Complications of Spinal Cord Injury Over the First Year After Discharge From Inpatient Rehabilitation

The role of payment sources in the continuation of rehabilitation therapy in tertiary hospitals for patients with traumatic spinal cord injury: a study in Southwest China

Medical security support for rehabilitation therapy in China is different from that in other countries. We investigated whether the discharge plan to continue rehabilitation therapy in tertiary hospitals for patients after traumatic spinal cord injury (TSCI) was influenced by payment sources or other conditions. This was a cross-sectional, observational study. Information was collected on the general condition, caregiver, types of payment sources for continued rehabilitation, American Spinal Injury Association Impairment Scale (AIS) scores, and discharge plans. In total, 135 patients with TSCI (107 male, mean age 41.00 ± 13.73 years, mean spinal cord injury duration 238.43 ± 345.54 days) were enrolled. Medical insurance (43%) and out-of-pocket payments (27.4%) were the primary payment sources. Although most patients were beyond the acute phase, 40% continued rehabilitation therapy at other tertiary hospitals. The caregiver, payment sources, injury level, AIS level, and complete urinary tract infection (UTI) were different due to discharge plans (p > .05). Patients seemingly consider a higher AIS level and co-UTI as the requirement for tertiary hospital therapy. In non-medical insurance payment source patients, the discharge plan also differed due to the AIS level and co-UTI (p > .05). However, in medical insurance patients, the discharge plan differed only in terms of TSCI duration (p > .05). The restricted duration of medical coverage restricted the continuation of rehabilitation therapy and influenced the discharge plan of most patients with TSCI.

Clinical Remote Monitoring of Individuals With Spinal Cord Injury at Risk for Pressure Injury Recurrence Using mHealth: Protocol for a Pilot, Pragmatic, Hybrid Implementation Trial

BACKGROUND

Pressure injuries are one of the most challenging secondary conditions for individuals with spinal cord injuries and related disorders (SCI/D) owing to inherent, lifelong risk factors that include a lack of sensory and motor function below the level of injury and reliance on a wheelchair for daily mobility, resulting in prolonged periods of sitting. Although many factors contribute to the development of pressure injuries, the pressure between the skin and a surface is always a factor and the development of injury is dependent on the magnitude and duration of the pressure. Clinically, broad recommendations for relieving pressure are used because we know very little about the unique day-to-day life patterns of the individual wheelchair user. Typically, it is after the occurrence of a pressure injury that the therapist will check equipment fit and the effectiveness of pressure offloading and ask about other surfaces they sit on in their home and community. This time-lapsed, largely self-reported data are fraught with recall bias and inaccuracies that the therapist incorporates into a plan of care.

OBJECTIVE

This study's objective is to pilot-test the implementation and clinical effectiveness of a telehealth model of care combined with our mobile health (mHealth) Assisted Weight-Shift device for remote monitoring of factors related to maintaining skin health and wheelchair setup. Our overall hypothesis is that this study will result in an effective implementation plan, and the enhanced connected model of care using remote monitoring of pressure management will result in pilot-level, improved clinical outcomes for adults with spinal cord injury at high risk for pressure injury recurrence.

METHODS

For all aims, we will use a mixed methods design using an exploratory, sequential approach to include the strengths of both qualitative and quantitative data. For aims 1 and 2, we will iteratively collect qualitative data from therapists, patients with SCI/D, and other stakeholders. For aim 3, we will perform a hybrid effectiveness-implementation randomized controlled trial to pilot-test the intervention. The projected results include an iteratively developed and tested implementation plan that meets moderate to high levels of acceptability, feasibility, and appropriateness. Additionally, the pilot trial results are expected to show positive trends in relevant clinical outcomes related to reduced pressure injury incidence, recurrence, and improved healing when compared with the standard of care.

RESULTS

Currently, 6 participants have been recruited for our aim-1 qualitative study.

CONCLUSIONS

This study will expand upon our previous study to move the Assisted Weight-Shift system into routine clinical care, which was a strong desire of adults with SCI/D for improved individualized care plans to prevent pressure injuries. The results of this study will guide the next steps in a full, hybrid effectiveness-implementation trial with the goal of improving care to prevent pressure injuries.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51849.

Tracking activity-based therapy for people living with spinal cord injury or disease: insights gained through focus group interviews with key stakeholders

PURPOSE

The development of a tool to track participation in activity-based therapy (ABT) for people with spinal cord injury or disease (SCI/D) was identified as a priority of the Canadian ABT Community of Practice. The objective of this study was to understand multi-stakeholder perspectives on tracking ABT participation across the continuum of care.

MATERIALS AND METHODS

Forty-eight individuals from six stakeholder groups (persons living with SCI/D; hospital therapists; community trainers; administrators; researchers; and funders, advocates and policy experts) were recruited to participate in focus group interviews. Participants were asked open-ended questions concerning the importance of and parameters around tracking ABT. Transcripts were analyzed using conventional content analysis.

RESULTS

Themes reflected the Who, What, Where, When, Why and How of tracking ABT. Participants described the importance of involving hospital therapists, community trainers and individuals with SCI/D in tracking ABT to capture both subjective and objective parameters across the continuum of care and injury trajectory. Digital tracking tools were favoured, although paper-based versions were regarded as a necessity in some circumstances.

CONCLUSIONS

Findings highlighted the importance of tracking ABT participation for individuals with SCI/D. The information may guide the development of ABT practice guidelines and support the implementation of ABT in Canada.

Provider perspectives of community-acquired pressure injury prevention in veterans with spinal cord injury

CONTEXT/OBJECTIVE

Community-acquired pressure injuries (CAPrI) are a common and costly complication of spinal cord injury (SCI). Most studies and interventions focus on the prevention of pressure injuries acquired in the hospital. The goal of this study is to better understand SCI provider perspectives of the risks, actions and resources needed to prevent CAPrIs.

DESIGN

Qualitative descriptive, semi-structured interviews of SCI providers analyzed using a deductive-inductive approach.

SETTING

Three geographically different veteran health administration spinal cord injury/disorder centers.

PARTICIPANTS

30 interprofessional SCI providers.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Provider perspective of risks, actions and resources for CAPrI prevention in veterans with SCI.

RESULTS

30 interviews revealed a model of provider perspectives of CAPrI prevention including veteran risk characteristics, veteran preventive activities and provider, family, community caregiving resources.

CONCLUSION

Understanding provider perspectives of Veteran CAPrI preventive risks, actions and resources guides more appropriate interventions to prevent CAPrIs in individuals living with SCI.

Electroacupuncture promotes the repair of the damaged spinal cord in mice by mediating neurocan-perineuronal net

AIMS

This study aimed to investigate the effect of perineuronal net (PNN) and neurocan (NCAN) on spinal inhibitory parvalbumin interneuron (PV-IN), and the mechanism of electroacupuncture (EA) in promoting spinal cord injury (SCI) repair through neurocan in PNN.

METHODS

A mouse model of SCI was established. Sham-operated mice or SCI model mice were treated with chondroitin sulfate ABC (ChABC) enzyme or control vehicle for 2 weeks (i.e., sham+veh group, sham+ChABC group, SCI+veh group, and SCI+ChABC group, respectively), and then spinal cord tissues were taken from the T10 lesion epicenter for RNA sequencing (RNA-seq). MSigDB Hallmark and C5 databases for functional analysis, analysis strategies such as differential expression gene analysis (DEG), Kyoto Encyclopedia of Genes and Genomes (KEGG), gene set enrichment analysis (GSEA), and protein-protein interaction (PPI). According to the results of RNA-seq analysis, the expression of NCAN was knocked down or overexpressed by virus intervention, or/and EA intervention. Polymerase chain reaction (PCR), immunofluorescence, western blot, electrophysiological, and behavioral tests were performed.

RESULTS

After the successful establishment of SCI model, the motor dysfunction of lower limbs, and the expression of PNN core glycan protein at the epicenter of SCI were reduced. RNA-seq and PCR showed that PNN core proteoglycans except NCAN showed the same expression trend in normal and injured spinal cord treated with ChABC. KEGG and GSEA showed that PNN is mainly associated with inhibitory GABA neuronal function in injured spinal cord tissue, and PPI showed that NCAN in PNN can be associated with inhibitory neuronal function through parvalbumin (PV). Calcium imaging showed that local parvalbumin interneuron (PV-IN) activity decreased after PNN destruction, whether due to ChABC treatment or surgical bruising of the spinal cord. Overexpression of neurocan in injured spinal cord can enhance local PV-IN activity. PCR and western blot suggested that overexpression or knockdown of neurocan could up-regulate or down-regulate the expression of GAD. At the same time, the activity of PV-IN in the primary motor cortex (M1) and the primary sensory cortex of lower (S1HL) extremity changed synchronously. In addition, overexpression of neurocan improved the electrical activity of the lower limb and promoted functional repair of the paralyzed hind limb. EA intervention reversed the down-regulation of neurocan, enhanced the expression of PNN in the lesioned area, M1 and S1HL.

CONCLUSION

Neurocan in PNN can regulate the activity of PV-IN, and EA can promote functional recovery of mice with SCI by upregulating neurocan expression in PNN.

Development of a decision support tool to prevent community acquired pressure injuries for use in the spinal cord injury clinic using the delphi technique

STUDY DESIGN

Delphi Technique.

OBJECTIVES

Describe the development of a decision support tool to prevent community-acquired pressure injuries (CAPrIs) in individuals with spinal cord injury (SCI) for use in SCI clinics, called the Community-Acquired Pressure Injury Prevention-Field Implementation Tool (CAPP-FIT).

SETTING

Veteran Health Administration Hospital, Chicago, Illinois, USA.

METHODS

Concept mapping of current pressure injury (PrI) guidelines and qualitative research describing risks, actions, and resources needed to prevent CAPrIs associated with SCI were used to develop 40 veteran checklist items (Items) along with 37 associated provider actions (Actions) for the tool. The Delphi technique was used to refine Items and Actions with a panel of interprofessional SCI providers (n = 15), veterans with SCI (n = 4), and caregivers (n = 3) to determine consensus on a 4-point Likert scale (strongly agree-strongly disagree) for each Item and Action. A 75% agreement was set for responses rated as strongly agree or agree.

RESULTS

Panelists were 60% female, 62% White, 33% veterans with SCI or caregivers, 33% wound care certified with a mean age of 59 years. Two survey rounds were required for consensus for 41 Item and 38 Action CAPP-FIT. Response rate was 95% for both rounds. Delphi round 1 showed all but two Actions affirming agreement above 75%. Substantive comments from panelists required revision to 5 Items and 9 Actions and one additional Item/Actions related to coping, meeting threshold percent agreement in Round 2.

CONCLUSIONS

The CAPP-FIT could become a useful tool for Veterans living with SCI, caregivers, and SCI providers.

Genomic Biomarkers Can Provide a Deeper Understanding of Recurrent Pressure Injuries

OBJECTIVE

To identify genetic biomarkers predisposing individuals with spinal cord injury (SCI) to recurrent pressure injuries (PIs).

METHODS

Repeated measures of the transcriptome profile of veterans with SCI at three Veterans Spinal Cord Injuries and Disorders Centers. Exclusion criteria included having significant active systemic disease at time of enrollment. Researchers obtained comprehensive profiles of clinical and health factors and demographic information relevant to PI history at enrollment and at each follow-up visit by reviewing patients' medical charts. Whole blood samples were collected at 6- to 12-month intervals for 2 to 4 years. In addition to DNA profiling with whole genome sequencing of the patients, RNA sequencing was performed to assess pathways associated with PI risk.

RESULTS

Whole genome sequencing analysis identified 260 genes that showed increased prevalence of single-nucleotide variations in exonic regions with high (>20) combined annotation-dependent depletion scores between persons with high versus low intramuscular adipose tissue levels when cross-referenced with persons who had recurrent PIs. Gene set enrichment analysis using Hallmark and KEGG (Kyoto Encyclopedia of Genes and Genomes) gene sets of these candidate genes revealed enrichment in genes encoding proteins involved in fatty acid metabolism (P < .01). Further, RNA sequencing revealed upregulated activity in biological senescence pathways and downregulated activity in antimicrobial protection pathways.

CONCLUSIONS

Genomic biomarkers may complement electronic health records to support management of complex interactive health issues such as risk of recurrent PIs in people with SCI. These findings may also be leveraged for homogeneous phenotypic grouping of higher-risk individuals.

Pre-Hospital and Post-Hospital Quality of Care in Traumatic Spinal Column and Cord Injuries in Iran

STUDY DESIGN

A retrospective study.

OBJECTIVES

The quality of care (QoC) for spinal column/cord injury patients is a major health care concern. This study aimed to implement the QoC assessment tool (QoCAT) in the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to define the current state of pre- and post-hospital QoC of individuals with Traumatic Spinal Column and Spinal Cord Injuries (TSC/SCIs).

METHODS

The QoCAT, previously developed by our team to measure the QoC in patients with TSC/SCIs, was implemented in the NSCIR-IR. The pre-hospital QoC was evaluated through a retrospective analysis of NSCIR-IR registry data. Telephone interviews and follow-ups of patients with SCI evaluated the QoC in the post-hospital phase.

RESULTS

In the pre-hospital phase, cervical collars and immobilization were implemented in 46.4% and 48.5% of the cases, respectively. Transport time from the scene to the hospital was documented as <1 hour and <8 hours in 33.4% and 93.9% of the patients, respectively. Post-hospital indicators in patients with SCI revealed a first-year mortality rate of 12.5% (20/160), a high incidence of secondary complications, reduced access to electrical wheelchairs (4.2%) and modified cars (7.7%), and low employment rate (21.4%).

CONCLUSION

These findings revealed a significant delay in transport time to the first care facilities, low use of immobilization equipment indicating low pre-hospital QoC. Further, the high incidence of secondary complications, low employment rate, and low access to electrical wheelchairs and modified cars indicate lower post-hospital QoC in patients with SCI. These findings imply the need for further planning to improve the QoC for patients with TSC/SCIs.

Development and validation of a differentiation-related signature based on single-cell RNA sequencing data of immune cells in spinal cord injury

Background

After spinal cord injury (SCI), the native immune surveillance function of the central nervous system is activated, resulting in a substantial infiltration of immune cells into the affected tissue. While numerous studies have explored the transcriptome data following SCI and revealed certain diagnostic biomarkers, there remains a paucity of research pertaining the identification of immune subtypes and molecular markers related to the immune system post-spinal cord injury using single-cell sequencing data of immune cells.

Methods

The researchers conducted an analysis of spinal cord samples obtained at three time points (3,10, and 21 days) following SCI using the GSE159638 dataset. The SCI subsets were delineated through pseudo-time analysis, and differentiation related genes were identified after principal component analysis (PCA), cell clustering, and annotation techniques. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were employed to assess the differentiation-related genes (DRGs) across different subsets. The molecular subtypes of SCI were determined using consensus clustering analysis. To further explore and validate the correlation between the molecular subtypes and the immune microenvironment, the CIBERSORT algorithm was employed. High-value diagnostic gene markers were identified using LASSO regression, and their diagnostic sensitivity was assessed using receiver operating characteristic curves (ROC) and quantitative real-time polymerase chain reaction (qRT-PCR).

Results

Three SCI subsets were obtained, and differentiation-related genes were characterized. Within these subsets, two distinct molecular subtypes, namely C1 and C2, were identified. These subtypes demonstrated significant variations in terms of immune cell infiltration levels and the expression of immune checkpoint genes. Through further analysis, three candidate biomarkers (C1qa, Lgals3 and Cd63) were identified and subsequently validated.

Conclusions

Our study revealed a diverse immune microenvironment in SCI samples, highlighting the potential significance of C1qa, Lgals3 and Cd63 as immune biomarkers for diagnosing SCI. Moreover, the identification of immune checkpoints corresponding to the two molecular subtypes suggests their potential as targets for immunotherapy to enhance SCI repair in future interventions.

Intravesical hyaluronic acid with chondroitin sulphate to prevent urinary tract infection after spinal cord injury

CONTEXT/OBJECTIVE

Prevention of urinary tract infection (UTI) after spinal cord injury is an important goal. Intravesical hyaluronic acid with chondroitin sulphate (HA+CS) has been effective in preventing UTI in other settings. We aimed to demonstrate safety and feasibility of a standard treatment course of 7 intravesical HA+CS instillations over 12 weeks, in patients with acute (Arm A) and chronic (Arm B) spinal cord injury (SCI).

DESIGN

Follow-up of adverse events, quality of life bladder management difficulty (BMD) and bladder complication (BC) T-scores at baseline (Arm B only), 12 and 24 weeks, and symptomatic urinary tract infection (UTI).

RESULTS

Of 33 and 14 individuals screened, 2 and 8 participants were recruited to the study for Arm A and Arm B respectively. Of the 10 participants, 8 completed all 7 instillations. HA+CS commonly caused cloudy urine with urinary sediment which was mild and short-lived. In Arm B, a mean reduction in BMD and BC T-scores was observed from baseline (57.3 and 54.4 respectively), of 6.8 and 4.3 at 12 weeks and 1.6 and 2.8 at 24 weeks, respectively. Four participants with a history of frequent UTI in the prior 12 months did not have UTI in the 24 weeks of the study.

CONCLUSIONS

HA+CS was well tolerated. Recruitment was more difficult in early acute SCI; participants with chronic SCI were highly motivated to reduce UTI and manage self-administration without difficulty. Larger case-control or randomized controlled trials in patients with neurogenic bladder from SCI are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03945110.

Risk constellation of hospital acquired pressure injuries in patients with a spinal cord injury/ disorder - focus on time since spinal cord injury/ disorder and patients' age

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The aim of this study was to evaluate how time since spinal cord injury/disorder (SCI/D) and patients' age influence risk constellation for hospital acquired pressure injuries (HAPI) in patients with a SCI/D.

SETTING

Acute care and rehabilitation clinic specialized in SCI/D.

METHODS

We collected patients' characteristics and 85 risk factors for HAPI development in adults with SCI/D with at least one HAPI during their inpatient stay between August 2018 and December 2019. We analyzed patients' characteristics and HAPI risk factors using descriptive statistics according to time since SCI/D ( < 1 year, 1-15 years, > 15 years) and patients' age (18-35 years, 35-65 years, > 65 years).

RESULTS

We identified 182 HAPI in 96 patients. Comparing patients with SCI/D < 1 year with the other groups, autonomic dysreflexia (p < 0.001), abnormal body temperature (p = 0.001), hypertensive episode (p = 0.005), and pneumonia (p < 0.001) occurred more frequently; mean hemoglobin (p < 0.001), albumin (p = 0.002) and vitamin D levels (p = 0.013) were significantly lower, and patients with time since SCI/D < 1 year scored fewer points (10-12) on the Braden Scale (p < 0.001). Comparing groups per patients' age, only the SCIPUS score was higher in patients > 65 years compared to the other two groups (p = 0.002).

CONCLUSIONS

Different risk factor constellation seem to be underlying HAPI development with more differences in patients time since SCI/D than patients' age. Awareness of these differences in risk factor constellation depending on time since SCI/D in these patients might lead to different HAPI prevention strategies.

SPONSORSHIP

The study team didn't receive any additional sponsorship.

Total Knee Arthroplasty in Patients with Spinal Cord Injury: Impact on Medical Complications, Hospital Costs and Length of Stay

INTRODUCTION

Patients with spinal cord injury (SCI) with degenerative joint disease of the knee may require total knee arthroplasty (TKA). This study examines the demographic and immediate postoperative outcomes of patients with SCI who undergo TKA.

METHODS

Admissions data for TKA and SCI were analyzed from the National Inpatient Sample database using International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. An extensive array of preoperative and postoperative variables was compared among SCI TKA patients and non-SCI TKA patients. An unmatched and matched analysis using a 1:1 propensity match algorithm was conducted to compare the two groups.

RESULTS

Patients with SCI tend to be younger and have a 7.518 times greater risk of acute renal failure, 2.3 times greater risk of blood loss, and higher risk of local complications, including periprosthetic fracture and prosthetic infection. The average length of stay in the SCI cohort was 2.12 times greater, with a 1.58 times higher mean total incurred charge than the non-SCI group.

CONCLUSION

SCI is associated with an increased risk of acute renal failure, blood loss anemia, periprosthetic fractures and infections, a longer length of stay, and greater incurred charges in TKA patients.

STUDY DESIGN

Retrospective study.

Clinical Occurrences in the Neurorehabilitation of Dogs with Severe Spinal Cord Injury

This prospective observational clinical study in a population of tetraplegic and paraplegic dogs (n = 488) with or without deep pain sensation, similar to humans ASIA A and B, investigated the prevalence of clinical occurrences in a rehabilitation center with a hospitalization regime between 15 days and 9 months. A checklist of occurrences was used for easy identification and monitoring, resulting in a total of 79.5% occurrences. There were 58% of dogs with neurogenic bladder, 35.5% with diarrhea, 21.3% with urinary incontinence, and 20.5% with fecal incontinence. A low incidence of respiratory problems (e.g., pneumonia) and urinary tract infections may suggest the efficacy of some applied measures in this study, such as thoracic and abdominal POCUS evaluation, positioning strategies, physical exercises, respiratory kinesiotherapy, and early implementation of a functional neurorehabilitation protocol. These can be essential measures to prevent clinical occurrences, mainly in breeds such as the French Bulldog and the Dachshund.

Investigation of health literacy level and its effect on quality of life in patients with spinal cord injury

OBJECTIVES

To determine the health literacy (HL) level in patients with traumatic spinal cord injury (SCI) and evaluate the relationship between HL and the quality of life (QoL).

STUDY DESIGN

Cross-sectional study.

SETTING

Ankara Physical Medicine and Rehabilitation Education and Research Hospital, Turkey.

PARTICIPANTS

A total of 77 patients with traumatic SCI aged 15-65 years where the trauma had occurred at least a month ago before data collection and who were attending the rehabilitation program at the hospital as inpatients we included in the study.

OUTCOME MEASURES

The European Health Literacy Questionnaire Turkish Adaptation (HLS-TR) was used for the evaluation of the HL level, and the Short Form-36 was used for the evaluation of the QoL.

RESULTS

The HL level was inadequate in 32.5%, problematic-limited in 40.3%, sufficient in 19.5%, and excellent in 7.8% of the patients. The vitality and mental health subdimensions of the QoL were found to be statistically significantly better in participants with excellent, sufficient or problematic-limited HL compared to those with an inadequate level.

CONCLUSIONS

According to our results, the HL level of the majority of patients with SCI who are hospitalized in our hospital is low, and there is a relationship between HL and QoL. In conclusion, steps need to be taken to increase the HL levels of patients to improve their QoL, taking into account the important effect of HL on the QoL.

Triangulation of veteran and provider models of preventing community-acquired pressure injuries in spinal cord injury to reveal convergence and divergence of perspectives

CONTEXT/OBJECTIVE

Community-acquired pressure injuries (CAPrI) are a common and costly complication of spinal cord injury (SCI). The majority of PrIs occur in the community, but there is little guidance in CAPrI prevention. This study describes how provider and veteran perspectives of CAPrI prevention converge and diverge.

DESIGN

The Farmer triangulation method was used to compare two models from previous qualitative research describing provider and veteran perspectives of CAPrI prevention based on the framework of CAPrI risks, resources, and preventive activities. The previous qualitative research revealed the provider model of CAPrI prevention using semi-structured interviews with interprofessional SCI providers at the Veteran Health Administration (VA) (n = 30). A qualitative descriptive design using photovoice (n = 30) with or without guided tours (n = 15) revealed the Veteran model of CAPrI prevention.

SETTING

The previous qualitative research was conducted at three geographically different VA spinal cord injury/disorder centers in the United States (north, south, west).

PARTICIPANTS

30 interprofessional SCI providers; 30 Veterans living with SCI at three VA SCI Centers in the United States.

INTERVENTIONS

n/a.

OUTCOME MEASURES

Provider-Veteran perspectives of CAPrI prevention that demonstrated agreement, partial agreement, divergence, and silence.

RESULTS

Providers and veterans agreed on what is basic care, and the importance of family, caregiver and health provider/system supports, but they viewed motivation, veteran role, informal supports, and adequacy of supports differently.

CONCLUSION

Understanding how SCI providers and veterans living with SCI view prevention in the community informs how to promote preventive care in the context of veterans' lives.

Bladder Management Strategies for Urological Complications in Patients with Chronic Spinal Cord Injury

Neurogenic lower urinary tract dysfunction, common in patients with chronic spinal cord injury, inevitably results in urological complications. To address neurogenic lower urinary tract dysfunction after spinal cord injury, proper and adequate bladder management is important in spinal cord injury rehabilitation, with the goal and priorities of the protection of upper urinary tract function, maintaining continence, preserving lower urinary tract function, improvement of SCI patients' quality of life, achieving compatibility with patients' lifestyles, and decreasing urological complications. This concise review aims to help urologists address neurogenic lower urinary tract dysfunction by focusing on the risks of long-term urological complications and the effects of different bladder management strategies on these complications based on scientifically supported knowledge.

Lower extremity fracture prevention and management in persons with spinal cord injuries and disorders: The patient perspective

CONTEXT/OBJECTIVE

To describe patient experiences with fracture prevention and management among persons with spinal cord injuries/disorders (SCI/D).

DESIGN

Qualitative data collected via semi-structured telephone interviews.

SETTING

Veterans Health Administration (VA) SCI/D System of Care.

PARTICIPANTS

Veterans with SCI/D (n = 32) who had experienced at least one lower-extremity fracture in the prior 18 months.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Interview questions addressed patients': pre-fracture knowledge of osteoporosis and bone health, diagnosis and management of osteoporosis, history and experiences with fracture treatment, and post-fracture care and experiences.

RESULTS

Participants expressed concerns about bone health and fractures in particular, which for some, limited activities and participation. Participants recalled receiving little information from providers about bone health or osteoporosis and described little knowledge about osteoporosis prevention prior to their fracture. Few participants reported medication management for osteoporosis, however many reported receiving radiographs/scans to confirm a fracture and most reported being managed non-operatively. Some reported preference for surgical treatment and believed their outcomes would have been better had their fracture been managed differently. Many reported not feeling fully included in treatment decision-making. Some described decreased function, independence and/or participation post-fracture.

CONCLUSION(S)

Our results indicate that persons with SCI/D report lacking substantive knowledge about bone health and/or fracture prevention, and following fracture, feel unable and/or hesitant to resume pre-fracture participation. In addition, our findings indicate that individuals with SCI/D may not feel as engaged as they would like to be in establishing fracture treatment plans. As such, persons with SCI/D may benefit from ongoing discussions with providers about risks and benefits of fracture treatment options and consideration of subsequent function and participation, to ensure patients preferences are considered.

A Scoping Review of the Characteristics of Activity-based Therapy Interventions Across the Continuum of Care for People Living With Spinal Cord Injury or Disease

Objective

To identify the characteristics of activity-based therapy (ABT) that individuals with spinal cord injury and disease (SCI/D) participate in across the continuum of care.

Data Sources

A search of 8 databases was conducted from inception to 4 March 2020: Medline, CINAHL, Embase, Emcare, PEDro, APA PsycINFO, Cochrane Database of Systematic Reviews, and the CENTRAL. The search strategy used terms identifying the population (SCI/D) and concept (ABT).

Study Selection

Original studies involving individuals with SCI/D ≥16 years of age participating in ABT interventions for >1 session were included in the review. The Joanna Briggs Institute guidelines for scoping reviews were followed. The initial search produced 2306 records. Title, abstract, and full-text screening by 2 independent reviewers yielded 140 articles.

Data Extraction

Data extraction was conducted by 3 independent reviewers and charted according to key themes. Data fields included participant demographics, ABT interventions, exercises, parameters, technology, and setting. Data synthesis included frequency counts and descriptive analysis of key themes.

Data Synthesis

Eighty percent of participants were male. Eighty-seven percent of studies included individuals with tetraplegia (26% exclusive). Fifty-six percent of studies occurred in a research lab. Fifty-four percent of studies were single modality interventions encompassing the whole body (71%). Sixteen main types of ABT exercises were identified. The most common were treadmill training (59%), muscle strengthening (36%), and overground walking (33%). Electrical stimulation (50%) and virtual reality (6%) were used in combination with an ABT exercise. Eighty-four types of parameters were identified. Six were general intervention parameters and 78 were specific to the type of ABT exercise. Sixteen main categories of technology were reported. The most common were motorized treadmills (47%) and transcutaneous electrical stimulation (44%).

Conclusions

The characteristics of ABT are diverse in scope. The results will inform the content to include in tools that track ABT participation and performance.

Spinal Cord Injury Patient's Physical and Psychological Care Needs at Home from Patients’ and Caregivers’ Perspectives: A Qualitative Study

Background: Limited studies have attempted to identify the care needs of patients with spinal cord injury (SCI) and their professional caregivers at home and after discharge from the hospital. However, little information about these needs has led to increased physical and psychological complications and thus a reduced quality of life in SCI patients. Objectives: This study aimed to explain the experiences of patients and their caregivers regarding physical and psychological care needs at home. Method: This qualitative descriptive study was conducted on 24 SCI patients and their professional caregivers using the conventional content analysis. Data were collected through unstructured and semi-structured interviews. Purposeful sampling was continued until data saturation was reached. The conventional content analysis approach proposed by Graneheim and Lundman (continuous comparison) was used to analyze the data. Results: The age range of the participants was 29 - 48 years, with an average age of 37.8 years. Seven of the participants had paraplegia, and three of them had tetraplegia. The results of data analysis led to the extraction of two main categories, including physical and psychological care needs. Conclusions: By identifying the real needs of patients after discharge from the hospital, we emphasize the need to remove barriers to home health care services and provide more financial support to meet patients' needs. Therefore, policymakers are encouraged to use the results of this study to plan at-home patient care services.

Pressure Injuries and Management after Spinal Cord Injury

Spinal cord injury (SCI) results in motor paralysis and sensory loss that places individuals at particularly high risk of pressure injuries. Multiple comorbidities associated with autonomic, cardiovascular, pulmonary, endocrine, gastrointestinal, genitourinary, neurological, and musculoskeletal dysfunction makes it even more likely that pressure injuries will occur. This manuscript will review the structure and function of the integumentary system, and address the multidisciplinary approach required to prevent and manage pressure injuries in this vulnerable population.

Building and Sustaining Inpatient-Clinician Collaboration in Spinal Cord Injury Rehabilitation: A Case Example Using the Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) and Goal Planning Programme

Goal planning is core for the delivery of the biopsychosocial model of rehabilitation and is commonly practiced in spinal cord injury (SCI) and other physical health settings. Despite a strong theoretical basis from several branches of psychology, evidence regarding specific practice, interventions and impact has yet to be established, with no universal standards in this area. Study One outlines the standards used at the National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital since the inception of the SMS-NAC and goal planning programme in 1989. The results outline the impact of a quality improvement project undertaken since 2016 and track the interventions used to improve inpatient care. Study Two reports on an international survey of rehabilitation measure usage and goal planning practice with inpatient adult and children and young people (CYP) with SCI. Respondents replied that inpatient presence at goal planning meetings only took place in 75% (adult) and 76% (CYP) of services, with more services indicating 4 or more members of the multidisciplinary team being present (85% and 90%, respectively). This paper demonstrates the gains that can be made when a structured quality improvement methodology is used and highlights the need for standards regarding goal planning in SCI rehabilitation to be developed.

Empowerment, Communication, and Navigating Care: The Experience of Persons With Spinal Cord Injury From Acute Hospitalization to Inpatient Rehabilitation

Background

Spinal cord injury (SCI) results in long-term functional impairments that significantly impact participation and role in the community. Newly injured persons are often reintroduced to the community with significant deficits in knowledge, including how to access and navigate community resources and supports. This warrants a better understanding of the patient experience of in-hospital care and discharge planning to ensure individuals with SCI are best supported during transitions in care and while living in the community.

Objective

To explore the lived experience of persons with acute SCI and their perceptions of care, focusing on the initial hospital experiences to inpatient rehabilitation.

Methods

A phenomenological research study was conducted using semi-structured interviews. Eligible participants had differing etiologies of SCI (including non-traumatic and traumatic SCI), were over the age of 18 at the time of initial care, and experienced acute hospital and inpatient rehabilitation at an Alberta-based institution within the last 10 years. One-on-one interviews took place between March and June 2021 over telephone or virtual platforms (Zoom). Interview transcripts, and field notes developed the text, which underwent hermeneutic analysis to develop central themes.

Results

The present study included 10 participants living with an SCI in Alberta, Canada. Most participants (80%) were male. Participants' age ranged from 24 to 69 years. The median years since initial SCI was 3 years. Interviews lasted 45–75 min. Seven participants identified as having a traumatic SCI injury and three identified as having a non-traumatic SCI. The interplay between empowerment and disempowerment emerged as the core theme, permeating participants' meanings and perceptions. Three main themes emerged from the interviews regarding the perceptions of the SCI patient experience. Each theme represents a perception central to their inpatient experience: desire to enhance functional independence to empower confidence and self-management; need for effective communication with healthcare providers to support recovery; and navigating appropriate care supports to enhance preparedness for discharge and returning home.

Conclusion

This study demonstrates the significant need to enhance education of person/family-centered SCI care, foster positive communication between care recipients and care providers, and facilitate better in-hospital access to appropriate navigation and wayfinding supports.

Progression in translational research on spinal cord injury based on microenvironment imbalance

Spinal cord injury (SCI) leads to loss of motor and sensory function below the injury level and imposes a considerable burden on patients, families, and society. Repair of the injured spinal cord has been recognized as a global medical challenge for many years. Significant progress has been made in research on the pathological mechanism of spinal cord injury. In particular, with the development of gene regulation, cell sequencing, and cell tracing technologies, in-depth explorations of the SCI microenvironment have become more feasible. However, translational studies related to repair of the injured spinal cord have not yielded significant results. This review summarizes the latest research progress on two aspects of SCI pathology: intraneuronal microenvironment imbalance and regenerative microenvironment imbalance. We also review repair strategies for the injured spinal cord based on microenvironment imbalance, including medications, cell transplantation, exosomes, tissue engineering, cell reprogramming, and rehabilitation. The current state of translational research on SCI and future directions are also discussed. The development of a combined, precise, and multitemporal strategy for repairing the injured spinal cord is a potential future direction.

Preventative Services Use and Risk Reduction for Potentially Preventative Hospitalizations among People with Traumatic Spinal Cord Injury

OBJECTIVE

To examine the risk of potentially preventable hospitalizations (PPHs) for adults (18 years or older) with traumatic spinal cord injury (TSCI) to identify the most common types of preventable hospitalizations and their associative risk factors.

DESIGN

Cohort study.

SETTING

Using 2007-2017 U.S. claims data from the Optum Clinformatics Data Mart, we identified adults (18 years or older) with diagnosis of TSCI (n=5380). Adults without TSCI diagnosis were included as controls (n=1,074,729). Using age and sex, we matched individuals with and without TSCI (n=5173) with propensity scores to address potential selection bias. Generalized linear regression was applied to examine the risk of TSCI on PPHs. Models were adjusted for age; sex; race and ethnicity; Elixhauser comorbidity count; any cardiometabolic, psychological, and musculoskeletal chronic conditions; U.S. Census Division; socioeconomic variables; and use of certain preventative care services. Adjusted odds ratios were compared within a 4-year follow-up period.

PARTICIPANTS

Adults with and without TSCI (N=5,173).

INTERVENTION

Not applicable.

MAIN OUTCOMES MEASURES

Any PPH and specific PPHs RESULTS: Adults with TSCI had higher risk for any PPH (odds ratio [OR], 1.67; 95% CI,1.20-2.32), as well as PPHs because of urinary tract infection (UTI) (OR, 3.78; 95% CI, 2.47-5.79), hypertension (OR, 3.77; 95% CI, 1.54-9.21), diabetes long-term complications (OR, 2.54; 95% CI, 1.34-4.80), and pneumonia (OR, 1.71; 95% CI. 1.21-2.41). Annual wellness visit was associated with reduced PPH risk compared with cases and controls without annual wellness visit (OR, 0.57; 95% CI, 0.46-0.71) and among people with TSCI (OR, 0.69; 95% CI, 0.55-0.86) compared with cases without annual wellness visit.

CONCLUSIONS

Adults with TSCI are at a heightened risk for PPH. They are also more susceptible to certain PPHs such as UTIs, pneumonia, and heart failure. Encouraging the use of preventative or health-promoting services, especially for respiratory and urinary outcomes, may reduce PPHs among adults with TSCI.

Incidence, severity and time course of pressure injuries over the first two years following discharge from hospital in people with spinal cord injuries in Bangladesh

DESIGN

Cohort study embedded in a clinical trial.

SETTING

Community, Bangladesh.

OBJECTIVES

To determine the incidence, severity and time course of pressure injuries over the first two years following discharge from hospital in people with spinal cord injuries (SCI) in Bangladesh.

METHODS

Participants (n = 186) were contacted by telephone 39 times and assessed face-to-face 4 to 6 times over the two years following discharge. At each point of contact the presence and severity of pressure injuries were determined using the Pressure Ulcer Scale for Healing (PUSH). Survival analyses were conducted to determine the time course of development of pressure injuries and recovery from pressure injuries. Lasso regression was used to construct multivariable prediction models.

RESULTS

Seventy-seven participants (41%; 95% CI 34% to 49%) developed at least one pressure injury in the first two years after discharge (incidence rate 0.27 per person-year, 95% CI 0.22 to 0.34). Most pressure injuries were on the sacrum (23%). Pressure injuries took a median (IQR) of 40 (29 to 57) days to heal. The median (IQR) peak PUSH score was 11.0/17 (8.0 to 13.5). The multivariable prediction models had poor predictive properties (maximum c-statistic 0.75).

CONCLUSION

Pressure injuries impose a large health burden on people with SCI in Bangladesh. However, they are difficult to predict, treat and prevent. Further research is needed to identify who is at most risk and to find solutions for the treatment and prevention of pressure injuries in Bangladesh and other low-middle income countries.

Systematic Review of Incidence Studies of Pneumonia in Persons with Spinal Cord Injury

Pneumonia continues to complicate the course of spinal cord injury (SCI). Currently, clinicians and policy-makers are faced with only limited numbers of pneumonia incidence in the literature. A systematic review of the literature was undertaken to provide an objective synthesis of the evidence about the incidence of pneumonia in persons with SCI. Incidence was calculated per 100 person-days, and meta-regression was used to evaluate the influence of the clinical setting, the level of injury, the use of mechanical ventilation, the presence of tracheostomy, and dysphagia. For the meta-regression we included 19 studies. The incidence ranged from 0.03 to 7.21 patients with pneumonia per 100 days. The main finding of this review is that we found large heterogeneity in the reporting of the incidence, and we therefore should be cautious with interpreting the results. In the multivariable meta-regression, the incidence rate ratios showed very wide confidence intervals, which does not allow a clear conclusion concerning the risk of pneumonia in the different stages after a SCI. Large longitudinal studies with a standardized reporting on risk factors, pneumonia, and detailed time under observation are needed. Nevertheless, this review showed that pneumonia is still a clinically relevant complication and pneumonia prevention should focus on the ICU setting and patients with complete tetraplegia.

Timing and pattern of readmission in individuals with spinal cord injury in the setting of a specialized medical home

BACKGROUND

The rate of readmission in individuals with spinal cord injury (SCI) is known to be high (28% to 45%) during the first year post-injury and post-rehabilitation. However, there are several critical gaps in our knowledge including the timing pattern of medical complications and the pattern of health complications associated with readmissions.

OBJECTIVE

To identify the timing and pattern of complications associated with hospital readmissions in individuals with traumatic SCI and non-traumatic spinal cord disorders (SCI) post-discharge from an inpatient rehabilitation facility (IRF).

DESIGN

Secondary analysis of a three year prospective cohort study.

SETTING

An SCI medical home.

PARTICIPANTS

Individuals who were readmitted (n = 53) within the first year (N = 176) post-discharge from an IRF.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Timing and pattern of all-cause hospital readmissions.

RESULTS

Eighty one percent of the readmitted patients experienced readmission within the first six months after discharge, and 36% of the initial readmissions occurred within 30 days of discharge from an IRF. The trend line for the timing of the first readmission post-discharge from an IRF was curvilinear, with a sharp decrease in the number of new patients readmitted for months 1-7 and then a slight increase between 9 and 12 months. Urological and respiratory complications were related to repeat readmissions.

CONCLUSION

The patient is at the greatest risk of readmission in the first 6 months, with a secondary increase in risk at 9 months. Possible reasons may include reduction in in-home and outpatient therapy and skilled nursing over the first year post-SCI.

Validity of the Urinary Symptom Questionnaires for people with neurogenic bladder (USQNB) who void or use indwelling catheters

STUDY DESIGN

Descriptive Psychometrics Study OBJECTIVES: Neurogenic lower urinary tract dysfunction (NLUTD), or "neurogenic bladder" is a common and disruptive condition for individuals with spinal cord injury (SCI) and disease (including multiple sclerosis, MS). Our team has developed patient-centered instruments of urinary symptoms specific to patients with NLUTD, across bladder management methods. Validity evidence is needed to support the use of two new instruments, Urinary Symptom Questionnaires for people with Neurogenic Bladder (USQNB) for those who manage their bladder with indwelling catheters (IDC), or who void (V).

SETTING

Online surveys completed by individuals in the United States with NLUTD due to either SCI or MS who manage their bladder with indwelling catheters (SCI, n = 306; MS, n = 8), or by voiding (SCI, n = 103; MS, n = 383). A total of n = 381 USQNB-IDC respondents (five control groups), and 351 USQNB-V respondents (four control groups), contributed to our convergent and divergent validity evidence.

METHODS

Data were collected online to estimate key aspects of psychometric validity (content, reflection of the construct to be measured; face, recognizability of the contents as representing the construct to be measured; structural, the extent to which the instrument captures recognizable dimensions of the construct to be measured). Divergent and convergent validity evidence was derived from multiple control groups, while evidence of criterion validity was derived from attribution of each item to their experience "with a UTI".

RESULTS

Evidence of face, content, criterion, convergent, and divergent validity was compiled for each instrument.

CONCLUSIONS

The instruments demonstrate adequate, multi-dimensional, validity evidence to recommend their use for decision-making by patients, clinicians, and researchers.

The Stockholm Spinal Cord Uro Study: 3. Urodynamic characteristics in a regional prevalence group of persons with spinal cord injury and indications for improved follow-up

AIMS

Examine the outcome of urodynamic studies in a regional prevalence group of patients with traumatic spinal cord injury (SCI), explore relationships between urodynamic parameters and renal complications/other SCI-related dysfunctions, assess the role of urodynamics in SCI follow-up.

METHODS

In a cross-sectional study, 211 patients were included, who attended a yearly check-up and had urodynamics performed as part of the follow-up in addition to S-creatinine, S-cystatin-C, renal ultrasound, and a questionnaire regarding complications. Relationships between urodynamic parameters and renal complications/other SCI-related dysfunctions were explored by descriptive and comparative statistics.

RESULTS

Neurogenic detrusor overactivity (NDO) was found in 150, underactive/acontractile detrusor in 44, normal detrusor function in 17 patients. Maximum detrusor pressures during filling/voiding in NDO attained mean levels of >40 cm H₂O in 68% of patients and >25 cm H₂O in 83%. Reduced compliance of the bladder wall, cystometric bladder capacity <250 mL, and detrusor overactivity leakage during filling were associated with higher detrusor pressures. Detrusor overactivity during more than one-third of the filling phase was significantly related to signs of renal complications among patients with SCI duration 11-20 years. No significant relationships were found between other urodynamic parameters and renal/other SCI-related complications. Renal complications in underactive/acontractile and normal detrusor function co-varied with evidence of previous NDO and other co-morbidities which may negatively influence kidney function.

CONCLUSIONS

Maximum detrusor pressures during the filling/voiding phases attained high levels in a majority of patients. Detrusor overactivity during more than one-third of the filling phase was significantly related to signs of renal complications.

The impact of body mass index on one-year mortality after spinal cord injury

Objective: Evaluate the association between body mass index (BMI, kg/m²) and one-year mortality among people who survived the first 90 days after spinal cord injury (SCI).Design: Cohort study.Setting: Eighteen SCI Model Systems centers throughout the United States.Participants: 6640 participants (men, 79.6%; mean age, 42.8 ± 17.7y; Whites, 62.3%) who had an SCI between October 2006 and March 2017.Interventions: Not applicable.Outcome Measures: All-cause mortality and causes of death. Life table method was used to estimate mortality rates, while Cox proportional hazard model was conducted to assess the impact of BMI on mortality after adjusting for demographic and injury-related factors.Results: Based on BMI obtained during initial rehabilitation, participants were classified into underweight (4.2%), normal weight (41.2%), overweight (30.9%) and obese (23.8%) groups, and their corresponding one-year mortality rates were 2.6%, 1.8%, 3.1%, 3.5%, respectively (P = 0.002). After adjusting for potential confounding factors, people with obesity had a higher mortality risk than those with normal weight (hazard ratio, 1.51; 95% confidence interval, 1.00-2.28). The most frequent causes of death for people with obesity were infective and parasitic diseases and respiratory diseases, while respiratory diseases were the most frequent for people with other BMI statuses.Conclusion: People with obesity who incur an SCI need special attention to prevent early mortality. Future studies should explore factors that contribute to such a higher mortality after SCI, such as preexisting conditions and comorbidities. The effects of BMI on long-term mortality also deserve further investigation.

Study on the characteristics of microcirculation in the site of pressure ulcer in patients with spinal cord injury

To investigate the characteristics of pressure ulcer microcirculation in SCI patients with pressure ulcer, and to provide evidence for the treatment of pressure ulcer in patients with SCI. Group 1 (n = 12) SCI patients with pressure ulcer, 23 pressure ulcers were included. Group 2 (n = 15) SCI patients without pressure ulcer and the control group (n = 16) healthy adults. The application of laser Doppler perfusion imaging system (Moor FLPI) detector to the microcirculation perfusion of the sacrum area of the control group, the observation group 2 and the pressure ulcer site of the observation group 1, record the microcirculation perfusion (PU), The data of microcirculation perfusion (PU) were compared and analyzed. The correlation between microcirculation perfusion and healing time of pressure ulcer was analyzed. (1) The microcirculation perfusion was highest in the pressure ulcer center. (2) SCI patients and healthy adults had no significant difference of microcirculation perfusion at sacrococcygeal skin. (3) The lower the microcirculation perfusion of the pressure ulcer center, the longer the healing time of pressure ulcer. The healing time and the microcirculation perfusion of pressure ulcer center was negatively correlated. Microcirculation perfusion detection is a noninvasive and effective method for the determination of the scope of pressure ulcer, detection and direction judgment of pressure ulcer sinus tract, monitoring and guidance of pressure ulcer treatment, and prediction of the healing time of pressure ulcer.

Protocol-Specific Effects of Intermittent Hypoxia Pre-Conditioning on Phrenic Motor Plasticity in Rats with Chronic Cervical Spinal Cord Injury

"Low-dose" acute intermittent hypoxia (AIH; 3-15 episodes/day) is emerging as a promising therapeutic strategy to improve motor function after incomplete cervical spinal cord injury (cSCI). Conversely, chronic "high-dose" intermittent hypoxia (CIH; > 80-100 episodes/day) elicits multi-system pathology and is a hallmark of sleep apnea, a condition highly prevalent in individuals with cSCI. Whereas daily AIH (dAIH) enhances phrenic motor plasticity in intact rats, it is abolished by CIH. However, there have been no direct comparisons of prolonged dAIH versus CIH on phrenic motor outcomes after chronic cSCI. Thus, phrenic nerve activity and AIH-induced phrenic long-term facilitation (pLTF) were assessed in anesthetized rats. Experimental groups included: 1) intact rats exposed to 28 days of normoxia (Nx28; 21% O2; 8 h/day), and three groups with chronic C2 hemisection (C2Hx) exposed to either: 2) Nx28; 3) dAIH (dAIH28; 10, 5-min episodes of 10.5% O2/day; 5-min intervals); or 4) CIH (IH28-2/2; 2-min episodes; 2-min intervals; 8 h/day). Baseline ipsilateral phrenic nerve activity was reduced in injured versus intact rats but unaffected by dAIH28 or IH28-2/2. There were no group differences in contralateral phrenic activity. pLTF was enhanced bilaterally by dAIH28 versus Nx28 but unaffected by IH28-2/2. Whereas dAIH28 enhanced pLTF after cSCI, it did not improve baseline phrenic output. In contrast, unlike shorter protocols in intact rats, CIH28-2/2 did not abolish pLTF in chronic C2Hx. Mechanisms of differential responses to dAIH versus CIH are not yet known, particularly in the context of cSCI. Further, it remains unclear whether enhanced phrenic motor plasticity can improve breathing after cSCI.

Traumatic spinal cord injury caused by low falls and high falls: a comparative study

BACKGROUND

Quite a few traumatic spinal cord injuries (TSCI) were caused by falls. However, the comparison of different causes of TSCI or the epidemiological characteristics of TSCI caused by falls of different heights are rare. This study investigated the epidemiological characteristics of TSCI caused by falls and conducted a comparison between low falls and high falls.

METHOD

Data from cases with TSCI admitted to China Rehabilitation Research Center from 2010 to 2019 were collected, including age, gender, occupation, cause, neurological level, and severity of the injury in admission, combined injuries, complications, and rehabilitation length of stay. Mann-Whitney U and chi-square (χ2) tests were used to assess the differences between two groups at a statistical significance level of 0.05.

RESULT

A total of 1858 TSCI cases were included and 41.7% were caused by falls, 11.4% by low falls and 30.3% by high falls, respectively. Patients with fall-induced TSCI were older and had a shorter rehabilitation length of stay than those with non-fall-induced TSCI. Patients with high fall-induced TSCI were younger and more likely to suffer from paraplegia, severer injuries, and combined injuries, and had longer time from injury to rehabilitation and rehabilitation length of stay, compared with patients with low fall-induced TSCI.

CONCLUSION

Falls is the leading causes of TSCI and high fall is becoming more common. Attention not only should be paid to high falls for the severe injury and longer hospitalization, but also low falls due to the higher neurological level of the injury and the aging of population in China.

Guideline No. 416: Labour, Delivery, and Postpartum Care for People with Physical Disabilities

OBJECTIVE

To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada.

TARGET POPULATION

This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline.

OUTCOMES

Safe and compassionate care for people with physical disabilities who are giving birth.

BENEFITS, HARMS, AND COSTS

Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth.

EVIDENCE

A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Maternal-fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities.

RECOMMENDATIONS

Excretory dysfunction and quality of life after a spinal cord injury: A cross-sectional study

AIMS AND OBJECTIVES

To determine the aspects of excretory dysfunction most influential in determining the quality of life of survivors of spinal cord injury.

BACKGROUND

Excretory dysfunction is one of the most common and troublesome sequelae of spinal cord injury. Previous studies have shown that it can restrict social participation restriction, cause readmission and generally influence quality of life substantially.

DESIGN

A cross-sectional survey of hospital inpatients following STOBE guidelines.

METHODS

A convenience sample of 101 patients with traumatic or non-traumatic spinal cord injury were asked about their experiences of excretory dysfunction, and management and their self-perceived quality of life. Univariate analysis and multiple linear regression were performed to isolate the most important relationships.

RESULTS

Only 2 of the 101 subjects professed to be unaffected by excretion dysfunction. Bladder-related dysfunction was the most frequently mentioned type of problem. Quality of life impairment was found to be most often associated with bladder accidents, bowel accidents and having more than one bladder complications.

CONCLUSIONS

Excretory dysfunction substantially impacts quality of life after a spinal cord injury. Bladder accidents, bowel accidents and more than one bladder complication are factors independently influencing the quality of life of spinal cord injury survivors.

RELEVANCE TO CLINICAL PRACTICE

To improve excretion-related QOL, patients' bladder and bowel self-management training should be strengthened seeking to prevent complications and reduce the risk of bladder and bowel accidents.

Effects of 16-Form Wheelchair Tai Chi on the Autonomic Nervous System among Patients with Spinal Cord Injury

Objective

This study aims to investigate the effects of 16-form Wheelchair Tai Chi (WCTC16) on the autonomic nervous system among patients with spinal cord injury (SCI).

Methods

Twenty patients with chronic complete thoracic SCI were recruited. Equivital life monitoring system was used to record and analyze heart rate variability (HRV) of patients for five minutes before and after five consecutive sets of WCTC16, respectively. The analysis of HRV in the time domain included RR intervals, the standard deviation of all normal RR intervals (SDNN), and the root mean square of the differences between adjacent NN intervals (RMSSD). The analysis of HRV in the frequency domain included total power (TP), which could be divided into very-low-frequency area (VLFP), low-frequency area (LFP), and high-frequency area (HFP). The LF/HF ratio as well as the normalized units of LFP (LFPnu) and HFP (HFPnu) reflected the sympathovagal balance.

Results

There was no significant difference in RR interval, SDNN, RMSSD, TP, HEP, VLFP, and LFP of SCI patients before and after WCTC16 exercise (P > 0.05). LFPnu and HF peak decreased, while HFPnu and LF/HF increased in SCI patients after WCTC16 exercise. The differences were statistically significant (P < 0.001).

Conclusion

WCTC16 can enhance vagal activity and decrease sympathetic activity so that patients with chronic complete thoracic SCI can achieve the balanced sympathovagal tone.

The journey of sexuality after spinal cord injury: Implications for allied health professionals

The purpose of this phenomenological study, which reflected the lived experiences of seven individuals living in Alberta with spinal cord injury (SCI), was to gain insights into how individuals with SCI (a) are ill-equipped after injury with respect to post-injury sexual function education, (b) explore their sexuality after injury, (c) learn about the importance of role models and friends living with similar injuries, and (d) explain barriers to access reasonable care surrounding sexual health and counselling reflective of intersectionality of sexuality and disability, among other factors. The intent is also to provide a basis for others living with SCI to be aware that they are not alone in their experiences as well as inform others, including professionals working in the area of SCI, of what some experiences of living with SCI are. This study uncovered real lived experiences of individuals with SCI and their experience of sexuality and relationships after injury. Recommendations are highlighted with the intention of informing professionals, including counselling psychologists and other health related professionals.

Mortality and secondary complications four years after traumatic spinal cord injury in Cape Town, South Africa

STUDY DESIGN

A prospective, regional, population-based study.

OBJECTIVES

(1) Determine the mortality rate and factors associated with it 4 years after a TSCI and (2) The point prevalence of secondary medical complications of survivors at 4 years.

SETTING

Communities of the Cape metropolitan area, South Africa.

METHODS

All persons (n = 145) sustaining a TSCI from 15 September 2013 to 14 September 2014 were eligible for follow-up at 4 years. Participants were contacted after 4 years. The next of kin, via verbal autopsy, was used to establish cause of death. Those who were alive at 4 years were asked to indicate any secondary medical complications. Logistic regression techniques were used to identify independently associated risk indicators for death and development of secondary complications, respectively.

RESULTS

Of the initial 145 persons, 87 were included and accounted for. Of these, 21 (24%) had died, 55 (63%) were alive and completed the survey, and 11 (13%) were classified as alive but did not submit the survey. The main cause of death reported was septicaemia (n = 7; 33%), followed by unknown natural causes (n = 7; 33%), then pressure injuries (n = 5; 24%). Out of the 55 persons alive, 89% had at least one medical complication at the time of enquiry, while more than 50% experienced 6 or more complications. The most common complications were pain (80%), muscle spasms (76%), sleeping problems (56%), and bladder dysfunction (44%).

CONCLUSIONS

Almost one-quarter of persons with TSCI have died 4 years after injury. Also, secondary complications were found to be highly prevalent at 4 years. This information could be used to develop secondary complications prevention programmes to reduce premature deaths.

SPONSORSHIP

This study was funded by the Medical Research Council of South Africa within the Research Capacity Development Initiative.

Life satisfaction in persons with spinal cord injury across the seasons

STUDY DESIGN

Longitudinal study.

OBJECTIVES

This study aimed to examine level and variations of life satisfaction (LS) across the seasons in persons with spinal cord injury (SCI).

SETTING

Polish sample of persons with SCI.

METHODS

The study included 56 persons with SCI, who repeatedly completed the Life Satisfaction Questionnaire (LiSaT-9), and a study-specific questionnaire across the four seasons in a calendar year. Mixed model analyses were performed to: (1) examine seasonal changes in LS; (2) explore the possible moderating factors on seasonal changes in LS.

RESULTS

There were significant seasonal trends in overall and domain-specific LS scores; yet, these changes differed in terms of shape (i.e. linear vs. quadratic). In general, the highest LS scores occurred in spring across all domains, followed by a significant reduction in summer; yet, there were u-shape trends in LS domain scores for life as a whole, vocational, and financial situation and partner relations (P-for-quadratic trends ≤0.05). Five individual characteristics, i.e. place of living, education, gender, physical activity, and time since injury significantly moderated seasonal trends in LS scores (P's for interaction ≤ 0.05).

CONCLUSION

Life satisfaction in persons with SCI differs significantly in relation to different seasons throughout a year. The season of the year should be considered in future studies on LS and included in evaluating and projecting healthcare interventions or programs for persons with SCI.

Characteristics of activity-based therapy interventions for people living with spinal cord injury or disease across the continuum of care: a scoping review protocol

INTRODUCTION

Individuals living with spinal cord injury and disease (SCI/D) experience sensory and motor impairments below their neurological level of injury. Activity-based therapies (ABT) are interventions that provide activation of the neuromuscular system below the level of lesion with the goal of retraining the nervous system to recover a specific motor task. ABT can lead to increased function and improved quality of life; however, research and clinical settings currently lack tools to track participation in ABT. As a first step towards developing such a tool, a scoping review will be conducted with the objective of identifying the characteristics of ABT that individuals with SCI/D participate in across the continuum of care.

METHODS AND ANALYSIS

The review will follow the Joanna Briggs Institute scoping review framework. Studies that involve at least two sessions of ABT for individuals with SCI/D aged ≥16 years will be included. Seven databases were searched from their inception to 4 March 2020: Medline, Embase, Emcare, Cumulative Index to Nursing and Allied Health Literature, APA PsycINFO, Physiotherapy Evidence Database, Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials. The search will be rerun in November 2020 prior to manuscript submission. Screening of titles and abstracts will be followed by a review of full texts to identify articles meeting inclusion criteria. Stakeholders will be consulted for the creation of the data extraction table. The Downs and Black Checklist or the Mixed Methods Appraisal Tool will be used to assess article quality. Results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review. Study findings will be shared with key stakeholder groups through academic, clinical and public venues.

The Relationship Between Psychological and Physical Secondary Conditions and Family Caregiver Burden in Spinal Cord Injury: A Correlational Study

Background: Caregiver burden (CB) is a consequence of providing care to people with spinal cord injury (SCI). However, there is a lack of clarity about the influence of secondary conditions of care recipients on family caregivers. Secondary conditions refer to the physical and psychological complications that can occur after SCI and lead to increased hospitalization and reduced functionality, quality of life, and social participation. Objective: To assess the impact of physical and psychological secondary conditions of people with SCI on the perceived burden of family caregivers. Methods: A multicenter, cross-sectional study of 56 dyads of family caregivers and individuals with SCI in two urban spinal units in Italy and Ireland. Care recipients completed a toolset consisting of demographic information and assessments of functional, physical, and psychological health. Caregivers completed a multidimensional measure of CB. Bivariate data analysis was used. Results: No significant differences between centers were identified. CB was found to be related to physical secondary conditions and functional independence but not to mental health of care recipients. Bladder dysfunction and urinary tract infections influenced all dimensions of CB, whereas pressure injuries influenced only the time-dependent dimension. Level and completeness of injury and duration of caregiving increased CB. Conclusion: Findings indicate the value of a reduction in secondary conditions not just for individuals with SCI but also for their family caregivers. To reduce the individual and family burden of secondary conditions, a two-pronged, multidimensional approach, focusing on self-management for care recipients and psychoeducational support for caregivers, is required.

Engaging in the prevention of pressure injuries in spinal cord injury: A qualitative study of community-dwelling individuals' different styles of prevention in Switzerland

Context: Spinal cord injury (SCI) is a complex chronic condition with multiple self-management requirements and a high prevalence of complications. Pressure injuries (PIs) are among the most common ones and represent a frequent reason for re-hospitalization. This study aimed to identify styles of prevention that individuals with SCI adopt to deal with the risk of developing PIs.Design: Qualitative explorative interview study. Data was collected through semi-structured interviews, which were transcribed verbatim and analyzed following the principles of thematic analysis.Setting: Switzerland.Participants: The participants were a purposive sample of community-dwelling Swiss residents with SCI for at least five years.Interventions: Not applicable.Outcome measures: Not applicable.Results: Although all participants (N = 20) showed at least a basic knowledge of prevention of PIs by describing some preventive measures, they had different prevention styles characterized by different behavioral patterns (i.e. complying with all recommended measures, performing only a selection of them or delegating them to others) and different beliefs and attitudes towards prevention.Conclusion: By identifying the style of prevention of an individual, it is possible to develop tailored interventions that have an impact on the factors which seem to play a role in determining the adoption of preventive behaviors (i.e. perceived susceptibility to PIs, attitudes towards prevention, and self-efficacy). Such interventions would constitute a concrete effort to support individuals with SCI during their self-management. Besides alleviating a frequent and disabling medical complication and contributing to an enhanced quality of life, these interventions might also help decrease healthcare costs.

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

The Role of Vacuum Assisted Closure in Patients with Pressure Ulcer and Spinal Cord Injury: A Systematic Review

BACKGROUND

Patients with spinal cord injury (SCI) tend to develop pressure ulcers (PrUs) because of prolonged immobility. This study assessed the efficacy of vacuum assisted closure for healing of PrUs in individuals with SCI.

METHODS

In a systematic review, CINAHL, PubMed, Cochrane Clinical Trials, DARE, MEDLINE, Scopus, Embase, Science Direct, PsycInfo and Spinal Cord Journal were searched in March 2019. The search combined related terms for pressure ulcer, spinal cord injury, and vacuum assisted closure. Each database was searched from its inception with no restrictions on year of publication.

RESULTS

The search yielded 7 studies for inclusion in a qualitative analysis. The studies included a variety of methodologies, specifically 2 randomized controlled trials, 2 assessor-blinded crossover and retrospective cohort study, 1 prospective non-randomized trial, 1 randomized case study and 1 case report. The meta-analysis was unsuccessful. Only descriptive results mean±SD were reported as well as time to heal and time to discharge after admission.

CONCLUSION

The studies that we included in our qualitative synthesis showed that vacuum assisted closure promoted the healing of PrUs in individuals with SCI.

Differentiation of human adipose-derived stem cells into neuron/motoneuron-like cells for cell replacement therapy of spinal cord injury

Human adipose-derived stem cells (hADSCs) are increasingly presumed to be a prospective stem cell source for cell replacement therapy in various degenerative and/or traumatic diseases. The potential of trans-differentiating hADSCs into motor neuron cells indisputably provides an alternative way for spinal cord injury (SCI) treatment. In the present study, a stepwise and efficient hADSC trans-differentiation protocol with retinoic acid (RA), sonic hedgehog (SHH), and neurotrophic factors were developed. With this protocol hADSCs could be converted into electrophysiologically active motoneuron-like cells (hADSC-MNs), which expressed both a cohort of pan neuronal markers and motor neuron specific markers. Moreover, after being primed for neuronal differentiation with RA/SHH, hADSCs were transplanted into SCI mouse model and they survived, migrated, and integrated into injured site and led to partial functional recovery of SCI mice. When ablating the transplanted hADSC-MNs harboring HSV-TK-mCherry overexpression system with antivirial Ganciclovir (GCV), functional relapse was detected by motor-evoked potential (MEP) and BMS assays, implying that transplanted hADSC-MNs participated in rebuilding the neural circuits, which was further confirmed by retrograde neuronal tracing system (WGA). GFP-labeled hADSC-MNs were subjected to whole-cell patch-clamp recording in acute spinal cord slice preparation and both action potentials and synaptic activities were recorded, which further confirmed that those pre-conditioned hADSCs indeed became functionally active neurons in vivo. As well, transplanted hADSC-MNs largely prevented the formation of injury-induced cavities and exerted obvious immune-suppression effect as revealed by preventing astrocyte reactivation and favoring the secretion of a spectrum of anti-inflammatory cytokines and chemokines. Our work suggests that hADSCs can be readily transformed into MNs in vitro, and stay viable in spinal cord of the SCI mouse and exert multi-therapeutic effects by rebuilding the broken circuitry and optimizing the microenvironment through immunosuppression.

Caring for Patients With Physical Disabilities: Assessment of an Innovative Spinal Cord Injury Session That Addresses an Educational Gap

Despite the fact that one fifth of Americans live with disability, caring for these patients is not routinely part of the undergraduate medical student curriculum. An innovative session addressing care of patients with spinal cord injury was developed for medical students and led by physiatrists, faculty experts in communications, and individuals with spinal cord injury. A mixed-method design was used in evaluating students' knowledge, skills, and attitudes following this curriculum. Quantitative evaluation was performed with a written essay question and checklist items from an objective structured clinical examination station. The session was given to 296 students from 2016 to 2018. On the objective structured clinical examination, 94% asked about sexual function, 85% asked about activities of daily living, 77% asked about instrumental activities of daily living, and 47% of students evaluated skin health. Students demonstrated respectful (99%) and nonjudgmental (99%) attitudes with spinal cord injury standardized patients and 91% interacted with the standardized patients caretaker appropriately. Themes emerged from the student survey including the following: the value of having real patients present during the session, exposure to physical medicine and rehabilitation as a specialty, and the advantage of a small group format. This session provided students with tools necessary to care for patients with spinal cord injury.

Malignant Melanotic Schwannian Tumor Presenting with Spinal Cord Infarction Due to Occlusion of the Artery of Adamkiewicz: Case Report and Review of the Literature

BACKGROUND

Malignant melanotic schwannian tumors (MMSTs) are rare peripheral nerve sheath tumors that typically exhibit benign clinical presentation and histopathology but malignant long-term behavior.

CASE DESCRIPTION

We report a case of a 22-year-old male with a T9-11 MMST who presented with acute paraplegia and complete loss of sacral function. Despite emergent decompression, he did not recover motor, sensory or bladder function, although bowel function did normalize.

CONCLUSIONS

The anatomic location and rapid presentation of permanent deficits are suggestive of infarction of the spinal cord supplied by the artery of Adamkiewicz, a rare presentation of this disorder and of spinal schwannomas in general.