interested respondents were scheduled for an interview. Recruitment occurred between April 2022 and November 2023. Participants were recruited until data saturation was reached (i.e. the point at which no new concepts pertaining to our topic and objectives of interest emerged from the interviews). 18 Participants were eligible for the study if they were working in a level I intensive care unit setting in Ontario and had treated at least one mechanically ventilated spinal cord injury patient within the year prior to their recruitment. We excluded pediatric intensive care unit physiotherapists, since physiotherapists who work with children may have specialized training, use different approaches and equipment than those used for the adult population and their experiences may not align with the ones of physiotherapists who work with adults.
Data collection
Two trained qualitative researchers (NP & SM) conducted individual semistructured interviews via Zoom or telephone depending on participant's availability and preference. The interviewer was not known to the participants prior to the study. An interview guide was developed based on the study's aims and the research questions (see Supplemental File 1). Contextual information (i.e. demographics, years of practice, and geographic practice location) was collected during the interview from the participants to describe our sample. Each interview lasted an average of 60 minutes, and all interviews were audio and/or video-recorded, transcribed verbatim, and checked for accuracy and completeness. All identifiable information was cleared from the transcripts for anonymity, with unique identification numbers assigned to each participant.
Data analysis
Thematic analysis was employed according to the steps outlined by Braun and Clarke. 19 In line with the interpretative description approach, the inductive analysis began with repeated immersion in the transcripts by three researchers (SMC, WL, and SM) to become well acquainted with the data. This was followed by conducting open coding on a subset of transcripts to generate an initial set of codes capturing preliminary insights from the data. Following this, SMC, WL, and SM convened to discuss their preliminary observations and establish a comprehensive coding scheme. The researchers subsequently applied this scheme to all transcripts and merged similar codes into broader categories. These codes and categories were then reviewed and combined into larger categories aligned with the research objectives. SMC, WL, and SM merged the raw data, coded, and categorized data to formulate initial themes and titling each theme, which were subsequently shared with the broader research team for feedback and refinement. Engaging multiple researchers in this process bolstered the quality of the data analysis by reducing bias and enhancing trustworthiness of the interpretations presented. We adhered to recognized reporting criteria by applying the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist.
Results
In total, we included n = 11 physiotherapists in our study. Detailed participant characteristics are reported in Table 1. To maintain anonymity, we assigned unique identifiers to each physiotherapist participant.
Participant characteristics.
We identified three overarching themes with several subthemes: (1) spinal cord injury care provision is improved by physiotherapist presence and collaboration with patients’ circle of care in the intensive care unit; (2) increased access to resources and further specialized education and training could address challenges in physiotherapist treatments and assessments; and (3) physiotherapist involvement in acute spinal cord injury patients’ care can optimize safety.
Participants described a number of facilitators that enhanced the administration and delivery of physiotherapist assessments and treatments, ultimately improving care provision for mechanically ventilated spinal cord injury patients in an intensive care unit setting. There has been an overall increase in the integration of physiotherapy within the intensive care unit setting as there is “generally more FTEs or more positions allocated to physiotherapists” (PT003). This reflects the growing acceptance of intensive care unit physiotherapy as a crucial component of patient care for this population. In addition, engaging in collaborative approaches and communication with the circle of care as well as mentorship/learning from peers’ experiences have been described as crucial components to improving care provision.
In addition to gaining theoretical knowledge and training as a student in physiotherapy school, “mentorship and collaboration with other physios” (PT003) was described as a valuable way to gain practical skills and learn from the expertise of others. Most physiotherapists explained that at the beginning of their practice with this specific patient population, they were able to gain more practical training by working closely with other experienced colleagues. This often inspired them to build their own roles and formulate treatment plans for this particular patient population: “What's been helpful has always been having another physiotherapist to help get ideas with, right? So, started out, I had a mentor that was able to walk me through a lot of those issues, so that was very helpful.” (PT009)
Participants also reflected on the importance of collaboration within a patient's circle of care as it helped teams set goals and achieve them more quickly and appropriately. This circle includes healthcare professionals, families, and patients. Participants noted that there are values in establishing effective “communications and maintaining the contact with patients’ family members, while showing them how they can help the patient when they are visiting” (PT008). It was evident from physiotherapists’ comments that effective communication and collaboration are interconnected skills that enable interprofessional teams to function efficiently and deliver high-quality care to mechanically ventilated spinal cord injury patients in the intensive care unit setting. Participants further discussed that it was beneficial having established team-based physiotherapy as this enabled them to address the diversity of difficulties encountered by patients and optimize care provision in the intensive care unit setting. One participant noted: “Just working collaboratively with other physiotherapists on our unit. So, co-treating patients together. Being able to discuss and come up with goals and think outside of the box. Get creative. So, working together to see how you can optimise what we can do in this setting here.” (PT006)
Almost all physiotherapists highlighted the importance of collaborative work between various healthcare professionals, such as occupational therapists and respiratory therapists, nursing staff, and physicians involved directly with patient care, to ensure the best possible patient-centred care provision. By collaborating with the interprofessional team, participants felt that they optimized patient care since they could “coordinate treatments so that we’re not disturbing the patient too many times in one hour, one part of the day” (PT001).
Participants identified a need for greater access to resources such as relevant literature and equipment, training, educational materials for team members, and opportunities for additional collaborations with healthcare professionals in order to confront challenges that physiotherapists faced when treating and assessing mechanically ventilated patients in the intensive care unit.
Accessibility to available resources including relevant literature and equipment was identified as a persistent gap impacting care delivery. Participants noted that a lack of adequate and accessible resources was an obstacle to the optimal delivery of physiotherapy-related services to mechanically ventilated spinal cord injury patients in the intensive care unit setting. This included information and education (e.g. up-to-date literature) in order to prevent over-dependence on colleagues’ expertise and, instead, promote evidence-based practices. They also noted that tangible supports were absent, including equipment such as appropriate chairs, as they “do not always have the chair available, because, sometimes we are too busy, and have too many other clients occupying those chairs so that we have to put them in a temporary chair, which is not ideal” (PT008). Participants thus stressed the importance of addressing these resource gaps by recruiting more staff and conducting more research on this “niche population” (PT006) in order to address the paucity of evidence and practice guidance.
Most participants also stated that “the biggest challenge on average has been time” (PT003) to dedicate to each patient, coupled with insufficient employer and team support, staff shortage, “and sometimes just to find that sufficient assistance can be difficult” (PT006). In turn, this created considerable difficulties in delivering efficient physiotherapy services in intensive care unit settings, including “[being] short-staffed and…challenge[s] in terms of time management and prioritizing patients if you have a full load” (PT008) as well as managing the “different specialties and disciplines that are often involved in these patients’ care. So, sometimes just finding the protected time to actually assess the patient. Especially in that acute phase when they’re still having lots of tests being done” (PT006).
Opportunities for further collaborations with broader healthcare teams were identified as crucial for seamless transitions and continuity of care. To ensure seamless patient care transitions and continuity, participants explained that “Having more communication between the different levels of care” (PT05) was crucial. Participants further described that “sometimes it is unclear where the patient is going to end up and how things will go” (PT06). Thus, recommending that “it would be ideal if we have a better idea of where the patient is going to end up downstream and how things will go by having a little bit more of a better communication path between intensive care unit level, Level II intensive care unit, and rehab” (PT06). Participants further explained that “there is a place for occupational therapists and respiratory therapists with this population” (PT011) as well as more integrated teamwork among healthcare professionals as they contribute specialized competence that augments physiotherapy. This, in turn, improves the holistic care of this niche patient population.
Training and educational resources for team members were often reported as insufficient and strengthening them was highlighted fundamental to address complex care needs. Most participants noted that “in terms of working [in] intensive care unit care, we do not really get many direct training regarding spinal cord injury, and so we have to seek that ourselves, asking other colleagues, or other OTs [occupational therapists] who have that experience or seek that courses outside of work” (PT001). Consequently, participants highlighted a need to address the training and educational resource shortage to ensure that physiotherapists and the team are well-trained to meet the complex needs of this specific patient population to ensure better care and improved patient outcomes. Additionally, participants felt there is a need for “more education for families, like what exercises they can do with the patients. Education for nursing on how to get the patients to participate actively in bed mobility. I think that's huge” (PT011) in order to foster a collaborative care environment.
Physiotherapists’ autonomy over diagnosis and determination of treatments was viewed variably across participants, with some feeling “there [are] really no barriers to what physios are able to do. So, we’re actually quite autonomous in terms of what we do… and we have free reign, basically, in terms of what we feel we need to assess” (PT004). In contrast, others believed that physiotherapists should have more autonomy in selecting the right equipment and making assessments and treatment decisions. Additionally, participants noted that certain treatments require external authorization, for example, “sometimes there are patients who probably would benefit from actual chest physiotherapy as part of their daily treatments. But we are not able to just facilitate that on our own. That requires a doctor's orders here” (PT006), resulting in a delayed care. Consequently, participants highlighted a need for a balanced level of autonomy, which in turn, could enable them to diagnose and manage treatment plans independently and tailor interventions more precisely to meet the specific needs and conditions of their patients. For example, one participant shared: “I think, ideally, if we had a little bit more autonomy over what kind of equipment is used. So, for example… I think it would be helpful if we could …have the autonomy and ability to determine whether or not we think a patient needs chest physiotherapy to help with secretion management because that is one of the biggest things with spinal cord injury patients.” (PT006)
Participants explained that integrating effective and robust communication and collaborative practices with thorough patient assessments creates a safer care environment as this fosters a cohesive team dynamic and promotes appropriate safety measures aligned with patients’ evolving needs and conditions.
Communication and collaboration with circle of care and ensuring sufficient assistance from the team members were identified as critical for safe and needs-tailored care delivery. Clear, continuous communication and collaboration among all members of the patient's care team was described by participants as essential to ensure that spinal cord injury patients in the intensive care unit receive care that is delivered in a safe manner and is tailored to their specific needs. Participants further elaborated on the value of working closely with the respiratory therapists to provide respiratory care and chest physiotherapy and working in conjunction with the occupational therapists for “proper seating and doing the mechanically lifting [of the patients] to the chair” (PT002). Participants also highlighted the importance of working closely with spinal cord injury intensive care unit nurses, having “discussion with them, determining whether or not a patient will require the abdominal binder and the tensor” (PT006) or “just to get a general idea of how the patient is doing. How stable they are, and whether or not they would be appropriate for me [physiotherapists] to go in and see them” (PT007).
Initial assessment of the patient and its environment, patient-dependent therapies and treatments, and indicators guided real-time safety decisions. Participants described using subjective and objective measures to optimize patient safety during therapy and to facilitate appropriate patient-specific modifications. Participants highlighted the importance of being able to monitor a patient's response throughout an assessment as it allowed them to ensure that the patient is tolerating the session. This includes monitoring of vitals as well as a patient's verbal and nonverbal response throughout therapy. For example, one participant explained: “when I look at the responses, see if they’re able to verbally or nod or shake their head to my questions when I’m asking them if they’re okay, or if they can tolerate this. Or if they need, tone it down. Checking their vitals on the screens” (PT001).
Participants elaborated on how close monitoring throughout therapy enables them to safely modify their assessment or treatment, such as whether to continue or terminate an activity. “So, for example, that a patient is on a high amount of blood pressure support, and especially if we do that chair and bed position as we see that their blood pressure drops significantly, then we know that we can’t progress doing active out of bed mobility at that time. Even if otherwise, it would seem appropriate” (PT005).
Physiotherapists role in pressure injury prevention was identified as crucial. Participants expressed physiotherapists have a significant role in preventing and monitoring pressure injuries, as one participant shared: ”So, like I said, developing tools to promote optimal positioning. Monitoring skin during sessions, especially around equipment, splints that we have recommended and put on the patients. Ensuring that they have appropriate cushions. Education to the nurses about how frequent to change positions. Those are all interventions that I have been involved in as a physiotherapist to minimize skin breakdown, pressure injury.” (PT003)
Participants pointed out that physiotherapists work closely with “nurses and occupational therapists in pressure relief monitoring and equipment provision” (PT002). The importance of a collaborative approach with good communication was highlighted as this increases awareness of a patient's skin condition among the team and allows appropriate changes to the treatment plan. One participant described working with a nurse: “so, as we [physiotherapists] turn the patient, the nurse usually looks at any coccyx injuries or skin breakdown in that area. They’ll [nurses] let us [physiotherapists] know there is an injury there that we need to be monitoring” (PT009). And when skin breakdown occurs, physiotherapists work with occupational therapists to optimize positioning for pressure relief. “When there are actual breakdowns, occupational therapist and I [physiotherapist] work together, and the occupational therapist tends to play a bigger role with proper cushioning and proper equipment for positioning in bed. But, we [physiotherapists] also monitor and provide positioning relief” (PT002).
Discussion
This qualitative study explored physiotherapists’ experiences and perspectives on treating patients with an acute spinal cord injury who are mechanically ventilated in intensive care units in Ontario. Physiotherapists spoke about their rationale for chosen interventions as well as the similarities, differences and challenges in their practice.
Our findings offer unique insight into how physiotherapists perceive their roles and the belief in how their involvement in early mobilization and respiratory interventions positively influenced patient recovery. At the same time, physiotherapists reflected on persistent barriers to care—such as gaps in mentorship, training, and clinical autonomy—which often shaped their experiences and limited their capacity to deliver optimal care. These reflections point to a need for targeted improvements in education and institutional support to ensure physiotherapists are equipped and empowered to meet the demands of this highly specialized area of practice. Substantial evidence supports the vital role of early physiotherapy for mechanically ventilated patients in reducing both intensive care unit and hospital lengths of stay, enhancing mobility, and preventing secondary complications such as avoiding muscle atrophy and pressure ulcers.20–24 This was echoed by physiotherapists in our study, who emphasized the significance of early physiotherapy interventions and the wide range of treatment offerings available for spinal cord injury patients, including positioning, mobilization, and respiratory support, which may lead to improved functional outcomes and reduced long-term disability. Physiotherapists also noted that the increased physiotherapist presence in the intensive care setting contributed to a boost in communication and collaboration amongst the healthcare teams, patients, and their families. The significance of teamwork was highlighted, especially in optimizing patient safety during assessments and interventions. Physiotherapists agreed that early hospital care of spinal cord injury patients often involves complex decision making and requires a solid understanding of hemodynamic management. This finding aligns with existing literature, which stresses that the diverse and complex nature of spinal cord injury treatment and management requires coordinated interprofessional collaboration. 25 Such collaboration ensures that providers are equipped to make clinical decisions that prioritize patient safety. 25 Despite the recognition of positive collaboration amongst providers, many still see opportunities for stronger partnerships with other disciplines, such as occupational therapy and respiratory therapy. For instance, all physiotherapists in our study identified pressure injury prevention as a shared role amongst themselves, nurses, and occupational therapists, where they heavily rely on their colleagues’ contributions. The benefits of a more integrated approach to spinal cord injury rehabilitation were recognized, aligning with existing literature supporting an interprofessional team approach toward pressure ulcer prevention that fosters collaboration among the team, optimizing patient care and enhancing staff satisfaction. 26 Most physiotherapists in our study reported that even though they received formal university education on the fundamentals of treating this niche population, their learning primarily came from lived hands-on experiences and mentorship from their senior colleagues within the field. According to our interpretations, informal mentorship—which we define from our data as a natural relationship that developed between a more experienced clinician and a novice clinician (rather than two individuals brought together officially for mentorship goals to be met)—was more frequently mentioned by participants than formal mentorship. Our findings affirm existing literature that emphasizes that mentorship serves as a bridge between theory and clinical practice when it comes to integrating new healthcare professionals into routine care, ultimately optimizing the productivity and satisfaction of mentees. 27 However, our study suggests that mentorship, while valuable, should not be a substitute for formal education and training. As Carthas and McDonnel 28 suggest, formal mentorship programs and training are necessary to ensure that physiotherapists succeed in acute care settings by practicing in an evidence-based manner. Consequently, sustaining informal mentorships alongside formal training and support, as suggested in previous studies, would facilitate the creation of a more robust system of support for physiotherapists working in acute spinal cord injury care. 27 Growing evidence shows that early physiotherapy interventions, such as early mobilization and stimulation of activities, play a critical role in positively impacting and preventing physical impairments in critically ill intensive care patients. 29 Studies regularly indicate that early mobilization administered by physiotherapists may lead to reduced hospital stays, shortened length of intensive care unit stay, and minimized functional decline while increasing patient mobility after discharge. 29 In fact, the Society of Critical Care Medicine's “ICU Liberation Bundle” outlines early mobility and exercise as a critical element in decreasing hospital deaths, reducing delirium, and cutting intensive care unit readmissions in half. 30 Substantial evidence supports the significance of physiotherapy interventions to improve ventilation, including abdominal binders, positioning, mobilization and deep breathing exercises in enhancing functional outcomes in mechanically ventilated patients. 31 Our findings add further support for the key roles physiotherapists play in improving safety and optimizing outcomes in this patient population through their regular vital signs check-ins and interprofessional collaborations with the healthcare team to ensure the administration of safe and appropriate interventions. These findings align with the literature, which underscores the importance of monitoring and maintaining patients’ safety and screening for the presence of contra-indications before and during mobilization and activation in the intensive care unit to consider any potential risks and benefits.29,32
The major strength of our study is that it is one of the very first to explore physiotherapy practice patterns for acute mechanically ventilated spinal cord injury patients in an intensive care unit setting. Our qualitative approached enabled us to gain detailed narrative insight into the experiences of physiotherapists that the literature is presently missing. Our study sample was largely homogenous (e.g. most physiotherapists were practicing in teaching hospitals in Toronto, Ontario, Canada), thereby limiting the transferability of the findings to other provinces or healthcare settings. Furthermore, all participants identified as female, and on average, had 8 years of experiences, which may not fully represent the experiences of physiotherapists of other genders and levels of career experience. Institutional resources and clinician backgrounds may potentially have impact on reported practices and challenges. Therefore to address this limitation, future studies should include physiotherapists from diverse settings, regions, backgrounds, and career stages to assess which findings apply broadly.
Clinical messages
Physiotherapists achieve the best results to optimize safety and intervention through close collaboration with team members.
Physiotherapists highlighted limited education, training, equipment, and intensive care unit-specific guidelines as key barriers to evidence-informed care for mechanically ventilated spinal cord injury patients.
Mentorship between seasoned and novice physiotherapists builds confidence and sharpens clinical judgment in the challenging intensive care setting.
Supplemental Material
sj-docx-1-cre-10.1177_02692155251413203 - Supplemental material for Physiotherapy practice with mechanically ventilated spinal cord injury patients in the intensive care unit (ICU): A qualitative study of physiotherapists’ experiences and perspectives
Supplemental material, sj-docx-1-cre-10.1177_02692155251413203 for Physiotherapy practice with mechanically ventilated spinal cord injury patients in the intensive care unit (ICU): A qualitative study of physiotherapists’ experiences and perspectives by Sabrina Massoni Camilo, Winnie La, Shaghayegh Mirbaha, Nicole Cooper, Tracy Anthony and Marina B. Wasilewski in Clinical Rehabilitation
Footnotes
Ethical approval and informed consent statements
The Research Ethics Board at Sunnybrook Health Sciences Centre approved our interviews (approval: REB# 5025) on 22 December 2021. All participants provided written and verbal informed consent prior to participation, in accordance with ethics board approval.
Any other identifying information related to the authors and/or their institutions, funders, approval committees, etc, that might compromise anonymity. Not applicable
Consent to participate
All participants provided written and verbal informed consent prior to participation, in accordance with ethics board approval.
Author contribution
SMC , WL led the protocol development, recruitment, data collection/analysis, interpretation, and manuscript drafting/revisions. SM, NC, and TA was involved in supported recruitment, data collection/analysis, interpretation, and manuscript drafting/revisions.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a Sunnybrook Practice Based Research and Innovation (PBRI) Seed Grant.
Declaration of conflicting interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
The datasets generated during and/or analyzed during the current study are not publicly available due to participant confidentiality considerations but are available from the corresponding author on reasonable request.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
