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

Depression-like behavior is associated with deficits in cognition and hippocampal neurogenesis in a subset of spinally contused male, but not female, rats

Depression and cognitive deficits present at higher rates among people with spinal cord injury (SCI) compared to the general population, yet these SCI comorbidities are poorly addressed. Sex and age appear to play roles in depression incidence, but consensus on the direction of their effects is limited. Systemic and cortical inflammation and disruptions in hippocampal neurogenesis have been identified as potential treatment targets, but a comprehensive understanding of these mechanisms remains elusive. We used a rodent SCI model to interrogate these gaps in knowledge. We examined post-injury depression-like behavior and cognitive deficits, as well as the association between affect, cognition, chronic hippocampal inflammation and hippocampal neurogenesis, in young and middle-aged male and female Sprague-Dawley rats. Depression-like behavior manifested in male and female subsets of SCI rats irrespective of age, at rates commensurate with the incidence of clinical depression. Changes in components of behavior were driven by sex and age, and affective outcomes were independent of common post-injury pathophysiological outcomes including locomotor functional deficits and spinal lesion severity. Interestingly, however, only male depression-like SCI rats exhibited deficits in hippocampal-associated spatial cognition. Neurogenesis was also disrupted in only SCI males in regions of the hippocampus responsible for affective outcomes. Decreased neurogenesis among middle-aged male subjects coincided with increases in numbers of the pro-inflammatory markers CD86 and iNOS, while middle-aged females had increased numbers of cells expressing Iba-1 and anti-inflammatory marker CD206. Overall, the present data suggest that post-SCI depression and cognition may be affected, in part, by sex- and age-dependent changes in hippocampal neurogenesis and inflammation. Hippocampal neurogenesis is a potential target to address psychological wellbeing after SCI, but therapeutic strategies must carefully consider sex and age as biological variables.

Anxiety and Depression after Spinal Cord Injury: A Cross-Sectional Study

Spinal cord injury (SCI) is a life-changing event that often results in chronic physical damage and challenges in maintaining a good quality of life as it affects every aspect of life. These situations require adjustment, increasing vulnerability to psychological disorders. The objective of this study was to evaluate the impact of SCI on psychological morbidity in individuals with subacute and chronic SCI. The present investigation was designed to determine the presence and extent of psychological complications following SCI. We used two reliable questionnaires and validated psychological assessments to study depression (BDI) and anxiety (STAI), a broad range of factors derived from SCI that may be predictors of certain psychological problems. The psychological assessment revealed alterations in depression and anxiety, although the data do not exceed those of previous investigations. No clear predisposing factors leading to certain psychological pathologies were found. In addition, individuals in the subacute and chronic stages differed in their scores. In individuals with SCI, identifying predictors of psychological problems is difficult, but premature assessment of mental state is essential. This early diagnosis of possible problems or changes at the mental level is fundamental and necessary to avoid possible alterations at the cognitive level and, of course, more serious mental complications.

Efficacy of Interventions to Improve Cognitive Function in Adults with Spinal Cord Injury: A Systematic Review

Cognitive impairment is a common complication following spinal cord injury (SCI) and imposes a significant negative impact on adjustment, functional independence, physical and mental health, and quality of life. It is unclear whether interventions for cognitive impairment following SCI are effective. A systematic review of controlled trials was performed to evaluate the effect of interventions on cognitive functions in adults with SCI using search engines: Embase, The Cochrane Library, MEDLINE, Scopus, CINAHL, and Web of Science up to December 2023. Two reviewers independently screened the articles, and study findings were synthesized and summarized. The risk of bias was evaluated using the Cochrane Risk of Bias 2.0 tool. Eight moderate-quality studies were found that investigated the effects of physical exercise/activity-based therapy plus cognitive training or intermittent hypoxia, diet modification and dietary supplements, tibial nerve or cortical stimulation, and drug therapy on cognitive function in SCI. Physical exercise/activity-based therapy plus cognitive training showed most promise for improving cognitive functions, while drug therapy, diet modification, and dietary supplements showed potential for improving cognitive function. However, about half of the participants experienced heightened instability in blood pressure following the administration of midodrine, and one participant reported gastrointestinal side effects after taking omega-3 fatty acids. There was no evidence of improvement in cognitive function for stimulation techniques. The current review highlights the scarcity of research investigating the effectiveness of interventions that target cognitive function after SCI. Further, the effects of these eight studies are uncertain due to concerns about the quality of designs and small sample sizes utilized in the trials, as well as the employment of insensitive neurocognitive tests when applied to adults with SCI. This review highlights a significant gap in knowledge related to SCI cognitive rehabilitation.

Neuromuscular electrical stimulation to combat cognitive aging in people with spinal cord injury: protocol for a single case experimental design study

INTRODUCTION

Individuals with spinal cord injury (SCI) can experience accelerated cognitive aging. Myokines (factors released from muscle cells during contractions), such as brain-derived neurotrophic factor (BDNF), are thought to have beneficial effects on cognition. Neuromuscular electrical stimulation (NMES) was shown to elicit a large release of myokines. However, the effects of NMES on cognitive function have not been studied.

OBJECTIVE

To present the study protocol for a clinical trial evaluating the effects of NMES aimed at improving cognition and BDNF.

METHODS

A replicated randomized three-phases single-case experimental design (SCED) with sequential multiple baseline time series and a single-armed prospective trial will be conducted with 15 adults with chronic SCI (> 12 months after injury) above L1 neurological level undergoing 30-min quadriceps NMES, 3 days per week for 12 weeks.

MAIN STUDY ENDPOINTS

Primary endpoint is cognitive performance (assessed by a smartphone test) conducted three times per week during the baseline phase with random duration of 3 to 8 weeks, the intervention phase of 12 weeks, and the follow-up phase of 3 weeks after a no measurement rest period of 12 weeks. Secondary endpoints are changes in BDNF levels and cognitive performance measured before the baseline period, before and after intervention and after a 12 weeks follow-up.

CONCLUSION

This will be the first study investigating the effects of 12 weeks NMES on both cognition and BDNF levels in individuals with SCI. The SCED results provide information on individual treatment effect courses which may direct future research.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05822297, 12/01/2023).

The role of clinical and demographic predictors for understanding the cognitive impairment in Spinal Cord Injury (SCI) patients

STUDY DESIGN

Using a cross-sectional design, we extracted sociodemographic and clinical data from 488 Spinal Cord Injury (SCI) patients during their initial assessment before receiving intensive rehabilitation treatment.

OBJECTIVES

The primary objectives of this study were to ascertain the prevalence of cognitive impairment in the study sample and specify the key clinical and demographic predictors of cognitive functioning in SCI patients.

SETTING

Lucy Montoro Rehabilitation Institute (LMRI), University of Sao Paulo, Sao Paulo, Brazil.

METHODS

We utilized independent univariate and multivariate regression models with the Montreal Cognitive Assessment (MoCA) scale, adapted for individuals with visual impairment. Moreover, we consider scores from the execution tasks (visuospatial/executive) as the dependent variable.

RESULTS

Our findings demonstrate that approximately 80% of the evaluated study sample exhibited cognitive impairment. Through the multivariate regression models, we show that several factors, including age, education, depression levels, and the use of analgesics and/or opioids, are significant predictors of total cognitive scores. These factors are independent of the clinical features associated with SCI, such as age, sex, education, and time since the injury.

CONCLUSIONS

The results indicate a high prevalence of significant cognitive impairment within the sample, with age, education, depression levels, and the use of analgesics and/or opioids emerging as the primary predictors of total cognitive scores, independent of the clinical features correlated to SCI. These findings hold significant implications for both clinical research and practice, offering valuable guidance for comprehensive management throughout hospitalization and rehabilitation.

Characterization of Sleep, Emotional, and Cognitive Functions in a New Rat Model of Concomitant Spinal Cord and Traumatic Brain Injuries

Traumatic injuries to the spinal cord or the brain have serious medical consequences and lead to long-term disability. The epidemiology, medical complications, and prognosis of isolated spinal cord injury (SCI) and traumatic brain injury (TBI) have been well described. However, there are limited data on patients suffering from concurrent SCI and TBI, even if a large proportion of SCI patients have concomitant TBI. The complications associated with this "dual-diagnosis" such as cognitive or behavioral dysfunction are well known in the rehabilitation setting, but evidence-based and standardized approaches for diagnosis and treatment are lacking. Our goal was to develop and characterize a pre-clinical animal model of concurrent SCI and TBI to help identifying "dual-diagnosis" tools. Female rats received a unilateral contusive SCI at the thoracic level alone (SCI group) or combined with a TBI centered on the contralateral sensorimotor cortex (SCI-TBI group). We first validated that the SCI extent was comparable between SCI-TBI and SCI groups, and that hindlimb function was impaired. We characterized various neurological outcomes, including locomotion, sleep architecture, brain activity during sleep, depressive- and anxiety-like behaviors, and working memory. We report that SCI-TBI and SCI groups show similar impairments in global locomotor function. While wake/sleep amount and distribution and anxiety- and depression-like symptoms were not affected in SCI-TBI and SCI groups in comparison to the control group (laminectomy and craniotomy only), working memory was impaired only in SCI-TBI rats. This pre-clinical model of concomitant SCI and TBI, including more severe variations of it, shows a translational value for the identification of biomarkers to refine the "dual-diagnosis" of neurotrauma in humans.

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.

Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: A retrospective multicenter study

BACKGROUND

Although previous studies have demonstrated the advantages of early surgery for traumatic spinal cord injury (SCI), the appropriate surgical timing for cervical SCIs (CSCIs) without bone injury remains controversial. Here, we investigated the influence of relatively early surgery within 48 h of injury on the neurological recovery of elderly patients with CSCI and no bone injury.

METHODS

In this retrospective multicenter study, we reviewed data from 159 consecutive patients aged ≥65 years with CSCI without bone injury who underwent surgery in participating centers between 2010 and 2020. Patients were followed up for at least 6 months following CSCI. We divided patients into relatively early (≤48 h after CSCI, n = 24) and late surgery (>48 h after CSCI, n = 135) groups, and baseline characteristics and neurological outcomes were compared between them. Multivariate analysis was performed to identify factors associated with neurological recovery.

RESULTS

The relatively early surgery group demonstrated a lower prevalence of cardiac disease, poorer baseline American Spinal Injury Association (ASIA) impairment scale grade, and lower baseline ASIA motor score (AMS) than those of the late surgery group (P < 0.030, P < 0.001, and P < 0.001, respectively). Although the AMS was lower in the relatively early surgery group at 6 months following injury (P = 0.001), greater improvement in this score from baseline to 6-months post injury was observed (P = 0.010). Multiple linear regression analysis revealed that relatively early surgery did not affect postoperative improvement in AMS, rather, lower baseline AMS was associated with better AMS improvement (P < 0.001). Delirium (P = 0.006), pneumonia (P = 0.030), and diabetes mellitus (P = 0.039) negatively influenced postoperative improvement.

CONCLUSIONS

Although further validation by future studies is required, relatively early surgery did not show a positive influence on neurological recovery after CSCI without bone injury in the elderly.

Brain activation during the N-back working memory task in individuals with spinal cord injury: a functional near-infrared spectroscopy study

Cognitive impairments have frequently been reported in individuals with spinal cord injury (SCI) across different domains such as working memory, attention, and executive function. The mechanism of cognitive impairment after SCI is not well understood due to the heterogeneity of SCI sample populations, and may possibly be due to factors such as cardiovascular dysfunction, concomitant traumatic brain injury (TBI), hypoxia, sleep disorders, and body temperature dysregulation. In this study, we implement the Neuropsychiatric Unit Cognitive Assessment Tool (NUCOG) to assess cognitive differences between individuals with SCI and age-matched able-bodied (AB) controls. We then use an N-back working memory task and functional near-infrared spectroscopy (fNIRS) to elucidate the neurovascular correlates of cognitive function in individuals with SCI. We observed significant differences between the SCI and AB groups on measures of executive function on the NUCOG test. On the N-back task, across the three levels of difficulty: 0-back, 2-back, and 3-back, no significant differences were observed between the SCI and AB group; however, both groups performed worse as the level of difficulty increased. Although there were no significant differences in N-back performance scores between the two groups, functional brain hemodynamic activity differences were observed between the SCI and AB groups, with the SCI group exhibiting higher maximum oxygenated hemoglobin concentration in the right inferior parietal lobe. These findings support the use of fNIRS to study cognitive function in individuals with SCI and may provide a useful tool during rehabilitation to obtain quantitative functional brain activity metrics.

Improving Outcomes in People with Spinal Cord Injury: Encouraging Results from a Multidisciplinary Advanced Rehabilitation Pathway

Spinal cord injury (SCI) consists of damage to any segment of the spinal cord extending to potential harm to nerves in the cauda equina. Rehabilitative efforts for SCI can involve conventional physiotherapy, innovative technologies, as well as cognitive treatment and psychological support. The aim of this study is to evaluate the feasibility of a dedicated, multidisciplinary, and integrated intervention path for SCI, encompassing both conventional and technological interventions, while observing their impact on cognitive, motor, and behavioral outcomes and the overall quality of life for individuals with SCI. Forty-two patients with SCI were included in the analysis utilizing electronic recovery system data. The treatment regimen included multidisciplinary rehabilitation approaches, such as traditional physiotherapy sessions, speech therapy, psychological support, robotic devices, advanced cognitive rehabilitation, and other interventions. Pre-post comparisons showed a significant improvement in lower limb function (Fugl Meyer Assessment-FMA < 0.001), global cognitive functioning (Montreal Cognitive Assessment-MoCA p < 0.001), and perceived quality of life at both a physical and mental level (Short Form-12-SF-12 p < 0.001). Furthermore, we found a significant reduction in depressive state (Beck Depression Inventory-BDI p < 0.001). In addition, we assessed patient satisfaction using the Short Form of the Patient Satisfaction Questionnaire (PSQ), offering insights into the subjective evaluation of the intervention. In conclusion, this retrospective study provides positive results in terms of improvements in motor function, cognitive functions, and quality of life, highlighting the importance of exploring multidisciplinary approaches.

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.

Massive body-brain disconnection consequent to spinal cord injuries drives profound changes in higher-order cognitive and emotional functions: A PRISMA scoping review

Spinal cord injury (SCI) leads to a massive disconnection between the brain and the body parts below the lesion level representing a unique opportunity to explore how the body influences a person's mental life. We performed a systematic scoping review of 59 studies on higher-order cognitive and emotional changes after SCI. The results suggest that fluid abilities (e.g. attention, executive functions) and emotional regulation (e.g. emotional reactivity and discrimination) are impaired in people with SCI, with progressive deterioration over time. Although not systematically explored, the factors that are directly (e.g. the severity and level of the lesion) and indirectly associated (e.g. blood pressure, sleeping disorders, medication) with the damage may play a role in these deficits. The inconsistency which was found in the results may derive from the various methods used and the heterogeneity of samples (i.e. the lesion completeness, the time interval since lesion onset). Future studies which are specifically controlled for methods, clinical and socio-cultural dimensions are needed to better understand the role of the body in cognition.

The gray matter atrophy and related network changes occur in the higher cognitive region rather than the primary sensorimotor cortex after spinal cord injury

Objective

This study used functional magnetic resonance imaging (fMRI) to explore brain structural and related network changes in patients with spinal cord injury (SCI).

Methods

Thirty-one right-handed SCI patients and 31 gender- and age-matched healthy controls (HC) were included. The gray matter volume (GMV) changes in SCI patients were observed using voxel-based morphometry (VBM). Then, these altered gray matter clusters were used as the regions of interest (ROIs) for whole-brain functional connectivity (FC) analysis to detect related functional changes. The potential association between GMV and FC values with the visual analog scale (VAS), the American Spinal Injury Association (ASIA) score, and the course of injuries was investigated through partial correlation analysis.

Results

GMV of the frontal, temporal, and insular cortices was lower in the SCI group than in the HC group. No GMV changes were found in the primary sensorimotor area in the SCI group. Besides, the altered FC regions were not in the primary sensorimotor area but in the cingulate gyrus, supplementary motor area, precuneus, frontal lobe, and insular. Additionally, some of these altered GMV and FC regions were correlated with ASIA motor scores, indicating that higher cognitive regions can affect motor function in SCI patients.

Conclusions

This study demonstrated that gray matter and related network reorganization in patients with SCI occurred in higher cognitive regions. Future rehabilitation strategies should focus more on cognitive functions.

Spinal cord epidural stimulation for motor and autonomic function recovery after chronic spinal cord injury: A case series and technical note

Background:

Traumatic spinal cord injury (tSCI) is a debilitating condition, leading to chronic morbidity and mortality. In recent peer-reviewed studies, spinal cord epidural stimulation (scES) enabled voluntary movement and return of over-ground walking in a small number of patients with motor complete SCI. Using the most extensive case series (n = 25) for chronic SCI, the present report describes our motor and cardiovascular and functional outcomes, surgical and training complication rates, quality of life (QOL) improvements, and patient satisfaction results after scES.

Methods:

This prospective study occurred at the University of Louisville from 2009 to 2020. scES interventions began 2–3 weeks after surgical implantation of the scES device. Perioperative complications were recorded as well as long-term complications during training and device related events. QOL outcomes and patient satisfaction were evaluated using the impairment domains model and a global patient satisfaction scale, respectively.

Results:

Twenty-five patients (80% male, mean age of 30.9 ± 9.4 years) with chronic motor complete tSCI underwent scES using an epidural paddle electrode and internal pulse generator. The interval from SCI to scES implantation was 5.9 ± 3.4 years. Two participants (8%) developed infections, and three additional patients required washouts (12%). All participants achieved voluntary movement after implantation. A total of 17 research participants (85%) reported that the procedure either met (n = 9) or exceeded (n = 8) their expectations, and 100% would undergo the operation again.

Conclusion:

scES in this series was safe and achieved numerous benefits on motor and cardiovascular regulation and improved patient-reported QOL in multiple domains, with a high degree of patient satisfaction. The multiple previously unreported benefits beyond improvements in motor function render scES a promising option for improving QOL after motor complete SCI. Further studies may quantify these other benefits and clarify scES’s role in SCI patients.

Myokines may target accelerated cognitive aging in people with spinal cord injury: A systematic and topical review

Persons with spinal cord injury (SCI) can suffer accelerated cognitive aging, even when correcting for mood and concomitant traumatic brain injury. Studies in healthy older adults have shown that myokines (i.e. factors released from muscle tissue during exercise) may improve brain health and cognitive function. Myokines may target chronic neuroinflammation, which is considered part of the mechanism of cognitive decline both in healthy older adults and SCI. An empty systematic review, registered in PROSPERO (CRD42022335873), was conducted as proof of the lack of current research on this topic in people with SCI. Pubmed, Embase, Cochrane and Web of Science were searched, resulting in 387 articles. None were considered eligible for full text screening. Hence, the effect of myokines on cognitive function following SCI warrants further investigation. An in-depth narrative review on the mechanism of SCI-related cognitive aging and the myokine-cognition link was added to substantiate our hypothetical framework. Readers are fully updated on the potential role of exercise as a treatment strategy against cognitive aging in persons with SCI.

Cognitive Impairment in Individuals With Spinal Cord Injury: Findings of a Systematic Review With Robust Variance and Network Meta-analyses

BACKGROUND AND OBJECTIVES

Estimates of the prevalence (10%-60%) of cognitive impairment in individuals with spinal cord injury (SCI) are too broad, and which domains of cognition are most affected is unclear. We performed a meta-analysis to investigate impairments across domains of cognitive functioning to provide a nuanced picture of research conducted to date into cognitive impairment after SCI.

METHODS

Results of peer-reviewed studies published in English between 1980 and 2021 comparing ≥20 participants with SCI with able-bodied controls were synthesized using meta-analysis. The primary outcomes were neurocognitive test scores categorized into 5 cognitive domains as listed in the Diagnostic and Statistical Manual of Mental Disorders: Complex Attention, Executive Functioning, Learning and Memory, Language, and Perceptual Motor Function. Two researchers independently assessed and verified extracted data to comply with meta-analytic reporting guidelines. Robust variance estimation meta-analysis was conducted to determine an overall pooled effect size across all cognitive domains using data extracted from studies. Using network meta-analysis, we synthesized eligible studies and made comparisons with the 5 domains of cognitive functioning serving as the outcomes and SCI as the condition.

RESULTS

Of 4,783 potential studies, 13 met final inclusion criteria. Studies met 6 of 8 quality assessment criteria generally. Results suggested that adults with SCI experience reduced cognitive functioning (effect size: -0.84; 95% CI -1.24 to -0.44, p < 0.001) compared with able-bodied individuals, with deficits mostly in attention (g = -0.64; 95% CI -0.92 to -0.38) and executive functioning (g = -0.61, 95% CI -0.89 to -0.04). Publication bias and high heterogeneity (I2: 86%) qualify these findings and highlight the need to improve research methods in this area.

DISCUSSION

Adults with SCI seem more likely than adults who are able-bodied to display cognitive impairments mostly in areas of attention and executive functioning. Research practices must become consistent to reduce heterogeneity so that the validity and reliability of the results of future studies into cognitive impairment after SCI improves.

A Narrative Review of Research on Adjustment to Spinal Cord Injury and Mental Health: Gaps, Future Directions, and Practice Recommendations

Spinal cord injury (SCI) results in autonomic, motor, and sensory impairments that can compromise mental health. Guidelines directing the management of mental health following SCI presently address clinical anxiety, depression, post-traumatic stress, substance use disorders, and suicide. However, evidence suggests that perhaps as many as 70% of individuals with SCI do not develop a clinically diagnosable mental health disorder. Therefore, the authors contend that understanding non-clinical cognitive and psychological aspects of adjustment post-SCI is paramount and that the application of this knowledge to the formulation of adjustment-enhancing interventions is crucial. To assist with this endeavour, we examine existing mental health guidelines targeting SCI, and present a narrative review of research on the under-represented topics of adjustment, coping, grief, and resilience. We include mild cognitive impairment, which reflects a common factor that can compromise adjustment. Loss and stress trigger processes of adjustment, coping, grief, and resilience. SCI involves loss and stress triggering these processes, arguably without exception. Our study applied a narrative review methodology searching Google Scholar and PsychInfo databases for terms adjustment, coping, grief, resilience, and cognitive impairment. Qualitative studies and quantitative studies were selected to capture bottom-up and top-down perspectives. Reference lists of retrieved papers were searched as appropriate. Reviewed literature suggested that existing guidelines concerning mental health following SCI neglect positive processes of adjustment and suggest this neglect contributes to a deficits-based view of mental health following SCI. Research into "positive" or adjustment-enhancing processes is mostly cross-sectional, heterogenous, and poorly positioned to inform future guideline-development. Researchers should achieve consensus over the operationalisation of essential processes and overcome a fixation with "outcomes" to better inform management of mental health after SCI.

Exploring the Impact of Different Port Governances on Smart Port Development Strategy in Taiwan and Spain

With the rapid development of new technologies, such as automation, big data, and artificial intelligence, a port that utilizes these technologies can significantly improve its operational efficiency and make it economically more competitive. Despite its increasing importance, there is no standard definition of a smart port, resulting in each country having its own smart port development strategy. In this study, we explore how varied port governance of port authorities may impact the smart port development strategy. First, we established a set of evaluation criteria, using the Borda count and fuzzy analytic hierarchy process, to obtain the key indicators for the development of smart ports in Taiwan. Then, we compared the preferred indicators of Taiwan’s smart port development strategy with those of Spanish ports. An obvious difference in this ranking comparison is found. This indicates that Taiwan’s strategy focuses on optimizing maritime safety, while Spain’s strategy focuses on improving operational economics. Finally, we analyzed the differences between the smart port development strategies of these two countries using the latest port governance classification table. The results of the above analysis are also verified by comparing the differences in port legislation between them. It turns out that the private sector is deeply involved in the operation of ports in Taiwan compared with Spain. Our main contribution lies in providing a clear pathway for developing a smart port in Taiwan in the future and investigating the reasons for different smart port development strategies in different countries.

What the study of spinal cord injured patients can tell us about the significance of the body in cognition

Although in the last three decades philosophers, psychologists and neuroscientists have produced numerous studies on human cognition, the debate concerning its nature is still heated and current views on the subject are somewhat antithetical. On the one hand, there are those who adhere to a view implying 'disembodiment' which suggests that cognition is based entirely on symbolic processes. On the other hand, a family of theories referred to as the Embodied Cognition Theories (ECT) postulate that creating and maintaining cognition is linked with varying degrees of inherence to somatosensory and motor representations. Spinal cord injury induces a massive body-brain disconnection with the loss of sensory and motor bodily functions below the lesion level but without directly affecting the brain. Thus, SCI may represent an optimal model for testing the role of the body in cognition. In this review, we describe post-lesional cognitive modifications in relation to body, space and action representations and various instances of ECT. We discuss the interaction between body-grounded and symbolic processes in adulthood with relevant modifications after body-brain disconnection.

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.

Prognostic Factors for Cervical Spinal Cord Injury without Major Bone Injury in Elderly Patients

In the current aging society, there has been a marked increase in the incidence of cervical spinal cord injury (CSCI) without major bone injury. This multi-center study aimed to identify predictors of neurological improvement in elderly patients with CSCI without major bone injury. The participants were 591 patients aged ≥65 years with CSCI without major bone injury and a minimum follow-up period of three months. Neurologic status was defined using the American Spinal Injury Association (ASIA) impairment scale (AIS). Univariate and multi-variate analyses were performed to identify prognostic factors for walking recovery in AIS A-C cases and full upper extremity motor recovery in AIS D cases. In AIS A-C cases, body mass index (odds ratio (OR): 1.112), magnetic resonance imaging signal change (OR: 0.240), AIS on admission (OR: 3.497), comorbidity of dementia/delirium (OR: 0.365), and post-injury pneumonia (OR: 0.194) were identified as independent prognostic factors for walking recovery. The prevalence of ossification of the posterior longitudinal ligament (OR: 0.494) was also found to be an independent prognostic factor in AIS B and C cases only. In AIS D cases, age (OR: 0.937), upper extremity ASIA motor score on admission (OR: 1.230 [per 5 scores]), and operation (OR: 0.519) were independent prognostic factors for full motor recovery. The severity of AIS at admission was the strongest predictor of functional outcomes. Promoting rehabilitation, however, through measures to reduce cognitive changes, post-injury pneumonia, and unhealthy body weight changes can contribute to greater neurological improvement in AIS A-C cases.

Does lack of brain injury mean lack of cognitive impairment in traumatic spinal cord injury?

OBJECTIVE

Traumatic spinal cord injury (tSCI) has implications in many areas, including cognitive functioning. Findings regarding cognitive problems in people with SCI are inconsistent, presumably due to multiple variables than can affect performance, among them emotional variables. The purpose of the current study was to elucidate cognitive sequalae in some individuals with tSCI with no medical record of brain injury, while taking emotional variables into consideration.

DESIGN

Cross-sectional, with two groups.

SETTING

A public rehabilitation center.

PARTICIPANTS

Twenty participants with tSCI at least ten months post injury and twenty non-SCI controls, matched for sex, age, and education.

INTERVENTION

None.

OUTCOME MEASURES

A battery of neuropsychological tests tapping executive functions, memory, attention, and naming abilities, in addition to questionnaires assessing depression and distress.

RESULTS

When emotional variables were statistically controlled, participants with tSCI showed higher levels of depression and distress and scored lower than non-SCI control participants on all cognitive tests except naming. Executive functions were found to have the highest effect size, though no specific ability was sensitive enough to differentiate between the groups in a binary logistic regression analysis.

CONCLUSION

In some individuals with chronic tSCI, lower cognitive ability that is unrelated to emotional distress might result from spinal cord damage and its implications in a population who's medical records show no indication of brain injury. This highlights the importance of conducting cognitive evaluation following SCI, so that deficits can be effectively addressed during rehabilitation.

The Relationship between Cognitive Performance and Quality of Life in Elite Athletes after Spinal Cord Injury

BACKGROUND

The present investigation was designed to determine cognitive performance and quality of life (QoL) in a group of elite athletes who sustained spinal cord injury (SCI).

METHODS

nine participants suffering a SCI participated in the study. Different cognitive functions were evaluated through the following tests: COWAT, Digit Span, Stroop color-word and QoL through the WHOQoL-BREF scale.

RESULTS

Generally, participants positively assessed their overall quality of life and health status. Although the tests conducted indicate reduced cognitive function among the athletes, it did not affect the reduction in QoL. Single correlations between the results of cognitive tests and QoL could be treated as coincidental.

CONCLUSIONS

Despite the observed decline in selected cognitive functions, the participants positively assessed their quality of life and physical health.Reduced cognitive functioning could be influenced by the impact of sleep-disordered breathing, pain, depressive disorders and medication. This indicates the need for an individualized approach to define the patient's deficits, needs and best care. Further studies with a larger group of participants are needed.

Cognitive function, quality of life, and aging: relationships in individuals with and without spinal cord injury

Background: Correlations between aging, cognitive impairment and poor quality of life (QOL) have been observed for many patient populations.Objective: The purpose of this study was to examine these correlations in individuals with and without spinal cord injury (SCI).Methods: 23 individuals with complete SCI and 20 individuals without SCI ("NON") underwent assessment of cognitive function via the NIH Toolbox for Neurological and Behavioral Function. Participants self-rated QOL via global and symptom/domain-specific measures.Results: SCI rated global QOL to be lower than NON for the EQ-5D QALY (p < .001), but not the EQ-5D VAS, which imposes no penalty for wheeled mobility. Low QOL clustered mainly in domains pertaining to physical function/symptoms. Participants with SCI reported high QOL for positive affect/well-being and resilience. Cognitive function in SCI did not differ from NON. However, strong correlations between age and cognition observed in NON (all R² > 0.532) were absent in SCI. Significant correlations between cognition and QOL were prevalent for NON but not for SCI.Conclusions: Dissociation of age, cognition and QOL occurred with SCI. Divergence between EQ-5D QALY and VAS suggests that individuals with SCI may recalibrate personal assessments of QOL in ways that minimize the importance of mobility impairment.

Psychological assessments of a senile patient with tetraplegia who received brain-computer interface implantation: a case report

OBJECTIVE

Research on individuals with brain-computer interface (BCI) presents not only technological challenges but ethical challenges (e.g., psychological aspects) as well. We assessed the mental health of a senile patient with tetraplegia after an invasive implantation of BCI and a long-term daily training, in order to provide new experience about the ethical impact of BCI on users and inform future clinical applications of such devices.

METHODS

This case was a 71-year-old man with tetraplegia for 2 years. Prior to the implant surgery of BCI, and 1 month, 2 months, 3 months, and 9 months after training, a series of tests for cognition, emotion, social support, sleep, and quality of life were performed to evaluate the patient's mental health.

RESULTS

Compared with baseline before surgery, the patients' cognition, emotion, social support, sleep, and quality of life improved after the surgery and the long-term daily training. At 3 months post-training, the patient's cognitive score measured by Mini-mental State Examination reached the cutoff point for cognitive impairment in the elderly. Subjective well-being and quality of life showed a slight decline at 9 months post-training compared with that 3 months post-training but remained above the baseline.

CONCLUSION

This study shows the psychological benefits in a senile patient after an invasive BCI implantation and a long-term daily training. BCI ethics is still in its early stages, and further research is needed to understand emerging psychological states of this specific population.

Differences between males and females with spinal cord injury in the experience of subliminal and explicit sexual pictures

STUDY DESIGN

Observational cross-sectional study.

OBJECTIVES

To determine the differences between persons with spinal cord injury (SCI) and control individuals in terms of conscious and unconscious sexual responses to subliminally presented visual sexual stimuli.

SETTING

Spinal cord injury rehabilitation center in northern Italy.

METHODS

A two-part behavioral experiment was conducted on 40 participants (27 individuals with SCI; 13 controls). In first part, all participants were subliminally exposed to a prime picture (neutral or sexual) and asked to rate the extent to which they were emotionally aroused, while watching a set of explicit target pictures (neutral or sexual). In the second part, choice reaction time task was employed, wherein participants were shown a subliminal prime picture (neutral or sexual) followed by an explicit target picture (neutral or sexual) superimposed by a black dot and were asked to locate the dot as fast as possible.

RESULTS

In the first part, men with SCI reported higher levels of emotional arousal to explicit sexual target pictures compared to other groups. In the second part, slower choice reaction times were found in the SCI group, particularly with sexual prime picture. Moreover, females with SCI spent more time during implicit motor learning tasks with sexual target pictures than other groups.

CONCLUSION

We found differences in the experience of subliminal and explicit sexual pictures not only between the two groups, but also between females and males with SCI. Attention should thus be paid when considering sexual experience at subliminal and conscious level in SCI population for future research and rehabilitative protocols.

The adapted symbol digit modalities test: Examining the impact of response modality

BACKGROUND

Information processing speed is often impaired in neurological disorders, as well as with healthy aging. Thus, being able to accurately assess information processing speed is of high importance. One of the most commonly used tests to examine information processing speed is the Symbol Digit Modalities Test (SDMT), which has been shown to have good psychometric properties.

OBJECTIVES

The current study aims to examine differences between two response modalities, written and oral, on the performance of an adapted version of the Symbol Digit Modalities Test.

METHODS

Ninety-nine individuals completed two alternate forms of the adapted version of the SDMT (aSDMT). Participants were instructed to complete the five lines of the task as quickly and accurately as possible. On one form participants were instructed to provide their response in writing and on the other one, orally. Form and response modality (oral vs. written) were counterbalanced to control for practice effects.

RESULTS

On average, there was a significant difference between response modalities, such that participants needed more time to respond when the response modality was written. For both response modalities, time to complete each line of stimuli decreased as the task progressed. While changes in response time on the first four lines of stimuli on the oral version were not found, there was a substantial improvement in response time on the fifth line. In contrast, on the written version a gradual learning effect was observed, in which response time was the slowest on the first two lines, an intermediate response time was noted on line 3, and the fastest response time was achieved on lines four and five.

CONCLUSION

The current study demonstrates that response modality, oral versus written, can significantly impact performance efficiency (the length of time it takes to complete a task), but not accuracy (total correct responses), on a new adaptation of the SDMT, the aSDMT.

Motor demands of cognitive testing may artificially reduce executive function scores in individuals with spinal cord injury

Objective: To determine whether the motor demands of cognitive tests contribute to differences in cognitive function scores in participants with and without spinal cord injury (SCI).Design: Cohort study.Setting: Rehabilitation research laboratory.Participants: 68 individuals without SCI ("NON") and 22 individuals with motor complete SCI ("SCI").Interventions: None.Outcome Measures: NIH Toolbox cognitive assessments, including two with motor demands and reaction-time based scoring (Dimensional Change Card Sort (DCCS), Flanker Inhibitory Control and Attention (Flanker) and two without timed scoring (List Sorting Working Memory (List Sorting), Picture Sequence Memory Test (Picture Sequence). Tests were administered with and without the assistance of a proctor on two randomly-determined days (>24 hr interval). For DCCS and Flanker, the motor-task score offset was estimated as the difference between the proctored and non-proctored scores.Results: For demographically-corrected data, proctoring reduced DCCS and Flanker scores (P < 0.001) but mitigated apparent differences between SCI and NON (all P > 0.403). SCI and NON did not differ for List Sorting (P > 0.072) but did differ significantly for Picture Sequence (P < 0.001). Significant practice effects existed for memory-based tests (List Sorting and Picture Sequence); all P < 0.015, effect size>0.645.Conclusions: DCCS and Flanker scores for individuals with SCI may be artificially reduced consequent to secondary motor demands of the tests. Proctoring and computation of a motor-response score offset enables comparisons to be made between individuals with SCI and a Non-SCI control cohort; however, further work is needed to determine whether offset-adjusted scores can be compared to standardized normative values.

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.

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.

The Neural Mechanisms Underlying Processing Speed Deficits in Individuals Who Have Sustained a Spinal Cord Injury: A Pilot Study

Our objective was to determine differences in brain activation during a processing-speed task in individuals with SCI compared to a group of age-matched healthy controls and to a group of older healthy controls. Ten individuals with cervical SCI (C3-C5), 10 age-matched healthy controls and 10 older healthy controls participated in a cross-sectional study in which performance on neuropsychological tests of processing speed and brain activation were the main outcome measures. The brain areas used by the individuals with SCI during the processing-speed task differed significantly from the age-matched healthy controls, but were similar to the older control cohort, and included activation in frontal, parietal and hippocampal areas. This suggests that individuals with SCI may compensate for processing-speed deficits by relying on brain regions that classically support control cognitive processes such as executive control and memory.

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.

The impact of level of injury on patterns of cognitive dysfunction in individuals with spinal cord injury

Context: While it is well recognized that physical and physiological changes are more prominent in individuals with higher neurologic levels of spinal cord injury (SCI), the impact of level of lesion on cognition is less clear. Design: Cross-sectional, 3-group. Setting: Non-profit rehabilitation research foundation. Participants: 59 individuals with SCI (30 with tetraplegia, 29 with paraplegia) and 30 age-matched healthy controls (HC). Interventions: None. Outcome Measures: Neuropsychological tests in the domains of attention, working memory, processing speed, executive control, and learning and memory. Results: Results indicated significantly lower test performance in individuals with paraplegia on new learning and memory testing compared to HC. In contrast, compared to HC the group with tetraplegia, showed a significantly impaired performance on a processing speed task, and both the tetraplegia and the paraplegia groups were similarly impaired on a verbal fluency measure. SCI groups did not differ on any cognitive measure. Conclusion: Individuals with SCI may display different patterns of cognitive performance based on their level of injury.

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.

Diverse cognitive impairment after spinal cord injury is associated with orthostatic hypotension symptom burden

This study: 1) compared cognitive functioning between individuals with chronic (>1 year) spinal cord injury (SCI) and non-injured controls and, 2) assessed associations between symptoms of autonomic dysreflexia and orthostatic hypotension with cognitive functioning in SCI participants with a history of unstable blood pressure (BP). Thirty-two individuals with SCI (C4-L2, American Spinal Injury Association Impairment Scale A-D) and thirty age, sex-matched non-injured controls participated in this study. Participants completed a motor-free neuropsychological test battery assessing 1) memory, 2) attention/concentration/psychomotor speed and, 3) executive function. Nineteen participants with SCI who had injuries ≥T6 and a history of unstable BP also completed the Autonomic Dysfunction Following Spinal Cord Injury (ADFSCI) questionnaire. Cognitive function was significantly lower in people with SCI across measures of memory and executive function compared to non-injured controls. Significant, moderate-to-large associations were observed between cumulative (frequency x severity) orthostatic hypotension and total BP instability symptoms scores, with measures of attention/concentration/psychomotor speed and executive function. These data demonstrate a 10 - 65% reduced performance across specific realms of cognitive functioning in individuals with SCI relative to non-injured controls. Furthermore, cumulative subjective scores for symptoms of unstable BP were associated with diverse cognitive deficits. These findings, in individuals without co-occurring traumatic brain injury, imply cardiovascular dysregulation plays a role in cognitive deficits observed in this population.

Interventions and cognitive functioning in adults with traumatic spinal cord injuries: a systematic review and meta-analysis

AIM

This research synthesized scientific evidence on the impact of interventions for adults with traumatic spinal cord injury on cognition, to understand if current intervention approaches are appropriate in light of the risk of post-injury cognitive impairments.

METHOD

Medline, Central, Embase, Scopus, PsycINFO and PubMed were searched for intervention in persons with SCI assessing cognition pre- and post-intervention. Study quality was completed using the National Institutes of Health quality assessment tools. Results were grouped by type of intervention. The meta-analysis involved calculation of pooled effect sizes for interventions utilizing the same cognitive measure.

RESULTS

Eleven studies of moderate quality discussed drug therapy, transcutaneous tibial nerve stimulation, diet modification and dietary supplements, and inpatient rehabilitation. Some aspects of cognition were negatively affected by drugs while diet modification and supplement use, and transcutaneous tibial nerve stimulation showed no evidence of a difference in cognitive scores when compared with no intervention. Inpatient rehabilitation revealed a small but beneficial effect, when results of seven studies were pooled.

CONCLUSION

Evidence on the effects of interventions on cognitive functioning in patients with traumatic spinal cord injury is sparse and inconclusive, so work in this area is timely. It is valuable to know not only which interventions are effective for improving cognition, but also how other commonly used interventions, intended to treat other injury sequela, can affect cognition. PROSPERO: CRD42018087238.Implications for rehabilitationHistorically, rehabilitation of patients with traumatic spinal cord injury has targeted physical impairments, with little attention to cognition; this research aimed to understand if current interventions are appropriate in light of the risk of patients' cognitive impairments. Evidence on the effects of drug therapy, diet and dietary supplements interventions on cognitive functioning in traumatic spinal cord injury is sparse and inconclusive.Combining multiple inpatient rehabilitation interventions shows a positive but heterogeneous effect on the cognitive functioning; interventions applied earlier show greater gains.A major challenge for clinicians is to select an outcome measure sensitive to change over time, and to relate the results to patients' change in cognitive abilities with intervention applicationResearch to understand the functional effect of spinal cord injury on the widely distributed networks of the central and autonomic nervous systems subserving cognition, is timely.

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.

Patterns of cognitive deficits in persons with spinal cord injury as compared with both age-matched and older individuals without spinal cord injury

Context/Objective: Cognitive deficits can impact as many as 60% of individuals with spinal cord injury (SCI). In an effort to identify the nature of cognitive deficits in SCI, we examined neuropsychological test performance in individuals with SCI, age matched healthy controls and older healthy controls.Design: Participants completed a motor-free neuropsychological test battery assessing attention, working memory, information processing speed, new learning /memory and executive control.Setting: Outpatient rehabilitation research facility.Participants: Participants included 60 individuals with chronic spinal cord injury [SCI; 32 with paraplegia (T2-T12) and 28 with tetraplegia (C3-T1)], 30 age-matched healthy controls (AMHC; 30-40 years old) and 20 older healthy controls (OHC; 50-60 years old).Outcome Measures: Wechsler Intelligence Scale - 3^rd edition (WAIS-III) Digit Span and Letter-Number Sequencing; Symbol Digit Modalities Test (SDMT) - oral version; California Verbal Learning Test-II; Paced Auditory Serial Addition Test (PASAT); Wechsler Abbreviated Scale of Intelligence (WASI); Delis-Kaplan Executive Function System; Verbal Fluency subtest.Results: Significant differences were noted between the SCI and AMHC groups on measures of information processing speed, new learning and memory, and verbal fluency. No significant differences were noted between the groups on tests of attention or working memory.Conclusion: The current study documented differences in specific realms of cognitive functioning between a chronic SCI sample and AMHC. Implications for cognitive rehabilitation and overall quality of life are discussed. Additional research is needed utilizing a more comprehensive battery of motor-free neuropsychological tests that avoid the confound of upper limb motor limitations on cognitive performance.