Fatigue and tiredness in people with spinal cord injury

The Sir Ludwig Guttmann lecture 2023: psychosocial factors and adjustment dynamics after spinal cord injury

STUDY DESIGN

Narrative review OBJECTIVES: Sir Ludwig Guttmann realised spinal cord injury (SCI) rehabilitation should incorporate more than a biomedical approach if SCI patients were to adjust to their injury and achieve productive social re-integration. He introduced components into rehabilitation he believed would assist his patients build physical strength as well as psychological resilience that would help them re-engage with their communities. We pay tribute to Sir Ludwig by presenting research that has focussed on psychosocial factors that contribute to adjustment dynamics after SCI.

SETTING

Not applicable.

METHODS

Five factors with a psychosocial source will be examined, featured in my research, namely psychological distress, cognitive impairment, pain catastrophizing, sleep disorder and fatigue. A multifactorial model of adjustment will be examined.

RESULTS

Evidence shows these factors can be significant barriers to adjustment and reciprocally related to self-efficacy and life decisions. A theoretical rehabilitation framework/model is presented called the SCI Adjustment Model (SCIAM), that explains the process of adjustment dynamics. It describes how multifactorial factors contribute to adjustment in a non-linear process over time.

CONCLUSIONS

Key clinical messages include: (i) adjustment dynamics will be enhanced if viewed through the lens of a multifactorial model that clarifies how multiple psychosocial factors can combine and act as barriers or facilitators to adjustment; (ii) judiciously using this information, assess and then strategize to reduce the influence of barriers or strengthen facilitators during SCI rehabilitation and beyond, and (iii) integrate psychosocial guidelines and a person-centred approach into SCI rehabilitation to achieve treatment goals.

Methodology and Experimental Protocol for Fatigue Analysis in Suggestopedia Teachers

BACKGROUND

Among all professions, teaching is significantly affected by psycho-social risks with approximately 33.33% of educators reporting work-related fatigue. Suggestopedia, an effective pedagogical approach developed in Bulgaria, claims to induce positive psychological and cognitive benefits in both teachers and students. In order to gather scientific evidence, given the above statement, we designed a methodology to detect fatigue in Suggestopedia teachers based on neurocognitive analysis and psychological assessment.

METHODS

An increase in the EEG theta and alpha band powers is considered among the most reliable markers of fatigue. The proposed methodology introduces a robust framework for fatigue analysis. Initially, the changes in EEG band powers using the resting state EEG activity before and after teaching are measured. Subsequently, validated psychological questionnaires are used to gain subjective feedback on fatigue. The study participants include a control group (traditional teachers) and the test group (suggestopedia teachers) to assess whether suggestopedia practice mitigates fatigue among teachers.

OBSERVATIONS

In a pilot study, the EEG data was analyzed by evaluating the interrelations between EEG bands and the alpha-beta ratio. The results of the proposed study are expected to provide comprehensive analysis for the fatigue levels of teachers. In future research, our goal is to position the described methodology as a robust approach for evaluating cognitive and emotional states.

Cognitive, behavioral and psychiatric symptoms in patients with spinal cord injury: a scoping review

Spinal Cord Injury (SCI) is a condition where the spinal cord is damaged and experiences partial or complete loss of motor and/or sensory function, which is typically less than normal. After SCI, patients may exhibit more severe psychiatric symptoms and experience cognitive impairments, including reduced speed and attention processing capacity, as well as difficulties with executive function and episodic memory retention. Among the behavioral and psychiatric symptoms, depression, anxiety, substance use disorder, and posttraumatic stress disorder are the most common. This review aims to investigate the cognitive, behavioral, or psychiatric symptoms of the patient with SCI and their influence on the rehabilitation process. Studies were identified from an online search of PubMed, Web of Science, Cochrane Library, and Embase databases. Studies published between 2013-2023 were selected. This review has been registered on OSF (n) 3KB2U. We have found that patients with SCI are at high risk of cognitive impairment and experience a wide range of difficulties, including tasks based on processing speed and executive function. This clinical population may experience adjustment disorders with depression and anxiety, as well as other psychiatric symptoms such as fatigue, stress, and suicidal ideation. This review has demonstrated that SCI patients may experience psychiatric symptoms and cognitive impairments that affect their functioning. At the same time, these patients may be more prone to various adjustment and mood disorders. Moreover, these two aspects may interact with each other, causing a range of symptoms, increasing the risk of hospitalization, and delaying the rehabilitation process.

The effects of mental fatigue on fine motor performance in humans and its neural network connectivity mechanism: a dart throwing study

While it is well known that mental fatigue impairs fine motor performance, the investigation into its neural basis remains scant. Here, we investigate the impact of mental fatigue on fine motor performance and explore its underlying neural network connectivity mechanisms. A total of 24 healthy male university students were recruited and randomly divided into two groups: a mental fatigue group (MF) and a control group (Control). Both groups completed 50 dart throws, while electroencephalography (EEG) data were collected. Following the Stroop intervention, participants in the MF group exhibited a decrease in Stroop task accuracy and throwing performance, and an increase in reaction time along with VAS and NASA scores. The EEG data during dart-throwing revealed that the network connectivity strength of theta oscillations in the frontal and left central regions was significantly higher in the MF group compared with the Control group, while the network connectivity strength of alpha oscillations in the left parietal region was significantly enhanced. The interregional connectivity within the theta and alpha rhythm bands, particularly in the frontal-central-parietal network connections, also showed a significant increase in the MF group. Mental fatigue impairs dart throwing performance and is accompanied by increased connectivity in alpha and theta.

Efficacy of the immediate adipose-derived stromal vascular fraction autograft on functional sensorimotor recovery after spinal cord contusion in rats

BACKGROUND

Spinal cord injuries (SCI) lead to functional alteration with important consequences such as motor and sensory disorders. The repair strategies developed to date remain ineffective. The adipose tissue-derived stromal vascular fraction (SVF) is composed of a cocktail of cells with trophic, pro-angiogenic and immunomodulatory effects. Numerous therapeutic benefits were shown for tissue reconstitution, peripheral neuropathy and for the improvement of neurodegenerative diseases. Here, the therapeutic efficacy of SVF on sensorimotor recovery after an acute thoracic spinal cord contusion in adult rats was determined.

METHOD

Male Sprague Dawley rats (n = 45) were divided into 3 groups: SHAM (without SCI and treatment), NaCl (animals with a spinal lesion and receiving a saline injection through the dura mater) and SVF (animals with a spinal lesion and receiving a fraction of fat removed from adipocytes through the dura mater). Some animals were sacrificed 14 days after the start of the experiment to determine the inflammatory reaction by measuring the interleukin-1β, interleukin-6 and Tumor Necrosis Factor-α in the lesion area. Other animals were followed once a week for 12 weeks to assess functional recovery (postural and locomotor activities, sensorimotor coordination). At the end of this period, spinal reflexivity (rate-dependent depression of the H-reflex) and physiological adjustments (ventilatory response to metabosensitive muscle activation following muscle fatigue) were measured with electrophysiological tools.

RESULTS

Compared to non-treated animals, results indicated that the SVF reduced the endogenous inflammation and increased the behavioral recovery in treated animals. Moreover, H-reflex depression and ventilatory adjustments to muscle fatigue were found to be comparable between SHAM and SVF groups.

CONCLUSION

Our results highlight the effectiveness of SVF and its high therapeutic potential to improve sensorimotor functions and to restore the segmental sensorimotor loop and the communication between supra- and sub-lesional spinal cord regions after traumatic contusion.

Impact of Robotic-Assisted Gait Therapy on Depression and Anxiety Symptoms in Patients with Subacute Spinal Cord Injuries (SCIs)-A Prospective Clinical Study

BACKGROUND

Mood disorders, especially depression, and emotional difficulties such as anxiety are very common problems among patients with spinal cord injuries (SCIs). The lack of physical training may deteriorate their mental state, which, in turn, has a significant impact on their improvement in functioning. The aim of the present study was to examine the influence of innovative rehabilitation approaches involving robotic-assisted gait therapy (RAGT) on the depression and anxiety symptoms in patients with SCI.

METHODS

A total of 110 participants with subacute SCIs were enrolled in this single-center, single-blinded, single-arm, prospective study; patients were divided into experimental (robotic-assisted gait therapy (RAGT)) and control (conventional gait therapy with dynamic parapodium (DPT)) groups. They received five training sessions per week over 7 weeks. At the beginning and end of therapy, the severity of depression was assessed via the Depression Assessment Questionnaire (KPD), and that of anxiety symptoms was assessed via the State-Trait Anxiety Inventory (STAI X-1).

RESULTS

SCI patients in both groups experienced significantly lower levels of anxiety- and depression-related symptoms after completing the seven-week rehabilitation program (KPD: Z = 6.35, p < 0.001, r = 0.43; STAI X-1: Z = -6.20, p < 0.001, r = 0.42). In the RAGT group, post-rehabilitation measurements also indicated an improvement in psychological functioning (i.e., decreases in depression and anxiety and an increase in self-regulation (SR)). Significant results were noted for each variable (STAI X-1: Z = -4.93; KPD: Z = -5.26; SR: Z = -3.21). In the control group, there were also decreases in the effects on depression and state anxiety and an increase in self-regulation ability (STAI X-1: Z = -4.01; KPD: Z = -3.65; SR: Z = -2.83). The rehabilitation modality did not appear to have a statistically significant relationship with the magnitude of improvement in the Depression Assessment Questionnaire (KPD) (including self-regulation) and State-Trait Anxiety Inventory (STAI) scores. However, there were some significant differences when comparing the groups by the extent and depth of the injury and type of paralysis. Moreover, the study did not find any significant relationships between improvements in physical aspects and changes in psychological factors.

CONCLUSIONS

Subjects in the robotic-assisted gait therapy (RAGD) and dynamic parapodium training (DPT) groups experienced decreases in anxiety and depression after a 7-week rehabilitation program. However, the rehabilitation modality (DPT vs. RAGT) did not differentiate between the patients with spinal cord injuries in terms of the magnitude of this change. Our results suggest that individuals with severe neurological conditions and complete spinal cord injuries (AIS A, according to the Abbreviated Injury Scale classification) may experience greater benefits in terms of changes in the psychological parameters after rehabilitation with RAGT.

Cognitive Failure in Adults with Spinal Cord Injury: A Valuable Adjunct Measure for Enhancing Cognitive Assessment and Rehabilitation Outcomes

Cognitive impairment is common in persons with spinal cord injury (SCI), impacting their daily functioning and rehabilitation. This study assesses the extent of self-reported cognitive failures in everyday life in persons with SCI and its relationships with objective neurocognitive measures and psychosocial factors, including depressive mood, anxiety, perceived control, and fatigue. The differences between forty-one adults with a chronic SCI and forty-one able-bodied controls were examined. The participants completed the Cognitive Failures Questionnaire (CFQ) to assess cognitive failure and neurocognitive tests assessing attention and executive functions, as well as a psychosocial assessment. The SCI group reported higher cognitive failure rates than the able-bodied group (31.7% versus 19%, p > 0.05). Objective neurocognitive tests did not significantly correlate with the CFQ scores in either group. However, the CFQ scores were positively associated with most psychosocial factors, even after controlling for covariates. The CFQ scores were significantly associated with depressive mood in persons with SCI. These findings highlight the importance of incorporating self-reported cognitive measures into neurocognitive assessments and rehabilitation planning for adults with SCI. Self-reports capture everyday cognitive challenges that objective tests may miss. Additionally, this study highlights the strong connections between cognitive failures and psychosocial issues, particularly mood disorders, emphasizing the need for comprehensive rehabilitation and psychosocial support post-SCI, addressing both cognitive and emotional wellbeing.

Health impacts reported in the Spinal Cord Injury COVID-19 Pandemic Experience Survey (SCI-CPES)

CONTEXT

In people with spinal cord injury (SCI), infections are a leading cause of death, and there is a high prevalence of diabetes mellitus, obesity, and hypertension, which are all comorbidities associated with worse outcomes after COVID-19 infection.

OBJECTIVE

To characterize self-reported health impacts of COVID-19 on people with SCI related to exposure to virus, diagnosis, symptoms, complications of infection, and vaccination.

METHODS

The Spinal Cord Injury COVID-19 Pandemic Experience Survey (SCI-CPES) study was administered to ask people with SCI about their health and other experiences during the COVID-19 pandemic.

RESULTS

223 community-living people with SCI (male = 71%; age = 52±15 years [mean±SD]; paraplegia = 55%) completed the SCI-CPES. Comorbidities first identified in the general population as associated with poor outcomes after COVID-19 infection were commonly reported in this SCI sample: hypertension (30%) and diabetes (13%). 23.5% of respondents reported a known infection exposure from someone who visited (13.5%) or lived in their home (10%). During the study, which included a timeframe when testing was either unavailable or scarce, 61% of respondents were tested for COVID-19; 14% tested or were presumed positive. Fever, fatigue, and chills were the most common symptoms reported. Of the 152 respondents surveyed after COVID-19 vaccines became available, 82% reported being vaccinated. Race and age were significantly associated with positive vaccination status: most (78%) individuals who were vaccinated identified as Non-Hispanic White and were older than those who reported being unvaccinated (57±14 vs. 43±13 years, mean±SD).

CONCLUSIONS

Self-reported COVID-19 symptoms were relatively uncommon and not severe in this sample of people with SCI. Potential confounders and limitations include responder, recruitment and self-reporting biases and changing pandemic conditions. Future studies on this topic should query social distancing and other behavioral strategies. Large retrospective chart review studies may provide additional data on incidence and prevalence of COVID-19 infections, symptoms, and severities in the SCI population.

Inspiratory muscle training on quality of life in individuals with spinal cord injury: A systematic review and meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

The objective was to summarize the effectiveness of Inspiratory Muscle Training (IMT) on the quality of life in individuals with Spinal Cord Injury (SCI).

METHODS

An online systematic literature search was conducted in the following databases: PubMed/MEDLINE, PubMed CENTRAL, EMBASE, ISI Web of Science, SciELO, CINAHL/SPORTDiscus, and PsycINFO. Randomized and non-randomized clinical studies investigating the effectiveness of IMT in quality of life were included in the present study. The results used the mean difference and 95% confidence interval for maximal inspiratory pressure (MIP), forced expiratory volume in 1 s (FEV1), maximal expiratory pressure (MEP), and the standardized mean differences for the quality of life and maximum ventilation volume.

RESULTS

The search found 232 papers, and after the screening, four studies met the inclusion criteria and were included in the meta-analytical procedures (n = 150 participants). No changes were demonstrated in the quality of life domains (general health, physical function, mental health, vitality, social function, emotional problem, and pain) after IMT. The IMT provided a considerable effect over the MIP but not on FEV1 and MEP. Conversely, it was not able to provide changes in any of the quality of life domains. None of the included studies evaluated the IMT effects on the expiratory muscle maximal expiratory pressure.

CONCLUSION

Evidence from studies shows that inspiratory muscle training improves the MIP; however, this effect does not seem to translate to any change in the quality of life or respiratory function outcomes in individuals with SCI.

Prevalence of secondary health conditions and mental status in persons with long-term spinal cord injury in South Africa: Comparison between public and private healthcare sectors

BACKGROUND

Spinal cord injuries typically result in a range of negative health outcomes and health states, which impacts overall functioning, health and well-being. It remains important to establish the prevalence (burden) of health outcomes to help with the development of optimal treatment strategies.

OBJECTIVES

To determine the prevalence and treatment rates of secondary health conditions (SHCs) and mental health states in persons with long-term spinal cord injury (SCI) receiving public compared with private healthcare services in South Africa.

METHODS

A cross-sectional survey included 200 community-dwelling persons with long-term SCI, 60% with paraplegia, 53% with complete injuries and 156 from the public and 44 from private healthcare sectors. The following modules of the International Spinal Cord Injury (InSCI) community survey were used: (i) demographic and injury characteristics; (ii) SHCs and treatment rates; and (iii) vitality and emotional well-being. All statistical analyses were stratified according to healthcare sector.

RESULTS

Pain (47% v. 57), sexual dysfunction (59% v. 41%) and muscle spasms (54% v. 43%) were the most common SHCs in both cohorts, and the period prevalence was significantly higher for sleeping problems (41% v. 25%), sexual dysfunction (59% v. 41%) and contractures (42% v. 20%) in the public compared with the private cohort. Persons with SCI in the private cohort received treatment more often for sleeping problems (100% v. 45%), autonomic dysreflexia (75% v. 27%) and pain (56% v. 33%) than their counterparts with public insurance. Negative mental health states were prevalent in both groups.

CONCLUSION

SHCs and negative mental health were common in persons with SCI in South Africa, while those with public insurance reporter a higher occurrence of sleep problems and contractures, as well as lower treatment rates. Overall, a need exists to better support persons with SCI in the long-term context to facilitate improved functioning and wellbeing.

Links between excessive daytime sleepiness and EEG power and activation in two subtypes of ADHD

OBJECTIVES

This study aimed to replicate previously reported EEG characteristics between typically developing (TD) children and two subtypes of Attention Deficit Hyperactivity Disorder (ADHD) using a frontal, single-channel, dry-sensor portable EEG device, and explore whether differences are moderated by excessive daytime sleepiness (EDS).

METHODS

Children with ADHD Inattentive (ADHD-I) and ADHD Combined presentation (ADHD-C) and typically-developing (TD) children (N = 34 in each group) had frontal EEG recorded during eyes-closed resting, eyes-open resting, and focus tasks. Participants also completed the Children's Self-Report Sleep Patterns - Sleepiness Scale as a measure of EDS.

RESULTS

Consistent with previous literature, there were increases in frontal delta and theta power in the ADHD-C compared to ADHD-I and TD groups, in all conditions. Novel power and activation effects in ADHD subtypes, as well as significant group and EDS interactions for alpha and beta power were also found.

CONCLUSIONS

These findings highlight the importance of considering ADHD subtypes and EDS when exploring EEG characteristics, and have important implications for the diagnosis and treatment of children with ADHD.

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.

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.

Investigating Dynamics of the Spinal Cord Injury Adjustment Model: Mediation Model Analysis

Spinal cord injury (SCI) is a severe neurological injury that results in damage to multiple bodily systems. SCI rehabilitation requires a significant focus on improving adjustment to the injury. This paper presents a detailed description of the Spinal Cord Injury Adjustment Model (SCIAM), which clarifies how individuals adjust to SCI and contends that adjustment to SCI is a multifactorial process involving non-linear dynamic adaptation over time. Evidence supporting SCIAM is also discussed. Mediation analyses were conducted to test the mediator dynamics proposed by the model. The analyses tested the relationship between two moderators (self-care and secondary health conditions), mediators (two self-efficacy items and appraisal of quality of life or QoL), and positive versus negative vitality/mental health as outcomes. Results showed that higher self-efficacy and perceived QoL was related to greater independence in self-care and reduced negative impacts of secondary health conditions. This study supported the mediation role of self-efficacy and other appraisals such as perceived QoL in enhancing self-care and buffering the negative impact of health challenges. In conclusion, it is important to employ a holistic model such as SCIAM to conceptualise and increase understanding of the process of adjustment following a severe neurological injury such as SCI.

The Need for a Specialized Neurocognitive Screen and Consistent Cognitive Impairment Criteria in Spinal Cord Injury: Analysis of the Suitability of the Neuropsychiatry Unit Cognitive Assessment Tool

The assessment of mild cognitive impairment (MCI) following spinal cord injury (SCI) is vital. However, there are no neurocognitive screens which have been developed specifically to meet the unique requirements for SCI, nor are there consistent MCI criteria applied to determine the rates of MCI. The aim of this study was to determine the suitability of a neurocognitive screen for assessing MCI in adults with SCI. A total of 127 participants were recruited. Socio-demographic and injury related variables were assessed. All participants completed the screen. Descriptive statistics are provided for total/domain screen scores and all items, and the screen’s ability to distinguish MCI was examined. Congeneric confirmatory factor analyses (CFA) were employed to investigate structural validity. The screen total score was sensitive to differences in neurocognitive capacity, as well as for time since the injury occurred (p < 0.01). The MCI rate ranged between 17−36%. CFA revealed attention and visuoconstruction domains had an adequate model fit and executive function had poor fit, while CFA models for memory and language did not fit the data (did not converge), hence could not be determined. While the screen differentiated between those with MCI and those without, and MCI as a function of time since injury, limitations of its suitability for assessing MCI after SCI exist, demonstrating the need for a specialized neurocognitive screen for adults with SCI.

Trans-Spinal Electrical Stimulation Therapy for Functional Rehabilitation after Spinal Cord Injury: Review

Spinal cord injury (SCI) is one of the most debilitating injuries in the world. Complications after SCI, such as respiratory issues, bowel/bladder incontinency, pressure ulcers, autonomic dysreflexia, spasticity, pain, etc., lead to immense suffering, a remarkable reduction in life expectancy, and even premature death. Traditional rehabilitations for people with SCI are often insignificant or ineffective due to the severity and complexity of the injury. However, the recent development of noninvasive electrical neuromodulation treatments to the spinal cord have shed a ray of hope for these individuals to regain some of their lost functions, a reduction in secondary complications, and an improvement in their life quality. For this review, 250 articles were screened and about 150 were included to summarize the two most promising noninvasive spinal cord electrical stimulation methods of SCI rehabilitation treatment, namely, trans-spinal direct current stimulation (tsDCS) and trans-spinal pulsed current stimulation (tsPCS). Both treatments have demonstrated good success in not only improving the sensorimotor function, but also autonomic functions. Due to the noninvasive nature and lower costs of these treatments, in the coming years, we expect these treatments to be integrated into regular rehabilitation therapies worldwide.

Is the presence of home entrance steps associated with community participation of people with mobility impairments?

BACKGROUND

Little is known about how home entrances are related to community participation for people with mobility impairments.

OBJECTIVE

This investigation explored how the need to navigate steps at the entrance of a home affects the community participation levels of people with mobility impairments.

METHODS

This survey study used pre-measure data collected from three different samples. Participants were adults living independently in the community aged 18-94 years old who self-reported having a mobility impairment. Measures included the Brief Community Engagement Questionnaire to examine potential differential effects on the number of non-discretionary trips people make into the community (e.g., getting groceries, medications) versus the number of discretionary activities (e.g., socializing outside the home) people reported over seven days.

RESULTS

People with mobility impairments were less likely to report a stepped entrance than people without MI, but when the entrance they use the most had steps they reported significantly higher exertion to use the entrance. The presence of steps had no effect on non-discretionary trips (p = .74), but was associated with 49% (p < .01) fewer discretionary activities reported by people with mobility impairment relative to those without MI.

CONCLUSION

Steps at the home entrance of people with mobility impairment may be an important mediating factor in their level of participation. When researchers and practitioners evaluate interventions that aim to increase community participation of people with mobility impairment, they should control for the presence of steps at their home entrance.

Community integration programs and interventions for people with spinal cord injury: a scoping review

AIM

The focus of this scoping review was to identify the extent, range, and nature of studies that have been published regarding community integration programs and interventions that support people during the transition home from hospital following spinal cord injury.

METHODS

Four electronic databases and one search engine were searched for articles published between 2010 and 2020. Grey literature and manual searches were also done.

RESULTS

Of the 16 articles included, 8 were published in peer-reviewed journals. Two of these did not include an evaluation. Study designs included but were not limited to pilot studies (n = 2); mixed methods evaluations (n = 2); single-site randomized controlled trials (n = 3); and, non-randomized single-arm study design (n = 1). The articles were from the United States (n = 12), Canada (n = 2), Australia (n = 1), and the United Kingdom (n = 1).

CONCLUSION

The majority of interventions focused on addressing health-related educational needs, followed by community mobility. Goal setting and promoting self-efficacy were identified as important components, and the importance of involvement of people with lived experience was also highlighted. There was a lack of focus on management of relationships, including addressing sexuality needs. This review highlights the need for further empirical evaluation of implemented programs and interventions in this area, particularly in countries other than the USA, to inform service development.IMPLICATIONS FOR REHABILITATIONSuccessful community integration is an important outcome of spinal cord injuries rehabilitation.The majority of published programs focus on health-related educational needs, followed by community mobility.It is recommended that goal setting and promoting self-efficacy are included in programs.It is recommended that people with lived experience of spinal cord injuries are involved in interventions.It is recommended that programs include a focus on management of relationships, including addressing sexuality needs.

A neuro-cardiac self-regulation therapy to improve autonomic and neural function after SCI: a randomized controlled trial protocol

BACKGROUND

Spinal cord injury (SCI) is associated with autonomic imbalance and significant secondary conditions, including cardiac and brain dysfunction that adversely impact health and wellbeing. This study will investigate the effectiveness (intention-to-treat) of a neuro-cardiac self-regulation therapy to improve autonomic and neural/brain activity in adults with SCI living in the community.

METHODS

A two-arm parallel, randomised controlled trial in which adults with SCI living in the community post-rehabilitation will be randomly assigned to a treatment or control group. The treatment group (N = 60) aged 18-70 years with a chronic traumatic or non-traumatic SCI, will receive intervention sessions once per week for 10 weeks, designed to regulate autonomic activity using computer-based feedback of heart rate variability and controlled breathing (called HRV-F). Comprehensive neurophysiological and psychological assessment will occur at baseline, immediate post-treatment, and 6 and 12-months post-treatment. Primary outcome measures include electrocardiography/heart rate variability (to assess autonomic nervous system function) and transcranial doppler sonography (to assess cerebral blood circulation in basal cerebral arteries). Secondary outcomes measures include continuous blood pressure, electroencephalography, functional near-infrared spectroscopy, respiration/breath rate, electrooculography, cognitive capacity, psychological status, pain, fatigue, sleep and quality of life. Controls (N = 60) will receive usual community care, reading material and a brief telephone call once per week for 10 weeks and be similarly assessed over the same time period as the HRV-F group. Linear mixed model analysis with repeated measures will determine effectiveness of HRV-F and latent class mixture modelling used to determine trajectories for primary and selected secondary outcomes of interest.

DISCUSSION

Treatments for improving autonomic function after SCI are limited. It is therefore important to establish whether a neuro-cardiac self-regulation therapy can result in improved autonomic functioning post-SCI, as well as whether HRV-F is associated with better outcomes for secondary conditions such as cardiovascular health, cognitive capacity and mental health.

TRIAL REGISTRATION

The study has been prospectively registered with the Australian and New Zealand Clinical Trial Registry ( ACTRN12621000870853 .aspx). Date of Registration: 6th July 2021. Trial Sponsor: The University of Sydney, NSW 2006. Protocol version: 22/07/2021.

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.

Neuropsychological Study in Patients with Spinal Cord Injuries

The present investigation was designed to determinate the nature, pattern, and extent of cognitive deficits in a group of participants with subacute and chronic spinal cord injury (SCI). Methods: A cross-sectional study was conducted in both patients with subacute and chronic SCI. Different cognitive functions were evaluated through a neuropsychological protocol designed for this purpose, taking into account the patient’s emotional state. Results: A total of 100 patients suffering a spinal cord injury were evaluated. There were no differences between the two groups when age, sex, level of education, and region of origin were studied. The chronic injured patients obtained lower scores in the neuropsychological evaluation protocol respective to the subacute injured patients. Conclusions: Subjects with chronic spinal cord injury presented a cognitive profile that differed greatly in the number of altered cognitive functions as well as in their magnitude from the subacute spinal cord injured patient profile. Moreover, cognitive dysfunction may be important beyond the end of the first stage of rehabilitation as it can affect an individual’s quality of life and possible integration in society.

Effect of Rāja yoga Meditation on Psychological and Functional Outcomes in Spinal Cord Injury Patients

Background:

Spinal cord injury (SCI) is a debilitating disorder with dysfunction in daily activities and psychological consequences like anxiety as well as depression impacting the quality of life substantially. Existing treatments focus mainly on rehabilitation, symptom reduction, and secondary complications. However, psychological, social, and existential issues are least addressed in the prevailing models.

Aims:

To study the role of meditation in addressing psychological impairment and any resultant improvement in functional outcomes in SCI patients.

Methods:

Nonrandomized controlled study was conducted in a tertiary care center for SCI patients. Hospital inpatients were recruited into either experimental intervention group (add on easy rāja yoga with conventional rehabilitation-ER n = 50) or control intervention group (conventional rehabilitation alone-CR n = 50). Patients in the ER group received easy rāja yoga for 1 month, along with conventional rehabilitation and the CR group patients received only conventional rehabilitation. All the subjects were assessed for psychological (perceived stress scale [PSS], Hospital Anxiety and Depression Scale [HADS]) and functional impairment (spinal cord independence measure (SCIM), numeric pain rating (NPR) and WHO quality of life-BRIEF (WHOQOLBREF)] at baseline and after 1 month.

Results:

After 1 month of add-on easy rāja yoga, there was significant decrease in the scores of HADS (F[1,88] = 272.92, P < 0.001), PSS (F[1,88] = 274.41, P < 0.001) and NPR (F[1,88] = 60.60, P < 0.001) and significant increase in the scores of WHOQOLBREF (F[1,88] = 349.94, P < 0.001) and SCIM (F[1,88] = 29.09, P < 0.001) in the ER group compared to CR group in analysis of covariance.

Conclusion:

One-month add-on easy rāja yoga improves psychological and functional outcomes (HADS, PSS, NPR, WHOQOLBREF and SCIM) in patients with SCI. Future studies with robust designs are needed to validate the results.

Multidimensional review of cognitive impairment after spinal cord injury

Cognitive impairment is highly prevalent in the population with spinal cord injury (SCI) and exerts a significant impact on functional independence and quality of life in this population. A number of neuroscientists have conducted preliminary investigations of cognitive deficits after SCI, but achieved marginally contradictory results due to some limitations such as the heterogeneity in the sample population, sample size, types of tests utilized, study design, and time since SCI. Therefore, this review mainly focuses on the characteristics, assessments, potential causality and treatment of cognitive impairment for better understanding such deficits in the SCI population.

A prospective cohort study investigating contributors to mild cognitive impairment in adults with spinal cord injury: study protocol

BACKGROUND

Studies report rates of mild cognitive impairment (MCI) in spinal cord injury (SCI) range between 10 and 60%. This broad estimate of MCI in SCI is most likely a result of: (i) inconsistent operationalization of MCI; (ii) heterogeneity among individuals with SCI; (iii) failure to account for MCI subtypes, thereby adding to the heterogeneity of samples; and, (iv) poor control for traumatic brain injury (TBI) that obscures differentiation of MCI attributable to TBI versus other factors. There is a paucity of longitudinal studies following the course of MCI in SCI, and none that account for multiple predictors of MCI, including interactions among predictors.

METHODS

An inception cohort longitudinal study will assess approximately 100 individuals aged 17-80 years with acute SCI, with measures taken at three timepoints (baseline, 3 months post-baseline, and 12 months post-injury). Data relevant to medical care received within the first 24-48 h of presentation to the emergency department will be analysed, as will measures of cognition, injury characteristics, medical history, personal factors, psychological status, psychosocial functioning, and quality of life. Latent class mixture modelling will determine trajectories for the primary outcome of interest, cognitive functioning and its subtypes, and secondary outcomes of interest such as depression. Multiple regression analyses will identify predictors of MCI and its subtypes.

DISCUSSION

The prospective design will reveal change in cognitive functioning across time and unveil different outcome trajectories; thus addressing the lack of knowledge on trajectories of MCI and MCI subtypes in SCI. Through subtyping MCI, we hope to yield groups of cognitively impaired individuals with SCI that are potentially more homogenous and thereby stable and predictable. This is the first study to capture emergency department and acute care diagnostic evidence of mild TBI, which has been poorly controlled in previous studies. Our study will also be the first to distinguish the contribution of TBI from other factors to the development of MCI in individuals with SCI.

TRIAL REGISTRATION

The study was prospectively registered with the Australian and New Zealand Clinical Trial Registry ( ACTRN12619001702101 ) on 3rd December 2019.

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.

Cognitive Dysfunction in Persons with Chronic Spinal Cord Injuries

Cognitive dysfunction (CD) is pervasive in individuals who have chronic spinal cord injuries (SCI). Although classically associated with concomitant traumatic brain injuries, many other causes have been proposed, including premorbid neuropsychological conditions, mood disorders, substance abuse, polypharmacy, chronic pain and fatigue, sleep apnea, autonomic dysregulation, post-intensive care unit syndrome, cortical reorganizations, and neuroinflammation. The consequences of CD are likely widespread, affecting rehabilitation and function. CD in those with SCI should be recognized, and potentially treated, in order to provide the best patient care.

Excessive daytime sleepiness in adults with spinal cord injury and associations with pain catastrophizing and pain intensity

STUDY DESIGN

Pre-post cohort mixed factorial design.

OBJECTIVE

Excessive daytime sleepiness (EDS) and chronic pain are major problems for people with spinal cord injury (SCI). However, the relationship between chronic pain and EDS requires clarification. The goal of the study was to determine associations between pain catastrophizing (PC) and pain intensity (PI) with EDS in adults with SCI.

SETTING

New South Wales, Australia.

METHODS

Participants included 45 adults with SCI and 44 able-bodied controls. The relationship between PI, PC, and EDS was explored by determining the influence of PC and PI on the performance of both groups in a behavioral test of EDS called the Oxford Sleep Resistance Test. PC and PI were assessed by self-report. The association between EDS, pain, and other relevant factors like fatigue and mood was established using multidimensional scaling in the SCI group data.

RESULTS

PC was found to have a significant association with EDS, with 33.3% falling asleep in the SCI group with low PC, compared with 70% in those with high PC. Only 10% of the controls fell asleep regardless of PC. PI did not significantly influence EDS in either group. Multidimensional scaling showed EDS was closely related to PC, PI, pain interference, fatigue, and mood.

CONCLUSIONS

PC appears to be strongly associated with EDS in SCI. Findings suggest significant sleep benefits may occur in adults with SCI by treating cognitive biases like PC, as well as addressing associated factors like fatigue, pain interference, low mood, and so on.

Combining ICA Clustering and Power Spectral Density for Feature Extraction of Mental Fatigue of Spinal Cord Injury Patients

This paper presents the combination of clustering-based independent component analysis (ICASSO) and power spectral density (PSD) as a features extractor of mental fatigue from spinal cord injury (SCI) patients. Initially, the results show that SCI and abled-bodied groups have no differences in EEG for alert and mental fatigue states. Further, the coefficient determination (R²) is calculated for testing the variation of data alert vs. fatigue on the SCI group, resulting in a lower R² for proposed combination of ICASSO and PSD method compared to the PSD method only. With the lower R² values, this shows that the proposed method ICASSO and PSD is able to provide superior distinction for separating fatigue vs. alert data variation. The statistical significance is found across four EEG bands and EEG channels.

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.

Beyond the Diagnosis: Lived Experiences of Persons with Spinal Cord Injury in a Selected Town in Ghana

Background

Although several studies have been conducted on the lived experiences of persons with spinal cord injury (SCI) in high income countries, there is no published data on such experiences in Ghana. The purpose of this study was to explore the lived experiences of persons with SCI in the Tamale Metropolis of the Northern Region of Ghana.

Material and Methods

A qualitative descriptive design involving thirteen participants was conducted at the Tamale Metropolis-Ghana. A purposive sampling technique was used to recruit participants, using the Neurosurgical Unit of the Tamale Teaching Hospital as an outlet for recruitment of the sample. Data was gathered mainly through face-to-face in-depth interviews. The data was analyzed concurrently with data collection, using thematic content analysis. Ethical approval was obtained for the study from the Noguchi Memorial Institute for Medical Research and the research unit of the Tamale Teaching Hospital.

Results

The three main themes that emerged from the data during analysis were “physical effects,” “psychological effects,” and “social issues.” Conclusion. The findings from the study suggest that SCI is a life threatening condition and that persons with SCI grapple with a myriad of physical symptoms that range from chronic pain and paralysis of lower and/or upper limbs, to bladder and bowel incontinence. These physical symptoms have significant psychological and social effects on the functioning of the affected persons.

Daytime sleepiness and its relationships to fatigue and autonomic dysfunction in adults with spinal cord injury

OBJECTIVE

To determine the extent of daytime sleepiness in adults with spinal cord injury (SCI) and investigate the contribution of fatigue and autonomic function to sleepiness status.

METHODS

Participants included 45 adults with SCI attending outpatient services or living in the community and 44 able-bodied controls. The Oxford Sleep Resistance Test (OSLER) was used to assess daytime sleepiness, while eye blink rate duration (electrooculography) and the Iowa Fatigue Scale assessed fatigue. Heart rate variability (HRV) was used to assess autonomic function. Survival analysis (Kaplan Meier) was used to estimate the rate of loss in participation in the OSLER task, as a measure of daytime sleepiness. Repeated measures ANOVA was used to determine HRV differences between groups. Regression analysis was used to establish factors that contributed to daytime sleepiness.

RESULTS

Participants with high lesions ("T3 and above") had significantly increased daytime sleepiness. OSLER results revealed only 33% of those with high lesions remained awake during the task. Those with high lesions also had significantly reduced sympathetic activity while no differences in parasympathetic activity were found between groups. Lesion completeness had no effect. Standardized variation in heart rate, slow eye blinks, low frequency HRV and self-reported fatigue contributed to daytime sleepiness.

CONCLUSION

Neurological lesions at "T3 or above" have an increased risk of daytime sleepiness, impacting on independence in daily functional tasks and work performance. Autonomic imbalance alters cardiovascular control, affecting health and wellbeing. The interaction of these factors requires further investigation.

Cognitive function after spinal cord injury: A systematic review

OBJECTIVE

To systematically examine the incidence of cognitive impairment in individuals with spinal cord injury (SCI), as well as identify potential contributing and confounding factors.

METHODS

Studies quantitatively reporting cognitive ability after spinal cord injury were searched electronically via Medline, CINAHL, Embase, and PsycINFO. Manual screening for references within articles was also performed. A total of 2,481 studies were screened and a total of 70 were included in this review, 21 reporting cognitive function after SCI compared to an able-bodied control group and 49 with no able-bodied controls. Studies were analyzed for the incidence of impairment and the interactions with concomitant traumatic brain injury, psychological or somatic complaints, decentralized cardiovascular control, sleep apnea, neurologic level of injury, and age.

RESULTS

There is a high volume of evidence reporting substantial cognitive impairment in individuals with SCI. Potential co-contributors include concomitant brain injury, psychological or somatic comorbidities, decentralized cardiovascular control, and sleep apnea. Cognitive functioning was negatively correlated with age. No clear agreement was found for the incidence of cognitive impairment or its association with level of injury.

CONCLUSION

Current evidence suggests that individuals with SCI should be examined and addressed for cognitive impairment. Future studies aimed at identifying potential secondary causative factors should employ stringent controls for co-occurring brain trauma since it appears to be a major contributor and confounder to impaired cognition.

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.

Reduced Quality of Life, Fatigue, and Societal Participation After Polytrauma

Objective:

This cross-sectional study analyzed associations between and determinants for health-related quality of life (HRQoL), fatigue, and societal participation in polytrauma patients.

Summary of background data:

More polytrauma patients survive their injuries, often resulting in long-term disabilities. HRQoL is therefore an important outcome of trauma care. Fatigue and societal participation may be related to HRQoL. Also, their relation to severe injuries has not been studied to date.

Methods:

A total of 283 polytrauma patients (injury severity score ≥ 16) admitted to the Dutch level 1 Trauma Centre West were analyzed. HRQoL was measured by the physical component summary (PCS) and mental component summary (MCS) scores of the SF-36, fatigue by the multidimensional fatigue inventory, and societal participation by the Utrecht scale for evaluation of rehabilitation-participation. Age, sex, comorbidity, injury pattern, injury severity, and time since trauma were analyzed as potential determinants.

Results:

A total of 122 patients (43%) responded after a median follow-up of 15 (range, 10–23) months after polytrauma; 44% reported reduced physical health (PCS &lt; 45) and 47% reported reduced mental health (MCS &lt; 45). HRQoL was highly correlated with all fatigue and participation subscales. Severe head injury was associated with worse mental health. Female patients reported more general and mental fatigue and were less satisfied with their ability to perform daily activities. Patients with pre-existing comorbidity experienced worse physical health, more fatigue, and reduced societal participation.

Conclusions:

One to 2 years after trauma, polytrauma patients report reduced HRQoL, which is associated with more fatigue and reduced societal participation. Trauma rehabilitation strategies should focus on early recognition of reduced HRQoL, fatigue, and societal participation and facilitate early intervention to improve these outcomes.

Cognitive performance of people with traumatic spinal cord injury: a cross-sectional study comparing people with subacute and chronic injuries

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To assess the impact of spinal cord injury (SCI) on cognitive function in individuals with subacute and chronic SCI.

SETTING

National Hospital for SCI patients (Spain).

METHODS

The present investigation was designed to determine the nature, pattern, and extent of cognitive deficits in a group of participants with subacute (n = 32) and chronic (n = 34) SCI, using a comprehensive battery of reliable and validated neuropsychological assessments to study a broad range of cognitive functions. Twenty-seven able-bodied subjects matched to the groups with SCI for age and educational level formed the control group.

RESULTS

The neuropsychological assessment showed alterations in the domain of attention, processing speed, memory and learning, executive functions, and in recognition in participants with SCI. The prevalence of cognitive dysfunction in the chronic stage was also confirmed at the individual level. The comparison of the neuropsychological assessment between the groups with subacute and chronic SCI showed a worsening of cognitive functions in those with chronic SCI compared to the group with subacute SCI.

CONCLUSIONS

In participants with SCI, cognitive dysfunctions are present in the subacute stage and worsen over time. From a clinical point of view, we confirmed the presence of cognitive dysfunction that may interfere with the first stage of rehabilitation which is the most intense and important. Moreover, cognitive dysfunction may be important beyond the end of the first stage of rehabilitation as it can affect an individual's quality of life and possible integration to society.

Gut Microbiota Are Disease-Modifying Factors After Traumatic Spinal Cord Injury

Spinal cord injury (SCI) disrupts the autonomic nervous system (ANS), impairing its ability to coordinate organ function throughout the body. Emerging data indicate that the systemic pathology that manifests from ANS dysfunction exacerbates intraspinal pathology and neurological impairment. Precisely how this happens is unknown, although new data, in both humans and in rodent models, implicate changes in the composition of bacteria in the gut (i.e., the gut microbiota) as disease-modifying factors that are capable of affecting systemic physiology and pathophysiology. Recent data from rodents indicate that SCI causes gut dysbiosis, which exacerbates intraspinal inflammation and lesion pathology leading to impaired recovery of motor function. Postinjury delivery of probiotics containing various types of "good" bacteria can partially overcome the pathophysiologal effects of gut dysbiosis; immune function, locomotor recovery, and spinal cord integrity are partially restored by a sustained regimen of oral probiotics. More research is needed to determine whether gut dysbiosis varies across a range of clinically relevant variables, including sex, injury level, and injury severity, and whether changes in the gut microbiota can predict the onset or severity of common postinjury comorbidities, including infection, anemia, metabolic syndrome, and, perhaps, secondary neurological deterioration. Those microbial populations that dominate the gut could become "druggable" targets that could be manipulated via dietary interventions. For example, personalized nutraceuticals (e.g., pre- or probiotics) could be developed to treat the above comorbidities and improve health and quality of life after SCI.

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.

An in-depth understanding of the impact of the environment on participation among people with spinal cord injury

PURPOSE

To identify environmental factors associated with participation and gain an in-depth understanding of relationships between environmental factors and participation among people with spinal cord injury.

METHOD

Six focus groups (n= 30) with individuals with spinal cord injury were conducted. Two independent coders thematically analyzed the transcribed data.

RESULTS

Twenty environmental factors were identified, all of which were classified into eight categories: built environment; natural environment; assistive technology; transportation; information and technology access; economics; social support and social attitudes; and systems, services and policies. While all factors had direct impacts on individuals' participation outcomes, factors within the categories of societal attitudes, policies and economics also affected participation through affecting other environmental factors. Some factors together also showed cumulative or countering effects on participation. Accordingly, a conceptual model of the relationships between environmental factors and participation was constructed.

CONCLUSIONS

This study highlighted key environmental factors and their impacts on participation of people with spinal cord injury. The findings support previous research findings but also suggest that different factors may have different levels of impact on participation. Based on our findings, rehabilitation practitioners and policymakers can prioritize intervention plans to optimize the environment for people with spinal cord injury and improve their societal participation. Implications for rehabilitation Environmental factors are critical contributors to participation among people with spinal cord injury (SCI) and need to be addressed in rehabilitation programs. Factors with broader impacts on participation, such as societal attitudes and policies, should be treated as priorities in intervention plans aimed at improving participation among people with SCI. Rehabilitation practitioners should not only consider how the community supports people with SCI but also consider how rehabilitation programs change the community.

Evaluation of a specialized yoga program for persons with a spinal cord injury: a pilot randomized controlled trial

Objectives

The purpose of this randomized controlled trial was to evaluate the effects of a specialized yoga program for individuals with a spinal cord injury (SCI) on pain, psychological, and mindfulness variables.

Materials and methods

Participants with SCI (n=23) were outpatients or community members affiliated with a rehabilitation hospital. Participants were randomized to an Iyengar yoga (IY; n=11) group or to a 6-week wait-list control (WLC; n=12) group. The IY group participated in a twice-weekly 6-week seated IY program; the WLC group participated in the same yoga program, after the IY group’s yoga program had ended. Pain, psychological, and mindfulness measures were collected at two time points for both groups (within 1–2 weeks before and after program 1 and at a third time point for the WLC group (within 1 week after program 2).

Results

Linear mixed-effect growth models were conducted to evaluate the main effects of group at T2 (postintervention), controlling for T1 (preintervention) scores. T2 depression scores were lower (F_1,18=6.1, P<0.05) and T2 self-compassion scores higher (F_1,18=6.57, P< 0.05) in the IY group compared to the WLC group. To increase sample size and power, the two groups were combined and analyzed across time by comparing pre- and postintervention scores. Main effects of time were found for depression scores, (F_1,14.83=6.62, P<0.05), self-compassion, (F_1,16.6=4.49, P<0.05), mindfulness (F_1,16.79=5.42, P<0.05), mindful observing (F_1,19.82=5.06, P<0.05), and mindful nonreactivity, (F_1,16.53=4.92, P<0.05), all showing improvement after the intervention.

Discussion

The results indicated that a specialized 6-week yoga intervention reduced depressive symptoms and increased self-compassion in individuals with SCI, and may also have fostered greater mindfulness.

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.