Spinal cord injury facts and figures at a glance

Intervention Design of High-Intensity Interval Training in Individuals With Spinal Cord Injury: Narrative Review and Future Perspectives

Background

Individuals with spinal cord injury (SCI) have lower levels of physical activity compared to the nondisabled population. Exercise guidelines recommend moderate or vigorous exercise to improve cardiovascular health and reduce cardiometabolic risk factors in persons with SCI. High-intensity interval training (HIIT) is a popular exercise choice and encompasses brief periods of vigorous exercise paired with intermittent periods of recovery.

Objectives

This review describes the available literature on HIIT for individuals with SCI, including differences in protocol design and suggested areas of further investigation.

Methods

Our institution's library system performed the comprehensive search. The primary keywords and phrases used to search included spinal cord injury, high-intensity interval training, tetraplegia, paraplegia, and several other related terms.

Results

Initially 62 records were screened, and 36 were deemed outside the scope of this review. Twenty-six studies published between 2001 and 2021 fulfilled the eligibility criteria and were divided among two researchers for review and analysis. All records required persons with SCI and a standardized HIIT intervention. Study design varied widely with respect to mode of exercise, prescribed intensity, duration of performance intervals, and session duration. This variability necessitates further investigation into the specifics of a HIIT prescription and the associated outcomes for persons with SCI.

Conclusion

Standardization of HIIT protocols may lead to more robust conclusions regarding its effects on cardiorespiratory fitness as well as mitigation of cardiometabolic risk factors. Meta-analyses will eventually be needed on proper dosing and session parameters to improve cardiorespiratory fitness and cardiometabolic risk factors.

Precision medicine for traumatic cervical spinal cord injuries: accessible and interpretable machine learning models to predict individualized in-hospital outcomes

BACKGROUND CONTEXT

A traumatic spinal cord injury (SCI) can cause temporary or permanent motor and sensory impairment, leading to serious short and long-term consequences that can result in significant morbidity and mortality. The cervical spine is the most commonly affected area, accounting for about 60% of all traumatic SCI cases.

PURPOSE

This study aims to employ machine learning (ML) algorithms to predict various outcomes, such as in-hospital mortality, nonhome discharges, extended length of stay (LOS), extended length of intensive care unit stay (ICU-LOS), and major complications in patients diagnosed with cervical SCI (cSCI).

STUDY DESIGN

Our study was a retrospective machine learning classification study aiming to predict the outcomes of interest, which were binary categorical variables, in patients diagnosed with cSCI.

PATIENT SAMPLE

The data for this study were obtained from the American College of Surgeons (ACS) Trauma Quality Program (TQP) database, which was queried to identify patients who suffered from cSCI between 2019 and 2021.

OUTCOME MEASURES

The outcomes of interest of our study were in-hospital mortality, nonhome discharges, prolonged LOS, prolonged ICU-LOS, and major complications. The study evaluated the models' performance using both graphical and numerical methods. The receiver operating characteristic (ROC) and precision-recall curves (PRC) were used to assess model performance graphically. Numerical evaluation metrics included AUROC, balanced accuracy, weighted area under PRC (AUPRC), weighted precision, and weighted recall.

METHODS

The study employed data from the American College of Surgeons (ACS) Trauma Quality Program (TQP) database to identify patients with cSCI. Four ML algorithms, namely XGBoost, LightGBM, CatBoost, and Random Forest, were utilized to develop predictive models. The most effective models were then incorporated into a publicly available web application designed to forecast the outcomes of interest.

RESULTS

There were 71,661 patients included in the analysis for the outcome mortality, 67,331 for the outcome nonhome discharges, 76,782 for the outcome prolonged LOS, 26,615 for the outcome prolonged ICU-LOS, and 72,132 for the outcome major complications. The algorithms exhibited an AUROC value range of 0.78 to 0.839 for in-hospital mortality, 0.806 to 0.815 for nonhome discharges, 0.679 to 0.742 for prolonged LOS, 0.666 to 0.682 for prolonged ICU-LOS, and 0.637 to 0.704 for major complications. An open access web application was developed as part of the study, which can generate predictions for individual patients based on their characteristics.

CONCLUSIONS

Our study suggests that ML models can be valuable in assessing risk for patients with cervical cSCI and may have considerable potential for predicting outcomes during hospitalization. ML models demonstrated good predictive ability for in-hospital mortality and nonhome discharges, fair predictive ability for prolonged LOS, but poor predictive ability for prolonged ICU-LOS and major complications. Along with these promising results, the development of a user-friendly web application that facilitates the integration of these models into clinical practice is a significant contribution of this study. The product of this study may have significant implications in clinical settings to personalize care, anticipate outcomes, facilitate shared decision making and informed consent processes for cSCI patients.

A new balance assessment tool for quantifying balance impairment in patients with motor incomplete spinal cord injury: Pilot study

OBJECTIVE

This study aimed to quantitatively and objectively evaluate the balance impairment in patients with motor incomplete spinal cord injury (SCI) using a new evaluation tool for balance and to assess its role in comprehensive balance assessment.

DESIGN

Retrospective pilot study.

SETTING

Rehabilitation hospital.

PARTICIPANTS

14 patients with motor incomplete spinal cord injury.

INTERVENTIONS

None.

OUTCOME MEASURES

We retrospectively compared and analyzed the results of 14 patients with motor incomplete SCI who underwent various balance assessments, including the FRA510S test, using correlation.

RESULTS

The agreement between the FRA510S and existing balance assessment was confirmed through Bland-Altman plots; moreover, high degree of agreement was observed in Berg Balance Scale in the eye closed state and in Five Times Sit-to-Stand Test in the eye open state.

CONCLUSIONS

It was confirmed that the FRA510S equipment provides quantitative values for balance function. Balance assessment using the FRA510S, along with neurological, electrophysiological, and clinical tests, may provide comprehensive additional information related to falls and gait rehabilitation in patients with SCI.

At-Home High-Intensity Interval Training for Individuals with Paraplegia Following Spinal Cord Injury: A Pilot Study

Objective

This pilot study aimed to assess the efficacy of a 16-week at-home high-intensity interval training (HIIT) program among individuals with spinal cord injury (SCI).

Methods

Eight individuals (age: 47±11 (SD) years, 3 females) with SCI below the sixth thoracic vertebrae participated in a 16-week at-home HIIT program using an arm ergometer. Participants completed baseline graded exercise tests to determine target heart rate zones. HIIT was prescribed thrice per week. Each training session consisted of six one-minute bouts with a target heart rate ~80% heart rate reserve (HRR), interspersed with two minutes of recovery at ~30% HRR. A portable heart rate monitor and phone application provided visual feedback during training and allowed for measurements of adherence and compliance. Graded exercise tests were completed after 8 and 16 weeks of HIIT. Surveys were administered to assess participation, self-efficacy, and satisfaction.

Results

Participants demonstrated a decrease in submaximal cardiac output (P=0.028) and an increase in exercise capacity (peak power output, P=0.027) following HIIT, indicative of improved exercise economy and maximal work capacity. An 87% adherence rate was achieved during the HIIT program. Participants reached a high intensity of 70% HRR or greater during ~80% of intervals. The recovery HRR target was reached during only ~35% of intervals. Self-reported metrics of satisfaction and self-efficacy with at-home HIIT scored moderate to high.

Conclusion

Participants demonstrated an improvement in exercise economy and maximal work capacity following at-home HIIT. Additionally, participant adherence, compliance, satisfaction, and self-efficacy metrics suggest that at-home HIIT was easily implemented and enjoyable.

Initial Evidence for Reliable and Valid Use of Scores on the 8-Item Econ-QOL Short Form to Measure Economic Quality of Life in Caregivers of Persons With Traumatic Brain Injury

OBJECTIVE

To provide reliability and validity data to support the clinical utility of Economic Quality of Life Measure (Econ-QOL) scores in caregivers of civilians and service members/veterans with traumatic brain injury (TBI).

DESIGN

Cross-sectional survey study.

SETTING

Three academic medical centers and a Veterans Affairs treatment facility.

PARTICIPANTS

376 caregivers of civilians (n=213) and service members/veterans (n=163) with TBI (N=376).

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Econ-QOL and several patient-reported outcome measures (Traumatic Brain Injury Caregiver Quality of Life Caregiver-Specific Anxiety and Caregiver Strain, Patient-Reported Outcomes Measurement Information System sleep-related impairment, Neurological Quality of Life Measurement System positive affect and well-being) and measures of financial status (self-reported income).

RESULTS

Internal consistency reliability of the Econ-QOL Short Form scores were excellent (all Cronbach's alphas ≥.92). There were no floor or ceiling effects for scores. There was evidence of convergent and discriminant validity, with the Econ-QOL scores having the strongest relationships with self-reported income (convergent validity evidence) and weak relationships with the other measures (discriminant validity evidence). Individuals with scores that were "below or possibly below" the poverty line (according to 2016 federal government poverty level thresholds) reported worse economic quality of life relative to those individuals who were definitely above the poverty line, supporting known-groups validity.

CONCLUSIONS

This article establishes the clinical utility of scores on the Econ-QOL Short Form in caregivers of persons with TBI and provides evidence that it is valid and appropriate to use such scores not only in a variety of different disability populations (eg, spinal cord injury, stroke) but also in caregivers.

Memristive circuit-based model of central pattern generator to reproduce spinal neuronal activity in walking pattern

Existing methods of neurorehabilitation include invasive or non-invasive stimulators that are usually simple digital generators with manually set parameters like pulse width, period, burst duration, and frequency of stimulation series. An obvious lack of adaptation capability of stimulators, as well as poor biocompatibility and high power consumption of prosthetic devices, highlights the need for medical usage of neuromorphic systems including memristive devices. The latter are electrical devices providing a wide range of complex synaptic functionality within a single element. In this study, we propose the memristive schematic capable of self-learning according to bio-plausible spike-timing-dependant plasticity to organize the electrical activity of the walking pattern generated by the central pattern generator.

Tectorigenin alleviates the apoptosis and inflammation in spinal cord injury cell model through inhibiting insulin-like growth factor-binding protein 6

Since tectorigenin has been reported to possess anti-inflammation, redox balance restoration, and anti-apoptosis properties, we determine to unravel whether tectorigenin has potential in alleviating spinal cord injury (SCI). Herein, PC12 cells were induced by lipopolysaccharide (LPS) to establish in vitro SCI models. The cell viability and apoptosis were detected through cell counting kit-8 and flow cytometry assays. The caspase-3/8/9 content was measured by colorimetric method. Western blot was conducted to quantify the expressions of cleaved caspse-3/8/9, IGFBP6, TLR4, IκBα, p-IκBα, RELA proto-oncogene, p65, and p-p65. Enzyme-linked immunosorbent assay and real-time quantitative polymerase chain reaction were carried out to quantitate expressions of IGFBP6, interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α). SwissTargetPrediction and GSE21497 database were utilized to predict the potential therapeutic targets of tectorigenin. Comparison of IGFBP6 expression in SCI tissues and normal tissues was analyzed by GEO2R. Our study found that LPS induced the declined cell viability, elevated cell apoptosis, upregulation of caspase-3/8/9, cleaved caspase-3/8/9, IL-1β, IL-6, TNF-α, IGFBP6, and TLR4, and the activation of IκBα and p65 in PC12 cells. Tectorigenin reversed the above effects of LPS. IGFBP6 was predicted to be the potential therapeutic target of tectorigenin and was overexpressed in SCI tissues. Notably, IGFBP6 overexpression offset the effects of tectorigenin on PC12 cells. In conclusion, tectorigenin could alleviate the LPS-induced apoptosis, inflammation, and activation of NF-κB signaling in SCI cell models via inhibiting IGFBP6.

Partial Restoration of Spinal Cord Neural Continuity via Sural Nerve Transplantation Using a Technique of Spinal Cord Fusion

Background

Spinal cord injury (SCI) can cause paralysis and serious chronic morbidity, and there is no effective treatment. Based on our previous experimental results of spinal cord fusion (SCF) in mice, rats, beagles, and monkeys, we developed a surgical protocol of SCF for paraplegic human patients. We designed a novel surgical procedure of SCF, called sural nerve transplantation (SNT), for human patients with lower thoracic SCI and distal cord dysfunction.

Methods

We conducted a clinical trial (ChiCTR2000030788) and performed SNT in 12 fully paraplegic patients due to SCI between T1 and T12. We assessed pre- and postoperative central nerve pain, motor function, sensory function, and autonomic nerve function. Conduction of action potentials across the sural nerve transplant was evaluated. Neural continuity was also examined by diffusion tensor imaging (DTI).

Results

Among the 12 paraplegic patients enrolled in this clinical trial, seven patients demonstrated improved autonomic nerve functions. Seven patients had clinically significant relief of their symptoms of cord central pain. One patient, however, developed postoperative cord central pain (VAS: 4). Five patients had varying degrees of recovered sensory and/or motor functions below the single neurologic level 1 month after surgery. One patient showed recovery of electrophysiologic, motor-evoked potentials 6 months after the operation. At 6 months after surgery, DTI indicated fusion and nerve connections of white cord and sural nerves in seven patients.

Conclusion

SNT was able to fuse the axonal stumps of white cord and sural nerve and at least partially improve the cord central pain in most patients. Although SNT did not restore the spinal cord continuity in white matter in some patients, SNT could restore spinal cord continuity in the cortico-trunco-reticulo-propriospinal pathway, thereby restoring in part some motor and sensory functions. SNT may therefore be a safe, feasible, and effective method to treat paraplegic patients with SCI. Future clinical trials should be performed to optimize the type/technique of nerve transplantation, reduce surgical damage, and minimize postoperative scar formation and adhesion, to avoid postoperative cord central pain.

Clinical Trial Registration

[http://www.chictr.org.cn/showproj.aspx?proj=50526], identifier [ChiCTR2000030788].

Indicators of Quality of Care in Individuals With Traumatic Spinal Cord Injury: A Scoping Review

STUDY DESIGN

Scoping review.

OBJECTIVES

To identify a practical and reproducible approach to organize Quality of Care Indicators (QoCI) in individuals with traumatic spinal cord injury (TSCI).

METHODS

A comprehensive literature review was conducted in the Cochrane Central Register of Controlled Trials (CENTRAL) (Date: May 2018), MEDLINE (1946 to May 2018), and EMBASE (1974 to May 2018). Two independent reviewers screened 6092 records and included 262 full texts, among which 60 studies were included for qualitative analysis. We included studies, with no language restriction, containing at least 1 quality of care indicator for individuals with traumatic spinal cord injury. Each potential indicator was evaluated in an online, focused group discussion to define its categorization (healthcare system structure, medical process, and individuals with Traumatic Spinal Cord Injury related outcomes), definition, survey options, and scale.

RESULTS

A total of 87 indicators were identified from 60 studies screened using our eligibility criteria. We defined each indicator. Out of 87 indicators, 37 appraised the healthcare system structure, 30 evaluated medical processes, and 20 included individuals with TSCI related outcomes. The healthcare system structure included the impact of the cost of hospitalization and rehabilitation, as well as staff and patient perception of treatment. The medical processes included targeting physical activities for improvement of health-related outcomes and complications. Changes in motor score, functional independence, and readmission rates were reported as individuals with TSCI-related outcomes indicators.

CONCLUSION

Indicators of quality of care in the management of individuals with TSCI are important for health policy strategists to standardize healthcare assessment, for clinicians to improve care, and for data collection efforts including registries.

Quantitative Assessment of Clinician Assistance During Dynamic Rehabilitation Using Force Sensitive Resistors

Background: Neuromodulation using epidural electrical stimulation (EES) has shown functional restoration in humans with chronic spinal cord injury (SCI). EES during body weight supported treadmill training (BWSTT) enhanced stepping performance in clinical trial participants with paraplegia. Unfortunately, tools are lacking in availability to quantify clinician assistance during BWSTT with and without EES. Force sensitive resistors (FSRs) have previously quantified clinician assistance during static standing; however, dynamic tasks have not been addressed.

Objective: To determine the validity of FSRs in measurements of force and duration to quantify clinician assistance and participant progression during BWSTT with EES in participants with SCI.

Design: A feasibility study to determine the effectiveness of EES to restore function in individuals with SCI.

Methods: Two male participants with chronic SCI were enrolled in a pilot phase clinical trial. Following implantation of an EES system in the lumbosacral spinal cord, both participants underwent 12 months of BWSTT with EES. At monthly intervals, FSRs were positioned on participants' knees to quantity forces applied by clinicians to achieve appropriate mechanics of stepping during BWSTT. The FSRs were validated on the benchtop using a leg model instrumented with a multiaxial load cell as the gold standard. The outcomes included clinician-applied force duration measured by FSR sensors and changes in applied forces indicating progression over the course of rehabilitation.

Results: The force sensitive resistors validation revealed a proportional bias in their output. Loading required for maximal assist training exceeded the active range of the FSRs but were capable of capturing changes in clinician assist levels. The FSRs were also temporally responsive which increased utility for accurately assessing training contact time. The FSRs readings were able to capture independent stance for both participants by study end. There was minimal to no applied force bilaterally for participant 1 and unilaterally for participant 2.

Conclusions: Clinician assistance applied at the knees as measured through FSRs during dynamic rehabilitation and EES (both on and off) effectively detected point of contact and duration of forces; however, it lacks accuracy of magnitude assessment. The reduced contact time measured through FSRs related to increased stance duration, which objectively identified independence in stepping during EES-enabled BWSTT following SCI.

The combination of nanoscaffolds and stem cell transplantation: Paving a promising road for spinal cord injury regeneration

Spinal cord injury (SCI), one of the most devastating traumas, has caused long-term disability in millions of people worldwide. The pathophysiology of SCI primarily occurs in two stages classified as primary injury and secondary injury. Due to the rupture of axons and the apoptosis of neurons, patients lose their motor, sensory, and reflex functions, which also imposes a huge burden on families and society. However, traditional surgery does not facilitate neuronal regeneration. Although neural stem cells (NSCs) have the potential for multidirectional differentiation, the probability of differentiation into neurons and survival are still low. Surprisingly, the unique properties of nanotechnologies enable targeted drug delivery while reducing adverse reactions, assisting NSCs in differentiating into neurons. Here, recent studies on promising nanoscaffolds are highlighted, and their strengths and drawbacks are evaluated. Although the treatment of SCI remains fraught with challenges, the combination of nanoscaffolds and NSCs pave a promising road for SCI regeneration.

The Natural History of Spinal Cord Injury

The natural history of spinal cord injury is in a state of flux. Our knowledge about the prevalence, epidemiology, and natural history spinal cord injury is in evolution. In this article, we summarize these considerations to provide a state-of-the-art synopsis of the neurologic outcomes of this condition.

GAS5 knockdown alleviates spinal cord injury by reducing VAV1 expression via RNA binding protein CELF2

Long non-coding RNA growth arrest specific transcript 5 (GAS5) has been found to be implicated in the pathogenesis of central nervous diseases and to be a contributor to hypoxic brain injury. However, the roles and molecular mechanisms of GAS5 in spinal cord injury (SCI) have not thoroughly investigated. Here, we reported that GAS5 knockdown improved rat locomotor function and alleviated pathological damage of spinal cord tissues by reducing oxidative stress, caspase-3 activity and vav guanine nucleotide exchange factor 1 (VAV1) expression in SCI rat models. GAS5 knockdown inhibited the increase of malondialdehyde (MDA) level and cell apoptotic rate induced by oxygen-glucose deprivation (OGD) and weakened the inhibitory effects of OGD on superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) activities and cell viability in RN-Sc cells, suggesting that GAS5 loss mitigated OGD-triggered oxidative stress and cell injury in RN-Sc cells. Molecular mechanism explorations revealed that GAS5 recruited CUGBP, Elav-like family member 2 (CELF2) to the coding region of VAV1 mRNA, resulting in the increase of VAV1 mRNA stability and expression levels. VAV1 knockdown weakened OGD-induced oxidative stress and cell injury in RN-Sc cells. VAV1 loss alleviated GAS5-induced oxidative stress and cell injury in OGD-treated RN-Sc cells. As a conclusion, our findings suggested that GAS5 aggravated SCI by increasing VAV1 expression via binding with CELF2, deepening our understanding on function and molecular basis of GAS5 in SCI.

The burden of the current curative expenditure of injury in Dalian, China-a study based on the "system of health accounts 2011"

BACKGROUND

Injury is one of the major public health problems and causes more than 5 million deaths in the world annually. Cases of specific types of injury are life-threatening and heavily-burdened to individuals and society. This study was aimed to assess the financial burden of injury on patients.

METHODS

A total of 565 medical institutions were selected with multistage stratified cluster random sampling, containing 152,553 valid samples. Subsequently, the distribution of injury current curative expenditure (CCE) in different dimensions (including age and site of injury) was analyzed under the framework of System of Health Accounts 2011 (SHA 2011) using the established database.

RESULTS

In China, both urban and rural injury mortality rates showed an upward trend of more than 5 percentage points from 2006 to 2016. In Dalian, the CCE of injury reached 1572.73 million RMB, accounting for 7.45% of the total CCE. Those aged 15-24 reported larger proportion of CCE than the other age groups. As for the injuries in body parts, injuries occurred to the spine, lower limb, head and foreign body cost most.

CONCLUSIONS

Dalian has a relatively serious burden of injury costs. The essential and primary goal is to reduce the cost. Young people should pay attention to protect their head and limbs from injury, and related government sectors should implement preventive and educative measures.

Injury volume extracted from MRI predicts neurologic outcome in acute spinal cord injury: A prospective TRACK-SCI pilot study

Conventional MRI measures of traumatic spinal cord injury severity largely rely on 2-dimensional injury characteristics such as intramedullary lesion length and cord compression. Recent advances in spinal cord (SC) analysis have led to the development of a robust anatomic atlas incorporated into an open-source platform called the Spinal Cord Toolbox (SCT) that allows for quantitative volumetric injury analysis. In the current study, we evaluate the prognostic value of volumetric measures of spinal cord injury on MRI following registration of T2-weighted (T2w) images and segmented lesions from acute SCI patients with a standardized atlas. This IRB-approved prospective cohort study involved the image analysis of 60 blunt cervical SCI patients enrolled in the TRACK-SCI clinical research protocol. Axial T2w MRI data obtained within 24 h of injury were processed using the SCT. Briefly, SC MRIs were automatically segmented using the sct_deepseg_sc tool in the SCT and segmentations were manually corrected by a neuro-radiologist. Lesion volume data were used as predictor variables for correlation with lower extremity motor scores at discharge. Volumetric MRI measures of T2w signal abnormality comprising the SCI lesion accurately predict lower extremity motor scores at time of patient discharge. Similarly, MRI measures of injury volume significantly correlated with motor scores to a greater degree than conventional 2-D metrics of lesion size. The volume of total injury and of injured spinal cord motor regions on T2w MRI is significantly and independently associated with neurologic outcome at discharge after injury.

Design of a Passive, Variable Stiffness Exoskeleton for Triceps Deficiency Mitigation

Individuals with neurological impairment, particularly those with cervical level spinal cord injuries (SCI), often have difficulty with daily tasks due to triceps weakness or total loss of function. More demanding tasks, such as sit-skiing, may be rendered impossible due to their extreme strength demands. Design of exoskeletons that address this issue by providing supplemental strength in arm extension is an active field of research but commercial devices are not yet available for use. Most current designs employ electric motors that necessitate the addition of bulky power sources and extraneous wiring, rendering the devices impractical in daily life. The possibility of powering an upper extremity exoskeleton passively has been explored, but to date, none have delivered sufficient function or strength to provide useful assistance for sit-skiing. We seek to rectify this with the design of a passively actuated exoskeletal arm brace capable of operating in two, adjustable-strength modes: one for low level gravity compensation to aid in active range of motion, and the other for more stringent weight bearing activities. The mechanism developed through this paper allows for an affordable, lightweight, modular device that can be adjusted and customized for the needs of each individual patient.

Needs, priorities, and attitudes of individuals with spinal cord injury toward nerve stimulation devices for bladder and bowel function: a survey

Study Design:

Survey.

Objectives:

To investigate the needs and priorities of people with spinal cord injury for managing neurogenic bladder and bowel function and to determine their willingness to adopt neuromodulation interventions for these functions.

Methods:

Anonymous online survey. It was advertised by word-of-mouth by community influencers and social media, and by advertisement in newsletters of advocacy groups.

Results:

Responses from 370 individuals (27% female, 73% male) were included. Bladder emptying without catheters was the top priority for restoring bladder function, and maintaining fecal continence was the top priority for restoring bowel function. The biggest concerns regarding external stimulation systems were wearing a device with wires connecting to electrodes on the skin and having to don and doff the system daily as needed. The biggest concerns for implanted systems were the chances of experiencing problems with the implant that required a revision surgery or surgical removal of the whole system. Respondents were willing to accept an external (61%) or implanted (41%) device to achieve improved bladder or bowel function.

Conclusions:

Bladder and bowel dysfunction remain important unmet challenges for individuals living with SCI who answered our survey. These individuals are willing to accept some potential risks of nerve stimulation approaches given potential benefits. Additional consumer input is critical for guiding both research and translation to clinical use and personalized medicine.

Factors Associated With In-Hospital Outcomes of Traumatic Spinal Cord Injury: 10-year Analysis of the US National Inpatient Sample

INTRODUCTION

Traumatic spinal cord injury (SCI) is a life-altering event. Motor vehicle accidents and falls are common causes of traumatic SCI, and SCI outcomes may be affected by patients' ages and injury sites. This study aimed to investigate the factors associated with unfavorable in-hospital outcomes, focusing on the impact of patients' ages and SCI lesion sites.

METHODS

Data of 25,988 patients hospitalized with traumatic SCI in the US National Inpatient Sample (NIS) database from 2005 to 2014 were extracted and analyzed. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with SCI outcomes, including in-hospital deaths, adverse discharge, and prolonged hospital stays.

RESULTS

Multivariate analysis revealed that the oldest ages (>65 years) were significantly associated with increased in-hospital mortality compared with the youngest ages at all lesion sites (cervical, odds ratio [OR]: 5.474, 95% confidence interval [CI]: 4.465 to 6.709; thoracic, OR: 5.940, 95% CI: 3.881 to 9.091; and lumbosacral, OR: 6.254, 95% CI: 2.920 to 13.394). Older ages were also significantly associated with increased adverse outcomes at all sites (cervical, OR: 2.460, 95% CI: 2.180 to 2.777; thoracic, OR: 2.347, 95% CI: 1.900 to 2.900; and lumbosacral, OR: 2.743, 95% CI: 2.133 to 3.527). Intermediate ages (35 to 64) were also significantly associated with increased in-hospital death and adverse discharge at cervical and thoracic SCIs, but not at lumbosacral sites.

DISCUSSION

For hospitalized patients with traumatic SCI, older age independently predicts worse in-hospital outcomes, with greatest effects seen in patients aged 65 years and older. Study findings suggest that extra vigilance and targeted management strategies are warranted in managing SCI patients aged 65 years and older during hospitalization.

Shock waves promote spinal cord repair via TLR3

Spinal cord injury (SCI) remains a devastating condition with poor prognosis and very limited treatment options. Affected patients are severely restricted in their daily activities. Shock wave therapy (SWT) has shown potent regenerative properties in bone fractures, wounds, and ischemic myocardium via activation of the innate immune receptor TLR3. Here, we report on the efficacy of SWT for regeneration of SCI. SWT improved motor function and decreased lesion size in WT but not Tlr3-/- mice via inhibition of neuronal degeneration and IL6-dependent recruitment and differentiation of neuronal progenitor cells. Both SWT and TLR3 stimulation enhanced neuronal sprouting and improved neuronal survival, even in human spinal cord cultures. We identified tlr3 as crucial enhancer of spinal cord regeneration in zebrafish. Our findings indicate that TLR3 signaling is involved in neuroprotection and spinal cord repair and suggest that TLR3 stimulation via SWT could become a potent regenerative treatment option.

Effects of Hydrogel-Fiber on Cystic Cavity after Spinal Cord Injury

Spinal cord injury (SCI) affects millions of people around the world, however, functional recovery is far from satisfying. The continuous emergence of biomaterials provides a new idea for the repair of SCI. Hydrogels can mimic the extracellular matrix (ECM), however, the unstable hydrogel shape limits its application. In this study, we evaluate the effect of hydrogel fiber (Polycaprolactone, PCL fiber was added to the hydrogel) on the recovery after SCI. 20 adult male Wistar rats were randomly divided into 4 groups: SCI+hydrogel group (H), SCI+hydrogel + PCL fiber group (HF), SCI group (SCI) and SHAM group (SHAM) and (N=5). SCI contusion injury was induced by a MASCIS Impactor (20g weight, 50cm high) at the T9 level in rats. Hydrogels or PCL fiber were administered into the SCI site one week after surgery. Periodical Basso, Beattie, and Bresnahan (BBB) locomotor score, spinal cord hematoxylin and eosin stain (HE) staining, and immunofluorescence staining were performed 28 days after the operation. HE staining showed that the average cystic cavity area in SCI (20.78 ±2.93 mm²) group was significantly higher than that in H group (6.54 ±0.85 mm²), HF group (5.06 ±0.76 mm²) and SHAM group (1.76 ±0.27 mm²) (P <; 0.001). There was no significant difference in BBB motor score among the HF group (16.80±1.10), SCI (14.20±1.09) and H group (15.00±1.23) (P > 0.05), except the sham group. Immunofluorescence showed higher NeuN positive cells in both the H group and the HF group. This preliminary result may indicate that PCL fiber optimized the strength of hydrogels, thus providing better support for the axon regeneration. Future investigation is needed to further characterize PCL fiber and elucidate related mechanisms.

The Integrated Transcriptome Bioinformatics Analysis Identifies Key Genes and Cellular Components for Spinal Cord Injury-Related Neuropathic Pain

BACKGROUND

Spinal cord injury (SCI) is one of the most devastating diseases with a high incidence rate around the world. SCI-related neuropathic pain (NeP) is a common complication, whereas its pathomechanism is still unclear. The purpose of this study is to identify key genes and cellular components for SCI-related NeP by an integrated transcriptome bioinformatics analysis.

METHODS

The gene expression profile of 25 peripheral blood samples from chronic phase SCI patients (E-GEOD-69901) and 337 normal peripheral blood samples were downloaded from ArrayExpress and Genotype-Tissue Expression Portal (GTEx), respectively. A total of 3,368 normal peripheral blood mononuclear cells (PBMC) were download from Sequence Read Archive (SRA713577). Non-parametric tests were used to evaluate the association between all of differential expression genes (DEGs) and SCI-related NeP. CellPhoneDB algorithm was performed to identify the ligand-receptor interactions and their cellular localization among single PBMCs. Transcription factor (TF) enrichment analysis and Gene Set Variation Analysis (GSVA) were used to identify the potential upstream regulatory TFs and downstream signaling pathways, respectively. Co-expression analysis among significantly enriched TFs, key cellular communication genes and differentially expressed signaling pathways were performed to identify key genes and cellular components for SCI-related NeP.

RESULTS

A total of 2,314 genes were identified as DEGs between the experimental and the control group. Five proteins (ADRB2, LGALS9, PECAM1, HAVCR2, LRP1) were identified in the overlap of proteins in the significant ligand-receptor interactions of PBMCs and protein-protein interaction (PPI) network based on the DEGs. Only HAVCR2 was significantly associated with NeP (P = 0.005). Besides, the co-expression analysis revealed that TF YY1 had significantly co-expression pattern with cellular communication receptor HAVCR2 (R = -0.54, P < 0.001) in NK cells while HAVCR2 was also co-expressed with mTOR signaling pathway (R = 0.57, P < 0.001). The results of RT-qPCR and external dataset validation supported the signaling axis with the most significant co-expression patterns.

CONCLUSION

In peripheral blood of chronic SCI, HAVCR2 might act as a key receptor on the surface of NK cells and interact with ligand LGALS9 secreted by CD14+ monocytes, inhibiting NK cells through mTOR signaling pathway and ultimately predicting the occurrence of SCI-related NeP. This hypothetical signaling axis may provide prognostic biomarkers and therapeutic targets for SCI-related NeP.

Healthcare utilization following spinal cord injury: Objective findings from a regional hospital registry

OBJECTIVE

The purpose was to describe the prevalence and characteristics of healthcare utilization among individuals with spinal cord injury (SCI) from a Level I trauma center.

DESIGN

Retrospective data analysis utilizing a local acute trauma registry for initial hospitalization and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year.

SETTING

Dallas, TX, USA.

PARTICIPANTS

Six hundred and sixty four patients were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty five patients that expired during initial hospitalization and 18 patients with unspecified SCI (defined by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591.

OUTCOME MEASURES

Data included demographic and clinical characteristics, charges, and healthcare utilization.

RESULTS

Mean age was 46.1 years (±18.9 years), the majority of patients were male (74%), and Caucasian (58%). Of the 591 patients, 345 (58%) had additional inpatient or emergency healthcare utilization accounting for 769 additional visits (median of 3 visits per person). Of the 769 encounters, 534 (69%) were inpatient and 235 (31%) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension, and tobacco use.

CONCLUSION

Individuals with SCI experience high levels of healthcare utilization which are costly and may be preventable. Increasing our understanding of the prevalence and causes for healthcare utilization after acute SCI is important to target preventive strategies.

Survival in 222 Patients With Severe CSCI: An 8-Year Epidemiologic Survey in Western China

OBJECTIVE

To assess the survival and the predictors of mortality in patients with severe cervical spinal cord injuries (CSCI).

DESIGN

Retrospective study.

PARTICIPANTS

From January 1, 2010, to May 31, 2018, patients who suffered from severe CSCIs in Western China were enrolled in this study (N=222).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Survival rates and mortality risk factors. Measures were calculated by the product-limit method (Kaplan-Meier) and the Cox model.

RESULTS

The overall 1-year, 3-year, 5-year, and 8-year postoperative mortalities were 24.4%, 30.6%, 33.3%, 36.2%, and 39.0%, respectively. Most deaths occurred within 36 months after the injury. According to the Cox proportional hazards model, the significant predictors of survival were as follows: (1) age; (2) neurologic level; (3) treatment options (surgical or conservative); (4) ventilator support (P<.05). The 8-year mortality for older patients (>50y) was 50.2%, which was significantly higher than that for younger patients (32.4%, <50y). The risk of death was 2.053 times higher in higher levels of injury (C1-C4) than in lower levels of injury (C5-C8) (P<.05). Compared with conservative treatment, patients who received surgical treatment (either anterior or posterior decompression) had a lower risk of death (P<.05). No significant difference was detected in the risk of death between early surgery (<3d) and mid-term surgery (3-7d) (P>.05). However, patients who received late-term surgery (>7d) had a higher mortality risk (P<.05). The overall 8-year mortality risk of patients who needed ventilator support was much higher than those who did not need ventilator support (P<.05).

CONCLUSIONS

Age, neurologic level, ventilator dependence, treatment options, and timing to surgery were main risk factors for mortality in patients with severe CSCIs. Better understanding of the predictors for survival could possibly contribute to the improvement of survival rates.

Serum MicroRNAs Reflect Injury Severity in a Large Animal Model of Thoracic Spinal Cord Injury

Therapeutic development for spinal cord injury is hindered by the difficulty in conducting clinical trials, which to date have relied solely on functional outcome measures for patient enrollment, stratification, and evaluation. Biological biomarkers that accurately classify injury severity and predict neurologic outcome would represent a paradigm shift in the way spinal cord injury clinical trials could be conducted. MicroRNAs have emerged as attractive biomarker candidates due to their stability in biological fluids, their phylogenetic similarities, and their tissue specificity. Here we characterized a porcine model of spinal cord injury using a combined behavioural, histological, and molecular approach. We performed next-generation sequencing on microRNAs in serum samples collected before injury and then at 1, 3, and 5 days post injury. We identified 58, 21, 9, and 7 altered miRNA after severe, moderate, and mild spinal cord injury, and SHAM surgery, respectively. These data were combined with behavioural and histological analysis. Overall miRNA expression at 1 and 3 days post injury strongly correlates with outcome measures at 12 weeks post injury. The data presented here indicate that serum miRNAs are promising candidates as biomarkers for the evaluation of injury severity for spinal cord injury or other forms of traumatic, acute, neurologic injury.

Validation of a field spinal motion restriction protocol in a level I trauma center

BACKGROUND

Spinal motion restriction (SMR) after traumatic injury has been a mainstay of prehospital trauma care for more than 3 decades. Recent guidelines recommend a selective approach with cervical spine clearance in the field when criteria are met.

MATERIALS AND METHODS

In January 2014, the Department of Health Services of the City of Los Angeles, California, implemented revised guidelines for cervical SMR after blunt mechanism trauma. Adult patients (aged ≥18 y) with an initial Glasgow Coma Scale (GCS) score of ≥13 presented to a single level I trauma center after blunt mechanism trauma over the following 1-y period were retrospectively reviewed. Demographics, injury data, and prehospital data were collected. Cervical spine injury (CSI) was identified by International Classification of Disease, Ninth Revision, codes.

RESULTS

Emergency medical services transported 1111 patients to the emergency department who sustained blunt trauma. Patients were excluded if they refused c-collar placement or if documentation was incomplete. A total of 997 patients were included in our analysis with 172 (17.2%) who were selective cleared of SMR per protocol. The rate of Spinal Cord Injury was 2.2% (22/997) overall and 1.2% (2/172) in patients without SMR. The sensitivity and specificity of the protocol are 90.9% (95% confidence interval: 69.4-98.4) and 17.4% (95% confidence interval: 15.1-20.0), respectively, for CSI. Patients with CSI who arrived without immobilization having met field clearance guidelines, were managed without intervention, and had no neurologic compromise.

CONCLUSIONS

Guidelines for cervical SMR have high sensitivity and low specificity to identify CSI. When patients with injuries were not placed on motion restrictions, there were no negative clinical outcomes.

A bridging SF/Alg composite scaffold loaded NGF for spinal cord injury repair

Neurons loss and axons degeneration after spinal cord injury (SCI) gradually give rise to result in functional motor and sensory impairment. A bridging biomaterial scaffold that allows the axons to grow through has been investigated for the repair of injured spinal cord. In this study, we introduced a silk fibroin (SF)-based neurobridge as scaffold enriched with/without nerve growth factor (NGF) that can be utilized as a therapeutic approach for spinal cord repair. NGF released from alginate (Alg) microspheres on SF scaffold (SF/Alg composites scaffolds) to the central lesion site of SCI significantly enhanced the sparing of spinal cord tissue and increased the number of surviving neurons. This optimal multi-disciplinary approach of combining biomaterials, controlled-release microspheres and neurotrophic factors offers a promising treatment for the injured spinal cord.

Factors predictive of survival and estimated years of life lost in the decade following nontraumatic and traumatic spinal cord injury

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To identify factors predictive of survival after spinal cord injury (SCI).

SETTING

Tertiary care institution.

METHODS

Multiple-variable Cox proportional hazards regression analysis for 759 patients with SCI (535 nontraumatic and 221 traumatic) included age, sex, completeness of injury, level of injury, functional independence measure (FIM) scores, rehabilitation length of stay and SCI cause. Estimated years of life lost in the decade after injury was calculated for patients vs uninjured controls.

RESULTS

Median follow-up was 11.4 years. Population characteristics included paraplegia, 58%; complete injury, 11%; male sex, 64%; and median rehabilitation length of stay, 16 days. Factors independently predictive of decreased survival were increased age (+10 years; hazard ratio (HR (95% CI)), 1.6 (1.4-1.7)), male sex (1.3 (1.0-1.6)), lower dismissal FIM score (-10 points; 1.3 (1.2-1.3)) and all nontraumatic causes. Metastatic cancer had the largest decrease in survival (HR (95% CI), 13.3 (8.7-20.2)). Primary tumors (HR (95% CI), 2.5 (1.7-3.8)), vascular (2.5 (1.6-3.8)), musculoskeletal/stenosis (1.7 (1.2-2.5)) and other nontraumatic SCI (2.3 (1.5-3.6)) were associated with decreased survival. Ten-year survival was decreased in nontraumatic SCI (mean (s.d.), 1.8 (0.3) years lost), with largest decreases in survival for metastatic cancer and spinal cord ischemia.

CONCLUSIONS

Age, male sex and lower dismissal FIM score were associated with decreased survival, but neither injury severity nor level was associated with it. Survival after SCI varies depending on SCI cause, with survival better after traumatic SCI than after nontraumatic SCI. Metastatic cancer and vascular ischemia were associated with the greatest survival reduction.

Induced Pluripotent Stem Cells for Traumatic Spinal Cord Injury

Spinal cord injury (SCI) is a common cause of mortality and neurological morbidity. Although progress had been made in the last decades in medical, surgical, and rehabilitation treatments for SCI, the outcomes of these approaches are not yet ideal. The use of cell transplantation as a therapeutic strategy for the treatment of SCI is very promising. Cell therapies for the treatment of SCI are limited by several translational road blocks, including ethical concerns in relation to cell sources. The use of iPSCs is particularly attractive, given that they provide an autologous cell source and avoid the ethical and moral considerations of other stem cell sources. In addition, different cell types, that are applicable to SCI, can be created from iPSCs. Common cell sources used for reprogramming are skin fibroblasts, keratinocytes, melanocytes, CD34+ cells, cord blood cells and adipose stem cells. Different cell types have different genetic and epigenetic considerations that affect their reprogramming efficiencies. Furthermore, in SCI the iPSCs can be differentiated to neural precursor cells, neural crest cells, neurons, oligodendrocytes, astrocytes, and even mesenchymal stromal cells. These can produce functional recovery by replacing lost cells and/or modulating the lesion microenvironment.

Comparison of RNAi NgR and NEP1-40 in Acting on Axonal Regeneration After Spinal Cord Injury in Rat Models

This study was intended to compare the therapeutic efficacies of NEP1-40 and SiNgR199 on treating spinal cord injury (SCI). Nogo-A, growth associated protein 43 (GAP-43), microtubule associated protein 2 (MAP-2), and amyloid βA4 precursor protein (APP) expressions were determined using western blot and quantitative PCR. Neurite outgrowth detected the growth of neurites, and BDA anterograde tracing was used to label the regenerated axonal. Rats' behavior was assessed with Basso, Beattie, and Bresnahan locomotor rating scale (BBB). Somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) were recorded to evaluate the recovery of the sensory and motor systems. Successful establishment of SCI model was verified by immunocytochemical analysis. The increased expression of APP, as well as the decreased expression of GAP-43 and MAP-2, was observed in the SCI model group, but the trends were reversed after the treatments of NEP1-40, siNgR199, and NEP1-40 + siNgR199. Compared with the SCI group, the average neurite length and the BDA-positive fibers were increased in the NEP1-40, siNgR199, and NEP1-40 + siNgR199 groups. The rats in the siNgR199 group and the NEP1-40 + siNgR199 group both showed significantly higher BBB scores than SCI model group and NEP1-40 group. Suggested by electrophysiological evaluation, both the latency and the amplitude of SEPs as well as MEPs had recovered in the NEP1-40, siNgR199, and NEP1-40 + siNgR199 groups after SCI. Both NEP1-40 and siNgR had repairing effects on SCI, suggesting their role in facilitating axonal regeneration after SCI.

Wheelchair use and lipophilic statin medications may influence bone loss in chronic spinal cord injury: findings from the FRASCI-bone loss study

We identified a protective bone effect at the knee with lipophilic statin use in individuals with chronic spinal cord injury. Lipophilic statin users gained bone at the knee compared to non-users and wheelchair users lost bone compared to walkers. Ambulation and or statins may be effective osteogenic interventions in chronic spinal cord injury (SCI).

INTRODUCTION

SCI increases the risk of osteoporosis and low-impact fractures, particularly at the knee. However, during the chronic phase of SCI, the natural history and factors associated with longitudinal change in bone density remain poorly characterized. In this study, we prospectively assessed factors associated with change in bone density over a mean of 21 months in 152 men and women with chronic SCI.

METHODS

A mixed model procedure with repeated measures was used to assess predictors of change in bone mineral density (PROC MIXED) at the distal femur and proximal tibia. Factors with a p value of <0.10 in the univariate mixed models, as well as factors that were deemed clinically significant (gender, age, and walking status), were assessed in multivariable models. Factors with a p value of ≤0.05 were included in the final model.

RESULTS

We found no association between bone loss and traditional osteoporosis risk factors, including age, gender, body composition, or vitamin D level or status (normal or deficient). In both crude and fully adjusted models, wheelchair users lost bone compared to walkers. Similarly, statin users gained bone compared to nonusers.

CONCLUSIONS

The statin finding is supported by reports in the general population where statin use has been associated with a reduction in bone loss and fracture risk. Our results suggest that both walking and statins may be effective osteogenic therapies to mitigate bone loss and prevent osteoporosis in chronic SCI. Our findings also suggest that loss of mechanical loading and/or neuronal factors contribute more to disuse osteoporosis than traditional osteoporosis risk factors.

Organ-on-a-Chip: New Platform for Biological Analysis

Direct detection and analysis of biomolecules and cells in physiological microenvironment is urgently needed for fast evaluation of biology and pharmacy. The past several years have witnessed remarkable development opportunities in vitro organs and tissues models with multiple functions based on microfluidic devices, termed as “organ-on-a-chip”. Briefly speaking, it is a promising technology in rebuilding physiological functions of tissues and organs, featuring mammalian cell co-culture and artificial microenvironment created by microchannel networks. In this review, we summarized the advances in studies of heart-, vessel-, liver-, neuron-, kidney- and Multi-organs-on-a-chip, and discussed some noteworthy potential on-chip detection schemes.

Body machine interfaces for neuromotor rehabilitation: a case study

High-level spinal cord injury (SCI) survivors face every day two related problems: recovering motor skills and regaining functional independence. Body machine interfaces (BoMIs) empower people with sever motor disabilities with the ability to control an external device, but they also offer the opportunity to focus concurrently on achieving rehabilitative goals. In this study we developed a portable, and low-cost BoMI that addresses both problems. The BoMI remaps the user's residual upper body mobility to the two coordinates of a cursor on a computer monitor. By controlling the cursor, the user can perform functional tasks, such as entering text and playing games. This framework also allows the mapping between the body and the cursor space to be modified, gradually challenging the user to exercise more impaired movements. With this approach, we were able to change the behavior of our SCI subject, who initially used almost exclusively his less impaired degrees of freedom - on the left side - for controlling the BoMI. At the end of the few practice sessions he had restored symmetry between left and right side of the body, with an increase of mobility and strength of all the degrees of freedom involved in the control of the interface. This is the first proof of concept that our BoMI can be used to control assistive devices and reach specific rehabilitative goals simultaneously.

Effectiveness of repeated transplantations of hematopoietic stem cells in spinal cord injury

AIM: To evaluate the short and long-term effects of the complex cell therapy of 202 cases of spinal cord injury (SCI).

METHODS: The main arm included 202 cases of SCI and the control arm included 20 SCI cases. For the therapy the hematopoietic stem cells (HSCs) and progenitor cells (PCs) were mobilized to peripheral blood by 8 subcutaneous injections of granulocyte colony-stimulating factor (G-CSF) for 4 d and are harvested at day 5. The cells were administered to the main arm intrathecally every 3 mo for a long term (3-5 years) according to the internal research protocol international medical institute of tissue engineering. Magnetic resonance imaging of the site of injury and urodynamic tests were performed every 6 mo. Motor evoked potentials (MEP), somatosensory evoked potentials (SSEP) were evaluated every 3 mo. The patients were evaluated with american spianl injury association (ASIA) index, functional independence measure index, the Medical Research Council Scale, the International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI-92) and specifically developed scales. The function of bladder was evaluated by a specifically developed clinical scale. The long-term clinical outcomes were assessed for the SCI patients who received no less than 20 intrathecal transplantations of HSCs and hematopoietic precursors (HPs).

RESULTS: The restoration of neurologic deficit after HSCs and HPs transplantations was proved stable and evident in 57.4% of the cases. In 42.6% cases no neurologic improvement has been observed. In 50% of the cases the motor restoration began after the first transplantation, which is confirmed in average by 9.9 points improvement in neurologic impairment as compared to the baseline (P < 0.05). Repair of the urinary system was observed in 47.7% of the cases. The sensitivity improved from baseline 124.3 points to 138.4 after the first and to 153.5 points after the second transplantations of HSCs and HPs (P < 0.05, between the stages of research). The evaluation with ASIA index demonstrated regress of neurologic symptoms in 23 cases. Motor progress was also assessed with the ISCISCI-92 motor and sensory scores, and the data coincided with those received with the specifically developed scale. The number of the patients with the signs of locomotive repair was 56.9%. No life threatening complications or adverse effects have been observed.

CONCLUSION: The method is safe, effective and considerably improves the life quality of SCI patients. The therapy is approved for clinical use as the treatment of choice.

SUBAXIAL CERVICAL FRACTURE: APPLICATION AND CORRELATION OF AO AND SLIC

Objective:To evaluate the AO/Magerl classification and the SLIC (Subaxial Cervical Spine Injury Classification), used in the cervical spine fractures and assess whether they are correlated to the neurological severity of patients, the choice of approach to be used, de duration of surgery an between themselves.Method:Retrospective analysis of medical records and radiological image files of 77 patients surgically treated of subaxial cervical fracture or dislocation from August 2010 to September 2012.Results:The SLIC classification showed a strong correlation with neurological deficit and Pearson correlation value of -0.600. The AO classification was not correlated with the Frankel scale and the value of Pearson was 0.06 with a statistical significance of 0.682 (p<0.05), that is, unable to determine or suggest the severity of the deficit. When compared to each other the two classifications showed statistical correlation and the value of Pearson was 0.282 with a significance value of 0.022 (p<0.05).Conclusion:Among the most used classifications, the SLIC has been able to statistically define the need for surgical treatment and the severity of the neurological status, but was unable to predict the approach or the time of the surgery; the classification AO failed to predict the severity of neurological injury, surgical time, and did not help to choose the approach, just being a morphological classification.

Measuring stigma after spinal cord injury: Development and psychometric characteristics of the SCI-QOL Stigma item bank and short form

OBJECTIVE

To develop a calibrated item bank and computer adaptive test (CAT) to assess the effects of stigma on health-related quality of life in individuals with spinal cord injury (SCI).

DESIGN

Grounded-theory based qualitative item development methods, large-scale item calibration field testing, confirmatory factor analysis, and item response theory (IRT)-based psychometric analyses.

SETTING

Five SCI Model System centers and one Department of Veterans Affairs medical center in the United States.

PARTICIPANTS

Adults with traumatic SCI.

MAIN OUTCOME MEASURES

SCI-QOL Stigma Item Bank

RESULTS

A sample of 611 individuals with traumatic SCI completed 30 items assessing SCI-related stigma. After 7 items were iteratively removed, factor analyses confirmed a unidimensional pool of items. Graded Response Model IRT analyses were used to estimate slopes and thresholds for the final 23 items.

CONCLUSIONS

The SCI-QOL Stigma item bank is unique not only in the assessment of SCI-related stigma but also in the inclusion of individuals with SCI in all phases of its development. Use of confirmatory factor analytic and IRT methods provide flexibility and precision of measurement. The item bank may be administered as a CAT or as a 10-item fixed-length short form and can be used for research and clinical applications.

Overview of the Spinal Cord Injury--Quality of Life (SCI-QOL) measurement system

CONTEXT/OBJECTIVE

The Spinal Cord Injury--Quality of Life (SCI-QOL) measurement system was developed to address the shortage of relevant and psychometrically sound patient reported outcome (PRO) measures available for clinical care and research in spinal cord injury (SCI) rehabilitation. Using a computer adaptive testing (CAT) approach, the SCI-QOL builds on the Patient Reported Outcomes Measurement Information System (PROMIS) and the Quality of Life in Neurological Disorders (Neuro-QOL) initiative. This initial manuscript introduces the background and development of the SCI-QOL measurement system. Greater detail is presented in the additional manuscripts of this special issue.

DESIGN

Classical and contemporary test development methodologies were employed. Qualitative input was obtained from individuals with SCI and clinicians through interviews, focus groups, and cognitive debriefing. Item pools were field tested in a multi-site sample (n=877) and calibrated using item response theory methods. Initial reliability and validity testing was performed in a new sample of individuals with traumatic SCI (n=245).

SETTING

Five Model SCI System centers and one Department of Veterans Affairs Medical Center across the United States.

PARTICIPANTS

Adults with traumatic SCI.

INTERVENTIONS

n/a

OUTCOME MEASURES

n/a

RESULTS

The SCI-QOL consists of 19 item banks, including the SCI-Functional Index banks, and 3 fixed-length scales measuring physical, emotional, and social aspects of health-related QOL (HRQOL).

CONCLUSION

The SCI-QOL measurement system consists of psychometrically sound measures for individuals with SCI. The manuscripts in this special issue provide evidence of the reliability and initial validity of this measurement system. The SCI-QOL also links to other measures designed for a general medical population.

Development and initial evaluation of the SCI-FI/AT

OBJECTIVES

To describe the domain structure and calibration of the Spinal Cord Injury Functional Index for samples using Assistive Technology (SCI-FI/AT) and report the initial psychometric properties of each domain.

DESIGN

Cross sectional survey followed by computerized adaptive test (CAT) simulations.

SETTING

Inpatient and community settings.

PARTICIPANTS

A sample of 460 adults with traumatic spinal cord injury (SCI) stratified by level of injury, completeness of injury, and time since injury.

INTERVENTIONS

None

MAIN OUTCOME MEASURE

SCI-FI/AT RESULTS: Confirmatory factor analysis (CFA) and Item response theory (IRT) analyses identified 4 unidimensional SCI-FI/AT domains: Basic Mobility (41 items) Self-care (71 items), Fine Motor Function (35 items), and Ambulation (29 items). High correlations of full item banks with 10-item simulated CATs indicated high accuracy of each CAT in estimating a person's function, and there was high measurement reliability for the simulated CAT scales compared with the full item bank. SCI-FI/AT item difficulties in the domains of Self-care, Fine Motor Function, and Ambulation were less difficult than the same items in the original SCI-FI item banks.

CONCLUSION

With the development of the SCI-FI/AT, clinicians and investigators have available multidimensional assessment scales that evaluate function for users of AT to complement the scales available in the original SCI-FI.