Trends in life expectancy after spinal cord injury

"The Other Thousand Hours": A Spinal Cord Injury Self-Management Program Qualitative Analysis

People with spinal cord injury experience secondary health conditions (SHCs) at a high rate which impacts life expectancy and functional performance. Self-management (SM) is an evidence-based approach to reduce the negative effects of SHCs, but prior SM programs have not been successful for the spinal cord injury (SCI) population. We sought to describe the experiences of participants completing a group-based telehealth program that is tailored to the SCI population: The Spinal Cord Injury Self-Management (SCISM) Program. We conducted interviews using Interpretive Phenomenological Analysis to examine participants' experiences. Twenty-two participants completed the interviews. Four themes ("A Sense of Community," "Being Held Accountable," "I'm Still Learning," and "Being Proactive Instead of Reactive") emerged. People with SCI require continued support throughout the chronic stage of SCI particularly at the community level to address mental health as well as the learning and application of SM skills through tailored interventions that foster community and accountability.

Needs Assessment of Self-Management for Individuals With Chronic Spinal Cord Injury/Disease

Since the 1980s, survivorship for persons with spinal cord injury/disease (SCI/D) has significantly improved; however, life expectancy remains lower than the general population due to secondary health conditions (SHCs) that lead to decreased function and death. This study explored (1) facilitators and barriers to engaging in self-management (SM) for persons with SCI/D and (2) stakeholder perspectives on potential SM program components and content for intervention development. Around 38 participants with SCI/D responded to this cross-sectional study and needs assessment conducted at the University of Missouri, Columbia. Responses were analyzed to determine descriptive statistics. Participants indicated barriers to SM include transportation/distance, presence of SHCs, and a lack of local resources. Participants noted that virtual SM programs with strong psychological health/coping components were preferred. These findings should guide the development of an SM program tailored to SCI/D to reduce the prevalence and impact of SHC on the SCI/D population.

Profiling Immunological Phenotypes in Individuals During the First Year After Traumatic Spinal Cord Injury: A Longitudinal Analysis

Abstract Individuals with SCI are severely affected by immune system changes, resulting in increased risk of infections and persistent systemic inflammation. While recent data support that immunological changes after SCI differ in the acute and chronic phases of living with SCI, only limited immunological phenotyping in humans is available. To characterize dynamic molecular and cellular immune phenotypes over the first year, we assess RNA (bulk-RNA sequencing), protein, and flow cytometry (FACS) profiles of blood samples from 12 individuals with SCI at 0-3 days and at 3, 6, and 12 months post injury (MPI) compared to 23 uninjured individuals (controls). We identified 967 differentially expressed (DE) genes in individuals with SCI (FDR <0.001) compared to controls. Within the first 6 MPI we detected a reduced expression of NK cell genes, consistent with reduced frequencies of CD56bright, CD56dim NK cells present at 12 MPI. Over 6MPI, we observed increased and prolonged expression of genes associated with inflammation (e.g. HMGB1, Toll-like receptor signaling) and expanded frequencies of monocytes acutely. Canonical T-cell related DE genes (e.g. FOXP3, TCF7, CD4) were upregulated during the first 6 MPI and increased frequencies of activated T cells at 3-12 MPI. Neurological injury severity was reflected in distinct whole blood gene expression profiles at any time after SCI, verifying a persistent 'neurogenic' imprint. Overall, 2876 DE genes emerge when comparing motor complete to motor incomplete SCI (ANOVA, FDR <0.05), including those related to neutrophils, inflammation, and infection. In summary, we identify a dynamic immunological phenotype in humans, including molecular and cellular changes which may provide potential targets to reduce inflammation, improve immunity, or serve as candidate biomarkers of injury severity.

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.

Global, regional, and national burden of spinal cord injury, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Spinal cord injury (SCI) is a major cause of health loss due to premature mortality and long-term disability. We aimed to report on the global, regional, and national incidence, prevalence, and years of life lived with disability (YLDs) for SCI from 1990 to 2019, using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

Using GBD 2019 data pooled in DisMod-MR 2.1, a Bayesian meta-regression tool, we systematically derived numbers and age-standardised rate changes with 95% uncertainty intervals (95% UIs) for the incidence, prevalence, and YLDs for SCI from 1990 to 2019 for the whole world, 21 GBD regions, and 204 countries and territories. We report trends based on age, sex, year, cause of injury, and level of injury.

FINDINGS

Globally, 20·6 million (95% UI 18·9 to 23·6) individuals were living with SCI in 2019. The incidence of SCI was 0·9 million (0·7 to 1·2) cases with an estimated 6·2 million (4·5 to 8·2) YLDs. SCI rates increased substantially from 1990 to 2019 for global prevalence (81·5%, 74·2 to 87·1), incidence (52·7%, 30·3 to 69·8), and YLDs (65·4%, 56·3 to 76·0). However, global age-standardised rates per 100 000 population showed small changes in prevalence (5·8%, 2·6 to 9·5), incidence (-6·1%, -17·2 to 1·5), and YLDs (-1·5%, -5·5 to 3·2). Data for 2019 shows that the incidence of SCI increases sharply until age 15-19 years, where it remains reasonably constant until 85 years of age and older. By contrast, prevalence and YLDs showed similar patterns to each other, with one peak at around age 45-54 years. The incidence, prevalence, and YLDs of SCI have consistently been higher in men than in women globally, with a slight and steady increase for both men and women from 1990 to 2019. Between 1990 and 2019, SCI at neck level was more common than SCI below neck level in terms of incidence (492 thousand [354 to 675] vs 417 thousand [290 to 585]), prevalence (10·8 million [9·5 to 13·9] vs 9·7 million [9·2 to 10·4]), and YLDs (4·2 million [3·0 to 5·8] vs 1·9 million [1·3 to 2·5]). Falls (477 thousand [327 to 683] cases) and road injuries (230 thousand [122 to 389] cases) were the two leading causes of SCI globally in 2019.

INTERPRETATION

Although age-standardised rates of incidence, prevalence, and YLDs for SCI changed only slightly, absolute counts increased substantially from 1990 to 2019. Geographical heterogeneity in demographic, spatial, and temporal patterns of SCI, at both the national and regional levels, should be considered by policy makers aiming to reduce the burden of SCI.

FUNDING

Bill & Melinda Gates Foundation.

Longitudinal changes in employment, health, participation, and quality-of-life and the relationships with long-term survival after spinal cord injury

STUDY DESIGN

Cohort study.

OBJECTIVE

To identify five-year longitudinal changes in employment, health, participation, and quality-of-life outcomes (QOL) among participants with chronic spinal cord injury (SCI) and to compare the amount of change in these outcomes between those surviving and those not surviving until follow-up.

METHODS

Participants were 1157 individuals from the SCI Longitudinal Aging Study, who have completed at least two self-report assessments separated by five-year intervals. The main outcome measures were 13 indicators related to employment, health, participation, and QOL/psychosocial indicators. Survival status measured at follow-up.

RESULTS

Those who survived to follow up had a history indicating a greater likelihood of employment, better health, participation, and QOL/psychosocial indicators. Among survivors, longitudinal declines were limited to the percent employed and participation indicators, whereas those deceased by follow-up had significant undesirable changes in employment, participation, health, and QOL/psychosocial indicators. More specifically, compared to the survivors, those deceased by follow-up experienced a greater increase in hospitalizations, decreases in nights away from home, and declines in global satisfaction over the five-year interval.

CONCLUSIONS

Longitudinal declines in employment and some aspects of participation are common among long-term survivors and may be part of the natural course of outcomes after SCI. However, more dramatic increases in hospitalizations, fewer nights away from home, and declining satisfaction may be red flags for declining longevity.

Diagnosis and Management of Cardiovascular Risk in Individuals With Spinal Cord Injury: A Narrative Review

More than 16 000 Americans experience spinal cord injury (SCI), resulting in chronic disability and other secondary sequelae, each year. Improvements in acute medical management have increased life expectancy. Cardiovascular disease is a leading cause of death in this population, and seems to occur earlier in individuals with SCI compared with the general population. People with SCI experience a high burden of traditional cardiovascular disease risk factors, including dyslipidemia and diabetes, and demonstrate anatomic, metabolic, and physiologic changes alongside stark reductions in physical activity after injury. They also experience multiple, complex barriers to care relating to disability and, in many cases, compounding effects of intersecting racial and socioeconomic health inequities. Given this combination of risk factors, some investigators have proposed that people with SCI are at increased risk for cardiovascular disease, beyond that associated with traditional risk factors, and SCI could be considered a risk-enhancing factor, analogous to other risk-enhancing factors defined by the 2019 American Heart Association/American College of Cardiology Primary Prevention Guidelines. However, more research is needed in this population to clarify the role of traditional risk factors, novel risk factors, health care access, social determinants of health, and intersectionality of disability, race, and socioeconomic status. There is an urgent need for primary care physicians and cardiologists to have awareness of the importance of timely diagnosis and management of cardiac risk factors for people with SCI.

Advances in Spinal Cord Neuromodulation: The Integration of Neuroengineering, Computational Approaches, and Innovative Conceptual Frameworks

Spinal cord stimulation (SCS) is an approved treatment for intractable pain and has recently emerged as a promising area of research for restoring function after spinal cord lesion. This review will focus on the historical evolution of this transition and the path that remains to be taken for these methods to be rigorously evaluated for application in clinical practice. New developments in SCS are being driven by advances in the understanding of spinal cord lesions at the molecular, cellular, and neuronal levels, as well as the understanding of compensatory mechanisms. Advances in neuroengineering and the computational neurosciences have enabled the development of new conceptual SCS strategies, such as spatiotemporal neuromodulation, which allows spatially selective stimulation at precise time points during anticipated movement. It has also become increasingly clear that these methods are only effective when combined with intensive rehabilitation techniques, such as new task-oriented methods and robotic aids. The emergence of innovative approaches to spinal cord neuromodulation has sparked significant enthusiasm among patients and in the media. Non-invasive methods are perceived to offer improved safety, patient acceptance, and cost-effectiveness. There is an immediate need for well-designed clinical trials involving consumer or advocacy groups to evaluate and compare the effectiveness of various treatment modalities, assess safety considerations, and establish outcome priorities.

Advances in Spinal Cord Stimulation

Neuromodulation, specifically spinal cord stimulation (SCS), has become a staple of chronic pain management for various conditions including failed back syndrome, chronic regional pain syndrome, refractory radiculopathy, and chronic post operative pain. Since its conceptualization, it has undergone several advances to increase safety and convenience for patients and implanting physicians. Current research and efforts are aimed towards novel programming modalities and modifications of existing hardware. Here we review the recent advances and future directions in spinal cord stimulation including a brief review of the history of SCS, SCS waveforms, new materials for SCS electrodes (including artificial skins, new materials, and injectable electrodes), closed loop systems, and neurorestorative devices.

Risk factors for thirty-day morbidity and mortality after spinal trauma

BACKGROUND

Traumatic Spinal Injuries (TSI) often follow high velocity injuries and frequently accompanied by polytrauma. While most studies have focussed on outcomes of spinal cord injuries, the incidence and risk factors that predict morbidity and mortality after TSI has not been well-defined.

METHODS

Data of consecutive patients of TSI (n = 2065) treated over a 5-year-period were evaluated for demographics, injury mechanisms, neurological status, associated injuries, timing of surgery and co-morbidities. The thirty-day incidence and risk factors for complications, length of stay and mortality were analysed.

RESULTS

The incidence of spinal trauma was 6.2%. Associated injuries were seen in 49.7% (n = 1028), and 33.5% (n = 692) patients had comorbidities. The 30-day mortality was 0.73% (n = 15). Associated chest injuries (p = 0.0001), cervical spine injury (p = 0.0001), ASIA-A neurology (p < 0.01) and ankylosing spondylitis (p = 0.01) correlated with higher mortality. Peri-operative morbidity was noted in 571 patients (27.7%) and were significantly associated with age > 60 (p = 0.043), ASIA-A neurology (p < 0.05), chest injuries (p = 0.042), cervical and thoracic spine injury (p < 0.0001). The mean length of stay in hospital was 8.87 days. Cervical spine injury (p < 0.0001), delay in surgery > 48 h (p = 0.011), Diabetes mellitus (p = 0.01), Ankylosing spondylitis (p = 0.009), associated injuries of chest, head, pelvis and face (p < 0.05) were independent risk factors for longer hospital stay.

CONCLUSION

Key predictors of mortality after spinal trauma were cervical spine injury, complete neurological deficit, chest injuries and ankylosing spondylitis, while additionally higher age and thoracic injuries contributed to higher morbidity and prolonged hospitalisation. Notably multi-level injuries, higher age, co-morbidities and timing of surgery did not influence the mortality.

A preliminary study on the feasibility of community game-based respiratory muscle training for individuals with high cervical spinal cord injury levels: a novel approach

Background

Respiratory disorders result in rehospitalization and premature death of patients with cervical spinal cord injuries (CSCI). Community game-based respiratory muscle training (RMT) programs could reduce secondary complications.

Methods

We examined the feasibility and preliminary efficacy of RMT as a community-based exercise program. Among the 10 included participants (eight male and two female), four, one, one, and four reported C3, C4, C5, and C6 complete injuries, respectively (eight graded by American Spinal Injury Association impairment scale [ASIA] A and two by ASIA B). Their mean age was 43 ± 12.3 y. The time since injury was 10 ± 6.7 y. The participants completed an RMT program for 60 min/day, twice weekly, for 8 weeks. The participants were trained in the use of a newly developed game-based RMT device. The device provides consistent pressure for respiratory muscle strength and endurance training. Seven RMT devices were modified to allow 10 game-based RMT programs. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV₁), peak expiratory flow (PEF), vital capacity (VC), inspiratory capacity (IC), inspiratory reserve volume (IRV), expiratory reserve volume (ERV), maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), and peak cough flow (PCF) were measured.

Results

There were improvements after RMT compared to pre-RMT in FVC (p = 0.027, 10.62%, 0.22 effect size [ES]), PEF (p = 0.006, 23.21%, 0.45 ES), VC (p = 0.002, 35.52%, 0.60 ES), IC (p = 0.001, 46.94%, 0.81 ES), IRV (p = 0.001, 90.53%, 1.22 ES), MIP (p = 0.002, 97.25%, 1.32 ES), MEP (p = 0.005, 141.12%, 1.07 ES), and PCF (p = 0.001, 35.60%, 0.74 ES). The participants reported a positive impact of the program.

Conclusions

Community game-based RMT for individuals with CSCI appears to be safe and feasible. Community exercise with RMT use may have a positive impact on the respiratory measures for patients with CSCI who are vulnerable to respiratory compromise.

Trial registration

KCT0005980.

Testosterone and long pulse width stimulation (TLPS) for denervated muscles after spinal cord injury: a study protocol of randomised clinical trial

INTRODUCTION

Long pulse width stimulation (LPWS; 120-150 ms) has the potential to stimulate denervated muscles and to restore muscle size in denervated people with spinal cord injury (SCI). We will determine if testosterone treatment (TT)+LPWS would increase skeletal muscle size, leg lean mass and improve overall metabolic health in persons with SCI with denervation. We hypothesise that the 1-year TT+LPWS will upregulate protein synthesis pathways, downregulate protein degradation pathways and increase overall mitochondrial health.

METHODS AND ANALYSIS

Twenty-four male participants (aged 18-70 years with chronic SCI) with denervation of both knee extensor muscles and tolerance to the LPWS paradigm will be randomised into either TT+neuromuscular electrical stimulation via telehealth or TT+LPWS. The training sessions will be twice weekly for 1 year. Measurements will be conducted 1 week prior training (baseline; week 0), 6 months following training (postintervention 1) and 1 week after the end of 1 year of training (postintervention 2). Measurements will include body composition assessment using anthropometry, dual X-ray absorptiometry and MRI to measure size of different muscle groups. Metabolic profile will include measuring of basal metabolic rate, followed by blood drawn to measure fasting biomarkers similar to hemoglobin A1c, lipid panels, C reactive protein, interleukin-6 and free fatty acids and then intravenous glucose tolerance test to test for insulin sensitivity and glucose effectiveness. Finally, muscle biopsy will be captured to measure protein expression and intracellular signalling; and mitochondrial electron transport chain function. The participants will fill out 3 days dietary record to monitor their energy intake on a weekly basis.

ETHICS AND DISSEMINATION

The study was approved by Institutional Review Board of the McGuire Research Institute (ID # 02189). Dissemination plans will include the Veteran Health Administration and its practitioners, the national SCI/D services office, the general healthcare community and the veteran population, as well as the entire SCI community via submitting quarterly letters or peer-review articles.

TRIAL REGISTRATION NUMBER

NCT03345576.

Nutrient composition influences the gut microbiota in chronic thoracic spinal cord-injured rats

Chronic spinal cord injury (SCI) results in an increased predisposition to various metabolic problems that can be exacerbated by consuming a diet rich in calories and saturated fat. In addition, gastrointestinal symptoms have been reported after SCI, including intestinal dysbiosis of the gut microbiome. The effects of both diet and SCI on the gut microbiome of adult male Long Evans rats euthanized 16 wk after injury were investigated. The rats were either thoracic spinal contused or received sham procedures. After 12 wk of either a low-fat or high-fat diet, cecal contents were analyzed, revealing significant microbial changes to every taxonomic level below the kingdom level. Shannon α diversity analyses demonstrated a significant difference in diversity between the groups based on the surgical condition of the rats. SCI produced a unique signature of changes in commensal bacteria that were significantly different than Sham. Specific changes in commensal bacteria as a result of diet manipulation had high fidelity with reports in the literature, such as Clostridia, Thiohalorhabdales, and Pseudomonadales. In addition, novel changes in commensal bacteria were identified that are unique dietary influences on SCI. Linear regression analysis on body fat and lean mass showed that a consequence of chronic SCI produces uncoupled associations between some commensal bacteria and body composition. In conclusion, despite tightly controlling the protein content and varying the carbohydrate and fat contents, Sham and SCI rats respond uniquely to diet. These data provide potential direction for therapeutic modulation of the microbiome to improve health and wellness following SCI.

Social participation as a mediator of the relationships of socioeconomic factors and longevity after traumatic spinal cord injury

STUDY DESIGN

Cohort study.

OBJECTIVE

Previous research has indicated that socioeconomic factors affect longevity after traumatic spinal cord injury (SCI). Our purpose was to evaluate whether social participation mediates the relationship between socioeconomic factors and survival status after SCI.

SETTING

Medical university in the southeastern United States.

METHODS

Participants (N = 1540) met the following inclusion criteria: traumatic SCI of at least 1-year duration, minimum of 18 years of age, and having residual impairment from SCI. The main outcome measures were a) survival status as of December 31, 2019, identified by the National Death Index (NDI) search, b) socioeconomic status (SES), measured by education, employment status, and family income, and c) participation, measured by marital/relationship status, hours out of bed per day, days leaving home per week, and nights away home during the past year.

RESULTS

Thirty nine percent of participants (n = 602) were decreased by the end of 2019. Socioeconomic factors were associated with longevity controlling for demographic, injury characteristics, and health status. However, the association of SES with longevity was mediated by three social participation mobility indicators (hours out of bed, days out of house, and nights away from home), such that SES was no longer significantly related to longevity after inclusion of the participation variables.

CONCLUSIONS

Although socioeconomic factors are related to longevity, their relationship appears to be mediated by social participation mobility indicators. Intervention studies are needed to address the modifiable factors that may promote longevity, including promoting an active lifestyle.

Spinal Cord Injury Impairs Lung Immunity in Mice

Pulmonary infection is a leading cause of morbidity and mortality after spinal cord injury (SCI). Although SCI causes atrophy and dysfunction in primary and secondary lymphoid tissues with a corresponding decrease in the number and function of circulating leukocytes, it is unknown whether this SCI-dependent systemic immune suppression also affects the unique tissue-specific antimicrobial defense mechanisms that protect the lung. In this study, we tested the hypothesis that SCI directly impairs pulmonary immunity and subsequently increases the risk for developing pneumonia. Using mouse models of severe high-level SCI, we find that recruitment of circulating leukocytes and transcriptional control of immune signaling in the lung is impaired after SCI, creating an environment that is permissive for infection. Specifically, we saw a sustained loss of pulmonary leukocytes, a loss of alveolar macrophages at chronic time points postinjury, and a decrease in immune modulatory genes, especially cytokines, needed to eliminate pulmonary infections. Importantly, this injury-dependent impairment of pulmonary antimicrobial defense is only partially overcome by boosting the recruitment of immune cells to the lung with the drug AMD3100, a Food and Drug Administration-approved drug that mobilizes leukocytes and hematopoietic stem cells from bone marrow. Collectively, these data indicate that the immune-suppressive effects of SCI extend to the lung, a unique site of mucosal immunity. Furthermore, preventing lung infection after SCI will likely require novel strategies, beyond the use of orthodox antibiotics, to reverse or block tissue-specific cellular and molecular determinants of pulmonary immune surveillance.

Immune dysfunction after spinal cord injury - A review of autonomic and neuroendocrine mechanisms

Infections impair neurological outcome and increase mortality after spinal cord injury (SCI). Emerging data show that pathogens more easily infect individuals with SCI because SCI disrupts neural and humoral control of immune cells, culminating with the development of "SCI-induced immune deficiency syndrome" (SCI-IDS). Here, we review data that implicate autonomic dysfunction and impaired neuroendocrine signaling as key determinants of SCI-IDS. Although it is widely appreciated that mature leukocyte dysfunction is a canonical feature of SCI-IDS, new data indicate that SCI impairs the development and mobilization of immune cell precursors in bone marrow. Thus, this review will also explore how the post-injury acquisition of a "bone marrow failure syndrome" may be the earliest manifestation of SCI-IDS.

A Scoping Review of Registered Clinical Studies on Management of Individuals With Acute Spinal Cord Injury (2000-2020): Trends and Characteristics of the Research Initiatives

ABSTRACT

This scoping review examined the current trends and characteristics of the clinical research initiatives on the management of acute spinal cord injury. This review included all clinical studies on the acute treatment of spinal cord injury that were registered in the ClinicalTrials.gov website from February 2000 to December 2020. The search strategy combined the terms "acute spinal cord injury" and "treatment." There has been a gradual increase in the number of registered clinical studies on acute treatment of spinal cord injury over the past two decades. Of the 116 studies, there were 103 interventional studies, 12 observational studies, and 1 registry. While 115 clinical studies recruited male and female participants, most of the registered clinical studies included only adults with an upper age limit after spinal cord injury. Most of the registered clinical studies were interventional studies led by single institutions in North America (n = 70), Europe (n = 29), and Asia (n = 15). Most of the research initiatives were interventional studies on new therapies for management of individuals with spinal cord injury (n = 91). In conclusion, the results of this scoping review suggest that although there has been an increase in the amount and diversity of the research initiatives on treatment of acute spinal cord injury over the past two decades, their generalizability remains relatively limited.

Neurorehabilitation using a voluntary driven exoskeletal robot improves trunk function in patients with chronic spinal cord injury: a single-arm study

Body weight-supported treadmill training with the voluntary driven exoskeleton (VDE-BWSTT) has been shown to improve the gait function of patients with chronic spinal cord injury. However, little is known whether VDE-BWSTT can effectively improve the trunk function of patients with chronic spinal cord injury. In this open-label, single-arm study, nine patients with chronic spinal cord injury at the cervical or thoracic level (six males and three females, aged 37.8 ± 15.6 years, and time since injury 51.1 ± 31.8 months) who underwent outpatient VDE-BWSTT training program at Keio University Hospital, Japan from September 2017 to March 2019 were included. All patients underwent twenty 60-minute gait training sessions using VDE. Trunk muscular strength, i.e., the maximum force against which patient could maintain a sitting posture without any support, was evaluated in four directions: anterior, posterior, and lateral (right and left) after 10 and 20 training sessions. After intervention, lateral muscular strength significantly improved. In addition, a significant positive correlation was detected between the change in lateral trunk muscular strength after 20 training sessions relative to baseline and gait speed. The change in trunk muscular strength after 20 training sessions relative to baseline was greatly correlated with patient age. This suggests that older adult patients with chronic spinal cord injury achieved a greater improvement in trunk muscle strength following VDE-BWSTT. All these findings suggest that VDE-BWSTT can improve the trunk function of patients with chronic spinal cord injury and the effect might be greater in older adult patients. The study was approved by the Keio University of Medicine Ethics Committee (IRB No. 20150355-3) on September 26, 2017.

Cause of Death Trends Among Persons With Spinal Cord Injury in the United States: 1960-2017

OBJECTIVE

To identify trends in causes of death after spinal cord injury (SCI) that could enhance understanding of why life expectancy after SCI has not improved in the last 3 decades.

DESIGN

Cohort study.

SETTING

Twenty-nine SCI Model Systems and 3 Shriners Hospitals.

PARTICIPANTS

Individuals with traumatic SCI (N=49,266) enrolled in the SCI Collaborative Survival Study Database between 1973 and 2017.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Age-standardized cause-specific SCI mortality rates and 95% confidence intervals were calculated for 5 time intervals (1960-1979, 1980-1989, 1990-1999, 2000-2009, and 2010-2017).

RESULTS

A total of 17,249 deaths occurred in 797,226 person-years of follow-up. Since 2010, the highest mortality rate was for respiratory diseases, followed by heart disease, cancer, infective and parasitic diseases (primarily septicemia), and unintentional injuries. Mortality rates for respiratory diseases, cancer, stroke, urinary diseases, and digestive diseases, initially decreased significantly but remained relatively stable since 1980, whereas essentially no progress occurred for infective and parasitic diseases. Mortality rates for heart disease, pulmonary embolus, and suicide decreased significantly throughout the entire study period, but were offset by increases in mortality rates for endocrine (primarily diabetes), nutritional, and metabolic diseases, as well as unintentional injuries. From 2010 to 2017, the overall age-standardized mortality rate was 3 times higher for individuals with SCI than the general population, ranging from 27% higher for cancer to 9 times higher for infective and parasitic diseases.

CONCLUSION

Improving life expectancy after SCI will require: (1) reducing mortality rates from respiratory diseases and septicemia that have remained high, (2) reversing current trends in diabetes and unintentional injury deaths, and (3) continuing to reduce mortality from heart disease and other leading causes.

Influence of severity and level of injury on the occurrence of complications during the subacute and chronic stage of traumatic spinal cord injury: a systematic review

OBJECTIVE

Secondary health conditions (SHCs) are long-term complications that frequently occur due to traumatic spinal cord injury (tSCI) and can negatively affect quality of life in this patient population. This study provides an overview of the associations between the severity and level of injury and the occurrence of SHCs in tSCI.

METHODS

A systematic search was conducted in PubMed and Embase that retrieved 44 studies on the influence of severity and/or level of injury on the occurrence of SHCs in the subacute and chronic phase of tSCI (from 3 months after trauma). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

In the majority of studies, patients with motor-complete tSCI (American Spinal Injury Association [ASIA] Impairment Scale [AIS] grade A or B) had a significantly increased occurrence of SHCs in comparison to patients with motor-incomplete tSCI (AIS grade C or D), such as respiratory and urogenital complications, musculoskeletal disorders, pressure ulcers, and autonomic dysreflexia. In contrast, an increased prevalence of pain was seen in patients with motor-incomplete injuries. In addition, higher rates of pulmonary infections, spasticity, and autonomic dysreflexia were observed in patients with tetraplegia. Patients with paraplegia more commonly suffered from hypertension, venous thromboembolism, and pain.

CONCLUSIONS

This review suggests that patients with a motor-complete tSCI have an increased risk of developing SHCs during the subacute and chronic stage of tSCI in comparison with patients with motor-incomplete tSCI. Future studies should examine whether systematic monitoring during rehabilitation and the subacute and chronic phase in patients with motor-complete tSCI could lead to early detection and potential prevention of SHCs in this population.

Men with spinal cord injury have a smaller prostate volume than age-matched able-bodied men: a meta-analysis of case-control studies

STUDY DESIGN

Meta-analysis OBJECTIVES: Denervation and androgen deficiency, peculiar to individuals with chronic spinal cord injury (SCI), could hinder, to some extent, both prostate growth and activity. To comprehensively assess the relationship between SCI and prostate volume, we carried out a meta-analysis of the available case-control studies.

METHODS

A thorough search of MEDLINE, Scopus and Web of Science was carried out to identify studies comparing prostate volume in men with and without SCI. Quality of the studies was assessed using the Newcastle-Ottawa Scale (NOS). Mean differences (MDs) in prostate volume were combined using a random effect model. Funnel plot was used to assess publication bias.

RESULTS

Four studies met the inclusion criteria and provided information on 278 men with SCI and 1385 able-bodied controls. The overall difference in prostate volume between the two groups reached the statistical significance (pooled MD: -14.85 ml, 95% CI: -27.10 to -2.61, p = 0.02). In a subgroup analysis including only the studies with the highest NOS score, the pooled MD remained significant (pooled MD: -18.56, 95% CI: -33.14 to -3.99, p = 0.01). The shape of funnel plot did not allow to rule out a possible publication bias.

CONCLUSIONS

This meta-analysis suggests that in men with SCI, prostate volume tends to be smaller than in age-matched able-bodied men. Longitudinal studies of men with long-lasting SCI in advanced age are warranted to clarify whether this condition is associated with a lower risk of age-related prostate proliferative diseases.

Emergency surgery for traumatic spinal cord injury in a secondary hospital: A case report

Background:

Cervical spinal cord injury (SCI) is a life-threatening condition. Prompt surgical intervention is needed to avoid hemodynamic and respiratory catastrophe. In Indonesia, however, spine surgery is more common in tertiary hospitals and thus might prolong the time gap to surgery due to referral waiting time.

Case Description:

We performed an emergency surgery for a patient with complete SCI due to unstable cervical fracture. The patient was in spinal shock and experienced respiratory arrest after radiological workup. Stability was achieved in the ICU and patient was directly sent to operating theater. Anterior-posterior approach was chosen to decompress and stabilize the cervical spine. The patient was discharged on postoperative day 17 and was seen well at 1-month follow-up.

Conclusion:

The capability to perform spine procedures should not be exclusive to tertiary hospitals in Indonesia. Satisfying results can be achieved with the presence of capable neurosurgeons or orthopedic surgeons and anesthesiologists in lower-level hospitals.

Nutritional interventions for spinal cord injury: preclinical efficacy and molecular mechanisms

Spinal cord injury (SCI) is a debilitating condition that leads to motor, sensory, and autonomic impairments. Its intrinsic pathophysiological complexity has hindered the establishment of effective treatments for decades. Nutritional interventions (NIs) for SCI have been proposed as a route to circumvent some of the problems associated with this condition. Results obtained in animal models point to a more holistic effect, rather than to specific modulation, of several relevant SCI pathophysiological processes. Indeed, published data have shown NI improves energetic imbalance, oxidative damage, and inflammation, which are promoters of improved proteostasis and neurotrophic signaling, leading ultimately to neuroprotection and neuroplasticity. This review focuses on the most well-documented Nis. The mechanistic implications and their translational potential for SCI are discussed.

Community exercise for individuals with spinal cord injury with inspiratory muscle training: A pilot study

Context/Objective: Respiratory disorders are a common cause of rehospitalization, and premature death in individuals with spinal cord injuries (SCI). Respiratory training combined with community exercise programs may be a method to reduce secondary complications in this population.Objective: The present study explores the inclusion of inspiratory muscle training (IMT) in an existing community exercise program.Design: Case series.Setting: Community.Participants: Participants (N = 6) completed the exercise program. Five were male and one was female; four reported incomplete injuries, and two reported complete injuries; four had cervical injuries, and two had thoracic injuries. The average age was 33 years (SD = 18.6) and time since injury was 7 years (SD = 4.0).Interventions: Participants completed an 8-week program, once-per-week for 4 h that included a circuit of resistance training, aerobic exercise, trunk stability, and education. IMT was completed as a home exercise program.Outcome Measures: Transfer test, T-shirt test, four-directional reach, four-directional trunk strength, weekly training diaries, and a subjective interview.Results: Twenty-eight training logs were collected. All measures improved: transfer test (mean = -14.62, SD = 7.00 s), T-shirt test (mean = -7.83, SD = 13.88 s), four-directional reach (mean = 3.75, SD = 8.06 in) and hand-held dynamometer (mean = 6.73, SD = 8.02 kg). Individuals reported a positive impact of the program.Conclusions: This pilot study demonstrated community exercise with IMT use may have positive impact on functional measures for people with SCI who are vulnerable to respiratory compromise. Continued education may increase successful health outcomes.Trial Registration: NCT03743077.

Sigma 1 receptor agonist cutamesine promotes plasticity of serotonergic boutons in lumbar enlargement in spinal cord injured rats

Cutamesine, a sigma-1 receptor agonist, functions in both neuroprotection and neurite outgrowth. We assessed the therapeutic effects of cutamesine in a rodent spinal cord injury (SCI) model to demonstrate pre-clinical proof-of-concept. First of all, in order to determine optimal cutamesine dose, cutamesine was administered to normal rats and BDNF protein levels in the lumbar spinal cord were assessed by Western blot. Next, for the SCI model, spinal cords of adult female Sprague-Dawley rats were contused using an Infinite Horizon Impactor. Two weeks post-injury, rats were randomly assigned to receive daily subcutaneous injections of either cutamesine (3.0 mg/kg/day) or saline (as a control) for another two weeks. Immunohistochemistry for BDNF and 5-HT was assessed at four and twelve weeks post-injury in the lumbar spinal cord. Locomotor function was assessed weekly using the BBB locomotor scale until twelve weeks after SCI and CatWalk XT 10.5 gait analysis was conducted at twelve weeks after SCI. In normal rats, cutamesine treatment (3.0 mg/kg/day) significantly up-regulated BDNF expression in the lumbar spinal cord. In SCI rats, cutamesine treatment (3.0 mg/kg/day) significantly increased the fluorescence intensity of neuronal BDNF and serotonin boutons in the injured spinal cord compared to saline. However, cutamesine treatment did not promote significant locomotor recovery. Recent work indicates that cutamesine treatment alone did not promote locomotor recovery in spite of immunohistological changes. Future work will explore the influence of combining cutamesine with other treatment promoting plasticity (e.g. rehabilitative training) in SCI rats.

Impact of Frailty on Morbidity and Mortality in Adult Patients Presenting with an Acute Traumatic Cervical Spinal Cord Injury

OBJECTIVE

The aim of this study was to determine if baseline frailty was an independent predictor of adverse events (AEs) and in-hospital mortality in patients being treated for acute cervical spinal cord injury (SCI).

METHODS

A retrospective cohort study was performed using the National Trauma Database (NTDB) from 2017. Adult patients (>18 years old) with acute cervical SCI were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification diagnostic and procedural coding systems. Patients were categorized into 3 cohorts based on the criteria of the 5-item modified frailty index (mFI-5): mFI = 0, mFI = 1, or mFI≥2. Patient demographics, comorbidities, type of injury, diagnostic and treatment modality, AEs, and in-patient mortality were assessed. A multivariate logistic regression analysis was used to identify independent predictors of in-hospital AEs and mortality.

RESULTS

Of 8986 patients identified, 4990 (55.5%) were classified as mFI = 0, 2328 (26%) as mFI = 1, and 1668 (18.5%) as mFI≥2. On average, the mFI≥2 cohort was 5 years older than the mFI = 1 cohort and 22 years older than the mFI = 0 cohort (P < 0.001). Most patients in each cohort sustained either complete SCI or central cord syndrome after a fall or transport accident (mFI = 0, 77.31% vs. mFI = 1, 89.5% vs. mFI≥2, 93.65%). With respect to in-hospital events, the proportion of patients who experienced any AE increased significantly along with frailty score (mFI = 0, 30.42% vs. mFI = 1, 31.74% vs. mFI≥2, 34.95%; P < 0.001). In-hospital mortality followed a similar trend, increasing with frailty score (mFI = 0, 10.53% vs. mFI = 1, 11.33% vs. mFI≥2, 16.23%; P < 0.001). On multivariate regression analysis, both mFI = 1 1.21 (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.05-1.4; P = 0.008) and mFI≥2 (OR, 1.23; 95% CI, 1.05-1.45; P = 0.012) predicted AEs, whereas only mFI≥2 was found to be a predictor for in-hospital mortality (OR, 1.45; 95% CI, 1.14-1.83; P = 0.002).

CONCLUSIONS

Increasing frailty is associated with an increased risk of AEs and in-hospital mortality in patients undergoing treatment for cervical SCI.

Incidence of Renal Tract Abnormalities on Ultrasonography in Patients with Spinal Cord Injury: A Retrospective Pilot Study of a Military Cohort Undergoing Long-Term Institutional Rehabilitation

Study Design

Retrospective pilot study.

Purpose

To assess the incidence of renal tract abnormalities using ultrasonography (US) in a military cohort with traumatic spinal cord injury (TSCI) at a tertiary level spinal cord injury center.

Overview of Literature

Neurogenic bladder in TSCI patients results in significant urological morbidity. There is lack of data for these patients during the first 18 months of long-term rehabilitation in an institutional setting.

Methods

We retrospectively reviewed patient records to collect data on demographic characteristics, injury level, injury severity, time since injury, bladder management methods (such as an indwelling catheter [IC], clean intermittent catheterization [CIC], or self-voiding [S]); we correlated these data with the findings of the renal tract US.

Results

The study included 73 out of 81 male participants. The mean patient age was 29.99 years; the study group included 34.2% tetraplegics and 65.8% people with paraplegia. The time since injury was 6–12 months for 42.5% of the subjects and 12–18 months for 57.5% of the subjects. A normal US scan was recorded in 65.7% patients, and bladder trabeculation was the commonest finding in 15.1% of the subjects, followed by hydronephrosis (HDN) in 12.3%, and renal calculus and atrophy in 1.3% participants each. We found 22.22% of the IC group participants had higher US abnormalities than those in the reflex voiding group (statistically non-significant difference, p=0.7). Trabeculations (21.4%) and HDN (19%) were more common in those who had sustained the injury 12–18 months previously as compared to that in those who had injured themselves 6–12 months previously (p=0.04). The proportion of patients who had a normal US scan was higher in the group who sustained the injury 6–12 months previously versus those who had sustained the injury 12–18 months previously; the difference was statistically significant (p=0.02). There was no significant (p=0.72) correlation in the bladder management method, injury level, and renal tract abnormalities between the groups.

Conclusions

This retrospective study shows that 65% of TSCI participants had no renal tract abnormality on US scan and bladder trabeculation ruled out as the most common finding. Long-term supervised rehabilitation may help achieve good renal quality of life; however, further prospective trials are required on this subject.

Traumatic Spinal Cord Disorders: Current Topics and Future Directions

Traumatic spinal cord injury (tSCI) is a life-changing and potentially overwhelming event. The sudden disruption of the spinal cord's integrity necessitates rapid attention at a specialized medical center, and involves a multilateral collaboration between neurologists, spine surgeons, critical care physicians, and trauma specialists. Even with care under ideal conditions, many tSCI patients have significant disability that persists for the rest of their lives. However, recently, we have seen a proliferation in clinical and translational trials that offer the promise that new treatments may be available soon.

Effects of Respiratory Muscle Training on Baroreflex Sensitivity, Respiratory Function, and Serum Oxidative Stress in Acute Cervical Spinal Cord Injury

Background: respiratory complications are a leading cause of morbidity and mortality in individuals with spinal cord injury (SCI). We examined the effects of respiratory muscle training (RMT) in patients with acute cervical SCI. Methods: this prospective trial enrolled 44 adults with acute cervical SCI, of which twenty received RMT and twenty-four did not receive RMT. Respiratory function, cardiovascular autonomic function, and reactive oxidative species (ROS) were compared. The experimental group received 40-min high-intensity home-based RMT 7 days per week for 10 weeks. The control group received a sham intervention for a similar period. The primary outcomes were the effects of RMT on pulmonary and cardiovascular autonomic function, and ROS production in individuals with acute cervical SCI. Results: significant differences between the two groups in cardiovascular autonomic function and the heart rate response to deep breathing (p = 0.017) were found at the 6-month follow-up. After RMT, the maximal inspiratory pressure (p = 0.042) and thiobarbituric acid-reactive substances (TBARS) (p = 0.006) improved significantly, while there was no significant difference in the maximal expiratory pressure. Significant differences between the two groups in tidal volume (p = 0.005) and the rapid shallow breathing index (p = 0.031) were found at 6 months. Notably, the SF-36 (both the physical (PCS) and mental (MCS) component summaries) in the RMT group had decreased significantly at the 6-month follow-up, whereas the clinical scores did not differ significantly (p = 0.333) after RMT therapy. Conclusions: High-intensity home-based RMT can improve pulmonary function and endurance and reduce breathing difficulties in patients with respiratory muscle weakness after injury. It is recommended for rehabilitation after spinal cord injury.

Effects on Outcomes of Hyperglycemia in the Hyperacute Stage after Acute Traumatic Spinal Cord Injury

Hyperglycemia has adverse effects on neuronal recovery after brain injury, but its effects after spinal cord injury (SCI) are understudied. This retrospective cohort study examined the potential effects on outcomes of hyperglycemia in the hyperacute stage after acute traumatic SCI. This study included all individuals enrolled in the National Acute Spinal Cord Injury Study 3 (NASCIS-3). Glycemic levels at 24 h, at 48 h, and at day 7 after acute SCI were examined as potential determinants of survival, neurological outcomes (using NASCIS motor, sensory, and pain scores), and functional outcome (using the Functional Independence Measure [FIM]) within the first year post-SCI. Hyperglycemia was defined using two thresholds (140 mg/dL and 180 mg/dL). Study subjects were 76 females and 423 males with an overall mean age of 36 years who sustained mostly cervical SCI due to motor vehicle accidents or falls. Hyperglycemia diagnosed at day 7 post-injury was associated with significantly greater mortality rates post-SCI. Among the survivors, hyperglycemia during the hyperacute stage was not significantly correlated with neurological recovery post-SCI. Hyperglycemia persistent until day 7 was significantly correlated with lower functional scores post-SCI. These results suggest that hyperglycemia at day 7 is correlated with greater mortality rates within the first year post-SCI. Although hyperglycemia during the hyperacute stage was not associated with neurological recovery, hyperglycemia at day 7 may adversely affect functional recovery within the first year post-SCI. Future investigations are needed to determine the optimal glycemic target in the management of patients with SCI.

Systemic Inflammation and the Breakdown of Intestinal Homeostasis Are Key Events in Chronic Spinal Cord Injury Patients

Our aim was to investigate the subset distribution and function of circulating monocytes, proinflammatory cytokine levels, gut barrier damage, and bacterial translocation in chronic spinal cord injury (SCI) patients. Thus, 56 SCI patients and 28 healthy donors were studied. The levels of circulating CD14^+highCD16^-, CD14^+highCD16⁺, and CD14^+lowCD16⁺ monocytes, membrane TLR2, TLR4, and TLR9, phagocytic activity, ROS generation, and intracytoplasmic TNF-α, IL-1, IL-6, and IL-10 after lipopolysaccharide (LPS) stimulation were analyzed by polychromatic flow cytometry. Serum TNF-α, IL-1, IL-6 and IL-10 levels were measured by Luminex and LPS-binding protein (LBP), intestinal fatty acid-binding protein (I-FABP) and zonulin by ELISA. SCI patients had normal monocyte counts and subset distribution. CD14^+highCD16^- and CD14^+highCD16⁺ monocytes exhibited decreased TLR4, normal TLR2 and increased TLR9 expression. CD14^+highCD16^- monocytes had increased LPS-induced TNF-α but normal IL-1, IL-6, and IL-10 production. Monocytes exhibited defective phagocytosis but normal ROS production. Patients had enhanced serum TNF-α and IL-6 levels, normal IL-1 and IL-10 levels, and increased circulating LBP, I-FABP, and zonulin levels. Chronic SCI patients displayed impaired circulating monocyte function. These patients exhibited a systemic proinflammatory state characterized by enhanced serum TNF-α and IL-6 levels. These patients also had increased bacterial translocation and gut barrier damage.

Peripheral Neuropathy in the Lower Limbs of Individuals With Spinal Cord Injury or Disease: A Retrospective Study

PURPOSE

This study investigated the frequency and types of peripheral neuropathy in the lower limbs of patients undergoing rehabilitation after traumatic spinal cord injury or spinal cord disease.

METHODS

This study included consecutive patients with spinal cord injury/spinal cord disease who had electrophysiological assessments during their admission in a rehabilitation center from October 2015 to July 2019. Patients with traumatic spinal cord injury were compared with patients with nontraumatic spinal cord disease.

RESULTS

There were 67 patients (52 male patients, 15 female patients; mean age = 56.5 yrs) of whom 36 patients had spinal cord injury and 31 patients had spinal cord disease. Most of the patients were middle-aged men with at least one preexisting medical comorbidity, who were mostly admitted for rehabilitation of cervical, incomplete spinal cord injury/spinal cord disease. Most patients (86.6%) had abnormal electrophysiological studies representing 5.57% of all admissions. A length-dependent polyneuropathy was diagnosed in 0.77% of all admissions (n = 8). The group of patients with spinal cord injury was comparable with the group of patients with spinal cord disease regarding the other baseline data, clinical, and electrophysiological findings.

CONCLUSIONS

Diseases of the peripheral nervous system were similarly found among patients undergoing rehabilitation for either spinal cord injury or spinal cord disease. A length-dependent polyneuropathy was diagnosed in 0.77% of all admissions. Timely diagnosis and proper treatment of the cause of peripheral neuropathies in the lower limbs in these patients may potentially influence rehabilitation protocols and improve patient outcomes.

Empirical Validity of a Generic, Preference-Based Capability Wellbeing Instrument (ICECAP-A) in the Context of Spinal Cord Injury

BACKGROUND

Assessing the validity of generic instruments across different clinical contexts is an important area of methodological research in economic evaluation and outcomes measurement.

OBJECTIVE

Our objective was to examine the empirical validity of a generic, preference-based capability wellbeing instrument (ICECAP-A) in the context of spinal cord injury.

METHODS

This study consisted of a secondary analysis of data collected using an online cross-sectional survey. The survey included questions regarding demographics, injury classifications and characteristics, secondary health conditions, quality of life and wellbeing, and functioning in activities of daily living. Analysis comprised the descriptive assessment of Spearman's rank correlations between item-/dimension-level data for the ICECAP-A and four preference-based health-related quality of life (HRQoL) instruments, and discriminant and convergent validity approaches to examine 21 evidence-informed or theoretically derived constructs. Constructs were defined using participant and injury characteristics and responses to a range of health, wellbeing and functioning outcomes.

RESULTS

Three hundred sixty-four individuals completed the survey. Mean index score for the ICECAP-A was 0.761; 12 (3%) individuals reported full capability (upper anchor; score = 1), and there were no reports of zero capabilities (lower anchor; score = 0). The strongest correlations were dominated by items and dimensions on the comparator (HRQoL) instruments that are non-health aspects of quality of life, such as happiness and control over one's life (including self-care). Of 21 hypothesised constructs, 19 were confirmed in statistical tests, the exceptions being the exploratory hypotheses regarding education and age at injury.

CONCLUSION

The ICECAP-A is an empirically valid outcome measure for assessing capability wellbeing in people with spinal cord injury living in a community setting. The extent to which the ICECAP-A provides complementary information to preference-based HRQoL instruments is dependent on the comparator.

Respiratory complications during initial rehabilitation and survival following spinal cord injury in Sweden: a retrospective study

Study design

Retrospective study.

Objectives

To determine prevalence of respiratory complications in individuals with spinal cord injury (SCI) during the initial rehabilitation at the spinal cord injury unit (SCU) and to describe the subsequent effect on mortality.

Setting

The SCU at the university hospital in Gothenburg, Sweden.

Methods

We reviewed the medical charts of newly injured persons with SCI who were admitted to the SCU between 1/1/2010 and 12/31/2014. Outcome measures were time to death, length of stay, occurrence of respiratory complications, and the use of breathing aids.

Results

A total of 136 consecutive individuals were included; 53% with cervical SCI and 20% with lower SCI suffered from one or several respiratory complications during their initial rehabilitation in the SCU. At follow-up, 10/1/2018, 20% of the individuals were deceased. The most common cause of death was related to respiratory insufficiency. The individuals with respiratory complications during the initial rehabilitation in the SCU had particularly shortened survival compared with those without. The relative risk (RR) of dying if the person suffered from any respiratory complications during their initial rehabilitation in the SCU was 2.1 times higher than for those with no respiratory complications (RR, 2.1; 95% CI, 1.1–3.9).

Conclusions

Having respiratory complications at the SCU provides preliminary data to support the claim that respiratory complications predict premature mortality. Early diagnosis and prophylactic measures seem to be necessary to mitigate the adverse consequences of serious respiratory problems.

Psychological factors and risk of mortality after spinal cord injury

Objective: Identify the association of personality and purpose in life with competing risks of multiple causes of death after spinal cord injury (SCI), using data from the SCI Longitudinal Health Study. Design: Prospective cohort study with data collected in 1997-1998 and 2007-2009. Mortality status determined as of December 31, 2016. Setting: Specialty hospital in the Southeastern United States. Participants: 3070 adults with chronic (>1-year), traumatic SCI. Interventions: N/A. Outcome Measures: We examined 6 psychological factors (Purpose in Life and 5 scales of the Zuckerman-Kuhlman Personality Questionnaire) and risk of mortality due to 6 specific causes of death, building on published analyses of behavioral and health/clinical risk and protective factors. Results: There were 803 deaths. Four of the 6 psychological factors were predictive of all-cause mortality. All except 1 personality scale were related to cause-specific mortality. Psychological factors were most predictive of unintentional injury deaths. Purpose in life was protective of death due to pneumonia; whereas, Activity was protective of death due to diseases of heart and blood vessels and to unintentional injury. Sociability, Impulsive-Sensation Seeking, and Neuroticism-Anxiety were risk factors for death due to unintentional injury. Neuroticism-Anxiety was related to death due to septicemia. There were no significant psychological predictors of cancer. Conclusions: Rehabilitation professionals have a central role in promoting purpose in life as a means of increasing longevity. By assessing personality factors predictive of specific causes of mortality, those at risk may be targeted for cause-specific prevention strategies.

Aging With Disability: Populations, Programs, and the New Paradigm An Introduction to the Special Issue

Objective: The purpose of this article is to introduce a special issue dedicated to research at the intersection of aging and disability. Method: We provide some context for the importance of cross-disciplinary collaboration among aging and disability researchers and summarize the nine articles in this issue. Results: Articles in the special issue are centered around several overarching themes. These include meaningful social and community participation, goals and values in the context of disability, and the reach and effectiveness of programs and policies on rehabilitation and service utilization. Conclusion: As care models continue to merge aging and disability services, collaboration among traditional aging and disability research networks can lead to improved outcomes for adults aging with long-term disability.

Evaluation of a ketogenic diet for improvement of neurological recovery in individuals with acute spinal cord injury: study protocol for a randomized controlled trial

BACKGROUND

Therapies that significantly improve the neurological and functional recovery of individuals with spinal cord injury (SCI) are still urgently needed. The ketogenic diet (KD) has been shown to improve forelimb motor function in an SCI rat model, likely by reducing inflammation and cell death in the spinal cord. Furthermore, our recent pilot study in patients with SCI showed that, compared with a standard hospital diet (SD), 5 weeks of KD started during acute care improved upper extremity motor function and reduced serum levels of a neuroinflammatory blood protein. The primary goals of the current study are to: 1) show the safety and feasibility of administering a KD during acute care for SCI; 2) determine if consuming 5 weeks of a KD significantly improves motor and sensory functions, functional independence and glycemic control; and 3) quantify serum biomarkers that are linked to improvements in neurological recovery and functional independence via targeted proteomics.

METHODS/DESIGN

In a single-masked, longitudinal, randomized, parallel-controlled study, a total of 60 eligible, acutely traumatic spinal cord injured (cervical 5 to thoracic 12) participants ranging in age from 18 to 60 years with American Spinal Injury Association impairment scale (AIS) grades A-C (AIS-A, sensorimotor complete; AIS-B, sensory incomplete/motor complete; and AIS-C, nonfunctional motor incomplete) are being enrolled. Neurological and functional examinations, resting energy expenditure, blood, urine, and stool collections, and protein analyses related to neurological recovery will be performed within 72 h of injury (baseline measure) and repeated after 5 weeks of KD or SD (discharge measure). We anticipate a completion rate of 80% with a total of 48 participants.

DISCUSSION

Intervention with a more neuroprotective diet during acute care of SCI can be implemented anywhere in the world at low cost and without major regulatory hurdles. Better functional recovery will lead to a better quality of life and long-term health outcomes in individuals with SCI. While this study targets SCI, if successful it has the potential to improve neurological outcomes for individuals with various traumatic injuries.

TRIAL REGISTRATION

NCT03509571 Registered on April 28, 2018.

Psychological Morbidity and Chronic Disease Among Adults With Traumatic Spinal Cord Injuries: A Longitudinal Cohort Study of Privately Insured Beneficiaries

OBJECTIVE

To compare the longitudinal incidence of psychological morbidities and multimorbidity and estimates of chronic diseases among adults with spinal cord injuries (SCIs) as compared with adults without SCIs.

METHODS

Privately insured beneficiaries who had medical coverage at any time between January 1, 2001, and December 31, 2017 were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code for a traumatic SCI (n=6,847).

RESULTS

Adults with SCIs (n=6847) had a higher incidence of adjustment reaction (7.2% [n=493] vs 5.0% [n=42,862]), anxiety disorders (19.3% [n=1,322] vs 14.1% [n=120,872]), depressive disorders (29.3% [n=2,006] vs 9.3% [n=79,724]), alcohol dependence (2.4% [n=164] vs 1.0% [n=8,573]), drug dependence (2.3% [n=158] vs 0.8% [n=6,858]), psychogenic pain (1.0% [n=69] vs 0.2% [n=1,715]), dementia (6.5% [n=445] vs 1.5% [n=12,859]), insomnia (10.9% [n=746] vs 7.2% [n=61,722]), and psychological multimorbidity (37.4% [n=2,561] vs 23.9% [n=204,882]) as compared with adults without SCIs (n=857,245). The adjusted hazard ratios (HRs) of each psychological outcome were significantly higher for individuals with SCI and ranged from 1.18 (95% CI, 1.08-1.29) for anxiety disorders to 3.32 (95% CI, 1.93-5.71) for psychogenic pain. Adults with SCIs also had a significantly higher prevalence of all chronic diseases and chronic disease multimorbidity (51.1% vs 14.1%), except human immunodeficiency virus infection/AIDS. After propensity matching for age, education, race, sex, and chronic diseases (n=5884 matched pairs), there was still a significantly higher incidence of most psychological disorders and psychological multimorbidity among adults with SCIs.

CONCLUSION

Adults with traumatic SCIs experienced an increased incidence of psychological morbidities and multimorbidity as compared with adults without SCIs. Clinical efforts are needed to improve mental health screening and targeted interventions to reduce the risk for psychological disease onset in the traumatic SCI population.

Enhancing Transitions From Rehabilitation Patient to Wellness Participant for People With Disabilities: An Opportunity for Hospital Community Benefit

Pressure is increasing on not-for-profit hospitals to demonstrate that they provide sufficient benefit to the community to justify their tax-exempt status. Many industry observers have suggested that this community benefit should address unmet medical needs within the community, deficits in the social determinants of health, or health disparities within communities. We argue that one area of clear unmet need is assistance in helping bridge the transition that people with disabilities (PWD) must make from rehabilitation patient to wellness participant. Programs to bridge this transition are necessary because many PWD struggle to identify strategies to maintain and maximize their own well-being after discharge from the healthcare system. As a result, PWD have worse health outcomes than non-disabled individuals. To address these needs, we propose hospitals take a leading role in establishing new, community-based efforts to provide PWD with benefits that will support their effort to self-manage health. Hospitals are well-suited to lead the creation of these programs because of the important role they play in providing services to PWD and because of their ability to bring together multiple stakeholders required to make supportive programs sustainable.

Similar Adenoma Detection Rates in Colonoscopic Procedures of Patients with Spinal Cord Injury Compared to Controls

BACKGROUND

Cancer is a major cause of death in patients with spinal cord injury (SCI). Preventive strategies, such as colonoscopy, deal with higher burdens that may lead to lower quality.

AIMS

The primary objective was to evaluate the adenoma detection rate. Secondary objectives were to investigate other quality indicators regarding bowel preparation, sedation, and endoscopy.

METHODS

Consecutive SCI patients who had undergone colonoscopy from 2003 to 2014 were assigned to a control group matched for age, gender, and year of procedure and reviewed retrospectively.

RESULTS

Bowel preparation lasted longer (3.6 ± 1.5 vs. 1.2 ± 0.6 days, p = 0.001), achieved unsatisfactory cleansing results more often (23.7 vs. 3.6%) and caused more adverse events in 236 SCI compared to 414 control patients. Colonoscopy needed a longer time (36.9 vs. 25.0 min) and remained incomplete more often (24.6 vs. 4.6%), resulting in more re-colonoscopies (14.8 vs. 4.3%). Endoscopy- and sedation-related adverse events were equal. However, neither overall nor size-dependent polyp (30.9 vs. 34.8%), adenoma (21.2 vs. 21.0%), advanced adenoma (6.8 vs. 7.2%), or cancer (1.7 vs. 2.0%) detection rates differed.

CONCLUSION

Despite intensified protocols, bowel preparation shows inferior results in SCI patients; colonoscopy needs more effort to succeed but achieves a comparable quality.

Rib Hyperostosis as a Risk Factor for Poor Prognosis in Cervical Spine Injury Patients With Diffuse Idiopathic Skeletal Hyperostosis

STUDY DESIGN

Retrospective multi-center study.

OBJECTIVE

To identify the morphological features of costovertebral joints and ribs in surgically managed cervical injury patients with diffuse idiopathic skeletal hyperostosis (DISH) and to examine its impact on their vital prognosis.

SUMMARY OF BACKGROUND DATA

Several reports have indicated that DISH is an independent risk factor for mortality after spinal fracture. The reason for the high mortality in cervical injury patients with DISH is unclear, although some reports have suggested a possible association between pulmonary complications and mortality.

METHODS

From 1999 to 2017, a total of 50 DISH patients (44 males) with cervical spine injuries who underwent spinal surgery were enrolled (average age 74 yrs). Prognosis and clinical risk factor data were collected; the morphological features of the patients' costovertebral joints and ribs were evaluated with computed tomography. The influence of each proposed risk factor and thoracic morphological feature on mortality was tested with univariate and multivariate analyses.

RESULTS

The survival rate at 5 years after surgery was 52.3%. Nineteen (38%) patients died, and the most common cause of death was pneumonia (68%). Costovertebral bone excrescences and rib hyperostosis were found to be thoracic pathognomonic signs; their frequencies were 94% and 82%, respectively, and these conditions occurred in an average of 7.0 joints and 4.7 bones, respectively. The results of the log-rank test showed a significant difference in age, injury severity score (ISS), costovertebral bone excrescences, and rib hyperostosis. The results of age-adjusted multivariate analysis indicated that age (hazard ratio [HR] = 8.65, 95% confidence interval [CI] = 1.10-68.28, P = 0.041) and rib hyperostosis (HR = 3.82, 95% CI = 1.38-10.57, P = 0.010) were associated with mortality.

CONCLUSION

Reduced chest wall mobility associated with rib hyperostosis in cervical spine injury patients with DISH leads to a poor prognosis.

LEVEL OF EVIDENCE

3.

Electrical stimulation and denervated muscles after spinal cord injury

Spinal cord injury (SCI) population with injury below T10 or injury to the cauda equina region is characterized by denervated muscles, extensive muscle atrophy, infiltration of intramuscular fat and formation of fibrous tissue. These morphological changes may put individuals with SCI at higher risk for developing other diseases such as various cardiovascular diseases, diabetes, obesity and osteoporosis. Currently, there is no available rehabilitation intervention to rescue the muscles or restore muscle size in SCI individuals with lower motor neuron denervation. We, hereby, performed a review of the available evidence that supports the use of electrical stimulation in restoration of denervated muscle following SCI. Long pulse width stimulation (LPWS) technique is an upcoming method of stimulating denervated muscles. Our primary objective is to explore the best stimulation paradigms (stimulation parameters, stimulation technique and stimulation wave) to achieve restoration of the denervated muscle. Stimulation parameters, such as the pulse duration, need to be 100–1000 times longer than in innervated muscles to achieve desirable excitability and contraction. The use of electrical stimulation in animal and human models induces muscle hypertrophy. Findings in animal models indicate that electrical stimulation, with a combination of exercise and pharmacological interventions, have proven to be effective in improving various aspects like relative muscle weight, muscle cross sectional area, number of myelinated regenerated fibers, and restoring some level of muscle function. Human studies have shown similar outcomes, identifying the use of LPWS as an effective strategy in increasing muscle cross sectional area, the size of muscle fibers, and improving muscle function. Therefore, displaying promise is an effective future stimulation intervention. In summary, LPWS is a novel stimulation technique for denervated muscles in humans with SCI. Successful studies on LPWS of denervated muscles will help in translating this stimulation technique to the clinical level as a rehabilitation intervention after SCI.

Hepatic dysfunction after spinal cord injury: A vicious cycle of central and peripheral pathology?

The liver is essential for numerous physiological processes, including filtering blood from the intestines, metabolizing fats, proteins, carbohydrates and drugs, and regulating iron storage and release. The liver is also an important immune organ and plays a critical role in response to infection and injury throughout the body. Liver functions are regulated by autonomic parasympathetic innervation from the brainstem and sympathetic innervation from the thoracic spinal cord. Thus, spinal cord injury (SCI) at or above thoracic levels disrupts major regulatory mechanisms for hepatic functions. Work in rodents and humans shows that SCI induces liver pathology, including hepatic inflammation and fat accumulation characteristic of a serious form of non-alcoholic fatty liver disease (NAFLD) called non-alcoholic steatohepatitis (NASH). This hepatic pathology is associated with and likely contributes to indices of metabolic dysfunction often noted in SCI individuals, such as insulin resistance and hyperlipidemia. These occur at greater rates in the SCI population and can negatively impact health and quality of life. In this review, we will: 1) Discuss acute and chronic changes in human and rodent liver pathology and function after SCI; 2) Describe how these hepatic changes affect systemic inflammation, iron regulation and metabolic dysfunction after SCI; 3) Describe how disruption of the hepatic autonomic nervous system may be a key culprit in post-injury chronic liver pathology; and 4) Preview ongoing and future research that aims to elucidate mechanisms driving liver and metabolic dysfunction after SCI.

A Systematic Methodology to Analyze the Impact of Hand-Rim Wheelchair Propulsion on the Upper Limb

Manual wheelchair propulsion results in physical demand of the upper limb extremities that, because of its repetitive nature, can lead to chronic pathologies on spinal cord injury patients. The aim of this study was to design and test a methodology to compare kinematic and kinetic variables of the upper limb joints when propelling different wheelchairs. Moreover, this methodology was used to analyze the differences that may exist between paraplegic and tetraplegic patients when propelling two different wheelchairs. Five adults with paraplegia and five adults with tetraplegia performed several propulsion tests. Participants propelled two different wheelchairs for three minutes at 0.833 m/s (3 km/h) with one minute break between the tests. Kinematic and kinetic variables of the upper limb as well as variables with respect to the propulsion style were recorded. Important differences in the kinetic and kinematic variables of the joints of the upper limb were found when comparing paraplegic and tetraplegic patients. Nevertheless, this difference depends on the wheelchair used. As expected, in all tests, the shoulder shows to be the most impacted joint.

Risk of prostate cancer in men with spinal cord injury: A systematic review and meta-analysis

A lower risk of prostate cancer has been reported in men with spinal cord injury (SCI) as compared to that observed in able-bodied subjects. As injury-related consequences can have opposite effects on prostate pathophysiology, this meta-analysis aimed to (1) establish the existence/quantify the extent of decreased prostate cancer risk following SCI and (2) find out if there is any statistically significant difference in prostate-specific antigen (PSA) levels between SCI and able-bodied subjects. MEDLINE, Cochrane Library, Scopus, CINAHL, and ScienceDirect databases were used. Only studies reporting a prostate cancer diagnosis and/or PSA levels following SCI and in able-bodied controls were included. Five studies provided information about prostate cancer on 35 293 subjects with SCI and 158 140 controls. Six studies were included in PSA analysis which reported information on 391 men with SCI and 1921 controls. Pooled estimates indicated that SCI reduced the prostate cancer risk by approximately 50% as compared to controls, whereas differences in PSA levels were not statistically significant. Funnel plots suggested the presence of publication bias only in PSA analysis. Between-study heterogeneity was established and when, according to meta-regression models, analysis was restricted to studies including men with mean age over 55 years, prostate cancer risk in SCI decreased up to 65.0% than that in controls with no heterogeneity (P = 0.33, I² = 9%). In conclusion, in men over 55 years old, SCI decreases the prostate cancer risk up to 65.0% than that in controls. The large between-study heterogeneity on PSA confirms its poor reliability as a screening tool for prostate cancer in SCI.

Skeletal muscle hypertrophy and attenuation of cardio-metabolic risk factors (SHARC) using functional electrical stimulation-lower extremity cycling in persons with spinal cord injury: study protocol for a randomized clinical trial

Background

Persons with spinal cord injury (SCI) are at heightened risks of developing unfavorable cardiometabolic consequences due to physical inactivity. Functional electrical stimulation (FES) and surface neuromuscular electrical stimulation (NMES)-resistance training (RT) have emerged as effective rehabilitation methods that can exercise muscles below the level of injury and attenuate cardio-metabolic risk factors. Our aims are to determine the impact of 12 weeks of NMES + 12 weeks of FES-lower extremity cycling (LEC) compared to 12 weeks of passive movement + 12 weeks of FES-LEC on: (1) oxygen uptake (VO₂), insulin sensitivity, and glucose disposal in adults with SCI; (2) skeletal muscle size, intramuscular fat (IMF), and visceral adipose tissue (VAT); and (3) protein expression of energy metabolism, protein molecules involved in insulin signaling, muscle hypertrophy, and oxygen uptake and electron transport chain (ETC) activities.

Methods/Design

Forty-eight persons aged 18–65 years with chronic (> 1 year) SCI/D (AIS A-C) at the C5-L2 levels, equally sub-grouped by cervical or sub-cervical injury levels and time since injury, will be randomized into either the NMES + FES group or Passive + FES (control group). The NMES + FES group will undergo 12 weeks of evoked RT using twice-weekly NMES and ankle weights followed by twice-weekly progressive FES-LEC for an additional 12 weeks. The control group will undergo 12 weeks of passive movement followed by 12 weeks of progressive FES-LEC. Measurements will be performed at baseline (B; week 0), post-intervention 1 (P1; week 13), and post-intervention 2 (P2; week 25), and will include: VO₂ measurements, insulin sensitivity, and glucose effectiveness using intravenous glucose tolerance test; magnetic resonance imaging to measure muscle, IMF, and VAT areas; muscle biopsy to measure protein expression and intracellular signaling; and mitochondrial ETC function.

Discussion

Training through NMES + RT may evoke muscle hypertrophy and positively impact oxygen uptake, insulin sensitivity, and glucose effectiveness. This may result in beneficial outcomes on metabolic activity, body composition profile, mitochondrial ETC, and intracellular signaling related to insulin action and muscle hypertrophy. In the future, NMES-RT may be added to FES-LEC to improve the workloads achieved in the rehabilitation of persons with SCI and further decrease muscle wasting and cardio-metabolic risks.

Trial registration

ClinicalTrials.gov, NCT02660073. Registered on 21 Jan 2016.

Time-related changes in quality of life in persons with lower limb amputation or spinal cord injury: protocol for a systematic review

BACKGROUND

Experiencing a lower limb amputation (LLA) or spinal cord injury (SCI) is a life-changing event, affecting physical and systemic function as well as having psychological and social impacts. However, the severity of the physical impairment and/or motor disability demonstrates a poor relationship with patient-reported quality of life, suggesting that other factors determine such outcomes. As such, holistic health-related quality of life (QoL) assessment is an important tool to monitor long-term outcomes. While there are some studies that have assessed the influence of variables such as age at time of injury occurrence and time since injury on changes in QoL, there are no systematic reviews which synthesise this evidence.

METHODS/DESIGN

All follow-up study designs will be included, where data from multiple time points are presented. Searches will target both SCI and LLA populations where a validated measure of QoL has been used: Medical Outcome Study Short-Form 36/12 or the World Health Organization Quality of Life instruments 100 and BREF. Studies must include adult participants (≥ 18 years at time of injury) and detail time since injury event and patient age. The primary objective is to establish the effects of participant age and time since injury on QoL scores. Secondary objectives include determining between-group effects (i.e. LLA vs. SCI). We will search PubMed, Embase and Web of Science databases, supplemented by hand-searching references within existing review articles and experimental studies. Reviewer pairs will conduct screening and quality assessment of included papers. Results will be stratified by impairment, QoL tool, age/time since injury and additional variables such as sex, race, comorbidity or disease aetiology, as appropriate. If sufficient high-quality data exist, a meta-analysis will be conducted.

DISCUSSION

The results of this systematic review will summarise evidence of how QoL changes across the life course, relative to both patient age and time since injury, for both LLA and SCI populations. By enabling a direct comparison of different chronic conditions, disability-specific differences in QoL changes over the life course can be identified.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018096633 .