International bowel function basic spinal cord injury data set. Spinal Cord. 2009;47:230-234. [PMID: 18725887 DOI: 10.1038/sc.2008.102]

Are micro enemas administered with a squeeze tube and a 5 cm-long nozzle as good or better than micro enemas administered with a 10 cm-long catheter attached to a syringe in people with a recent spinal cord injury? A non-inferiority, crossover randomised controlled trial

STUDY DESIGN

Double blind, non-inferiority crossover randomised controlled trial.

OBJECTIVES

To determine if micro enemas administered with a squeeze-tube and a 5 cm-long nozzle (squeeze-tube method) are as good or better than micro enemas administered with a 10 cm-long catheter attached to a syringe (catheter method) in people with a recent spinal cord injury.

SETTING

Two inpatient spinal cord injury units located in Sydney, Australia.

METHODS

Twenty people admitted to hospital with recent spinal cord injury were randomly assigned to two treatment sequences; 4 weeks of micro enemas delivered by the squeeze-tube method followed by 4 weeks of micro enemas delivered by the catheter method, or vice versa. Each treatment sequence was 8 weeks with a crossover at the end of week 4. The primary outcome was time to complete bowel care. Secondary outcomes reflected faecal incontinence, quality of life, perception of treatment effectiveness and participant reported time to complete bowel care. The primary and secondary outcomes were measured by blinded assessors in week 4 and week 8. A non-inferiority margin of 10 min for time to complete bowel care was set a priori.

RESULTS

The mean between group difference (95% confidence interval) for the time to complete bowel care was -0.5 min (-2.8 to 1.8), where a negative value favours the catheter method. Results were similar for all secondary outcomes.

CONCLUSIONS

Micro enemas delivered by the squeeze-tube method are as good or better than micro enemas delivered by the catheter method in people with a recent spinal cord injury.

How to learn the International Standards to document remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) content: Self-study through booklet is not enough

OBJECTIVE

To investigate the baseline knowledge of autonomic functions and specifically the International Standards to document remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) among medical students and to present the effective methods in learning of the ISAFSCI.

DESIGN

Interventional training session.

SETTING

A tertiary hospital.

PARTICIPANTS

37 medical students.

INTERVENTIONS

Before training, a self-rating questionnaire including 24 concepts extracted from the ISAFSCI was administrated to the students. Then students were divided into two groups. One group (N = 19) had a one-hour ISAFSCI booklet self-study (BSS), while the other group (N = 18) received a one-hour lecture-based learning (LBL) about the ISAFSCI. After BSS/LBL, all students were examined by a 15-question written test on the knowledge of ISAFSCI.

MAIN OUTCOME MEASURES

Baseline knowledge self-rating questionnaire before training and comparison of post-training performance on the written test between the BSS and LBL groups.

RESULTS

Before training, students were familiar with only 8 out of the 24 concepts within the questionnaire (demonstrating baseline knowledge rate beyond 50%). Significant difference in post-training performance (P<0.05) between BBS and LBL groups was noted for 5 of 15 items tested, including hypohydrosis, broncho-pulmonary system, lower urinary tract function, bowel function and female sexual function. All questions except the one regarding hypohydrosis were answered with greater than 80% accuracy by LBL group.

CONCLUSION

Use of ISAFSCI booklet alone for self-study by medical students is not sufficient to obtain bassline knowledge of autonomic discussions after SCI. It is recommended that formal lecture or presentation should be used to improve the effectiveness of learning the ISAFSCI for medical students.

Level of injury is an independent determining factor of gut dysbiosis in people with chronic spinal cord injury: A cross-sectional study

STUDY DESIGN

A cross-sectional study.

OBJECTIVE

To investigate the correlations between gut microbiota and metabolic parameters in people with different levels of chronic spinal cord injury (SCI).

SETTING

An SCI-specialized rehabilitation facility in a university hospital.

METHODS

Forty-three participants with chronic SCI were recruited. Blood samples of each participant were collected for analysis of metabolic parameters. Feces were collected after the bowel opening method the patient routinely uses to evaluate fecal bacterial microbiota using quantitative RT-PCR. Body composition was examined using dual-energy x-ray absorptiometry (DEXA). Data were analyzed to evaluate the correlations between gut microbiota and other parameters.

RESULTS

Of the 43 participants, 31 people (72.1%) were paraplegic and 12 people (27.9%) tetraplegic. Thirty-two people (74.4%) were diagnosed with obesity using the percentage of body fat (% body fat) criteria. The mean (SD) ratio of Firmicutes:Bacteroides (F/B), which represents the degree of gut dysbiosis, was 18.3 (2.45). Using stepwise multivariable linear regression analysis, both having tetraplegia and being diagnosed with obesity from % body fat evaluated by DEXA were independent positively-correlating factors of F/B (p < 0.001 and p = 0.001, respectively), indicating more severe gut dysbiosis in people with tetraplegia than paraplegia.

CONCLUSION

In people with chronic SCI, having tetraplegia and being diagnosed with obesity from % body fat evaluated by DEXA are independent positive-correlating factors of gut dysbiosis. These results indicate a significant association between gut microbiota and the characteristics of SCI as well as metabolic parameters.

Acute Implantation of a Bioresorbable Polymer Scaffold in Patients With Complete Thoracic Spinal Cord Injury: 24-Month Follow-up From the INSPIRE Study

BACKGROUND

Based on 6-month data from the InVivo Study of Probable Benefit of the Neuro-Spinal Scaffold for Safety and Neurological Recovery in Patients with Complete Thoracic Spinal Cord Injury (INSPIRE) study (NCT02138110), acute implantation of an investigational bioresorbable polymer device (Neuro-Spinal Scaffold [NSS]) appeared to be safe in patients with complete thoracic spinal cord injury (SCI) and was associated with an ASIA Impairment Scale (AIS) conversion rate that exceeded historical controls.

OBJECTIVE

To evaluate outcomes through 24 months postimplantation.

METHODS

INSPIRE was a prospective, open-label, multicenter, single-arm study. Eligible patients had traumatic nonpenetrating SCI with a visible contusion on MRI, AIS A classification, neurological level of injury at T2-T12, and requirement for open spine surgery ≤96 hours postinjury.

RESULTS

Nineteen patients underwent NSS implantation. Three patients had early death determined by investigators to be unrelated to the NSS or its implantation procedure. Seven of 16 evaluable patients (44%) had improvement of ≥1 AIS grade at 6 months (primary end point) to AIS B (n = 5) or AIS C (n = 2). Three patients with AIS B at 6 months had further neurological improvement to AIS C by 12 (n = 2) and 24 (n = 1) months, respectively; none have deteriorated per latest available follow-up. No unanticipated or serious adverse device effects were reported.

CONCLUSION

In this small group of patients with complete thoracic SCI, acute NSS implantation within the spinal cord appeared to be safe with no long-term neurological issues identified during the 24-month follow-up. Patients remain stable, with additional AIS conversions observed in some patients at 12 months and beyond. These data further support the safety and probable benefit of NSS implantation in this patient population.

Phase 1 Safety Trial of Autologous Human Schwann Cell Transplantation in Chronic Spinal Cord Injury

A phase 1 open-label, non-randomized clinical trial was conducted to determine feasibility and safety of autologous human Schwann cell (ahSC) transplantation accompanied by rehabilitation in participants with chronic spinal cord injury (SCI). Magnetic resonance imaging (MRI) was used to screen eligible participants to estimate an individualized volume of cell suspension to be implanted. The trial incorporated standardized multi-modal rehabilitation before and after cell delivery. Participants underwent sural nerve harvest, and ahSCs were isolated and propagated in culture. The dose of culture-expanded ahSCs injected into the chronic spinal cord lesion of each individual followed a cavity-filling volume approach. Primary outcome measures for safety and trend-toward efficacy were assessed. Two participants with American Spinal Injury Association Impairment Scale (AIS) A and two participants with incomplete chronic SCI (AIS B, C) were each enrolled in cervical and thoracic SCI cohorts (n = 8 total). All participants completed the study per protocol, and no serious adverse events related to sural nerve harvest or ahSC transplantation were reported. Urinary tract infections and skin abrasions were the most common adverse events reported. One participant experienced a 4-point improvement in motor function, a 6-point improvement in sensory function, and a 1-level improvement in neurological level of injury. Follow-up MRI in the cervical (6 months) and thoracic (24 months) cohorts revealed a reduction in cyst volume after transplantation with reduced effect over time. This phase 1 trial demonstrated the feasibility and safety of ahSC transplantation combined with a multi-modal rehabilitation protocol for participants with chronic SCI.

Evaluation of the International Spinal Cord Injury Bowel Function Basic Data Set Version 2.0 in Children and Youth With Spinal Cord Injury

OBJECTIVES

To establish the utility and feasibility of the International Spinal Cord Injury/Dysfunction (SCI/D) Bowel Function Basic Data Set Version 2.0 in pediatric SCI populations.

METHODS

This was a noninterventional, repeated measure design conducted in Pennsylvania, Maryland, Illinois, Kentucky, and South Carolina. The International Spinal Cord Injury/Dysfunction (SCI/D) Bowel Function Basic Data Set Version 2.0 was administered repeatedly, twice at the point of care and once over the phone. Time to complete the data set was recorded. Inter- and intrarater reliability was examined by intraclass correlation coefficients (ICC) with 95% confidence intervals (CI), and agreement between the bowel function basic data set variables and medical records was calculated using percentages. Intrarater reliability involved the same person administering the data once at the point of care and once over the phone.

RESULTS

Forty-one children/youth ages 1 to 20 years participated in this study. Average time to complete the data set was 5.17 minutes. Interrater reliability was good to excellent (ICC ≥ 0.75) for most variables. Five variables had moderate interrater reliability (ICC = 0.05-0.74) and three had poor interrater reliability (ICC < 0.05). With the exception of one variable that had poor intrarater reliability (constipating agent, ICC = 0.00) and one that approached moderate reliability (digital evacuation, ICC = 0.74), intrarater reliability was good to strong for every bowel variable (ICC = 0.88-1.00). Only 12 (32%) medical records had explicit documentation of one or more of the variables on the Basic Bowel Function Basic Data Set V2.0.

CONCLUSION

The results support future research with a larger and more diverse sample of children with SCI to build upon the psychometric work described herein.

Who recovers independent bowel management during the first year following a traumatic spinal cord injury? A case-control study

OBJECTIVES

1) document the characteristics of patients with impaired bowel functioning during the subacute and chronic phases; 2) identify factors associated with recovery of independent bowel functioning during the first year following TSCI in patients who present impaired bowel functioning during the subacute phase, when bowel rehabilitation is completed.

DESIGN

Case-control study on 123 adult TSCI patients. Bowel function assessments using item 7 of the SCIM-III were obtained 3-months following TSCI and during the early chronic phase. Univariate and multivariate analyses were conducted to identify predictors associated with recovery of independent bowel functioning between the initial assessment and follow-up.

RESULTS

Of the 110 patients available for analysis, 54 (49%) displayed impaired bowel functioning 3-months following TSCI. Of these, 19 (35%) recovered independent bowel functioning over the following 9 months. The total motor score (TMS) was the only significant predictor of this outcome. A TMS lower than 42 was 100% predictive of absence of recovery.

CONCLUSION

Recovering independent bowel management 1-year after TSCI was possible in 35% of patients despite impaired bowel functioning during the subacute phase. TMS measured 3-months post-injury could be useful for prognosticating potential for bowel functioning recovery since patients with TMS < 42 are unlikely to recover.

Current State of Knowledge on Digital Rectal Stimulation in Individuals With Traumatic and Nontraumatic Spinal Cord Injury: A Scoping Review

OBJECTIVES

To map and characterize the nature of the evidence on the use of digital rectal stimulation for bowel management in individuals with spinal cord injury (SCI).

DATA SOURCES

Five electronic databases were searched (ie, MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, and Cochrane Incontinence Group) from 1990 to November 2019.

STUDY SELECTION

Articles that provided information on the use of digital rectal stimulation either alone or in combination with treatments were included. Title and abstract screening was split between 2 reviewers after reaching consensus on the first 100 studies screened. Full-texts were reviewed independently by 2 reviewers. Discrepancies were resolved by a third reviewer.

DATA EXTRACTION

The data extraction form was developed by 2 reviewers and piloted. Data were extracted by one reviewer and checked for accuracy by a second reviewer.

DATA SYNTHESIS

A total of 4841 studies were screened, including 425 full text articles; 33 articles were identified. Thirty-two studies focused solely on individuals with SCI and 1 study explored the experiences of caregivers of individuals with SCI. The majority of participants were aged between 30 and 59 years old. Most studies used quantitative methods (n=30, 91%). Fourteen of the studies (42%) were cross-sectional. Within experimental or quasiexperimental designs, digital rectal stimulation was commonly studied as an adjunct to other methods such as suppositories or enemas. Incontinence and defecation time were the most commonly examined outcomes.

CONCLUSION

There were few studies found that focus on digital rectal stimulation. Further studies examining experience, effectiveness, complications, and long-term outcomes are warranted.

Community dwelling life- and health issues among persons living with chronic spinal cord injury in North Macedonia

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

The purpose was to reveal late health consequences and life issues after a traumatic spinal cord injury (tSCI) in North Macedonia (NM).

SETTING

Community dwelling adults with tSCI in NM.

METHODS

Persons that sustained tSCI in 1999-2005 were selected, physical examined and a questionnaire was administered. Descriptive statistics were conducted.

RESULTS

From 203 eligible persons, 40 agreed to participate. Mean (range) age at time of injury was 36 (27-75) years and time since injury ranged 9-20 years. Around seventy percent reported current health problems, of which pain and spasm (>60%) were most prevalent, followed by urinary tract infections and pressure injuries. About 30% had never been to a medical specialist and ≈70% had only once been to physiotherapy after discharge from the primary inpatient period. Only one participant had a fully adjusted home for a person with a disability. Those with most severe tSCI (American Spinal Injury Association Impairment Scale (AIS) A, B, and C) seldom left their homes. About 50% were retired and/or unemployed, 50% were working.

CONCLUSION

This is the first study describing community-dwelling persons with a tSCI in NM. Our study revealed that persons with tSCI reported health issues mostly related to pain, spasms, urinary tract infections and pressure injuries. They lacked follow-ups, experienced physical barriers and poor inclusion in the society, and lacked financial support. Therefore, they were often socially isolated and fully dependent on their families. NM is in need of structured rehabilitation programs and better adaption for persons with reduced mobility.

Validation of the Monitoring Efficacy of Neurogenic Bowel Treatment on Response (MENTOR) Tool in a Japanese Rehabilitation Setting

Study design: Prospective observational study. Objective: To validate the Monitoring Efficacy of NBD Treatment On Response (MENTOR) tool in individuals with a spinal cord injury (SCI) or spina bifida, suffering from neurogenic bowel dysfunction (NBD) in a rehabilitation center in Japan. Methods: First, the MENTOR tool was translated from English to Japanese using a validated translation process. Second, the MENTOR tool was validated in a rehabilitation clinic in Japan. Participants completed the MENTOR tool prior to a consultation with an expert physician. According to the results of the tool, each participant was allocated to one of three categories regarding change in treatment: “adequately treated,” “further discussion,” and “recommended change.” The results of the MENTOR tool were compared with the treatment decision made by an expert physician, who was blinded to the results of the MENTOR tool. Results: A total of 60 participants completed the MENTOR tool. There was an acceptable concordance between individuals allocated as respectively, being adequately treated (100%) and recommended change in treatment (61%) and the physicians’ decision on treatment. The concordance was lower for individuals allocated as requiring further discussion (48%). Conclusions: In this study the MENTOR tool was successfully validated in a Japanese rehab setting. The tool will help identify individuals with SCI that need further treatment of their NBD symptoms.

Effect of Different Forms of Activity-Based Recovery Training on Bladder, Bowel, and Sexual Function After Spinal Cord Injury

OBJECTIVES

To investigate whether the urogenital and bowel functional gains previously demonstrated post-locomotor step training after chronic spinal cord injury could have been derived due to weight-bearing alone or from exercise in general.

DESIGN

Prospective cohort study; pilot trial with small sample size.

SETTING

Urogenital and bowel scientific core facility at a rehabilitation institute and spinal cord injury research center in the United States.

PARTICIPANTS

Men and women (N=22) with spinal cord injury (American Spinal Injury Association Impairment Scale grades of A-D) participated in this study.

INTERVENTIONS

Approximately 80 daily 1-hour sessions of either stand training or nonweight-bearing arm crank ergometry. Comparisons were made with previously published locomotor training data (step; N=7).

MAIN OUTCOME MEASURES

Assessments at both pre- and post-training timepoints included cystometry for bladder function and International Data Set Questionnaires for bowel and sexual functions.

RESULTS

Cystometry measurements revealed a significant decrease in bladder pressure and limited improvement in compliance with nonweight-bearing exercise but not with standing. Although International Data Set questionnaires revealed profound bowel dysfunction and marked deficits in sexual function pretraining, no differences were identified poststand or after nonweight-bearing exercise.

CONCLUSIONS

These pilot trial results suggest that, although stand and weight-bearing alone do not benefit pelvic organ functions after spinal cord injury, exercise in general may contribute at least partially to the lowering of bladder pressure and the increase in compliance that was seen previously with locomotor training, potentially through metabolic, humoral, and/or cardiovascular mechanisms. Thus, to maximize activity-based recovery training benefits for functions related to storage and emptying, an appropriate level of sensory input to the spinal cord neural circuitries controlling bladder and bowel requires task-specific stepping.

Examining the complexity of functioning in persons with spinal cord injury attending first rehabilitation in Switzerland using structural equation modelling

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To examine the associations between activities, body structures and functions, and their relationship with aetiology, age and sex in persons with spinal cord injury (SCI) at discharge from first rehabilitation.

SETTING

Swiss SCI Cohort Study (SwiSCI).

METHODS

The study included 390 participants with newly acquired SCI and the International Classification of Functioning, Disability and Health (ICF) as conceptual frame of reference. Body structures were represented by injury level and severity; body functions by cardiovascular, pulmonary, skin, bowel and urinary functions and pain; mental functions by anxiety, depression, optimism and self-esteem; and activities by independence in performing activities of daily living (ADL). Using structural equation modelling (SEM), indirect effects of body structures and functions on independence in performing ADL through mental functions were tested for each mental function separately. For each structural model, fit was assessed using several indices and differences in aetiology, age and sex groups were explored.

RESULTS

The structural model about optimism showed good fit in all indices; the models about anxiety, depression and self-esteem showed conflicting fit indices, respectively. Within all models, effects on independence in performing ADL were mainly direct. Pain showed significant (P < 0.05) indirect effects on independence in performing ADL within the depression, optimism and self-esteem models. The model about anxiety showed differences in aetiology groups.

CONCLUSIONS

Using an ICF-based modelling approach, this study presents an attempt towards a more comprehensive understanding of functioning in first rehabilitation of persons with SCI, which might be fundamental for rehabilitation planning.

The data set development for the National Spinal Cord Injury Registry of Iran (NSCIR-IR): progress toward improving the quality of care

STUDY DESIGN

Descriptive study.

OBJECTIVES

The aim of this manuscript is to describe the development process of the data set for the National Spinal Cord Injury Registry of Iran (NSCIR-IR).

SETTING

SCI community in Iran.

METHODS

The NSCIR-IR data set was developed in 8 months, from March 2015 to October 2015. An expert panel of 14 members was formed. After a review of data sets of similar registries in developed countries, the selection and modification of the basic framework were performed over 16 meetings, based on the objectives and feasibility of the registry.

RESULTS

The final version of the data set was composed of 376 data elements including sociodemographic, hospital admission, injury incidence, prehospital procedures, emergency department visit, medical history, vertebral injury, spinal cord injury details, interventions, complications, and discharge data. It also includes 163 components of the International Standards for the Neurologic Classification of Spinal Cord Injury (ISNCSCI) and 65 data elements related to quality of life, pressure ulcers, pain, and spasticity.

CONCLUSION

The NSCIR-IR data set was developed in order to meet the quality improvement objectives of the registry. The process was centered around choosing the data elements assessing care provided to individuals in the acute and chronic phases of SCI in hospital settings. The International Spinal Cord Injury Data Set was selected as a basic framework, helped by comparison with data from other countries. Expert panel modifications facilitated the implementation of the registry process with the current clinical workflow in hospitals.

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

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

Fecal Incontinence and Neurogenic Bowel Dysfunction in Women With Traumatic and Nontraumatic Spinal Cord Injury

BACKGROUND

In the literature on chronic spinal cord injury, neurogenic bowel dysfunction has not gained as much attention as bladder dysfunction, the traditional cause of morbidity and mortality.

OBJECTIVE

The purpose of this study was to investigate the prevalence of fecal incontinence and conditions associated with fecal incontinence in women with spinal cord injury.

DESIGN

In this cross-sectional study, data were obtained from an electronic medical chart database containing standardized questionnaires.

SETTINGS

The study was conducted at the Clinic for Spinal Cord Injuries, Rigshospitalet, where patients from Eastern Denmark are followed every second year.

PATIENTS

Women who sustained a spinal cord injury between September 1999 and August 2016 and attended a consultation between August 2010 and August 2016 were included. If the bowel function questionnaire had never been answered, the woman was excluded.

MAIN OUTCOME MEASURES

The newest completed questionnaire regarding bowel function, urinary bladder function, quality of life, neurologic level/completeness/etiology of injury, mobility status, and spousal relationship was obtained from each woman.

RESULTS

Among the 733 identified women, 684 were included, of whom only 11% had a complete motor injury. A total of 35% experienced fecal incontinence, varying from daily to less than monthly, and 79% experienced bowel dysfunction. Fecal incontinence was associated with urinary incontinence and decreased satisfaction with life in general and psychological health. In the multivariate logistic regression analysis, the odds of daily-monthly fecal incontinence increased significantly with increasing age, myelomeningocele as etiology of injury, a more complete paraplegic injury, use of wheelchair permanently, and follow-up <3 months.

LIMITATIONS

There were missing data in the study, including 12% with no answer to the fecal incontinence question.

CONCLUSIONS

Fecal incontinence is a severe problem that affects more than one third of women with spinal cord injury and is associated with decreased quality of life. The present study emphasizes that women with myelomeningocele, a more complete paraplegic injury, older age, short follow-up period, and permanent wheelchair use have an increased risk of fecal incontinence. See Video Abstract at http://links.lww.com/DCR/A985. INCONTINENCIA FECAL Y DISFUNCIÓN NEUROGÉNICA DEL INTESTINO EN MUJERES CON LESIÓN DE LA MEDULA ESPINAL TRAUMÁTICA Y NO TRAUMÁTICA: En la literatura sobre la lesión crónica de la médula espinal, la disfunción neurógena del intestino no ha ganado tanta atención como la disfunción de la vejiga, la causa tradicional de morbilidad y mortalidad. OBJETIVÓ:: Investigar la prevalencia de la incontinencia fecal y las condiciones asociadas con la incontinencia fecal en mujeres con lesión de la médula espinal. DISEÑO:: En este estudio transversal, los datos se obtuvieron de una base de datos de registros médicos electrónicos que contenía cuestionarios estandarizados. CONFIGURACIÓN:: Clínica para Lesiones de la Médula Espinal, Rigshospitalet, donde los pacientes del Este de Dinamarca son seguidos cada dos años.

PACIENTES

Mujeres que sufrieron una lesión en la médula espinal entre Septiembre de 1999 a Agosto de 2016 y asistieron a una consulta entre Agosto de 2010 a Agosto de 2016. Si nunca se había respondido el cuestionario de la función intestinal, se excluyó a la mujer.

MEDIDA DE RESULTADOS PRINCIPALES

Se obtuvo el cuestionario más reciente y completo sobre la función intestinal, la función de la vejiga urinaria, la calidad de vida, el nivel neurológico/integridad/etiología de la lesión, el estado de movilidad y la relación con el cónyuge.

RESULTADOS

Entre las 733 mujeres identificadas, se incluyeron 684, de las cuales solo el 11% tenía una lesión de motor completa. Un total de 35% experimentó incontinencia fecal que varió de diaria a menos de mensual, y el 79% experimentó disfunción intestinal. La incontinencia fecal se asoció con incontinencia urinaria y disminución de la satisfacción de vida en general y con la salud psicológica. En el análisis de regresión logística multivariable, las probabilidades de incontinencia fecal diaria-mensual aumentaron significativamente con el aumento de la edad, el mielomeningocele como etiología de la lesión, una lesión parapléjica más completa, el uso de silla de ruedas de forma permanente y el seguimiento <3 meses.

LIMITACIONES

Faltaban datos en el estudio, incluyendo el 12% sin respuesta a la pregunta sobre incontinencia fecal.

CONCLUSIONES

La incontinencia fecal es un problema grave que afecta a más de un tercio de las mujeres con lesión de la médula espinal y se asocia con una disminución de calidad de vida. El presente estudio enfatiza que las mujeres con mielomeningocele, una lesión parapléjica más completa, mayor edad, corto período de seguimiento y uso de silla de ruedas permanente tienen un mayor riesgo de incontinencia fecal. Vea el Video del Resumen en http://links.lww.com/DCR/A985.

Implementation of a Neurogenic Bowel Program for Spinal Cord Injury in the Acute Care Setting: Perceptions of Patients and Staff

A prospect cohort and case-control was employed to (1) establish a neurogenic bowel (NB) program after spinal cord injury (SCI) in the acute care setting; (2) examine clinician knowledge ability to deliver the NB program; and (3) evaluate patient knowledge, satisfaction, and quality of life. Educational in-service describing NB clinical practice guidelines (CPGs) and order set was delivered to staff followed by a pre-/post-education, 3- and 12-month survey. The patient intervention followed 24 patients with NB to evaluate the program and compared to 28 retrospective case-control patients followed by a pre-/post-intervention survey to measure knowledge of SCI, NB program and quality of life. Injury information and bowel medication use was compared between cases and controls. Clinician knowledge of NB CPGs improved. There were no significant clinical differences between patient groups. Patient knowledge and satisfaction improved post-intervention. Education to staff and patients is imperative to facilitate a NB program to meet the needs for individuals with SCI.

Cross-sectional and prospective data-collection in North Macedonia-methodological considerations

Study design

Cross-sectional and prospective cohort-study.

Objectives

To describe methodological issues, experienced challenges related to data collection in North Macedonia and to discuss possible improvements of epidemiological data collection in future studies.

Setting

Clinic for Traumatology, Orthopedics, Anesthesia, Reanimation, Intensive Care Unit and Emergency Center, Mother Teresa Skopje University Hospital, Skopje and community settings, North Macedonia.

Method

A description of methodological challenges experienced in collecting data from 78 persons with acute and chronic traumatic spinal cord injury (SCI) examined and interviewed in 2015-2017 using a semiquantitative questionnaire and standard assessments tools.

Results

This study identified three major challenges with data collection in this setting: (1) research logistics and procedures, such as recruitment, infrastructure, and compensation, (2) ethical issues and the initial lack of mutual trust and understanding between researchers and participants, and (3) scientific quality and interpretation, including representativeness.

Conclusions

Methodological issues influenced by settings, are important to consider when interpreting study results. Healthcare systems vary between (and sometimes in) countries, language and culture may introduce barriers to understanding, and epidemiological research also rely on infrastructure and surroundings. For this study, making time for and listening to the participants without being intruding was of special importance in building trust and a good relationship with the participants during recruiting participants and collecting data. We here provide suggestions regarding how to facilitate future epidemiological data collections in North Macedonia.

Gut microbiota dysbiosis in male patients with chronic traumatic complete spinal cord injury

BACKGROUND

Neurogenic bowel dysfunction (NBD) is a major physical and psychological problem in patients with spinal cord injury (SCI), and gut dysbiosis is commonly occurs in SCI. Here, we document neurogenic bowel management of male patients with chronic traumatic complete SCI in our centre and perform comparative analysis of the gut microbiota between our patients and healthy males.

METHODS

A total of 43 male patients with chronic traumatic complete SCI (20 with quadriplegia and 23 with paraplegia) and 23 healthy male adults were enrolled. Clinical data and fresh stool specimens were collected from all participants. Face-to-face interviews were conducted to survey the neurogenic bowel management of 43 patients with SCI. Gut microbiomes were analysed by sequencing of the V3-V4 region of the 16S rRNA gene.

RESULTS

NBD was common in adult male patients with chronic traumatic complete SCI. Patients with quadriplegia exhibited a longer time to defecate than did those with paraplegia and had higher NBD scores and heavier neurogenic bowel symptoms. The diversity of the gut microbiota in the SCI group was reduced, and the structural composition was different from that of the healthy adult male group. The abundance of Veillonellaceae and Prevotellaceae increased, while Bacteroidaceae and Bacteroides decreased in the SCI group. The abundance of Bacteroidaceae and Bacteroides in the quadriplegia group and Acidaminococcaceae, Blautia, Porphyromonadaceae, and Lachnoclostridium in the paraplegia group were significantly higher than those in the healthy male group. Serum biomarkers (GLU, HDL, CR, and CRP), NBD defecation time and COURSE had significant correlations with microbial community structure. Microbial community structure was significantly associated with serum biomarkers (GLU, HDL, CR, and CRP), NBD defecation time, and COURSE.

CONCLUSIONS

This study presents a comprehensive landscape of the gut microbiota in adult male patients with chronic traumatic complete SCI and documents their neurogenic bowel management. Gut microbiota dysbiosis in SCI patients was correlated with serum biomarkers and NBD symptoms.

Training with brain-machine interfaces, visuo-tactile feedback and assisted locomotion improves sensorimotor, visceral, and psychological signs in chronic paraplegic patients

Spinal cord injury (SCI) induces severe deficiencies in sensory-motor and autonomic functions and has a significant negative impact on patients' quality of life. There is currently no systematic rehabilitation technique assuring recovery of the neurological impairments caused by a complete SCI. Here, we report significant clinical improvement in a group of seven chronic SCI patients (six AIS A, one AIS B) following a 28-month, multi-step protocol that combined training with non-invasive brain-machine interfaces, visuo-tactile feedback and assisted locomotion. All patients recovered significant levels of nociceptive sensation below their original SCI (up to 16 dermatomes, average 11 dermatomes), voluntary motor functions (lower-limbs muscle contractions plus multi-joint movements) and partial sensory function for several modalities (proprioception, tactile, pressure, vibration). Patients also recovered partial intestinal, urinary and sexual functions. By the end of the protocol, all patients had their AIS classification upgraded (six from AIS A to C, one from B to C). These improvements translated into significant changes in the patients' quality of life as measured by standardized psychological instruments. Reexamination of one patient that discontinued the protocol after 12 months of training showed that the 16-month break resulted in neurological stagnation and no reclassification. We suggest that our neurorehabilitation protocol, based uniquely on non-invasive technology (therefore necessitating no surgical operation), can become a promising therapy for patients diagnosed with severe paraplegia (AIS A, B), even at the chronic phase of their lesion.

Implementation of a Standardized Dataset for Collecting Information on Patients With Spinal Cord Injury

Background: Over the last decade, the International Spinal Cord Injury Data Sets project developed a number of International Spinal Cord Injury Data Sets (ISCIDS) that can be used to collect standardized information on patients with SCI. Objective and Methods: The aim of this article is to describe the process of translating the ISCIDS into Dutch and reaching consensus on a Dutch National SCI Data Set (NDD). The interrater reliability of the NDD and implementation of the NDD at eight rehabilitation centers with a specialty in rehabilitation after SCI in the Netherlands are described. Results: NDD was implemented successfully at all eight centers. Some adaptations were made to the ISCIDS, especially to the core data set. The reliability coefficients of the NDD items were at least sufficient (mean kappa per data set ranged between .68 and .91), and mean agreement per data set ranged from 66% to 97%. Experiences from the participating centers were mainly positive as well. The main obstacle for use was thought to be the absence of a link between the local patient files and the national database, which necessitates double data entry. Conclusion: Although the results on interrater reliability are based on a small sample size and the assessment situation is different from the normal clinical situation, this study showed the NDD to be a useful instrument to collect standardized information on patients with SCI in the Netherlands. In the future, a connection between systems or another way to centrally collect the data is recommended to prevent double data entry and to guarantee continuation of administration of the NDD.

Electronic medical record: data collection and reporting for spinal cord injury

STUDY DESIGN

Presentation of implementation of International Spinal Cord Injury (SCI) Data Sets, International Standards for Neurological Classification of SCI (ISNCSCI), and other structured SCI tools in to the Electronic Medical Record (EMR) Epic.

OBJECTIVES

To describe the implementation of SCI tools in Epic at Rigshospitalet, University of Hospital, Capital Region of Denmark, and the ambitions for the future development of SCI related structured data and their reporting in the Epic EMR to be able to standardize data collection to facilitate research within institutions and collaboratively with other institutions locally and globally.

SETTING

Denmark and United States of America.

METHODS

The general content of the EMR Epic and the SCI-specific structured data implemented are described as well as the tools for reporting.

RESULTS

The ISNCSCI is made available via access to http://isncscialgorithm.azurewebsites.net/. After filling in the test data on the website, one can save the completed form as an image within the patient's chart. The International SCI Core Data Set and 13 International SCI Basic Data Sets (Table 1) are nearly completely implemented in the Danish version of Epic as SmartForms. In addition, 14 functional measures, including the Spinal Cord Independence Measure III, are implemented as flowsheets (Table 2).

CONCLUSIONS

The possibility of entering international recognized structured data into the EMR gives better possibility for data sharing across SCI centers worldwide.

SPONSORSHIP

Gianna Maria Rodriguez, Stacey Cohen, and Fin Biering-Sørensen are users of Epic, but have no economic relationship with Epic. Kelly Tausk and Josh Martin are employees of Epic.

Assessment of neurogenic bowel dysfunction impact after spinal cord injury using the International Classification of Functioning, Disability and Health

BACKGROUND

Bowel function is frequently compromised after spinal cord injury (SCI). Regardless of this crucial importance in patients' lives, there is still scarce literature on the Neurogenic Bowel Dysfunction (NBD) deleterious impact on SCI patient's lives and only few studies correlating NBD severity with quality of life (QoL). To our knowledge there are no studies assessing the impact of NBD on the context of ICF domains.

AIM

To assess NBD after SCI using ICF domains and to assess its impact in QoL.

DESIGN

Retrospective data analysis and cross-sectional phone survey.

SETTING

Outpatient spinal cord injury setting.

POPULATION

Portuguese adult spinal cord injury patients.

METHODS

Retrospective analysis of demographic data, lesion characteristics and bowel management methods at last inpatient discharge. Cross-sectional phone survey assessing current bowel management methods, the Neurogenic Bowel Dysfunction Score and a Likert Scale questionnaire about the impact on ICF domains and QoL.

RESULTS

Sixty-four patients answered the questionnaire. The majority was male (65.6%), mean age 56.6±15.6 years, AIS A lesion (39.1%), with a traumatic cause (71.9%). The main bowel management methods were contact laxatives, suppositories and osmotic laxatives. 50.1% of patients scored moderate or severe NBD. Considering ICF domains, the greatest impact was in personal and environmental factors, with 39.1% reporting impact in financial costs, 45.3% in need of assistance, 45.3% in emotional health and 46.9% in loss of privacy. There was a significant association between severity of NBD and negative impact on QoL (P<0.05).

CONCLUSIONS

The study confirms the major impact of NBD on personal and environmental factors of ICF and on the quality of life of SCI population.

CLINICAL REHABILITATION IMPACT

These findings confirm that it is relevant to identify the main ICF domains affected by NBD after SCI in order to address targeted interventions, working toward changes in health policies and psychosocial aspects.

Progress of the Dutch Spinal Cord Injury Database: Completeness of Database and Profile of Patients Admitted for Inpatient Rehabilitation in 2015

Background: In the Dutch International Spinal Cord Injury (SCI) Data Sets project, we translated all International SCI Data Sets available in 2012 and created a Dutch SCI Database (NDD). Objective: To describe the number of included patients and completeness of the NDD, and to use the NDD to provide a profile of people with traumatic SCI (T-SCI) and non-traumatic SCI (NT-SCI) in the Netherlands. Methods: The NDD includes patients admitted for their first inpatient rehabilitation after onset of SCI to 1 of the 8 rehabilitation centers with a specialty in SCI rehabilitation in the Netherlands. Data of patients admitted in 2015 were analyzed. Results: Data for 424 patients were available at admission; for 310 of these patients (73.1%), discharge data were available. No significant differences were found between patients with and without data at discharge. Data were nearly complete (>90%) for lower urinary tract, bowel, pain, and skin. Data on sexual function has the lowest completion rate. Complete neurological and functional data were available for 41.7% and 38%, respectively. Most patients were male (63.4%), had NT-SCI (65.5%), and had incomplete SCI (58.4% D). Patients with T-SCI differed from patients with NT-SCI on most characteristics, and they stayed considerably longer in the rehabilitation center (112 days vs 65 days, p < .001). Place of discharge was not different between both groups. Conclusion: With the NDD, we collect important data on the majority of Dutch SCI patients, although much work needs to be done to improve the completeness of the data collection.

Facilitators and Barriers to International Collaboration in Spinal Cord Injury: Results from a Survey of Clinicians and Researchers

International collaboration in spinal cord injury (SCI) research is necessary to overcome the challenges often encountered by clinicians and researchers, including participant recruitment, high cost, and the need for specialized expertise. However, international collaboration poses its own obstacles. The objective of this study was to conduct an international online survey to assess barriers and facilitators to international SCI clinical research, potential initiatives to facilitate future collaborations, and the use of SCI-specific data sets and standards. Results were analyzed using descriptive statistics. Of 364 total respondents, 213 completed the survey, with the majority of these participants based in North America (38%), Asia (22%), Europe (18%), and Oceania (16%). Over half had more than 10 years of experience in SCI research or clinical practice (57%) and 60% had previous experience with international collaborations. Funding was identified as a top barrier (82%), a facilitator (93%), and a proposed future initiative (97%). Communication and technology were also identified as strong facilitators and proposed future initiatives. The International Standards for Neurological Classification of SCI were used by 69% of participants, the International Standards to document remaining Autonomic Function after SCI by 13% of participants, and the International SCI Data Sets by 45% of participants. As the need for international collaborations in SCI research increases, it is important to identify how clinicians and researchers can be supported by SCI consumer and professional organizations, funders, and networks. Furthermore, unique solutions to overcome modifiable barriers and creation of new facilitators are also needed.

Improvements in bladder, bowel and sexual outcomes following task-specific locomotor training in human spinal cord injury

OBJECTIVE

Locomotor training (LT) as a therapeutic intervention following spinal cord injury (SCI) is an effective rehabilitation strategy for improving motor outcomes, but its impact on non-locomotor functions is unknown. Given recent results of our labs' pre-clinical animal SCI LT studies and existing overlap of lumbosacral spinal circuitries controlling pelvic-visceral and locomotor functions, we addressed whether LT can improve bladder, bowel and sexual function in humans at chronic SCI time-points (> two years post-injury).

STUDY DESIGN

Prospective cohort study; pilot trial with small sample size.

METHODS

Eight SCI research participants who were undergoing 80 daily one-hour sessions of LT on a treadmill using body-weight support, or one-hour of LT and stand training on alternate days, as part of another research study conducted at the Kentucky Spinal Cord Injury Research Center, University of Louisville, were enrolled in this pilot trial. Urodynamic assessments were performed and International Data Set questionnaire forms completed for bladder, bowel and sexual functions at pre-and post-training time points. Four usual care (non-trained; regular at-home routine) research participants were also enrolled in this study and had the same assessments collected twice, at least 3 months apart.

RESULTS

Filling cystometry documented significant increases in bladder capacity, voiding efficiency and detrusor contraction time as well as significant decreases in voiding pressure post-training relative to baseline. Questionnaires revealed a decrease in the frequency of nocturia and urinary incontinence for several research participants as well as a significant decrease in time required for defecation and a significant increase in sexual desire post-training. No significant differences were found for usual care research participants.

CONCLUSIONS

These results suggest that an appropriate level of sensory information provided to the spinal cord, generated through task-specific stepping and/or loading, can positively benefit the neural circuitries controlling urogenital and bowel functions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03036527.

Body System Effects of a Multi-Modal Training Program Targeting Chronic, Motor Complete Thoracic Spinal Cord Injury

The safety and efficacy of pharmacological and cellular transplantation strategies are currently being evaluated in people with spinal cord injury (SCI). In studies of people with chronic SCIs, it is thought that functional recovery will be best achieved when drug or cell therapies are combined with rehabilitation protocols. However, any functional recovery attributed to the therapy may be confounded by the conditioned state of the body and by training-induced effects on neuroplasticity. For this reason, we sought to investigate the effects of a multi-modal training program on several body systems. The training program included body-weight-supported treadmill training for locomotion, circuit resistance training for upper body conditioning, functional electrical stimulation for activation of sublesional muscles, and wheelchair skills training for overall mobility. Eight participants with chronic, thoracic-level, motor-complete SCI completed the 12-week training program. After 12 weeks, upper extremity muscular strength improved significantly for all participants, and some participants experienced improvements in function, which may be explained by increased strength. Neurological function did not change. Changes in pain and spasticity were highly variable between participants. This is the first demonstration of the effect of this combination of four training modalities. However, balancing participant and study-site burden with capturing meaningful outcome measures is also an important consideration.

Impact of bladder, bowel and sexual dysfunction on health status of people with thoracolumbar spinal cord injuries living in the community

OBJECTIVE

The disruption of autonomic function following a spinal cord injury (SCI) is common and can negatively affect quality of life. The objective of this study was to describe the prevalence of bladder/bowel incontinence and sexual dysfunction in community-dwelling individuals with a thoracolumbar SCI and examine the impact on general physical and mental health status.

METHODS

Participants who sustained a traumatic SCI to the thoracolumbar region of the spinal cord and classified as American Spinal Injury Association Impairment Scale (AIS) A to D were recruited. Demographic, injury data, MRI classification and neurological data were collected on admission. At follow-up, the neurological data, a questionnaire collecting participant-reported secondary health conditions (SHCs) (e.g. bladder incontinence, depression etc.) following SCI and health status measured by Short Form-36 were obtained. Regression models determined the association of health status with demographic/injury-related data, types and number of SHCs.

RESULTS

Of the 51 participants, 58.8% reported bladder incontinence, 54.0% bowel incontinence, 60.8% sexual dysfunction and 29.4% had all three. The regression models demonstrated that age at injury, bowel incontinence, sexual dysfunction, presence of pain, motor score at follow-up and the number of SHCs were significant predictors of health status. The number of SHCs was more predictive than all other demographic and injury variables for health status.

CONCLUSION

Results highlight the high prevalence of self-reported bowel/bladder incontinence and sexual dysfunction in the traumatic thoracolumbar SCI population and support the need for standardized assessments. Several demographic, injury-related and SHCs impacted health status and should be considered for the management of individuals living in the community.

Safety of Autologous Human Schwann Cell Transplantation in Subacute Thoracic Spinal Cord Injury

The rationale for implantation of autologous human Schwann cells (SCs) in persons with subacute spinal cord injury (SCI) is based on evidence that transplanted SCs are neuroprotective, support local axonal plasticity, and are capable of myelinating axons. A Phase I clinical trial was conducted to evaluate the safety of autologous human SC transplantation into the injury epicenter of six subjects with subacute SCI. The trial was an open-label, unblinded, non-randomized, non-placebo controlled study with a dose escalation design and standard medical rehabilitation. Participants were paraplegics with neurologically complete, trauma-induced spinal lesions. Autologous SCs were cultured in vitro from a sural nerve harvested from each participant and injected into the epicenter of the spinal lesion. Outcome measures for safety were protocol compliance, feasibility, adverse events, stability of neurological level, absence of detectable mass lesion, and the emergence of clinically significant neuropathic pain or muscle spasticity no greater than expected for a natural course cohort. One year post-transplantation, there were no surgical, medical, or neurological complications to indicate that the timing or procedure for the cell transplantation was unsafe. There were no adverse events or serious adverse events related to the cell therapy. There was no evidence of additional spinal cord damage, mass lesion, or syrinx formation. We conclude that it is feasible to identify eligible candidates, appropriately obtain informed consent, perform a peripheral nerve harvest to obtain SCs within 5-30 days of injury, and perform an intra-spinal transplantation of highly purified autologous SCs within 4-7 weeks of injury.

Ageing with neurogenic bowel dysfunction

STUDY DESIGN

Longitudinal study with postal survey.

OBJECTIVES

To describe changes in the patterns of neurogenic bowel dysfunction and bowel management in a population of people with spinal cord injury (SCI) followed for two decades.

SETTING

Members of the Danish SCI Association.

METHODS

In 1996, a validated questionnaire on bowel function was sent to the members of the Danish SCI Association (n=589). The same questionnaire was sent to all the surviving members in 2006 (n=284) and in 2015 (n=178). A total of 109 responded to both the 1996 and 2015 questionnaires.

RESULTS

Comparing data from 2015 with those from the exact same participants in 1996, the proportion of respondents needing more than 30 min for each defaecation increased from 21 to 39% (P<0.01), the use of laxatives increased (P<0.05) and the proportion considering themselves very constipated increased from 19 to 31% (P<0.01). In contrast, the proportion suffering from faecal incontinence remained stable at 18% in 1996 and 19% in 2015. During the 19-year period, there had been no significant change in the methods for bowel care, but 22 (20%) had undergone surgery for bowel dysfunction, including 11 (10%) who had some form of stoma.

CONCLUSION

Self-assessed severity of constipation increased but quality of life remained stable in a cohort of people with SCI followed prospectively for 19 years. Methods for bowel care remained surprisingly stable but a large proportion had undergone stoma surgery.

International spinal cord injury bowel function basic data set (Version 2.0)

STUDY DESIGN

International expert working group.

OBJECTIVES

To revise the International Spinal Cord Injury (SCI) Bowel Function Basic Data Set as a standardized format for the collecting and reporting of a minimal amount of information on bowel function in clinical practice and research.

SETTING

Working group appointed by the American Spinal injury association (ASIA) and the International Spinal Cord Society (ISCoS).

METHODS

The draft prepared by the working group was reviewed by the International SCI Data Set Committee and later by members of the ISCoS Executive and Scientific Committees and the ASIA board. The revised data set was posted on the ASIA and ISCoS websites for 1 month to allow further comments and suggestions. Changes resulting from a Delphi process among experts in children with SCI were included. Members of ISCoS Executive and Scientific Committees and the ASIA board made a final review and approved the data set.

RESULTS

The International SCI Bowel Function Basic Data Set (Version 2.0) consists of the following 16 items: date of data collection, gastrointestinal and anal sphincter dysfunction unrelated to SCI, surgical procedures on the gastrointestinal tract, defecation method and bowel-care procedures, average time required for defecation, frequency of defecation, uneasiness, headache or perspiration during defecation, digital stimulation or evacuation of the anorectum, frequency of fecal incontinence, flatus incontinence, need to wear pad or plug, oral laxatives and prokinetics, anti-diarrheal agents, perianal problems, abdominal pain and discomfort and the neurogenic bowel dysfunction score.

CONCLUSION

The International SCI Bowel Function Basic Data Set (Version 2.0) has been developed.

Epidural Spinal Stimulation to Improve Bladder, Bowel, and Sexual Function in Individuals With Spinal Cord Injuries: A Framework for Clinical Research

While some recent studies that apply epidural spinal cord stimulation (SCS) have demonstrated a breakthrough in improvement of the health and quality of the life of persons with spinal cord injury (SCI), the numbers of people who have received SCS are small. This is in sharp contrast to the thousands of persons worldwide living with SCI who have no practical recourse or hope of recovery of lost functions. Thus, the vision is to understand the full potential of this new intervention and to determine if it is safe and effective in a larger cohort, and if it is scalable so that it can be made available to all those who might benefit. To achieve this vision, the National Institute of Biomedical Imaging and Bioengineering called for and organized a consortium of multiple stakeholder groups: foundations addressing paralysis, federal and public agencies, industrial partners, academicians, and researchers, all interested in the same goal. Based on input from consortium participants, we have reasoned that a first step is to define a scalable SCS approach that is effective in restoring lost autonomic physiology, specifically bladder, bowel, and sexual function. These functions are most critical for improving the quality of life of persons living with SCI. This report outlines a framework for conducting the research needed to define such an effective SCS procedure that might seek Food and Drug Administration approval and be implemented at the population level.

Standardization of Data for Clinical Use and Research in Spinal Cord Injury

Increased survival after spinal cord injury (SCI) worldwide has enhanced the need for quality data that can be compared and shared between centers, countries, as well as across research studies, to better understand how best to prevent and treat SCI. Such data should be standardized and be able to be uniformly collected at any SCI center or within any SCI study. Standardization will make it possible to collect information from larger SCI populations for multi-center research studies. With this aim, the international SCI community has obtained consensus regarding the best available data and measures for use in SCI clinical practice and research. Reporting of SCI data is likewise standardized. Data elements are continuously updated and developed using an open and transparent process. There are ongoing internal, as well as external review processes, where all interested parties are encouraged to participate. The purpose of this review paper is to provide an overview of the initiatives to standardize data including the International Spinal Cord Society's International SCI Data Sets and the National Institutes of Health, National Institute of Neurological Disorders and Stroke Common Data Elements Project within SCI and discuss future opportunities.

Long-Term Outcomes and Longitudinal Changes of Neurogenic Bowel Management in Adults With Pediatric-Onset Spinal Cord Injury

OBJECTIVES

To describe long-term outcomes of neurogenic bowel dysfunction (NBD), determine changes over time in the type of bowel program, and determine changes in psychosocial outcomes associated with NBD-related factors in adults with pediatric-onset spinal cord injury (SCI).

DESIGN

Longitudinal cohort survey. Follow-up occurred annually for a total of 466 interviews, with most participants (75%) contributing to at least 3 consecutive interviews.

SETTING

Community.

PARTICIPANTS

Adults (N=131) who had sustained an SCI before the age of 19 years (men, 64.1%; tetraplegia, 58.8%; mean age ± SD, 33.4±6.1y; mean time since injury ± SD, 19.5±7.0y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Type and evacuation time of bowel management programs; standardized measures assessing life satisfaction, health perception, depressive symptoms, and participation. Generalized estimating equations were formulated to determine odds of change in outcomes over time.

RESULTS

At first interview, rectal suppository/enema use was most common (51%). Over time, the likelihood of using manual evacuation (odds ratio [OR]=1.077; 95% confidence interval [CI], 1.023-1.134; P=.005), oral laxatives (OR=1.052; 95% CI, 1.001-1.107; P=.047), and colostomy (OR=1.071; 95% CI, 1.001-1.147; P=.047) increased, whereas the odds of rectal suppository use decreased (OR=.933; 95% CI, .896-.973; P=.001). Bowel evacuation times were likely to decrease over time in participants using manual evacuation (OR=.499; 95% CI, .256-.974; P=.042) and digital rectal stimulation (OR=.490; 95% CI, .274-.881; P=.017), but increase for rectal suppository/enema use (OR=1.871; 95% CI, 1.264-2.771; P=.002). When the level of injury was controlled for, participants using manual evacuation and digital rectal stimulation were more likely to have increases in community participation scores (P<.05).

CONCLUSIONS

Changes in type of bowel program over time may be associated with the time required to complete bowel evacuation in this relatively young adult SCI population.

Risk Factors Associated With Neurogenic Bowel Complications and Dysfunction in Spinal Cord Injury

OBJECTIVES

To (1) assess the factors associated with methods of bowel management and bowel-related complications; and (2) determine the risk factors associated with bowel complications and overall bowel dysfunction, using multivariate modeling.

DESIGN

Cross-sectional observational study.

SETTING

A Spinal Cord Injury Model System, with additional participants recruited from other sites.

PARTICIPANTS

Subjects (N=291) who incurred traumatic spinal cord injury (SCI) with resultant neurogenic bowel who were ≥5 years postinjury at the time of interview.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Constipation, bowel incontinence, and neurogenic bowel dysfunction questionnaire scores. These measures were all derived from the Bowel and Bladder Treatment Index. Data analyses included descriptive and bivariate statistics as well as logistic and linear regression modeling.

RESULTS

Risk factors contributing to bowel incontinence included overall bowel dysfunction as measured by the neurogenic bowel dysfunction score, timing of bowel program, being married or having a significant other, urinary incontinence, constipation, and use of diuretics. Constipation was best predicted by age, race/ethnicity, using laxatives/oral medications, incomplete tetraplegia, frequency of bowel movements, abdominal pain, access to clinicians and caregivers, and history of bowel surgeries. Neurogenic bowel dysfunction scores were predicted by neurologic classification; use of laxatives, oral medications, or both; bowel incontinence; and frequency of fiber intake.

CONCLUSIONS

These results suggest a number of factors that should be considered when treating neurogenic bowel complications and dysfunction in persons with SCI.

Probiotics [LGG-BB12 or RC14-GR1] versus placebo as prophylaxis for urinary tract infection in persons with spinal cord injury [ProSCIUTTU]: a study protocol for a randomised controlled trial

Background

Urinary tract infections [UTIs] are very common in people with Spinal Cord Injury [SCI]. UTIs are increasingly difficult and expensive to treat as the organisms that cause them become more antibiotic resistant. Among the SCI population, there is a high rate of multi-resistant organism [MRO] colonisation. Non-antibiotic prevention strategies are needed to prevent UTI without increasing resistance. Probiotics have been reported to be beneficial in preventing UTIs in post-menopausal women in several in vivo and in vitro studies. The main aim of this study is to determine whether probiotic therapy with combinations of Lactobacillus reuteri RC-14 + Lactobacillus rhamnosus GR-1 [RC14-GR1] and/or Lactobacillus rhamnosus GG + Bifidobacterium BB-12 [LGG-BB12] are effective in preventing UTI in people with SCI compared to placebo.

Method

This is a multi-site randomised double-blind double-dummy placebo-controlled factorial design study conducted in New South Wales, Australia. All participants have a neurogenic bladder as a result of spinal injury. Recruitment started in April 2011.

Participants are randomised to one of four arms, designed for factorial analysis of LGG-BB12 and/or RC14-GR1 v Placebo. This involves 24 weeks of daily oral treatment with RC14-GR1 + LGG-BB12, RC14-GR1 + placebo, LGG-BB12 + placebo or two placebo capsules. Randomisation is stratified by bladder management type and inpatient status. Participants are assessed at baseline, three months and six months for Short Form Health Survey [SF-36], microbiological swabs of rectum, nose and groin; urine culture and urinary catheters for subjects with indwelling catheters. A bowel questionnaire is administered at baseline and three months to assess effect of probiotics on bowel function.

The primary outcome is time from randomisation to occurrence of symptomatic UTI. The secondary outcomes are change of MRO status and bowel function, quality of life and cost-effectiveness of probiotics in persons with SCI. The primary outcome will be analysed using survival analysis of factorial groups, with Cox regression modelling to test the effect of each treatment while allowing for the other, assuming no interaction effect. Hazard ratios and Kaplan-Meier survival curves will be used to summarise results.

Discussion

If these probiotics are shown to be effective in preventing UTI and MRO colonisation, they would be a very attractive alternative for UTI prophylaxis and for combating the increasing rate of antibiotic resistance after SCI.

Trial registration

Australian New Zealand Clinical Trials Registry [ACTRN 12610000512022]. Date of registration: 21 June 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-016-0136-8) contains supplementary material, which is available to authorized users.

Bowel dysfunction in spinal cord injury: current perspectives

Permanent disruptions of gastrointestinal function are very common sequel of spinal cord injury (SCI). When motor and sensory nervous integrity are severely affected, neurogenic gastrointestinal dysfunction is an inevitable consequence. Autonomic nervous system miss function has significantly diminished or lost sensory sensations followed with incomplete evacuation of stool from the rectal vault, immobility, and reduced anal sphincter tone all of those predisposing to increased risk of fecal incontinence (FI). The FI is, beside paralysis of extremities, one of the symptoms most profoundly affecting quality of life (QOL) in patients with SCI. We are reviewing current perspectives in management of SCI, discussing some pathophysiology mechanisms which could be addressed and pointing toward actual practical concepts in use for evaluation and improvements necessary to sustain SCI patients QOL.

Common data elements for spinal cord injury clinical research: a National Institute for Neurological Disorders and Stroke project

OBJECTIVES

To develop a comprehensive set of common data elements (CDEs), data definitions, case report forms and guidelines for use in spinal cord injury (SCI) clinical research, as part of the CDE project at the National Institute of Neurological Disorders and Stroke (NINDS) of the US National Institutes of Health.

SETTING

International Working Groups.

METHODS

Nine working groups composed of international experts reviewed existing CDEs and instruments, created new elements when needed and provided recommendations for SCI clinical research. The project was carried out in collaboration with and cross-referenced to development of the International Spinal Cord Society (ISCoS) International SCI Data Sets. The recommendations were compiled, subjected to internal review and posted online for external public comment. The final version was reviewed by all working groups and the NINDS CDE team before release.

RESULTS

The NINDS SCI CDEs and supporting documents are publically available on the NINDS CDE website and the ISCoS website. The CDEs span the continuum of SCI care and the full range of domains of the International Classification of Functioning, Disability and Health.

CONCLUSION

Widespread use of CDEs can facilitate SCI clinical research and trial design, data sharing and retrospective analyses. Continued international collaboration will enable consistent data collection and reporting, and will help ensure that the data elements are updated, reviewed and broadcast as additional evidence is obtained.

Outcomes of neurogenic bowel management in individuals living with a spinal cord injury for at least 10 years

OBJECTIVE

To describe bowel management and its outcomes in individuals living with a spinal cord injury (SCI) for at least 10 years.

DESIGN

Cross-sectional multicenter study.

SETTING

Dutch community.

PARTICIPANTS

Individuals (N=258; age range, 28-65y) who acquired their SCI between 18 and 35 years of age, who were at least 10 years post-SCI, and who used a wheelchair for their daily mobility.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The International SCI Bowel Function Basic Data Set, the neurogenic bowel dysfunction (NBD) score, and a single item on satisfaction with bowel management.

RESULTS

Mean time since injury (TSI) was 24±9 years. Seventy-four percent used ≥1 conservative bowel management method, specifically digital evacuation (35%) and mini enemas (31%). Transanal irrigation (TAI) and surgical interventions were used by 11% and 8%, respectively. Perianal problems were reported by 45% of the participants. Severe NBD was present in 36% of all participants and in 40% of those using a conservative method. However, only 14% were (very) dissatisfied with their current bowel management. Dissatisfaction with bowel management was significantly associated with constipation and severe NBD. With increasing TSI, there was a nonsignificant trend observed toward a decline in dissatisfaction with bowel management and a significant decline in severe NBD.

CONCLUSIONS

Although satisfaction rates were high, more than a third of the participants reported severe NBD and perianal problems. Apart from severe NBD, there were no significant associations between bowel problems and TSI. Conservative methods were most often used, but some of these methods were also significantly associated with the presence of severe NBD. Longitudinal research is necessary to provide more knowledge concerning the course of NBD with increasing TSI.

Autonomic dysreflexia during bowel evacuation procedures and bladder filling in subjects with spinal cord injury

STUDY DESIGN

Randomized, controlled clinical trial.

OBJECTIVES

Bladder and bowel management may cause serious autonomic dysreflexia (AD) in subjects with high spinal cord injury (SCI). We aimed at investigating autonomic responses to digital rectal evacuation (DE), transanal irrigation (TAI) with 500 ml and filling cystometry (FC) in SCI.

SETTING

Aarhus University Hospital, Denmark.

METHODS

Eight subjects with SCI (AIS A) at or above T6 (high SCI) and a previous history of AD were compared with three subjects with SCI (AIS A) between T10 and L2 (low SCI). In randomized order, DE, TAI and FC were performed. AD was defined as an acute rise in systolic blood pressure (sBP) of ⩾30 mm Hg above baseline. Blood levels of norepinephrine and epinephrine were determined before and shortly after the procedures.

RESULTS

During all three procedures, AD occurred in all patients with high SCI but not in those with low SCI. In high SCI subjects, DE increased median sBP from 127 (range: 86-154) to 188 (range: 140-206) mm Hg (P<0.02), TAI from 126 (range: 91-146) to 163 (range: 130-188) mm Hg (P<0.02) and FC from 125 (range: 106-149) to 200 (range: 179-220) mm Hg (P<0.01). The sBP increase was lower during TAI than during DE (P<0.05) or FC (P<0.02). In high SCI subjects, the blood levels of norepinephrine, but not those of epinephrine, increased significantly during all three stimuli (all P<0.05).

CONCLUSION

Bowel and bladder management caused AD in high SCI. The response is less severe during TAI than during FC or DE.

Electroacupuncture improves bladder and bowel function in patients with traumatic spinal cord injury: results from a prospective observational study

In order to explore the effect of electroacupuncture (EA) for chronic bowel and bladder dysfunction after traumatic spinal cord injury, 14 patients were treated with electroacupuncture once a day, five times a week for the first four weeks, and once every other day, three times a week for the following four weeks. The patients were then followed up for six months. After treatment, four (4/14, 28.57%) patients resumed normal voiding; six (6/14, 42.86%) resumed normal voiding for no less than half of all micturition behaviors; four (4/14, 28.57%) required supplementary urination methods for higher than half of all micturition behaviors. These effects persisted during followup. Mean postvoid RUV decreased by 190.29 ± 101.87 mL (P < 0.01) after treatment and by 198.86 ± 112.18 mL (P < 0.01) during followup. Patients' weekly urinary incontinence frequency decreased 7.14 ± 46.34 times/week (P = 0.036) after treatment and decreased 49.86 ± 44.38 times/week during followup. After treatment, four (4/14, 28.57%) patients resumed normal bowel movements (P = 0.025); five (5/14, 35.71%) reduced the dependence on supplementary defecation methods; five (5/14, 35.71%) had no changes. In patients with chronic bowel and bladder dysfunction after traumatic SCI, EA may provide a valuable alternative tool in improving patients' self-controlled bowel and bladder functions with minimal side effects.

Frequency and age effects of secondary health conditions in individuals with spinal cord injury: a scoping review

STUDY DESIGN

Scoping review.

OBJECTIVES

To gain a better understanding of the prevalence, course and association with age of secondary health conditions in individuals with spinal cord injury (SCI).

SETTING

Seattle, Washington, USA.

METHODS

We performed searches of electronic databases for studies published from 1986-2011 that provided information regarding the prevalence, course or associations with age and duration of secondary health conditions in individuals with SCI.

RESULTS

Ninety-two studies were included. The findings indicate that: (1) individuals with SCI experience a number of secondary health conditions, many of which occur at a higher rate in those with SCI than the normative population; (2) the most common conditions or symptoms are pain, bowel and bladder regulation problems, muscle spasms, fatigue, esophageal symptom and osteoporosis; (3) a number of conditions, including cardiovascular disease, diabetes, bone mineral density loss, fatigue and respiratory complications or infections, occur with higher frequency in older individuals or those with longer SCI duration, relative to younger individuals or those with shorter SCI duration; and (4) there is a marked lack of longitudinal research examining the natural course of health conditions in individuals aging with SCI.

CONCLUSIONS

The findings support the conclusion that individuals with SCI show signs of 'premature aging' in different organ systems. Longitudinal research is needed to understand when problems are most likely to emerge, and to develop and test the efficacy of interventions to prevent these health conditions and their negative impact.

Colorectal transport during defecation in subjects with supraconal spinal cord injury

STUDY DESIGN

Clinical study.

OBJECTIVES

To explore how supraconal spinal cord injury (SCI) affects colorectal emptying at defecation. Further, to relate findings to subject symptomatology expressed by bowel function scores and gastrointestinal transit time (GITT).

SETTING

Aarhus University Hospital, Denmark.

METHODS

Colorectal contents were marked by oral intake of (111)In-coated resin pellets. Movement of stools at defecation was assessed by comparing scintigrams performed before and just after defecation. Results from 15 subjects with SCI (14 males, median age=47 years (range: 22-74 years), SCI level: C5-Th9) were compared with those from 16 healthy volunteers (12 males, median age=31 years (range: 24-42 years)). Bowel symptoms were described from standard symptom scores, and GITT was assessed by radiopaque markers.

RESULTS

Median emptying at defecation was 31% of the rectosigmoid (range: 0% to complete emptying of the rectosigmoid and 49% of the descending colon) in subjects with SCI and 89% of the rectosigmoid (range: 53% to complete emptying of the rectosigmoid and the descending colon, and 3% of the transverse colon) in the control group (P<0.01). Colorectal emptying at defecation was associated with the St Mark's fecal incontinence score (P=0.02) but not with the Cleveland constipation score (P=0.17), the neurogenic bowel dysfunction score (P=0.12) or GITT (P=0.99).

CONCLUSION

Supraconal SCI results in significantly reduced emptying of stools at defecation. This is independent of changes in GITT.

Application of transanal irrigation for patients with spinal cord injury in South Korea: a 6-month follow-up study

STUDY DESIGN

A 6-month follow-up study.

OBJECTIVES

To investigate the outcome of transanal irrigation (TAI) in patients with spinal cord injury (SCI) and to identify factors significantly related to clinical success.

SETTING

Survey for community-dwelling patients with SCI in South Korea.

METHODS

Between December 2010 and March 2012, TAI was initiated with 52 patients (41 men; age: 44.5±11.0 years) with neurogenic bowel dysfunction (NBD). At 1, 3 and 6 months after initiation, a telephone interview was conducted. Data were collected on patient-specific bowel management and TAI performance as a new procedure.

RESULTS

Only 18 patients (34%) used TAI for at least 6 months, which was a lower compliance rate than similar studies in some European countries. Relative to the compliant group, the noncompliant group contained a higher proportion of tetraplegia than paraplegia (P=0.031), and a higher proportion dependent on physical help (P=0.034). In all, 33 of the 52 patients (63.5%) complained of practical problems with the TAI procedure such as expulsion of the rectal catheter. Fifteen patients (28.8%) presented with adverse effects. The incidence of practical problems or adverse effects did not alter the frequency of patient-reported successful outcome.

CONCLUSION

Korean participants showed a relatively lower compliance rate with TAI. We conclude that TAI, combined with adequate patient instruction and physical assistance, has potential as a management tool for NBD in Korea.

Abdominal Pain: A Comparison between Neurogenic Bowel Dysfunction and Chronic Idiopathic Constipation

Introduction. Most spinal-cord-injured patients have constipation. One-third develop chronic abdominal pain 10 years or more after injury. Nevertheless, very little is known about the nature of abdominal pain after spinal cord injury (SCI). It may be neuropathic or caused by constipation. Aim. To compare characteristics of abdominal pain in SCI with able-bodied with chronic idiopathic constipation (CIC). Subjects and Methods. 21 SCI and 15 CIC patients were referred for treatment of bowel symptoms. Constipation-related symptoms were assessed with the Cleveland Constipation Scoring System and the International Spinal Cord Injury Basic Bowel Function Data Set. Characteristics of abdominal pain were described using the Brief Danish Pain Questionnaire. Total gastrointestinal transit times (GITT) were measured by radiopaque markers. Results. Seventeen (81%) SCI and 14 (93%) CIC patients reported abdominal pain or discomfort within the last month (P = 0.38). Pain was considered more intense by CIC than by SCI patients (P < 0.05). Only minor differences were found in patient's qualitative description of abdominal pain or in the location of pain. In neither SCI nor CIC was pain associated with GITT. Conclusion. Most characteristics of abdominal pain among SCI patients resemble those of CIC. This indicates that constipation is a major cause of pain after SCI.

Medical rehabilitation after natural disasters: why, when, and how?

Natural disasters can cause significant numbers of severe, disabling injuries, resulting in a public health emergency and requiring foreign assistance. However, since medical rehabilitation services are often poorly developed in disaster-affected regions and not highly prioritized by responding teams, physical and rehabilitation medicine (PRM) has historically been underemphasized in global disaster planning and response. Recent development of the specialties of "disaster medicine" and "disaster rehabilitation" has raised awareness of the critical importance of rehabilitation intervention during the immediate postdisaster emergency response. The World Health Organization Liaison Sub-Committee on Rehabilitation Disaster Relief of the International Society of Physical and Rehabilitation Medicine has authored this report to assess the role of emergency rehabilitation intervention after natural disasters based on current scientific evidence and subject matter expert accounts. Major disabling injury types are identified, and spinal cord injury, limb amputation, and traumatic brain injury are used as case studies to exemplify the challenges to effective management of disabling injuries after disasters. Evidence on the effectiveness of disaster rehabilitation interventions is presented. The authors then summarize the current state of disaster-related research, as well as lessons learned from PRM emergency rehabilitation response in recent disasters. Resulting recommendations for greater integration of PRM services into the immediate emergency disaster response are provided. This report aims to stimulate development of research and practice in the emerging discipline of disaster rehabilitation within organizations that provide medical rehabilitation services during the postdisaster emergency response.