History, implementation, and current status of the National Spinal Cord Injury Database

Multivariable Prediction Models for Traumatic Spinal Cord Injury: A Systematic Review

Background

Traumatic spinal cord injuries (TSCI) greatly affect the lives of patients and their families. Prognostication may improve treatment strategies, health care resource allocation, and counseling. Multivariable clinical prediction models (CPMs) for prognosis are tools that can estimate an absolute risk or probability that an outcome will occur.

Objectives

We sought to systematically review the existing literature on CPMs for TSCI and critically examine the predictor selection methods used.

Methods

We searched MEDLINE, PubMed, Embase, Scopus, and IEEE for English peer-reviewed studies and relevant references that developed multivariable CPMs to prognosticate patient-centered outcomes in adults with TSCI. Using narrative synthesis, we summarized the characteristics of the included studies and their CPMs, focusing on the predictor selection process.

Results

We screened 663 titles and abstracts; of these, 21 full-text studies (2009-2020) consisting of 33 distinct CPMs were included. The data analysis domain was most commonly at a high risk of bias when assessed for methodological quality. Model presentation formats were inconsistently included with published CPMs; only two studies followed established guidelines for transparent reporting of multivariable prediction models. Authors frequently cited previous literature for their initial selection of predictors, and stepwise selection was the most frequent predictor selection method during modelling.

Conclusion

Prediction modelling studies for TSCI serve clinicians who counsel patients, researchers aiming to risk-stratify participants for clinical trials, and patients coping with their injury. Poor methodological rigor in data analysis, inconsistent transparent reporting, and a lack of model presentation formats are vital areas for improvement in TSCI CPM research.

Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care

Only 100 years ago, traumatic spinal cord injury (SCI) was commonly lethal. Today, most people who sustain SCI survive with continual efforts to improve their quality of life and neurological outcomes. SCI epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. Early treatment has become more intensive with decompressive surgery and proactive interventions to improve spinal cord perfusion. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries. We review four registry networks: the North American Clinical Trials Network (NACTN) SCI Registry, the National Spinal Cord Injury Model Systems (SCIMS) Database, the Rick Hansen SCI Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury (EMSCI). We compare the registries' focuses, data platforms, advanced analytics use, and impacts. We also describe how registries' data can be combined with electronic health records (EHRs) or shared using federated analysis to protect registrants' identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes such as early decompression. They've also revealed latent disease-modifying factors, helped develop clinical trial stratification models, and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science.

Early Predictors and Outcomes of American Spinal Injury Association Conversion at Discharge in Surgical and Nonsurgical Management of Sports-Related Spinal Cord Injury

OBJECTIVE

This study aims to evaluate the rate of improvement in neurologic recovery of patients with sports-related spinal cord injury (SRSCI) who had surgical intervention (SS) and those who did not (NSS). We aimed to 1) evaluate the rate of American Spinal Injury Association (ASIA) conversion in patients with and without surgery, and 2) assess predictors of conversion in ASIA grade.

METHODS

The National Spinal Cord Injury Model Systems Database (SCIMS) was used from 1973 to 2016. Patients with SRSCI were included. The primary outcome was rate of conversion in ASIA grade. Multivariate logistic regression was performed with separate subgroup analysis on patients with cervical injury (represented by odds ratio [OR]; 95% confidence interval [CI]).

RESULTS

A total of 1647 patients had SRSCI with 1502 (91%) SSs. Most patients (88%) were male, white (87%), and between the ages of 15 and 29 years (63%). Patients undergoing SS had significantly longer inpatient rehabilitation length of stay (LOS) (P < 0.001) and a more patients undergoing SS had complete motor or sensory loss compared with the NSS group. Multivariate logistic regression showed that injury at the thoracic level (OR, 0.41; 95% CI, 0.21-0.78), age 15-29 years (OR, 0.44; 95% CI, 0.20-0.97]), water-based injury (OR, 0.45; 95% CI, 0.21-0.95), and ASIA impairment grades of B, C, and D at admission were significantly associated with ASIA SCORE conversion.

CONCLUSIONS

We found that patients undergoing SS had longer LOS and a higher prevalence of complete injuries. Surgical intervention was not associated with conversion in ASIA grade to an improved status at time of discharge in a large cohort of patients with SRSCI and in a subcohort of patients with cervical SRSCI.

Colorectal cancer mortality after spinal cord injury

Context: Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the US. There is paucity of data regarding CRC and the spinal cord injury (SCI) community. Persons with SCI have suboptimal rates of colonoscopies and face extensive barriers to care. The aim of our study was to compare CRC mortality in persons with SCI to CRC mortality in the general population.Design: A prospective follow-up study.Setting: Analysis of the National SCI database.Participants: 54,965 persons with SCI.Interventions: Not applicable.Outcome Measures: Current survival status and causes of death were determined. The expected number of CRC deaths was calculated for the general US population, using ICD-10 codes. Standardized mortality ratios (SMR) were calculated as the ratio of observed to expected CRC deaths stratified by current age, sex, race, time post-injury and neurologic group.Results: The CRC mortality was 146 persons out of 54,965 persons with SCI. The overall SMR was determined to be 1.11 (95% CI [0.94, 1.31]). Among subgroups, one finding was significant and this was for patients with injury level C1-4 with an American Spinal Injury Association Impairment Scale Grade of A, B or C with an SMR of 1.68 ([95% CI [1.03-2.61]).Conclusion: Although persons with SCI receive suboptimal rates of preventative care screenings and report extensive barriers to care, overall, they are not at an increased risk of CRC mortality. The current recommendations for CRC screening should be continued for these individuals while reducing barriers to care.

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.

Longitudinal Trends and Prevalence of Bowel Management in Individuals With Spinal Cord Injury

Background: Neurogenic bowel dysfunction (NBD) following spinal cord injury (SCI) represents a major source of morbidity, negatively impacting quality of life and overall independence. The long-term changes in bowel care needs are not well-reported, preventing consensus on the natural course and optimal management of NBD following injury. Objectives: To understand the changes in bowel management needs over time following SCI. Methods: A retrospective observational study using the National Spinal Cord Injury Model Systems database evaluated the degree of independence with bowel management at discharge from inpatient rehabilitation across time (1988-2016). The prevalence and consecutive trajectory of bowel management was also evaluated at discharge and at each 5-year follow-up period, for 25 years. Results: The majority of individuals discharged from inpatient rehabilitation (n = 17,492) required total assistance with bowel management, a trend that significantly increased over time. However, by 5-years post injury, there was a significant shift in bowel management needs from total assistance to modified independence. In those with consecutive 25-year follow-up data (n = 11,131), a similar shift in bowel management to a less dependent strategy occurred even at chronic time points post injury, primarily in individuals with paraplegia and classified as motor and sensory complete. Conclusion: The findings of this study highlight the need for providing continued multipronged interventions (e.g., rehabilitative, educational, psycho-social) at the different stages of SCI to support individuals not only in the immediate years after discharge but also well into the chronic stages after injury.

An evaluation of the representativeness of a national spinal cord injury registry: a population-based cohort study

STUDY DESIGN

Population-based cohort study for the western part of Quebec.

OBJECTIVES

To determine the impact of declining to participate in a national spinal cord injury (SCI) registry on patient outcomes and continuum of care.

SETTING

Level-1 trauma center specialized in SCI care in Montreal, Canada.

METHODS

This cohort study compared the outcomes of 444 patients who were enrolled in the Rick Hansen SCI registry and 140 patients who refused. Logistic regression analyses were performed to assess the association between voluntary participation and the outcomes, while adjusting for confounding factors. The main outcomes were: attendance to follow-up 6- to 12-month post injury, 1-year mortality, and the occurrence of pressure injury during acute care.

RESULTS

Declining to be enrolled in the registry was a significant predictor of lower attendance to specialized follow-up (adjusted odds ratio [OR] 0.04, 95% confidence interval [CI] 0.02-0.08). It was also associated with a higher 1-year mortality rate (OR 12.50, CI 4.50-33.30) and higher occurrence of pressure injury (OR 2.56, CI 1.56-4.17).

CONCLUSIONS

This study sheds invaluable insight on individuals that researchers and clinicians are usually blind to in SCI cohort studies. This study suggests that decline to participate in a registry during the care hospitalization may be associated with worsened health, poorer outcomes, and reduced follow-up to specialized care. Declining the enrollment to voluntary registry could represent a potential prognostic factor for future research.

The urinary disorder-specific quality of life in patients after spinal cord injury: Polish translation, adaptation and validation of the Qualiveen and SF-Qualiveen

STUDY DESIGN

Prospective cohort validation study.

OBJECTIVES

In spinal cord injury (SCI), neurogenic lower urinary tract dysfunction is associated with a reduced quality of life. No specific questionnaire has been translated, culturally adapted, and validated into Polish language to assess urinary disorder-specific quality of life in people after SCI. In this study, we translated, adapted, and validated the Polish versions of the Qualiveen and SF-Qualiveen in individuals with SCI.

SETTING

University Hospital in Krakow, Poland.

METHODS

Translation and cross-cultural adaptation of the Qualiveen and SF-Qualiveen were done using international recommendations and well-established methods. Adult patients with SCI from the Department of Urology at the University Hospital in Krakow, Poland completed the Polish versions of the Qualiveen, SF-Qualiveen, and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) at baseline and 2 weeks later. The ICIQ-SF served as the reference instrument. Validity and reliability were determined.

RESULTS

Polish-speaking patients with SCI (n = 178) were included. Content validity/cross-cultural adaptation of the translated questionnaires was investigated during face-to-face interviews. Construct/criterion validity was assessed, and positive correlations were found between the Qualiveen and ICIQ-SF as well as the SF-Qualiveen and ICIQ-SF. A reliability study revealed good internal consistency (Cronbach's alpha > 0.8) and reproducibility (intraclass correlation coefficients > 0.8) for both adapted questionnaires. We did not identify floor or ceiling effect.

CONCLUSIONS

The Polish versions of the Qualiveen and SF-Qualiveen showed good measurement properties. Polish healthcare providers can now reliably and directly assess the urinary disorder-specific quality of life in individuals after SCI.

Relationship of American Spinal Injury Association Impairment Scale Grade to Post-injury Hospitalization and Costs in Thoracic Spinal Cord Injury

BACKGROUND

The lifetime economic burden of thoracic spinal cord injury (SCI) is known to be high, but evidence of variability of costs in relation to the American Spinal Injury Association Impairment Scale (AIS) grade is limited.

OBJECTIVE

To estimate lifetime economic costs of hospitalization by AIS grade in thoracic SCI.

METHODS

Using SCI Model Systems data from January 2000 to March 2016 from the National Spinal Cord Injury Statistical Center, we estimated mean total annual days of all-cause hospitalization by AIS grade among persons with thoracic SCI, based on assessments 1, 5, and 10 yr post-injury. We combined this information with secondary cost data and projections of life expectancy to estimate lifetime economic costs of hospitalization by AIS grade in persons aged 35 yr at time of thoracic SCI. Future costs were discounted to present value at 3% annually.

RESULTS

One year post-injury, mean total annual days of hospitalization ranged from 2.1 for persons with AIS-D injuries to 5.9 for those who were AIS-A. Similar differences were noted 5 and 10 yr post-SCI. The estimated net present value of expected lifetime costs of hospitalization following thoracic SCI at age 35 yr was $321 534, $249 514, $188 989, and $68 120 (2015 US$) for AIS-A, AIS-B, AIS-C, and AIS-D injuries, respectively.

CONCLUSION

Persons with less severe thoracic SCI, as reflected in AIS grade, spend fewer days in hospital over their lifetimes, leading to lower costs of inpatient care. Therapies improving AIS grade following thoracic SCI may provide cost savings in addition to addressing substantial unmet need.

Content comparison of the Spinal Cord Injury Model System Database to the ICF Generic Sets and Core Sets for spinal cord injury

STUDY DESIGN

Mapping of the National Spinal Cord Injury Model System (SCIMS) Database (NSCID) to the International Classification of Functioning, Disability and Health (ICF).

OBJECTIVES

To link the content of the latest two versions of the NSCID to the ICF; more specifically (1) to compare the content of the current NSCID 2016-2021 version to its predecessor (NSCID 2011-2016) using the ICF as a neutral reference framework, and (2) to compare the content contained in the NSCID 2016-2021 version with relevant ICF Sets.

SETTING

The forms of the NSCID 2016-2021 and 2011-2016 versions were linked to the ICF and contrasted. Comparability of the current version of the NSCID with the ICF Core Set for Spinal Cord Injury (SCI) in the post-acute and long-term context and the two generic ICF sets- ICF Generic-7 and ICF Generic-30 was then examined.

METHODS

ICF Linking Rules and descriptive statistics.

RESULTS

The current NSCID 2016-2021 version covers functioning as classified in the ICF with 8 ICF categories more comprehensively than its predecessor does. More than 50% of ICF categories contained in the two ICF Generic Sets were covered. The coverage of the brief ICF Core Sets for SCI by the NSCID 2016-2021 was more than 50%, but the coverage of the comprehensive core sets was low. Results showed the best coverage in the ICF component Activities and Participation.

CONCLUSIONS

This study emphasizes how the ICF and its Sets can serve as a reference framework to foster comparability of existing data sets from both clinical practice and research.

The association between the etiology of a spinal cord injury and time to mortality in the United States: A 44-year investigation

Objective: To determine the association between spinal cord injury (SCI) etiology categories and mortality, and examine the association between etiology sub-categories and mortality. Design: Prospective cohort study. Setting: Model Systems and Shriners Hospital SCI units. Participants: Data were analyzed from 42,627 cases in the SCI Model System Collaborative Survival Study Database from 1973 to 2017. Those with SCI etiologies categorized as vehicular, violent, sports, falls, pedestrian, and medical were included. Interventions: Not applicable. Outcome Measure: Time to mortality after SCI. Results: Relative to the sports related etiology category, those with medical, pedestrian, violence, falls, and vehicular related SCIs had a 2.00 (95% confidence intervals (CIs): 1.79-2.24), 1.57 (CIs: 1.34-1.83), 1.54 (CIs: 1.41-1.68), 1.35 (CIs: 1.25-1.45), and 1.26 (CIs: 1.17-1.35) higher hazard for mortality, respectfully. Persons with SCIs from automobile crashes had a 1.38 (CIs: 1.23-1.56) higher hazard for mortality, whereas those with SCIs from motorcycle crashes had a 1.21 (CIs: 1.04-1.39) higher hazard for mortality, relative to other etiologies within the vehicular category. Those with SCIs from diving had a 1.37 (CIs: 1.18-1.59) higher hazard for mortality relative to other etiologies within the sports category. Conclusions: Injury etiology categories and certain sub-categories were associated with a higher risk for early mortality. Understanding how additional factors such as socioeconomic status, co-occurring injuries, medical co-morbidities, and environmental aspects interact with SCI etiologies may provide insights for how etiology of injury impacts survival. These findings may serve as a development for extending long-term life expectancy by informing SCI prevention programs and care post-injury.

CONSORT-Assistive technology-180° rotating eating spoon improves the ability of eating of self-care patients with upper extremity dyskinesia: Rotating eating spoon improves eating ability

OBJECTIVE

This study aims to develop an assistive technology-180° rotating feeding spoon that could improve the ability of eating of self-care patients with upper extremity dyskinesia.

METHODS

The Brunnstrom 6-stage rating of hemiplegia was adopted. During the different recovery stages of the upper limbs, the patients orally ate using a feeding spoon with a non-rotatory head and a 180° rotating feeding spoon. The ability of these patients to eat by themselves was observed, and the basic activity of daily living (BADL) was assessed using the Barthel index (BI).

RESULTS

The Brunnstrom assessment scale was used to analyze the results of the patient's upper limb function examination, and the results revealed that the 180° rotating feeding spoon could assist patients with different degrees of upper limb dysfunction when eating independently.

CONCLUSIONS

The 180° rotating feeding spoon can assist patients with upper limb dysfunction when eating independently. For patients with different degrees of upper limb dysfunction, the spoon can provide different degrees of aid.

Therapeutic Application of Transcranial Magnetic Stimulation Combined with Rehabilitative Training for Incomplete Spinal Cord Injury: A Case Report

Background

Only a few researchers have therapeutically applied transcranial magnetic stimulation (TMS) for patients with spinal cord injury. The purpose of this case study was to evaluate the safety, feasibility, and efficacy of therapeutic TMS combined with rehabilitative training for a patient with tetraparesis resulting from incomplete spinal cord injury.

Case

An 82-year-old male patient with incomplete spinal cord injury was admitted to our department for long-term rehabilitation. Eighteen days prior to admission, the patient sustained the injury in a fall. At admission to our department, the patient was diagnosed as having injury of the spinal cord at the C6 level. From the 76th day after admission, when the patient was considered to have attained a plateau state of recovery, application of therapeutic TMS was initiated using a double-cone coil. Two 15-min sessions of 10-Hz TMS were scheduled for daily application. Simultaneously, rehabilitative training was continuously provided. This patient received a total of 30 sessions of TMS over 19 days. Neither adverse effects nor deterioration of neurological symptoms was recognized during the intervention period. With this application of TMS, some improvements were evident in the American Spinal Injury Association motor score, the knee muscle strength, and the calf circumference.

Discussion

This case study demonstrated the safety and feasibility of TMS combined with rehabilitative training in a patient with incomplete spinal cord injury. Our protocol featuring TMS might constitute a novel neurorehabilitation intervention for such patients; however, the efficacy of the protocol should be confirmed in a large number of patients.

Current and future international patterns of care of neurogenic bladder after spinal cord injury

PURPOSE

We aim to summarize the literature on international patterns of care for patients with neurogenic bladder (NGB) from spinal cord injury (SCI).

METHODS

We performed a PubMed database search, hand review of references, communication with professional societies, and registry evaluations for pertinent data.

RESULTS

Established patterns of care, including SCI registries and specialty centers, are available in high-resource countries such as the US and UK. As such, mortality rates from complications of NGB/SCI are lower. Access to intermittent catheterization supplies, among other resources, may be inadequate in many low-income regions. Cultural and religious beliefs may also hinder integration of proper bladder management in SCI patients. While guidelines exist in many parts of the world, it is unclear how rigorously they are disseminated or followed.

CONCLUSIONS

While there is a paucity of high-level evidence, the differences in patterns of care are closely related to socioeconomic status and resources of the geographic area. Future research efforts should focus on improving access to diagnostic modalities, supplies, and specialists in these areas.

Recommendations for urological follow-up of patients with neurogenic bladder secondary to spinal cord injury

PURPOSE

To review currently available guidelines and recommendations regarding urological follow-up of patients after spinal cord injury (SCI) and present an evidence-based summary to support clinicians in their clinical practice.

METHODS

Maximum data were collected according to different methods, including searches with multiple and specific keywords, reference checks, gray literature searches (congress reports, working papers, statement documents), and browsing-related Web site access. Obtained data were analyzed with the modified version of the Oxford grading system for recommendations using levels of evidence (LE) and grades of recommendation (GR).

RESULTS

Different surveillance strategies exist, but there is no consensus among authors and organizations. As a result, practice patterns vary around the world. The present review indicates that proper urological follow-up of SCI patients should consist of medical history (LE 1-4, GR B-C), clinical examination (LE 4, GR C), renal laboratory tests (LE 1-3, GR B), imaging surveillance of the upper urinary tract (LE 1-3, GR A-B), urodynamic study (LE 2-4, GR B-C), and cystoscopy/cytology (LE 1-4, GR D). Clinicians agree that SCI patients should be followed up regularly with an individually tailored approach. A 1-year follow-up schedule seems reasonable in SCI patients without additional risk factors of renal deterioration (LE 3-4, GR C). In those who manifest risk factors, report changes in bladder behavior, or present with already developed complications of neurogenic bladder dysfunction, follow-up plans should be modified with more frequent checkups (LE 4, GR C). Urodynamic study should be repeated and considered as a routine monitoring strategy.

CONCLUSION

Individuals with neurogenic lower urinary tract dysfunction are at increased risk of multiple complications. Nevertheless, proper follow-up after SCI improves the prognosis for these patients and their quality of life.

Spinal Cord Injury Model Systems: Review of Program and National Database From 1970 to 2015

The Spinal Cord Injury Model Systems (SCIMS) centers have provided continuous, comprehensive multidisciplinary care for persons with spinal cord injury (SCI) in the United States since their inception in 1970. In addition, the research conducted and the analysis of data collected at these centers facilitate advances in the care and the overall quality of life for people with SCI. Over the past 45 years, the SCIMS program and National Spinal Cord Injury Database (NSCID) have undergone major revisions, which must be recognized in the planning, conduct, and interpretation of SCIMS research to prevent misinterpretation of findings. Therefore, we provide herein a brief review of the SCIMS program and the associated NSCID throughout its history, emphasizing changes and accomplishments within the past 15 years, to facilitate a better understanding and interpretation of the data presented in SCIMS research publications, including the articles published in this special issue of the Archives.

Weight change after spinal cord injury

OBJECTIVES

To study the patterns of weight change after spinal cord injury (SCI) and identify associated risk factors.

STUDY DESIGN

Cohort study.

SETTING

Sixteen Spinal Cord Injury Model Systems (SCIMS), USA.

PARTICIPANTS

One thousand and ninety-four individuals with an SCI who were entered into the SCIMS and had a 1-year follow-up between October 2006 and November 2012.

INTERVENTION

Not applicable.

OUTCOME MEASURE

Change in body mass index (BMI) during the first year of injury. Height and weight were assessed during inpatient rehabilitation and 1 year after injury.

RESULTS

Mean BMI decreased from 26.3 to 25.8 kg/m² during the first year after SCI (mean change: -0.5 kg/m² (standard deviation: 3.58)). Weight loss was mainly observed among individuals classified as overweight or obese during rehabilitation (n  =  576) with a BMI decrease of 1.4 kg/m², which varied significantly by sex, education, neurological level, and the presence of vertebral injury. Weight gain was noted among individuals classified as underweight or normal weight during rehabilitation (n = 518) with a BMI increase of 0.5 kg/m², with the greatest increase among individuals of Hispanic origin (1.2 kg/m²), other marital status (1.2 kg/m²), age group 31-45 years (1.1 kg/m²), with less than high school education (1.1 kg/m²), without spinal surgery (0.9 kg/m²), and with motor functionally incomplete injury (0.8 kg/m²).

CONCLUSION

Our findings suggest that strategies for weight management should be addressed after a SCI to ameliorate the potential for unhealthful weight change, particularly among at-risk groups.

Long-term functional outcome in patients with acquired infections after acute spinal cord injury

OBJECTIVE

To investigate whether prevalent hospital-acquired pneumonia and wound infection affect the clinical long-term outcome after acute traumatic spinal cord injury (SCI).

METHODS

This was a longitudinal cohort study within the prospective multicenter National Spinal Cord Injury Database (Birmingham, Alabama). We screened datasets of 3,834 patients enrolled in 20 trial centers from 1995 to 2005 followed up until 2016. Eligibility criteria were cervical SCI and American Spinal Cord Injury Association impairment scale A, B, and C. Pneumonia or postoperative wound infections (Pn/Wi) acquired during acute medical care/inpatient rehabilitation were analyzed for their association with changes in the motor items of the Functional Independence Measure (FIM_motor) using regression models (primary endpoint 5-year follow-up). Pn/Wi-related mortality was assessed as a secondary endpoint (10-year follow-up).

RESULTS

A total of 1,203 patients met the eligibility criteria. During hospitalization, 564 patients (47%) developed Pn/Wi (pneumonia n = 540; postoperative wound infection n = 11; pneumonia and postoperative wound infection n = 13). Adjusted linear mixed models after multiple imputation revealed that Pn/Wi are significantly associated with lower gain in FIM_motor up to 5 years after SCI (-7.4 points, 95% confidence interval [CI] -11.5 to -3.3). Adjusted Cox regression identified Pn/Wi as a highly significant risk factor for death up to 10 years after SCI (hazard ratio 1.65, 95% CI 1.26 to 2.16).

CONCLUSION

Hospital-acquired Pn/Wi are predictive of propagated disability and mortality after SCI. Pn/Wi qualify as a potent and targetable outcome-modifying factor. Pn/Wi prevention constitutes a viable strategy to protect functional recovery and reduce mortality. Pn/Wi can be considered as rehabilitation confounders in clinical trials.

Effects of exercise training on urinary tract function after spinal cord injury

Spinal cord injury (SCI) causes dramatic changes in the quality of life, including coping with bladder dysfunction which requires repeated daily and nightly catheterizations. Our laboratory has recently demonstrated in a rat SCI model that repetitive sensory information generated through task-specific stepping and/or loading can improve nonlocomotor functions, including bladder function (Ward PJ, Herrity AN, Smith RR, Willhite A, Harrison BJ, Petruska JC, Harkema SJ, Hubscher CH. J Neurotrauma 31: 819-833, 2014). To target potential underlying mechanisms, the current study included a forelimb-only exercise group to ascertain whether improvements may be attributed to general activity effects that impact target organ-neural interactions or to plasticity of the lumbosacral circuitry that receives convergent somatovisceral inputs. Male Wistar rats received a T9 contusion injury and were randomly assigned to three groups 2 wk postinjury: quadrupedal locomotion, forelimb exercise, or a nontrained group. Throughout the study (including preinjury), all animals were placed in metabolic cages once a week for 24 h to monitor water intake and urine output. Following the 10-wk period of daily 1-h treadmill training, awake cystometry data were collected and bladder and kidney tissue harvested for analysis. Metabolic cage frequency-volume measurements of voiding and cystometry reveal an impact of exercise training on multiple SCI-induced impairments related to various aspects of urinary tract function. Improvements in both the quadrupedal and forelimb-trained groups implicate underlying mechanisms beyond repetitive sensory information from the hindlimbs driving spinal network excitability of the lumbosacral urogenital neural circuitry. Furthermore, the impact of exercise training on the upper urinary tract (kidney) underscores the health benefit of activity-based training on the entire urinary system within the SCI population.

Spinal cord injury-induced immune deficiency syndrome enhances infection susceptibility dependent on lesion level

Pneumonia is the leading cause of death after acute spinal cord injury and is associated with poor neurological outcome. In contrast to the current understanding, attributing enhanced infection susceptibility solely to the patient's environment and motor dysfunction, we investigate whether a secondary functional neurogenic immune deficiency (spinal cord injury-induced immune deficiency syndrome, SCI-IDS) may account for the enhanced infection susceptibility. We applied a clinically relevant model of experimental induced pneumonia to investigate whether the systemic SCI-IDS is functional sufficient to cause pneumonia dependent on spinal cord injury lesion level and investigated whether findings are mirrored in a large prospective cohort study after human spinal cord injury. In a mouse model of inducible pneumonia, high thoracic lesions that interrupt sympathetic innervation to major immune organs, but not low thoracic lesions, significantly increased bacterial load in lungs. The ability to clear the bacterial load from the lung remained preserved in sham animals. Propagated immune susceptibility depended on injury of central pre-ganglionic but not peripheral postganglionic sympathetic innervation to the spleen. Thoracic spinal cord injury level was confirmed as an independent increased risk factor of pneumonia in patients after motor complete spinal cord injury (odds ratio = 1.35, P < 0.001) independently from mechanical ventilation and preserved sensory function by multiple regression analysis. We present evidence that spinal cord injury directly causes increased risk for bacterial infection in mice as well as in patients. Besides obvious motor and sensory paralysis, spinal cord injury also induces a functional SCI-IDS ('immune paralysis'), sufficient to propagate clinically relevant infection in an injury level dependent manner.

Fall-induced spinal cord injury: External causes and implications for prevention

OBJECTIVE

To document the demographic and clinical profile of persons who sustained spinal cord injury (SCI) as a result of accidental falls and to determine the usual circumstances surrounding the fall-induced SCI.

DESIGN

Cohort study.

SETTING

21 SCI Model Systems centers throughout the United States.

PARTICIPANTS

6,408 individuals with traumatic SCI between 2005 and 2014 were recruited from the National SCI Database. 1,877 (29%) of them were injuries caused by falls.

INTERVENTIONS

Not applicable.

OUTCOMES MEASURES

External causes of injury documented by the International Classification of Diseases, 10(th) revision, Clinical Modification (ICD-10-CM).

RESULTS

Falls on the same level from slipping, tripping, and stumbling were the most common cause of fall-induced SCI (20%), followed by falls from building (16%), stairs and steps (16%), and ladder (9%). People who were 61 years of age and older had the highest frequency of falls on the same level, while those aged 16-45 years had a higher percentage of falls from buildings, usually work-related. The mechanisms of falls also varied by sex and race. Associated injury and vertebral injury occurred frequently among falls from buildings and ladders. High falls were more likely to be work-related and result in thoracic and complete injury, while low falls were more commonly associated with cervical and motor functionally incomplete injury.

CONCLUSION

The study findings of different mechanisms of falls by age, sex, race and medical consequences provide an insight for future interventions aimed at high risk persons, activities, and environmental factors for preventing or reducing fall-induced SCI.

Aging and Spinal Cord Injury: External Causes of Injury and Implications for Prevention

BACKGROUND

Despite a consistent trend toward older age at time of spinal cord injury (SCI), little is known about the external causes of SCI in the elderly.

OBJECTIVE

To examine environmental circumstances, documented by International Classification of Diseases, 10th Revision, Clinical Modification codes, at time of SCI among older adults.

METHODS

Data on individuals injured in 2005 or later were retrieved from the National SCI Database. Demographics, injury profiles, and external causes of injury were compared between the study group (age >60 years, n = 1,079) and reference group (age 16-45 years, n = 3,579) using chi-square and Student t tests.

RESULTS

Among the elderly, falls were the most common etiology of SCI (60%), followed by transport accidents (24%) and complications of medical and surgical care (12%). In the younger group, transport accidents were the most common etiology of SCI (49%), followed by falls (22%) and assault (21%). Falls on the same level (30%), from stairs and steps (22%), and other slipping, tripping, and stumbling (11%) were the most common mechanisms of falls in the elderly group. Among motor vehicle accidents, car occupant injured in a collision with another car was the most common mechanism of injury among the elderly (28%).

CONCLUSIONS

There is an urgent need for effective fall prevention programs among the elderly to reduce SCI in this expanding population. Details on the mechanisms of falls and other major causes of SCI among the elderly provided in this study should inform the development of future interventions for high-risk persons, activities, and environments.

Revisiting the status of oral health services in adult PM&R programs: a 40-year follow-up survey

PURPOSE

This survey compared the status of oral health service access and needs for adult Physical Medicine & Rehabilitation (PM&R) patients over a 40-year period.

METHODS

This report compares two surveys (1974 vs. 2014) of Directors of PM&R residency programs in the United States. The same 14 survey questions used in 1974 survey were repeated in 2014, with four new questions added.

RESULTS

The major comparative findings about oral health services were that while perceived need remained high and availability and adequacy of dental care remained low, program directors indicated a slightly lessened desirability, feasibility and overall support for the concept of integrating oral health services into their PM&R program in the 2014 survey.

CONCLUSION

These findings show that 40 years has not brought better access to oral health care for adult PM&R patients, only a slightly lessened enthusiasm in the program directors. Future research should explore the reasons underlying these disappointing outcomes.

Current pregnancy among women with spinal cord injury: findings from the US national spinal cord injury database

Study design

Cross-sectional study

Objective

To examine prevalence of pregnancy and associations with sociodemographic and clinical factors among women with spinal cord injury (SCI)

Setting

U.S. National Spinal Cord Injury Database, an SCI registry that interviews participants 1, 5, and then every 5 years post-injury. Data include SCI clinical details, functional impairments, participation measures, depressive symptoms, and life satisfaction. Women ages 18-49 are asked about hospitalizations in the last year relating to pregnancy or its complications. Data represent 1,907 women, who completed 3,054 interviews.

Methods

We used generalized estimating equations to examine bivariable associations between pregnancy and clinical and psychosocial variables and to perform multivariable regressions predicting pregnancy.

Results

Across all women, 2.0% reported pregnancy during the prior 12 months. This annual prevalence differed significantly by years elapsed since injury; the highest rate occurred 15 years post-injury (3.7%). Bivariable analyses found that younger age at injury was significantly associated with current pregnancy (P < 0.0001). Compared with nonpregnant women, those reporting current pregancy were significantly more likely to be married or partnered, have sport-related SCI, have higher motor scores, and have more positive psychosocial status scores. Multivariable analyses found significant associations between current pregnancy and age, marital status, motor score, and mobility and occupation scale scores.

Conclusions

Current pregnancy rates among reproductive-aged women with SCI are similar to rates of other U.S. women with chronic mobility impairments. More information is needed about pregnancy experiences and outcomes to inform both women with SCI seeking childbearing and clinicians providing their care.

Bladder cancer mortality after spinal cord injury over 4 decades

PURPOSE

We estimate bladder cancer mortality in people with spinal cord injury compared to the general population.

MATERIALS AND METHODS

Data and statistics were retrieved from the National Spinal Cord Injury Statistical Center and the National Center for Health Statistics. The mortality experience of the 45,486 patients with traumatic spinal cord injury treated at a Spinal Cord Injury Model System or Shriners Hospital was compared to the general population using a standardized mortality ratio. The standardized mortality ratio data were further stratified by age, gender, race, time since injury and injury severity.

RESULTS

Our study included 566,532 person-years of followup between 1960 and 2009, identified 10,575 deaths and categorized 99 deaths from bladder cancer. The expected number of deaths from bladder cancer would have been 14.8 if patients with spinal cord injury had the same bladder cancer mortality as the general population. Thus, the standardized mortality ratio is 6.7 (95% CI 5.4-8.1). Increased mortality risk from bladder cancer was observed for various ages, races and genders, as well as for those injured for 10 or more years and with motor complete injuries. Bladder cancer mortality was not significantly increased for ventilator users, those with motor incomplete injuries or those injured less than 10 years.

CONCLUSIONS

Individuals with a spinal cord injury can potentially live healthier and longer by reducing the incidence and mortality of bladder cancer. Study findings highlight the need to identify at risk groups and contributing factors for bladder cancer death, leading to the development of prevention, screening and management strategies.

Using Rasch motor FIM individual growth curves to inform clinical decisions for persons with paraplegia

STUDY DESIGN

A longitudinal retrospective study.

OBJECTIVE

To better understand individual-level temporal change in functional status for participants with paraplegia in the National Spinal Cord Injury Database (NSCID), as measured by Rasch Transformed Motor Functional Indepedence Measure (FIM) scores.

SETTING

Multicenter/Multistate longitudinal study across the United States.

METHODS

Non-linear random effects modeling, that is, individual growth curve analysis of retrospective data obtained from the National Institute on Disability and Rehabilitation Research (NIDRR) NSCID.

RESULTS

We generated non-linear individual level trajectories of recovery for Rasch Transformed Motor FIM scores that rise rapidly from inpatient rehabilitation admission to a plateau. Trajectories are based on relationships between growth parameters and patient and injury factors: race, gender, level of education at admission, age at injury, neurological level at discharge, American Spinal Injury Association Impairment Scale (AIS) at discharge, days from injury to first system inpatient rehabilitation admission, rehabilitation length of stay, marital status and etiology. On the basis of study results, an interactive tool was developed to represent individual level longitudinal outcomes as trajectories based upon an individual's given baseline characteristics, that is, information supplied by the covariates and provides a robust description of temporal change for those with paraplegia within the NSCID.

CONCLUSIONS

This methodology allows researchers and clinicians to generate and better understand patient-specific trajectories through the use of an automated interactive tool where a nearly countless number of longitudinal paths of recovery can be explored. Projected trajectories holds promise in facilitating planning for inpatient and outpatient services, which could positively impact long term outcomes.

Additive effect of age on disability for individuals with spinal cord injuries

OBJECTIVE

To examine the additive effect of age on disability for adults with spinal cord injury (SCI).

DESIGN

Prospective cohort study.

SETTING

SCI Model Systems.

PARTICIPANTS

Individuals with SCI (median age at injury, 32 y; range, 6-88 y) with a discharge motor FIM score and at least 1 follow-up motor FIM score who also provided measures of other covariates (N=1660). Of the total sample, 79% were men, 72% were white, 16% had incomplete paraplegia, 33% had complete paraplegia, 30% had incomplete tetraplegia, and 21% had complete tetraplegia.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary study outcome was the motor subscale of the FIM. A mixed-models approach was used to examine the additive effect of age on disability for individuals with SCI.

RESULTS

When controlling for motor FIM at discharge from rehabilitation, level and severity of injury, age at injury, sex, race, and the age × time interaction were not significant (P=.07). Age at the time of SCI was significantly associated with motor FIM (F1,238=22.49, P<.001). Two sensitivity analyses found significant interactions for both age × time (P=.03, P=.02) and age × time-square (P=.01, P=.006) models. Trajectory of motor FIM scores is moderated slightly by age at the time of injury. The older participants were at the time of injury, the greater the curvature and the more rapid decline were found in later years.

CONCLUSIONS

These findings indicate that age moderately influences disability for some individuals with SCI: the older the age at the time of injury, the greater the influence age has on disability. The findings serve as an important empirical foundation for the evaluation and development of interventions designed to augment accelerated aging experienced by individuals with SCI.

Economic Impacts of Treatment for Type II or III Thoracoabdominal Aortic Aneurysm in the United States

BACKGROUND

Current treatment for extensive thoracoabdominal aortic aneurysms (TAAAs) involves high-risk surgical and endovascular repairs, with a hospital mortality exceeding 20%, and a postoperative paraplegia rate beyond 10.5%.

OBJECTIVES

The aim of this study was to present an estimation of the economic impacts of surgical and endovascular treatments of types II and III TAAAs in the US as well as the economic consequences of the elimination of spinal cord injury and mortality via an endovascular repair of extensive TAAAs (1).

MATERIALS AND METHODS

We compared the current hospital charges of endovascular and surgical repair of extensive TAAAs, also provided a cost analysis of health care charges resulting from paraplegia in the United States, and determined the prevalence of extensive TAAAs found yearly during autopsies in the U.S. Based on the figures gathered and the frequency of Thoracic Aortic Aneurysms per year, we were able to calculate the nationwide inpatient hospital charges, the total average expenses affected by paraplegia during the first 12 months after the repair, the total average expenses after paraplegia for each subsequent year, mortality rate at 30 days and one year, and the number of extensive TAAAs ruptures.

RESULTS

The current nationwide inpatient hospital charges for type II or III TAAA repair cost $12484324 and $37612665 for endovascular repair and surgical repair respectively, and the total average expenses for patients affected by paraplegia during the first 12-month were $4882291 and $23179110 after endovascular repair and surgical repair respectively. The nationwide average expense after 10 years for patients undergoing surgical repair and affected by paraplegia is $33421910 and $6,316,183 for patients undergoing endovascular repair. Moreover, 55 patients with a type II or type III TAAA died after 30 days, and 100 after 1 year. The potential risk of type II or III TAAA ruptures is totally 1637 in a year.

CONCLUSIONS

Major economic impacts of type II or III TAAA repairs in the United States have been identified. An endovascular repair excluding spinal cord injury and mortality with the same average costs as present endovascular treatments makes it possible to save at least $53189742 after one year, 100 lives of operated patients would be saved after one year, and 1637 type II and III TAAA ruptures would be avoided yearly.

The burden of acute traumatic spinal cord injury among adults in the united states: an update

The current incidence estimate of 40 traumatic spinal cord injuries (TSCI) per million population/year in the United States (U.S.) is based on data from the 1990s. We sought to update the incidence and epidemiology of TSCI in U.S adults by using the Nationwide Emergency Department Sample (NEDS), the largest all-payer emergency department (ED) database in the United States. Adult ED visits between 2007 and 2009 with a principal diagnosis of TSCI were identified using International Classification of Diseases (ICD)-9 codes (806.0-806.9 and 952.0-952.9). We describe TSCI cumulative incidence, mortality, discharge disposition, and hospital charges weighted to the U.S. population. The estimated 3-year cumulative incidence of TSCI was 56.4 per million adults. Cumulative incidence of TSCI in older adults increased from 79.4 per million older adults in 2007 to 87.7 by the end of 2009, but remained steady among younger adults. Overall, falls were the leading cause of TSCI (41.5%). ED charges rose by 20% over the study period, and death occurred in 5.7% of patients. Compared with younger adults, older adults demonstrated higher adjusted odds of mortality in the ED (adjusted odds ratio [AOR]=4.4; 95% confidence interval [CI]: 1.1-16.6), mortality during hospitalization (AOR=5.9; 95% CI: 4.7-7.4), and being discharged to chronic care (AOR=3.7; 95% CI: 3.0-4.5). The incidence of TSCI is higher than previously reported with a progressive increase among older adults who also experience worse outcomes compared with younger adults. ED-related TSCI charges are also increasing. These updated national estimates support the development of customized prevention strategies based on age-specific risk factors.

Need for a comprehensive epidemiologic study of spinal cord injury in Poland: findings from a systematic review

STUDY DESIGN

Systematic literature review

OBJECTIVE

To review and assess the quality of available epidemiologic data of spinal cord injury (SCI) in Poland in the context of general International Classification of Functioning (ICF) domains and to answer the question whether there is a need for a comprehensive epidemiologic study of SCI in Poland.

METHODS

Databases Medline, Embase and Polish Medical Bibliography were searched using keywords 'spinal cord injury', 'paraplegia', 'tetraplegia' and 'Poland'.

INCLUSION CRITERIA

studies on humans, original papers, publication in 1979 or later. Case reports and studies with unclear inclusion criteria or performed on a population other than Polish were excluded. Full texts were reviewed for data on incidence, prevalence, etiology, mortality, natural history and outcome of comprehensive treatment. Quality of studies was assessed according to the modified Downs and Black criteria. The ICF model was applied to group the studies according to the ICF components.

RESULTS

Out of 536 identified papers, 224 articles were extracted and reviewed. Mean quality score was 11.04 points based on a 28-grade scale. Body functions and structures were assessed in 81.6%, activities in 22.4%, participation in 14.8%, environmental factors in 15.2% and personal factors in 47% of the studies reviewed.

CONCLUSION

Current epidemiologic data on SCI in Poland are insufficient and biased toward biomedical aspects. There is a need to develop a long-term research strategy for SCI in Poland in the form of a comprehensive cohort study.

Causes of spinal cord injury

BACKGROUND

Knowledge of the causes of spinal cord injury (SCI) and associated factors is critical in the development of successful prevention programs.

OBJECTIVE

This study analyzed data from the National SCI Database (NSCID) and National Shriners SCI Database (NSSCID) in the United States to examine specific etiologies of SCI by age, sex, race, ethnicity, day and month of injury, and neurologic outcomes.

METHODS

NSCID and NSSCID participants who had a traumatic SCI from 2005 to 2011 with known etiology were included in the analyses (N=7,834). Thirty-seven causes of injury documented in the databases were stratified by personal characteristics using descriptive analysis.

RESULTS

The most common causes of SCI were automobile crashes (31.5%) and falls (25.3%), followed by gunshot wounds (10.4%), motorcycle crashes (6.8%), diving incidents (4.7%), and medical/surgical complications (4.3%), which collectively accounted for 83.1% of total SCIs since 2005. Automobile crashes were the leading cause of SCI until age 45 years, whereas falls were the leading cause after age 45 years. Gunshot wounds, motorcycle crashes, and diving caused more SCIs in males than females. The major difference among race/ethnicity was in the proportion of gunshot wounds. More SCIs occurred during the weekends and warmer months, which seemed to parallel the increase of motorcycle- and diving-related SCIs. Level and completeness of injury are also associated with etiology of injury.

CONCLUSIONS

The present findings suggest that prevention strategies should be tailored to the targeted population and major causes to have a meaningful impact on reducing the incidence of SCI.

Functional neurological recovery after spinal cord injury is impaired in patients with infections

Infections are a common threat to patients after spinal cord injury. Furthermore, infections might propagate neuronal death, and consequently contribute to the restriction of neurological recovery. We investigated the association of infections (i.e. pneumonia and/or postoperative wound infections) with functional neurological outcome after acute severe traumatic spinal cord injury. We screened data sets of 24 762 patients enrolled in a prospective cohort study (National Spinal Cord Injury Database, Birmingham, AL, USA). Patients were assessed according to the ASIA classification. ASIA impairment scale-classified A and B patients recruited within 24 h post-trauma (n = 1436) were selected as being a major recruitment population for interventional trials. Patients with documented pneumonia and/or postoperative wound infections (n = 581) were compared with control subjects (non-documented infections, n = 855). The functional neurological outcome parameters (i) upward ASIA impairment scale conversions; (ii) gain of ASIA motor scores; and (iii) gain of motor and sensory levels were consecutively analysed over time up to 1 year after spinal cord injury. The group with pneumonia and/or postoperative wound infections revealed less ASIA impairment scale upward conversions after 1 year than the control group (ASIA impairment scale A: 17.2 versus 23.9%, P = 0.03; ASIA impairment scale B: 57.1 versus 74.7%, P = 0.009). ASIA motor score gain [median (interquartile range)] was lower in patients with infections [ASIA impairment scale A: 8 (4-12) versus 10 (5-17), P = 0.01; ASIA impairment scale B: 19.5 (8-53.5) versus 42 (20.5-64), P = 0.03)]. Analysis of acquired motor/sensory levels supported these findings. In ASIA impairment scale A patients, the gain in motor levels (21.7 versus 33.3%, P = 0.04) and sensory levels (24.4 versus 38 of 102, 37.3%, P = 0.03) was significantly lower in the group with pneumonia and/or postoperative wound infections than in the control group. Multiple regression analysis identified pneumonia and/or postoperative wound infections as independent risk factors for impaired ASIA impairment scale upward conversion (odds ratio: 1.89, 95% confidence interval: 1.36-2.63, P < 0.0005) or lower gain in ASIA motor score (regression coefficient: -8.21, 95% confidence interval: -12.29 to -4.14, P < 0.0005). Infections associated with spinal cord injury, such as pneumonia and/or postoperative wound infections, qualify as independent risk factors for poor neurological outcome after motor complete spinal cord injury. Infections constitute a clinically relevant target for protecting the limited endogenous functional regeneration capacity. Upcoming interventional trials might gain in efficacy with improved patient stratification and might benefit from complementary protection of the intrinsic recovery potential after spinal cord injury.

Epidemiology of traumatic spinal cord injury: trends and future implications

STUDY DESIGN

Review supplemented by inception cohort.

OBJECTIVES

To review trends in the incidence, prevalence, demographic characteristics, etiology, injury severity and selected treatment outcomes of traumatic spinal cord injury (SCI).

SETTING

International review and US model systems cohort.

METHODS

An extensive literature review was conducted to identify all relevant studies of descriptive epidemiology of traumatic SCI. This review was supplemented by analyses of trends in US SCI epidemiology that are reflected in the National Spinal Cord Injury Statistical Center and Shriners Hospital Spinal Cord Injury databases.

RESULTS

Incidence and prevalence of traumatic SCI in the United States are higher than in the rest of the world. Average age at injury is increasing in accordance with an aging general population at risk. The proportion of cervical injuries is increasing, whereas the proportion of neurologically complete injuries is decreasing. Injuries due to falls are increasing. Recent gains in general population life expectancy are not reflected in the SCI population. Treatment outcomes are changing as a result of increasing age and changes in US health care delivery.

CONCLUSION

Within the prevalent population, the percentage of elderly persons will not increase meaningfully until the high mortality rates observed among older persons significantly improve. Those who reach older ages will typically have incomplete and/or lower level injuries, and will have relatively high degrees of independence and overall good health.

Design of the Swiss Spinal Cord Injury Cohort Study

The overall goal of the Swiss Spinal Cord Injury Cohort Study (SwiSCI) is to gain a better understanding of how to support functioning, health maintenance, and quality-of-life of persons with spinal cord injury (SCI) along the continuum of care, in the community, and along their life span. The purpose of this study was to present the SwiSCI study design. SwiSCI is composed of three complementary pathways and will include Swiss persons 16 yrs or older who have diagnoses of traumatic or nontraumatic SCI. Pathway 1 is a retrospective study of medical files of patients admitted to one of the collaborating SCI centers between 2005 and 2009. Pathway 2 is a nationwide survey of persons with chronic SCI. Pathway 3 is an inception cohort study including persons with newly acquired SCI. SwiSCI is conducted in collaboration with the Swiss Paraplegic Association and the major specialized rehabilitation centers in Switzerland. Measurement instruments that are to be used in Pathway 2 and 3 cover body structures and functions, activities, participation, life satisfaction, and personal and environmental factors. SwiSCI is a prospective cohort study that will contribute to a comprehensive understanding of the lived experience of persons with SCI.

The impact of specialized centers of care for spinal cord injury on length of stay, complications, and mortality: a systematic review of the literature

Specialized centers of care for spinal cord injury (SCI) were first established in 1944 in England. The objective of these centers is to improve care and neurological recovery of patients suffering from a spinal cord injury. An interdisciplinary group of experts composed of medical and surgical specialists treating patients with SCI formulated the following questions: (1) Is there any evidence to suggest that specialized centers of care in SCI decrease the length of patient stay? and (2) Is there evidence that specialized centers of care for SCI reduce mortality and secondary complications? A systematic review of the current evidence was performed using multiple databases to answer these two specific questions. Two independent reviewers graded each paper using the Black and Downs method. Recommendations were then formulated based on the evidence available and were reviewed by a panel of experts using a modified Delphi approach. Two recommendations were formulated and both received complete agreement from a panel of experts. The first recommendation is "Early transfer of a patient with traumatic SCI to a specialized center of care should be done promptly to decrease overall length of stay." The second recommendation is "Early transfer of patients with traumatic SCI to an integrated multidisciplinary specialized center of care decreases overall mortality, and the number and severity of complications."

Trends in new injuries, prevalent cases, and aging with spinal cord injury

OBJECTIVE

To determine the characteristics of the newly injured and prevalent population with spinal cord injury (SCI) and assess trends over time.

DESIGN

Prospective cohort study.

SETTING

SCI Model Systems and Shriners Hospital SCI units.

PARTICIPANTS

The study population included people whose injuries occurred from 1935 to 2008 (N=45,442). The prevalent population was estimated based on those who were still alive in 2008. Losses to follow-up (approximately 10%) were excluded from the prevalent population.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographic and injury characteristics, mortality, self-reported health, rehospitalization, FIM, Craig Handicap Assessment and Reporting Technique, and the Diener Satisfaction with Life Scale.

RESULTS

Mean age at injury increased 9 years since the 1970s. Injuries caused by falls and injuries resulting in high-level tetraplegia and ventilator dependency are increasing, while neurologically complete injuries are decreasing. Discharge to a nursing home is increasing. The mean age of the prevalent population is slightly higher than that of newly injured individuals, and the percentage of incident and prevalent cases older than 60 years is the same (13%). Prevalent cases tend to be less severely injured than incident cases, and less than 5% of prevalent cases reside in nursing homes. Within the prevalent population, life satisfaction and community participation are greater among persons who are at least 30 years postinjury. These findings are a result of very high mortality rates observed after 60 years of age.

CONCLUSIONS

Within the prevalent population, the percentage of elderly persons will not increase meaningfully. Those who reach older ages will typically have incomplete and/or lower-level injuries and will have relatively high degrees of independence and overall good health.