A community-based intervention to prevent serious complications and death 2 years after discharge in people with spinal cord injury in Bangladesh (CIVIC): a randomised trial

Effect of a Mindfulness and Motivational Interviewing-Oriented Physical-Psychological Integrative Intervention for Community-Dwelling Spinal Cord Injury Survivors: A Mixed-Methods Randomized Controlled Trial

OBJECTIVE

To evaluate the feasibility, acceptability, and efficacy of a mindfulness and motivational interviewing-oriented physical-psychological integrated intervention in community-dwelling spinal cord injury (SCI) survivors.

DESIGN

A mixed-methods randomized controlled trial.

SETTING

Local organizations for handicapped in Hong Kong.

PARTICIPANTS

Community-dwelling adults with SCI (N=72).

INTERVENTIONS

Participants in the intervention group (n=36) received video-guided exercise for daily practice and online group psychological (mindfulness and motivational interviewing-oriented) weekly sessions for 8 weeks. Participants in the control group (n=36) received an 8-week online group didactic education on lifestyle discussions and general health suggestions.

MAIN OUTCOMES MEASURES

Primary outcomes included quality of life, physical activity, depression, and chronic pain. Secondary outcomes included exercise self-efficacy and mindfulness. Outcomes were measured at baseline, postintervention, and 3-month follow-up. Focus-group interviews were conducted postintervention.

RESULTS

The recruitment, retention, and adherence rates were 84.7%, 100%, and 98.6%, respectively. The intervention showed significant positive effects on preventing declines in quality of life at 3-month follow-up (Cohen d=0.70, 95% CI=0.22-1.18). Positive trends manifested in physical activity, depression, chronic pain, and exercise self-efficacy. Three qualitative categories were identified: subjective improvements in exercise, physical, and social well-being; perceived changes in mindfulness and mental well-being; and intervention facilitators and barriers.

CONCLUSIONS

The mindfulness and motivational interviewing-oriented physical-psychological integrated intervention is feasible and acceptable. The significant prolonged effect in maintaining quality of life and positive effects on physical and psychosocial well-being indicate its value to address major health challenges of community-dwelling SCI survivors.

Effectiveness and efficiency of telerehabilitation on functionality after spinal cord injury: A matched case-control study

BACKGROUND

Telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and health outcomes in patients with spinal cord injury (SCI). The clinical effectiveness of teleSCI is not known.

OBJECTIVES

To compare independence in activities of daily living and mobility capacity in patients following teleSCI and matched controls undergoing traditional rehabilitation.

DESIGN

Matched case-control study.

SETTING

TeleSCI occurring in home setting (cases) versus traditional rehabilitation on inpatient unit (controls).

PARTICIPANTS

Forty-two consecutive patients with SCI followed with teleSCI were compared to 42 historical rehabilitation inpatients (controls) matched for age, time since injury to rehabilitation admission, level of injury (paraplegia/tetraplegia), complete or incomplete injury, and etiology (traumatic/nontraumatic). The teleSCI group (n = 42) was also compared to the complete cohort of historical controls (n = 613).

INTERVENTIONS

The teleSCI group followed home-based telerehabilitation (3.5 h/day, 5 days/week, 67 days average duration) and historical controls followed in-person rehabilitation.

MAIN OUTCOME MEASURE(S)

The Functional Independence Measure (FIM), the Spinal Cord Independence Measure (SCIM) and the Walking Index for Spinal Cord Injury (WISCI). We formally compared gains, efficiency and effectiveness. International Standards for Neurological Classification of Spinal Cord Injury and the American Spinal Injury Association Impairment Scale (AIS) were used.

RESULTS

The teleSCI group (57.1% nontraumatic, 71.4% paraplegia, 73.8% incomplete, 52.4% AIS grade D) showed no significant differences compared with historical controls in AIS grades, neurological levels, duration, gains, efficiency and effectiveness in FIM, SCIM, or WISCI, although the teleSCI cohort had significantly higher admission FIM scores compared with the complete cohort of historical controls.

CONCLUSIONS

TeleSCI may provide similar improvements in mobility and functional outcomes as traditional rehabilitation in medically stable patients (predominantly with paraplegia and motor incomplete SCI) when provided with appropriate support and equipment.

Effectiveness of Telerehabilitation in Persons With Spinal Cord Injury During the COVID-19 Pandemic (TELE-SCOPE): A Single-Center, Double-Blind, Randomized Controlled Trial

Introduction The COVID-19 pandemic has posed numerous challenges in accessing adequate healthcare services, particularly for individuals with spinal cord injury (SCI). On the other hand, telerehabilitation has emerged as a promising solution to address healthcare needs. Since there was no study during the pandemic, we started this study with the aim of assessing the efficacy of telerehabilitation for individuals with SCI during the COVID-19 pandemic. Methods This is a prospective double-blind, randomized, controlled trial conducted in a tertiary rehabilitation care center hospital. Thirty participants with traumatic spinal cord injuries (age 18 years or more, either gender) were equally randomized to the telerehabilitation or control group (1:1). Biweekly telerehabilitation sessions (each session: 30 minutes) were provided. Participants in the control group were advised to continue standard usual care as advised previously during outpatient or inpatient rehabilitation. The Spinal Cord Independence Measure (SCIM III) (primary outcome measure) and Coronavirus Anxiety Scale (CAS) (secondary outcome measure) were evaluated at baseline, four weeks, and eight weeks. Results The mean age of the intervention group was 28.2±6.9 years, and the mean age of the control group was 26.3±7.7 years. The self-care (P = 0.03) and mobility domains (P=0.01) of the SCIM III in the intervention group compared to the control group, as determined through a between-group analysis, showed statistically significant differences. CAS also showed improvement in the intervention group compared to the control group. Within-group analysis showed a mean difference of 6.3 points in the intervention group compared to the control group (1.3 points). Conclusion Telerehabilitation intervention is safe, feasible, and effective in improving self-care and mobility domains in persons with spinal cord injuries during the pandemic. It is also effective in reducing the anxiety related to the coronavirus in this population. Further research with a larger sample size and a longer duration is needed to evaluate long-term effectiveness during such crises.

Interventions, stakeholders, and organization related to pressure ulcer prevention for individuals with spinal cord injuries in transition from hospital to home - A scoping review

STUDY DESIGN

Scoping review.

AIM OF THE STUDY

To obtain an overview of initiatives, organisational components, and stakeholders' perspectives on PU prevention in transitional care.

METHODS

Scoping review searching the databases: MEDLINE, EMBASE), CINAHL, Cochrane Library, Web of Science, and SCOPUS in May 2022. Inclusion of English-written research on pressure ulcer prevention in adult people with spinal cord injury in transition from hospital or rehabilitation centre to the home care environment.

RESULTS

Fifteen studies of different types are included in this study: six qualitative studies, four randomized controlled trials, three cohort studies, one cross-sectional study and an interventional study. The included studies are relatively low-level evidence but of acceptable quality.

CONCLUSION

Continuous tailored education and information about PU prevention and follow-up services are essential components in preventing PUs and rehabilitating people with SCI. The complexity of SCI requires adaptations, equipment and access to specialist care and treatment after discharge. However, there is a discrepancy between the international recommendations, the perceived needs, and the delivered healthcare services. The consequences are a lower quality of life and a higher risk of PUs for people with SCI.

Evaluation of a Physical-Psychological Integrative (PPI) intervention for community-dwelling spinal cord injury survivors: Study protocol of a preliminary randomized controlled trial

INTRODUCTION

There is a considerably large group of community-dwelling spinal cord injury (SCI) survivors living with low quality of life. Physical inactivity, depression, and chronic pain are major problems faced by SCI survivors discharged from the acute phase of treatment or inpatient rehabilitation. This study aims to evaluate the feasibility, acceptability, and preliminary effects of a Physical-Psychological Integrative (PPI) online group intervention on community-dwelling SCI survivors' physical activity, depression, and chronic pain.

METHODS

This is a two-arm pilot randomized controlled trial with repeated measures (pre-, post-intervention, and 3-month follow-up) design. Seventy-two participants will be randomly assigned to two study groups. The PPI intervention group will receive a video program for physical activity training and eight-week online group psychological interventions using skills of group-based motivational interviewing and mindfulness-based stress reduction. The control group will receive an eight-week online didactic education programed. Focus-group interviews will be conducted post-intervention to explore their views about acceptance and suggested improvements to the intervention. The feasibility of study procedures and the acceptability of interventions will be evaluated. The effectiveness of the PPI intervention will be evaluated by leisure-time physical activity, depression, chronic pain, exercise efficacy, mindfulness, and quality of life. We will use the generalized estimating equation to assess intervention effects and content analysis for interview data. This study has received ethical approval from the Hong Kong Polytechnic University (HSEARS20210705004) and was registered in ClinicalTrials.gov (NCT05535400).

DISCUSSION

This study will be the first to provide empirical data on the evaluation of an online-group intervention integrating both physical activity promotion and psychological approaches, aimed at reducing physical inactivity, depression, and chronic pain for community-dwelling SCI survivors in Hong Kong. The findings could provide evidence supporting the use of PPI intervention as a novel online group support, in addressing both the physical and psychological needs of community-dwelling SCI survivors.

Telerehabilitation for individuals with spinal cord injury in low-and middle-income countries: a systematic review of the literature

Study design

Systematic review.

Objective

To systematically review the evidence for the effectiveness of telerehabilitation as an intervention for people with spinal cord injury (SCI) in low-and middle-income countries (LMICs).

Setting

Not applicable.

Methods

MEDLINE (Ovid), Embase (Ovid), Pubmed and Global Health databases were used to identify studies published between 1946–2020 meeting the following criteria: (1) patients with SCI diagnosis; (2) in LMIC; (3) an outcome measuring clinical functional ability, quality of life or all-cause mortality reduction. The risk of bias in studies was graded using revised Cochrane risk-of-bias tool in randomised trials (RoB 2) and risk-of-bias tool in non-randomised trials (ROBINS-I). Evidence levels were graded with Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Results

In total, 107 articles were identified from the initial search. After screening, five studies were included. Some significant improvements to quality of life and pressure ulcer management were observed, alongside some improvement in functional ability with suggested improvement to depression scores. Telerehabilitation alleviated participants’ sense of social isolation, improved satisfaction scores and assisted them to remember techniques for SCI management. Telerehabilitation was valued by health professionals. There was no reduction in all-cause mortality.

Conclusion

There is insufficient evidence to recommend telerehabilitation as an intervention to treat and manage SCI in LMICs, although there is an indication of potential patient benefit. Further research is required to better understand the causal mechanisms underpinning the use of telerehabilitation and establish its efficacy, in the context of resource-limited settings.

Self-Management Embedded in Daily Activities: A Photoelicitation Focus Group Study among Persons with Spinal Cord Injury and Their Primary Caregivers in Bangladesh

Purpose

This study explored how community-dwelling persons with spinal cord injury (SCI) and their primary caregivers execute self-management strategies in daily activities. These strategies were mapped to a preexisting self-management framework.

Methods

Photoelicitation focus group discussions were conducted among 14 adults with SCI and their primary caregivers (in two groups). Moreover, a constant comparative framework was used to analyze the data.

Results

This study identified nine groups of self-management strategies, some of which could not be categorized under the three main self-management components generally accepted in the literature. Accordingly, a new component is proposed based off of this analysis, entitled management of social complexities, which includes crucial strategies such as (1) relocating to another environment, (2) behaving in an assertive manner, and (3) advocating for social change.

Conclusion

The results show that self-management, traditionally described as medical, emotional, and role management, should also include the management of social complexities. The identified strategies could be considered in the development of self-management enhancement programs in lower-middle-income countries.

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.

Telemedicine for Preventing and Treating Pressure Injury after Spinal Cord Injury: A Systematic Review and Meta-analysis (Preprint)

Background

Objective

Methods

Results

Conclusions

Incidence, severity and time course of pressure injuries over the first two years following discharge from hospital in people with spinal cord injuries in Bangladesh

DESIGN

Cohort study embedded in a clinical trial.

SETTING

Community, Bangladesh.

OBJECTIVES

To determine the incidence, severity and time course of pressure injuries over the first two years following discharge from hospital in people with spinal cord injuries (SCI) in Bangladesh.

METHODS

Participants (n = 186) were contacted by telephone 39 times and assessed face-to-face 4 to 6 times over the two years following discharge. At each point of contact the presence and severity of pressure injuries were determined using the Pressure Ulcer Scale for Healing (PUSH). Survival analyses were conducted to determine the time course of development of pressure injuries and recovery from pressure injuries. Lasso regression was used to construct multivariable prediction models.

RESULTS

Seventy-seven participants (41%; 95% CI 34% to 49%) developed at least one pressure injury in the first two years after discharge (incidence rate 0.27 per person-year, 95% CI 0.22 to 0.34). Most pressure injuries were on the sacrum (23%). Pressure injuries took a median (IQR) of 40 (29 to 57) days to heal. The median (IQR) peak PUSH score was 11.0/17 (8.0 to 13.5). The multivariable prediction models had poor predictive properties (maximum c-statistic 0.75).

CONCLUSION

Pressure injuries impose a large health burden on people with SCI in Bangladesh. However, they are difficult to predict, treat and prevent. Further research is needed to identify who is at most risk and to find solutions for the treatment and prevention of pressure injuries in Bangladesh and other low-middle income countries.

Effects of psychosocial support interventions on survival in inpatient and outpatient healthcare settings: A meta-analysis of 106 randomized controlled trials

BACKGROUND

Hospitals, clinics, and health organizations have provided psychosocial support interventions for medical patients to supplement curative care. Prior reviews of interventions augmenting psychosocial support in medical settings have reported mixed outcomes. This meta-analysis addresses the questions of how effective are psychosocial support interventions in improving patient survival and which potential moderating features are associated with greater effectiveness.

METHODS AND FINDINGS

We evaluated randomized controlled trials (RCTs) of psychosocial support interventions in inpatient and outpatient healthcare settings reporting survival data, including studies reporting disease-related or all-cause mortality. Literature searches included studies reported January 1980 through October 2020 accessed from Embase, Medline, Cochrane Library, CINAHL, Alt HealthWatch, PsycINFO, Social Work Abstracts, and Google Scholar databases. At least 2 reviewers screened studies, extracted data, and assessed study quality, with at least 2 independent reviewers also extracting data and assessing study quality. Odds ratio (OR) and hazard ratio (HR) data were analyzed separately using random effects weighted models. Of 42,054 studies searched, 106 RCTs including 40,280 patients met inclusion criteria. Patient average age was 57.2 years, with 52% females and 48% males; 42% had cardiovascular disease (CVD), 36% had cancer, and 22% had other conditions. Across 87 RCTs reporting data for discrete time periods, the average was OR = 1.20 (95% CI = 1.09 to 1.31, p < 0.001), indicating a 20% increased likelihood of survival among patients receiving psychosocial support compared to control groups receiving standard medical care. Among those studies, psychosocial interventions explicitly promoting health behaviors yielded improved likelihood of survival, whereas interventions without that primary focus did not. Across 22 RCTs reporting survival time, the average was HR = 1.29 (95% CI = 1.12 to 1.49, p < 0.001), indicating a 29% increased probability of survival over time among intervention recipients compared to controls. Among those studies, meta-regressions identified 3 moderating variables: control group type, patient disease severity, and risk of research bias. Studies in which control groups received health information/classes in addition to treatment as usual (TAU) averaged weaker effects than those in which control groups received only TAU. Studies with patients having relatively greater disease severity tended to yield smaller gains in survival time relative to control groups. In one of 3 analyses, studies with higher risk of research bias tended to report better outcomes. The main limitation of the data is that interventions very rarely blinded personnel and participants to study arm, such that expectations for improvement were not controlled.

CONCLUSIONS

In this meta-analysis, OR data indicated that psychosocial behavioral support interventions promoting patient motivation/coping to engage in health behaviors improved patient survival, but interventions focusing primarily on patients' social or emotional outcomes did not prolong life. HR data indicated that psychosocial interventions, predominantly focused on social or emotional outcomes, improved survival but yielded similar effects to health information/classes and were less effective among patients with apparently greater disease severity. Risk of research bias remains a plausible threat to data interpretation.

The cost of providing a community-based model of care to people with spinal cord injury, and the healthcare costs and economic burden to households of spinal cord injury in Bangladesh

DESIGN

Descriptive.

SETTING

Community, Bangladesh.

OBJECTIVES

To determine the costs associated with providing a community-based model of care delivered as part of the CIVIC trial to people discharged from hospital with recent spinal cord injury (SCI), and to determine the economic burden to households.

METHODS

Records were kept of the costs of providing a community-based model of care to participants of the CIVIC trial. Data were also collected at discharge and 2 years post discharge to capture out-of-pocket healthcare costs over the preceding 2 years, and the number of participants suffering catastrophic health expenditure and illness-induced poverty.

RESULTS

The mean cost of providing the community-based model of care to participants assigned to the intervention group (n = 204) was US$237 per participant. The mean out-of-pocket healthcare cost over the first 2 years post discharge was US$472 per participant (n = 410), and US$448 per control participant (n = 206). Median (IQR) equivalent annual household incomes prior to SCI and at 2 years post discharge were US$721 (US$452-1129) and US$464 (US$214-799), respectively. Of the 378 participants alive at 2 years, 324 (86%) had catastrophic health expenditure, and 161 of 212 participants who were not in poverty prior to injury (76%) were pushed into illness-induced poverty within 2 years of injury.

CONCLUSION

The cost of providing community-based support to people with SCI for 2 years post discharge in Bangladesh is relatively inexpensive but an overwhelming majority of households rapidly experience financial catastrophe, and most fall into poverty.