Secondary conditions following spinal cord injury in a population-based sample

A Systematic Review of the Impact of Spinal Cord Injury on Costs and Health-Related Quality of Life

OBJECTIVE

To systematically review the health-related quality of life (HRQoL) burden and costs of spinal cord injury (SCI) on health services, patients and wider society.

METHODS

A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was conducted in March 2021 through Scopus, PubMed and Embase databases. Inclusion criteria were quantitative studies on SCI reporting healthcare costs, social costs and/or HRQoL measured with the Euroqol EQ-5D or Short-Form 36. Risk of bias was assessed using the QualSyst tool. Descriptive analyses, random-effects direct meta-analysis and random-effects meta-regression were conducted.

RESULTS

A total of 67 studies were eligible for inclusion. SCI individuals tend to report higher HRQoL in mental than physical dimensions of the Short-Form 36. Neurological level of SCI negatively affects HRQoL. Cross-sectional studies find employment is associated with better HRQoL, but the effect is not observed in longitudinal studies. The estimated lifetime expenditure per individual with SCI ranged from US$0.7 million to US$2.5 million, with greater costs associated with earlier age at injury, neurological level, United States of America healthcare setting and the inclusion of non-healthcare items in the study.

CONCLUSIONS

SCI is associated with low HRQoL on mobility and physical dimensions. Mental health scores tend to be greater than physical scores, and most dimensions of HRQoL appear to improve over time, at least over the first year. SCI is associated with high costs which vary by country.

CLINICAL TRIALS REGISTRATION

This review was registered in PROSPERO (registration number: CRD42021235801).

Comparative analysis of effects of various toilet seat cushions on buttock pressure during toileting in persons with spinal cord injury

OBJECTIVES

To measure buttock pressure during toilet seating in persons with spinal cord injury (SCI).

DESIGN

A case series study.

SETTING

Kibikogen Rehabilitation Center for Employment Injuries.

METHODS

The study included 41 persons with SCI. Buttock pressure was measured during toilet seating, with or without a toilet seat cushion (foam cushion, gel cushion, air cushion) on the toilet seat.

RESULTS

The subjects were classified into three groups according to the site of the maximum pressure [greater trochanter (GT) region, ischial tuberosities (IT), and sacral region (SR)] recorded on the pressure map of the non-cushioned toilet seat, into the GT, IT and SR groups, respectively. All three types of cushions altered the buttock pressure distribution during no-cushion toilet seating. In the GT group, all three cushions significantly reduced the peak pressure in the GT area, compared to the control (no-cushion). The foam cushion significantly increased the peak pressure in the IT area (Pisch) in the GT group, relative to the control. However, the foam cushion significantly increased while the gel cushion significantly reduced Pisch, relative to the control. In SR group, the air cushion significantly reduced the peak pressure in the SR, relative to the control.

CONCLUSION

We recommend the use of the gel cushion for the IT group and the air cushion in GT and SR group to reduce buttock pressure during toilet seating in persons with SCI.

Dual utilization of Medicare and VA outpatient care among Veterans with spinal cord injuries and disorders

OBJECTIVE

Veterans with spinal cord injuries and disorders (SCI/D) utilizing Veterans Affairs healthcare facilities are also Medicare eligible. Use of multiple health care systems potentially duplicates or fragments care in this population; yet little is known about those using multiple systems. This study describes dual use of services paid for by VA and Medicare among Veterans with SCI/D.

DESIGN

Retrospective, cross-sectional, observational study.

PARTICIPANTS

Veterans with SCI/D (n = 13,902) who received healthcare services within the VA SCI System of Care and were eligible for or enrolled in Medicare in 2011.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Patient characteristics, average number of visits and patient level frequencies of reasons for visits were determined for individuals within healthcare utilization (VA only, Medicare only, or dual VA/Medicare) groups. Multinomial logistic regression analyses were used to investigate associations of patient variables on dual use.

RESULTS

65.3% of Veterans with SCI/D were VA only users for outpatient encounters, 4.4% had encounters paid for by Medicare only, and 30.3% were dual users. Veterans were less likely to be VA only users if they were older than 69 and if they had been injured for greater than ten years. African American Veterans with SCI (compared to white) were more likely to be VA only users.

CONCLUSION

A substantial number (∼30%) of Veterans with SCI/D are dual users. These numbers highlight the importance of improved strategies to coordinate care and increase health information sharing across systems.

Effects of behaviour change interventions on physical activity in people with spinal cord injury: A systematic review and meta-analysis

OBJECTIVES

This review investigated the effectiveness of behaviour-change interventions to improve physical activity (PA) participation in individuals with a spinal cord injury. Additionally, the review sought to analyse the change in PA behaviour that might be expected by utilising behaviour change in PA interventions and what specific intervention characteristics, application of behaviour change theories, and behaviour change techniques are most efficacious.

METHODS

The protocol was prospectively registered on PROSPERO: CRD42021252744, and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed in this review. Eight databases were comprehensively searched using a well-defined strategy developed in collaboration with an academic liaison librarian. Randomised, non-randomised controlled, and non-controlled studies were included in this review; however, controlled and non-controlled studies were analysed separately. Studies were included if participants were older than 16 years and had an SCI of any cause, level or severity, regardless of the time since injury. The behaviour change technique taxonomy version 1 was used to code the intervention characteristics for behaviour modification. The combined effects across studies were pooled in a meta-analysis, and the risk of bias was assessed using the Cochrane Risk of Bias 2 tool.

RESULTS

The search retrieved 10,155 titles and abstracts. After duplicate removal and screening against the eligibility criteria, 23 studies were included. The overall effect estimate of the change in PA participation in the controlled trials post-intervention was medium (d = 0.50, 95% CI = 0.31-0.70) in favour of behaviour-targeted interventions. The mean difference in PA volume between pre- and post-intervention was an increase of 22 minutes per week (95% CI = 5.96-38.90). Interventions that provided practical support (d = 0.81, 95% CI = 0.46-1.16), which were individualised (d = 0.62, 95% CI = 0.34-0.90) and that utilised monitoring (d = 0.59, 95% CI = 0.34-0.83) had a greater effect on change to PA than those that were group-based and did not utilise those specific techniques.

CONCLUSIONS

Interventions that target behaviour change to increase PA in people with SCI appear effective. Utilising behaviour change frameworks and specific behaviour change techniques augments PA uptake and levels, and interventions aimed at improving PA in people with SCI should incorporate a behaviour modification component. More research is needed on the isolated effect of intervention structure parameters and specific behaviour change techniques.

The experience of using a hospital bed alternative at home among individuals with spinal cord injury: A case series

OBJECTIVE

To inform clinicians' equipment recommendations by characterizing the experiences, skin integrity, and interface pressures in a series of recently discharged individuals with spinal cord injury (SCI) who chose to use an alternative adjustable bed system at home rather than a standard of care hospital bed with mattress overlay.

DESIGN

Mixed methods, observational case series.

SETTING

Community based.

METHODS

Four individuals with cervical SCIs and one partner of a participant with SCI completed interviews about their experiences using an alternative adjustable bed system and their skin health. Participants also underwent pressure mapping on their alternative adjustable bed system and on a standard of care hospital bed with mattress overlay. Interview themes were identified using a consensus qualitative approach. Pressure readings at the sacrum and ischial tuberosities in supine and at the greater trochanter in side lying were compared between surfaces.

OUTCOME MEASURES

Semi-structured interview, questionnaire, and pressure mapping.

RESULTS

All participants reported positive experiences utilizing an alternative adjustable bed system and no episodes of bed-related skin breakdown. Reasons for wanting an alternative adjustable bed included a greater sense of normalcy and larger size. Participants perceived their alternative beds to be comfortable, and to have features that aided their function and assisted their caregivers. Features used included head of bed elevation, height elevation, and bed rails. All participants had clinically acceptable pressure mapping patterns on the alternative adjustable bed system.

CONCLUSION

An adjustable bed system, combined with other skin protection strategies, may be appropriate for certain individuals with spinal cord injury.

Causes and length of stay of readmission among individuals with traumatic spinal cord injury: a prospective observational cohort study

BACKGROUND

Secondary conditions may reduce function and participation in individuals with chronic Spinal Cord Injury (SCI). The knowledge of reasons for readmission to the hospital may be enlightening to prevent them and remodel the health services.

STUDY DESIGN

Multicenter prospective observational study of all consecutive readmissions of persons with SCI after rehabilitation completion.

OBJECTIVES

To explore the characteristics of individuals with SCI readmitted to the hospital, the reasons for readmissions and the burden on hospitalization in terms of length of stay (LoS) for different conditions.

SETTING

31 Italian specialized SCI centers.

METHODS

Data on people with traumatic SCI readmitted to SCI centers were recorded about: age, sex, SCI level and severity group, geographical origin, readmission causes, clinical interventions during hospitalization, LoS and discharge destination. Linear and multiple logistic regression analyses were performed considering LoS (days) as dependent variable for correlations with independent variables. All tests were two-sided.

RESULTS

Among 1039 persons with traumatic SCI enrolled (mean age 46, males 85%, tetraplegia 43%), 59.09% of the readmissions were caused by urological problems, 39.74% by pressure injury and 35.41% by spasticity (68% readmitted for ≥2 causes, associated with longer LoS). The mean LoS was 48 days: pressure injury, rehabilitative needs, sexual, bowel, and pain problems were associated with longer and urological problems with shorter LoS. People from the South of the country were frequently (68%) readmitted to the northern centers.

CONCLUSIONS

Urological problems, pressure injury and spasticity were the most frequent causes of re-hospitalization in individuals with traumatic SCI. The migration trend seeking SCI-specific treatments suggests geographic areas to which health care organizations need to pay more attention.

The Impact of Social Determinants of Health on Pressure Injury Progression: A Retrospective Chart and Scoping Review

OBJECTIVE

To understand the effects of nutrition security and social determinants of health (SDOHs) on pressure injury (PI) progression through a scoping review and retrospective review of patients reporting to New England's largest healthcare system.

METHODS

Authors performed a scoping review for full-text, original articles reporting outcomes data specific to PIs in patients with socially informed nutrition insecurity. Investigators also performed a retrospective review of all patients from 2012 to 2021 to search for patients with PI documentation and International Classification of Diseases, Tenth Revision Z codes related to the SDOHs.

RESULTS

A full-text review of 2,323 articles from 1965 to 2020 failed to locate any eligible studies. Investigators identified 1,044 patients who met the inclusion criteria; 50.7% were men, 74.3% were White, and 13.3% had evidence of detrimental SDOHs. The average PI duration was 12.13 days (interquartile range, 6 days). Multivariate regression analysis revealed that PI duration was longer in men, Black patients, and patients with evidence of detrimental SDOHs compared with their converse counterparts (P < .0001). The presence of detrimental SDOHs independently predicted an increased duration of disease by 13.07 days (95% CI, 8.99-17.15; t = 6.29, P < .0001).

CONCLUSIONS

A patient's SDOH history has a significant and considerably stronger correlation with disease progression than predictors that are traditionally studied such as sex, race, or body mass index. These findings are novel, as highlighted by the absence of data uncovered in the literature. These data carry relevance for plastic surgeons wishing to prevent early recurrence following operative closure of PI-related wounds.

Assessing physical activity and health-related quality of life in individuals with spinal cord injury: a national survey in Thailand

PURPOSE

This study sought to; (i) investigate the proportion of Thai individuals with spinal cord injury (Thai-SCI) who met SCI-specific physical activity (PA) guidelines, (ii) describe PA and health-related quality of life (HRQOL) of Thai-SCI across different sociodemographic strata, and, (iii) measure the variance in HRQOL associated with the intensity and volume of leisure-time physical activities (LTPA).

METHODS

Two surveys, measuring PA and HRQOL, were used in this study. Descriptive analysis, parametric and non-parametric tests for comparing two or more groups were used to analyse the data. The relationship between PA levels and HRQOL scores was investigated using Spearman's correlation coefficients. All statistical significance level in this study were set to alpha < 0.05.

RESULTS

From the 200 participants, 14.5% met aerobic, 20.5% met strength training and 13.5% met both aerobic and strength training SCI-specific PA guidelines. Sedentary Thai-SCI accounted for 49% of the study sample. Thai-SCI spent 132.0 ± 254.3 (mean ± SD) minutes per week on moderate-to-heavy intensity LTPA. Average Physical and Mental Component Summary (PCS and MCS scores) of Thai-SCI were 42.3 ± 7.6 and 49.3 ± 8.4 (mean ± SD), respectively. Increases in average LTPA of moderate-to-heavy intensities were weakly correlated with increases in PCS scores and its sub-domains (r = 0.1-0.3, n = 200, all p < 0.05).

CONCLUSION

The average time spent on moderate-to-heavy intensity ADLs and LTPA were below SCI-specific PA guidelines and the WHO global recommendations for PA. The proportion of Thai-SCI who were sedentary was high, suggesting immediate action and implementation of strategies to promote PA for Thai-SCI.IMPLICATIONS FOR REHABILITATIONThe proportion of Thai people with spinal cord injury with a sedentary lifestyle was high.Healthcare providers in Thailand must engage to a greater degree in health-related physical activity promotion to effectively deliver physical activity and exercise knowledge to their clients with spinal cord injury.Likely, structured programs of physical activity and exercise deployed by healthcare professionals with the appropriate knowledge and skills might reverse the current trend to sedentary lifestyle in this population.Interventions to improve participation in physical activity and health-related quality of life should be tailored to the individual needs of Thai individuals with a spinal cord injury and might be better delivered seperately.

Prevalence of spasticity in humans with spinal cord injury with different injury severity

Spasticity is one of the most common symptoms manifested following spinal cord injury (SCI). The aim of this study was to assess spasticity in individuals with subacute and chronic SCI with different injury severity, standardizing the time and assessments of spasticity. We tested 110 individuals with SCI classified by the American Spinal Injury Association Impairment Scale (AIS) as either motor complete (AIS A and B; subacute, n = 25; chronic, n = 33) or motor incomplete (AIS C and D; subacute, n = 23; chronic, n = 29) at a similar time after injury (subacute, ∼1 mo after injury during inpatient rehabilitation and chronic, ≥1 yr after injury) using clinical (modified Ashworth scale) and kinematic (pendulum test) outcomes to assess spasticity in the quadriceps femoris muscle. Using both methodologies, we found that among individuals with subacute motor complete injuries, only a minority showed spasticity, whereas the majority exhibited no spasticity. This finding stands in contrast to individuals with subacute motor incomplete injury, where both methodologies revealed that a majority exhibited spasticity, whereas a minority exhibited no spasticity. In chronic injuries, most individuals showed spasticity regardless of injury severity. Notably, when spasticity was present, its magnitude was similar across injury severity in both subacute and chronic injuries. Our results suggest that the prevalence, not the magnitude, of spasticity differs between individuals with motor complete and incomplete SCI in the subacute and chronic stages of the injury. We thus argue that considering the "presence of spasticity" might help the stratification of participants with motor complete injuries for clinical trials.NEW & NOTEWORTHY The prevalence of spasticity in humans with SCI remains poorly understood. Using kinematic and clinical outcomes, we examined spasticity in individuals with subacute and chronic injuries of different severity. We found that spasticity in the quadriceps femoris muscle was more prevalent among individuals with subacute motor incomplete than in those with motor complete injuries. However, in a different group of individuals with chronic injuries, no differences were found in the prevalence of spasticity across injury severity.

Rehospitalization During the First 5 Years After the Onset of Traumatic Spinal Cord Injury: A Population-Based Study Using Administrative Billing Records

OBJECTIVE

Our objective was to identify the number, length of stay, and charges of rehospitalizations during the subsequent 5 years after discharge from the initial hospitalization by using administrative billing records from a population-based cohort with spinal cord injury (SCI) in the southeastern United States.

DESIGN

Analysis of administrative billing data.

SETTING

State-based surveillance data analyzed by an academic medical center in the southeastern United States.

PARTICIPANTS

A total of 1872 individuals (N=1872) from a state-based surveillance system in the southeastern United States whose onset was between January 1, 1998, and January 1, 2010.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The outcome measures were the number of rehospitalization episodes, length of stay, and total hospital charges for each episode of rehospitalization.

RESULTS

Seventy percent of participants were rehospitalized during the first 5 years after initial discharge, and the highest rehospitalization rates were in the first year (54%), being relatively stable in years 2-5 (21%-22%). Adjusted to 2019 US dollars, the average total rehospitalization charges were $214,716 per person during the 5 years. Participants who could walk independently had fewer rehospitalizations, fewer rehospitalization days, and less rehospitalization charges than the nonambulatory participants. College education was also associated with less rehospitalization charges.

CONCLUSIONS

Rehospitalization is a significant cost after SCI. Further longitudinal study on the population cohorts and billing data are needed to quantify these changes over time.

Preventative Services Use and Risk Reduction for Potentially Preventative Hospitalizations among People with Traumatic Spinal Cord Injury

OBJECTIVE

To examine the risk of potentially preventable hospitalizations (PPHs) for adults (18 years or older) with traumatic spinal cord injury (TSCI) to identify the most common types of preventable hospitalizations and their associative risk factors.

DESIGN

Cohort study.

SETTING

Using 2007-2017 U.S. claims data from the Optum Clinformatics Data Mart, we identified adults (18 years or older) with diagnosis of TSCI (n=5380). Adults without TSCI diagnosis were included as controls (n=1,074,729). Using age and sex, we matched individuals with and without TSCI (n=5173) with propensity scores to address potential selection bias. Generalized linear regression was applied to examine the risk of TSCI on PPHs. Models were adjusted for age; sex; race and ethnicity; Elixhauser comorbidity count; any cardiometabolic, psychological, and musculoskeletal chronic conditions; U.S. Census Division; socioeconomic variables; and use of certain preventative care services. Adjusted odds ratios were compared within a 4-year follow-up period.

PARTICIPANTS

Adults with and without TSCI (N=5,173).

INTERVENTION

Not applicable.

MAIN OUTCOMES MEASURES

Any PPH and specific PPHs RESULTS: Adults with TSCI had higher risk for any PPH (odds ratio [OR], 1.67; 95% CI,1.20-2.32), as well as PPHs because of urinary tract infection (UTI) (OR, 3.78; 95% CI, 2.47-5.79), hypertension (OR, 3.77; 95% CI, 1.54-9.21), diabetes long-term complications (OR, 2.54; 95% CI, 1.34-4.80), and pneumonia (OR, 1.71; 95% CI. 1.21-2.41). Annual wellness visit was associated with reduced PPH risk compared with cases and controls without annual wellness visit (OR, 0.57; 95% CI, 0.46-0.71) and among people with TSCI (OR, 0.69; 95% CI, 0.55-0.86) compared with cases without annual wellness visit.

CONCLUSIONS

Adults with TSCI are at a heightened risk for PPH. They are also more susceptible to certain PPHs such as UTIs, pneumonia, and heart failure. Encouraging the use of preventative or health-promoting services, especially for respiratory and urinary outcomes, may reduce PPHs among adults with TSCI.

Interface pressure reduction effects of wheelchair cushions in individuals with spinal cord injury: a rapid review

OBJECTIVE

Wheelchair cushion is routinely used to manage the sitting acquired pressure for an individual with spinal cord injury, but which kind of wheelchair cushion performs better in terms of interface pressure management is unclear. This review aims to compare different kinds of wheelchair cushions on their effect of interface pressure reduction in individuals with spinal cord injury.

METHODS AND RESULTS

The databases of MEDLINE, CINAHL, EMBASE and Web of Science were searched. Totally 10 studies were included in this review. Seven of the included studies indicated that air cushions were superior to gel cushions in interface pressure reduction. Three of the included studies reported that gel cushions were superior to polyurethane foam cushions in interface pressure reduction. The variables of measurement duration, measurement focus, measurement devices, cushion covering, sample variations and body positioning of patients may confound the comparison of interface pressure reduction effect of different wheelchair cushions among studies.

CONCLUSIONS

Air cushion was reported more consistently effective in interface pressure reduction than gel and foam cushions. While the variable parameters (measurement duration, focus, devices) and individual conditions (BMI, body positioning) may interfere the comparison among studies. Researches disseminating consistent parameters and clinical prescriptions with individualized evaluation are suggested for the establishment of an evidence-based practice in clinic.Implications for rehabilitationWheelchair cushion is routinely used for an individual post spinal cord injury to manage the sitting acquired pressure.Which kind of wheelchair cushion performs better in terms of interface pressure management is unclear.Air cushion is found more consistently effective in interface pressure reduction than gel cushion and foam cushion.Individualized evaluation of the interface pressure is suggested for the prescription of wheelchair cushion in clinic.

A systematic review of suicidal ideation and behaviors among adults with spinal cord injury

CONTEXT

Suicide is a public health crisis within the United States. Individuals with spinal cord injury (SCI) are vulnerable to negative outcomes such as suicide.

OBJECTIVE

This systematic review describes frequency of suicidal ideation (SI) and behaviors (suicide attempt [SA] and deaths) among samples of adults living with SCI. Associated risk and protective factors of SI and suicidal behaviors were also explored.

METHODS

On July 7, 2021, OVID Medline, EMBASE, OVID PsycINFO, Web of Science Core Collection, CINAHL, Cochrane Library, and Google Scholar databases were searched for SI, SA, and deaths by suicide among adults with a history of SCI. Risk of bias (RoB) was assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Results were synthesized descriptively considering the likely impact of RoB. The updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 reporting method was used.

RESULTS

Sixty-nine articles were included. Frequency of SI and SAs within study samples ranged from 4% to 67%, and 0% to approximately 66%, respectively. While assessment methods for SI and SA widely varied, suicide deaths data sources were more consistent. Studies assessing SI and SA generally had high RoB and the overall strength of evidence was low. Stronger observational study designs assessing death by suicide had low RoB and the overall strength of evidence was high. Very few studies examined protective factors.

DISCUSSION

Findings support previous work. Quality of evidence, and therefore confidence in the frequency of these outcomes, was impacted by the use of assessment measures without sufficient psychometric properties. The field will benefit from use of psychometrically sound measures to assess for SI, SA and suicide deaths. Furthermore, additional work is needed to elucidate risk and protective factors and to clearly characterize samples to increase generalizability of findings to the larger SCI community, including standardized reporting of SCI characteristics (e.g. use of American Spinal Injury Association classification system). Ultimately, improved suicide assessment and risk management is expected to prevent suicide among those living with SCI.

REGISTRATION

CRD42020164686.

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.

Genomic and Epigenomic Evaluation of Electrically Induced Exercise in People With Spinal Cord Injury: Application to Precision Rehabilitation

OBJECTIVE

Physical therapists develop patient-centered exercise prescriptions to help overcome the physical, emotional, psychosocial, and environmental stressors that undermine a person's health. Optimally prescribing muscle activity for people with disability, such as a spinal cord injury, is challenging because of their loss of volitional movement control and the deterioration of their underlying skeletal systems. This report summarizes spinal cord injury-specific factors that should be considered in patient-centered, precision prescription of muscle activity for people with spinal cord injury. This report also presents a muscle genomic and epigenomic analysis to examine the regulation of the proliferator-activated receptor γ coactivator 1α (PGC-1α) (oxidative) and myostatin (hypertrophy) signaling pathways in skeletal muscle during low-frequency (lower-force) electrically induced exercise versus higher-frequency (higher-force) electrically induced exercise under constant muscle recruitment (intensity).

METHODS

Seventeen people with spinal cord injury participated in 1 or more unilateral electrically induced exercise sessions using a lower-force (1-, 3-, or 5-Hz) or higher-force (20-Hz) protocol. Three hours after the exercise session, percutaneous muscle biopsies were performed on exercised and nonexercised muscles for genomic and epigenomic analysis.

RESULTS

We found that low-frequency (low-force) electrically induced exercise significantly increased the expression of PGC-1α and decreased the expression of myostatin, consistent with the expression changes observed with high-frequency (higher-force) electrically induced exercise. Further, we found that low-frequency (lower-force) electrically induced exercise significantly demethylated, or epigenetically promoted, the PGC-1α signaling pathway. A global epigenetic analysis showed that >70 pathways were regulated with low-frequency (lower-force) electrically induced exercise.

CONCLUSION

These novel results support the notion that low-frequency (low-force) electrically induced exercise may offer a more precise rehabilitation strategy for people with chronic paralysis and severe osteoporosis. Future clinical trials are warranted to explore whether low-frequency (lower-force) electrically induced exercise training affects the overall health of people with chronic spinal cord injury.

Characterizing the Experience of Spasticity after Spinal Cord Injury: A National Survey Project of the Spinal Cord Injury Model Systems Centers

OBJECTIVE

To characterize the qualities that individuals with spinal cord injury (SCI) associate with their experience of spasticity and to describe the relationship between spasticity and perceived quality of life and the perceived value of spasticity management approaches.

DESIGN

Online cross-sectional survey.

SETTING

Multicenter collaboration among 6 Spinal Cord Injury Model Systems hospitals in the United States.

PARTICIPANTS

Individuals with SCI (N=1076).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Qualities of Spasticity Questionnaire, modified Spinal Cord Injury-Spasticity Evaluation Tool (mSCI-SET), and the modified Patient-Reported Impact of Spasticity Measure (mPRISM).

RESULTS

Respondents indicated that spasms most often occurred in response to movement-related triggering events. However, spontaneous spasms (ie, no triggering event) were also reported to be among the most common types. Frequency of spasms appears to decline with age. The highest frequency of spasms was reported by 56% of respondents aged <25 years and by only 28% of those >55 years. Stiffness associated with spasticity was reported to be more common than spasms (legs, 65% vs 54%; trunk, 33% vs 18%; arms, 26% vs 15%). Respondents reported negative effects of spasticity more commonly than positive effects. Based on their association with negative scores on the mSCI-SET and the mPRISM, the 5 most problematic experiences reported were stiffness all day, interference with sleep, painful spasms, perceived link between spasticity and pain, and intensification of pain before a spasm. Respondents indicated spasticity was improved more by stretching (48%) and exercise (45%) than by antispasmodics (38%).

CONCLUSIONS

The experience of spasticity after SCI is complex and multidimensional, with consequences that affect mobility, sleep, comfort, and quality of life. Stiffness, rather than spasms, appears to be the most problematic characteristic of spasticity. Physical therapeutic interventions to treat spasticity warrant in-depth investigation.

The Involvement of CaV1.3 Channels in Prolonged Root Reflexes and Its Potential as a Therapeutic Target in Spinal Cord Injury

Spinal cord injury (SCI) results in not only the loss of voluntary muscle control, but also in the presence of involuntary movement or spasms. These spasms post-SCI involve hyperexcitability in the spinal motor system. Hyperactive motor commands post SCI result from enhanced excitatory postsynaptic potentials (EPSPs) and persistent inward currents in voltage-gated L-type calcium channels (LTCCs), which are reflected in evoked root reflexes with different timings. To further understand the contributions of these cellular mechanisms and to explore the involvement of LTCC subtypes in SCI-induced hyperexcitability, we measured root reflexes with ventral root recordings and motoneuron activities with intracellular recordings in an in vitro preparation using a mouse model of chronic SCI (cSCI). Specifically, we explored the effects of 1-(3-chlorophenethyl)-3-cyclopentylpyrimidine-2,4,6-(1H,3H,5H)-trione (CPT), a selective negative allosteric modulator of Ca_V1.3 LTCCs. Our results suggest a hyperexcitability in the spinal motor system in these SCI mice. Bath application of CPT displayed slow onset but dose-dependent inhibition of the root reflexes with the strongest effect on LLRs. However, the inhibitory effect of CPT is less potent in cSCI mice than in acute SCI (aSCI) mice, suggesting changes either in composition of Ca_V1.3 or other cellular mechanisms in cSCI mice. For intracellular recordings, the intrinsic plateau potentials, was observed in more motoneurons in cSCI mice than in aSCI mice. CPT inhibited the plateau potentials and reduced motoneuron firings evoked by intracellular current injection. These results suggest that the LLR is an important target and that CPT has potential in the therapy of SCI-induced muscle spasms.

Role of Baclofen in Modulating Spasticity and Neuroprotection in Spinal Cord Injury

Spinal cord injury (SCI) affects an estimated three million persons worldwide, with ∼180,000 new cases reported each year leading to severe motor and sensory functional impairments that affect personal and social behaviors. To date, no effective treatment has been made available to promote neurological recovery after SCI. Deficits in motor function is the most visible consequence of SCI; however, other secondary complications produce a significant impact on the welfare of patients with SCI. Spasticity is a neurological impairment that affects the control of muscle tone as a consequence of an insult, trauma, or injury to the central nervous system, such as SCI. The management of spasticity can be achieved through the combination of both nonpharmacological and pharmacological approaches. Baclofen is the most effective drug for spasticity treatment, and it can be administered both orally and intrathecally, depending on spasticity location and severity. Interestingly, recent data are revealing that baclofen can also play a role in neuroprotection after SCI. This new function of baclofen in the SCI scope is promising for the prospect of developing new pharmacological strategies to promote functional recovery in patients with SCI.

Decreasing re-hospitalizations and emergency department visits in persons with recent spinal cord injuries using a specialized medical home

Objective: To determine whether a specialized medical home can reduce re-hospitalizations and emergency department (ED) visits as compared to reports in the literature for persons with spinal cord injury (SCI) in the first year post-discharge from acute inpatient rehabilitation.Design: A three-year prospective cohort study.Setting: An academic free standing inpatient rehabilitation hospital (IRF), participating in the SCI Model Systems network, serving urban, rural and suburban settings in the mid-Atlantic region of the United States of America.Participants: 176 successive individuals with varying levels of SCI, inclusive of patients requiring mechanical ventilation, discharged from rehabilitation from 2/1/15 to 7/1/17, who met criteria and consented to participate.Interventions: Pre-discharge communication between the inpatient and outpatient staff was initiated, medication education by a pharmacist was added, 1 month of discharge medications was offered, and proactive phone calls to patients after discharge were instituted. In addition, patients were offered a 24/7 hotline to reach physician and nursing staff, and multidisciplinary outpatient follow-up was provided in conjunction with extensive proactive case management.Outcome measures: All-cause hospital readmission and ED visits.Results: Thirty percent of the individuals were readmitted within the first year after discharge from an IRF, and 24% were readmitted within the first year after onset. The incidence of readmission was 0.46 and 0.36 respectively. Forty-one percent had an ED visit.Conclusion: The results suggest that the medical home interventions decreased the rate and incidence of readmission and the rate of ED usage in the first year.

Secondary health conditions and disability among people with spinal cord injury: A prospective cohort study

Objective: To examine how secondary health conditions (SHCs) that develop early after a spinal cord injury (SCI) are related to disability over time.Design: Prospective cohort study.Setting: Two spinal units in New Zealand (Burwood Spinal Unit and Auckland Spinal Rehabilitation Unit).Participants: Between 2007 and 2009, 91 people participated in three telephone interviews approximately 6, 18, and 30 months after the occurrence of a SCI.Outcome measures: SHCs were measured using 14 items derived from the Secondary Complications Survey. Disability was measured using the 12-item World Health Organization Disability Assessment Schedule 2.0. Linear regression analyses were performed to investigate associations between SHCs at 6 months and disability at each assessment point.Results: The most prevalent SHCs were leg spasms, constipation, back pain, pain below the level of SCI, and shoulder pain. Constipation, urinary tract infection, and headaches at 6 months post-SCI were associated with significantly higher levels of disability at each subsequent follow-up, independent of age, sex and SCI impairment. Back pain, and pain below the SCI, at 6 months were associated with significantly greater disability at 18 months, and difficulty coughing at 6 months was associated with significantly greater disability at 30 months.Conclusion: The experience of specific SHCs in the first 6 months after an SCI is related to greater long-term disability. In order to reduce the disability burden of people with SCI, efforts should be directed toward early prevention of these SHCs.

Ambulation in Dogs With Absent Pain Perception After Acute Thoracolumbar Spinal Cord Injury

Acute thoracolumbar spinal cord injury (SCI) is common in dogs frequently secondary to intervertebral disc herniation. Following severe injury, some dogs never regain sensory function to the pelvic limbs or tail and are designated chronically "deep pain negative." Despite this, a subset of these dogs develop spontaneous motor recovery over time including some that recover sufficient function in their pelvic limbs to walk independently without assistance or weight support. This type of ambulation is commonly known as "spinal walking" and can take up to a year or more to develop. This review provides a comparative overview of locomotion and explores the physiology of locomotor recovery after severe SCI in dogs. We discuss the mechanisms by which post-injury plasticity and coordination between circuitry contained within the spinal cord, peripheral sensory feedback, and residual or recovered supraspinal connections might combine to underpin spinal walking. The clinical characteristics of spinal walking are outlined including what is known about the role of patient or injury features such as lesion location, timeframe post-injury, body size, and spasticity. The relationship between the emergence of spinal walking and electrodiagnostic and magnetic resonance imaging findings are also discussed. Finally, we review possible ways to predict or facilitate recovery of walking in chronically deep pain negative dogs. Improved understanding of the mechanisms of gait generation and plasticity of the surviving tissue after injury might pave the way for further treatment options and enhanced outcomes in severely injured dogs.

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.

Transcutaneous Spinal Cord Stimulation Induces Temporary Attenuation of Spasticity in Individuals with Spinal Cord Injury

Epidural spinal cord stimulation (SCS) is currently regarded as a breakthrough procedure for enabling movement after spinal cord injury (SCI), yet one of its original applications was for spinal spasticity. An emergent method that activates similar target neural structures non-invasively is transcutaneous SCS. Its clinical value for spasticity control would depend on inducing carry-over effects, because the surface-electrode-based approach cannot be applied chronically. We evaluated single-session effects of transcutaneous lumbar SCS in 12 individuals with SCI by a test-battery approach, before, immediately after and 2 h after intervention. Stimulation was applied for 30 min at 50 Hz with an intensity sub-threshold for eliciting reflexes in lower extremity muscles. The tests included evaluations of stretch-induced spasticity (Modified Ashworth Scale [MAS] sum score, pendulum test, electromyography-based evaluation of tonic stretch reflexes), clonus, cutaneous-input-evoked spasms, and the timed 10 m walk test. Across participants, the MAS sum score, clonus, and spasms were significantly reduced immediately after SCS, and all spasticity measures were improved 2 h post-intervention, with large effect sizes and including clinically meaningful improvements. The effect on walking speed varied across individuals. We further conducted a single-case multi-session study over 6 weeks to explore the applicability of transcutaneous SCS as a home-based therapy. Self-application of the intervention was successful; weekly evaluations suggested progressively improving therapeutic effects during the active period and carry-over effects for 7 days. Our results suggest that transcutaneous SCS can be a viable non-pharmacological option for managing spasticity, likely working through enhancing pre- and post-synaptic spinal inhibitory mechanisms, and may additionally serve to identify responders to treatments with epidural SCS.

Impact of spasticity on transfers and activities of daily living in individuals with spinal cord injury

CONTEXT/OBJECTIVE

For persons with spinal cord injury, spasticity commonly interferes with activities of daily living such as transfers. Electromyography can be used to objectively measure muscle spasms during transfers, but how electromyographic measures relate to the impact spasticity has on life, or to clinically-rated spasticity, is unclear. We aimed to characterize relationships among spasm duration and magnitude, impact of spasticity on daily life, and a clinical measure of extensor spasticity, as well as to determine reliability of the electromyographic measures.

DESIGN

Participants (N=19) underwent electromyographic measurements of involuntary muscle activity (spasm duration and magnitude) evoked in quadriceps muscles during transfers on two days. Impact of spasticity on daily life was measured with the Spinal Cord Injury Spasticity Evaluation Tool. Clinically-rated spasticity severity was measured with the Spinal Cord Assessment Tool for Spastic reflexes.

RESULTS

No significant associations were found between impact of spasticity and spasm duration, spasm magnitude, or clinical extensor spasticity score. Absolute and normalized spasm duration were positively associated with clinical extensor spasticity score (rho=0.510-0.667, P < 0.05). Spasm measures during transfers had good to excellent day-to-day reliability (rho=0.656-0.846, P < 0.05).

CONCLUSIONS

Electromyographic and clinical measures of involuntary activity in the lower extremity do not significantly relate to perceived impact of spasticity on daily life. However, quadriceps spasm duration during transfers is related to clinically-rated extensor spasticity. Electromyography is a reliable method of quantifying quadriceps spasms during transfers. Future investigations should identify factors that influence the impact of spasticity on life, which may help direct treatment strategies to reduce problematic impact.

The lifetime cost of spinal cord injury in Ontario, Canada: A population-based study from the perspective of the public health care payer

OBJECTIVE

To determine the publicly funded health care system lifetime cost-of-illness of spinal cord injury (SCI) from the perspective of the Ontario Ministry of Health and Long-term Care.

METHODS

Individuals hospitalized for their first SCI between the years 2005 and 2011 were identified and their health care costs were calculated using Ontario administrative health care data. From this information, lifetime costs were estimated using phase-based costing methods. The spinal cord injured cohort was matched to a non-spinal cord injured using propensity score matching. Net costs were determined by calculating the difference in costs between the two matched groups. Net costs were also presented for subgroups stratified by demographic characteristics.

RESULTS

A total of 1,716 individuals with SCI were identified and matched in our study. The net lifetime cost of SCI was $336,000 per person. Much of the costs were observed in the first year post-SCI. The lifetime cost of SCI for individuals with a concurrent pressure ulcer at the initial hospitalization rises to $479,600. Costs were also higher for individuals with cervical or thoracic injury or requiring inpatient rehabilitation.

CONCLUSIONS

Spinal cord injury is a substantial burden to the health care system. Our results are limited to the direct health care costs from the publicly funded health care payer perspective. Further analysis with a broader perspective is needed to understand the full economic impact of this catastrophic condition.

Assessment of quality of life in relation to spasticity severity and socio-demographic and clinical factors among patients with spinal cord injury

Objective: To assess the impact of spasticity severity as well as socio-demographic and clinical factors on quality of life (QOL) and to identify factors predicting poor QOL among patients with spinal cord injury (SCI)Design: Descriptive cross-sectional study.Setting: Tertiary care clinic in Istanbul, Turkey.Participants: A total of 110 patients with SCI (mean (SD) age: 43.8 (14.7) years, 58.2% were males) were enrolled.Assessments: The American Spinal Injury Association (ASIA) Impairment Scale (AIS), Modified Ashworth Scale (MAS) and Turkish version of the World Health Organization Quality of life questionnaire (WHOQOL-BREF) were utilized to determine the SCI category, severity of spasticity and QOL scores, respectively.Outcome measures: The WHOQOL-BREF scores were evaluated with respect to the severity of spasticity, aetiology and duration of SCI, AIS category and method of bladder management.Results: The mean (SD) physical health (41.9 (15.3) vs. 46.5 (10.9), P = 0.029), social relationships (45.6 (20.2) vs. 53.8 (17.3), P = 0.025) and total WHOQOL-BREF scores were significantly lower in patients with more severe spasticity. Multivariate linear regression analysis revealed that severity of spasticity was a significant predictor of decreased WHOQOL-BREF total scores, physical domain scores and social relations domain scores by 11.381 (P = 0.007), 11.518 (P = 0.005) and 17. 965 (P = 0.004), respectively.Conclusion: In conclusion, addressing QOL in relation to severity of spasticity for the first time among Turkish SCI patients, our findings revealed a negative impact of the spasticity severity on the WHOQOL-BREF scores, particularly for physical health and social relationship domains.

Considerations in the Management of Upper Extremity Spasticity

Spasticity is a movement disorder characterized by a velocity-dependent increase in muscle tone and a hyperexcitable stretch reflex. Common causes of spasticity include cerebral palsy, spinal cord injury, and stroke. Surgical treatment plans for spasticity must be highly individualized and based on the characteristics of patients and the spasticity in order to maximize functional gains. Candidates for surgery must be carefully selected. In this article, the authors review the pathophysiology of spasticity and discuss general considerations for surgical management with an emphasis on patient factors and spasticity characteristics. Specific considerations for the common causes of spasticity are presented.

Common Etiologies of Upper Extremity Spasticity

Spasticity is a motor disorder that manifests as a component of the upper motor neuron syndrome. It is associated with paralysis and can cause significant disability. The most common causes leading to spasticity include stroke, traumatic brain injury, multiple sclerosis, spinal cord injury, and cerebral palsy. This article discusses the pathophysiology and clinical findings associated with each of the most common etiologies of upper extremity spasticity.

Self-management of pain and depression in adults with spinal cord injury: A scoping review

Context: Pain and depression are two prevalent secondary complications associated with spinal cord injury (SCI) that negatively impact health and well-being. Self-management strategies are growing in popularity for helping people with SCI to cope with their pain and depression. However, there is still a lack of research on which approaches are best suited for this population.Objective: The aim of this scoping review was to determine what is known about the self-management of pain and depression through the use of pharmacological and non-pharmacological therapies in adults with SCI.Methods: Seven electronic databases were searched for articles published between January 1, 1990 and June 13, 2017. Grey literature was searched and additional articles were identified by manually searching the reference lists of included articles.Results: Overall, forty-two articles met the inclusion criteria; with the majority reporting on the self-management of pain, rather than on depression or on both complications. Non-pharmacological interventions were more likely to include self-management strategies than pharmacological interventions. A limited number of studies included all of the core self-management tasks and skills.Conclusions: There are significant knowledge gaps on effective self-management interventions for pain and depression post-SCI. There is a need to develop interventions that are multi-faceted, which include both pharmacological and non-pharmacological therapies to address multimorbidity.

H-reflex disinhibition by lumbar muscle inflammation in a mouse model of spinal cord injury

Inflammation is a common comorbidity in patients with traumatic spinal cord injury (SCI). Recent reports indicate that inflammation hinders functional recovery in animal models of SCI. However, the spinal mechanisms underlying this alteration are currently unknown. Considering that spinal plasticity is a therapeutic target in patients and animal models of SCI, these mechanisms remain to be clarified. Using injections of complete Freund's adjuvant (CFA) in lumbar muscles as a model of persistent inflammation, the objective of this study was to assess the impact of inflammation on spinal reflex excitability after a complete midthoracic spinal transection in mice. To this end, the excitability of spinal reflexes was examined by measuring H-reflex frequency-dependent depression (FDD) on days 7, 14 and 28 following a complete spinal transection. H-reflex parameters were compared between spinal mice with CFA and control spinal mice. On day 7, lumbar muscle inflammation disinhibited the H-reflex, reflected by an attenuation of H-reflex FDD (p < 0.01), although this effect did not persist later on, either on day 14 or day 28. These results indicate that lumbar muscle inflammation alters spinal reflex excitability transiently in spinal mice. Considering that changes in spinal reflex excitability are associated with poor functional recovery after SCI, this implies that inflammation should be treated effectively to promote optimal recovery following SCI.

Economic Consequences of an Implanted Neuroprosthesis in Subjects with Spinal Cord Injury for Restoration of an Effective Cough

Objective: To determine if an implanted neuroprosthesis for restoration of an effective cough is less costly than conventional methods of respiratory management. Methods: Nonrandomized clinical trial of participants (N = 14) with spinal cord injury (SCI) using the Cough Stimulator device in the inpatient hospital setting for Cough Stimulator implantation and outpatient hospital or residence for follow-up. A neuroprosthesis was implanted for restoration of an effective cough. The annual costs associated with respiratory management, without (pre implantation) and with (post implantation) the neuroprosthesis, were examined over a 4-year period. Results: The total cost related to implantation of the Cough Stimulator was $59,891, with no maintenance costs over subsequent years. The incidence of respiratory tract infections and the need for caregiver support fell significantly following implantation. The costs associated with respiratory tract infections fell significantly from a mean of $36,406 ± 11,855/year to $13,284 ± 7,035/year (p < .05) pre and post implantation, respectively. Costs fell further to $8,817 ± 5,990 and $4,467 ± 4,404 following the 2nd and 3rd years post implantation (p < .05), respectively. The costs associated with caregiver support fell significantly from $25,312 ± 8,019/year to $2,630 ± 2,233/year (p < .05) pre and post implantation, respectively, and remained low in subsequent years (p < .05). Other costs related to secretion management fell significantly and remained low in subsequent years (p < .05). Break-even analysis demonstrated that this point was reached in the first year. Conclusion: The results of this investigation demonstrate that implantation and use of the Cough Stimulator resulted in significant reductions in the overall costs of respiratory management in this patient population.

Research on prevalence of secondary conditions in individuals with disabilities: an overview

Individuals with disabilities may be at increased risk of a number of secondary conditions. Secondary conditions influence health status and quality of life. Many of these conditions are preventable and their consequences can be managed. Knowledge of the prevalence, course, and association with age of secondary conditions is needed for better prevention and management. The aim of present study was to review the available literature on the prevalence of secondary conditions in individuals with disability. We performed searches of electronic databases for studies published between 1980 and 2017 that provided information on the prevalence of secondary conditions in individuals with disabilities. The reference list of all relevant citations was also reviewed for further material. Nineteen papers were included. The findings indicate that (i) studies were mainly population-based descriptive studies, (ii) researchers used different questionnaires, (iii) the most common studied population are patients with spinal cord injury, and (iv) even though secondary conditions are different in different patient populations, the main secondary conditions are pain, spasticity, urinary tract infections, fatigue, depression, and sleep problems. The prevalence of each condition varies widely depending on the studied population and research methodologies across studies. There is still much information that remains to be obtained on the prevalence, definition, and conceptual organization of secondary conditions. There is also a lack of longitudinal studies on the natural course of these conditions.

Clinical feasibility of gait training with a robotic exoskeleton (WPAL) in an individual with both incomplete cervical and complete thoracic spinal cord injury: A case study

BACKGROUND

Patients with tetraplegia can achieve independent gait with lateral-type powered exoskeletons; it is unclear whether medial-type powered exoskeletons allow for this.

OBJECTIVE

To investigate gait training with a medial-type powered exoskeleton wearable power-assist locomotor (WPAL) in an individual with incomplete cervical (C5) and complete thoracic (T12) spinal cord injury (SCI).

METHODS

The 60-session program was investigated retrospectively using medical records. Upon completion, gait performance was examined using three-dimensional motion analyses and surface electromyography (EMG) of the upper limbs.

RESULTS

The subject achieved independent gait with WPAL and a walker in 12 sessions. He continuously extended his right elbow; his left elbow periodically flexed/extended. His pelvic inclination was larger than the trunk inclination during single-leg stance. EMG activity was increased in the left deltoid muscles during ipsilateral foot-contact. The right anterior and medial deltoid muscle EMG activity increased just after foot-off for each leg, as did the right biceps activity. Continuous activity was observed in the left triceps throughout the gait cycle; activity was unclear in the right triceps.

CONCLUSIONS

These results suggest the importance of upper limb residual motor function, and may be useful in extending the range of clinical applications for robotic gait rehabilitation in patients with SCI.

Development of VariLeg, an exoskeleton with variable stiffness actuation: first results and user evaluation from the CYBATHLON 2016

BACKGROUND

Powered exoskeletons are a promising approach to restore the ability to walk after spinal cord injury (SCI). However, current exoskeletons remain limited in their walking speed and ability to support tasks of daily living, such as stair climbing or overcoming ramps. Moreover, training progress for such advanced mobility tasks is rarely reported in literature. The work presented here aims to demonstrate the basic functionality of the VariLeg exoskeleton and its ability to enable people with motor complete SCI to perform mobility tasks of daily life.

METHODS

VariLeg is a novel powered lower limb exoskeleton that enables adjustments to the compliance in the leg, with the objective of improving the robustness of walking on uneven terrain. This is achieved by an actuation system with variable mechanical stiffness in the knee joint, which was validated through test bench experiments. The feasibility and usability of the exoskeleton was tested with two paraplegic users with motor complete thoracic lesions at Th4 and Th12. The users trained three times a week, in 60 min sessions over four months with the aim of participating in the CYBATHLON 2016 competition, which served as a field test for the usability of the exoskeleton. The progress on basic walking skills and on advanced mobility tasks such as incline walking and stair climbing is reported. Within this first study, the exoskeleton was used with a constant knee stiffness.

RESULTS

Test bench evaluation of the variable stiffness actuation system demonstrate that the stiffness could be rendered with an error lower than 30 Nm/rad. During training with the exoskeleton, both users acquired proficient skills in basic balancing, walking and slalom walking. In advanced mobility tasks, such as climbing ramps and stairs, only basic (needing support) to intermediate (able to perform task independently in 25% of the attempts) skill levels were achieved. After 4 months of training, one user competed at the CYBATHLON 2016 and was able to perform 3 (stand-sit-stand, slalom and tilted path) out of 6 obstacles of the track. No adverse events occurred during the training or the competition.

CONCLUSION

Demonstration of the applicability to restore ambulation for people with motor complete SCI was achieved. The CYBATHLON highlighted the importance of training and gaining experience in piloting an exoskeleton, which were just as important as the technical realization of the robot.

Antispasmodic medications may be associated with reduced recovery during inpatient rehabilitation after traumatic spinal cord injury

OBJECTIVE

To determine whether antispasmodic medications are associated with neurological and functional outcomes during the first year after traumatic spinal cord injury (SCI).

DESIGN/METHODS

Retrospective analysis of prospectively collected data from six inpatient SCI rehabilitation centers. Baseline-adjusted outcomes at discharge and one-year follow-up were compared using analysis of covariance between patients who received antispasmodic medication on at least 5 days during inpatient rehabilitation and patients who did not.

OUTCOME MEASURES

Rasch-transformed motor subscore of the Functional Independence Measure (FIM); International Standards for Neurological Classification of Spinal Cord Injury motor scores, grade, and level.

RESULTS

Of 1,259 patients, 59.8%, 35.4%, and 4.8% were injured at the cervical, thoracic, and lumbosacral levels, respectively. 65.6% had motor complete injury. Rasch-transformed motor FIM score at admission averaged 23.3 (95% confidence interval (CI) 22.4-24.2). Total motor score averaged 39.2 (95% CI 37.8-40.6). 685 patients (54.4%) received one or more antispasmodic medications on at least 5 days. After controlling for demographic and injury variables at admission, Rasch-transformed motor FIM scores at discharge were significantly lower (P = 0.018) in patients receiving antispasmodic medications than in those who did not. This trend persisted in secondary analyses for cervical, thoracic, and lumbosacral subgroups. Multivariate regression showed that receiving antispasmodic medication significantly contributed to discharge motor FIM outcome. At one-year follow-up, no outcomes significantly differed between patients ON or OFF antispasmodics.

CONCLUSIONS

Antispasmodic medications may be associated with decreased functional recovery at discharge from inpatient traumatic SCI rehabilitation. Randomized prospective studies are needed to directly evaluate the effects of antispasmodic medication on recovery.

A survey of deep tissue injury in elite female wheelchair basketball players

OBJECTIVE

To investigate deep tissue injuries (DTIs) in elite female wheelchair basketball players and identify factors associated with their occurrence.

METHODS

Study participants were 22 female wheelchair basketball players on the Japanese national team. The sacral and bilateral ischial regions of each participant were examined using ultrasonography to detect DTIs.

RESULTS

DTIs were found in 15 players (68.2%). DTIs were more frequent in players with a central nervous system disorder (CNSd) (85.7%) than in those with skeletal system disease (SSd) (37.5%, p = 0.020), and in players using a wheelchair in daily life (84.6%) than those using a wheelchair only for basketball (44.4%, p = 0.046). Players with pelvic instability were more likely to have DTIs (90.9% vs. 45.5%, p = 0.017). DTIs were deeper in the ischial region than the sacral region (p = 0.022). Players with CNSd had more DTIs in sacral regions (90% vs. 10%, p = 0.014). Players with DTIs had lower systolic blood pressure (sBP), red blood cell (RBC) count, and serum creatinine levels (sCr) (all p < 0.05).

CONCLUSIONS

Ischial DTIs were deeper than sacral DTIs. Players with CNSd had more sacral DTIs than those with SSd. CNSd, wheelchair use in daily life, pelvic instability, and lower sBP, RBC, and sCr increased the risk of DTIs.

Development of a clinical spasticity scale for evaluation of dogs with chronic thoracolumbar spinal cord injury

OBJECTIVE To develop a spasticity scale for dogs with chronic deficits following severe spinal cord injury (SCI) for use in clinical assessment and outcome measurement in clinical trials. ANIMALS 20 chronically paralyzed dogs with a persistent lack of hind limb pain perception caused by an acute SCI at least 3 months previously. PROCEDURES Spasticity was assessed in both hind limbs via tests of muscle tone, clonus, and flexor and extensor spasms adapted from human scales. Measurement of patellar clonus duration and flexor spasm duration and degree was feasible. These components were used to create a canine spasticity scale (CSS; overall score range, 0 to 18). Temporal variation for individual dogs and interrater reliability were evaluated. Gait was quantified with published gait scales, and CSS scores were compared with gait scores and clinical variables. Owners were questioned regarding spasticity observed at home. RESULTS 20 dogs were enrolled: 18 with no apparent hind limb pain perception and 2 with blunted responses; 5 were ambulatory. Testing was well tolerated, and scores were repeatable between raters. Median overall CSS score was 7 (range, 3 to 11), and flexor spasms were the most prominent finding. Overall CSS score was not associated with age, SCI duration, lesion location, or owner-reported spasticity. Overall CSS score and flexor spasm duration were associated with gait scores. CONCLUSIONS AND CLINICAL RELEVANCE The CSS could be used to quantify hind limb spasticity in dogs with chronic thoracolumbar SCI and might be a useful outcome measure. Flexor spasms may represent an integral part of stepping in dogs with severe SCI.

Improving Patient Experiences and Outcomes Through Personal Care Aide Training

Introduction:

The rapidly aging US population is resulting in major challenges including delivering quality care at lower costs in the face of a critical health-care workforce shortage. The movement toward home care has dramatically increased the need for qualified, paid personal care aides (PCAs). Adequate PCA training that focuses on skills for person-centered, at home support is an imperative. This study provides evidence that clients of PCAs who have completed a comprehensive, evidence-based PCA training program, titled Building Training…Building Quality (BTBQ), report higher satisfaction and better health outcomes, compared to clients of PCAs with lesser or other training.

Methods:

A mixed-methods, quasi-experimental design was used to compare self-reported survey responses from clients of BTBQ-trained PCAs (treatment group) with responses from clients of non-BTBQ-trained PCAs (control group).

Results:

Clients of BTBQ-trained PCAs had significantly fewer falls and emergency department visits compared to clients whose PCAs had no BTBQ training (P < .05). Conclusion: BTBQ-like PCA training reduces costly adverse events.

The Spinal Cord Injury Spasticity Evaluation Tool: A Persian adaptation and validation study

OBJECTIVE

To adapt the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) into the Persian language (SCI-SETp) and to examine the reliability and validity of the SCI-SETp in patients with spinal cord injury (SCI).

DESIGN

A cross-sectional and prospective cohort validation study.

SETTING

University Neurological Physiotherapy Clinic.

PARTICIPANTS

Adult patients with SCI.

MAIN OUTCOME MEASURES

SCI-SET.

RESULTS

There was no missing data. No floor or ceiling effect was observed. Cronbach's α coefficient was 0.862. Factor analysis suggested 1 factor structure (Eigenvalue = 8.49) explained 24.27% of the total variance. The ICC_agreement for test-retest reliability was 0.84. The standard error of measurement and the smallest detectable change was 0.30 and 0.82, respectively. The divergent relationships demonstrated the SCI-SETp uniqueness construct.

CONCLUSION

The results support the reliability and validity of the SCI-SETp for assessing the impact of spasticity on daily life of patients with SCI.

Health care utilization in persons with spinal cord injury: part 2-determinants, geographic variation and comparison with the general population

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

To investigate annual rates and geographic variation of health care utilization in persons with spinal cord injury (SCI), and to identify factors associated with health care utilization.

SETTING

Community setting, entire country of Switzerland.

METHODS

Annual rates of planned and emergency visits to the general practitioner (GP), planned and emergency outpatient clinic visits and in-patient hospitalizations were compared between individuals with chronic SCI, over 16 years of age residing in Switzerland between late 2011 and early 2013 and a population sample (2012) of the Swiss general population. Risk factors for increased health service utilization were identified by means of regression models adjusted for spatial variation.

RESULTS

Of 492 participants (86.2% response rate), 94.1% visited a health care provider in the preceding year, with most persons visiting GPs (88.4%) followed by outpatient clinics (53.1%) and in-patient hospitals (35.9%). The increase in utilization as compared with the general population was 1.3-, 4.0- and 2.9-fold for GP, outpatient clinic and in-patient hospital visit, respectively. GP utilization was highest in persons with low income (incidence rate ratio (IRR) 1.85) and old age (IRR 2.62). In the first 2 years post injury, health service visits were 1.7 (GP visits) to 5.8 times (emergency outpatient clinic visits) more likely compared with those later post injury.

CONCLUSIONS

People with SCI more frequently use health services as compared with the general population, across all types of medical service institutions. GP services were used most often in areas where availability of specialized outpatient clinic services was low.

Beware of the toilet: The risk for a deep tissue injury during toilet sitting

A pressure injury (PrI) compromises quality of life and can be life-threatening. The fundamental cause of PrIs is sustained deformations in weight-bearing soft tissues, e.g., during prolonged sitting on inadequate surfaces such as a toilet seat. In nursing homes and geriatric facilities, patients need assistance using the restroom, and patients being left on the toilet for tens-of-minutes is a real-world scenario, unfortunately. Nevertheless, there are no published studies regarding sustained tissue loads during toilet sitting and their effects on tissue physiology. Here, the biomechanical and microcirculatory responses of the buttock tissues to toilet sitting were investigated using finite element modeling and cutaneous hemodynamic measurements, to explore the potential etiology of PrIs occurring on the toilet. We found that prolonged sitting on toilet seats involves a potential risk for PrI development, the extent of which is affected by the seat design. Additionally, we found that specialized toilet seat cushions are able to reduce this risk, by lowering instantaneous tissue exposures to internal stresses (by up to 88%) and maintaining reduced interface pressures. Furthermore, hemodynamic variables were altered during the toilet sitting; in particular, tcPO₂ was decreased by 49% ± 7% (44 ± 2[mmHg] to 22 ± 4[mmHg]) during sitting. The current study confirms that investing in expensive PrI prevention (PIP) products is likely to be ineffective for an immobilized patient who is left to sit on a bare toilet seat for long times. This argument highlights the need for a holistic-care approach, employing PIP devices that span across the entire environment where bodyweight forces apply to tissues.

Bacterial load of conditioned pressure ulcers is not a predictor for early flap failure in spinal cord injury

OBJECTIVES

Pressure ulcers impose a major lifetime medical problem to patients with high-grade spinal cord injury (SCI). For patients with stages 3-4 pressure ulcers, plastic surgery is often the only remaining treatment option. Despite considerable flap failure rates of around 30%, only sparse knowledge exists on predictors for flap failure. Hence, identification of predictors for flap failures is needed.

METHODS

We prospectively enrolled 38 SCI patients with stages 3-4 pressure ulcers scheduled for plastic surgery. Preoperative wound swabs, intraoperative tissue samples and postoperative drainage liquids were microbiologically analyzed. In multivariable logistic regression analyses, bacterial loads of deep tissue cultures of intraoperative samples as well as other clinical variables were analyzed with respect to the prediction of flap failures.

RESULTS

The flap failure rate was 27.5%. Bacterial loads of deep tissue cultures were not predictive for flap failure, neither was the colonization with a specific bacterial strain. We observed a considerable fluctuation of microbiological environment from initial swab cultures, intraoperative samples and postoperative drainage fluids. Antibioprophylaxis was sufficient in only 75% of deep tissue cultures and 69% of drainage fluids. Insufficient antibioprophylaxis was associated with a higher flap failure rates (odds ratio 6.3, confidence interval 1.2-41.0).

CONCLUSION

After inpatient wound conditioning, bacterial load analysis of intraoperative wound tissue cultures is ineffective in order to predict flap failure rates in SCI patients with stages 3-4 pressure ulcers after flap surgery. Instead, insufficient antibioprophylaxis might be a factor contributing to flap failure.

Depressive symptomatology after spinal cord injury: A multi-center investigation of multiple racial-ethnic groups

OBJECTIVE

To identify (1) racial-ethnic differences in depressive symptomatology after spinal cord injury (SCI) and (2) the relationship of multiple additional factors to depressive symptoms, including health behaviors, employment, fatigue, and pain interference.

DESIGN

Cross-sectional Setting: Data were collected at 3 specialty hospitals in different regions of the USA (Southeastern, Mountain, Western).

PARTICIPANTS

Participants (N = 1,063) were identified from outpatient records of the 3 hospitals with oversampling of racial-ethnic minority groups.

INTERVENTIONS

N/A Main Outcome Measure(s): The outcome, depressive symptomatology, was measured by the Older Adult Health and Mood Questionnaire (OAHMQ). Participant demographic and injury characteristics were measured as statistical controls, as well as other variables including health behavior factors, depression/stress relief medication usage, fatigue, and pain interference. The multivariate analyses were developed using OLS regression models and logistic regression models.

RESULTS

Employment was protective for depressive symptomatology, whereas fatigue, pain interference, and binge drinking were risk factors for higher OAHMQ scores. Although there were no bivariate racial-ethnic differences in depressive symptoms, fatigue and pain interference had suppression effects on the relationship between race-ethnicity and depressive symptomatology. After controlling for fatigue and pain interference, Hispanic participants had significantly lower OAHMQ scores and lower odds of probable major depression (PMD) than non-Hispanic Whites and Blacks.

CONCLUSIONS

Fatigue and pain interference are associated with both race-ethnicity and depressive symptomatology. Assuming the same level of fatigue and pain interference, Hispanics will have a lower risk of depressive symptoms than non-Hispanic Whites and Blacks.