Sleep disturbances in the spinal cord injured: an epidemiological questionnaire investigation, including a normal population

Lifestyle and health changes in wheelchair users with a chronic disability after 12 weeks of using the WHEELS mHealth application

PURPOSE

The aim of this study was to determine changes in physical activity, nutrition, sleep behaviour and body composition in wheelchair users with a chronic disability after 12 weeks of using the WHEELS mHealth application (app).

METHODS

A 12-week pre-post intervention study was performed, starting with a 1-week control period. Physical activity and sleep behaviour were continuously measured with a Fitbit charge 3. Self-reported nutritional intake, body mass and waist circumference were collected. Pre-post outcomes were compared with a paired-sample t-test or Wilcoxon signed-rank test. Fitbit data were analysed with a mixed model or a panel linear model. Effect sizes were determined and significance was accepted at p < .05.

RESULTS

Thirty participants completed the study. No significant changes in physical activity (+1.5 √steps) and sleep quality (-9.7 sleep minutes; -1.2% sleep efficiency) were found. Significant reduction in energy (-1022 kJ, d = 0.71), protein (-8.3 g, d = 0.61) and fat (-13.1 g, d = 0.87) intake, body mass (-2.2 kg, d = 0.61) and waist circumference (-3.3 cm, d = 0.80) were found.

CONCLUSION

Positive changes were found in nutritional behaviour and body composition, but not in physical activity and sleep quality. The WHEELS app seems to partly support healthy lifestyle behaviour.Implications for RehabilitationHealthy lifestyle promotion is crucial, especially for wheelchair users as they tend to show poorer lifestyle behaviour despite an increased risk of obesity and comorbidity.The WHEELS lifestyle app seems to be a valuable tool to support healthy nutrition choices and weight loss and to improve body satisfaction, mental health and vitality.

Melatonin secretion and sleep disorders in patients with spinal cord injuries

STUDY DESIGN

Prospective observational study.

OBJECTIVES

To evaluate melatonin secretion, daytime sleepiness and sleep disorders in patients with spinal cord injuries (SCI), and their association with lesion level.

SETTING

Specialized neuro rehabilitation hospital in France METHODS: Prospective observational study of patients aged over 18 hospitalized in for spinal cord injury. Sleep quality was measured with the Pittsburgh Sleep Quality Index (PQSI), daytime sleepiness with the Epworth Sleepiness scale (ESS), and melatonin secretion by 24 h urinary dosage of 6-sulphatoxy-melatonin.

RESULTS

213 patients were screened, 21 patients were included: 17 complete (AIS A) and 4 lesions (AIS B), 76% of traumatic origin with 12 tetraplegic and 9 paraplegic, mean 10 (range 0.5-40) years after injury. Mean age was 46.8 ± 14.7 years, mean BMI 23.56 ± 4.1 and men outnumbered women (15 vs 6). Melatonin secretion was analyzed by 24 h secretion and by secretion profile. Comparing retained vs abolished secretion, only 23% (4/17) of patients with a lesion above T8 retained melatonin secretion, compared to 80% (4/5) with a lesion below T8 (p = 0.022). Non significant differences were found in secretion profile in patients who retained secretion: no patient with a lesion above T8 had a normal secretion profile compared to 50% with a lesion below T8 and in the impact of partial vs total lesions above T8 in whom 17% (2/12) of complete ASIA-A lesions and 50% (2/4) of incomplete lesions retained secretion.

CONCLUSION

Lesions of the spinal cord above T8 are strongly associated with abolition of melatonin secretion.

The Sleep Parameters of Olympic Athletes: Characteristics and Assessment Instruments

This systematic review aims to identify the sleep parameters of Olympic athletes and the instruments used to assess and monitor the sleep of these athletes. The search was conducted until February 2023 and was performed in PubMed, Web of Science, and Scopus databases. This systematic review has included studies that investigated at least one of the following sleep parameters: total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), awakenings after sleep onset (WASO), quality of sleep, daytime sleepiness, and chronotype; the participants were Olympic athletes. The search returned a total of 280 studies. After screening based on exclusion and inclusion criteria, 11 studies were included. The main results demonstrate that Olympic athletes have TST of 06:10 h, SE of 84%, SOL of 28 min, and WASO of 49 min. The most predominant chronotype is indifferent; over half of the athletes have poor sleep quality and complaints. Furthermore, actigraphy was the most used method to assess sleep. It is concluded that Olympic athletes have TST, SE, and WASO poor than the recommended values. In addition, sleep complaints and poor sleep quality were also observed. Among the objective sleep assessment methods, actigraphy was the method most frequently used in this population.

Mental health, sleep, and pain in elite Para athletes and the association with injury and illness-A prospective study

INTRODUCTION

The interest in the health of Para athletes continues to increase. Still, there are few studies that have evaluated health parameters beyond injury and illness in this athlete population.

OBJECTIVE

To assess (1) the weekly proportion of elite Para athletes reporting anxiety/depression, low sleep levels (≤7 hours), and pain over 52 weeks; (2) and to explore whether these health parameters are associated with the risk for a sports injury or illness.

DESIGN

A 52-week prospective study, part of the Sports-related Injury and Illness in Paralympic Sport Study (SRIIPSS).

SETTING

A total of 107 Swedish elite Para athletes with physical, visual, and intellectual impairment participated.

MAIN OUTCOME MEASURES

Data on self-reported anxiety/depression, sleep levels, pain, and injuries/illnesses were collected weekly. Comparisons of these parameters preceding an injury/illness were made using Friedman's analysis of variance (ANOVA).

RESULTS

The proportion of athletes reporting weekly anxiety/depression was 34.1%; 60.9% of athletes reported sleeping ≤7 hours and 49.9% reported pain. In exploratory analyses, there were no significant differences between weeks before an injury for any of the variables. There were significant differences in levels of sleep over the weeks, where sleep levels were significantly higher (>10 hours) 4 weeks prior to an illness (p = .016).

CONCLUSION

This cohort of elite Para athletes reported relatively high levels of anxiety/depression, low sleep levels, and pain, which is a concern. High sleep levels and the risk for illness might be an indication of overtraining, which commonly leads to persistent fatigue and an increased susceptibility to infections. Monitoring of the health of elite Para athletes is recommended to be able to improve performance and health in this population.

Review of the Most Cited Patient-Reported Outcome Measure (PROM) Studies Published in the Neurospine Surgical Literature

Patient-reported outcome measures (PROMs) are validated tools that are widely utilized in research and patient care. Their diversity, quality, and application remain matters of peak research interest. This article is a review of the PROMs that were utilized in high-impact publications in the neurospine surgical literature. The 50 most cited articles on the subject were selected and analysed. Most (42 articles) were published in spine journals and, in particular, in the journal Spine (Phila Pa 1976) (28 articles). A total of 34 PROMs were utilized, of which 24 were used only once in single studies. The four most common PROMs were Scoliosis Research Society-22 (SRS-22) (15 articles), Short Form-12 and Short Form-36 (SF-12 and SF-36) (11 articles), Ronald-Morris Disability Questionnaire (RMDQ) (nine articles), and Oswestry Disability Index (ODI) (five articles). Nineteen articles focused on validating translated versions of 11 PROMs to other languages. The languages that had the maximal number of tools translated to amongst the highly cited articles were Italian (six tools), Portuguese (four tools), German (three tools), and Japanese (three tools). The most common diagnoses and the PROMs used for them were back pain and cervical spine disorder (SF-12 and SF-36 (nine articles), RMDQ (eight articles), and ODI (five articles)), and idiopathic scoliosis (SRS-22) (14 articles)). The median (range) article citation number was 137 (78-675). The four most cited PROMs were SRS-22 (2,869), SF-12 and SF-36 (2,558), RMDQ (1,456), and ODI (852). Citation numbers were positively impacted by article age and participant number but not by tool type or clinical diagnosis. In conclusion, a wide range of PROMs was utilized in the 50 most cited publications in the neurospine surgical literature. The majority were disease-specific rather than generic and targeted particular spine pathology. Neurosurgical PROMs were under-represented amongst the most cited articles. Awareness of the PROMs used in high-impact studies may be helpful in tool selection in future research. PROMs are valuable in standardizing subjective outcomes. Their use in research and clinical settings in any validated language is highly encouraged.

The impact of sleep quality on health, participation and employment outcomes in people with spinal cord injury: Analyses from a large cross-sectional survey

BACKGROUND

Poor sleep is common in people with spinal cord injury (SCI), yet little is known about its impact on employment and participation outcomes.

OBJECTIVES

This study aimed to (1) describe the sleep quality of a large sample of Australians with SCI and compare the results to data from an adult control and other clinical populations; (2) examine associations between sleep quality and participant characteristics; and (3) explore the relationship between sleep and outcomes.

METHODS

Cross-sectional data from the Australian arm of the International Spinal Cord Injury (Aus-InSCI) survey from 1579 community-dwelling people aged >18 years with SCI were analysed. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI). Relationships between participant characteristics, sleep quality and other outcomes were examined with linear and logistic regression.

RESULTS

The PSQI was completed by 1172 individuals; 68% reported poor sleep (global PSQI score >5). Subjective sleep quality in people with SCI was poor (mean PSQI = 8.5, SD 4.5) when compared to adults without SCI (PSQI = 5.00, SD 3.37) and with traumatic brain injury (PSQI = 5.54, SD 3.94). Financial hardship and problems with secondary health conditions were significantly associated with worse sleep quality (p < 0.05). Poor sleep quality was strongly associated with lower emotional wellbeing and energy, and greater problems with participation (p < 0.001). Individuals engaged in paid work reported better sleep quality (mean PSQI = 8.1, SD 4.3) than unemployed individuals (mean PSQI = 8.7, SD 4.6; p < 0.05). Following adjustment for age, pre-injury employment, injury severity and years of education, better sleep quality remained strongly associated with being employed (OR 0.95, 95% CI 0.92 to 0.98; p = 0.003).

CONCLUSIONS

This study demonstrated pervasive and impactful relationships between sleep quality and important SCI outcomes. Poor sleep quality was strongly associated with worse emotional wellbeing and vitality, unemployment and lower participation. Future studies should aim to determine whether treating sleep problems can improve outcomes for people living with SCI.

Altered Core Temperature and Salivary Melatonin in Athletes with a Cervical Spinal Cord Injury

Sleep disturbances are common in athletes with a cervical spinal cord injury (cSCI) and may be associated with circadian alterations. Therefore, the purpose of this study was to compare physiological circadian outputs between athletes with a cSCI and non-disabled controls (CON). Eight male wheelchair athletes with a cSCI and eight male CON (30±4 and 30±6 yrs, respectively) had their core body temperature (T_core), skin temperature (T_skin), and salivary melatonin measured during a 24 h period. In the cSCI group, daytime T_core was significantly lower (36.5 (0.2) vs 36.9 (0.3)°C; p=0.02) and time of the T_core sleep minimum was significantly earlier (23:56±00:46 vs 02:39 ± 02:57; p=0.04). The athletes with a cSCI had significantly lower T_core values during the beginning of the night compared with the CON group, but their T_core increased at a greater rate, thereafter, indicated by a significant time/group interaction (p=0.04). Moreover, the cSCI group did not display a salivary melatonin response and exhibited significantly lower concentrations at 22:00 (p=0.01) and 07:00 (p=0.01) compared with the CON group. Under natural living conditions, athletes with a cSCI displayed circadian changes in the T_core rhythm and nocturnal melatonin production.

The Sleep Parameters of Paralympic Athletes: Characteristics and Assessment Instruments

CONTEXT

Sleep serves many important functions for athletes, particularly in the processes of learning, memory, recovery, and cognition.

OBJECTIVES

Define the sleep parameters of Paralympic athletes and identify the instruments used to assess and monitor sleep Paralympic athletes.

EVIDENCE ACQUISITION

This systematic review was carried out based on the PRISMA guidelines. The survey was conducted in April 2020, the searches were carried out again in September 2021 to check whether there were new scientific publications in the area of sleep and Paralympic sport, searches were performed in the following databases: PubMed, Web of Science, Scopus, SPORTDiscus, Virtual Health Library (BIREME), and SciELO. This systematic review has included studies that investigated at least one of the following sleep parameters: total sleep time, sleep latency, sleep efficiency, number of awakenings, quality of sleep, daytime sleepiness, and chronotype; the participants were comprised of athletes with disabilities. Studies published at any time in English, Portuguese, and Spanish, were included.

EVIDENCE SYNTHESIS

Data extraction and study selection were performed by 2 researchers independently, and a third author was consulted as necessary. The search returned a total of 407 studies. Following the screening based on exclusion and inclusion criteria, a total of 13 studies were considered. Paralympic athletes have a low amount (7.06 h) of sleep with poor quality and sleep latency (28.05 min), and 57.2% have daytime sleepiness, with the majority belonging to the indifferent chronotype (53, 5%). Moreover, 11 studies assess sleep using subjective instruments (questionnaires), and 2 studies used an objective instrument (actigraphy).

CONCLUSIONS

Sleep disorders are common among Paralympic athletes, poor sleep quality and quantity, and high rates of daytime sleepiness. Subjective methods are most commonly used to assess sleep.

Physical health among the Finnish spinal cord injury population according to the Patient Reported Outcome Measurement Information System (PROMIS®)

OBJECTIVE

The aim of this study is to assess the physical health in the Finnish Spinal cord injury (SCI) population using the Patient Reported Outcome Measurement Information System (PROMIS®) and make a comparison to the general United States (US) population. Furthermore, the aim is to explore the associations between pain interference, pain intensity, sleep disturbance, and fatigue and physical function.

DESIGN

Cross-sectional study. This study is part of the Finnish Spinal Cord Injury (FinSCI) community survey study.

SETTING

Community, Finland.

PARTICIPANTS

884 persons with SCI.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Physical health was measured with custom Patient Reported Outcome Measure System (PROMIS®) short forms.

RESULTS

Higher age and lesion level indicated more severe physical function impairments. Persons ≥46 years exhibited more pain interference symptoms compared to younger participants. On average, the Finnish SCI population had 1.3 SD lower physical function and 0.9 SD higher pain interference T-scores compared to the US general population (P < 0.001). The most significant association was observed between pain interference and physical function (r = -0.364, P < 0.001).

CONCLUSIONS

The present study provides a description of the state of physical health in the Finnish spinal cord injury population, as well as the associations between the physical health areas. The results highlight the substantiality of pain management in terms of improving physical function.

TRIAL REGISTRATION NUMBER

NCT04649814.

Nocturnal bladder emptying and Quality of Life in patients with spinal cord injury

BACKGROUND

Little is known about the relationship between sleep disruption due to nocturnal bladder emptying and Quality of Life in patients with spinal cord injury.

AIM

The aim of this study was to evaluate the possible influence of number of nocturnal bladder emptying, bladder emptying method and nocturnal incontinence on the Quality of Life of patients with spinal cord injury.

DESIGN

The design of this paper is a cross-sectional descriptive study.

SETTING

The setting is in- and outpatient.

POPULATION

Seventy-nine patients aged between 18 and 77 years with SCI in a first rehabilitation period or follow-up.

METHODS

Patients were asked to complete Short Form-36 and Incontinence Quality of Life questionnaires and a medical information form. Independent samples t-tests and ANOVA were used to compare scores between groups.

RESULTS

The response rate was 71 out of 79 (89%; 51 males and 20 females). 16 paraplegic and 4 tetraplegic patients were chronic, 29 paraplegic and 22 tetraplegic patients were in rehabilitation therapy or had finished this treatment recently. The paraplegic group had a significantly better Short Form-36 total score and emotional function score, while the tetraplegic group had a significantly better Incontinence Quality of Life total score and avoidance and limiting behavior score. The paraplegic patients with 0-1 nocturnal bladder emptying had better Short Form-36-derived Quality of Life than those with ≥2 emptying. Quality of Life score was not associated with gender, leg oedema, incontinence, or acute/chronic group. Incontinence Quality of Life score was significantly better for patients with incomplete spinal cord injury. Fully completed questionnaires were returned by 36 patients; at least 1 item was missing for 35 participants.

CONCLUSIONS

General Short Form-36-derived Quality of Life was better for the paraplegic population. Incontinence-related Quality of Life was better in tetraplegic patients, most of whom used suprapubic catheterization. Paraplegic patients had compromised sleep and Quality of Life when the patient had to wake up two or more times at night to empty the bladder by voiding or intermittent catheterization. The high number of incomplete responders indicates the shortcomings of Quality-of-Life questionnaires for wheelchair-bound patients with spinal cord injury.

CLINICAL REHABILITATION IMPACT

The use of suprapubic catheterization should be considered to improve Quality of Life for tetraplegic patients. For paraplegic patients, we must focus urological policy on aiming to reduce the number of nighttime bladder emptying to one or none.

Daily Variation in Sleep Quality is Associated With Health-Related Quality of Life in People With Spinal Cord Injury

OBJECTIVE

Although sleep difficulties are common after spinal cord injury (SCI), little is known about how day-to-day fluctuations in sleep quality affects health-related quality of life (HRQOL) among these individuals. We examined the effect of sleep quality on same-day HRQOL using ecological momentary assessment methods over a 7-day period.

DESIGN

Repeated-measures study involving 7 days of home monitoring; participants completed HRQOL measures each night and ecological momentary assessment ratings 3 times throughout the day; multilevel models were used to analyze data.

SETTING

Two academic medical centers.

PARTICIPANTS

A total of 170 individuals with SCI (N=170).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily sleep quality was rated on a scale of 0 (worst) to 10 (best) each morning. Participants completed end-of-day diaries each night that included several HRQOL measures (Sleep Disturbance, Sleep-related Impairment, Fatigue, Cognitive Abilities, Pain Intensity, Pain Interference, Ability to Participate in Social Roles and Activities, Depression, Anxiety) and ecological momentary assessment ratings of HRQOL (pain, fatigue, subjective thinking) 3 times throughout each day.

RESULTS

Multilevel models indicated that fluctuations in sleep quality (as determined by end-of-day ratings) were significantly related to next-day ratings of HRQOL; sleep quality was related to other reports of sleep (Sleep Disturbance; Sleep-related Impairment; Fatigue) but not to other aspects of HRQOL. For ecological momentary assessment ratings, nights of poor sleep were related to worse pain, fatigue, and thinking. Generally, sleep quality showed consistent associations with fatigue and thinking across the day, but the association between sleep quality and these ecological momentary assessment ratings weakened over the course of the day.

CONCLUSIONS

Findings highlight the important association between sleep and HRQOL for people with SCI. Future work targeting sleep quality improvement may have positive downstream effects for improving HRQOL in people with SCI.

Rapid GFAP and Iba1 expression changes in the female rat brain following spinal cord injury

Evidence suggests that rapid changes to supporting glia may predispose individuals with spinal cord injury (SCI) to such comorbidities. Here, we interrogated the expression of astrocyte- and microglial-specific markers glial fibrillary acidic protein (GFAP) and ionized calcium binding adaptor molecule 1 (Iba1) in the rat brain in the first 24 hours following SCI. Female Sprague-Dawley rats underwent thoracic laminectomy; half of the rats received a mild contusion injury at the level of the T10 vertebral body (SCI group), the other half did not (Sham group). Twenty-four hours post-surgery the amygdala, periaqueductal grey, prefrontal cortex, hypothalamus, lateral thalamus, hippocampus (dorsal and ventral) in rats were collected. GFAP and Iba1 mRNA and protein levels were measured by real-time quantitative polymerase chain reaction and Western blot. In SCI rats, GFAP mRNA and protein expression increased in the amygdala and hypothalamus. In contrast, gene and protein expression decreased in the thalamus and dorsal hippocampus. Interestingly, Iba1 transcripts and proteins were significantly diminished only in the dorsal and ventral hippocampus, where gene expression diminished. These findings demonstrate that as early as 24 hours post-SCI there are region-specific disruptions of GFAP and Iba1 transcript and protein levels in higher brain regions. All procedures were approved by the University of Technology Sydney Institutional Animal Care and Ethics Committee (UTS ACEC13-0069).

Perceived sleep problems after spinal cord injury: Results from a community-based survey in Switzerland

Objective: To investigate the burden of sleep problems within the Spinal Cord injured (SCI) community with respect to the general population (GP) in Switzerland. The study further explored potential predictors for receiving treatment for sleep problems after SCI.Design: Cross-sectional study.Setting: SCI community in Switzerland.Participants: Individuals diagnosed with an SCI, aged 16 years or older that permanently reside in Switzerland (N = 1549).Interventions: Not applicable.Outcome measures: Perceived sleep problems within the SCI community and GP. For those with sleep problems and SCI, an indicator for having received treatment was measured.Results: 58.8% of survey participants indicated having a sleep problem; 69.4% of those with a sleep problem did not indicate receiving treatment. Amongst people living with an SCI, individuals between the ages of 46-60 years (adjusted Odds Ratio, OR = 3.07; 95% CI 1.54-6.16), participants reporting severe financial hardship (OR = 2.90; 95% CI) 1.69-4.96, and those that indicated having pain (OR = 5.62; 95% CI 3.52-8.98) were more likely to have a chronic sleep problem. In comparison to the Swiss GP, the prevalence of having a sleep problem was 18% higher among persons with SCI, with the largest discrepancy for males with paraplegia between the ages of 46-60 years (Prevalence ratio, PR = 1.28; 95% CI, 1.21-1.36).Conclusion: Individuals with SCI experience more sleep problems compared to the Swiss GP. Findings from this study suggest that clinical screening for sleep issues targeting high risk groups is needed to reduce the large prevalence of non-treatment in individuals with SCI.

Detection of Sleep-Disordered Breathing in Patients with Spinal Cord Injury Using a Smartphone

Patients with spinal cord injury (SCI) have an increased risk of sleep-disordered breathing (SDB), which can lead to serious comorbidities and impact patients’ recovery and quality of life. However, sleep tests are rarely performed on SCI patients, given their multiple health needs and the cost and complexity of diagnostic equipment. The objective of this study was to use a novel smartphone system as a simple non-invasive tool to monitor SDB in SCI patients. We recorded pulse oximetry, acoustic, and accelerometer data using a smartphone during overnight tests in 19 SCI patients and 19 able-bodied controls. Then, we analyzed these signals with automatic algorithms to detect desaturation, apnea, and hypopnea events and monitor sleep position. The apnea–hypopnea index (AHI) was significantly higher in SCI patients than controls (25 ± 15 vs. 9 ± 7, p < 0.001). We found that 63% of SCI patients had moderate-to-severe SDB (AHI ≥ 15) in contrast to 21% of control subjects. Most SCI patients slept predominantly in supine position, but an increased occurrence of events in supine position was only observed for eight patients. This study highlights the problem of SDB in SCI and provides simple cost-effective sleep monitoring tools to facilitate the detection, understanding, and management of SDB in SCI patients.

The Effect of Cannabis-Based Medicine on Neuropathic Pain and Spasticity in Patients with Multiple Sclerosis and Spinal Cord Injury: Study Protocol of a National Multicenter Double-Blinded, Placebo-Controlled Trial

Disease or acquired damage to the central nervous system frequently causes disabling spasticity and central neuropathic pain (NP), both of which are frequent in multiple sclerosis (MS) and spinal cord injury (SCI). Patients with MS and SCI often request treatment with cannabis-based medicine (CBM). However, knowledge about effects, side effects, choice of active cannabinoids (Δ9-tetrahydrocannabinol (THC), cannabidiol (CBD) alone or in combination), and doses of CBM remains limited. Using a double-blind, parallel design in a national multicenter cohort, this study examines the effect of CBM on spasticity and NP. Patients are randomized to treatment with capsules containing either THC, CBD, THC and CBD, or placebo. Primary endpoints are patient-reported pain and spasticity on a numerical rating scale. Other endpoints include quality of life and sleep, depression and anxiety, and relief of pain and spasticity. Side-effects of CBM are described. In a sub-study, the pharmacodynamics (PD) and pharmacokinetics (PK) of oral capsule CBM are examined. We expect that the study will contribute to the literature by providing information on the effects and side-effects of CBD, THC, and the combination of the two for central neuropathic pain and spasticity. Furthermore, we will describe the PD/PK of THC and CBD in a patient population.

Sleep disruption considerations for Paralympic athletes competing at Tokyo 2020

The role of sleep is now recognized as an important component for success in athletic performance, and sleep is proposed to be one of the most effective recovery strategies available. Insufficient sleep is commonly reported among athletes while several factors have been put forward to explain why elite athletes might experience poor sleep. However, Paralympic athletes may be predisposed to a greater risk of poor sleep due to the associated complexities of some impairment types. In fact, clinical research has previously shown that individuals with disabilities have a higher prevalence of sleep disturbances when compared to their able-bodied counterparts. However, research and evidence-based practices regarding the sleep of elite Paralympic athletes are limited. Firstly, this narrative review aims to identify challenges associated with the Paralympic games to obtain optimal sleep. Secondly, identify the specific risk factors to sleep associated with particular impairment groups within the Paralympic population, and lastly to propose potential sleep-enhancing strategies that might be of relevance for Paralympic athletes. From this review, initial observations have identified that Paralympic athletes may have a heightened risk of sleep-related problems, and importantly highlighted the current lack of understanding within this population group. Furthermore, this review identified where further research is warranted to better understand how specific impairments impact sleep and, consequently, athletic performance. Additionally, this review highlighted that the forthcoming Tokyo games may offer a unique challenge for athletes trying to obtain optimal sleep, due to the anticipated thermal demands and the consequent irregular scheduling of events.

Sleep Characteristics of Highly Trained Wheelchair Rugby Athletes With and Without a Cervical Spinal Cord Injury During the Competitive Season

Sleep behaviors although significantly relevant to exercise recovery are poorly characterized in Para-sport athletes. Therefore, the main aims of this study were to describe sleep quality and quantity of highly trained wheelchair rugby (WR) athletes during the competitive season, and to investigate whether impairment type or attending a training camp influenced sleep outcomes. Eighteen male WR athletes (mean ± SD; age: 30 ± 5 years) with cervical spinal cord injuries (n = 11) (CSCI) and without (n = 7) (NON-SCI) wore an activity monitor over a 16-day period to objectively quantify sleep parameters, while the Pittsburgh Sleep Quality Index (PSQI) and nightly sleep diary entries were used as subjective means. A sub-sample of the athletes (n = 11) had their sleep monitored during a 3-night training camp to assess the impact of environmental change on sleep. Furthermore, as an additional exploratory measure core temperature was measured for a single night-time period using ingestible telemetry capsules. The athletes had total sleep times and sleep efficiency scores of 7.06 (1.30) h.min [median (interquartile range)] and 81 (9)%, respectively. Sleep onset latency and wake after sleep onset were 13 (24) min and 1.11 (0.45) h.min, respectively. No significant differences were found in objective sleep variables between the impairment groups despite the CSCI group being significantly more likely to report a poorer night's sleep (p = 0.04). Furthermore, attending the training camp caused a significant reduction in total sleep time for both groups [Δ38 ± 33 min; (95% CI: 18–60 min) p < 0.01]. This study highlights suboptimal sleep characteristics that are present in both CSCI and NON-SCI wheelchair athletes, as defined by the National Sleep Foundation. Although objective scores did not differ between groups, athletes with a CSCI rated their sleep worse. Furthermore, the disruption of sleep during training camp reflects an additional risk factor that is important to recognize for those working with wheelchair athletes.

Relationship Between Sleep-Disordered Breathing and Neurogenic Obesity in Adults With Spinal Cord Injury

Spinal cord injury (SCI) substantially increases the risk of neurogenic obesity, diabetes, and metabolic syndrome. Much like in the general population, a discussion of these syndromes in SCI would be incomplete without acknowledging the association of SCI with sleep-disordered breathing (SDB). This article will outline the interplay between obesity and obstructive sleep apnea (OSA), discussing the pathophysiology of obesity in OSA both for the general population and SCI population. The role of insulin resistance in SDB and SCI will also be examined. The epidemiology and pathophysiology of OSA and central sleep apnea in SCI are discussed through an examination of current evidence, followed by a review of central sleep apnea in SCI. Principles of diagnosis and management of SDB will also be discussed. Because sleep deprivation in itself can be a risk factor for developing obesity, the significance of comorbid insomnia in SCI is explored. Ultimately, a thorough sleep history, testing, and treatment are key to improving the sleep of individuals with SCI and to potentially reducing the impact of neurogenic obesity and metabolic syndrome.

Exercise Recovery Practices of Wheelchair Court Sports Athletes

ABSTRACT

Murphy, CJ, Mason, BS, and Goosey-Tolfrey, VL. Exercise recovery practices of wheelchair court sports athletes. J Strength Cond Res 35(2): 366-372, 2021-Research that describes the recovery practices of Para-athletes around training and competition is limited. This study investigated if and why athletes in wheelchair court sports (basketball, rugby, and tennis) use recovery strategies, what type of strategies are used, and whether the period of the season influences the prevalence of use. A cross-sectional questionnaire was developed to acquire data pertaining to individual characteristics, recovery habits, reasons for use/nonuse, the use of specific recovery strategies, and lifestyle habits. One hundred forty-four athletes (92 = international and 52 = national/club) completed the questionnaire online. In total, 85% (n = 122) of athletes reported using at least one type of recovery strategy, yet most specific types of recovery strategies were not popular (<34% of recovery strategy users). The most commonly used type of recovery strategy was stretching (n = 117), whereas both stretching and heat-related recovery were the most highly rated types of recovery strategies (μ = 4.2/5). The 3 most prevalent reasons for use across all strategies were "reduces muscle soreness," "reduces muscle tightness," and "reduces muscle spasms." The prevalence of sleep complaints was apparent with 38% (n = 55) of respondents reporting difficulties sleeping. This study highlights that although the frequent use of well-known recovery practices is positive, the lack of diversity in strategies implemented may have implications due to the specific requirements of exercise recovery. Therefore, strength and conditioning professionals should educate wheelchair athletes further around this area and increase the range of recovery-specific and impairment-specific strategies used.

Association between sleep quality and participation in people with spinal cord injury: A preliminary study

OBJECTIVE

To explore the association between perceived sleep quality and participation in people with spinal cord injury (SCI).

DESIGN

Cross-sectional study.

SETTING

Spinal unit at the Città della Salute e della Scienza University Hospital of Turin, Italy.

PARTICIPANTS

From May to July 2019, 55 consecutive outpatients were recruited.

OUTCOME MEASURES

A set of structured questionnaires was administered. It included sociodemographic data, the Pittsburgh Sleep Quality Index, the Utrecht Scale for Evaluation of Rehabilitation-Participation, the Spinal Cord Independence Measure Self-Report, the Short Form version 12.2, and the Hospital Anxiety and Depression Scale. T-tests were used to highlight differences between participation and participant characteristics. Bivariate analyses and linear regressions were performed to identify associations between sleep quality and participation.

RESULTS

Differences in participation occurred mainly in individuals with a higher level of injury, caregiver dependency, and lower functional level. Participants reporting better sleep quality had more frequent (r = -0.36, P < 0.01), less restricted (r = -0.32, P < 0.05), and more satisfactory participation (r = -0.33, P < 0.01). Linear regression analyses showed that poor sleep quality was significantly associated with reduced participation frequency (β = -0.30, P = 0.03) and less satisfaction with participation (β = -0.49, P < 0.001). Moreover, age, number of hours slept at night, and time since injury were associated with satisfaction with participation.

CONCLUSIONS

An association was found between sleep quality and participation in people with SCI. Given the high prevalence of sleep problems and their association with all dimensions of participation, the promotion of sleep quality should be encouraged because it may positively affect participation.

Bed Sensor Technology for Objective Sleep Monitoring Within the Clinical Rehabilitation Setting: Observational Feasibility Study

Background

Since adequate sleep is essential for optimal inpatient rehabilitation, there is an increased interest in sleep assessment. Unobtrusive, contactless, portable bed sensors show great potential for objective sleep analysis.

Objective

The aim of this study was to investigate the feasibility of a bed sensor for continuous sleep monitoring overnight in a clinical rehabilitation center.

Methods

Patients with incomplete spinal cord injury (iSCI) or stroke were monitored overnight for a 1-week period during their in-hospital rehabilitation using the Emfit QS bed sensor. Feasibility was examined based on missing measurement nights, coverage percentages, and missing periods of heart rate (HR) and respiratory rate (RR). Furthermore, descriptive data of sleep-related parameters (nocturnal HR, RR, movement activity, and bed exits) were reported.

Results

In total, 24 participants (12 iSCI, 12 stroke) were measured. Of the 132 nights, 5 (3.8%) missed sensor data due to Wi-Fi (2), slipping away (1), or unknown (2) errors. Coverage percentages of HR and RR were 97% and 93% for iSCI and 99% and 97% for stroke participants. Two-thirds of the missing HR and RR periods had a short duration of ≤120 seconds. Patients with an iSCI had an average nocturnal HR of 72 (SD 13) beats per minute (bpm), RR of 16 (SD 3) cycles per minute (cpm), and movement activity of 239 (SD 116) activity points, and had 86 reported and 84 recorded bed exits. Patients with a stroke had an average nocturnal HR of 61 (SD 8) bpm, RR of 15 (SD 1) cpm, and movement activity of 136 (SD 49) activity points, and 42 reported and 57 recorded bed exits. Patients with an iSCI had significantly higher nocturnal HR (t₁₈=−2.1, P=.04) and movement activity (t₁₈=−1.2, P=.02) compared to stroke patients. Furthermore, there was a difference between self-reported and recorded bed exits per night in 26% and 38% of the nights for iSCI and stroke patients, respectively.

Conclusions

It is feasible to implement the bed sensor for continuous sleep monitoring in the clinical rehabilitation setting. This study provides a good foundation for further bed sensor development addressing sleep types and sleep disorders to optimize care for rehabilitants.

A review of sleep research in patients with spinal cord injury

Study design: Systematic review. Objectives: Sleep disturbances are a common complaint among individuals with spinal cord injury (SCI) and were not usually present before the SCI. Their sleep disturbances, including disrupted sleep, spasms, and problems with initiating and sustaining sleep through the night, affect SCI individuals' overall quality of life due to excessive tiredness and low energy levels during the day. Despite the high prevalence of sleep complaints in this population, current knowledge about sleep in the SCI population has not been systematically assessed. Setting: Capital Region of Denmark. Methods: We systematically reviewed literature identified from the PubMed and EMBASE databases following PRISMA guidelines.Thirty-seven articles met our inclusion criteria, as only controlled studies were included. This could be a comparison of (1) SCI individuals and able-bodied controls, (2) cervical with thoracolumbar SCI individuals, or (3) cervical, thoracolumbar SCI individuals and able-bodied controls. Results: Individuals with SCI have a higher prevalence of sleep-disordered breathing and periodic leg movements during sleep (PLMS), lower heart rate, but no nocturnal lowering of blood pressure. 24-hour energy expenditure and sleeping metabolic rate were significantly lower, and bowel movements were altered. Endocrine alterations were found in investigations of melatonin, cortisol and antidiuretic hormone. Questionnaires revealed a high prevalence of subjectively poorer sleep quality in individuals with SCI compared with able-bodied controls. Conclusions: There are significant differences between groups with SCI and able-bodied controls. SCI objectively and subjectively markedly affects an individual's sleep.

Sleep quality in individuals with short-duration chronic spinal cord injury

The aim of the study is to estimate the association between spinal cord injuries related medical factors and subjective sleep disturbance in individuals with short-duration chronic spinal cord injury. Seventy-nine individuals with traumatic spinal cord injuries were included in our study and evaluated using the Beck Depression Index for severity of depressive symptoms, Short-Form Health Survey for quality of life, Douleur Neuropathique 4 score for neuropathic pain severity, and the Pittsburgh Sleep Quality Index for subjective sleep disturbances in a tertiary rehabilitation center. Associated subjective sleep disturbance factors were predicted using multivariate binary logistic regression analysis. Subjective sleep disturbance frequency was 74.7 %, and significantly higher in individuals with paraplegia (P = 0.025, odds ratio, 9.74, 95% confidence interval, 1.21-78.14). Intermittent nighttime catheterization frequency and neuropathic pain severity levels were significantly higher in individuals with subjective sleep disturbance, and quality of life and depressive symptoms were significantly worse in individuals with subjective sleep disturbance. Poor-sleep quality was associated significantly with shorter spinal cord injury duration. The strongest associated factors for sleep disturbance were paraplegic involvement, severity of depressive symptoms (Beck Depression Index score), and quality of life (Short-Form Health Survey general health perceptions score) (odds ratio: 95% confidence interval, 29.75; 1.66-534.36, 1.47; 1.11-1.95, and 0.91; 0.85-0.97, respectively). Our study suggests that paraplegic involvement, low quality of life, and depressive mood are related to sleep disturbance in individuals with traumatic spinal cord injury.

Sleep of Wheelchair Rugby Athletes: Training, Rest and Competition

The aim of this study was to evaluate the sleep-wake cycle of wheelchair rugby athletes during the pre-season compared to in-season. Wheelchair Rugby athletes wore an actigraph monitor during two respective 10-day periods: 1) pre-season and 2) in-season, each of which comprised three training days, three rest days, and four competition days, respectively. In addition, the players completed questionnaires regarding sleepiness, subjective quality of sleep, and chronotype, as well as the use of the sleep diary along with the actigraph measurements (20 days). The wheelchair rugby athletes had poor subjective sleep quality in both stages observed by sleep efficiency below 85% (ES 0.31) and high score in the Pittsburgh questionnaire (effect size-ES 0.55), the actigraphy results presented an increase of sleep latency (ES 0.47), and wake after sleep onset (ES 0.42). When comparing the athlete’s routine, the competition days, demonstrated a reduction in the total time of sleep and the sleep efficiency, in addition to an increase in wakefulness after sleep onset when compared with the training and rest periods. As a result, the wheelchair rugby players did not describe a pattern of sleep-wake cycle during different training phases, as well as poor sleep quality.

General Sleep Disturbance Scale (GSDS-IT) in people with spinal cord injury: a psychometric study

STUDY DESIGN

Psychometric study.

OBJECTIVE

This study sought to analyze the psychometric properties of the Italian version of the General Sleep Disturbance Scale (GSDS-IT) in a population of individuals with spinal cord injury (SCI).

SETTING

Italy.

METHODS

Its reliability was assessed using the Cronbach's alpha and intraclass correlation coefficient (ICC), while its concurrent validity was assessed using the Pearson's correlation coefficient in relation to the Pittsburgh Sleep Quality Index (PSQI). The obtained scores were compared with the cut-off score for the GSDS-IT among a healthy Italian population (38.5).

RESULTS

The GSDS-IT was administered to 57 participants with SCI who were recruited from all over Italy. The GSDS-IT was found to have good internal consistency (Cronbach's α of 0.76) and good test-retest reliability (ICC of 0.7), and it showed positive and significant values for all the PSQI domains. Based on the cut-off score of 38.5, 56% of participants tested positive for sleep disturbances upon admission (t0), while among the randomized participants submitted for the test-retest after 24 h (t1), 75% tested positive for sleep disturbances.

CONCLUSION

The GSDS-IT is a valid, reliable, and time-efficient tool for measuring sleep disturbances over the past week in a population with SCI.

Identification of clinically related requirements of a novel assistive device for people with a high spinal cord injury

People with spinal cord injuries (SCI), and particularly with high level lesions, can potentially lose the ability to effectively operate computers. The Multimedia Authoring and Management using your Eyes and Mind (MAMEM) project aims to design and produce a novel assistive device to support computer use by individuals with SCI and other disabilities. The solution harnesses eye tracking and brain waves, as measured by encephalography (EEG), to manipulate common computer functions. This paper describes the first step in the project, during which we defined clinically related requirements of the assistive device. These definitions were based on data from three sources: (1) a narrative review; (2) a focus group of SCI rehabilitation professionals; and (3) structured questionnaires administrated to potential computer users with SCI, addressing computer-use habits, barriers, and needs. We describe both the collection of data from each source and the clinically related requirements extracted. The novel three-source requirement assessment method is discussed, and the advantages and disadvantages of each data source are reported. In conclusion, we suggest that this approach makes it possible to organize, discuss, and prioritize the requirements, and to create a work program while planning the device. This increases our level of certainty that the efficacy and adequacy of the assistive device will be maximized, in terms of the clinical needs of users.

Sleep Complaints and Sleep Quality in Spinal Cord Injury: A Web-Based Survey

STUDY OBJECTIVES

The purpose of this study was to determine sleep quality and presence of sleep disorders in participants with spinal cord injury (SCI).

METHODS

A web-based survey, available online from February 2011 to July 2013, using validated sleep questionnaires, advertised via the internet and locally through SCI consumer organizations in the United States, Australia, New Zealand, and Canada, was designed to evaluate sleep in adults with self-reported SCI. Demographic characteristics and medical history were obtained from participant self-report.

RESULTS

In our study population, 70% of the 304 participants were male with a mean age of 45 ± 13 years. The mean duration of injury was 16 ± 12 years. Cervical injuries were reported by 49% and thoracic injuries noted in 40% of participants. Increased sleep apnea risk was noted in 31% of participants, with 66% reporting snoring. Insomnia symptoms were reported by 54% of the respondents. Almost 40% of participants ranked their sleep quality as "fairly bad" to "very bad" in the previous month, 29% reported "often" or "almost always" waking up because of pain, and 22% had difficulty falling asleep because of leg cramps. In the past year, 27% of the respondents reported daily uncomfortable leg sensations and 28% found these leg symptoms to be "moderately to extremely distressing."

CONCLUSIONS

This study increases the awareness that insomnia, sleep apnea, and poor sleep quality are common in individuals with chronic SCI; often coexisting. There is a need for increased screening for sleep problems by healthcare providers taking care of individuals living with SCI.

Positive airway pressure for sleep-disordered breathing in acute quadriplegia: a randomised controlled trial

RATIONALE

Highly prevalent and severe sleep-disordered breathing caused by acute cervical spinal cord injury (quadriplegia) is associated with neurocognitive dysfunction and sleepiness and is likely to impair rehabilitation.

OBJECTIVE

To determine whether 3 months of autotitrating CPAP would improve neurocognitive function, sleepiness, quality of life, anxiety and depression more than usual care in acute quadriplegia.

METHODS AND MEASUREMENTS

Multinational, randomised controlled trial (11 centres) from July 2009 to October 2015. The primary outcome was neurocognitive (attention and information processing as measure with the Paced Auditory Serial Addition Task). Daytime sleepiness (Karolinska Sleepiness Scale) was a priori identified as the most important secondary outcome.

MAIN RESULTS

1810 incident cases were screened. 332 underwent full, portable polysomnography, 273 of whom had an apnoea hypopnoea index greater than 10. 160 tolerated at least 4 hours of CPAP during a 3-day run-in and were randomised. 149 participants (134 men, age 46±34 years, 81±57 days postinjury) completed the trial. CPAP use averaged 2.9±2.3 hours per night with 21% fully 'adherent' (at least 4 hours use on 5 days per week). Intention-to-treat analyses revealed no significant differences between groups in the Paced Auditory Serial Addition Task (mean improvement of 2.28, 95% CI -7.09 to 11.6; p=0.63). Controlling for premorbid intelligence, age and obstructive sleep apnoea severity (group effect -1.15, 95% CI -10 to 7.7) did not alter this finding. Sleepiness was significantly improved by CPAP on intention-to-treat analysis (mean difference -1.26, 95% CI -2.2 to -0.32; p=0.01).

CONCLUSION

CPAP did not improve Paced Auditory Serial Addition Task scores but significantly reduced sleepiness after acute quadriplegia.

TRIAL REGISTRATION NUMBER

ACTRN12605000799651.

A randomised controlled trial of nasal decongestant to treat obstructive sleep apnoea in people with cervical spinal cord injury

STUDY DESIGN

Prospective, double-blind, randomised, placebo-controlled, cross-over trial of nasal decongestion in tetraplegia.

OBJECTIVES

Tetraplegia is complicated by severe, predominantly obstructive, sleep apnoea. First-line therapy for obstructive sleep apnoea is nasal continuous positive airway pressure, but this is poorly tolerated. High nasal resistance associated with unopposed parasympathetic activation of the upper airway contributes to poor adherence. This preliminary study tested whether reducing nasal decongestion improved sleep.

SETTING

Participants' homes in Melbourne and Sydney, Australia.

METHODS

Two sleep studies were performed in participants' homes separated by 1 week. Participants were given a nasal spray (0.5 mL of 5% phenylephrine or placebo) in random order and posterior nasal resistance measured immediately. Outcomes included sleep apnoea severity, perceived nasal congestion, sleep quality and oxygenation during sleep.

RESULTS

Twelve middle-aged (average (SD) 52 (12) years) overweight (body mass index 25.3 (6.7) kg/m²) men (C4-6, AIS A and B) participated. Nasal resistance was reduced following administration of phenylephrine (p = 0.02; mean between treatment group difference -5.20: 95% confidence interval -9.09, -1.32 cmH₂O/L/s). No differences were observed in the apnoea hypopnoea index (p = 0.15; -6.37: -33.3, 20.6 events/h), total sleep time (p = 0.49; -1.33: -51.8, 49.1 min), REM sleep% (p = 0.50; 2.37: -5.6, 10.3), arousal index (p = 0.76; 1.15: -17.45, 19.75), 4% oxygen desaturation index (p = 0.88; 0.63: -23.5, 24.7 events/h), or the percentage of mouth breathing events (p = 0.4; -8.07: -29.2, 13.0) between treatments. The apnoea hypopnoea index did differ between groups, however, all except one participant had proportionally more hypopnoeas than apnoeas during sleep after decongestion.

CONCLUSIONS

These preliminary data found that phenylephrine acutely reduced nasal resistance but did not significantly change sleep-disordered breathing severity.

Actigraphy-based evaluation of sleep quality and physical activity in individuals with spinal cord injury

Study design

Cross-sectional study.

Background

Sleep disturbances are frequently reported by individuals with spinal cord injury (SCI) and are associated both with poor quality of life and reduced ability to participate in rehabilitation and daily life activities.

Objectives

This study investigated sleep quality based on self-reports and actigraphy in individuals with SCI as compared to able-bodied. We also explored the relationship between sleep quality, physical activity, and neuropathic pain.

Setting

Institute Guttmann, Neurorehabilitation Hospital, Badalona, Barcelona, Spain.

Methods

Fourteen SCI patients (12 males, 43.10 ± 10.59 y.o.) and 10 healthy individuals (7 males, mean age 46.21 ± 12.58 y.o.) were enrolled in the study. Participants wore wrist actigraphs for 7 consecutive days to characterize their sleep-wake cycle, rest-activity circadian rhythm and physical activity. Sleep quality, chronotype, daytime sleepiness, neuropathic pain severity and interference were assessed based on questionnaires.

Results

SCI individuals reported poorer sleep quality compared to healthy individuals. Actigraphy-based sleep measurements revealed that patients woke up later, spent more time in bed and slept longer compared to the healthy controls but did not differ significantly in the estimated sleep efficacy and number of awakenings from the able-bodied controls. In individuals with SCI greater physical activity predicted higher sleep efficacy and less awakening episodes as well as shorter sleep latency and lower sleep disturbance.

Conclusions

The actigraphy-based sleep estimates indicate that patients with SCI spent more time in bed and slept longer but their sleep efficacy was similar to able-bodied controls. Maintaining regular physical activity could improve pain control and sleep quality.

Impact Of Spinal Cord Injury On Sleep: Current Perspectives

Sleep disorders are commonly encountered in people living with spinal cord injury (SCI). Primary sleep disorders such as sleep-disordered breathing (SDB), sleep-related movement disorders, circadian rhythm sleep-wake disorders, and insomnia disorder are common conditions after SCI but remain under-recognized, underdiagnosed and therefore remain untreated for a majority of patients. Sleep disturbances in people living with SCI are associated with significant impairments of daytime function and quality of life. Previous reviews have described findings related mainly to SDB but have not examined the relationship between other sleep disorders and SCI. This narrative review examines various sleep abnormalities and related functional and physical impairments in people living with SCI. It discusses new evidence pertaining to management, highlights existing limitations in the literature and recommends future directions for research.

Caregiver expectations of recovery among persons with spinal cord injury at three and six months post-injury: A brief report

Objective: Caregivers of patients with spinal cord injury (SCI) have increased risk of depression, anxiety, and diminished quality of life. Unmet expectations for recovery may contribute to poorer outcomes.Design: Prospective, longitudinal observation study.Settings: Trauma/Critical care ICU at baseline, telephone for follow-ups.Participants: Caregivers of patients with SCI (n = 13).Interventions: None.Outcome Measures: Expectations for recovery were assessed across four primary domains identified in a review of the literature including: pain severity, level of engagement in social/recreational activities, sleep quality, and ability to return to work/school. Caregivers' forecasts of future recovery were compared to later perceived actual recovery.Results: At three months, 75% of caregivers had unmet expectations for social engagement recovery, 50% had unmet expectations for pain decrease, and 42% had unmet expectations for sleep improvement and resuming work. Rates of unmet expectations were similar at six months, with 70% of caregivers reporting unmet expectations for social engagement recovery, 50% with unmet expectations for pain decrease, and 40% with unmet expectations for sleep improvement.Conclusion: Unmet caregiver expectations for recovery could pose a risk for caregiver recovery and adjustment. Our results show that caregiver expectations merit further investigation for their link with caregiver mental health.

Melatonin and cortisol in individuals with spinal cord injury

STUDY OBJECTIVES

The aim of this study was to investigate circadian rhythm and sleep complaints in individuals with spinal cord injury (SCI) as determined by diurnal saliva melatonin and cortisol as well as activity measurements and subjective sleep quality.

METHODS

Fourteen patients with cervical SCI (cSCI), six patients with thoracic SCI (tSCI) and eight able-bodied controls all underwent two consecutive weeks wearing a wrist actigraph in addition to filling out a sleep diary. During one 24-h period, cortisol and melatonin were measured at 4-h intervals. Furthermore, participants' sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and their overall daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS).

RESULTS

The cSCI group demonstrated lower melatonin levels compared with the tSCI group and the controls at the 24:00 and 04:00 time points. Moreover, at one time point the tSCI group had a higher cortisol level than the cSCI group and the controls. In addition, baseline systolic blood pressure and oxygen saturation were significantly lower in the cSCI group. No differences were found in activity measurements or self-reported sleep quality.

CONCLUSIONS

Individuals with cSCI demonstrate reduced melatonin secretion compared with tSCI individuals, but not in other circadian measures. This supports an involvement of melatonergic cervical fibers associated with the cervical lesion.

Periodic limb movements in tetraplegia

OBJECTIVE

To establish the prevalence of Periodic Limb Movements during Sleep (PLMS) in patients with tetraplegia, controlling for obstructive sleep apnea. To explore whether demographic and injury characteristics affect PLMS.

STUDY DESIGN

Retrospective cohorts.

SETTING AND PARTICIPANTS

One hundred seventy-three participants with acute (<12 months) and 92 with chronic (>12 months) tetraplegia who underwent full overnight diagnostic sleep studies.

INTERVENTIONS AND OUTCOME MEASURES

Two hundred sixty-two sleep study recordings were included. A randomly selected subgroup of 21 studies was assessed for PLM during wakefulness. Data were analysed according to the current American Academy of Sleep Medicine guidelines.

RESULTS

Of the participants, 41.6% (43(15.7) years and 14.9% female) had a motor and sensory complete lesion. Sleep was poor with both OSA (87.8% with apnea hypopnoea index ≥ 5) and PLMS (58.4% with PLMS per hour PLMSI > 15) highly prevalent. There was no difference in the PLMSI between those with OSA (36.3(39.8)) or without (42.2(37.7), P = 0.42). PLMS were evident during REM and NREM sleep in all of the 153 patients with PLMSI > 15. All 21 participants in the subgroup of studies analysed for the PLM during quiet wakefulness, exhibited limb movements. None of the modelled variables (injury completeness, gender, OSA severity or time since injury) significantly predicted a PLMSI > 15 (P = 0.343).

CONCLUSION

In conclusion, this study confirms the high prevalence of PLM in tetraplegia and the presence of leg movements in NREM and REM sleep along with wakefulness after controlling for OSA. No associations between the presence of PLMS and patient characteristics or injury specific aspects were found.

On Denny-Brown's 'spastic dystonia' - What is it and what causes it?

In this review, we will work around two simple definitions of two different entities, which most often co-exist in patients with lesions to central motor pathways: Spasticity is "Enhanced excitability of velocity-dependent responses to phasic stretch at rest", which will not be the subject of this review, while Spastic dystonia is tonic, chronic, involuntary muscle contraction in the absence of any stretch or any voluntary command (Gracies, 2005). Spastic dystonia is a much less well understood entity that will be the subject this review. Denny-Brown (1966) observed involuntary sustained muscle activity in monkeys with lesions restricted to the motor cortices . He further observed that such involuntary muscle activity persisted following abolition of sensory input to the spinal cord and concluded that a central mechanism rather than exaggerated stretch reflex activity had to be involved. He coined the term spastic dystonia to describe this involuntary tonic activity in the context of otherwise exaggerated stretch reflexes. Sustained involuntary muscle activity in the absence of any stretch or any voluntary command contributes to burdensome and disabling body deformities in patients with spastic paresis. Yet, little has been done since Denny-Brown's studies to determine the pathophysiology of this non- stretch or effort related sustained involuntary muscle activity following motor lesions and there is a clear need for research studies in order to improve current therapy. The purpose of the present review is to discuss some of the possible mechanisms that may be involved in the hope that this may guide future research. We discuss the existence of persistent inward currents in spinal motoneurones and present the evidence that the channels involved may be upregulated following central motor lesions. We also discuss a possible contribution from alterations in synaptic inputs from surviving or abnormally branched sensory and descending fibres leading to over-activity and lack of motor coordination. We finally discuss evidence of alterations in motor cortical representational maps and basal ganglia lesions.

Poor sleep in adults with pediatric-onset spinal cord injury: associations with pain, health, and activity

OBJECTIVE

To investigate medical complications that increase risk for poor sleep in adults with pediatric-onset spinal cord injury (SCI) and explore the relation of poor sleep to psychosocial outcomes.

METHOD

This was a cross-sectional study of individuals with pediatric-onset SCI interviewed between 2011-2015. Participants were recruited from a pediatric specialty hospital and answered questions about demographics, injury characteristics, pain, and medical complications and completed standardized outcome measures, including: Pittsburgh Sleep Quality Index, SF12v2 Health Survey, Craig Handicap Assessment and Recording Technique (CHART), and Subjective Happiness Scale.

RESULTS

The study included 180 participants between the ages of 19 and 51 (M=34.20 y; SD=7.28) who sustained their SCI before the age of 19 (M=13.48y; SD=4.59). Participants were predominantly male (62%) and Caucasian (84%). A majority had tetraplegia (56%) and complete injuries (74%). Poor sleep occurred with greater frequency in those with tetraplegia and who were unemployed. Neck (OR=2.80, P = 0.001), shoulder (OR=2.15, P = 0.011), arm (OR=3.06, P = 0.004), and lower extremity pain (OR=2.72, P = 0.004) were associated with increased risk of poor sleep. In a logistic regression analysis, chronic medical conditions and continuous pain were most likely to be associated with poor sleep. Individuals with poor sleep reported lower levels of mobility, perceived health, and subjective happiness.

CONCLUSION

Pain and secondary complications significantly increase the odds of poor sleep. Furthermore, poor sleep is associated with decreased mobility and measures of well-being. Preventive measures to reduce risk factors and improve sleep quality after pediatric-onset SCI should be considered.

Qualitative Experience of Sleep in Individuals With Spinal Cord Injury

Poor sleep contributes to adverse health outcomes making it important to understand sleep in medically vulnerable populations, including those with spinal cord injury (SCI). However, little attention has been paid to circumstances specific to SCI that may negatively affect sleep, or to consequences of poor sleep in this population. The objective of this study was to examine the experience of sleep among individuals with SCI. Secondary analysis using thematic coding of qualitative data from an ethnographic study of community-dwelling adults with SCI was conducted. Sleep-related data were found in transcripts for 90% of the sample. Participants described diminished sleep duration and irregular sleep patterns. Several factors contributing to poor sleep were identified, including SCI-related circumstances and sleep environment. Participants also discussed how poor sleep affected occupational engagement. This study highlights the extent of sleep disturbance experienced after SCI and the subsequent impact on occupational performance, and provides direction for clinical practice.

Effectiveness of dietary supplements in spinal cord injury subjects

BACKGROUND

Individuals with spinal cord injury (SCI) consume more dietary supplements than the general population. However, there is limited information regarding the clinical effectiveness of dietary supplements in SCI population.

OBJECTIVE

To systematically review the effectiveness of dietary supplements for the prevention or treatment of health-related conditions associated with SCI.

METHODS

Randomized or non-randomized controlled clinical trials were selected, comparing the effect of any dose and form of a dietary supplement (defined by the Dietary Supplement Health and Education Act), with either no treatment, placebo, or other medication. Data Sources included the Cochrane Database, DARE, LILACS, CINAHL, EMBASE, MEDLINE, OTSeeker, PEDro, PsycINFO, SpeechBITE, ScienceDirect, Scopus, clinicaltrials.gov, Google Scholar, and OpenGrey. Two reviewers independently classified articles from January 1970 through October 2015, and 18 articles were selected.

RESULTS

Due to the heterogeneity of outcome measures across studies, a meta-analysis was not conducted. However, high-quality evidence showed that cranberry supplementation is not effective for prevention of urinary tract infections (UTIs) in SCI. Moderate-quality evidence supported a beneficial effect of vitamin D, alpha-lipoic acid, and omega-3 supplementation, although replication of results is needed. There were conflicting results for the effect of creatine supplementation on improvement of motor outcomes. Low-quality evidence does not permit assessment of the effectiveness of melatonin, whey protein, vitamin C, and Chinese herb in SCI.

CONCLUSIONS

There is sufficient data suggesting that cranberry supplementation is ineffective for prevention of UTIs in individuals with SCI. There is insufficient data to support or refute the use of any other dietary supplement in individuals with SCI.

Nasal Resistance Is Elevated in People with Tetraplegia and Is Reduced by Topical Sympathomimetic Administration

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is common in individuals with tetraplegia and associated with adverse health outcomes. The causes of the high prevalence of OSA in this population are unknown, but it is important to understand as standard treatments are poorly tolerated in tetraplegia. Nasal congestion is common in tetraplegia, possibly because of unopposed parasympathetic activity. Further, nasal obstruction can induce OSA in healthy individuals. We therefore aimed to compare nasal resistance before and after topical administration of a sympathomimetic between 10 individuals with tetraplegia (T) and 9 able-bodied (AB) controls matched for OSA severity, gender, and age.

METHODS

Nasal, pharyngeal, and total upper airway resistance were calculated before and every 2 minutes following delivery of ≈0.05 mL of 0.5% atomized phenylephrine to the nostrils and pharyngeal airway. The surface tension of the upper airway lining liquid was also assessed.

RESULTS

At baseline, individuals with tetraplegia had elevated nasal resistance (T = 7.0 ± 1.9, AB = 3.0 ± 0.6 cm H2O/L/s), that rapidly fell after phenylephrine (T = 2.3 ± 0.4, p = 0.03 at 2 min) whereas the able-bodied did not change (AB = 2.5 ± 0.5 cm H2O/L/s, p = 0.06 at 2 min). Pharyngeal resistance was non-significantly higher in individuals with tetraplegia than controls at baseline (T = 2.6 ± 0.9, AB = 1.2 ± 0.4 cm H2O/L/s) and was not altered by phenylephrine in either group. The surface tension of the upper airway lining liquid did not differ between groups (T = 64.3 ± 1.0, AB = 62.7 ± 0.6 mN/m).

CONCLUSIONS

These data suggest that the unopposed parasympathetic activity in tetraplegia increases nasal resistance, potentially contributing to the high occurrence of OSA in this population.

Prevalence of depression, fatigue, and sleep disturbances in patients with myelopathy: Their relation with functional and neurological recovery

OBJECTIVES

To observe the prevalence of fatigue, depression, and sleep disturbance in patients with myelopathy and their correlation with neurological and functional recovery.

PATIENTS AND METHODS

Study conducted in a university tertiary research hospital with 127 patients with myelopathy (92 males) admitted to neurorehabilitation unit between January 2010 and December 2013. Mean age was 32.71 ± 13.08 years (range 15-65 years), and mean duration of injury was 76.22 ± 82.5 days (range 14-365 days). Functional status and impairments were assessed using Barthel Index and Spinal Cord Independence Measures. Depression, fatigue, and sleep disturbances were assessed using Hospital Anxiety and Depression Scale, Fatigue Severity Scale, and Pittsburgh Sleep Quality Index scales, respectively. Neurological recovery was assessed using American Spinal Injury Association's impairment scale.

RESULTS

Forty-four out of 104 (42%) patients had borderline or confirmed depression, 36/108 (33%) had significant fatigue, and 62/106 (58%) had significant sleep disturbances at admission. Significant correlation was observed between change in fatigue and depression scores with change in functional status scores (P < 0.05) but no correlation (P > 0.05) between change in sleep disturbance scores and functional status score and neurological recovery (P > 0.05). Similarly, change in fatigue and depression scores had no correlation with neurological status improvement. Fatigue, depression, and sleep disturbance scores showed significant improvement, that is, admission vs. discharge scores (P < 0.05) with significant correlation between improvement in all three variables (P < 0.05).

CONCLUSIONS

Study variables showed significant improvement in the present study with myelopathy patients but not necessarily correlating with functional and neurological recovery.

Comparison of Sleep Problems in Individuals with Spinal Cord Injury and Multiple Sclerosis

STUDY OBJECTIVES

Sleep problems are common in spinal cord injury (SCI) and multiple sclerosis (MS). However, the degree to which sleep problems differ between these distinct clinical populations has not been evaluated. In this study, we examined self-reported sleep problems in individuals with SCI and those with MS, and compared these clinical groups on the Medical Outcomes Study Sleep Scale (MOS-SS).

METHODS

Participants were 1,677 individuals (SCI = 581; MS = 1,096) enrolled in longitudinal study of self-reported health outcomes in SCI and MS. Univariate and multivariate analysis of covariance examined group differences on global sleep problems and domain-specific subscales of the MOS-SS.

RESULTS

Individuals with SCI reported an average of 30 fewer min of sleep per night (Sleep Quantity subscale) and significantly greater difficulty initiating and maintaining sleep (Sleep Disturbance subscale) compared to individuals with MS. However, groups did not differ on global sleep problems (Sleep Problems Index 9).

CONCLUSIONS

Although global sleep problems are more common in SCI and MS than in the general population, these groups exhibit differing sleep problem profiles, and thus may require unique treatment approaches to address the specific domains of sleep affected. For individuals with SCI, an additional focus on increasing sleep quantity and reducing sleep disruptions may be warranted.

The contribution of the pineal gland on daily rhythms and masking in diurnal grass rats, Arvicanthis niloticus

Melatonin is a hormone rhythmically secreted at night by the pineal gland in vertebrates. In diurnal mammals, melatonin is present during the inactive phase of the rest/activity cycle, and in primates it directly facilitates sleep and decreases body temperature. However, the role of the pineal gland for the promotion of sleep at night has not yet been studied in non-primate diurnal mammalian species. Here, the authors directly examined the hypothesis that the pineal gland contributes to diurnality in Nile grass rats by decreasing activity and increasing sleep at night, and that this could occur via effects on circadian mechanisms or masking, or both. Removing the pineal gland had no effect on the hourly distribution of activity across a 12:12 light-dark (LD) cycle or on the patterns of sleep-like behavior at night. Masking effects of light at night on activity were also not significantly different in pinealectomized and control grass rats, as 1h pulses of light stimulated increases in activity of sham and pinealectomized animals to a similar extent. In addition, the circadian regulation of activity was unaffected by the surgical condition of the animals. Our results suggest that the pineal gland does not contribute to diurnality in the grass rat, thus highlighting the complexity of temporal niche transitions. The current data raise interesting questions about how and why genetic and neural mechanisms linking melatonin to sleep regulatory systems might vary among mammals that reached a diurnal niche via parallel and independent pathways.

Comparison of self-report sleep measures for individuals with multiple sclerosis and spinal cord injury

OBJECTIVE

To investigate self-report measures of sleep disturbances and sleep-related impairments in samples of individuals with multiple sclerosis (MS) or spinal cord injury (SCI).

DESIGN

Cross-sectional survey.

SETTING

Community based.

PARTICIPANTS

Adults (age ≥18y) (N=700) with either MS (n=461) or SCI (n=239) who were enrolled in a longitudinal survey of self-reported health outcomes and who completed self-report sleep measures at 1 time point.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Medical Outcomes Study Sleep Scale (MOS-S), Patient Reported Outcomes Measurement Information System (PROMIS) sleep disturbance short form, and PROMIS sleep-related impairments short form.

RESULTS

Mean scores on the MOS-S sleep index II were significantly worse for both the MS and SCI samples than those of previously reported samples representative of the U.S. general population (P<.0001 for each group). The PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form scores of the MS sample were also significantly different from those reported for the calibration cohort (P<.0001 on each scale). However, although the scores of the SCI sample were significantly different from those of the comparison cohort for the PROMIS sleep-related impairments short form (P=.045), the differences on the PROMIS sleep disturbance short form were not significant (P=.069).

CONCLUSIONS

Although the MOS-S scores for the MS and SCI cohorts clearly indicated significantly high levels of sleep-related problems and were consistent with existing literature, the more ambiguous findings from the PROMIS sleep disturbance short form and PROMIS sleep-related impairments short form suggest that not enough is currently known about how these instruments function when applied to those with chronic neurologic dysfunction.