Telehealth for people with spinal cord injury: a narrative review

The Ideal Neurogenic Bladder Management Team

This article discusses the ideal neurogenic bladder management team for patients who have neurogenic lower urinary tract dysfunction (NLUTD). It emphasizes the importance of a diverse team, including urologists, physiatrists, neurologist and others, working collaboratively to prevent complications and enhance patient outcomes. Owing to the unique nuances of the various neurologic conditions and patterns of NLUTD dysfunction, the roles of different specialists in the interdisciplinary team are outlined. This article describes 3 team models: multidisciplinary, interdisciplinary, and transdisciplinary, highlighting the benefits of collaborative approaches.

Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice on telerehabilitation. The European PRM position (UEMS PRM Section)

INTRODUCTION

The evidence on the utility and effectiveness of rehabilitation interventions delivered via telerehabilitation is growing rapidly. Telerehabilitation is expected to have a key role in rehabilitation in the future.

AIM

The aim of this evidence-based position paper (EBPP) is to improve PRM physicians' professional practice in telerehabilitation to be delivered to improve functioning and to reduce activity limitations and/or participation restrictions in individuals with a variety of disabling health conditions.

METHODS

To produce recommendations for PRM physicians on telerehabilitation, a systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section.

RESULTS

The systematic literature review is reported together with the 32 recommendations resulting from the Delphi procedure.

CONCLUSIONS

It is recommended that PRM physicians deliver rehabilitation services remotely, via digital means or using communication technologies to eligible individuals, whenever required and feasible in a variety of health conditions in favor of the patient and his/her family, based on evidence of effectiveness and in compliance with relevant regulations. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians in telerehabilitation.

Perspectives from the spinal cord injury community with teleSCI services during the COVID-19 pandemic: a qualitative study

PURPOSE

To explore individuals with spinal cord injury (SCI) experiences with and perceptions towards teleSCI services during the COVID-19 global pandemic in British Columbia, Canada.

METHOD

Using maximum variation sampling, we invited selected individuals from a larger quantitative dataset (n = 71) to partake in an interview. In total, 12 individuals participated in the study. Interviews were recorded and transcribed verbatim. Interview transcripts were then coded and analysed by team members using qualitative descriptive analysis.

RESULTS

Individuals with an SCI perceived teleSCI services to be convenient, accessible, affordable, and an effective way to access some healthcare services during the COVID-19 pandemic. However, in-person healthcare was still needed by many participants to effectively manage and treat their SCI-associated secondary conditions.

CONCLUSION

Our findings suggest that, in a post-pandemic world, the SCI community would benefit from blended models of healthcare delivery that leverage telecommunication technologies to increase accessibility to healthcare while still providing in-person care for assessments and treatments.Implications for RehabilitationIndividuals with an SCI perceived teleSCI services to be convenient, accessible, affordable, and an effective way to access some healthcare services during the COVID-19 pandemic. However, in-person healthcare was still needed and desired by those with an SCI to effectively manage and treat their SCI-associated secondary conditions.In a post-pandemic world, individuals with an SCI would benefit from blended models of healthcare delivery that leverage telecommunication technologies to increase accessibility to healthcare, while still providing in-person care for those requiring ongoing treatment and management of secondary conditions associated with the patient's SCI.TeleSCI services offer the potential to allow healthcare professionals and SCI specialists to collaborate (digitally) with patients at the same time. This patient-centered approach could not only help healthcare professionals strategize effective remedies to better manage secondary conditions associated with SCI but could result in overall better-quality care received by those within the SCI community.

Exploring the Lived Experiences of Individuals With Spinal Cord Injury During the COVID-19 Pandemic

The global spread of severe acute respiratory syndrome coronavirus 2019 (COVID-19) has affected over 100 countries and has led to the tragic loss of life, overwhelmed health care systems and severely impacted the global economy. Specifically, individuals living with spinal cord injury (SCI) are particularly vulnerable during the COVID-19 pandemic as they often face adverse impacts on their health, emotional well-being, community participation, and life expectancy. The objective of this study was to investigate the lived experience of individuals with SCI during the COVID-19 pandemic in Ontario, Canada. An exploratory design with a qualitative descriptive approach was used to address the study objective. Nine semi-structured interviews were conducted with individuals with traumatic and non-traumatic SCI (37-69 years, C3-L5, AIS A-D, and 5-42 years post-injury). Using reflexive thematic analysis, the following themes were created: (1) Caregiver exposure to COVID-19; (2) Staying physically active in quarantine; (3) Living in social isolation; (4) Difficulty obtaining necessary medical supplies; (5) Access to health services and virtual care during COVID-19; and (6) Fighting COVID-19 misinformation. This is one of the first studies to explore the impact of COVID-19 on individuals living with SCI in Ontario. This study contributes to a greater understanding of the challenges faced by individuals living with SCI and provides insight into how to better support and respond to the specific and unique needs of individuals with SCI and their families during a national emergency or pandemic.

Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Impact of the COVID-19 pandemic on the quality of life and accessing rehabilitation services among patients with spinal cord injury and their fear of COVID-19

BACKGROUND

The unanticipated coronavirus disease (COVID-19) had a negative effect on the quality of life (QoL) of patients with spinal cord injury (SCI) and made significant changes in their daily routine. Patients with SCI face additional health risks, especially mental, behavioral, and physical. Without regular physiotherapy sessions, patients' psychological and functional abilities can deteriorate, and complications can occur. There is little information available about the impact of COVID-19 on the quality of life of patients with SCI, and their access to rehabilitation services during the pandemic.

OBJECTIVE

This study was designed to examine the effects of the COVID-19 pandemic on the quality of life of patients with SCI and also their fear of COVID-19. The pandemic's impact on the accessibility of rehabilitation services and attendance at physiotherapy sessions in one Chinese hospital were also documented.

DESIGN

An observational study based on an online survey.

SETTING

Outpatients clinic at the rehabilitation department of Wuhan's Tongji Hospital.

PARTICIPANTS

People who had been diagnosed with a spinal cord injury (SCI) and who were receiving regular medical monitoring as outpatients at the rehabilitation department were invited to participate in our study (n = 127).

INTERVENTION

Not applicable.

OUTCOME MEASURES

A 12-Item Short-Form Health Survey (SF-12) designed to measure participants' quality of life before and during the pandemic. Their fear of COVID-19 was quantified using the Fear of COVID-19 Scale (FCV-19S). Demographic and medical status information was extracted from their medical records. Their use of rehabilitation services and attendance at physical therapy sessions was also documented.

RESULTS

Seventy-nine patients with SCI completed the SF-12 and FCV-19 scale. The mental and physical aspects of the participants' quality of life declined significantly, during the epidemic compared to the pre-epidemic period. More than half of the participants have experienced fear of COVID-19 based on FCV-19S. Most received only irregular physical therapy during routine checkups. Worry about virus transmission was the most common cause cited for not attending regular physical therapy sessions.

CONCLUSIONS

The quality of life of these Chinese patients with SCI declined during the pandemic. Most of the participants were shown a high level of fear of COVID-19 and were classified as having an intense fear of COVID-19, in addition to the impact of the pandemic on their access to rehabilitation services and attendance at physical therapy sessions.

Development of a Remote Version of the Graded Redefined Assessment of Strength, Sensation, and Prehension (GRASSP): Validity and Reliability

BACKGROUND

The Graded Redefined Assessment of Strength, Sensation, and Prehension (GRASSP V1.0) was developed in 2010 as a 3-domain assessment for upper extremity function after tetraplegia (domains: Strength, Sensibility, and Prehension). A remote version (rGRASSP) was created in response to the growing needs of the field of Telemedicine.

OBJECTIVE

The purpose of this study was to assess the psychometric properties of rGRASSP, establishing concurrent validity and inter-rater reliability.

METHODS

Individuals with tetraplegia (n = 61) completed 2 visits: 1 in-person and 1 remote. The first visit was completed in-person to administer the GRASSP, and the second visit was conducted remotely to administer the rGRASSP. The rGRASSP was scored both by the administrator of the rGRASSP (Examiner 1), and a second assessor (Examiner 2) to establish inter-rater reliability. Agreement between the in-person and remote GRASSP evaluations was assessed using the intraclass correlation coefficient (ICC) and Bland-Altman agreement plots.

RESULTS

The remote GRASSP demonstrated excellent concurrent validity with the GRASSP (left hand intraclass correlation coefficient (ICC) = .96, right ICC = .96). Concurrent validity for the domains was excellent for strength (left ICC = .96, right ICC = .95), prehension ability (left ICC = .94, right ICC = .95), and prehension performance (left ICC = .92, right ICC = .93), and moderate for sensibility (left ICC = .59, right ICC = .68). Inter-rater reliability for rGRASSP total score was high (ICC = .99), and remained high for all 4 domains. Bland-Altman plots and limits of agreements support these findings.

CONCLUSIONS

The rGRASSP shows strong concurrent validity and inter-rater reliability, providing a psychometrically sound remote assessment for the upper extremity in individuals with tetraplegia.

Telepsychology for Individuals With Spinal Cord Injury: Protocol for a Randomized Control Study of Video-Based Cognitive Behavioral Therapy

Background

A substantial proportion of individuals with spinal cord injury (SCI) experience depression, which has been negatively associated with recovery and community participation after injury. Despite significant barriers to seeking and receiving in-person mental health care, little research has focused on the efficacy of telepsychology among individuals with SCI.

Objectives

To describe the design and implementation of an ongoing single-center, randomized controlled, video-based cognitive behavioral therapy (CBT) intervention among individuals with SCI.

Methods

Participants within 1 year of SCI will be randomized 1:1 to intervention or usual care in a 24-week study. Intervention participants will engage in 10 sessions of CBT over 12 weeks with a licensed clinical psychologist, using iPads via Apple FaceTime. Primary outcomes are depressive symptomatology, anxiety, and life satisfaction (as measured by the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 and Satisfaction with Life Scale, respectively) measured at three time points (baseline, 12 weeks, and 24 weeks). These and other measures are also assessed during monthly telephone surveys conducted between primary timepoints.

Results

Recruitment is ongoing. Forty-six participants have been enrolled thus far.

Conclusion

Telepsychology is a convenient, flexible, and effective alternative to traditional in-person services. We anticipate that intervention participants will experience improvements in depressive and anxiety symptoms and will have greater life satisfaction. Telepsychology interventions among individuals with SCI are tasked to maintain participant privacy, provide assistive technology and/or engage caregivers to minimize mobility limitations, and manage risk remotely. Challenges encountered include recruitment during the COVID-19 pandemic. Early intervention on symptoms of psychological morbidity using telepsychology may facilitate greater adaptation following SCI.

Videoconferencing in Pressure Injury: Randomized Controlled Telemedicine Trial in Patients With Spinal Cord Injury

Background

Geographical, financial and travel-related barriers may impact access to necessary health care for people in need of long-term follow-up.

Objective

The goal of the research was to perform a nonblinded, randomized, controlled trial on health-related quality of life (HRQoL), healing, interaction, and satisfaction of patients with spinal cord injury (SCI) and PI receiving multidisciplinary videoconference consultations from a wound clinic to the participant’s home versus regular outpatient care. The multidisciplinary team consisted of a medical doctor, a wound nurse, and an occupational therapist. In both groups, district nurses attended the consultations at the participant’s home.

Methods

A total of 56 participants, 28 in each group, were randomized to a videoconference group (VCG) or a regular care group (RCG). Validated questionnaires were used to measure and compare the follow-up effect on HRQoL. Percentage reduction of wound volume was measured at end of the follow-up. A Likert scale was used to measure the satisfaction of the patients and district nurses regarding the interaction between different modalities of care in the 2 groups.

Results

The HRQoL did not show significant differences between the 2 groups (P values ranging from .09 to .88) or the rate of PI healing, experienced interaction, and satisfaction in the groups. A total of 67% (37/55) of all PIs healed, 64% (18/28) in the VCG and 70% (19/27) in the RCG. Mean reduction in ulcer volume was 79% in the VCG and 85% in the RCG (P=.32). A Kaplan-Meier plot with a logrank test regarding time to healing did not show any significant difference between the 2 groups.

Conclusions

Videoconference-based care seems to be a safe and efficient way to manage PIs in terms of HRQoL, healing, interaction, and satisfaction compared to conventional care for people with SCI. This should be considered when planning for future care. SCI has a huge impact on the individual, the family, and the health care system. There is an urgent need to improve systems of care so that individuals who live far from specialists and require long-term follow-up for conditions such as PI can get optimal treatment.

Trial Registration

ClinicalTrials.gov NCT02800915; https://clinicaltrials.gov/ct2/show/NCT02800915 and Current Research Information System in Norway (CRISTIN) 545284; https://app.cristin.no/projects/show.jsf?id=545284

Investigating the Challenges and Benefits of Engaging in Peer Support via Videoconferencing for People with Spinal Cord Injury

Background: One of the greatest challenges faced by people following a spinal cord injury is reintegrating into the community. Peer mentors are people who have had shared experiences of disadvantage and distress and have successfully navigated their way through the associated challenges to lead meaningful lives. Historically, peer mentoring services have been predominantly delivered via face-to-face interactions. Little is known about the experience of people with spinal cord injury engaging in online peer support services, and what the challenges and benefits are of this mode of delivery. Methods: An anonymous online survey consisting of closed and open response questions was used to collect data. Quantitative data were analysed descriptively and qualitative data were analysed using inductive content analysis. Results: Positive benefits of engaging in peer support via videoconferencing included convenience and social connectedness. The main barriers were problems with Wi-Fi and internet connections, inconsistencies between platforms and having to learn new platforms. Even though responses were mixed when comparing videoconferencing to face-to-face peer support, most participants felt socially connected. Conclusions: Addressing barriers through the provision of appropriate technology, and targeted and individualised assistance, is important to facilitate uptake of online peer support for people with spinal cord injury.

SCiPad: evaluating telemedicine via iPad facetime for general spinal cord injury care

Study design

Uncontrolled clinical pilot study.

Objectives

To assess usage, perceived impact, and satisfaction with a telemedicine program among individuals with spinal cord injury (tele-SCI).

Setting

Community-based.

Methods

Participants (N = 83) were recruited from acute SCI inpatient rehabilitation and outpatient SCI care at a community hospital to participate in a 6-month tele-SCI intervention administered by SCI subspecialty board-certified physiatrists via iPad FaceTime. In addition to monthly follow up interview calls, psychosocial and Quality of Life (QoL) measures were collected at baseline and post-intervention. A program satisfaction survey was also collected post-intervention.

Results

Seventy-five percent of participants engaged in tele-SCI visits (Median [IQR]: 2.5 [2.0, 4.0]) for a total of 198 tele-SCI visits. Bladder and bowel concerns were the leading topics discussed during tele-SCI visits, followed by neurological, pain, and functional concerns. Tele-SCI users resided further away (Median miles [IQR] – 114[73–177] vs. 81[46–116], p = 0.023) and reported seeking more clinical advice (Median [IQR] – 1.5[0–4.0] vs. 0[0–1.0], p = 0.002) compared to non-tele-SCI users. All other clinical utilization, baseline characteristics, psychosocial measures, and QoL did not differ among those who used tele-SCI and those who did not. The satisfaction survey suggested satisfaction with the tele-SCI intervention (89%), study equipment (89%), staff responsiveness (100%), and improved motivation for self-monitoring of health (71%).

Conclusion

Study findings suggest that tele-SCI is a feasible modality for providing general SCI care. Further research is required to examine longer-term efficacy of remotely-provided care among individuals living with SCI.

Pediatric rehabilitation services during COVID-19 pandemic in the United Arab Emirates

Introduction/Objective. COVID-19 pandemic has changed the rehabilitation practice across the globe. A sudden transition from in-person therapy at the center to remote therapy challenged the managers and multi-disciplinary team members providing pediatric rehabilitation. The main objective of this research was to assess the provision of services for children with disabilities during COVID-19 in the United Arab Emirates. Methods. Two surveys were developed by the research team, one for the managers and the others for multidisciplinary team members. Both surveys were validated through experts followed by a pilot study. The final versions of the survey were sent to all the pediatric rehabilitation centers within the United Arab Emirates in September 2020. A total of 44 managers and 434 multidisciplinary team members completed the survey. Results. The accessibility of the pediatric rehabilitation services was reported to be very high with 77%. Regarding the cost for running the services, almost half (46%) of managers reported them to be costlier than normal. Telerehabilitation was the most common approach utilized with synchronized live video calls (86%), YouTube video clips (88%), and created own videos (65%). Conclusion. Telerehabilitation appeared to be the most efficient model used for pediatric rehabilitation during the pandemic. The future investments for the continued use of telerehabilitation require planning, budgeting, investing, and creating supportive environments for parents, children, and multidisciplinary team members. There is a need for sharing platforms for educational and therapeutic resources created during the pandemic, with ongoing research on telerehabilitation.

Current Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury (TeleSCI)

Purpose of Review

Telehealth and telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and improve health outcomes in the spinal cord injury population. This review provides an overview of the recent literature on the topic of teleSCI and provides insights on current evidence, future directions, and considerations when using teleSCI for clinical care.

Recent Findings

TeleSCI is used most often for preventive health; management of chronic pain, anxiety, and depression; and rehabilitation-related interventions. As video telehealth becomes mainstream, growth in wearable monitors, bio and neurofeedback mechanisms, and app-based care is expected.

Summary

TeleSCI is growing in prevalence, demonstrates positive impact on health outcomes, and requires ongoing study to identify, refine, and implement best practices.

A Multicenter Evaluation of the Feasibility, Patient/Provider Satisfaction, and Value of Virtual Spine Consultation During the COVID-19 Pandemic

Objective

To assess the feasibility, patient/provider satisfaction, and perceived value of telehealth spine consultation after rapid conversion from traditional in-office visits during the COVID-19 pandemic.

Methods

Data were obtained for patients undergoing telehealth visits with spine surgeons in the first 3 weeks after government restriction of elective surgical care at 4 sites (March 23, 2020, to April 17, 2020). Demographic factors, technique-specific elements of the telehealth experience, provider confidence in diagnostic and therapeutic assessment, patient/surgeon satisfaction, and perceived value were collected.

Results

A total of 128 unique visits were analyzed. New (74 [58%]), preoperative (26 [20%]), and postoperative (28 [22%]) patients were assessed. A total of 116 (91%) visits had successful connection on the first attempt. Surgeons felt very confident 101 times (79%) when assessing diagnosis and 107 times (84%) when assessing treatment plan. The mean and median patient satisfaction was 89% and 94%, respectively. Patient satisfaction was significantly higher for video over audio-only visits (P < 0.05). Patient satisfaction was not significantly different with patient age, location of chief complaint (cervical or thoracolumbar), or visit type (new, preoperative, or postoperative). Providers reported that 76% of the time they would choose to perform the visit again in telehealth format. Sixty percent of patients valued the visit cost as the same or slightly less than an in-office consultation.

Conclusions

This is the first study to demonstrate the feasibility and high patient/provider satisfaction of virtual spine surgical consultation, and appropriate reimbursement and balanced regulation for spine telehealth care is essential to continue this existing work.

A Randomized Controlled Trial of Local Delivery of a Rho Inhibitor (VX-210) in Patients with Acute Traumatic Cervical Spinal Cord Injury

Acute traumatic spinal cord injury (SCI) can result in severe, lifelong neurological deficits. After SCI, Rho activation contributes to collapse of axonal growth cones, failure of axonal regeneration, and neuronal loss. This randomized, double-blind, placebo-controlled phase 2b/3 study evaluated the efficacy and safety of Rho inhibitor VX-210 (9 mg) in patients after acute traumatic cervical SCI. The study enrolled patients 14-75 years of age with acute traumatic cervical SCIs, C4-C7 (motor level) on each side, and American Spinal Injury Association Impairment Scale (AIS) Grade A or B who had spinal decompression/stabilization surgery commencing within 72 h after injury. Patients were randomized 1:1 with stratification by age (<30 vs. ≥30 years) and AIS grade (A vs. B with sacral pinprick preservation vs. B without sacral pinprick preservation). A single dose of VX-210 or placebo in fibrin sealant was administered topically onto the dura over the site of injury during decompression/stabilization surgery. Patients were evaluated for medical, neurological, and functional changes, and serum was collected for pharmacokinetics and immunological analyses. Patients were followed up for up to 12 months after treatment. A planned interim efficacy-based futility analysis was conducted after ∼33% of patients were enrolled. The pre-defined futility stopping rule was met, and the study was therefore ended prematurely. In the final analysis, the primary efficacy end-point was not met, with no statistically significant difference in change from baseline in upper-extremity motor score at 6 months after treatment between the VX-210 (9-mg) and placebo groups. This work opens the door to further improvements in the design and conduct of clinical trials in acute SCI.

Diagnosis of a chronic spinal cord injury via televisit in a patient from an underserved community

A 42-year-old woman from a medically underserved community in rural New England was referred by her primary care provider (PCP) for televisit during the coronavirus disease 2019 (COVID-19) pandemic following 2 years of chronic neck pain and numbness in her left hand that was initially concerning for demyelinating disease. Upon further evaluation, it was revealed that she had experienced a traumatic fall with a concussion and symptoms consistent with central cord syndrome but had refused magnetic resonance imaging (MRI) at her initial medical evaluation. On MRI conducted 1 month prior to neurosurgical evaluation she was found to have a disc bulge and 4-mm T2-hyperintense lesion at the C4–C5 level that was consistent with a chronic spinal cord injury secondary to spinal trauma with associated vertebrogenic injury. This televisit confirmed the diagnosis of chronic spinal cord injury for this patient and allowed for discussion of future interventions, avoided further unnecessary referrals, and increased access to care.

COVID-19 and spinal cord injury and disease: results of an international survey as the pandemic progresses

STUDY DESIGN

An online survey.

OBJECTIVES

To follow-up with and re-query the international spinal cord community's response to the Coronavirus Disease 2019 (COVID-19) pandemic by revisiting questions posed in a previous survey and investigating new lines of inquiry.

SETTING

An international collaboration of authors and participants.

METHODS

Two identical surveys (one in English and one in Spanish) were distributed via the internet. Responses from both surveys were pooled and analyzed for demographic and response data.

RESULTS

Three hundred and sixty-six respondents were gathered from multiple continents and regions. The majority (63.1%) were rehabilitation physicians and only 12.1% had patients with spinal cord injury/disease (SCI/D) that they knew had COVID-19. Participants reported that the COVID-19 pandemic had caused limited access to clinician and support services and worsening medical complications. Nearly 40% of inpatient clinicians reported that "some or all" of their facilities' beds were being used by medical and surgical patients, rather than by individuals requiring inpatient rehabilitation. Respondents reported a 25.1% increase in use of telemedicine during the pandemic (35% used it before; 60.1% during), though over 60% felt the technology incompletely met their patients' needs.

CONCLUSION

The COVID-19 pandemic has negatively impacted the ability of individuals with SCI/D to obtain their "usual level of care." Moving forward into a potential "second wave" of COVID-19, patient advocacy and efforts to secure access to thorough and accessible care are essential.

Virtual Care in the Veterans Affairs Spinal Cord Injuries and Disorders System of Care During the COVID-19 National Public Health Emergency

Telehealth reduces disparities that result from physical disabilities, difficulties with transportation, geographic barriers, and scarcity of specialists, which are commonly experienced by individuals with spinal cord injuries and disorders (SCI/D). The Department of Veterans Affairs (VA) has been an international leader in the use of virtual health. The VA's SCI/D System of Care is the nation's largest coordinated system of lifelong care for people with SCI/D and has implemented the use of telehealth to ensure that Veterans with SCI/D have convenient access to their health care, particularly during the restrictions that were imposed by the COVID-19 pandemic.

Substantiating Clinical Effectiveness and Potential Barriers to the Widespread Implementation of Spinal Cord Injury Telerehabilitation: A Systematic Review and Qualitative Synthesis of Randomized Trials in the Recent Past Decade

Introduction: Telemedicine across many specialties in clinical practice has been established in the literature regarding technology platforms, privacy issues, cost, and clinical effectiveness. However, the lack of data in these areas applicable to spinal cord injury telerehabilitation (teleSCI) still exists. The gaps in these knowledge areas continue to hinder its widespread implementation and serve as pathways for focused efforts in teleSCI research. Objective: This systematic review aims to substantiate the clinical effectiveness and potential barriers to teleSCI implementation by verifying the statistical significance of various clinical outcomes from randomized trials published within the recent past decade. Methods: A qualitative synthesis of randomized studies, conducted across various regions, was systematically reviewed after identifying relevant records from database search engines. Applied filters in the search included publication dates (2010-2020), humans, full-text, and no language preference. The 13 studies were selected per Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram, and the risk of bias across studies was evaluated by using the Physiotherapy Evidence Database scale of quality assessment. Results: Quantitative outcome measurements demonstrated positive impact across studies: 79.1% (34/43) of all measurements were statistically significant for positive outcomes and 18.6% (8/43) yielded no effect but were significant. Primary outcomes addressed various spinal cord injury (SCI) management areas; 38.5% (5/13) of studies also assessed secondary outcomes. Interventional platforms were conventional technologies used in telemedicine. One study (7.7%) achieved data encryption; no studies presented cost-analysis data. Conclusion: The majority of studies demonstrated significant positive outcomes to validate teleSCI clinical effectiveness through conventional technology. These results further expand our understanding of teleSCI's impact and its demonstrated potential for improving SCI individuals' lives. However, heterogeneity of selected studies limits the conclusive recommendations to address potential barriers to its widespread implementation. Moreover, the development of new data is warranted to promote "buy-in" of widespread teleSCI implementation.

It's Corona Calling: Time for Telerehabilitation!

The Covid-19 pandemic has caused a disproportionate impact on people with disabilities and the elderly. Moreover, the pandemic can be likened to disasters caused by catastrophic weather events which will increase in the future in response to climate change. To forestall these threats, rehabilitation professionals must to come together internationally to prepare and proactively educate their peers and patients. This can be done through observance of such times as Day for Tomorrow. Moreover, rehabilitation professionals need to transition to greener forms of healthcare in order to assure that in the future we all sustain our abilities.

Could Virtual Reality play a role in the rehabilitation after COVID-19 infection?

Post-COVID-19 patients, particularly those who needed high care, are expected to have high needs for physical, psychological and cognitive rehabilitation. Yet, the resources needed to provide rehabilitation treatment are expected to be inadequate because healthcare systems faced a shortage of high-quality treatment of these symptoms already before the COVID-19 crisis emerged in patients with comparable needs. In this viewpoint, we discuss the potential of Virtual Reality (VR) administering fast, tailor-made rehabilitation at a distance, and offering a solution for the impending surge of demand for rehabilitation after COVID-19. VR consists of a head-mounted display (HMD) that can bring the user by computer-generated visuals into an immersive, realistic multi-sensory environment. Several studies on VR show its potential for rehabilitation and suggest VR to be beneficial in post-COVID-19. The immersion of VR may increase therapy adherence and may distract the patient from experienced fatigue and anxiety. Barriers still have to be overcome to easily implement VR in healthcare. We argue that embedding VR in virtual care platforms would assist in overcoming these barriers and would stimulate the spread of VR therapy, both for post-COVID-19 patients in the present and possibly for other patients with similar rehabilitation needs in the future.

Barriers and facilitators of education provided during rehabilitation of people with spinal cord injuries: A qualitative description

Background

After a spinal cord injury (SCI), individuals must acquire their maximum level of independence before returning to their previous social and working conditions. The education provided during rehabilitation is one of the basic but complex aspects that influence the health perspectives of people with SCI. Gaining the perspective of SCI survivors experienced barriers and resources to enhance the education process may assist healthcare professionals in understanding this complex aspect of their practice. Through a qualitative descriptive analysis, this study aimed to identify the perceived barriers and facilitators of education provided during the rehabilitation of individuals with SCI.

Methods

A purposive sample of 22 adults with SCI and at least six months of home experience was recruited. Participants were assigned into four mini focus groups according to their level of independence. The focus groups were audio-recorded, transcribed verbatim, and analysed using a thematic analysis.

Results

Three themes were identified: the readiness to education, the individual characteristics, and the environmental and social characteristics influencing education. Participants perceived education to be an ongoing process made up of consecutive phases, each of which had to be overcome before participants felt ready to reappraise their health and well-being. This process was affected by individual, environmental, and social factors.

Conclusions

Education is constantly provided by all members of the rehabilitation team. These must stress the relevance of the contents presented, increase SCI survivors’ motivation to set achievable goals, and consider filling the gap that the patients perceive between rehabilitation centres and available community resources. The findings of this study promote the design of structured educational programmes, increasing knowledge, and improve the health perspective of SCI survivors, their families, and providers.

Provision of care through telemedicine during a natural disaster: a case study

Introduction

As the frequency and intensity of natural disasters increases, disaster preparedness is necessary for individuals with disabilities, including those with spinal cord injury (SCI). However, despite vulnerability to poorer outcomes, disaster preparedness for individuals with SCI is inadequate. Telemedicine has been effectively used to mitigate the impact of natural disasters. In this case study, we describe the provision of clinical care, via telemedicine, to an individual with SCI who was affected by the California Valley Fire in 2015.

Case presentation

The individual described was an adult who sustained a SCI. Before discharge from acute inpatient rehabilitation, they enrolled in a research study, through which they received outpatient SCI-specific care via telemedicine (teleSCI). The participant attended several teleSCI visits prior to the start of the Valley Fire. In the midst and immediate aftermath of prolonged wildfire, and despite experiencing significant personal loss as a result of the fire, the participant continued to receive teleSCI services. TeleSCI was used to address emergent and extant medical concerns and to facilitate replacement of medical supplies and equipment destroyed by fire.

Discussion

TeleSCI was used to provide continuity of care and was responsive to the needs of an individual with SCI severely affected by wildfire. Emergency preparedness that meets the needs of persons with disabilities is critical during times of crisis. Telemedicine may be an effective tool that can be applied to meet the medical needs of individuals with SCI and to mitigate the impact of disasters.

Follow-up consultations through telerehabilitation for wheelchair recipients with paraplegia in a developing country: a case report

INTRODUCTION

Persons with disability (PWD) in the Philippines find it difficult to attend regular face-to-face rehabilitation due to distance, transportation and food expenses, disability, and time constraints. Being a developing country, Filipino rehabilitation doctors have to be resourceful to overcome these barriers and try alternative ways to reach out to their patients, such as through telemedicine, specifically telerehabilitation.

CASE PRESENTATION

After receiving free wheelchairs, two patients with paraplegia secondary to spinal cord disease were unable to report for in-clinic wheelchair reassessment. Telerehabilitation was attempted for the first time to conduct wheelchair follow-up using a commonly available social media application through synchronous and asynchronous methods. During the teleconsultation, the rehabilitation doctors used the wheelchair follow-up form from the World Health Organization translated into Filipino. There were apprehensions at first, especially from the side of the patients, regarding the method, effectiveness, and safety of telerehabilitation. In the end, the patients found telerehabilitation easy, safe, and convenient, and were satisfied with the practical wheelchair modifications and exercise recommendations.

DISCUSSION

Telerehabilitation is a viable alternative to provide universal access to rehabilitation care and overcome the barriers to in-clinic visits among indigent PWD in a resource-limited country. Unlike in developed countries, we do not have readily available customized telemedicine platforms and telemonitoring equipment to conduct telerehabilitation. Nonetheless, we can make use of what is locally available, affordable, and convenient to our patients.

What self-care behaviours are essential for people with spinal cord injury? A systematic review and meta-synthesis

Purpose: To systematically identify, evaluate, and synthesise the qualitative literature on the self-care behaviours, skills, and strategies performed by individuals with spinal cord injury (SCI).Review methods: The Joanna Briggs Institute (JBI) meta-aggregation method was followed. The search was conducted on five databases and limited to papers published from January 2000 to March 2020. Two independent reviewers screened, extracted the data from, and assessed the methodological quality of selected papers using the JBI qualitative assessment and critical appraisal instrument.Results: Eleven qualitative papers were included. Three synthesised findings with a moderate level of confidence emerged from 90 findings: people with SCI perform self-directed or directed-by-other behaviours focused on their physical condition (i); and on their social life (ii); people with SCI perform self-directed behaviours focused on their emotional well-being (iii). Individuals with SCI are aware of their condition and incorporate self-care behaviours into their routine to maintain health and prevent complications.Conclusion: This meta-synthesis provides evidence on the self-care behaviours performed by people with SCI to prevent, control, and manage the physical, emotional, and social effects of their condition. These findings may help healthcare providers to understand the self-care process in SCI survivors and tailor educational programmes to their experiences.IMPLICATIONS FOR REHABILITATIONSCI survivors are directly responsible for their health and must reach their maximum level of independence by acquiring self-care behaviours and adjusting them over time.Self-care behaviours must be incorporated into SCI survivors' daily routine to maintain their condition, promote their social participation, and prevent complications.Caregiver contributions to self-care should be given more value, as these are fundamental to maintain SCI survivors' well-being and social participation.

Pressure ulcers after traumatic spinal injury in East Africa: risk factors, illustrative case, and low-cost protocol for prevention and treatment

STUDY DESIGN

Retrospective, case-control study.

OBJECTIVES

In a traumatic spinal injury (TSI) cohort from Tanzania, we sought to: (1) describe potential risk factors for pressure ulcer development, (2) present an illustrative case, and (3) propose a low-cost outpatient protocol for prevention and treatment.

SETTING

Tertiary referral hospital.

METHODS

All patients admitted for TSI over a 33-month period were reviewed. Variables included demographics, time to hospital, injury characteristics, operative management, length of hospitalization, and mortality. Pressure ulcer development was the primary outcome. Regressions were used to report potential predictors, and international guidelines were referenced to construct a low-cost outpatient protocol.

RESULTS

Of 267 patients that met the inclusion criteria, 51 developed a pressure ulcer. Length of stay was greater for patients with pressure ulcers compared with those without (45 vs. 30 days, p < 0.001). Potential predictors for developing pressure ulcers were: increased days from injury to hospital admission (p = 0.036), American Spinal Injury Association Impairment Scale grade A upon admission (p < 0.001), and thoracic spine injury (p = 0.037). The illustrative case described a young male presenting ~2 months after complete thoracic spinal cord injury with a grade IV sacral pressure ulcer that lead to septic shock and death. Considering the dramatic consequences of pressure ulcers in lower- and middle-income countries (LMICs), we proposed a low-cost protocol for prevention and treatment targeting support surfaces, repositioning, skin care, nutrition, follow-up, and dressing.

CONCLUSIONS

Pressure ulcers after TSI in LMICs can lead to increased hospital stays and major adverse events. High-risk patients were those with delayed presentation, complete neurologic injuries, and thoracic injuries. We recommended aggressive prevention and treatment strategies suitable for resource-constrained settings.

COVID-19 and spinal cord injury and disease: results of an international survey

STUDY DESIGN

An online survey.

OBJECTIVES

To query the international spinal cord medicine community's engagement with and response to the novel coronavirus (COVID-19) pandemic and to assess pandemic-specific information needs and patient concerns.

SETTING

An international collaboration of authors and participants.

METHODS

Two near-identical surveys (one English and one Spanish language) were distributed via the internet. Responses from those questions shared between the surveys were pooled then analyzed; four questions' responses (those not shared) were analyzed separately.

RESULTS

A total of 783 responses were submitted from six continents. Few participants (5.8%) had tested their outpatients with SCI/D for COVID-19; only 4.4% reported having a patient with SCI/D with the virus. Of respondents who worked at an inpatient facility, 53.3% reported that only individuals with symptoms were being screened and 29.9% said that no screening was occurring. Participants relayed several concerns offered by their patients with SCI/D, including vulnerability to infection (76.9%) and fragility of caretaker supply (42%), and those living in countries with guaranteed health care were more likely to report widespread availability of COVID-19 testing than were those living in countries without universal care, χ2 (3, N = 625) = 46.259, p < 0.001.

CONCLUSION

There is substantial variability in the rehabilitation medicine community in COVID-19 screening practices and availability of screening kits. People living with SCI/D are expressing legitimate and real concerns about their vulnerability to COVID-19. More and rapid work is needed to address these concerns and to standardize best-practice protocols throughout the rehabilitation community.

A bellweather for climate change and disability: educational needs of rehabilitation professionals regarding disaster management and spinal cord injuries

Study design

Cross-sectional survey.

Objective

Persons with disabilities are disproportionately impacted by extreme weather disasters and climate change. Individuals with spinal cord injury (SCI) are especially at risk due to inability to control their body temperature and mobility concerns. We surveyed rehabilitation professionals in the field of SCI to determine their experiences, concerns and educational needs regarding natural disasters, climate change and sustainability and the effects on their clientele.

Setting

Online survey available to an international cohort.

Methods

The survey was developed by the authors and conducted in 2019. It was distributed amongst various international health care organizations whose members care for persons with SCI. Descriptive statistics and chi-square test for association were performed using Microsoft Excel 2016.

Results

Of 125 respondents, 50% were from Europe, 18% from North America, and 18% from Asia; 74% were physicians and 13% physical therapists. In total 57.6% believed climate change had impacted their client's health and well-being. Respondents from North America were significantly less likely to report climate change had an impact on their patient's health than those from Asia or Europe (p < 0.01). In total 82.5% of respondents thought professionals should be concerned with sustainability and 85.5% were interested in further education.

Conclusions

Most respondents acknowledged a need for more information related to the disasters, climate change, and disability. Results underscore the need for further research, professional, and consumer education.

Improving quality of life after spinal cord injury in India with telehealth

Introduction

Despite adequate inpatient rehabilitation, a number of spinal cord injury (SCI) individuals suffer from difficulties at home and in their local environments. This is mainly prevalent in low-middle-income countries (LMIC) due to a lack of qualified personal caregivers. This issue could be addressed with the help of telehealth technology, which may be used in LMICs without economic concerns.

Case presentations

A 44-year-old male with C3 AIS C SCI and a 35-year-old female with T12 AIS A SCI were discharged after successful rehabilitation from a tertiary care spinal center. The patients demonstrated gradual loss in their independence, which was evident by monitoring their home activities biweekly for 4 weeks via a combination of telephone calls, live video chat, and WhatsApp. Subsequently after 4 weeks of consistent guidance, pre-post scores after teletherapy were analyzed for the self-care and mobility subcomponents of the self-reported SCIM III.

Discussion

After consistent supervised guidance via telehealth, self-care scores improved in the C3 AIS C case from 3 to 15 and in the T12 AIS A case from 4 to 15, while mobility scores respectively improved from 14 to 27 and 4 to 16. Identification of individual competencies, performance, and capacity in activities of daily living and participation, self-assessment, caregiver training, and home integration contributed toward successful community integration. This case series documents the benefits of using telehealth and home goal planning in the aftercare of SCI individuals, in order to improve quality of life in their local environment.

Participant-reported priorities and preferences for developing a home-based physical activity telemonitoring program for persons with tetraplegia: a qualitative analysis

Study design

Focus group.

Objectives

The purpose of this qualitative study was to explore perceptions and priorities of persons with spinal cord injury (SCI) for physical activity and to incorporate their feedback to inform future development of a physical activity program delivered via a telemonitoring platform.

Setting

New York.

Methods

Qualitative data were collected from a purposive sample of adults with tetraplegia (N = 7). Two investigators led an audio-recorded focus group using a moderator's guide. Data were analyzed using a six-phase thematic analysis approach.

Results

The discussion focused on two major areas, which resulted in multiple derived themes and subthemes. The first theme centered on the daily life of persons with tetraplegia, including changes after SCI, gain of function prioritization, and identification of psychosocial support systems that facilitate community reintegration after injury. The second theme centered on participant perceptions and recommendations for a physical activity program delivered via a telemonitoring platform. Desired design features included variations in schedule, diverse activities, or exercises included in each class, and optional two-way video to enable social interactions with classmates.

Conclusions

Participants favorably viewed the concept of a physical activity program delivered via a telemonitoring platform and contributed program design ideas. Although this was a small sample size, challenges to obtaining physical activity expressed by participants were consistent with those identified previously in larger studies of persons with tetraplegia. Therefore, we expect these concepts and their recommendations to be relevant to the greater SCI community.

Telemedicine in Rehabilitation

Telerehabilitation refers to the virtual delivery of rehabilitation services into the patient's home. This methodology has shown to be advantageous when used to enhance or replace conventional therapy to overcome geographic, physical, and cognitive barriers. The exponential growth of technology has led to the development of new applications that enable health care providers to monitor, educate, treat, and support patients in their own environment. Best practices and well-designed Telerehabilitation studies are needed to build and sustain a strong Telerehabilitation system that is integrated in the current health care structure and is cost-effective.

Lack of adequate care post spinal cord injury - a case report

Introduction

Health needs of individuals with spinal cord injury (SCI) are unmet in developing countries. Quality of life of these individuals is not on par with global standards. The decline in quality of life can be attributed to lack of a specialised rehabilitation centres, lack of expertise in local hospitals and lack of access to dedicated SCI wards/centres in India. The present case report depicts many such challenges in India.

Case presentation

As part of an online focus group, A 21-year-old male was identified who sustained SCI in motor vehicle. His care was inappropriate at the accident site. He was not taught basic skills such as bed mobility, transfers, and wheel-chair mobility and was not educated about long-term complications before discharged to home. Lack of training made him functionally dependent on others for his basic needs. There were few job opportunities for him in his state. He strongly emphasises the need to create an awareness regarding SCI among the general public in India.

Discussion

This case report depicts many challenges faced by a person with paraplegia in India. These include mishandling at the accident site, lack of adequate care post injury and lack of follow-up post discharge. In addition, lack of knowledge of SCI among the general public and lack of education regarding SCI for the patient and his care givers post injury are reported.

Facilitators and Barriers for Implementing an Internet Clinic for the Treatment of Pressure Injuries

Background: Pressure injuries (PIs) represent a frequent, often preventable, secondary complication of spinal cord injury (SCI) with serious consequences to health, societal participation, and quality of life. Specialized knowledge and service delivery related to treatment and prevention are typically located within major health centers. Introduction: For persons with SCI living at home, it can be challenging to access specialized PI care. A telehealth approach could help mitigate this challenge. This multisite pilot investigation assessed the feasibility of integrating information technologies within the management of PIs. Materials and Methods: Each study site formed a specialized interdisciplinary care team that identified components of their standard clinical care pathway and examined how they could be integrated with study technologies. A monitoring system was utilized to enable patients and caregivers to exchange clinical information with the care team. Results: Clinician and patient focus groups were completed to identify facilitators and barriers for long-term implementation. Findings demonstrate that this method of service delivery is feasible but requires further development. Discussion: This model of care requires refinement to address technological, regulatory, and clinician acceptance barriers; however, increased access to these services has the potential for improving PI healing or prevention rates in comparison with those not able to access specialized services. Conclusions: This project demonstrates that PI treatment services can be delivered effectively through the internet. Future trials can investigate efficacy and cost-effectiveness of this model of care to inform sustained implementation.

Hospital based care at home; study protocol for a mixed epidemiological and randomized controlled trial

Background

Individuals with spinal cord injuries (SCI) are prone to pressure ulcers (PUs) because of the loss of sensorimotor function involved as well as increased skin moisture. Treatment of PU after SCI is complicated, involving different specialties and with need for long-lasting follow-up. This study should identify risk factors for PU after SCI, and find an effective and less time-consuming treatment for the condition among different available methods for follow-up.

Method/design

The first part of this research project aims to investigate the prevalence of PU among persons with SCI based on an epidemiological design. The study will identify possible risk factors for acquiring PU. A questionnaire focusing on previous and present PUs will be sent to persons who suffered SCIs between January 2004 and January 2014. In the second part we will compare two different treatment regimens of PU through a randomized controlled pilot trial (RCT) where we will compare outpatient SCI follow-up in a hospital versus outpatient follow-up from the patient’s home, using telemedicine (teleSCI) interventions. We will compare the healing of the PU in the two groups (usual care versus teleSCI). The Tissue, Infection, Moisture Edge (TIME) registration form, the Photographic Wound Assessment Tool (PWAT) and the change in the ulcer size will be used to monitor the healing. Changes in health-related quality of life (HRQoL) and the need for assistance will be assessed using the Five Dimensions European Quality of Life scale (EQ-5D), the generic Medical Outcomes Study 12-item Short Form Health Survey (SF-12) modified version, the International Spinal Cord Injury Quality of Life Data set (ISCI-QoL Data set), and the Spinal Cord Independence Measure scale, version III (SCIM III). In addition to primary outcome measures, a cost-benefit evaluation and an assessment of patient satisfaction and participation will be performed, using customized questionnaires.

Discussion

The first part of the research project will reveal the epidemiology of PU after SCI, and explore the risk factors. This part enables further prevention of PU after SCI and this information will be used in the follow-up RCT. Videoconferencing in the outpatient follow-up of persons with SCI and PU will change clinical routines and facilitate interdisciplinary collaboration, communication and competence exchange among participants of the health care services. Our research protocol allows comparing methods for interaction between medical specialists at hospitals, local caregivers in the community, next of kin, and persons with SCI and PU. The RCT should identify advantages as well as challenges in the management of PU in different follow-up settings. This study aims to identify risk factors for PU after SCI, and find an effective and less time consuming treatment for the condition among different available methods for follow- up.

Trial registration

www.ClinicalTrials.gov, ID: NCT02800915, last update 9 October 2017.

The National Regional Ethical Committee (REC) 2014/ 684/ REK-Nord. https://helseforskning.etikkom.no/prosjekterirek/prosjektregister/prosjekt?p_document_id=469163&p_parent_id=473640&_ikbLanguageCode=n

https://app.cristin.no/projects/show.jsf?id=545284

https://www.sunnaas.no/kliniske-studier/bruk-av-telemedisin-som-virkemiddel-til-samhandling-i-poliklinisk-oppfolging-av-pasienter-med-ryggmargsskade-og-trykksar

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3185-y) contains supplementary material, which is available to authorized users.

Telemedicine using an iPad in the spinal cord injury population: a utility and patient satisfaction study

Study design

Prospective observational.

Objectives

To explore participants' experience, satisfaction, and utility of telemedicine.

Setting

Spinal cord injury (SCI) rehabilitation clinic at a county hospital.

Methods

Participants in this study received telemedicine appointments for routine scheduled care and/or urgent consults with a spinal cord injury specialist via iPad on FaceTime. Demographic changes, health care utilization, and medical complications were assessed. A Program Satisfaction Survey (PSS) was completed after a 6-month enrollment.

Results

Telemedicine visits included general follow-ups (51.25%), "multiple issues" (24.38%), skin (6.88%), bowel and bladder (5.63%), spasms (3.13%), and pain (3.13%). The PSS was collected (n = 45) and revealed positive results in perceived health, satisfaction with equipment/ease of use, and satisfaction with the program. Analysis of anecdotal comments revealed themes such as efficiency, convenience, and reduced barriers provided by telemedicine visits.

Conclusions

This study shows the feasibility and acceptance of a telemedicine intervention via iPad for individuals with SCI through positive PSS ratings and the wide variety of clinical topics addressed.

Sponsorship

Craig H. Neilsen Foundation.