Clinical correlates of fatigue in spinal cord injury

Socio-ecological Barriers to Leisure Time Physical Activity in Spanish Wheelchair Users With Spinal Cord Injury: Associations With Sociodemographic Characteristics and Functional Independence

OBJECTIVE

(1) To assess prevalence and severity of socio-ecological barriers to leisure time physical activity (LTPA) in a sample of adults with spinal cord injury (SCI); (2) to examine the association of these barriers with sociodemographic characteristics and functional independence (FI); and (3) to explore which socio-ecological levels of barriers might be associated with LTPA.

DESIGN

Cross-sectional study.

SETTING

Neurorehabilitation Hospital specialized in SCI.

PARTICIPANTS

207 wheelchair users with SCI living in the community who attended a comprehensive check-up (22.7% women, 47.5±10.7 mean age; N=207).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The short version of the Barriers to Physical Activity Questionnaire for People with Mobility Impairments was used to measure socio-ecological barriers to LTPA. The Spinal Cord Independence Measure III was used to measure FI. The Physical Activity Recall Assessment for People with SCI was used to quantify LTPA. Several multiple linear regression models were computed to examine the associations between socio-ecological barriers and sociodemographic factors, LTPA and FI.

RESULTS

A high prevalence of barriers to LTPA was found. Seven of these barriers (2 intrapersonal, 3 organizational, and 2 community) were present for >60% of the participants. Intrapersonal and organizational barriers had a higher effect on participants with lower FI and women. Interpersonal barriers were higher for older participants and with lower FI, while community barriers were higher for unemployed participants. Finally, intrapersonal and interpersonal barriers were negatively associated with LTPA, and FI revealed as a moderator of the intrapersonal barriers-LTPA relation.

CONCLUSIONS

Given their high prevalence and their association with LTPA, the development of interventions targeting socio-ecological barriers to LTPA in people with SCI becomes crucial. The associations of these barriers with FI and sociodemographic characteristics should also be considered for these interventions to be as specific and effective as possible.

Fatigue insights from walking tests in spinal cord injury and multiple sclerosis individuals

In the last decade, fatigue in clinical populations has been re-conceptualized, including dimensions such as perceived fatigue (trait and state fatigue) and fatigability. The aim of this study was to evaluate different expressions of fatigue in Spinal Cord Injury (SCI) and Multiple Sclerosis (MS) participants compared to able-bodied controls, during activities of daily living, especially during gait. A total of 67 participants were included in this study (23 with SCI, 23 with MS, and 21 able-bodied controls). All participants performed two functional tests (6-Minute Walk Test and 10-Meter Walk Test) and they completed the Fatigue Severity Scale (FSS). The rate of trait fatigue was different between groups, with MS participants showing the highest rate. Moreover, scores on functional tests and state fatigue were different between groups after the tests. Our results indicate that trait fatigue and state fatigue in individuals with SCI and MS are different with respect to able-bodied population. Both SCI and MS groups experienced more trait fatigue than control group in daily life. In addition, walking tasks produced similar levels of state fatigue between healthy people and patients with MS/SCI. However, these tests induced longer-lasting levels of state fatigue in the patients.

Factors Associated With Fatigue in People With Spinal Cord Injury: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the association between fatigue and clinical and demographic variables in people with spinal cord injury (SCI).

DATA SOURCES

Five databases (MEDLINE, Physiotherapy Evidence Database, Cochrane, Google Scholar, Cumulative Index to Nursing and Allied Health) were searched up to November 2021.

STUDY SELECTION

Observational studies that reported the association between fatigue and clinical and demographic variables in English or Spanish were eligible. Reviews, qualitative research studies, and nonoriginal articles were excluded. Twenty-three of the 782 identified studies met the inclusion criteria for the meta-analysis.

DATA EXTRACTION

Two researchers independently extracted the data. The strength of the association between each factor and fatigue was determined by the effect size. When the results of the effect size were expressed with different statistics, the correlation coefficient was the preferred estimation. The risk of bias was assessed using the Appraisal Tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale.

DATA SUMMARY

A pooled analysis of the associations between fatigue and 17 factors was performed. A direct association was found between fatigue and 9 factors (sorted by effect size): anxiety (r=0.57; 95% CI, 0.29-0.75), stress (r=0.54; 95% confidence interval [CI], 0.26-0.74), depression (r=0.47; 95% CI, 0.44-0.50), pain (r=0.34; 95% CI, 0.16-0.50), analgesic medication (r=0.32; 95% CI, 0.28-0.36), assistive devices (r=0.23; 95% CI, 0.17-0.29), lesion level (r=0.15; 95% CI, 0.07-0.23), incomplete SCI (r=0.13; 95% CI, 0.05-0.22), and medication (r=0.12; 95% CI, 0.01-0.23). An inverse association was found with 3 factors (sorted by effect size): self-efficacy (r=-0.63; 95% CI, -0.81 to -0.35), participation (r=-0.32; 95% CI, -0.58 to -0.001), and physical activity (r=-0.17; 95% CI, -0.28 to -0.05). No association was found with age, sex, educational level, time since injury, and spasticity.

CONCLUSIONS

Several factors were associated with fatigue in people with SCI, with those related to mental health showing the strongest associations. These results should be interpreted with caution because of the high heterogeneity observed in some factors.

Therapists' perspectives on using brain-computer interface-triggered functional electrical stimulation therapy for individuals living with upper extremity paralysis: a qualitative case series study

BACKGROUND

Brain computer interface-triggered functional electrical stimulation therapy (BCI-FEST) has shown promise as a therapy to improve upper extremity function for individuals who have had a stroke or spinal cord injury. The next step is to determine whether BCI-FEST could be used clinically as part of broader therapy practice. To do this, we need to understand therapists' opinions on using the BCI-FEST and what limitations potentially exist. Therefore, we conducted a qualitative exploratory study to understand the perspectives of therapists on their experiences delivering BCI-FEST and the feasibility of large-scale clinical implementation.

METHODS

Semi-structured interviews were conducted with physical therapists (PTs) and occupational therapists (OTs) who have delivered BCI-FEST. Interview questions were developed using the COM-B (Capability, Opportunity, Motivation-Behaviour) model of behaviour change. COM-B components were used to inform deductive content analysis while other subthemes were detected using an inductive approach.

RESULTS

We interviewed PTs (n = 3) and OTs (n = 3), with 360 combined hours of experience delivering BCI-FEST. Components and subcomponents of the COM-B determined deductively included: (1) Capability (physical, psychological), (2) Opportunity (physical, social), and (3) Motivation (automatic, reflective). Under each deductive subcomponent, one to two inductive subthemes were identified (n = 8). Capability and Motivation were perceived as strengths, and therefore supported therapists' decisions to use BCI-FEST. Under Opportunity, for both subcomponents (physical, social), therapists recognized the need for more support to clinically implement BCI-FEST.

CONCLUSIONS

We identified facilitating and limiting factors to BCI-FEST delivery in a clinical setting according to clinicians. These factors implied that education, training, a support network or mentors, and restructuring the physical environment (e.g., scheduling) should be targeted as interventions. The results of this study may help to inform future development of new technologies and interventions.

Physical health among the Finnish spinal cord injury population according to the Patient Reported Outcome Measurement Information System (PROMIS®)

OBJECTIVE

The aim of this study is to assess the physical health in the Finnish Spinal cord injury (SCI) population using the Patient Reported Outcome Measurement Information System (PROMIS®) and make a comparison to the general United States (US) population. Furthermore, the aim is to explore the associations between pain interference, pain intensity, sleep disturbance, and fatigue and physical function.

DESIGN

Cross-sectional study. This study is part of the Finnish Spinal Cord Injury (FinSCI) community survey study.

SETTING

Community, Finland.

PARTICIPANTS

884 persons with SCI.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Physical health was measured with custom Patient Reported Outcome Measure System (PROMIS®) short forms.

RESULTS

Higher age and lesion level indicated more severe physical function impairments. Persons ≥46 years exhibited more pain interference symptoms compared to younger participants. On average, the Finnish SCI population had 1.3 SD lower physical function and 0.9 SD higher pain interference T-scores compared to the US general population (P < 0.001). The most significant association was observed between pain interference and physical function (r = -0.364, P < 0.001).

CONCLUSIONS

The present study provides a description of the state of physical health in the Finnish spinal cord injury population, as well as the associations between the physical health areas. The results highlight the substantiality of pain management in terms of improving physical function.

TRIAL REGISTRATION NUMBER

NCT04649814.

Hand Motor Fatigability Induced by a Simple Isometric Task in Spinal Cord Injury

This study aimed: (1) to evaluate the hand motor fatigability in people with spinal cord injury (SCI) and compare it with measurements obtained form an able-bodied population; (2) to compare the hand motor fatigability in people with tetraplegia and in people with paraplegia; and (3) to analyse if motor fatigability is different in people with SCI with and without clinical significant perceived fatigability. Materials and Methods: 96 participants with SCI (40 cervical and 56 thoracolumbar) and 63 able-bodied controls performed a simple hand isometric task to assess motor fatigability. The Fatigue Severity Scale was used for perceived fatigability evaluation. Results: The main results of this study can be summarized as follows: (1) the waning in muscle force (motor fatigability) during a fatiguing task is similar in controls and participants with SCI; (2) the motor fatigability is influenced by the maximal muscle force (measured at the beginning of the task); and (3) the perceived fatigability and the motor fatigability are largely independent in the individuals with SCI. Conclusion: Our findings suggest that the capability to maintain a prolonged effort is preserved in SCI, and this capacity depends on the residual maximal muscle force in people with SCI.

Long-term physical therapy for neuropathic pain after cervical spinal cord injury and resting state electroencephalography: a case report

INTRODUCTION

Neuropathic pain after spinal cord injury is difficult to treat, and it is associated with abnormalities in the function of the thalamus-to-cortex neural circuitry. Aerobic exercise provides immediate improvement in neuropathic pain and is associated with abnormal resting electroencephalography (EEG) findings in patients with spinal cord injury. This study aimed to investigate whether physical therapy, including walking, can improve neuropathic pain and EEG peak alpha frequency (PAF) in the long term in a patient with cervical spinal cord injury.

CASE PRESENTATION

A 50-year-old man was admitted with a cervical spinal cord insufficiency injury sustained one week prior. The residual height was C5. Neuropathic pain was observed in the fingers bilaterally. A numerical rating scale (NRS) was evaluated to measure the weekly mean and maximum intensities of pain. Resting EEG was measured, and the PAF was calculated. Each time point was evaluated in 2-week intervals from the time of admission, and the rate of change (Δ) of PAF was calculated based on the initial evaluation. Interventions included 18 weeks of standard physical therapy focusing on gait, with additional intensive gait training (4-10 weeks). The NRS scores for the mean and maximum intensities of pain decreased significantly after 6 weeks, and ΔPAF increased significantly after 4 weeks. Improvement in PAF coincided with the start of intensive gait training.

DISCUSSION

PAF shifts to a high frequency during intensive gait training, suggesting the effectiveness of aerobic exercise. Furthermore, there is a close relationship between PAF, pain, and the quantification of pain changes.

Evidence on definitions, concepts, outcome instruments, and interventions for chronic fatigue in spinal cord injury: a scoping review protocol

OBJECTIVE

The objective of this review is to review the existing evidence on definitions, concepts, measurement instruments, and interventions for chronic fatigue in spinal cord injury.

INTRODUCTION

Chronic fatigue in people with spinal cord injury is an under-studied issue that affects between 25% and 56.6% of people with spinal cord injury. There are questions about how it is defined and managed due to its complex, multifactorial nature and relationship with related conditions. No overview of chronic fatigue in spinal cord injury exists and we are in need of a shared definition of chronic fatigue, as well as a comprehensive review of concepts and evidence supporting outcome instruments and interventions.

INCLUSION CRITERIA

This review will include empirical and non-empirical studies that focus on definitions, concepts, measurement instruments, and interventions for chronic fatigue in spinal cord injury. Studies that focus on peripheral muscle fatigue will only be included if they include chronic fatigue as a secondary outcome.

METHODS

This review will be done in three phases. Phase I will provide an overview of definitions of chronic fatigue in spinal cord injury and will include a qualitative analysis of concept attributes and characteristics. Phase II will focus on factors related to chronic fatigue and measurement instruments used to measure chronic fatigue, and phase III will focus on interventions. Full texts will be screened by two independent reviewers against inclusion criteria. Results will be presented in tabular form with a narrative summary.

Minimal Clinically Important Differences for Measures of Pain, Lung Function, Fatigue, and Functionality in Spinal Cord Injury

OBJECTIVE

The objective of this study was to determine the minimal clinically important differences (MCIDs) for the numerical pain rating scale (NPRS), peak cough flow (PCF), peak expiratory flow (PEF), fatigue severity scale (FSS), and London chest activities of daily living scale (LCADL) in patients with spinal cord injuries (SCIs) after rehabilitation.

METHODS

Inpatients with SCI from 2 rehabilitation centers participating in a daily rehabilitation program were recruited. The NPRS, PCF, PEF, FSS, and LCADL were collected at baseline and discharge. The global rating of change scale was performed at discharge. MCIDs were calculated using anchor (linear regression, mean change, and receiver operating characteristic curves) and distribution-based methods (0.5 times the baseline SD, standard error of measurement, 1.96 times standard error of measurement, and minimal detectable change) and pooled using arithmetic weighted mean.

RESULTS

Sixty inpatients with SCI (36 males; 54.5 [15.9] years) participated. On average their rehabilitation program lasted 7.3 (1.7) weeks. Pooled MCID estimates were 1.6 points for the NPRS, 69.8 L/min for the PCF, 77.4 L/min for the PEF, 1.1 points for the FSS, and 1.4 points for the LCADL.

CONCLUSION

Established MCIDs for NPRS, PCF, PEF, FSS, and LCADL will help health professionals to interpret results and guide rehabilitation interventions in patients with SCI.

IMPACT

Health professionals and researchers may now use -1.6 points for the NPRS, 69.8 L/min for the PCF, 77.4 L/min for the PEF, 1.1 points for the FSS, and 1.4 points for the LCADL to interpret if changes in pain, cough intensity, expiratory flow, fatigue and activities of daily living after rehabilitation of patients with SCI have been clinically relevant.

Longitudinal Assessment of Autonomic Function during the Acute Phase of Spinal Cord Injury: Use of Low-Frequency Blood Pressure Variability as a Quantitative Measure of Autonomic Function

High-level spinal cord injury (SCI) can disrupt cardiovascular autonomic function. However, the evolution of cardiovascular autonomic function in the acute phase following injury is unknown. We evaluated the timing, severity, progression, and implications of cardiovascular autonomic injury following acute SCI. We tested 63 individuals with acute traumatic SCI (aged 48 ± 2 years) at five time-points: <2 weeks, and 1, 3, 6-12, and >12 months post-injury. Supine beat-to-beat systolic arterial pressure (SAP) and R-R interval (RRI) were recorded and low-frequency variability (LF SAP and LF RRI) determined. Cross-spectral analyses were used to determine baroreflex function (low frequency) and cardiorespiratory interactions (high frequency). Known electrocardiographic (ECG) markers for arrhythmia and self-reported symptoms of cardiovascular dysfunction were determined. Comparisons were made with historical data from individuals with chronic SCI and able-bodied controls. Most individuals had high-level (74%) motor/sensory incomplete (63%) lesions. All participants had decreased LF SAP at <2 weeks (2.22 ± 0.65 mm Hg²). Autonomic injury was defined as high-level SCI with LF SAP <2 mm Hg². Two distinct groups emerged by 1 month: autonomically complete SCI with sustained low LF SAP (0.76 ± 0.17 mm Hg²) and autonomically incomplete SCI with increased LF SAP (5.46 ± 1.0 mm Hg², p < 0.05). Autonomically complete injuries did not recover over time. Cardiovascular symptoms were prevalent and worsened with time, especially in those with autonomically complete lesions, and chronic SCI. Baroreflex function and cardiorespiratory interactions were impaired after SCI. Risk of arrhythmia increased immediately after SCI, and remained elevated throughout the acute phase. Acute SCI is associated with severe cardiovascular dysfunction. LF SAP provides a simple, non-invasive, translatable, quantitative assessment of autonomic function, and is most informative 1 month after injury.

Exploring the causes and impacts of falls among ambulators with spinal cord injury using photovoice: a mixed-methods study

OBJECTIVES

This study explored: (1) fall circumstances experienced by ambulators with spinal cord injury (SCI) over a 6-month period, (2) the impacts of falls-related injuries and fall risk and (3) their preferences/recommendations for fall prevention.

DESIGN

A sequential explanatory mixed-methods design with two phases.

SETTING

A Canadian SCI rehabilitation hospital and community setting.

PARTICIPANTS

Thirty-three ambulators with SCI participated in phase 1 and eight participants that fell in phase 1 participated in phase 2.

METHODS

In phase 1, fall circumstances were tracked using a survey that was completed each time a participant fell during the 6-month tracking period. Phase 2 involved photovoice; participants took photographs of factors that influenced their fall risk and how their fall risk impacted their work/recreational activities. Participants discussed the photographs and topics related to fall prevention in an individual interview and a focus group.

RESULTS

Of the 33 participants, 21 fell in 6 months. Falls commonly occurred in the home while participants were changing positions or walking. Most falls occurred in the morning or afternoon. In phase 2, interviews and focus group discussion revealed three themes: (1) falls are caused by bodily impairments (eg, impaired reactive response during slips and trips and weakness and altered sensation in legs/feet), (2) impacts of fall-related injuries and fall risk (eg, psychosocial effects of fall-related injuries, limiting community participation due to the risk of falling and activity-dependent concern of falling) and (3) approaches to fall prevention (eg, fall prevention strategies used, components of fall prevention and utility of professional fall prevention strategies/interventions).

CONCLUSIONS

Fall prevention interventions/strategies should focus on minimising a person's fall risk within their home as most falls occurred in the home environment. Ambulators with SCI would benefit from education and awareness about common fall circumstances that they may encounter in their daily lives.

Does prolonged walking cause greater muscle fatigability in individuals with incomplete spinal cord injury compared with matched-controls?

BACKGROUND

Individuals with incomplete spinal cord injury (iSCI) might show muscle fatigability during walking, primarily over long distances. The cause can be related to the motor impairment and walking compensations identified in this population. However, evidence on the occurrence of muscle fatigability after prolonged walking in individuals with iSCI is conflicting.

RESEARCH QUESTION

Does prolonged walking cause higher muscle fatigability in individuals with iSCI compared with matched-controls?

METHODS

We adopted a repeated measures design, in which maximal voluntary isometric contractions were performed before and after a walking test to induce the fatigability, in 24 individuals with iSCI and 24 matched-controls. Body weight-normalized peak torque (PT/BW), rate of force development (RFD), root mean square (RMS) and neuromuscular efficiency were used to assess the muscle fatigability. A mixed model ANOVA (2 × 2) was used for between-group and within-group comparisons. The significance was set in 5%.

RESULTS

Individuals with iSCI showed a greater decline in the PT/BW and RMS after the walking test. However, the RFD presented a greater decrease in the control group.

SIGNIFICANCE

Our results showed that prolonged walking caused higher muscle fatigability in individuals with iSCI compared to healthy individuals. Therefore, muscle fatigability should be considered during the rehabilitation planning and in activities of daily living of individuals with iSCI. Moreover, the identification of muscle fatigability in individuals with iSCI might be useful to prevent high levels of physical exertion and, possibly, the risk of fall.

Effects of Robot-Assisted Gait Training in Individuals with Spinal Cord Injury: A Meta-analysis

Background

To investigate the effects of robot-assisted gait training (RAGT) on spasticity and pain in people with spinal cord injury (SCI). Material and methods. Four electronic databases (PubMed, Scopus, Medline, and Cochrane Central Register of Controlled Trials) were searched for studies published up to November 2019. Only human trials and of English language were included. The searched studies were reviewed and extracted independently by two authors. Randomized controlled trials (RCTs) and non-RCTs were pooled separately for analyses. Primary outcome measures included spasticity assessed by Ashworth scale (AS) or modified Ashworth scale (MAS) and pain assessed by VAS. Secondary outcome measures included lower extremity motor score (LEMS) and walking ability (i.e., 6-minute walk test, 10-meter walk test).

Results

A total of 225 studies were identified. Eighteen studies (7 RCTs and 11 non-RCTs) including 301 subjects met inclusion criteria. The outcome measure of spasticity significantly improved in favor of RAGT group in non-RCTs (AS: 95%CI = −0.202 to -0.068, p ≤ 0.001; MAS: 95%CI = −2.886 to -1.412, p ≤ 0.001). The results on pain did not show significant change after RAGT in either RCTs or non-RCTs. LEMS and walking ability significantly increased in favor of RAGT.

Conclusions

RAGT can improve spasticity and walking ability in people with SCI. The probable reason for no significant change in pain after RAGT is floor effect. RAGT is beneficial for normalizing muscle tone and for improving lower extremity function in people with SCI without causing extra pain.

Lifestyle modifications and pharmacological approaches to improve sexual function and satisfaction in men with spinal cord injury: a narrative review

STUDY DESIGN

A narrative review describing various components of sexual dysfunction in men with spinal cord injury (SCI), as well as addressing potential therapeutic approaches.

OBJECTIVES

Restoration of sexual function is considered one of the most important health priorities for individuals with SCI. The purpose of this review is to provide information regarding the factors that are less appreciated when considering changes to sexual function in men with SCI. We also propose therapeutic approaches, with a focus on lifestyle modifications, which have been shown to improve sexual function.

METHODS

A literature search was performed and limited evidence for therapeutic approaches in individuals with SCI was supplemented by consistent findings from the able-bodied population.

RESULTS

We evaluated the less addressed factors known to contribute to sexual dysfunction in men with SCI, including hormonal influences (i.e., testosterone deficiency, thyroid hormone, and cortisol), psychological factors (i.e., pain, fatigue, depression, and body image), and secondary SCI complications (i.e., urinary tract infection, pressure sores, and autonomic dysreflexia). To address these factors beyond standard medical treatments for sexual dysfunction, options include physical activity/exercise, diet, and specific medications for symptom relief (i.e., testosterone replacement therapy and selective serotonin reuptake inhibitors for depression).

CONCLUSIONS

Physical activity's potential application, efficacy across multiple aspects of sexuality, and the lack of side effects, suggests that long-term exercise is a viable solution to directly or indirectly improve sexual function in males with SCI. Diet and supplemental medications may further promote body composition changes, which more broadly affect sexuality.

Reliability of Cognitive Measures in Individuals With a Chronic Spinal Cord Injury

BACKGROUND

Following spinal cord injury (SCI), up to 64% of individuals experience cognitive deficit. However, the reliability of commonly used neuropsychological tests is currently unknown in this population.

OBJECTIVES

To evaluate the test-retest reliability of cognitive measures in individuals with SCI.

DESIGN

Cross-sectional study.

SETTING

Vancouver General Hospital.

PARTICIPANTS

Individuals with a chronic (>2 years) SCI (n = 22).

METHODS

Across three visits (separated by ~16 days), 22 participants with chronic SCI completed a neuropsychological battery evaluating memory (Rey Auditory-Verbal Learning Test [RAVLT]), attention/concentration/psychomotor speed (Digit Span Task, Stroop Test), and executive function (Trail Making Test A&B, Symbol Digit Modalities Test, Controlled Oral Word Association Test). Coefficients of variation (CV_intra ) and intraclass correlation coefficients (ICCs) were calculated to determine the reliability of each test between visits. Linear regressions were performed to assess the associations between variability (CV_intra ) and participant characteristics, such as age or highest education level attained. Repeated-measures, one-way analysis of variance (ANOVA) was conducted to determine any significant practice effects, and smallest real differences (SRDs) were calculated.

MAIN OUTCOME MEASUREMENTS

Repeated scores on aforementioned neuropsychological tests.

RESULTS

ICCs ranged from 0.77 to 0.93, with the exception of RAVLT recognition score (ICC = 0.27). Age showed a moderate association with CV_intra in RAVLT interference recall scores (r = 0.43, P = .047), but was not a confounding factor for other measures. Education was not associated with CV_intra . Significant practice effects were noted for most of the cognitive tests assessed.

CONCLUSIONS

Other than the RAVLT recognition score, these cognitive measures demonstrated good-to-excellent reliability. Although this is encouraging, test-retest variability should be considered when interpreting the efficacy of various cognitive training strategies to mitigate cognitive decline in this population. Thus, the SRD values presented herein will allow researchers and clinicians to identify "true" changes in cognitive function with repeated testing.

LEVEL OF EVIDENCE

III.

Transcutaneous Electrical Nerve Stimulation on Acupuncture Points Improves Myofascial Pain, Moods, and Sleep Quality

PURPOSE

The aim of this study was to evaluate the effects of transcutaneous electrical nerve stimulation at acupuncture points versus trigger points on myofascial pain, moods, and sleep quality.

DESIGN

A randomized controlled study recruited 64 patients with spinal cord injury with myofascial pain.

METHODS

Outcomes of pain, moods, and sleep quality were measured and analyzed by the generalized estimation equation, analysis of covariance, and paired t test. Transcutaneous electrical nerve stimulation was applied for seven consecutive days at Hegu (LI4) and Daling (PC7) acupuncture points or myofascial trigger points.

FINDING

Significant differences were found in pain intensity from Day 3 forward, after controlling for confounders. Significant within-group differences were found in pain, moods, and sleep quality.

CONCLUSIONS

Transcutaneous electrical nerve stimulation at acupuncture and trigger points effectively improved pain, moods, and sleep quality in patients with spinal cord injury with myofascial pain. Acupuncture points had superior improvement in pain intensity and slight improvement in sleep quality than did trigger points.

CLINICAL RELEVANCE

Transcutaneous electrical nerve stimulation at acupuncture points could be applied for improving myofascial pain.

Fatigability during volitional walking in incomplete spinal cord injury: cardiorespiratory and motor performance considerations

Fatigability describes the decline in force production (i.e., performance fatigability) and/or changes in sensations regulating performance (i.e., perceived fatigability) during whole-body activity and poses a major challenge to those living with spinal cord injuries (SCI). After SCI, the inability to overcome disruptions to metabolic homeostasis due to cardiorespiratory limitations and physical deconditioning may contribute to increased fatigability severity. The increased susceptibility to fatigability may have implications for motor control strategies and motor learning. Locomotor training approaches designed to reduce fatigability and enhance aerobic capacity in combination with motor learning may be advantageous for promoting functional recovery after SCI. Future research is required to advance the understanding of the relationship between fatigability, cardiorespiratory function and motor performance following SCI.

A Community Perspective on Bowel Management and Quality of Life after Spinal Cord Injury: The Influence of Autonomic Dysreflexia

Autonomic dysfunction is common in individuals with spinal cord injury (SCI) and leads to numerous abnormalities, including profound cardiovascular and bowel dysfunction. In those with high-level lesions, bowel management is a common trigger for autonomic dysreflexia (AD; hypertension provoked by sensory stimuli below the injury level). Improving bowel care is integral for enhancing quality of life (QoL). We aimed to describe the relationships between bowel care, AD, and QoL in individuals with SCI. We performed an online community survey of individuals with SCI. Those with injury at or above T7 were considered at risk for AD. Responses were received from 287 individuals with SCI (injury levels C1-sacral and average duration of injury 17.1 ± 12.9 [standard deviation] years). Survey completion rate was 73% (n = 210). Bowel management was a problem for 78%: it interfered with personal relationships (60%) and prevented staying (62%) and working (41%) away from home. The normal bowel care duration was >60 min in 24% and most used digital rectal stimulation (59%); 33% reported bowel incontinence at least monthly. Of those at risk for AD (n = 163), 74% had AD symptoms during bowel care; 32% described palpitations. AD interfered with activities of daily living in 51%. Longer durations of bowel care (p < 0.001) and more severe AD (p = 0.04) were associated with lower QoL. Bowel management is a key concern for individuals with SCI and is commonly associated with symptoms of AD. Further studies should explore ways to manage bowel dysfunction, increase self-efficacy, and ameliorate the impact of AD to improve QoL.

Fatigability, oxygen uptake kinetics and muscle deoxygenation in incomplete spinal cord injury during treadmill walking

PURPOSE

The purpose of the present study was to characterize hypothesized relationships among fatigability and cardiorespiratory fitness in individuals with chronic motor-incomplete SCI (iSCI) during treadmill walking. The theoretical framework was that exacerbated fatigability would occur concomitantly with diminished cardiorespiratory fitness in people with iSCI.

METHODS

Subjects with iSCI (n = 8) and an able-bodied reference group (REF) (n = 8) completed a 6-min walking bout followed by a walking bout of 30-min or until volitional exhaustion, both at a self-selected walking speed. Fatigability was assessed using both perceived fatigability and performance fatigability measures. Pulmonary oxygen uptake kinetics (VO₂ on-kinetics) was measured breath-by-breath and changes in deoxygenated hemoglobin/myoglobin concentration (∆[HHb]) of the lateral gastrocnemius was measured by near-infrared spectroscopy. Adjustment of VO₂ and ∆[HHb] on-kinetics were modeled using a mono-exponential equation.

RESULTS

Perceived fatigability and performance fatigability were 52% and 44% greater in the iSCI group compared to the REF group (p = 0.003 and p = 0.004). Phase II time constant (τp) of VO₂ on-kinetics and ∆[HHb] ½ time during resting arterial occlusion were 55.4% and 16.3% slower in iSCI vs REF (p < 0.01 and p = 0.047, respectively).

CONCLUSIONS

The results of the present study may suggest that compromised O₂ delivery and/or utilization may have contributed to the severity of fatigability in these individuals with iSCI. The understanding of the extent to which fatigability and VO₂ and Δ[HHb] on-kinetics impacts locomotion after iSCI will assist in the future development of targeted interventions to enhance function.

Multiple mediation path model of pain's cascading influence on physical disability in individuals with SCI from Colombia, South America

BACKGROUND

Research has begun to document the bivariate connections between pain in individuals with spinal cord injury (SCI) and various aspects of health related quality of life (HRQOL), such as fatigue, social functioning, mental health, and physical functioning.

OBJECTIVE

The purpose of this study was to construct and test a theoretical path model illuminating the stage-wise and sequential (cascading) HRQOL pathways through which pain increases physical disability in individuals with SCI in a sample from Colombia, South America. It was hypothesized that increased pain would lead to decreased energy, which would lead to decreased mental health and social functioning, which both would lead to emotional role limitations, which finally would lead to physical role limitations.

METHODS

A cross-sectional study assessed individuals with SCI (n = 40) in Neiva, Colombia. Participants completed a measure indexing various aspects of HRQOL.

RESULTS

The path model overall showed excellent fit indices, and each individual path within the model was statistically significant. Pain exerted significant indirect effects through all possible mediators in the model, ultimately suggesting that energy, mental health, social functioning, and role limitations-emotional were likely pathways through which pain exerted its effects on physical disability in individuals with SCI.

CONCLUSIONS

These findings uncover several potential nodes for clinical intervention which if targeted in the context of rehabilitation or outpatient services, could result in salubrious direct and indirect effects reverberating down the theoretical causal chain and ultimately reducing physical disability in individuals with SCI.

Prevalence of depression, fatigue, and sleep disturbances in patients with myelopathy: Their relation with functional and neurological recovery

OBJECTIVES

To observe the prevalence of fatigue, depression, and sleep disturbance in patients with myelopathy and their correlation with neurological and functional recovery.

PATIENTS AND METHODS

Study conducted in a university tertiary research hospital with 127 patients with myelopathy (92 males) admitted to neurorehabilitation unit between January 2010 and December 2013. Mean age was 32.71 ± 13.08 years (range 15-65 years), and mean duration of injury was 76.22 ± 82.5 days (range 14-365 days). Functional status and impairments were assessed using Barthel Index and Spinal Cord Independence Measures. Depression, fatigue, and sleep disturbances were assessed using Hospital Anxiety and Depression Scale, Fatigue Severity Scale, and Pittsburgh Sleep Quality Index scales, respectively. Neurological recovery was assessed using American Spinal Injury Association's impairment scale.

RESULTS

Forty-four out of 104 (42%) patients had borderline or confirmed depression, 36/108 (33%) had significant fatigue, and 62/106 (58%) had significant sleep disturbances at admission. Significant correlation was observed between change in fatigue and depression scores with change in functional status scores (P < 0.05) but no correlation (P > 0.05) between change in sleep disturbance scores and functional status score and neurological recovery (P > 0.05). Similarly, change in fatigue and depression scores had no correlation with neurological status improvement. Fatigue, depression, and sleep disturbance scores showed significant improvement, that is, admission vs. discharge scores (P < 0.05) with significant correlation between improvement in all three variables (P < 0.05).

CONCLUSIONS

Study variables showed significant improvement in the present study with myelopathy patients but not necessarily correlating with functional and neurological recovery.

Quality of life and pain multidimensional aspects in individuals with HTLV-1

HTLV-1 creates a chronic health condition that involves moderate to severe pain with a negative impact on quality of life (QoL). There is no consensus on which attitudes to pain are more related to the worsening of QoL in HTLV-1 infected patients. The aim of this study was to investigate the correlation between QoL and multidimensional aspects of pain in patients with HTLV-1. A cross-sectional study was conducted in Salvador, Bahia, Brazil. The study included individuals diagnosed with HTLV-1. The Short Form 36 Questionnaire was used to analyze QoL, and the Brief Pain Inventory was used to assess multidimensional aspects of pain. The mean pain intensity was 4.88±3.06 on the visual pain scale, and the average impact on QoL corresponded to a loss of approximately 40%. Moderate to high correlations between pain intensity and all domains of QoL were observed and compared reaction attitudes for general activity, mood, ability to walk, ability to work, relationships, sleep, and ability to enjoy life (r>0.40; p<0.05). Moderate correlations were found between all domains of QoL, pain intensity, and reactive attitudes to pain. The greatest pain intensity impacts involved difficulty to walk and to work, and interpersonal relationships in the emotional aspect of QoL.

Comparison of self-report sleep measures for individuals with multiple sclerosis and spinal cord injury

OBJECTIVE

To investigate self-report measures of sleep disturbances and sleep-related impairments in samples of individuals with multiple sclerosis (MS) or spinal cord injury (SCI).

DESIGN

Cross-sectional survey.

SETTING

Community based.

PARTICIPANTS

Adults (age ≥18y) (N=700) with either MS (n=461) or SCI (n=239) who were enrolled in a longitudinal survey of self-reported health outcomes and who completed self-report sleep measures at 1 time point.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Medical Outcomes Study Sleep Scale (MOS-S), Patient Reported Outcomes Measurement Information System (PROMIS) sleep disturbance short form, and PROMIS sleep-related impairments short form.

RESULTS

Mean scores on the MOS-S sleep index II were significantly worse for both the MS and SCI samples than those of previously reported samples representative of the U.S. general population (P<.0001 for each group). The PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form scores of the MS sample were also significantly different from those reported for the calibration cohort (P<.0001 on each scale). However, although the scores of the SCI sample were significantly different from those of the comparison cohort for the PROMIS sleep-related impairments short form (P=.045), the differences on the PROMIS sleep disturbance short form were not significant (P=.069).

CONCLUSIONS

Although the MOS-S scores for the MS and SCI cohorts clearly indicated significantly high levels of sleep-related problems and were consistent with existing literature, the more ambiguous findings from the PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form suggest that not enough is currently known about how these instruments function when applied to those with chronic neurologic dysfunction.

Pain and fatigue as mediators of the relationship between mobility aid usage and depressive symptomatology in ambulatory individuals with SCI

STUDY DESIGN

Cross-sectional cohort study.

OBJECTIVES

To investigate a mediational model where pain (intensity and interference) and fatigue mediate the relationship between the use of mobility aids and moderate-to-severe depressive symptomatology among ambulatory participants with spinal cord injury (SCI).

SETTING

A medical university in the southeastern United States.

METHODS

Ambulatory adults (N=652) with chronic SCI responded to a mail-in survey. The Patient Health Questionnaire-9 was used to assess moderate-to-severe depressive symptomatology. The Brief Pain Inventory was used to assess pain intensity and interference, and the Modified Fatigue Impact Scale-5-item version was used to assess fatigue. Participants self-reported use of mobility aids.

RESULTS

On examining mobility aids used for ambulation, 65% were found to have used at least one aid. Severe pain intensity was reported by 11%, and 14% reported severe pain interference. Disabling fatigue was reported by 10% of the participants. Twenty-one percent (n=138) reported moderate-to-severe levels of depressive symptoms. On examining the relationships between mobility aids and depressive symptomatology, using people as a mobility aid was associated with increased odds of depressive symptomatology (2.6) and always using a wheelchair was associated with lower odds (0.3). However, these relationships were no longer significant after controlling for the mediating variables pain intensity, pain interference and fatigue.

CONCLUSIONS

Pain and fatigue mediate the relationship between usage of certain mobility aids and depressive symptomatology. The use of people to assist in ambulation is associated with greater odds of moderate-to-severe depressive symptomatology, while always using a wheelchair is associated with lower odds.

The association of age, pain, and fatigue with physical functioning and depressive symptoms in persons with spinal cord injury

CONTEXT/OBJECTIVE

To describe the relationship of pain and fatigue with physical and psychological functioning in adults with spinal cord injury (SCI).

DESIGN

Cross-sectional survey.

SETTING

Community-based survey.

PARTICIPANTS

Convenience sample of individuals with SCI.

INTERVENTION

Not applicable.

OUTCOME MEASURES

Physical functioning (Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Functioning item bank items), depression (Patient Health Questionnaire-9 (PHQ-9)), pain severity (0-10 Numerical Rating Scale (NRS)), and fatigue (0-10 NRS).

RESULTS

Pain and fatigue were independently associated with depression, but only pain was associated with physical functioning. Additionally, depression was more severe among middle-aged participants relative to younger or older participants. Physical functioning declined with increasing age, as well as with higher level of injury.

CONCLUSIONS

The findings support the need for continued development of effective treatments for both pain and fatigue in order to prevent and mitigate the negative effects these symptoms can have on functioning.

Fatigue and tiredness in people with spinal cord injury

OBJECTIVE

Fatigue is a common symptom in people with neurological injury such as spinal cord injury (SCI), though its nature and occurrence in people with SCI are not well understood. The objective of this research was to investigate fatigue and its relationship to factors such as mood states and self efficacy in adult people with SCI compared to able-bodied controls.

METHODS

Participants included 41 adults with SCI living in the community and 41 able-bodied controls matched for age and sex ratios and education. All participants first completed a comprehensive psychological assessment and were then asked to take part in a 2-3 hour session composed of a regimen of cognitive tasks that required constant concentration and attention. Participants were assessed after completing this task.

RESULTS

The SCI group was found to have significantly elevated levels of fatigue, as well as elevated depressive mood, anxiety and poor self-efficacy. The SCI group was also found to suffer excessive levels of tiredness as a consequence of the 2-3 hour task. Factors such as depressive mood and poor self-efficacy were shown to increase the risk of excessive tiredness.

CONCLUSION

People with a neurological injury such as SCI have a high risk of having fatigue and are susceptible to experiencing excessive tiredness when performing extended tasks, and the presence of elevated depressive mood or poor expectations towards self management will increase this susceptibility. Implications for managing fatigue and improving social access in SCI populations are discussed.

Behavioral factors related to fatigue among persons with spinal cord injury

OBJECTIVE

To examine behavioral risk factors in relation to fatigue after spinal cord injury (SCI), specifically cardiovascular-related behaviors, prescription medication use, and alcohol and cigarette use.

DESIGN

Cross-sectional.

SETTING

A medical university in the southeastern United States.

PARTICIPANTS

Adults (N=2245) at least 1 year post-SCI from a large specialty hospital in the Southeast responded to a mail-in survey.

INTERVENTION

Not applicable.

MAIN OUTCOMES MEASURE

The Modified Fatigue Impact Scale-5-item version was used to assess disabling fatigue.

RESULTS

Of participants, 8.3% had disabling fatigue, 45.3% reported fatigue rarely to never impacted their life, and 46.4% reported having some fatigue. Persons who reported having less exercise than others with a similar injury level were 2.49 times as likely to have disabling fatigue as persons who reported more exercise. Those with a fair or poor diet were also more likely to have disabling fatigue. Use of prescription medication to treat pain was associated with disabling fatigue, as was being CAGE positive. Among nonbehavioral variables, race and injury severity were significantly associated with disabling fatigue.

CONCLUSIONS

We identified several behavioral predictors of disabling fatigue, including cardiovascular risk factors, prescription medication use, and alcohol use. These factors are important because they are able to be modified and could be potential factors for prevention or intervention.

Menopause characteristics and subjective symptoms in women with and without spinal cord injury

OBJECTIVE

To examine menopause transition characteristics and symptom bother in women with spinal cord injury (SCI).

DESIGN

Prospective cohort (4 data collection periods across 4 years).

SETTING

Community.

PARTICIPANTS

Women (n=62) with SCI (injury levels C6-T12, nonambulatory, >36mo postinjury; 86.1% retention) and women without SCI (n=66; 92.9% retention) with intact ovaries, not using hormone therapy, and between the ages of 45 and 60 years volunteered. A total of 505 observations were collected and analyzed.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Age at final menstrual period (FMP), transitions through menopause status classifications, and menopause symptom bother (vasomotor, somatic, psychologic symptoms).

RESULTS

The number of women transitioning through a menopause status classification over the course of the study did not significantly vary by group (P=.263), nor did age at FMP (P=.643). Women with SCI experienced greater bother of somatic symptoms (a subscale, P<.001), bladder infections (P<.001), and diminished sexual arousal (P=.012). Women without SCI had significantly greater bother of vasomotor symptoms (P=.020). There were no significant group by menopause status interactions; main effects for menopause status were significant only for vasomotor symptoms and vaginal dryness.

CONCLUSIONS

Results suggested that women with SCI experience greater symptom bother in certain areas, but that patterns of symptom bother across menopause, transition through menopause, and age at FMP are similar to those of their peers. Larger studies are needed to examine menopause outcomes with respect to level of injury and completeness of injury. These findings provide a framework that women with SCI and their health care providers can use to address the menopause transition and highlight the importance of multidisciplinary involvement to maximize health and well being during this transition.

Medication use is associated with fatigue in a sample of community-living individuals who have a spinal cord injury: a chart review

OBJECTIVES

To investigate the relationship between medications known to cause fatigue in spinal cord injury (SCI) and fatigue severity and to describe the pattern of prescription of these medications.

STUDY DESIGN

Retrospective chart review.

SETTING

GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada.

METHODS

Medical charts of 136 individuals admitted to the GF Strong Outpatient SCI Program between December 2004 and May 2007 were reviewed. Data collected included information on medications, clinical and demographic characteristics and Fatigue Severity Scale (FSS) scores. Multiple linear regression techniques were used to analyse the data.

RESULTS

Fifty-two percent of the subjects had clinically relevant fatigue. As a group, the subjects were taking 147 different medications; 41/147 medications were identified as causing fatigue. The two most commonly prescribed categories of medications were antispasticity medications (75 subjects) and analgesic medications (61 subjects). Although several variables were found to contribute to the FSS scores including the use of fatigue-causing medications, the presence of pain (7.6% of variance) and the use of fatigue-causing analgesics (4.2% of variance) explained the most variance in the scores.

CONCLUSION

Fatigue is prevalent in outpatients with SCI. Fatigue-causing medications contribute to a higher FSS score. Clinicians treating persons with SCI should be aware that fatigue is a common and significant problem. Clinicians should be aware that fatigue may be exacerbated by the use of medication and should enquire about the effects of medication on fatigue when assessing and prescribing new medications.

Perceptions of exercise mastery in persons with complete and incomplete spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To compare exercise-related self-perceptions in persons with complete and incomplete spinal cord injury (SCI) and to identify factors that explain the variance of perceived exercise mastery in the study population.

SETTING

Sunnaas Rehabilitation Hospital and the Norwegian School of Sport Sciences, Norway.

METHODS

A total of 116 respondents (47 persons with complete and 69 persons with incomplete SCI) answered a questionnaire measuring self-rated physical exercise habits and self-perceptions in exercise. Respondents with complete SCI performed a max test on an arm ergometer.

RESULTS

Exercisers with complete SCI reported a significantly higher perceived exercise mastery (P=0.002) and exercisers with incomplete SCI reported a significantly lower perceived exercise mastery (P=0.012) than nonexercisers. Exercisers in both groups reported a higher perceived fitness (complete SCI, P=0.016; incomplete SCI, P=0.004) than nonexercisers. A regression analysis showed that exercising versus nonexercising (exercise status) was the only variable that contributed to the variance in perceived exercise mastery for persons with complete SCI (P<0.001). For persons with incomplete injury, exercise status and exercise hours per week contributed to the variance in perceived exercise mastery.

CONCLUSION

Although perceived fitness is associated with exercise in the whole SCI population, perception of exercise mastery is negatively related to exercise in persons with incomplete SCI, in contrast to those with complete lesions.