Mortality, morbidity, and psychosocial outcomes of persons spinal cord injured more than 20 years ago

Propulsion kinetics of recumbent handcycling during high and moderate intensity exercise

People with spinal cord injuries (PwSCI) are at high risk of developing cardiovascular disease (CVD). While regular exercise can reduce risk of CVD, PwSCI face various barriers to exercise, including high rates of upper limb injuries, especially in the shoulder. Handcycling high intensity interval training (HIIT), which consists of periods of high intensity exercise followed by rest, is a potential exercise solution, but the musculoskeletal safety of HIIT is still unknown. In this study, we characterized three-dimensional continuous applied forces at the handle during handcycling HIIT and moderate intensity continuous training (MICT). These applied forces can give an early indication of joint loading, and therefore injury risk, at the shoulder. In all three directions (tangential, radial, and lateral), the maximum applied forces during HIIT were larger than those in MICT at all timepoints, which may indicate higher contact forces and loads on the shoulder during HIIT compared to MICT. The tangential and radial forces peaked twice in a propulsion cycle, while the lateral forces peaked once. Throughout the exercises, the location of tangential peak 2 and radial peak 1 was later in HIIT compared to MICT. This difference in maximum force location could indicate either altered kinematics or muscular fatigue at the end of the exercise protocol. These changes in kinematics should be more closely examined using motion capture or other modeling techniques. If we combine this kinetic data with kinematic data during propulsion, we can create musculoskeletal models that more accurately predict contact forces and injury risk during handcycling HIIT in PwSCI.

Paced breathing and respiratory movement responses evoked by bidirectional constant current stimulation in anesthetized rabbits

Objective: Diaphragm pacing (DP) is a long-term and effective respiratory assist therapy for patients with central alveolar hypoventilation and high cervical spinal cord injury. The existing DP system has some limitations, especially high price, inconvenience preoperative evaluation methods and diaphragm fatigue easily. Our objective was to develop a DP system and evaluated reliability through hardware testing and animal experiments. Methods: A DP system with bidirectional constant current was designed, manufactured and tested. Effects of a wide range of stimulus amplitudes (range: .5-2.5 mA) and frequencies (range: 10-250 Hz) on airflow and corresponding inspired volume were investigated during DP. Differences in airflow characteristics under various stimulation parameters were evaluated using power function. ECG interference in diaphragm electromyography (EMGdi) was filtered out using stationary wavelet transform to obtain pure EMGdi (EMGdi_p). 80-min period with a tendency for diaphragm fatigue by root mean square (RMS) and centroid frequency (f _c ) of EMGdi_p was studied. Results: The increase of stimulus frequency and amplitude in animals resulted in different degrees of increase in envoked volume. Significant difference in Airflow Index (b) between anesthesia and DP provided a simple, non-invasive and feasible solution for phrenic nerve conduction function test. Increased stimulation duration with the developed DP system caused less diaphragm fatigue. Conclusion: A modular, inexpensive and reliable DP was successfully developed. Its effectiveness was confirmed in animal experiments. Significance: This study is useful for design of future implantable diaphragmatic pacemakers for improving diaphragm fatigue and convenient assessment of respiratory activity in experiments.

Variation of diagnosis and treatment of catheter-associated urinary tract infections: an online survey among caretakers involved

Background

The diagnosis of a clinically significant catheter-associated urinary tract infection (CAUTI) in patients performing clean intermittent catheterization (CIC) or with an indwelling catheter (IC) can be challenging.

Objective

To get an insight into the variation of the used definition, diagnosis and management of CAUTIs by relevant healthcare workers in the Netherlands.

Design

An online clinical scenario-based survey.

Methods

The survey was built in Limesurvey and distributed to healthcare workers from randomly selected urology departments, rehabilitation departments/centres and general practice offices between January and May 2022. Questions regarding their field of experience, management strategies, used guidelines and two hypothetical cases with clinical scenarios of a possible CAUTI were included.

Results

A total of 172 individuals participated, of which 112 completed the survey. In all, 32 individuals who completed the survey partially were also included. Participants consisted of 68 [44 urologists, 22 rehabilitation doctors (RDs) and 2 general practitioners (GPs)] doctors, 60 nurses (46 from the urology department and 14 from rehabilitation centres/departments) and 16 medical assistants (13 from urology department and 3 from GP offices). The majority consulted patients with an IC or on CIC on a daily/weekly or monthly basis. In all, 35 urologists (79.5%), 9 RDs (40.9%), 21 (45.7%) nurses in the urology department and 6 (42.9%) nurses from a rehabilitation department/centre indicated bladder irrigation as a treatment option for prevention/treatment of CAUTIs, treatment of symptoms or treatment of blockage of the catheter. In the clinical scenarios presented, treatment discrepancies were seen between subspecialties and healthcare workers. Various guidelines were named for the definition of CAUTIs.

Conclusion

A considerable variation in diagnoses and management of CAUTIs between the healthcare workers involved was seen. Uniformity in diagnosing and managing CAUTIs, to prevent overtreatment and possible resistance to antibiotics, is advised. Suitable multidisciplinary guidelines are preferred.

Fat Oxidation during Exercise in People with Spinal Cord Injury, and Protocols Used: A Systematic Review

BACKGROUND

The aim of this study was to summarize evidence on energy metabolism through peak fat oxidation (PFO) and maximum fat oxidation (Fat_max), as well as to analyze the protocols used in people with spinal cord injury (SCI) and to examine the main factors related to fat oxidation ability (i.e., age, sex, level of physical activity, and level and degree of injury).

METHODS

Studies to determine PFO and Fat_max using indirect calorimetry with an arm exercise protocol for SCI patients were included after a systematic search. Other endpoints included study design, sample size, control group, demographic data, level of injury, physical condition, protocol, outcomes measured, and statistical findings.

RESULTS

Eight studies (n = 560) were included. The mean value of VO_2peak was 1.86 L∙min^-1 (range 0.75-2.60 L∙min^-1) (lowest value in the tetraplegic subjects). The PFO ranged between 0.06 and 0.30 g∙min^-1 (lowest rates: the non-trained subjects with cervical SCI; highest: the tetraplegic subjects). Two types of exercise protocol were found: arm cycle ergometer, and wheelchair propulsion with a computerized ergometer. Five studies used an incremental protocol (2-3 min/stage, different load increments); the rest performed tests of 20 min/stage at three intensities.

CONCLUSION

There are few existing studies measuring fat oxidation in SCI, many of which used small and heterogeneous samples. PFO was lower in SCI subjects when compared with non-injured people performing lower-limb exercise; however, comparing upper-limb exercise, people with SCI showed higher values.

A protocol for Removing Environmental Barriers to Independent Living (REBIL): An adapted evidence-based occupational therapy intervention to increase community participation for individuals aging with long-term physical disabilities

Background

People aging with long-term physical disabilities (PAwLTPD) are living longer and experiencing the challenges of aging, including the onset of secondary and age-related health conditions. PAwLTPD are at high risk of falls, fall injuries, diminished functional abilities, and compromised participation. However, no available programs support PAwLTPD to participate safely at home and in the community. The proposed study is to examine the feasibility and efficacy of an adapted intervention: Removing Environmental Barriers to Independent Living (REBIL).

Method/Design

A single-blinded randomized controlled trial (RCT) will be conducted. Participants who are 45-65 years old; self-report difficulty with ≥2 daily activities; have had a physical disability for ≥5 years; and live within 60 miles of the research lab are eligible. All participants will receive an initial in-home evaluation before randomization. The treatment group will receive REBIL (total five visits), which is tailored. The waitlist control group will be offered the same intervention after 6-month follow-up. Expected outcomes are high acceptability, fidelity, and adherence; low safety risk; improved community participation and daily activities performance; and fewer environmental barriers and fall hazards.

Discussion

Findings will serve as preliminary evidence for occupational therapy community practice. Outcomes will also inform future large, pragmatic trials.

Trial Registration

ClinicalTrials.gov identifier NCT04589988.

The Persistence of Staphylococcus aureus in Pressure Ulcers: A Colonising Role

Decubitus pressure ulcers (PU) are a major complication of immobilised patients. Staphylococcus aureus is one of the most frequently detected microorganisms in PU samples; however, its persistence and role in the evolution of these wounds is unknown. In this study, we analysed S. aureus strains isolated from PU biopsies at inclusion and day 28. Eleven S. aureus (21.1%) were detected in 52 patients at inclusion. Only six PUs (11.5%) continued to harbour this bacterium at day 28. Using a whole genome sequencing approach (Miseq^®, Illumina), we confirmed that these six S. aureus samples isolated at D28 were the same strain as that isolated at inclusion, with less than 83 bp difference. Phenotypical studies evaluating the growth profiles (Infinite M Mano, Tecan^®) and biofilm formation (Biofilm Ring Test^®) did not detect any significant difference in the fitness of the pairs of S. aureus. However, using the Caenorhabditis elegans killing assay, a clear decrease of virulence was observed between strains isolated at D28 compared with those isolated at inclusion, regardless of the clinical evolution of the PU. Moreover, all strains at inclusion were less virulent than a control S. aureus strain, i.e., NSA739. An analysis of polymicrobial communities of PU (by metabarcoding approach), in which S. aureus persisted, demonstrated no impact of Staphylococcus genus on PU evolution. Our study suggested that S. aureus presented a colonising profile on PU with no influence on wound evolution.

Leisure-time physical activity, anthropometrics, and body composition as predictors of quality of life domains after spinal cord injury: an exploratory cross-sectional study

The objective of the current work was to examine the relationships between quality of life (QOL) domains in persons with spinal cord injury (SCI) and their levels of weekly leisure-time physical activity (LTPA), anthropometric variables, and body composition variables. This exploratory cross-sectional study consisted of baseline data collected as part of a randomized clinical trial at a VA Medical Center and SCI center. A convenience sample of 36 community-dwelling persons with SCI participated in the current study. Outcome measures included the World Health Organization Quality of Life Short Form (WHOQOL-BREF), Leisure-Time Physical Activity Questionnaire for People with Spinal Cord Injury (LTPAQ-SCI), anthropomorphic measures (waist, hip, and abdominal circumference), and dual-energy x-ray absorptiometry (DXA) to quantify regional and total body composition. Multiple regression models suggested that engagement in LTPA accounted for 35.7% of the variance in physical health QOL, 33.5% in psychological QOL, 14.2% in social relationships QOL, and 38.2% in environmental QOL. Anthropometric measures accounted for 11.3%, 3.1%, 12.0%, and 6.7% of the variance in these QOL indices, respectively, and DXA indices accounted for 18.7%, 17.5%, 27.4%, and 21.9%. Within these models, the number of minutes of heavy LTPA per day uniquely predicted physical health QOL, the number of mild LTPA days per week uniquely predicted psychological QOL, and the amount of mild LTPA per day uniquely predicted environmental QOL. Bivariate analyses also suggested that android and trunk fat, as well as supine waist and abdominal circumferences, were positively associated with social relationships QOL. Encouraging individuals with SCI to engage in LTPA may robustly enhance multiple aspects of QOL while reducing the risk for cardiovascular and metabolic morbidities associated with SCI. Moreover, this may lead to a further understanding of how QOL may impact longitudinal intervention trials. The study protocol and procedures were reviewed and approved by the McGuire VA Research Institutional Review Board (IRB# 02152, approval date August 9, 2015; IRB# 02375, approval date May 2, 2018).

Theory Without Theories: Well-Being, Ethics, and Medicine

Medical ethics would be better if people were taught to think more clearly about well-being or (what I take to be the same thing) the concept of what is good for a person. Yet for a variety of reasons, bioethicists have generally paid little attention to this concept. Here, I argue, first, that focusing on general theories of welfare is not useful for practical medical ethics. I argue, second, for what I call the "theory-without-theories approach" to welfare in practical contexts. The first element of this approach is a focus on examining important and relatively uncontroversial constituents of welfare as opposed to general theories. The second key element is a framework for thinking about choice in relation to welfare, a framework I refer to as "the mild objectivity framework." I conclude with illustrations of the way in which the "theory without theories approach" can improve thinking in medicine.

Reconstruction of recalcitrant pressure ulcers with latissimus dorsi muscle-splitting free flaps

BACKGROUND

Reconstruction of recalcitrant pressure ulcers is very challenging because all available local tissues have been exhausted. Although occasionally suggested as reconstructive options in some reports, free flaps are still not favored for pressure ulcers because of the less available recipient vessels in buttock area and the need for position change. Here, we describe our experience with latissimus dorsi muscle-splitting free flaps harvested in prone position for recalcitrant pressure ulcers.

METHODS

Between January 2012 and January 2020, 10 patients of recalcitrant pressure ulcers underwent reconstruction using latissimus dorsi muscle-splitting free flaps. To harvest flaps in the prone position, the curvilinear incision was made along the line connecting the lateral border of the scapula and the midaxillary line of the armpit and the latissimus dorsi muscle was split just below the skin incision. Only the required amount of muscle was harvested including the 5 × 3 cm sized muscle cuff around bifurcation points of the transverse and descending branches.

RESULTS

Flap size ranged from 16 × 9 to 24 × 14 cm and the gluteal vessels were mainly used as recipients. The mean operation time was 170 mins. All the flaps survived but two patients suffered wound disruption and partial flap loss, respectively. During the mean follow-up periods of 2.45 years, there were no recurrences at the reconstruction site, and no patient complained of donor site morbidity.

CONCLUSIONS

Based on the results obtained from this consecutive series of patients, latissimus dorsi muscle-splitting free flaps are valuable option for recalcitrant pressure ulcer reconstruction.

Should We Delay Urodynamic Study When Patients With Spinal Cord Injury Have Asymptomatic Pyuria?

Objective

To assess the incidence of urinary tract infection (UTI) with post-urodynamic study (post-UDS) in patients with spinal cord injury (SCI) and study its relationship with pre-UDS pyuria.

Methods

Patients with SCI who were hospitalized and underwent UDS during a 4-year period were reviewed. Patients with pre-test lower urinary tract symptoms were excluded. Urinalysis and urine culture were performed before and 24 hours after UDS. Prophylactic antibiotics were administered for 5 days starting from the morning of the UDS. UTI was defined as bacteriuria with accompanying symptoms.

Results

Of 399 patients reviewed, 209 (52.4%) had pyuria in pre-UDS urinalysis, and 257 (64.4%) had bacteriuria in pre-UDS culture. Post-UDS UTI occurred in 6 (1.5%) individuals who all complained of fever: 5 (2.4%) of the post-UDS UTI cases occurred in patients with pre-UDS pyuria, and 1 (0.5%) in a person without. The differences between groups were not statistically significant (p=0.218). Of 221 patients with bacteriuria (gram-negative isolates) on pre-UDS culture, resistance to ciprofloxacin, cephalosporin, and trimethoprim/sulfamethoxazole (TMP/SMT) was noted in 52.9% (117 cases), 57.0% (126 cases), and 38.9% (86 cases), respectively.

Conclusion

No difference was found in the prevalence of post-UDS UTI based on the presence of pyuria in pre-UDS urinalysis. UDS may be performed even in SCI cases of pre-UDS pyuria without increasing the prevalence of post-UDS UTI if prophylactic antibiotics are administered. TMP/SMT could be used as a first-line antibiotic for the prevention of post-UDS UTI in Korea.

A Procedure to Define Customized Musculoskeletal Models for the Analysis of the Crutch-Orthosis-Assisted Gait of Spinal Cord Injured Subjects

Subjects suffering from spinal cord injury with lower extremity impairment generally use a wheelchair to move. However, some of them are capable of walking with the help of orthoses and crutches. Standing up and walking regularly have huge benefits for the general health state of these subjects, since it reduces the negative consequences of sedentarism. Therefore, achieving adherence to assisted gait is important, but there is a risk of abandoning due to several issues such as pain, fatigue, or very low speed, which can make the subject return to solely use the wheelchair. Musculoskeletal models can provide estimations of muscular forces and activations, which in turn enable to calculate magnitudes such as joint reactions, energetic cost, and bone stress and strain. These magnitudes can serve to evaluate the impact of assisted gait in the subject's health and to assess the likelihood of adherence. Moreover, they can be used as indicators to compare different assistive devices for a particular subject. As every spinal cord-injured (SCI) subject represents a different case, a procedure to define customized musculoskeletal models for the crutch-orthosis-assisted gait of SCI subjects is proposed in this paper. Issues such as selection of muscles and integration of models of trunk, upper and lower extremities, and assistive devices (crutches and orthoses) are addressed. An inverse-dynamics-based physiological static optimization method that takes into account muscle dynamics at low computational cost is applied to obtain estimates of muscle forces and joint reactions. The method is experimentally validated by electromyography in a case study.

Health-related quality of life and multidimensional fitness profile in polio survivors

PURPOSE

To assess and compare the HRQoL and physical fitness of polio survivors with healthy individuals.

METHODS

Thirty-seven polio survivors and 40 healthy individuals were recruited in this cross-sectional study. The Fatigue Severity Scale (FSS) was used to evaluate participant's level of fatigue; Short Form 36 (SF-36) was used for evaluating HRQoL, and hand-grip strength, lumbar trunk muscle endurance, flexibility, balance, and aerobic endurance were used as measures for physical fitness.

RESULTS

Polio survivors had lower HRQoL in most of the dimensions of the SF-36, and they showed a lower level of physical fitness than controls. In particular, mobility-related variables were 20-40% lower in people with PP.

CONCLUSIONS

Subjects with PP had lower scores for the physical component of the HRQoL questionnaire, reduced physical fitness, increased fatigue, less mobility, and a higher fall risk than controls. The outcomes of the study can be useful to the design of future programs tailored specifically to improve the assessment of the physical fitness of subjects with paralytic polio and to facilitate interventions based on appropriate physical exercise regimens.Implications for rehabilitationPost-polio syndrome is a disabling disease that impacts in fitness, physical and psychological health-related quality of life of polio survivors.Polio survivors should undergo physical activity programs that focus on improving mainly their mobility and physical functioning (walking, self-care, and climbing stairs), thereby reducing fall risk and fatigue.Individual tailored physical exercise programs should be promoted in order to improve HRQoL in this population.

Accelerometer assessment of physical activity in individuals with paraplegia who do and do not participate in physical exercise

OBJECTIVE

Our main goal was to measure physical activity (PA) in people with paraplegia. Secondarily, we aimed to establish the relationship between being engaged in physical exercise (PE) and reaching the recommended moderate-to-vigorous physical activity (MVPA) level. We further analyzed the effect of being engaged in PE on the PA levels.

DESIGN

Descriptive cross-sectional.

SETTING

Spanish associations for individuals with spinal cord injury.

PARTICIPANTS

Ninety-six manual wheelchair users with chronic paraplegia.

INTERVENTIONS

Participants wore a wrist accelerometer for one week.

OUTCOME MEASURES

Levels of PA and sedentary behavior. In addition, participants were classified into two groups, exercisers (EG) and non-exercisers (NEG) to analyze the effect of PE enrollment on the variables.

RESULTS

For all participants, a mean (SD) of 5,341.70 (966.4) minutes per week were spent engaged in sedentary behaviors, 2,188.99 (723.9) minutes were spent engaged in light activity, and 206.24 (180.0) minutes were spent engaged in MVPA. There was a significant relationship between PE and reaching the minimum levels of MVPA recommended [x2 (1) = 25.03, P < 0.01]. NEG showed a greater number of minutes per week for sedentary behavior [t (94) = 2.50, P < 0.05, r = 0.25]. The EG spent more than twice as much time doing MVPA than the NEG (263.8 min vs 114.3 min, respectively).

CONCLUSIONS

MVPA levels are low in manual wheelchair users who are not regular exercisers, but most of those who self-reported being regular exercisers reach the minimum levels recommended for health benefits. Sedentary behavior is a concern in this population.

Outcomes following stoma formation in patients with spinal cord injury

AIM

The formation of a diverting stoma of the bowel in patients with spinal cord injury (SCI) is a useful option in managing problems associated with prolonged bowel care, pressure ulcers and neurogenic bowel. This descriptive study examines surgical outcomes and the effect on an individual's health-related quality of life (HrQoL) in this complex group of patients.

METHODS

Data were retrospectively collected in all patients with SCI who underwent a diverting stoma at Prince of Wales Hospital, Sydney, between January 2013 and January 2018 via a self-report questionnaire developed specifically for the study.

RESULTS

Forty-three individuals were identified of whom 26 responded. 73% were men with a mean age of 45 years. The reasons for stoma formation included sacral pressure ulcer (50%), prolonged bowel care (35%), faecal incontinence (19%), constipation (8%), autonomic dysreflexia (8%), carer difficulties (8%) and haemorrhoids (4%). 76% of patients reported an improvement in HrQoL with 72% scoring their satisfaction with a stoma ≥ 8/10.

CONCLUSION

While stoma formation is often seen as a treatment of last resort, our study has shown that it is an effective management option for a number of conditions post-SCI. It can improve HrQoL and has a high level of satisfaction amongst patients. Ideally, patients who could potentially benefit from a stoma should be identified early and receive appropriate education and counselling to help facilitate informed and timely decision-making and reduce adverse bowel related impact on quality of life and adjustment post-SCI.

Diagnosis and Management of Osteomyelitis Associated With Stage 4 Pressure Ulcers: Report of a Query to the Emerging Infections Network of the Infectious Diseases Society of America

Background

Few studies exist to guide the management of patients with stage 4 pressure ulcers with possible underlying osteomyelitis. We hypothesized that infectious disease (ID) physicians would vary widely in their approach to such patients.

Methods

The Emerging Infections Network distributed a 10-question electronic survey in 2018 to 1332 adult ID physicians in different practice settings to determine their approach to such patients.

Results

Of the 558 respondents (response rate: 42%), 17% had managed no such patient in the past year. Of the remaining 464 respondents, 60% usually felt confident in diagnosing osteomyelitis; the strongest clinical indicator of osteomyelitis reported was palpable or visible bone at the ulcer base. Approaches to diagnosing osteomyelitis in patients with visible and palpable bone varied: 41% of respondents would assume osteomyelitis, 27% would attempt pressure off-loading first, and 22% would perform diagnostic testing immediately. Preferred tests for osteomyelitis were bone biopsy (for culture and histopathology) and magnetic resonance imaging. Respondents differed widely on favored route(s) (intravenous, oral, or both) and duration of antimicrobial therapy but would treat longer in the absence, vs presence, of full surgical debridement (P < .001). Overall, 62% of respondents opined that osteomyelitis under stage 4 pressure ulcers is usually or almost always treated excessively, and most (59%) suggested multiple topics for future research.

Conclusions

Regarding osteomyelitis underlying stage 4 pressure ulcers, ID physicians reported widely divergent diagnostic and treatment approaches. Most of the reported practice is not supported by the available evidence, which is quite limited and of low quality.

Development of Cardiometabolic Health indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Context: Spinal cord injury or disease (SCI/D) leads to unchanged low-density lipoprotein and cholesterol, very low high-density lipoprotein a form of dyslipidemia and physical inactivity which combine to increase risk of morbidity and mortality from cardiometabolic disease. Herein, we describe the selection of structure, process and outcome indicators for adults in the first 18 months post-SCI/D rehabilitation admission. Methods: A Pan-Canadian Cardiometabolic Health Working Group was formed to develop a construct definition. Cardiometabolic risk factors were summarized in a Driver diagram. Release of the Paralyzed Veterans of America "Identification and Management of Cardiometabolic Risk after Spinal Cord Injury" and the International Scientific Exercise Guidelines: "Evidence-based scientific exercise guidelines for adults with spinal cord injury", informed the group's focus on prevention strategies to advance this Domain of rehabilitation admission. Results: The structure indicator identifies during rehabilitation the presence of appropriate time and resources for physical exercise prescription. Process indicators are lipid profile assessment at rehabilitation admission and documented exercise prescriptions prior to discharge. The outcome indicators track patient's knowledge retention regarding exercise prescription at discharge, current exercise adherence and lipid status 18 months after rehabilitation discharge. Conclusion: Routine national implementation of these indicators at the specified time points will enhance efforts to detect dyslipidemia and assure routine participation in endurance exercise. These indicators align with international initiatives to improve cardiometabolic health through interventions targeting modifiable risk factors specifically endurance exercising and optimal lipid profiles, crucial to augmenting cardiometabolic health after SCI/D.

Long-term prescribing of nitrofurantoin for urinary tract infections (UTI) in veterans with spinal cord injury (SCI)

CONTEXT/OBJECTIVE

To evaluate the impact of long-term nitrofurantoin for UTI prophylaxis in veterans with SCI.

DESIGN

Matched pairs study.

SETTING

Veterans cared for at VA facilities from 10/1/2012-9/30/2013.

PARTICIPANTS

Veterans.

INTERVENTIONS

n/a.

OUTCOMES MEASURES

UTI, positive urine cultures, resistant cultures.

METHODS

Cases receiving long-term nitrofurantoin (≥90 days supply) were matched to controls by facility. Controls were patients who did not receive long-term nitrofurantoin with a history of ≥3 positive urine cultures and at least one diagnosis of UTI or asymptomatic bacteriuria in the previous year.

RESULTS

122 SCI cases were identified and matched to 196 controls. After adjusting for differences in baseline demographic characteristics, UTIs were less frequent in cases (OR = 0.60 [95% CI 0.44-0.72]). Cases had a greater mean number of days between positive urine cultures as compared to controls (<0.0001). Cases were more likely to have isolates resistant to nitrofurantoin (P ≤ 0.0001); however, the frequency of multi-drug resistant organisms isolated from the urine was not significantly different.

CONCLUSIONS

Long-term prescription of nitrofurantoin may reduce UTIs in veterans with SCI and there is no evidence that it promotes multi-drug resistance. Future prospective studies should be conducted prior to incorporating routine use of long-term nitrofurantoin into clinical care.

Would personal cooling vest be effective for use during exercise by people with thoracic spinal cord injury?

People with thoracic spinal cord injury (SCI), named people with paraplegia (PA), are vulnerable to thermal heat stress during exercise due to disruption in their thermal physiology. Using personal cooling vests with phase change material (PCM) or ice presents a possible solution for PA to suppress the increase in core temperature and body heat storage. With the limited published experimental studies about effective cooling vest for PA, this work aims to develop an altered PA bioheat model combined with cooling vest model to study cooling vest performance during exercise. The integrated PA bioheat and vest models predict core and skin temperatures, latent and sensible heat losses and change in body heat storage for PA with and without a cooling vest. The models were validated with published experimental data on PA without the cooling vest and on PA with two cooling vests; one using PCM at melting temperature of 15 °C and the other using ice packets during exercise. It was observed that sensible heat losses at the four torso segments (abdomen, lower back, chest and upper back) increased with the vest case compared to the no-vest case; while, latent heat losses decreased compared to the no-vest case. However, insignificant change was seen in core temperatures and body heat storage as was also reported experimentally. The performance of each of the cooling vest during exercise on PA was dependent on skin coverage area and melting temperatures.

Temporal analysis of cardiovascular control and function following incomplete T3 and T10 spinal cord injury in rodents

Spinal cord injury (SCI) is a devastating condition that results in whole‐body dysfunction, notably cardiovascular (CV) disruption and disease. Injury‐induced destruction of autonomic pathways in conjunction with a progressive decline in physical fitness contribute to the poor CV status of SCI individuals. Despite the wide use of exercise training as a therapeutic option to reduce CV dysfunction, little is known about the acute hemodynamic responses to the exercise itself. We investigated CV responses to an exercise challenge (swimming) following both high and low thoracic contusion to determine if the CV system is able to respond appropriately to the challenge of swimming. Blood pressure (BP) telemetry and echocardiography were used to track the progression of dysfunction in rodents with T3 and T10 SCI (n = 8 each) for 10 weeks postcontusion. At 1 week postinjury, all animals displayed a drastic decline in heart rate (HR) during the exercise challenge, likely a consequence of neurogenic shock. Furthermore, over time, all groups developed a progressive inability to maintain BP within a narrow range during the exercise challenge despite displaying normal hemodynamic parameters at rest. Echocardiography of T10 animals revealed no persistent signs of cardiac dysfunction; T3 animals exhibited a transient decline in systolic function that returned to preinjury levels by 10 weeks postinjury. Novel evidence provided here illustrates that incomplete injuries produce hemodynamic instability that only becomes apparent during an exercise challenge. Further, this dysfunction lasts into the chronic phase of disease progression despite significant recovery of hindlimb locomotion and cardiac function.

Bladder Neuromodulation in Acute Spinal Cord Injury via Transcutaneous Tibial Nerve Stimulation: Cystometrogram and Autonomic Nervous System Evidence From a Randomized Control Pilot Trial

Aim: Percutaneous tibial nerve stimulation is used to decrease incontinence in chronic neurogenic bladder. We report the findings from a subset of patients in a randomized control trial of transcutaneous tibial nerve stimulation (TTNS) for bladder neuromodulation in acute spinal cord injury (SCI) in whom heart rate variability (HRV) was recorded before and after cystometrogram (CMG). The aim was to correlate autonomic nervous system (ANS) changes associated with the CMG changes after the trial using HRV analyses.

Methods: The study was a double-blinded sham-controlled 2-week trial with consecutive acute SCI patients admitted for inpatient rehabilitation, randomized to TTNS vs. control sham stimulation. Pre- and Post- trial CMG were performed with concurrent 5-min HRV recordings with empty bladder and during filling. Primary outcomes were changes with CMG between/within groups and associations to the HRV findings.

Results: There were 10 subjects in the TTNS group and 6 in the control group. Pre-trial baseline subject characteristics, blood pressures (BPs), and CMG were similar between groups. In both groups, the pre-trial systolic BP increased during filling CMG. After the trial, the control group had significantly increased detrusor pressure and counts of detrusor-sphincter dyssynergia on CMG, not seen in the TTNS group. Also, the control group did not maintain rising BP post-trial, which was observed pre-trial and remained in the TTNS group post-trial. HRV was able to detect a difference in the ANS response to bladder filling between groups. Post-trial HRV was significant for markers of overall increased parasympathetic nervous system activity during filling in the controls, not seen in the TTNS group.

Conclusion: Preliminary evidence suggests that TTNS in acute SCI is able to achieve bladder neuromodulation via modulation of ANS functions.

Clinical Trial Registration:clinicaltrials.gov, NCT02573402.

Lifestyle intervention for adults with spinal cord injury: Results of the USC-RLANRC Pressure Ulcer Prevention Study

CONTEXT/OBJECTIVE

Medically serious pressure injuries (MSPrIs), a common complication of spinal cord injury (SCI), have devastating consequences on health and well-being and are extremely expensive to treat. We aimed to test the efficacy of a lifestyle-based intervention designed to reduce incidence of MSPrIs in adults with SCI.

DESIGN

A randomized controlled trial (RCT), and a separate study wing involving a nonrandomized standard care control group.

SETTING

Rancho Los Amigos National Rehabilitation Center, a large facility serving ethnically diverse, low income residents of Los Angeles County.

PARTICIPANTS

Adults with SCI, with history of one or more MSPrIs over the past 5 years: N=166 for RCT component, N=66 in nonrandomized control group.

INTERVENTIONS

The Pressure Ulcer Prevention Program, a 12-month lifestyle-based treatment administered by healthcare professionals, largely via in-home visits and phone contacts.

OUTCOME MEASURES

Blinded assessments of annualized MSPrI incidence rates at 12 and 24 months, based on: skin checks, quarterly phone interviews with participants, and review of medical charts and billing records. Secondary outcomes included number of surgeries and various quality-of-life measures.

RESULTS

Annualized MSPrI rates did not differ significantly between study groups. At 12 months, rates were .56 for intervention recipients, .48 for randomized controls, and .65 for nonrandomized controls. At follow-up, rates were .44 and .39 respectively for randomized intervention and control participants.

CONCLUSIONS

Evidence for intervention efficacy was inconclusive. The intractable nature of MSPrI threat in high-risk SCI populations, and lack of statistical power, may have contributed to this inability to detect an effect.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01999816.

Using the natural environment to address the psychosocial impact of neurological disability: A systematic review

Engaging with the natural environment contributes to favourable psychosocial health outcomes. A systematic review of research published before June 2017 was conducted to establish how engaging with natural environments impact the psychosocial health of people with a neurological disability. Identified studies included populations with dementia (n=14), brain injury (n=2), and stroke (n=2). Evidence suggests that engaging with gardens, and gardening, can favourably impact the emotional and social health of people with dementia and, an explanatory theoretical model is proposed. Considerable research gaps exist and further research investigating the psychosocial impact of engaging with natural environments for people with different neurological conditions (for example spinal cord injury or stroke) is warranted.

Well on wheels intervention: Satisfaction with life and health for adults with spinal cord injuries

Objective/Background: To examine how demographic and injury characteristics identify satisfaction with life (SWL), and assess the differential effects of a wellness intervention by baseline SWL groups.Design: Baseline and longitudinal analysis of a randomized controlled pilot intervention using decision tree regression and linear mixed models.Setting: Community based.Participants: Seventy-two individuals with spinal cord injury (SCI) were randomized to an intervention group (n = 39) or control group (n = 33). Participants were aged 44.1 ± 13.0 years and 13.1 ± 10.6 years post-injury. Most participants were male (n = 50; 69.4%) and had paraplegia (n = 38; 52.7%). Participants were classified as high versus low SWL at baseline using a cutoff score of 20.Interventions: The intervention aimed to increase self-efficacy, and in turn, increase engagement in health-promoting behaviors related to SWL. Six 4-hour in-person workshops were conducted over a 3-month period led by experts and peer-mentors who were available for support.Outcome measure(s): Self-efficacy for health practices, secondary condition severity, health-promoting behaviors, perceived stress, and SWL.Results: At baseline, participants with low SWL were recently injured (<4.5 years), while persons with high SWL were married and younger (<49 years old). Intervention participants with low SWL at baseline significantly improved SWL over time compared to those with high SWL (P = 0.02).Conclusion: Certain injury and demographic characteristics were associated with SWL, and intervention participants with low SWL at baseline improved their SWL over 2 years. Healthcare providers should consider time post-injury, marital status, and age in identifying individuals at risk for low SWL that may benefit from wellness interventions.

Mental disorder prevalence among U.S. Department of Veterans Affairs outpatients with spinal cord injuries

OBJECTIVES

Depression and other mental disorders are more prevalent among individuals living with spinal cord injury (SCI) than in the community at large, and have a strong association with quality of life. Yet little is known about the prevalence and predictors of mental disorders among U.S. military Veterans living with SCI. The primary aim of this study was to present an estimate of mental disorder point prevalence in this population. The secondary aim was to examine the relationship of mental disorders to demographics, injury characteristics, and other clinically relevant features such as impairment from mental health problems and life satisfaction.

DESIGN

Cross-sectional.

SETTING

A SCI & Disorders Center at a U.S. Veterans Affairs Medical Center.

PARTICIPANTS/METHODS

Administrative and medical records of 280 Veterans who attended annual comprehensive SCI evaluations were evaluated. Demographics, injury characteristics, self-reported mental and emotional functioning (i.e. SF-8 Health Survey), and clinician-determined mental disorder diagnoses were attained.

RESULTS

Overall, 40% of patients received at least one mental disorder diagnosis, most commonly depressive disorders (19%), posttraumatic stress disorder (12%), and substance or alcohol use disorders (11%). Several patient characteristics predicted mental disorders, including age, racial minority identity, non-traumatic SCI etiology, and incomplete (i.e. AIS D) vs. complete injury. Mental disorders were associated with greater impairment from health and mental health-related problems and less satisfaction with life.

CONCLUSIONS

Mental disorders are common among outpatients receiving VA specialty care for SCI. These findings highlight the importance of having adequate and effective available mental health services available for Veterans with SCI.

Quality of life after spinal cord injury in Thai individuals: A mixed-methods study

Background:

Patients with spinal cord injury (SCI) face various health-related difficulties. Physical limitations and health-related complications in individuals with SCI can lead to activity restrictions and lowering their quality of life (QoL). It is important to assess the QoL in population with SCI to gain more valuable insights into aspects of health-related QoL (HRQoL) that could play a key role in improving care for persons with SCI.

Objective:

To quantitatively measure the QoL in persons with SCI in Thailand and expand the results through qualitative investigation to provide meaning, context and depth of “how” and “why” they rated, defined and addressed their QoL in that way.

Methods:

The philosophical assumption of this study was set based on the post-positivist views using mixed-methods sequential explanatory design. The quantitative data were collected and analyzed in 101 Thai individuals with SCI using standardized Thai version of the Short Form Health Survey version 2 (SF-36v2), followed by the qualitative investigation of semi-structured interviews in 11 volunteers who participated in the SF-36v2 phase. Priority is given to quantitative data. The data integration occurred at the qualitative data collection through the data interpretation and discussion stage.

Results:

With regard to quantitative data, a recent study found a statistically significant difference (p<0.05) in four domains for male and three domains for the female when comparing the SF-36 Thai normative data with SF-36v2 SCI data. Qualitative data revealed that the most salient themes of HRQoL in individuals with SCI were “supporting factors toward QoL” and “driving force post injury”. The integration of the findings revealed that the qualitative data could individually explain and define QoL as well as support quantitative results. The connection of both findings indicated that the higher scores in psycho-social variables and lower scores in physical domains of SF-36v2 in Thai persons with SCI may be due to unique Thai family traditions and community values.

Conclusion:

The scores on SF-36v2 and the replies in the qualitative investigation of QoL themes of Thai individuals with SCI were similar to those of other research, but this study is unique in that it specifically represents the Thai socio-environmental-cultural aspects.

Functional independence of persons with long-standing motor complete spinal cord injury in the Netherlands

Context/Objective: Since life expectancy of persons with spinal cord injury (SCI) has improved, it is relevant to know whether this group is able to maintain functional abilities many years after onset of SCI. Objectives of this study were (1) to examine associations between time since injury (TSI) and functional independence in persons with long-standing SCI and (2) to explore associations between functional independence and level of injury, comorbidities, mental health, waist circumference and secondary health conditions (SHCs).Design: TSI-stratified cross-sectional study. Strata were 10-19, 20-29 and 30+ years.Setting: Community.Participants: 226 persons with long-standing SCI. Inclusion criteria: motor complete SCI; age at injury 18-35 years; TSI ≥ 10 years; current age 28-65 years; wheelchair dependency.Interventions: Not applicable.Outcome measures: The Spinal Cord Independence Measure III (SCIM) was administered by a trained research assistant. Level of injury, comorbidities, mental health, waist circumference and SHCs were assessed by a rehabilitation physician.Results: Mean TSI was 23.6 (SD 9.1) years. No significant differences in SCIM scores were found between TSI strata. SCIM scores were lower for persons with tetraplegia, autonomic dysreflexia, hypotension, more than four SHCs and a high waist circumference. In linear regression analyses, TSI nor age was associated with the SCIM total score. Only level of injury (β = -0.7; P < .001) and waist circumference (β = -0.1; P = .042) were independent determinants (explained variance 55%).Conclusion: We found no association between TSI and functional independence in persons with long-standing motor complete SCI. This study confirms the possible effect of overweight on functional independence.

Prescription drug claims following a traumatic spinal cord injury for older adults: a retrospective population-based study in Ontario, Canada

Study design

Retrospective cohort study.

Objectives

The objectives for this study were to examine the prevalence of polypharmacy for people with traumatic spinal cord injury (SCI) following injury and to determine risk factors.

Setting

Ontario, Canada

Methods

We used provincial-level administrative health services data of publicly funded healthcare encounters housed at the Institute for Clinical Evaluative Sciences, Toronto, Ontario. We examined prescription medications dispensed over a 1 year period post injury for persons 66+ years with an index traumatic SCI between 2004 and 2014. Polypharmacy was defined as being on 10 or more drug classes. Descriptive and analytical statistics were conducted. Relative risks and 95% confidence limits for factors related to polypharmacy were calculated using a robust Poisson multivariate regression model.

Results

We identified 418 cases of persons with traumatic SCI during the observation window. A total of 233 patients (56%) were taking at least 10 drug classes in the year following discharge from care for traumatic SCI. The mean number of drug classes taken post injury was 11 (SD = 6). Continuity of care was significantly associated with polypharmacy, with a higher continuity of care (having at least 75% of visits with the same doctor) reducing the risk of polypharmacy. The most common drugs prescribed were laxatives, opioids and cardiovascular-related drugs.

Conclusion

Findings suggest that polypharmacy is extensive among older adults with traumatic SCI. Persons with better continuity of care are less likely to have polypharmacy compared to those with less continuity.

Sponsorship

This project was funded by a Connaught New Investigator Award (University of Toronto), and the Craig H. Neilsen Foundation Psychosocial Research Pilot Grant (Grant #441259).

Special considerations in the urological management of the older spinal cord injury patient

PURPOSE

This paper reports the key findings of Committee 8 of the Joint SIU-ICUD Consultation on Urologic Management of the Spinal Cord Injured Patient and address issues pertaining to the older person with a SCI and the time-related changes relevant to their urological, gastrointestinal and functional management.

METHODS

A literature review using the Pubmed and Ovid search engines was performed examining pertinent literature regarding SCI in the older patient.

RESULTS

There is a rising incidence of both traumatic and non-traumatic spinal cord injury (SCI) in older people and improvements in healthcare and nutrition mean patients with SCI are living longer. Outcomes after a SCI in the older person are a sum of the effects of injury and its management compounded by specific effects of ageing and the emergence of unrelated comorbidities. Changes in health, comorbidities, cognition and dexterity with ageing have an impact on function and are important considerations in the management of the older patient with SCI. Treatment decisions are thus increasingly complex due to the need to take into account these changes and accompanying polypharmacy. For the person living with a SCI, changes in circumstances (social and financial) have an impact on quality of life and influence management and support strategies.

CONCLUSIONS

Older patients with SCI face additional challenges both in the acute setting and with ageing. Clinicians should take into account comorbid conditions, mental health, physical function, cognition and social support in making management decisions. With the global ageing population, health services planning will need to allow for increase in resources required to care for older patients with SCI.

Investigation of Microbiota Alterations and Intestinal Inflammation Post-Spinal Cord Injury in Rat Model

Although there has been a significant amount of research focused on the pathophysiology of spinal cord injury (SCI), there is limited information on the consequences of SCI on remote organs. SCI can produce significant effects on a variety of organ systems, including the gastrointestinal tract. Patients with SCI often suffer from severe, debilitating bowel dysfunction in addition to their physical disabilities, which is of major concern for these individuals because of the adverse impact on their quality of life. Herein, we report on our investigation into the effects of SCI and subsequent antibiotic treatment on the intestinal tissue and microbiota. For that, we used a thoracic SCI rat model and investigated changes to the microbiota, proinflammatory cytokine levels, and bacterial communication molecule levels post-injury and gentamicin treatment for 7 days. We discovered significant changes, the most interesting being the differences in the gut microbiota beta diversity of 8-week SCI animals compared to control animals at the family, genus, and species level. Specifically, 35 operational taxonomic units were enriched in the SCI animal group and three were identified at species level; Lactobacillus intestinalis, Clostridium disporicum, and Bifidobacterium choerinum. In contrast, Clostridium saccharogumia was identified as depleted in the SCI animal group. Proinflammatory cytokines interleukin (IL)-12, macrophage inflammatory protein-2 (MIP-2), and tumor necrosis factor alpha were found to be significantly elevated in intestinal tissue homogenate 4 weeks post-SCI compared to 8-weeks post-injury. Further, levels of IL-1β, IL-12, and MIP-2 significantly correlated with changes in beta diversity 8-weeks post-SCI. Our data provide a greater understanding of the early effects of SCI on the microbiota and gastrointestinal tract, highlighting the need for further investigation to elucidate the mechanism underlying these effects.

Participation restriction and assistance needs in people with spinal cord injuries of more than 40 year duration

Study design

Prospective observational.

Objectives

Examine changes in participation restriction and assistance needs in a sample of people with long-standing spinal cord injuries (SCIs).

Setting

Two British spinal centres.

Methods

The sample consisted of British ageing with SCI study participants who were seen at baseline (1990 or 1993) and in the final follow-up (2010). Outcome measures were the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF) and interview questions about assistance needs.

Results

Eighty-five Ageing study participants took part in 2010; their mean age was 67.65 years and the mean time since injury was 46.26 years. The mean CHART-SF physical independence subscore decreased from 97.44 in 1990 to 91.26 in 2010, mobility from 95.58 to 82.10, occupation from 86.82 to 64.49 and social integration from 96.29 to 88.68 (all p < 0.05). Increasing assistance needs were reported by 10.1% of participants in 1990, by 36.6% in 2010 (p < 0.05) and by 62.4% over the entire 20-year study period. Persons requiring more assistance were older and injured longer, had a more severe SCI and lower self-reported quality of life and life satisfaction (p < 0.05). In the multivariate logistic regression, the strongest predictor of needing more assistance was injury severity (p < 0.05).

Conclusions

An increase in participation restriction and in assistance needs was reported over the 20 year follow-up in persons injured more than 40 years ago. SCI severity was the main risk factor for needing more assistance. Clinical awareness of how participation changes with age may help provide timely intervention and offset declines.

Long-term bladder and bowel management after spinal cord injury: a 20-year longitudinal study

STUDY DESIGN

Prospective observational.

AIM

The aim of this study was to analyse changes in bladder and bowel management methods in persons with long-standing spinal cord injury (SCI).

SETTING

Two spinal centres in UK.

METHOD

Data were collected through interviews and examinations between 1990 and 2010 in a sample of persons injured more than 20 years prior to 1990.

RESULTS

For the 85 participants who completed the 2010 follow-up, the mean age was 67.7 years and the mean duration of injury was 46.3 years, 80% were male, 37.7% had tetraplegia AIS grade A, B, or C, 44.7% paraplegia AIS A, B, or C, and 17.6% an AIS D grade regardless of level. In all, 50.6% reported having changed their bladder method, 63.1% their bowel method, and 40.5% both methods since they enroled in the study. The reasons for change were a combination of medical and practical. In men, condom drainage remained the most frequent bladder method, and in women, suprapubic catheter replaced straining/expressing as the most frequent method. The use of condom drainage and straining/expressing bladder methods decreased, whereas the use of suprapubic and intermittent catheters increased. Manual evacuation remained the most frequent bowel management method. The percentage of participants on spontaneous/voluntary bowel emptying, straining and medications alone decreased, whereas the use of colostomy and transanal irrigation increased over time.

CONCLUSIONS

More than half the sample, all living with SCI for more than 40 years, required change in their bladder and bowel management methods, for either medical or practical reasons. Regular follow-ups ensure adequate change of method if/when needed.

Fundamental hemodynamic mechanisms mediating the response to myocardial ischemia in conscious paraplegic mice: cardiac output versus peripheral resistance

Autonomic dysfunction, a relative sedentary lifestyle, a reduced muscle mass and increased adiposity leads to metabolic abnormalities that accelerate the development of coronary artery disease (CAD) in individuals living with spinal cord injury (SCI). An untoward cardiac incident is related to the degree of CAD, suggesting that the occurrence of a significant cardiac event is significantly higher for individuals with SCI. Thus, understanding the fundamental hemodynamic mechanisms mediating the response to myocardial ischemia has the potential to positively impact individuals and families living with SCI. Accordingly, we systematically investigated if thoracic level 5 spinal cord transection (T₅X; paraplegia) alters the arterial blood pressure response to coronary artery occlusion and if the different arterial blood pressure responses to coronary artery occlusion between intact and paraplegic mice are mediated by changes in cardiac output and or systemic peripheral resistance and whether differences in cardiac output are caused by changes in heart rate and or stroke volume. To achieve this goal, the tolerance to 3 min of coronary artery occlusion was determined in conscious intact and paraplegic mice. Paraplegic mice had an impaired ability to maintain arterial blood pressure during coronary artery occlusion as arterial pressure fell to near lethal levels by 1.38 ± 0.64 min. The lower arterial pressure was mediated by a lower cardiac output as systemic peripheral resistance was elevated in paraplegic mice. The lower cardiac output was mediated by a reduced heart rate and stroke volume. These results indicate that in paraplegic mice, the arterial pressure response to coronary artery occlusion is hemodynamically mediated primarily by cardiac output which is determined by heart rate and stroke volume.

Enhancing quality practice for prevention and diagnosis of urinary tract infection during inpatient spinal cord rehabilitation

OBJECTIVES

To reduce the incidence of Urinary Tract Infection (UTI) in subacute SCI individuals admitted for tertiary inpatient rehabilitation.

DESIGN

A quality improvement team was assembled to improve UTI prevention/diagnosis. To plan data collection, UTI-related factors were mapped in an Ishikawa (fishbone) driver diagram. Data including patient demographics, presence and frequency of signs and/or symptoms of UTI and antibiotic initiation from August to December 2015 were recorded. Sensitivity, Specificity, Positive and Negative Predictive Values (PPV, NPV), and Likelihood Ratios (LR) were calculated for each sign and symptom.

SETTING

Tertiary SCI Rehabilitation Results: Among 55 inpatients with subacute SCI who had signs/symptoms prompting urine culture and sensitivity (C&S), 32 (58.18%) were diagnosed with a UTI. The most frequent symptoms were foul smelling urine (41%), change in urine color (31%), and incontinence (25%), and the most common sign was fever (34%). Most UTIs (81%) occurred among individuals using Clean Intermittent Catheterization (CIC), with 46% of catheterizations performed by nurses. Foul smelling urine had the highest sensitivity (0.50, 95% CI: 0.31-0.69), and new incontinence had the highest specificity (0.88, 95% CI: 0.69-0.97) for UTI diagnosis. The highest PPV belonged to the cloudy urine (0.71, 95% CI: 0.42-0.92). The combination of cloudy and foul smelling urine increased the PPV to 78% (95% CI: (0.40-0.97).

CONCLUSIONS

The concurrent presence of cloudy and foul smelling urine is predicted of UTI diagnosis inpatients tertiary setting. SCI inpatients are susceptible to UTI when learning CIC technique from nurses.

Clinical factors associated with C-reactive protein in chronic spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Determine clinical factors associated with plasma C-reactive protein (CRP) in persons with chronic spinal cord injury (SCI).

SETTING

Veterans Affairs Medical Center in Boston, MA, USA.

METHODS

Participants provided a blood sample, completed a respiratory health questionnaire and underwent dual X-ray absorptiometry (DXA) to assess total and regional body fat. Linear regression models were used to assess cross-sectional associations with plasma CRP.

RESULTS

In multivariable models, factors associated with a higher CRP included a greater BMI, urinary catheter use, a respiratory illness in the past week and non-white race. Mean CRP also increased with decreasing mobility (motorized wheelchair >hand-propelled wheelchair >walk with an assistive device >walk independently). Results were similar when adjusting for percentage android, gynoid, trunk or total fat mass in place of BMI. Level and completeness of SCI was not associated with CRP in multivariable models.

CONCLUSIONS

Clinical characteristics common in chronic SCI are associated with plasma CRP. These factors are more important than the level and completeness of SCI and some are potentially modifiable.

One-Year Mortality of Patients with Chronic Kidney Disease After Spinal Cord Injury: A 14-Year Population-Based Study

OBJECTIVE

Chronic kidney disease (CKD) has become a global public health burden because of its increasing incidence, high risk of progression to end-stage renal disease (ESRD), and poor prognosis. We aimed to investigate the 1-year mortality of patients with spinal cord injury (SCI) with CKD and ESRD, and compare it with that of patients with SCI without CKD by reviewing a large Taiwanese population data set.

METHODS

In this 14-year retrospective cohort study, the study group (SCI with CKD group, n = 3315) and comparison group (SCI without CKD group, n = 6630) were matched at a 1:2 ratio with propensity score matching by age, sex, comorbidities, length of intensive care unit stay, and length of stay. The 1-year mortality and the relative risks of mortality were calculated. Mortality stratified by age, sex, and comorbidities was also analyzed.

RESULTS

The SCI with CKD group had a significantly shorter survival period (10.13 vs. 10.97 months), higher 1-year mortality (17.65% vs. 8.54%), and higher risk of mortality than did the comparison group (adjusted hazard ratio, 2.25). Furthermore, patients with CKD with ESRD had a 7.71-fold higher risk of mortality than did patients with SCI without CKD for ages <50 years. The presence of comorbidities was a risk factor for mortality among patients with SCI CKD or ESRD in contrast to patients with SCI without CKD.

CONCLUSIONS

Patients with SCI with CKD, especially those with ESRD, have a higher risk of mortality than do patients who do not have CKD. Therefore, patients with CKD should have carefully monitoring for the development of 1-year mortality after SCI, especially for ESRD.

Long-term survival after traumatic spinal cord injury: a 70-year British study

STUDY DESIGN

Retrospective and prospective observational.

OBJECTIVES

Analyse long-term survival after traumatic spinal cord injury (SCI) in Great Britain over the 70-year study period, identify mortality risk factors and estimate current life expectancy.

SETTING

Two spinal centres in Great Britain.

METHODS

The sample consisted of patients with traumatic SCI injured 1943-2010 who survived the first year post-injury, had residual neurological deficit on discharge and were British residents. Life expectancy and trends over time were estimated by neurological grouping, age and gender, using logistic regression of person-years of follow-up combined with standard life table calculations.

RESULTS

For the 5483 cases of traumatic SCI the mean age at injury was 35.1 years, 79.7% were male, 31.1% had tetraplegia AIS/Frankel ABC, 41.2% paraplegia ABC,and 27.7% functionally incomplete lesion (all Ds). On 31 December 2014, 54% were still alive, 42.3% had died and 3.7% were lost to follow-up. Estimated life expectancies improved significantly between the 1950s and 1980s, plateaued during the next two decades, before slightly improving again since 2010. The estimated current life expectancy, compared with the general British population, ranged from 18.1 to 88.4% depending on the ventilator dependency, level and completeness of injury, age and gender.

CONCLUSIONS

Life expectancy after SCI improved significantly between the 1950s and 1980s, plateaued during the 1990s and 2000s, before slightly improving again since 2010, but still remains well below that of the general British population.

SPONSORSHIP

Buckinghamshire Healthcare NHS Trust Charitable Spinal Fund and Ann Masson Legacy for Spinal Research Fund, UK.

Weight change after spinal cord injury

OBJECTIVES

To study the patterns of weight change after spinal cord injury (SCI) and identify associated risk factors.

STUDY DESIGN

Cohort study.

SETTING

Sixteen Spinal Cord Injury Model Systems (SCIMS), USA.

PARTICIPANTS

One thousand and ninety-four individuals with an SCI who were entered into the SCIMS and had a 1-year follow-up between October 2006 and November 2012.

INTERVENTION

Not applicable.

OUTCOME MEASURE

Change in body mass index (BMI) during the first year of injury. Height and weight were assessed during inpatient rehabilitation and 1 year after injury.

RESULTS

Mean BMI decreased from 26.3 to 25.8 kg/m² during the first year after SCI (mean change: -0.5 kg/m² (standard deviation: 3.58)). Weight loss was mainly observed among individuals classified as overweight or obese during rehabilitation (n  =  576) with a BMI decrease of 1.4 kg/m², which varied significantly by sex, education, neurological level, and the presence of vertebral injury. Weight gain was noted among individuals classified as underweight or normal weight during rehabilitation (n = 518) with a BMI increase of 0.5 kg/m², with the greatest increase among individuals of Hispanic origin (1.2 kg/m²), other marital status (1.2 kg/m²), age group 31-45 years (1.1 kg/m²), with less than high school education (1.1 kg/m²), without spinal surgery (0.9 kg/m²), and with motor functionally incomplete injury (0.8 kg/m²).

CONCLUSION

Our findings suggest that strategies for weight management should be addressed after a SCI to ameliorate the potential for unhealthful weight change, particularly among at-risk groups.

Factors predictive of survival and estimated years of life lost in the decade following nontraumatic and traumatic spinal cord injury

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To identify factors predictive of survival after spinal cord injury (SCI).

SETTING

Tertiary care institution.

METHODS

Multiple-variable Cox proportional hazards regression analysis for 759 patients with SCI (535 nontraumatic and 221 traumatic) included age, sex, completeness of injury, level of injury, functional independence measure (FIM) scores, rehabilitation length of stay and SCI cause. Estimated years of life lost in the decade after injury was calculated for patients vs uninjured controls.

RESULTS

Median follow-up was 11.4 years. Population characteristics included paraplegia, 58%; complete injury, 11%; male sex, 64%; and median rehabilitation length of stay, 16 days. Factors independently predictive of decreased survival were increased age (+10 years; hazard ratio (HR (95% CI)), 1.6 (1.4-1.7)), male sex (1.3 (1.0-1.6)), lower dismissal FIM score (-10 points; 1.3 (1.2-1.3)) and all nontraumatic causes. Metastatic cancer had the largest decrease in survival (HR (95% CI), 13.3 (8.7-20.2)). Primary tumors (HR (95% CI), 2.5 (1.7-3.8)), vascular (2.5 (1.6-3.8)), musculoskeletal/stenosis (1.7 (1.2-2.5)) and other nontraumatic SCI (2.3 (1.5-3.6)) were associated with decreased survival. Ten-year survival was decreased in nontraumatic SCI (mean (s.d.), 1.8 (0.3) years lost), with largest decreases in survival for metastatic cancer and spinal cord ischemia.

CONCLUSIONS

Age, male sex and lower dismissal FIM score were associated with decreased survival, but neither injury severity nor level was associated with it. Survival after SCI varies depending on SCI cause, with survival better after traumatic SCI than after nontraumatic SCI. Metastatic cancer and vascular ischemia were associated with the greatest survival reduction.

Risk Factors Associated With Recurrent Urinary Tract Infection in Neurogenic Bladders Managed by Clean Intermittent Catheterization

OBJECTIVE

To identify risk factors for recurrent urinary tract infection (UTI) in patients who perform clean intermittent catheterization (CIC).

METHODS

A 6-year retrospective chart review of patients with spina bifida or tethered cord who perform clean intermittent catheterization (8 months to 58 years) was conducted. A strict case definition for UTI was applied, and per-subject UTI events, demographic, and clinical data were abstracted. Data were compared between groups defined by no or infrequent UTI (≤1.0 UTI/study year) and frequent UTI (>1.0 UTI/study year).

RESULTS

Of 194 total patients, 146 (75%) had no UTIs or infrequent UTIs, and 48 (25%) patients had frequent UTIs. On univariate analysis, only younger age and suprasacral cord lesions were associated with frequent UTIs (P = .002 and P = .007, respectively). Among the 128 patients with urodynamic studies, bladder capacity, compliance, detrusor overactivity, and detrusor leak point pressure were not associated with frequent UTI on univariate analysis. On multivariate analysis, increasing age was found to be associated with decreased odds of UTI by 7% per year (odds ratio 0.93, P = .016).

CONCLUSION

The risk of UTI among individuals with spina bifida or tethered cord declines with increasing age. Bladder function based on urodynamic parameters did not correlate with frequent UTIs.

Feasibility study of a novel approach to sore prevention in patients with spinal cord lesions: the computerized dynamic control Matrix 200 system

Objective: To evaluate the feasibility of a computerized mattress system based on a novel concept in sore prevention: continuous monitoring and adjustment of the interface pressure in small segments of contact between the skin and the supporting surface.

Design: A preliminary observational study.

Setting: The Spinal Department, Loewenstein Rehabilitation Hospital, Raanana, Israel.

Subjects: Twelve patients with spinal cord lesions.

Interventions: Patients were examined for signs of impending sores after lying on the mattress for up to 4 successive hours. The pressure within each of the mattress's air cells was continuously measured and adjusted.

Results: No evidence of redness or excessive perspiration was found in any of the areas considered to be high risk for bed sores. Maximal interface pressure was 22-30 mmHg in most of the examinations. Most of the patients felt comfortable on the mattress and the staff adapted easily to its operation.

Conclusions: The system is apparently safe, and at least as efficient as other existing means for preventing sores. In addition, it may allow for increased intervals between bed positionings. We conclude that this approach of pressure control has the potential to improve bed sore prevention in a rehabilitation hospital setting.

Effect of muscle contractions on cartilage: morphological and functional magnetic resonance imaging evaluation of the knee after spinal cord injury

Objective

To evaluate the effect of complete absence of muscle contractions on normal human cartilage in the presence of joint motion.

Methods

Patients with complete acute spinal cord injuries were enrolled. All patients underwent magnetic resonance imaging (MRI) on both knees as soon as their medical condition was stable and at six months after the primary lesion. All patients received rehabilitation treatment that included lower-limb passive motion exercises twice a day. The MRIs were analyzed by two radiologists with expertise in musculoskeletal disorders. A region of interest was established at the patellar facets and trochlea, and T2 relaxation times were calculated. The area under the cartilage T2 relaxation time curve was calculated and standardized.

Results

Fourteen patients with complete spinal cord injuries were enrolled, but only eight patients agreed to participate in the study and signed the informed consent statement. Two patients could not undergo knee MRI due to their clinical conditions. Initial knee MRIs were performed on six patients. After six months, only two patients underwent the second bilateral knee MRI. Both patients were neurologically classified as Frankel A. An increase in T2 values on the six-month MRI was observed for both knees, especially in the patellofemoral joint.

Conclusion

The absence of muscle contractions seems to be deleterious to normal human knee cartilage even in the presence of a normal range of motion. Further studies with a larger number of patients, despite their high logistical complexity, must be performed to confirm this hypothesis.

B-Cell Depletion with CD20 Antibodies as New Approach in the Treatment of Inflammatory and Immunological Events Associated with Spinal Cord Injury

Spinal cord injury (SCI) is a highly debilitating pathology that has irreversible impacts and results in functional loss. We evaluated the anti-inflammatory and immunologic role of antibody-mediated depletion of B cells through the glycoengineered anti-muCD20 antibody (18B12) in an experimental model of spinal cord compression, in vivo and ex vivo. Intraperitoneal 18B12 was administered at a dose of 30 mg/kg, 1 h and 6 h after SCI, and mice were sacrificed 24 h after trauma. We demonstrated, in vivo, that 18B12 slowed severe hindlimb motor dysfunction (Basso Mouse Scale score) and neuronal death by histological evaluation in SCI mice, as well as decreased expression of nuclear factor-kB, inducible nitric oxide synthase, cytokines, and glial fibrillary acidic protein. Also, 18B12 reduced expression of microglia, just as it lowered the expression of B and T lymphocytes. Moreover, in spinal cord organotypic cultures, pretreatment with 18B12 significantly reduced nitric oxide expression and protected cells from cell death [3-(4,5- dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay]. In this study, we showed that 18B12 treatment reduces the development of inflammation and tissue injury by alteration of the immune system associated with SCI. This study increases the current knowledge that B-cell depletion is able to exert immunomodulating actions in damaged spinal cords.

The effectiveness and satisfaction of web-based physiotherapy in people with spinal cord injury: a pilot randomised controlled trial

STUDY DESIGN

A pilot randomised controlled trial.

OBJECTIVES

The aims of this study were to evaluate the effectiveness and participant satisfaction of web-based physiotherapy in people with spinal cord injury (SCI).

SETTING

Community patients of a national spinal injury unit in a university teaching hospital, Scotland, UK.

METHODS

Twenty-four participants were recruited and randomised to receive 8 weeks of web-based physiotherapy (intervention), twice per week, or usual care (control). Individual exercise programmes were prescribed based on participants' abilities. The intervention was delivered via a website (www.webbasedphysio.com) and monitored and progressed remotely by the physiotherapist.

RESULTS

Participants logged on to the website an average of 1.4±0.8 times per week. Between-group differences, although not significant, were more pronounced for the 6-min walk test. Participants were positive about using web-based physiotherapy and stated that they would be happy to use it again and would recommend it to others. Overall, it was rated as either good or excellent.

CONCLUSIONS

Web-based physiotherapy was feasible and acceptable for people with SCI. Participants achieved good compliance with the intervention and rated the programme highly and beneficial for health and well-being at various states after injury. The results of this study warrant further work with a more homogeneous sample.

SPONSORSHIP

This study was funded by the Queen Elizabeth National Spinal Injuries Unit, Glasgow, UK.

Prevalence of pressure sores in a community sample of spinal injury patients

Objectives: To estimate the point prevalence of pressure sores in a community sample of spinal cord injured patients who were followed up by a spinal injuries unit and to evaluate whether self-management strategies were associated with decreased risk of pressure sores.

Setting: A regional spinal injuries unit, UK.

Design: Postal questionnaire survey. Main outcome measure: Presence of pressure sores.

Subjects: All patients who were being followed up on a regular basis by the unit.

Results: Out of 760, 520 replied to the questionnaire; 472 were eligible for analysis. Point prevalence of pressure sores was 23% (99). Failure to inspect the skin daily for pressure damage was associated with decreased prevalence of pressure sores (odds ratio (OR) 0.5; 95% confidence interval (CI) 0.2–0.83). Those who inspected their skin daily, however, had a higher proportion of stage I pressure sores, but this was not statistically significant. Smoking (OR 1.8; 95% CI 1–3.3) and pre-existing medical problems (OR 1.8; 95% CI 1–3) were associated with increased prevalence of pressure sores. Regular lifting of weight at least once in an hour while seated, age, gender, neurological level, employment status, living alone and faecal and urinary incontinence were not significant predictors of pressure sores.

Conclusions: Nearly one-quarter of participants had pressure sores at the time of the survey. Periodic weight lifts and daily inspection of skin for pressure damage were not associated with decreased prevalence of pressure sores in this sample. However, those who inspected skin daily tended to detect pressure damage early.