Use of screening to recruitment ratios as a tool for planning and implementing spinal cord injury rehabilitation research

The potential effects of untreated sleep-related breathing disorders on neuropathic pain, spasticity, and cardiovascular dysfunction following spinal cord injury: A cross-sectional prospective study protocol

INTRODUCTION

Sleep-related breathing disorders (SRBDs), neuropathic pain, spasticity and cardiovascular autonomic dysfunction are common after spinal cord injury (SCI). Prior studies suggest that systemic inflammation following SCI may be implicated in the development of neuropathic pain, spasticity and cardiovascular dysfunction. Given that SRBDs also cause a systemic inflammatory response, we hypothesized that individuals with SCI who develop more severe SRBDs would experience more intense neuropathic pain, more severe spasticity and more significant cardiovascular autonomic dysfunction.

METHODS

This cross-sectional prospective study will explore the previously understudied hypothesis that SRBDs are associated with increased neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in adult individuals with low-cervical/high-thoracic (injury level at C5 to T6), complete/incomplete (ASIA Impairment Scale A, B, C or D) SCI.

DISCUSSION

To our knowledge, no prior study has addressed this clinically relevant question on whether the degree of SRBDs affects the intensity of neuropathic pain, spasticity, and cardiovascular autonomic dysfunction in individuals with SCI. We anticipate that the results of this original study will provide key information for a future clinical trial on the use of continuous positive airway pressure (CPAP) therapy for moderate-to-severe SRBDs, which may better control neuropathic pain, spasticity, and cardiovascular autonomic dysfunction among individuals with SCI.

TRIAL REGISTRATION

The research protocol for this study was registered in the ClinicalTrials.gov website (NCT05687097). https://clinicaltrials.gov/ct2/show/NCT05687097.

A qualitative photo-elicitation study exploring the impact of falls and fall risk on individuals with subacute spinal cord injury

Background

Individuals living with chronic spinal cord injury or disease (SCI/D) are at an increased risk of falling. However, little is known about the impact of falls and fall risk in the subacute phase of SCI/D, despite this being a time when fall prevention initiatives are delivered. Hence, we explored the impact of falls and fall risk in individuals with subacute SCI/D as they transitioned from inpatient rehabilitation to community living.

Methods

This qualitative photo-elicitation study used an inductive thematic analysis. Eight individuals (7 male) undergoing inpatient rehabilitation at a Canadian tertiary rehabilitation hospital due to a new SCI/D participated. Six months following discharge, photo-elicitation interviewing was used to understand the impact of falls and fall risk. Over 7–14 days, participants completed a photo-assignment that involved taking photographs in response to questions, such as what increases/decreases your likelihood of falling? A semi-structured interview followed, in which participants described their photographs and discussed their experiences with falls, fall risk and fall prevention training.

Results

Four themes were identified. 1) Risk factors and strategies identified through lived experience. Participants discovered their fall risk factors and fall prevention strategies through “trial and error”. 2) Influences on the individual’s perception of their fall risk. Prior experience with falls, including falls experienced by themselves as well as friends and family, influenced their perception of fall risk. 3) Experiencing life differently due to increased fall risk. A high fall risk reduced participation, increased negative emotions and decreased independence and quality of life. 4) Falls training in rehabilitation can be improved. Prior experiences with falls training varied; however, participants expressed a desire for comprehensive and individualized training.

Conclusion

Although participants’ experiences with falls and fall prevention varied, falls and the risk of falling can have a significant impact on the first year of living with a SCI/D.

Machine Learning Prediction of Clinical Trial Operational Efficiency

Clinical trials are the gatekeepers and bottlenecks of progress in medicine. In recent years, they have become increasingly complex and expensive, driven by a growing number of stakeholders requiring more endpoints, more diverse patient populations, and a stringent regulatory environment. Trial designers have historically relied on investigator expertise and legacy norms established within sponsor companies to improve operational efficiency while achieving study goals. As such, data-driven forecasts of operational metrics can be a useful resource for trial design and planning. We develop a machine learning model to predict clinical trial operational efficiency using a novel dataset from Roche containing over 2,000 clinical trials across 20 years and multiple disease areas. The data includes important operational metrics related to patient recruitment and trial duration, as well as a variety of trial features such as the number of procedures, eligibility criteria, and endpoints. Our results demonstrate that operational efficiency can be predicted robustly using trial features, which can provide useful insights to trial designers on the potential impact of their decisions on patient recruitment success and trial duration.

Central Recruitment: A process for engaging and recruiting individuals with spinal cord injury/disease in research at Toronto Rehabilitation Institute

CONTEXT

Insufficient recruitment is a barrier to research and limits statistical power. We describe an initiative aimed to streamline recruitment and consent processes for inpatients with spinal cord injury or disease (SCI/D) via implementation of a Central Recruitment (CR) process. The CR process adhered to ethical standards, reduced participant burden, and maximized research participation.

METHODS

In this CR process, the inpatient's nurse affirmed suitability for research approach based on fluency, cognition and health stability. A patient research liaison (PRL) was the sole contact for information regarding the research process, and introduced ongoing studies, screened for eligibility, and completed the consent process(es).

RESULTS

Over five and a half years, 1,561 inpatients with SCI/D were screened for eligibility upon admission, of whom 80% (1256/1561) were deemed suitable for the PRL approach. Of those suitable for the CR process, 80% (1001/1256) agreed to discuss current research opportunities, 46% (235/516) consented to participate in one or more studies, and 86% (856/1001) agreed to future research contact.

CONCLUSION

This process adhered to ethical procedures and reduced the burden of having multiple researchers approach each individual inpatient regarding research participation, with high consent rates for low-risk studies. Future evaluation of the process scalability is underway.

Prevalence of postpartum depression and anxiety among women with spinal cord injury

Objective: To examine the prevalence of postpartum depression (PPD) and postpartum anxiety (PPA) in mothers with spinal cord injury (SCI).Design: Retrospective, cross-sectional study.Setting: Online multi-national study.Participants: We surveyed an international sample of 102 women who gave birth following cervical SCI (C1-C8, n = 30), upper thoracic SCI (T1-T6, n = 12) or lower level SCI (T7 & below, n = 60). Participants were primarily from Canada and Sweden, and mean age at childbirth was 30 ± 6 years.Outcome Measures: Subscales from the Pregnancy Risk Assessment Monitoring System (PRAMS) were used to measure PPD (PRAMS-3D) and PPA (PRAMS-2A).Results: PPD and PPA were most prevalent in women with cervical SCI, followed by upper thoracic SCI then lower SCI. Self-reported PPD was more prevalent than clinically diagnosed PPD in women with cervical SCI (P = 0.03) and upper thoracic SCI (P = 0.03). With cervical SCI, 75% of women diagnosed with MDD before pregnancy scored >9 on the PRAMS PPD subscale, indicating clinically relevant PPD. However, only 10% were diagnosed with PPD. Of women with lower SCI diagnosed with MDD before pregnancy, 25% had a clinically relevant score for self-reported PPD; 7% were diagnosed.Conclusions: This is currently the largest study examining PPD and PPA after SCI. Clinicians should be aware that mothers with SCI (particularly high-level SCI) may have increased risk of PPD and PPA. PPD is poorly understood in women with SCI and may even be underdiagnosed. SCI-related risk factors for PPD and PPA should be explored.

Functional Electrical Stimulation Plus Visual Feedback Balance Training for Standing Balance Performance Among Individuals With Incomplete Spinal Cord Injury: A Case Series

Individuals with an incomplete spinal cord injury (iSCI) are highly susceptible to falls during walking or standing. Our objective was to evaluate a therapeutic tool for standing balance that combined functional electrical stimulation, applied bilaterally to the plantarflexors and dorsiflexors, with visual feedback balance training (FES+VFBT). Five adults with iSCI completed 12 FES+VFBT sessions over 4 weeks. During the training sessions, participants completed each of the four balance exercises twice. Visual feedback of the center-of-pressure (COP) location was provided as participants completed the balance exercises and received FES to assist with performance of the exercises. A closed-loop FES system was used in which the COP was continually monitored and the level of electrical current administered was automatically adjusted. Balance abilities were assessed pre- and post- training using clinical balance scales (i.e., Berg Balance Scale, Mini-Balance Evaluation Systems Test, and Activities-specific Balance Confidence Scale) and biomechanical assessments (i.e., postural sway measures and limits of stability test during standing). User acceptability was explored through semi-structured interviews. Improvements were seen for four of the five participants on at least one of the clinical scales following completion of the training intervention. All participants showed greater maximal COP excursion area during the limits of stability test after the training intervention, whereas only one participant demonstrated a reduction in postural sway. Specific components of FES+VFBT, including the ability to safely practice challenging balance exercises, were deemed important by the participants. These results suggest that FES+VFBT has potential as an intervention for standing balance after iSCI.

Lessons learned from the pilot study of an orthostatic hypotension intervention in the subacute phase following spinal cord injury

Context: Following spinal cord injury (SCI) at the cervical or upper-thoracic level, orthostatic hypotension (OH) is observed in 13-100% of patients. This study aimed to test the feasibility of conducting a randomized controlled trial combining a dynamic tilt-table (Erigo^®) and functional electrical stimulation (FES) to mitigate OH symptoms in the subacute phase after SCI. Design: Pilot study. Setting: A tertiary rehabilitation hospital. Participants: Inpatients who had a C4-T6 SCI (AIS A-D) less than 12 weeks before recruitment, and reported symptoms of OH in their medical chart. Interventions: Screening sit-up test to determine eligibility, then 1 assessment session and 3 intervention sessions with Erigo^® and FES for eligible participants. Outcome measures: Recruitment rate, duration of assessment and interventions, resources used, blood pressure, and Calgary Presyncope Form (OH symptoms). Results: Amongst the 232 admissions, 148 inpatient charts were reviewed, 11 inpatients met all inclusion criteria, 7 participated in a screening sit-up test, and 2 exhibited OH. Neither of the two participants recruited in the pilot study was able to fully complete the assessment and intervention sessions due to scheduling issues (i.e. limited available time). Conclusion: This pilot study evidenced the non-feasibility of the clinical trial as originally designed, due to the low recruitment rate and the lack of available time for research in participant's weekday schedule. OH in the subacute phase after SCI was less prevalent and less incapacitating than expected. Conventional management and spontaneous resolution of symptoms appeared sufficient to mitigate OH in most patients with subacute SCI.

Can targeted job-information for adults with spinal cord dysfunction be effectively delivered online? A pilot study

OBJECTIVE

To pilot a novel email-based information package (Work and SCI) for job-seekers with an acquired spinal cord injury (SCI) or spinal cord dysfunction (SCI/D).

STUDY DESIGN

Prospective, non-randomized, repeated measures trial.

SETTING

Community dwelling cohort in Australia.

PARTICIPANTS

Five people with SCI (mean age 46.4 years, SD = 10.2; 4 female) initially reviewed Work and SCI. Twenty-four with SCI/D subsequently enrolled, of whom 16 (mean age 46.4 years, SD = 11.1; 7 female), completed the intervention.

INTERVENTION

Intervention participants accessed Work and SCI over a 4-week period.

OUTCOME MEASURES

Individual changes in pre-post scores for the My Vocational Situation Scale, Job Procurement Self-Efficacy Scale, Patient Health Questionnaire-9 and Life Orientation Test-Revised were examined.

RESULTS

Reliable change in pre-post scores across outcomes were reported by 38% (n = 6) of participants. Favorable comments on the Work and SCI resource were provided in addition to suggestions for improvement.

CONCLUSIONS

Preliminary data suggest that Work and SCI may help to establish vocational interests among job-seekers with a SCI/D, however further work is needed to enhance participant compliance. This might include moderator support to promote and maintain participation. A controlled design will also help to identify factors that influence engagement with the Work and SCI resource.

Does Muscle Atrophy and Fatty Infiltration Plateau or Persist in Chronic Spinal Cord Injury?

Atrophy and fatty infiltration of lower extremity muscle after spinal cord injury (SCI) predisposes individuals to metabolic syndrome and related diabetes and cardiovascular disease. The objective of this study was to prospectively measure changes in muscle atrophy and fat content of distal lower extremity muscles and explore related factors in a cohort of adults with chronic SCI and diverse impairments. Muscle cross-sectional area and density were calculated from peripheral quantitative computed tomography scans of the 66% site of the calf from 70 participants with chronic SCI (50 male, mean age 49 years, C2-T12, American Spinal Injury Association Impairment Scale A-D) at study enrollment and annually for 2 years. Mixed-model repeated measures analysis of variance (rANOVA) examined longitudinal changes in muscle area and density, and regression analyses explored factors related to muscle changes using 16 potential correlates selected a priori. A high degree of individual variation in muscle area and density change was observed over 2 years (range: 8.5 to  -22.6 cm²; 6.4 to -8.6 mg/cm³). Repeated measures analysis of variance revealed significant reductions in muscle area (estimated mean difference [95% confidence intervals] -1.76 [-3.29 to -0.23]) cm², p = 0.025) and density (-1.04 [-1.94 to -0.14] mg/cm³, p < 0.024); however, changes in area were not significant with outliers removed. Regression analyses explained a small proportion of the variability in muscle density change; however, none of the preselected variables were significantly related to changes in muscle density after post hoc sensitivity analyses. Lower extremity muscle size and fat content may not reach a "steady-state" after chronic SCI. Progressive atrophy and fatty infiltration of lower extremity muscle may have adverse implications for metabolic syndrome and cardiovascular disease risk and related mortality after chronic SCI.