Patterns of morbidity and rehospitalisation following spinal cord injury

Biomarker expression level changes within rectal gut-associated lymphoid tissues in spinal cord-injured rats

Neurogenic bowel dysfunction (NBD) is common after spinal cord injury (SCI). Gut-associated lymphoid tissue (GALT), an organized structure within the mucosal immune system, is important for the maintenance of gut homeostasis and body health and serves as the first line barrier/defense against diet antigens, commensal microbiota, pathogens, and toxins in mucosal areas. The current study examined gene expression levels along six segments of anorectal tissue using real-time polymerase chain reaction (RT-PCR) in uninjured rats (28-day sham surgical controls) and at both 28- and 42-days post-T9 contusion injury. Consistent with our previous report of functional regional differences in the ano-rectum, we demonstrate the existence of GALTs located primarily within the segment at 3-4.5 cm from the rectal dentate line (termed rectal GALTs-rGALTs) in shams with upregulated gene expression levels of multiple biomarkers, including B cell and T cell-related genes, major histocompatibility complex (MHC) class II molecules, and germinal center (GC)-related genes, which was further confirmed by histologic examination. In the same rectal tissue segment following T9 SCI, inflammation-related genes were upregulated at 28 days post-injury (DPI) indicating that microbial infection and inflammation of rGALTs modified structure and function of rGALTs, while at 42 DPI rGALTs exhibited resolution of inflammation and impaired structure/function for extrafollicular B cell responses. Taken together, our data suggest that rGALTs exists in rat rectum for homeostasis of gut microbiota/barrier. SCI induces microbial infection and inflammation in rectal tissues containing rGALTs, which could contribute to development of SCI-related gut microbiome dysbiosis, NBD, and systemic diseases.

Mental Health Disorders Due to Gut Microbiome Alteration and NLRP3 Inflammasome Activation After Spinal Cord Injury: Molecular Mechanisms, Promising Treatments, and Aids from Artificial Intelligence

Aside from its immediate traumatic effects, spinal cord injury (SCI) presents multiple secondary complications that can be harmful to those who have been affected by SCI. Among these secondary effects, gut dysbiosis (GD) and the activation of the NOD (nucleotide-binding oligomerization domain) like receptor-family pyrin-domain-containing three (NLRP3) inflammasome are of special interest for their roles in impacting mental health. Studies have found that the state of the gut microbiome is thrown into disarray after SCI, providing a chance for GD to occur. Metabolites such as short-chain fatty acids (SCFAs) and a variety of neurotransmitters produced by the gut microbiome are hampered by GD. This disrupts healthy cognitive processes and opens the door for SCI patients to be impacted by mental health disorders. Additionally, some studies have found an increased presence and activation of the NLRP3 inflammasome and its respective parts in SCI patients. Preclinical and clinical studies have shown that NLRP3 inflammasome plays a key role in the maturation of pro-inflammatory cytokines that can initiate and eventually aggravate mental health disorders after SCI. In addition to the mechanisms of GD and the NLRP3 inflammasome in intensifying mental health disorders after SCI, this review article further focuses on three promising treatments: fecal microbiome transplants, phytochemicals, and melatonin. Studies have found these treatments to be effective in combating the pathogenic mechanisms of GD and NLRP3 inflammasome, as well as alleviating the symptoms these complications may have on mental health. Another area of focus of this review article is exploring how artificial intelligence (AI) can be used to support treatments. AI models have already been developed to track changes in the gut microbiome, simulate drug-gut interactions, and design novel anti-NLRP3 inflammasome peptides. While these are promising, further research into the applications of AI for the treatment of mental health disorders in SCI is needed.

Prevalence, causes, and risk profile of rehospitalizations in persons with spinal cord injury within the first 10 years after primary rehabilitation

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aims to identify the prevalence, causes, time pattern and risk profile of rehospitalizations in persons with spinal cord injury (SCI) within a 10-year period following primary rehabilitation and identify most common secondary health conditions (SHCs) and risk profile leading to rehospitalizations.

SETTING

Specialized hospital and rehabilitation center for SCI in Switzerland.

METHODS

A retrospective analysis was conducted on clinical data from persons with SCI, discharged from initial rehabilitation between January 1, 2010, and December 31, 2012, and followed up over a period of ten years post-discharge. Descriptive statistical methods were utilized to compute the rehospitalization prevalence and to identify the primary reasons.

RESULTS

225 participants were included, 70% were male (n = 179), and the mean age was 50 years (SD 19, Range 17-88). 54% were classified as having paraplegia (n = 122), and 77% incomplete injuries (n = 180). Over the 10-year observation period post-discharge, 120 were readmitted at least once, (prevalence 53%). In total, 66 persons (29%) were rehospitalized once or twice, while 54 persons (24%) were rehospitalized three or more times, with a maximum of 14 times. In the 10-year period, the most common SHCs leading to rehospitalization were infections (19%), pressure injuries (18%), and gastrointestinal problems (16%). During the study period, 57 persons (25%) passed away.

CONCLUSIONS

Rehospitalization after primary rehabilitation is frequent and in the majority of the cases due to SHCs. The study findings are valuable for resource planning in healthcare and can guide the implementation of preventive measures to avoid SHCs.

Gut feelings: gastrointestinal signs in French bulldogs undergoing spinal surgery

Introduction

The French bulldog (FBD) is a brachycephalic breed prone to several neurological conditions, of which intervertebral disc herniation (IVDH) is considerably prevalent. Gastrointestinal (GI) disease is a reported complication in dogs surgically treated for IVDH. The objective of this study was to describe GI signs and their outcome in FBDs surgically treated for IVDH.

Materials and methods

Data regarding the GI signs (vomiting, diarrhoea and regurgitation), their frequency and short-term outcome in FBDs surgically treated for IVDH (cervical, thoracolumbar or lumbar) between January 2017 and April 2023 were obtained from medical records at one institution. Categorical variables were compared using Fisher exact tests, and ordinal/continuous data between categorical groups using Kruskal-Wallis or Mann-Whitney tests.

Results

Ninety-seven FBDs were included for analysis. GI signs occurred in 74/97 (76.3%) FBDs while hospitalised, with 33.8% and 66.2% developing GI signs pre- and post-operatively, respectively. FBDs that developed GI signs had a mean of 4.9 episodes. Diarrhoea was the most common GI sign encountered (51/74) compared to regurgitation (38/74) and vomiting (22/74). Resolution of GI signs occurred within a mean of 2.2 days. Mean duration of hospitalisation post-surgery was 4.6 days in FBDs that developed GI signs versus 3.7 days in FBDs that did not (p = 0.033). Anaesthesia length was associated with developing GI signs (p=0.037). Neurological severity, neuroanatomical localisation and surgical procedure were not associated with development of GI signs (p = 0.42, p = 0.794 and p = 1, respectively).

Conclusion

GI signs were commonly encountered in FBDs surgically treated for IVDH and associated with length of anaesthesia and prolonged hospitalisation.

Diet-microbiome interactions promote enteric nervous system resilience following spinal cord injury

Spinal cord injury (SCI) results in numerous systemic dysfunctions, including intestinal dysmotility and enteric nervous system (ENS) atrophy. The ENS has capacity to recover following perturbation, yet intestinal pathologies persist. With emerging evidence demonstrating SCI-induced alterations to gut microbiome composition, we hypothesized that microbiome modulation contributes to post-injury enteric recovery. Here, we show that intervention with the dietary fiber, inulin, prevents SCI-induced ENS atrophy and dysmotility in mice. While SCI-associated microbiomes and specific injury-sensitive gut microbes are not sufficient to modulate intestinal dysmotility after injury, intervention with microbially-derived short-chain fatty acid (SCFA) metabolites prevents ENS dysfunctions in injured mice. Notably, inulin-mediated resilience is dependent on IL-10 signaling, highlighting a critical diet-microbiome-immune axis that promotes ENS resilience post-injury. Overall, we demonstrate that diet and microbially-derived signals distinctly impact ENS survival after traumatic spinal injury and represent a foundation to uncover etiological mechanisms and future therapeutics for SCI-induced neurogenic bowel.

Diet-microbiome interactions promote enteric nervous system resilience following spinal cord injury

Spinal cord injury (SCI) results in a plethora of physiological dysfunctions across all body systems, including intestinal dysmotility and atrophy of the enteric nervous system (ENS). Typically, the ENS has capacity to recover from perturbation, so it is unclear why intestinal pathophysiologies persist after traumatic spinal injury. With emerging evidence demonstrating SCI-induced alterations to the gut microbiome composition, we hypothesized that modulation of the gut microbiome could contribute to enteric nervous system recovery after injury. Here, we show that intervention with the dietary fiber, inulin prevents ENS atrophy and limits SCI-induced intestinal dysmotility in mice. However, SCI-associated microbiomes and exposure to specific SCI-sensitive gut microbes are not sufficient to modulate injury-induced intestinal dysmotility. Intervention with microbially-derived short-chain fatty acid (SCFA) metabolites prevents ENS dysfunctions and phenocopies inulin treatment in injured mice, implicating these microbiome metabolites in protection of the ENS. Notably, inulin-mediated resilience is dependent on signaling by the cytokine IL-10, highlighting a critical diet-microbiome-immune axis that promotes ENS resilience following SCI. Overall, we demonstrate that diet and microbially-derived signals distinctly impact recovery of the ENS after traumatic spinal injury. This protective diet-microbiome-immune axis may represent a foundation to uncover etiological mechanisms and future therapeutics for SCI-induced neurogenic bowel.

Disrupted autonomic pathways in spinal cord injury: Implications for the immune regulation

Spinal Cord Injury (SCI) disrupts critical autonomic pathways responsible for the regulation of the immune function. Consequently, individuals with SCI often exhibit a spectrum of immune dysfunctions ranging from the development of damaging pro-inflammatory responses to severe immunosuppression. Thus, it is imperative to gain a more comprehensive understanding of the extent and mechanisms through which SCI-induced autonomic dysfunction influences the immune response. In this review, we provide an overview of the anatomical organization and physiology of the autonomic nervous system (ANS), elucidating how SCI impacts its function, with a particular focus on lymphoid organs and immune activity. We highlight recent advances in understanding how intraspinal plasticity that follows SCI may contribute to aberrant autonomic activity in lymphoid organs. Additionally, we discuss how sympathetic mediators released by these neuron terminals affect immune cell function. Finally, we discuss emerging innovative technologies and potential clinical interventions targeting the ANS as a strategy to restore the normal regulation of the immune response in individuals with SCI.

Healthcare utilization and outcomes of spinal cord injured veterans with stage 3-4 pressure injuries

BACKGROUND

Pressure injuries (PI) are a significant source of morbidity for individuals with spinal cord injury/disease (SCI/D). They are also associated with significant healthcare resource utilization including prolonged hospitalizations. However, the long-term outcomes in terms of wound recurrence-free survival, hospital readmission rates, and all-cause mortality in this population remain largely unknown.

OBJECTIVE

To examine the clinical characteristics, healthcare utilization and outcomes of SCI Veterans hospitalized at the VA North Texas Health Care System (VANTHCS) SCI inpatient unit with stage 3 and 4 PI, and compare these between those who received a myocutaneous flap surgery (flap patients (FP)) and those treated medically (non-flap patients (NFP)).

METHODS

A retrospective chart review was conducted of all adult patients admitted to the VANTHCS SCI/D unit with stage 3 or 4 pelvic PI between 1/1/2013 and 12/31/2018. Healthcare utilization and outcome information was extracted for pre-specified time points.

RESULTS

78 patients met criteria (113 hospitalizations; 27 FP; 51 NFP). Average length of stay (LOS) was 122 days; FP had a significantly higher LOS than NFP (P = 0.01). Average number of consults was 24. Estimated cost per hospitalization was $175,198. Readmission rate within 30 days was 12.39%. The mortality rate within 1 year of discharge was 21.57% for NFP, as opposed to 3.70% in the FP group. Only 5.00% of NFP wounds were healed at discharged with sustained healing at 1 year, significantly less than FP wounds (55.26%, P < 0.01).

CONCLUSIONS

Despite the high investment in terms of healthcare utilization, outcomes in terms of wound healing are poor. Additionally, nearly 22% of NFP died within one year of discharge. This calls into question the utility of prolonged hospitalizations for PI in the SCI/D population in terms of wound treatment efficacy, healthcare costs, and patient morbidity/mortality.

Impact of Activity-Based Training on Bowel Function in a Rat Model of Spinal Cord Injury

Significant bowel-related issues after spinal cord injury (SCI) that affect morbidity and quality of life (QOL) include diminished bowel motility, loss of sphincter control, gastric ulcers, autonomic dysreflexia, pain, diarrhea, constipation, and fecal incontinence. Clinical diagnoses and research in humans have largely relied on anorectal manometry (ARM) procedures to increase understanding of the functional effects of SCI on colorectal motility and defecation physiology. Recent pre-clinical rodent studies have also used ARM to further our understanding of bowel-related dysfunctions post-SCI. In the present study, the benefits of different activity-based training (ABT) durations on bowel function were examined. Six groups of male rats including two non-training (NT; uninjured and SCI) and four ABT (quadrupedal [Quad or Q] stepping on a treadmill) groups. All ABT animals received 4 weeks of 1-h daily stepping beginning 2 weeks post-SCI followed by variable amounts for 4 additional weeks (none; daily; once a week; daily for final 4th week only). Outcome measures included fecal output (home cage; metabolic cage) throughout the study and terminal measurements (post 8-week ABT) of external anal sphincter (EAS) electromyography, resting anorectal pressure, and giant contraction (GC) activation under urethane anesthesia. The results indicate that treadmill training normalized defecation amount based on feces weight and food intake, as well as GC frequency, EAS latency and amplitude during fecal expulsion, and resting pressure in specific areas within the colorectum. The two intermittent training groups consistently showed recorded metrics comparable to the non-injured group. The results demonstrate bowel dysfunction in the rodent SCI contusion model with improvements in functional outcomes following ABT. Importantly, the benefits to bowel-related functions with versus without intermittent ABT illustrate the need for periodic therapy to maintain the functional gains of ABT.

A case report of three people experiencing intractable autonomic dysreflexia following instillation of Uro-Tainer® Polyhexanide 0.02

INTRODUCTION

Historically, bladder washouts were used to instil therapeutic reagents directly into the bladder. This practice has expanded to include instillation of solutions that deal with catheter issues such as encrustation or formation of bio-film. They appear to provide a promising strategy for people with long term catheters. These products are readily available to purchase, but there is concern that people are using these solutions without a complete understanding of the purpose for the rinse and without clinical guidance to monitor response to treatment.

CASE PRESENTATION

These case studies include three people living with spinal cord injury (SCI) who developed severe autonomic dysreflexia (AD) when a catheter rinse was carried out using a particular solution. Each of the cases developed immediate and, in some cases, intractable AD requiring further intervention to resolve symptoms.

DISCUSSION

Catheter-associated urinary tract infection is a significant cause of morbidity and mortality in people living with SCI. Long-term catheters provide a vector for opportunistic micro-organisms to form bio-film and create an environment that promotes formation of struvite calculi, thus increasing the risk of chronic catheter blockage and urinary tract infection. Whilst these solutions are used to reduce these risks, they also pose additional risks to people susceptible to AD. These cases highlight the need for judicious patient selection and clinical oversight and management of adverse events when using catheter rinse solutions in certain people living with SCI. This is supported by a decision-making algorithm and a response to AD algorithm. This case report was prepared following the CARE Guidelines (supplementary file 1).

Priorities, needs and willingness of use of nerve stimulation devices for bladder and bowel function in people with spinal cord injury (SCI): an Australian survey

STUDY DESIGN

Anonymous online survey OBJECTIVES: To investigate the priorities, needs and willingness to adopt nerve stimulation devices for managing neurogenic bladder and bowel function in people with spinal cord injury (SCI) living in Australia.

SETTING

Online survey of people living with SCI in Australia.

METHODS

This anonymous online survey used Qualtrics and was advertised via standard communication channels, such as advocacy groups representing the SCI community in Australia, social media, attending SCI sporting events and by word-of-mouth.

RESULTS

Responses from 62 individuals (32% female, 68% male) were included. Bladder emptying through urethra without catheter was the highest priority for bladder function. Reducing time required for bowel routines and constipation were the top priorities regarding bowel function. The highest concern for internal/implanted devices was the 4% chance of device surgical removal, while wearing wires under the clothes was the main concern for external devices. 53% of respondents were willing to trial an implanted nerve stimulation device, while 70% would trial an external device to improve and gain independence in bladder and bowel function.

CONCLUSION

The findings of this study highlighted the potential role in which nerve stimulation can have in addressing bladder and bowel dysfunction in people with SCI, and have also identified that there was a need for Australian physiotherapists to evaluate their role in bladder and bowel dysfunction. Results from this study can help guide further research in nerve stimulation devices for bladder and bowel dysfunction in people with SCI.

SPONSORSHIP

n/a.

Co-design of the Spinal Cord Injury Health Maintenance Tool to Support Self-Management: A Mixed-Methods Approach

Background

There is a lack of consumer-friendly tools to empower and support people living with spinal cord injury (SCI) to self-manage complex health needs in community. This article describes the co-design process of the new SCI Health Maintenance Tool (SCI-HMT).

Methods

Co-design of the SCI-HMT using a mixed-methods approach included a rapid review, e-Delphi surveys with range of multidisciplinary health care professionals (n = 62), interviews of participants with SCI (n = 18) and general practitioners (n = 4), focus groups (n = 3 with 7, 4, and 4 participants with SCI, respectively), design workshops with stakeholders (n = 11, 8), and end-user testing (n = 41).

Results

The SCI-HMT (healthmaintenancetool.com) was developed based on participatory research with data synthesis from multiple sources. Five priority health maintenance issues for bladder, bowel, skin, pain, and autonomic dysreflexia were originally covered. Best practice recommendations, red flag conditions, referrals, and clinical pathways were agreed on through an e-Delphi technique. Qualitative analysis identified six broad key concepts for self-management, including early symptom recognition, role of SCI peers, knowledge sharing with primary care, general practitioners as gatekeepers, and shared decision-making and highlighted a need to place much stronger emphasis on mental health and well-being. Design workshops and end-user testing provided key insights about user experience, functionality, and content for the SCI-HMT.

Conclusion

The co-design process engaging end users, including people with SCI and general practitioners, enabled a shared understanding of the problem and identification of important needs and how to meet them. Informed by this process, the SCI-HMT is a freely accessible resource supporting SCI self-management, shared decision-making, and early problem identification.

Precision medicine for traumatic cervical spinal cord injuries: accessible and interpretable machine learning models to predict individualized in-hospital outcomes

BACKGROUND CONTEXT

A traumatic spinal cord injury (SCI) can cause temporary or permanent motor and sensory impairment, leading to serious short and long-term consequences that can result in significant morbidity and mortality. The cervical spine is the most commonly affected area, accounting for about 60% of all traumatic SCI cases.

PURPOSE

This study aims to employ machine learning (ML) algorithms to predict various outcomes, such as in-hospital mortality, nonhome discharges, extended length of stay (LOS), extended length of intensive care unit stay (ICU-LOS), and major complications in patients diagnosed with cervical SCI (cSCI).

STUDY DESIGN

Our study was a retrospective machine learning classification study aiming to predict the outcomes of interest, which were binary categorical variables, in patients diagnosed with cSCI.

PATIENT SAMPLE

The data for this study were obtained from the American College of Surgeons (ACS) Trauma Quality Program (TQP) database, which was queried to identify patients who suffered from cSCI between 2019 and 2021.

OUTCOME MEASURES

The outcomes of interest of our study were in-hospital mortality, nonhome discharges, prolonged LOS, prolonged ICU-LOS, and major complications. The study evaluated the models' performance using both graphical and numerical methods. The receiver operating characteristic (ROC) and precision-recall curves (PRC) were used to assess model performance graphically. Numerical evaluation metrics included AUROC, balanced accuracy, weighted area under PRC (AUPRC), weighted precision, and weighted recall.

METHODS

The study employed data from the American College of Surgeons (ACS) Trauma Quality Program (TQP) database to identify patients with cSCI. Four ML algorithms, namely XGBoost, LightGBM, CatBoost, and Random Forest, were utilized to develop predictive models. The most effective models were then incorporated into a publicly available web application designed to forecast the outcomes of interest.

RESULTS

There were 71,661 patients included in the analysis for the outcome mortality, 67,331 for the outcome nonhome discharges, 76,782 for the outcome prolonged LOS, 26,615 for the outcome prolonged ICU-LOS, and 72,132 for the outcome major complications. The algorithms exhibited an AUROC value range of 0.78 to 0.839 for in-hospital mortality, 0.806 to 0.815 for nonhome discharges, 0.679 to 0.742 for prolonged LOS, 0.666 to 0.682 for prolonged ICU-LOS, and 0.637 to 0.704 for major complications. An open access web application was developed as part of the study, which can generate predictions for individual patients based on their characteristics.

CONCLUSIONS

Our study suggests that ML models can be valuable in assessing risk for patients with cervical cSCI and may have considerable potential for predicting outcomes during hospitalization. ML models demonstrated good predictive ability for in-hospital mortality and nonhome discharges, fair predictive ability for prolonged LOS, but poor predictive ability for prolonged ICU-LOS and major complications. Along with these promising results, the development of a user-friendly web application that facilitates the integration of these models into clinical practice is a significant contribution of this study. The product of this study may have significant implications in clinical settings to personalize care, anticipate outcomes, facilitate shared decision making and informed consent processes for cSCI patients.

Factors associated with urinary tract infection in the early phase after performing intermittent catheterization in individuals with spinal cord injury: a retrospective study

Objectives

To investigate the occurrence rate of urinary tract infections (UTIs) in the early phase after performing intermittent catheterization (IC) and to explore the possible factors associated with UTIs after performing IC among people with spinal cord injury (SCI).

Setting

An inpatient rehabilitation department of a teaching hospital in China.

Design

Retrospective chart review.

Methods

A retrospective chart review was carried out for traumatic and non-traumatic SCI patients after performing IC during their inpatient stay. Demographic information, comorbidity of diabetes, urine analysis results before IC, method of IC (sterile or clean), use of bladder irrigation, cessation of IC and its reasons, and UTI events were collected.

Results

A total of 183 adult individuals were included, of which 60 (32.8%) of them were women. The median age was 49.0 years. The median time post-injury was 2 months. The overall occurrence rate of UTI after performing IC was 1.31 (95% confidence intervals: 0.96-1.77) events per 100 days. Sixty-nine (37.7%) patients discontinued IC during hospitalization, and UTIs were the leading reason for cessation (50.7%). Female sex, use of antibiotics for infections other than UTI, and use of bladder irrigation were found to be associated with a lower occurrence rate of UTI in the early phase after performing IC, with an odds ratio of 0.38 (p = 0.019), 0.20 (p = 0.022), and 0.24 (p < 0.001), respectively.

Conclusion

UTI after performing IC is prevalent among people with SCI. The study indicated that antibiotic prophylaxis and routine bladder irrigation might be associated with the reduction in UTI in the early phase after performing IC. Further research is needed to provide more evidence.

Effects of Recombinant IL-13 Treatment on Gut Microbiota Composition and Functional Recovery after Hemisection Spinal Cord Injury in Mice

In recent years, the gut-central nervous system axis has emerged as a key factor in the pathophysiology of spinal cord injury (SCI). Interleukin-13 (IL-13) has been shown to have anti-inflammatory and neuroprotective effects in SCI. The aim of this study was to investigate the changes in microbiota composition after hemisection injury and to determine whether systemic recombinant (r)IL-13 treatment could alter the gut microbiome, indirectly promoting functional recovery. The gut microbiota composition was determined by 16S rRNA gene sequencing, and correlations between gut microbiota alterations and functional recovery were assessed. Our results showed that there were no changes in alpha diversity between the groups before and after SCI, while PERMANOVA analysis for beta diversity showed significant differences in fecal microbial communities. Phylogenetic classification of bacterial families revealed a lower abundance of the Bacteroidales S24-7 group and a higher abundance of Lachnospiraceae and Lactobacillaceae in the post-SCI group. Systemic rIL-13 treatment improved functional recovery 28 days post-injury and microbiota analysis revealed increased relative abundance of Clostridiales vadin BB60 and Acetitomaculum and decreased Anaeroplasma, Ruminiclostridium_6, and Ruminococcus compared to controls. Functional assessment with PICRUSt showed that genes related to glyoxylate cycle and palmitoleate biosynthesis-I were the predominant signatures in the rIL-13-treated group, whereas sulfolactate degradation super pathway and formaldehyde assimilation-I were enriched in controls. In conclusion, our results indicate that rIL-13 treatment promotes changes in gut microbial communities and may thereby contribute indirectly to the improvement of functional recovery in mice, possibly having important implications for the development of novel treatment options for SCI.

Aging with spinal cord injury: A narrative review of consequences and challenges

Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.

SmartPill™ Administration to Assess Gastrointestinal Function after Spinal Cord Injury in a Porcine Model-A Preliminary Study

Gastrointestinal (GI) complications, including motility disorders, metabolic deficiencies, and changes in gut microbiota following spinal cord injury (SCI), are associated with poor outcomes. After SCI, the autonomic nervous system becomes unbalanced below the level of injury and can lead to severe GI dysfunction. The SmartPill™ is a non-invasive capsule that, when ingested, transmits pH, temperature, and pressure readings that can be used to assess effects in GI function post-injury. Our minipig model allows us to assess these post-injury changes to optimize interventions and ultimately improve GI function. The aim of this study was to compare pre-injury to post-injury transit times, pH, and pressures in sections of GI tract by utilizing the SmartPill™ in three pigs after SCI at 2 and 6 weeks. Tributyrin was administered to two pigs to assess the influences on their gut microenvironment. We observed prolonged GET (Gastric Emptying Time) and CTT (Colon Transit Time), decreases in contraction frequencies (Con freq) in the antrum of the stomach, colon, and decreases in duodenal pressures post-injury. We noted increases in Sum amp generated at 2 weeks post-injury in the colon, with corresponding decreases in Con freq. We found transient changes in pH in the colon and small intestine at 2 weeks post-injury, with minimal effect on stomach pH post-injury. Prolonged GETs and CTTs can influence the absorptive profile in the gut and contribute to pathology development. This is the first pilot study to administer the SmartPill™ in minipigs in the context of SCI. Further investigations will elucidate these trends and characterize post-SCI GI function.

Data-Driven Smart Living Lab to Promote Participation in Rehabilitation Exercises and Sports Programs for People with Disabilities in Local Communities

Patients discharged from hospitals after an inpatient course of medical treatment for any ailment or traumatic injury that results in disabling conditions and are rendered mobility impaired require ongoing systematic sports and exercise programs to maintain healthy lifestyles. Under such circumstances, a rehabilitation exercise and sports center, accessible throughout local communities, is critical for promoting beneficial living and community participation for these individuals with disabilities. An innovative data-driven system equipped with state-of-the-art smart and digital equipment, set up in architecturally barrier-free infrastructures, is essential for these individuals to promote health maintenance and overcome secondary medical complications following an acute inpatient hospitalization or suboptimal rehabilitation. A federally funded collaborative research and development (R&D) program proposes to build a multi-ministerial data-driven system of exercise programs using a smart digital living lab as a platform to provide pilot services in physical education and counseling with exercise and sports programs for this patient population. We describe the social and critical aspects of rehabilitating such a population of patients by presenting a full study protocol. A modified sub-dataset of the previously generated 280-item full dataset is applied using a data-collecting system-"The Elephant"-as an example of how data acquisition will be achieved to assess the effects of lifestyle rehabilitative exercise programs for people with disabilities.

Data-Driven Smart Living Lab to Promote Participation in Rehabilitation Exercises and Sports Programs for People with Disabilities in Local Communities

Patients discharged from hospitals after an inpatient course of medical treatment for any ailment or traumatic injury that results in disabling conditions and are rendered mobility impaired require ongoing systematic sports and exercise programs to maintain healthy lifestyles. Under such circumstances, a rehabilitation exercise and sports center, accessible throughout local communities, is critical for promoting beneficial living and community participation for these individuals with disabilities. An innovative data-driven system equipped with state-of-the-art smart and digital equipment, set up in architecturally barrier-free infrastructures, is essential for these individuals to promote health maintenance and overcome secondary medical complications following an acute inpatient hospitalization or suboptimal rehabilitation. A federally funded collaborative research and development (R&D) program proposes to build a multi-ministerial data-driven system of exercise programs using a smart digital living lab as a platform to provide pilot services in physical education and counseling with exercise and sports programs for this patient population. We describe the social and critical aspects of rehabilitating such a population of patients by presenting a full study protocol. A modified sub-dataset of the previously generated 280-item full dataset is applied using a data-collecting system—“The Elephant”—as an example of how data acquisition will be achieved to assess the effects of lifestyle rehabilitative exercise programs for people with disabilities.

Cost Implications of Insurance Associated Disparities in Post-Acute Traumatic Brain and Spinal Cord Injury Rehabilitation

Abstract Post-acute care after spinal cord injury (SCI) or traumatic brain injury (TBI) influences neurological function regained. Inpatient rehabilitation facilities (IRFs) have more intensive care and result in lower mortality and better functional outcomes compared with skilled nursing facilities (SNFs). This study sought to quantify inpatient rehabilitation access by insurance and estimate the cost implications. We conducted a retrospective observational cohort study utilizing 2015-2017 California Office of Statewide Health Planning and Development database of injured adults with SCI and/or TBI. The primary predictor was insurance status. The outcome was discharge destination (home, IRFs, SNFs, long-term acute care [LTAC]) modeled using multi-variable multinomial mixed-effects logistic regression controlling for age, diagnosis, Weighted Elixhauser Comorbidity Index, and New Injury Severity Score. Cost of care for discharge to IRFs versus SNFs was estimated by adjusted quantile regression. Cost simulation predicted the adjusted cost difference if all publicly insured participants were discharged to an IRF. We identified 83,230 patients with an injury mechanism and a primary acute care hospitalization diagnosis of TBI (90.9%), SCI (8.3%), or both (0.8%) who were discharged to an IRF, SNF, LTAC, or home. Publicly insured patients were more likely than privately insured patients to go to SNFs versus IRFs (odds ratio [OR]: 2.17, 95% confidence interval [CI 2.01-2.34]). Sub-group analysis of 6416 participants showed an adjusted median total cost difference of $18,461 (95% CI [$5,908-$38,064]) and adjusted cost-per-day of the post-acute encounter of $1,045 (95% CI [$752-$2,399]) higher for discharge to IRFs versus SNFs. Cost simulation demonstrated an additional adjusted cost of $364M annually for universal IRF access for the publicly insured. Publicly insured SCI and TBI Californians are less frequently discharged to IRFs compared with their privately insured counterparts resulting in a lower short-term cost of care. However, the consequences of decreased intensive rehabilitation utilization in terms of functional recovery and long-term cost implications require further investigation.

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.

Machine learning in clinical diagnosis, prognostication, and management of acute traumatic spinal cord injury (SCI): A systematic review

Background

Machine learning has been applied to improve diagnosis and prognostication of acute traumatic spinal cord injury. We investigate potential for clinical integration of machine learning in this patient population to navigate variability in injury and recovery.

Materials and methods

We performed a systematic review using PRISMA guidelines through PubMed database to identify studies that use machine learning algorithms for clinical application toward improvements in diagnosis, management, and predictive modeling.

Results

Of the 132 records identified, a total of 13 articles met inclusion criteria and were included in final analysis. Of the 13 articles, 5 focused on diagnostic accuracy and 8 were related to prognostication or management of traumatic spinal cord injury. Across studies, 1983 patients with spinal cord injury were evaluated with most classifying as ASIA C or D. Retrospective designs were used in 10 of 13 studies and 3 were prospective. Studies focused on MRI evaluation and segmentation for diagnostic accuracy and prognostication, investigation of mean arterial pressure in acute care and intraoperative settings, prediction of ambulatory and functional ability, chronic complication prevention, and psychological quality of life assessments. Decision tree, random forests (RF), support vector machines (SVM), hierarchical cluster tree analysis (HCTA), artificial neural networks (ANN), convolutional neural networks (CNN) machine learning subtypes were used.

Conclusions

Machine learning represents a platform technology with clinical application in traumatic spinal cord injury diagnosis, prognostication, management, rehabilitation, and risk prevention of chronic complications and mental illness. SVM models showed improved accuracy when compared to other ML subtypes surveyed. Inherent variability across patients with SCI offers unique opportunity for ML and personalized medicine to drive desired outcomes and assess risks in this patient population.

The role of mindfulness in quality of life of persons with spinal cord injury: a cross-sectional study

BACKGROUND

Quality of life is considered the most overarching psychosocial adaptation outcome following the rehabilitation of persons with spinal cord injury. Literature suggests that the quality of life of persons with spinal cord injury is determined by many personal and psychological factors, including mindfulness. This study aimed to identify the direct and indirect effect of mindfulness on the quality of life of persons living with spinal cord injury.

METHODS

Participants consisted of 231 members of three spinal cord injury organizations in the United States: United Spinal Association, North American Spinal Cord Injury Consortium, and Paralyzed Veterans of America-Wisconsin Chapter. The participants completed a set of standardized self-report questionnaires in an online Qualtrics survey. A hierarchical regression analysis was performed to identify the contribution of mindfulness to quality of life, controlling for sociodemographic and injury-related factors. A serial mediation analysis was performed to examine the indirect effect of mindfulness on quality of life.

RESULTS

In the hierarchical regression analysis, sociodemographic and injury-related factors (i.e., age, gender, race, marital status, education, employment, level and completeness of injury, comorbidities, frequency of hospitalization, pain intensity, and functional limitation) and mindfulness explained 59% variance on quality of life of the participants with spinal cord injury. Mindfulness uniquely contributed to the higher quality of life above and beyond sociodemographic and injury-related variables. In the serial mediation analysis, pain and functional limitation did not significantly mediate the relationship between mindfulness and quality of life. However, the indirect effects of mindfulness on functional limitation and quality of life through pain were significant.

CONCLUSION

The findings underscore the vital role of mindfulness in improving the quality of life of persons with spinal cord injury. Implications of these findings for future research and clinical practice are discussed.

Australian arm of the International Spinal Cord Injury (Aus-InSCI) Community Survey: 2. Understanding the lived experience in people with spinal cord injury

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

To identify common problems across key domains of functioning, health and wellbeing, as well as evaluate self-reported quality of life (QoL) by people with SCI, examining differences by age, gender, injury characteristics and level of mobility.

SETTING

Data from four state-wide SCI clinical services, one government insurance agency and three not-for-profit consumer organisations.

METHODS

Participants were 18 years or over with SCI and at least 12 months post-injury, recruited between Mar'18 and Jan'19. The Aus-InSCI questionnaire comprised 193 questions, including socio-demographics, SCI characteristics, body functions and structures, activities and participation, environmental and personal factors, and appraisal of health and well-being. General linear model was used to examine differences in functioning and QoL.

RESULTS

Participants (mean age 57 years, range 19-94 years) with tetraplegia and/or complete injuries had more health problems, activity/participation problems and environmental barriers. However, self-rated overall QoL did not differ for injury level or completeness. Participants with more recent injuries exhibited lower independence levels, more mental health problems and poorer satisfaction with self and their living conditions. Major activity/participation problems related to intimate relationships and accessing public transportation. Less than half of the working age population were engaged in paid work. The top two environmental barriers frequently related to accessing public places or homes and unfavourable climatic conditions.

CONCLUSIONS

This large, comprehensive community survey draws a detailed picture of the lived experience of people with SCI in Australia, identifying priority needs, gaps in services and barriers to achieving a full and satisfying life.

Decision tree–based machine learning analysis of intraoperative vasopressor use to optimize neurological improvement in acute spinal cord injury

OBJECTIVE

Previous work has shown that maintaining mean arterial pressures (MAPs) between 76 and 104 mm Hg intraoperatively is associated with improved neurological function at discharge in patients with acute spinal cord injury (SCI). However, whether temporary fluctuations in MAPs outside of this range can be tolerated without impairment of recovery is unknown. This retrospective study builds on previous work by implementing machine learning to derive clinically actionable thresholds for intraoperative MAP management guided by neurological outcomes.

METHODS

Seventy-four surgically treated patients were retrospectively analyzed as part of a longitudinal study assessing outcomes following SCI. Each patient underwent intraoperative hemodynamic monitoring with recordings at 5-minute intervals for a cumulative 28,594 minutes, resulting in 5718 unique data points for each parameter. The type of vasopressor used, dose, drug-related complications, average intraoperative MAP, and time spent in an extreme MAP range (< 76 mm Hg or > 104 mm Hg) were collected. Outcomes were evaluated by measuring the change in American Spinal Injury Association Impairment Scale (AIS) grade over the course of acute hospitalization. Features most predictive of an improvement in AIS grade were determined statistically by generating random forests with 10,000 iterations. Recursive partitioning was used to establish clinically intuitive thresholds for the top features.

RESULTS

At discharge, a significant improvement in AIS grade was noted by an average of 0.71 levels (p = 0.002). The hemodynamic parameters most important in predicting improvement were the amount of time intraoperative MAPs were in extreme ranges and the average intraoperative MAP. Patients with average intraoperative MAPs between 80 and 96 mm Hg throughout surgery had improved AIS grades at discharge. All patients with average intraoperative MAP > 96.3 mm Hg had no improvement. A threshold of 93 minutes spent in an extreme MAP range was identified after which the chance of neurological improvement significantly declined. Finally, the use of dopamine as compared to norepinephrine was associated with higher rates of significant cardiovascular complications (50% vs 25%, p < 0.001).

CONCLUSIONS

An average intraoperative MAP value between 80 and 96 mm Hg was associated with improved outcome, corroborating previous results and supporting the clinical verifiability of the model. Additionally, an accumulated time of 93 minutes or longer outside of the MAP range of 76–104 mm Hg is associated with worse neurological function at discharge among patients undergoing emergency surgical intervention for acute SCI.

Data acquisition process for VA and non-VA emergency department and hospital utilization by veterans with spinal cord injury and disorders in California using VA and state data

Context: To identify VA and non-VA Emergency Department (ED) and hospital utilization by veterans with spinal cord injury and disorders (SCI/D) in California.Design: Retrospective cohort study.Setting: VA and Office of Statewide Health Planning and Development (OSHPD) in California.Participants: Total 300 veterans admitted to the study VA SCI/D Center for initial rehabilitations from 01/01/1999 through 08/17/2014.Interventions: N/A.Outcome Measures: Individual-level ED visits and hospitalizations during the first-year post-rehabilitation.Results: Among 145 veterans for whom ED visit data available, 168 ED visits were identified: 94 (55.2%) at non-VA EDs and 74 (44.8%) at the VA ED, with a mean of 1.16 (±2.21) ED visit/person. Seventy-seven (53.1%) veterans did not visit any ED. Of 68 (46.9%) veterans with ≥ one ED visit, 20 (29.4%) visited the VA ED only, 34 (50.0%) visited non-VA EDs only, and 14 (20.6%) visited both VA and non-VA EDs. Among 212 Veterans for whom hospitalization data were available, 247 hospitalizations were identified: 82 (33.2%) non-VA hospitalizations and 165 (66.8%) VA hospitalization with a mean of 1.17 (±1.62) hospitalizations/person. One hundred-seven (50.5%) veterans had no hospitalizations. Of 105 veterans with ≥ one hospitalization, 58 (55.2%) were hospitalized at the study VA hospital, 15 (14.3%) at a non-VA hospital, and 32 (30.5%) at both VA and non-VA hospitals.Conclusion: Non-VA ED and hospital usage among veterans with SCI/D occurred frequently. The acquisition of non-VA healthcare data managed by state agencies is vital to accurately and comprehensively evaluate needs and utilization rates among veteran populations.

Relationship between neurogenic bowel dysfunction severity and functional status, depression, and quality of life in individuals with spinal cord injury

OBJECTIVES/CONTEXT

To evaluate the relationship between severity of neurogenic bowel dysfunction (NBD) and functional status, depression, and quality of life in individuals with spinal cord injury (SCI) and to determine the factors associated with developing moderate-to-severe NBD.

DESIGN

Cross-sectional study.

SETTING

University hospital rehabilitation outpatient clinic.

PARTICIPANTS

Individuals with traumatic SCI, at least one year post-injury (N = 92).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Neurogenic Bowel Dysfunction Score, Functional Independence Measure (FIM), Beck Depression Inventory (BDI), and Short Form-36 (SF-36).

RESULTS

In the current sample, we found that half of the individuals with SCI had moderate-to-severe NBD. Individuals with moderate and severe NBD had lower motor FIM (P = 0.008 and P = 0.006, respectively) and SF-36 physical functioning (PF) scale (P = 0.020 and P = 0.031, respectively) scores than individuals with very minor NBD. There was no difference in the BDI scores among individuals with different levels of NBD. Individuals with American Spinal Injury Association Impairment Scale (AIS) A injuries were more likely to develop moderate-to-severe NBD than those with AIS C (odds ratio (OR) = 6.52; 95% confidence interval (CI) 1.13-37.79; P = 0.005) or AIS D (OR = 17.19; 95% CI 3.61-81.82; p < 0.001) injuries.

CONCLUSION

Individuals with moderate-to-severe NBD had higher levels of dependency in activities of daily living and lower SF-36 PF scale scores than individuals with very minor NBD. Among individuals with SCI, completeness of injury was a significant factor for developing moderate-to-severe NBD.

Spinal cord injury-mediated changes in electrophysiological properties of rat gastric nodose ganglion neurons

In preclinical rodent models, spinal cord injury (SCI) manifests as gastric vagal afferent dysfunction both acutely and chronically. However, the mechanism that underlies this dysfunction remains unknown. In the current study, we examined the effect of SCI on gastric nodose ganglia (NG) neuron excitability and on voltage-gated Na⁺ (Na_V) channels expression and function in rats after an acute (i.e. 3-days) and chronic (i.e. 3-weeks) period. Rats randomly received either T3-SCI or sham control surgery 3-days or 3-weeks prior to experimentation as well as injections of 3% DiI solution into the stomach to identify gastric NG neurons. Single cell qRT-PCR was performed on acutely dissociated DiI-labeled NG neurons to measure Na_V1.7, Na_V1.8 and Na_V1.9 expression levels. The results indicate that all 3 channel subtypes decreased. Current- and voltage-clamp whole-cell patch-clamp recordings were performed on acutely dissociated DiI-labeled NG neurons to measure active and passive properties of C- and A-fibers as well as the biophysical characteristics of Na_V1.8 channels in gastric NG neurons. Acute and chronic SCI did not demonstrate deleterious effects on either passive properties of dissociated gastric NG neurons or biophysical properties of Na_V1.8. These findings suggest that although Na_V gene expression levels change following SCI, Na_V1.8 function is not altered. The disruption throughout the entirety of the vagal afferent neuron has yet to be investigated.

Prognostic Evaluation of Pressure Sore Surgery Index: Risk Assessment and Outcomes of a Retrospective Cohort Study

BACKGROUND

Complication rates of up to 46 percent are reported following pressure sore surgery. Pressure sore patients often exhibit ineffective postoperative wound healing despite tension-free flap coverage, necessitating surgical revision and prolonged hospitalization. Rather than pressure sore recurrence, such impaired healing reflects a failed progress through the physiologic stages of the normal wound-healing cascade. The principal objective of the study reported here was to elucidate potentially modifiable inherent variables that predict predisposition to impaired healing and to provide a tool for identifying cases at risk for complicated early postoperative recovery following pressure sore reconstruction.

METHODS

A retrospective chart review of late-stage (stage 3 or higher) sacral and ischial pressure sore patients who underwent flap reconstruction from 2014 to 2019 was performed. A multivariable logistic regression model was used to identify key patient and operative factors predictive of impaired healing. Furthermore, the Prognostic Evaluation of Pressure Sore Surgery Index (PEPSI) was established based on the identified risk factors.

RESULTS

In a cohort of 121 patients, 36 percent exhibited impaired healing. Of these, 34 patients suffered from dehiscences, necessitating surgical revision. Statistically significant risk factors comprising late recurrence (OR, 3.8), immobility (OR, 12.4), greater surface (>5 cm diameter; OR, 7.3), and inhibited thrombocytes (aspirin monotherapy; OR, 5.7) were combined to formulate a prognostic scoring system (PEPSI-LIGhT).

CONCLUSIONS

The PEPSI-LIGhT system serves as a prognostic instrument for assessing individual risk for impaired healing in pressure sore patients. Preoperative risk stratification supports rational decision-making regarding operative candidacy, allows evidence-based patient counseling, and supports the implementation of individualized treatment protocols.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Efficacy of Local Autologous Platelet-Rich Plasma in the Treatment of Pressure Ulcer in Spinal Cord Injury Patients

BACKGROUND

Pressure ulcer is one of the common complications occurring in spinal cord injury (SCI) patients. Platelet-rich plasma (PRP) has been found useful in the treatment of pressure ulcers in few studies. The purpose of this study was to evaluate the role of PRP in pressure ulcer healing in comparison to hydrogel dressing in SCI patients.

METHODS

In this randomized interventional study, 52 patients of SCI having pressure ulcers of grade III/IV were randomized into two groups of 26 each. In group A patients, hydrogel dressing was done while freshly prepared PRP was used in patients of group B. Pressure ulcers were evaluated at baseline and after three weeks and six weeks in terms of ulcer surface area, volume, Pressure Ulcer Scale for Healing (PUSH) score, histopathology, and ulcer healing parameters. Data were collected and quantitative variables were compared using unpaired t-test or Mann-Whitney test between the two groups and qualitative variables were compared using the chi-square test or Fisher's exact test. A p-value of <0.05 was considered statistically significant.

RESULTS

 Baseline characteristics were comparable in both groups. There was a significant improvement in ulcers in terms of surface area, volume, and PUSH score in both the groups but it was comparable (p-value >0.05). There was a significant improvement in the PRP group as compared to the other group in terms of epithelization, granulation, and neovascularization at three and six-week follow-up.

CONCLUSIONS

This study suggests that PRP is a possible and better alternative to conventional dressing methods for the treatment of pressure ulcers.

Elevated Serum Neuropeptide FF Levels Are Associated with Cognitive Decline in Patients with Spinal Cord Injury

BACKGROUND

Spinal cord injury (SCI) has high incidence globally and is frequently accompanied by subsequent cognitive decline. Accurate early risk-categorization of SCI patients for cognitive decline using biomarkers can enable the timely application of appropriate neuroprotective measures and the development of new agents for the management of SCI-associated cognitive decline. Neuropeptide FF is an endogenous neuropeptide with a multitude of functions and is associated with neuroinflammatory processes. This prospective study investigated the predictive value of serum neuropeptide FF levels measured after acute SCI for subsequent cognitive decline.

METHODS

88 patients presenting with acute SCI without preexisting neurological injury, brain trauma, or severe systemic illness and 60 healthy controls were recruited. Serum neuropeptide FF levels, clinical, and routine laboratory variables including low-density lipoprotein, high-density lipoprotein, fasting blood glucose, total triiodothyronine (TT3), total thyroxine (TT4), and thyroid-stimulating hormone (TSH) levels collected from all subjects were assessed. Montreal cognitive assessment (MoCA) was performed 3 months after enrollment. SCI patients were grouped according to quartile of serum neuropeptide FF level and MoCA scores were compared using ANOVA. Additionally, multivariate linear regression with clinical and laboratory variables was performed to predict MoCA scores.

RESULTS

SCI patients displayed significantly higher baseline serum neuropeptide FF levels than healthy controls (38.5 ± 4.1 versus 23.4 ± 2.0 pg/ml, p < 0.001∗∗). SCI patients in higher quartiles of baseline serum neuropeptide FF displayed significantly lower MoCA scores at 3 months. Linear regression analysis indicated serum neuropeptide FF levels as a significant independent predictor of worse MoCA scores after SCI (r = 0.331, p = 0.034∗).

CONCLUSION

Early serum neuropeptide FF levels significantly and independently predicted cognitive decline after acute SCI among patients without preexisting neurological disorders.

Goal attainment in mobility after acute rehabilitation of mobility-restricting paralysis syndromes with regard to the ambulatory therapeutic level of participation NeuroMoves : A German national multicenter observational cohort study

Background

A central goal of rehabilitation in patients with paralysis syndromes after stroke or spinal cord injury (SCI) is to restore independent mobility as a pedestrian or wheelchair user. However, after acute rehabilitation, the mobility frequently deteriorates in the ambulatory setting, despite the delivery of rehabilitative interventions such as physical therapy or the prescription of assistive devices. The aim of the NeuroMoves study is to identify factors that are associated with changes of mobility in the ambulatory setting after acute inpatient rehabilitation, with a particular focus on participation according to the ICF (International Classification of Functioning, Disability and Health).

Methods

The NeuroMoves study is intended as a national multicenter observational cohort study with 9 clinical sites in Germany. A total of 500 patients with mobility-restricting paralysis syndromes (i.e. stroke or SCI) are to be recruited during acute inpatient rehabilitation prior to discharge to the ambulatory setting. Patients will have 8 months of follow-up in the ambulatory setting. Three study visits at the clinical sites (baseline, midterm, and final) are planned at 4-months intervals. The baseline visit is scheduled at the end of the acute inpatient rehabilitation. During the visits, demographical data, neurological, functional, quality of life, and implementation measures will be assessed.

At baseline, each study participant receives an activity tracker (sensor for recording ambulatory mobility) along with a tablet computer for home use over the 8 months study duration. While mounted, the activity tracker records mobility data from which the daily distance covered by walking or wheelchair use can be calculated. Customized applications on the tablet computer remind the study participants to answer structured questionnaires about their health condition and treatment goals for physical therapy. Using the study participants’ tablet, therapists will be asked to answer structured questionnaires concerning treatment goals and therapeutic measures they have applied. The primary analysis concerns the association between mobility (daily distance covered) and the degree of participation-oriented rehab interventions. Further exploratory analyses are planned.

Discussion

The findings could inform healthcare decision-making regarding ambulatory care in Germany focusing on mobility-promoting interventions for patients with mobility-restricting paralysis syndromes.

Study registration

German Clinical Trials Register, DRKS-ID: DRKS00020487 (18.02.2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02167-y.

Factors associated with multiple hospital readmissions for individuals with spinal cord injury

Objective

To identify patient-level and clinical factors associated with multiple hospital readmissions in individuals with spinal cord injury (SCI).

Design

Retrospective cohort analysis of the publicly available dataset from the SCI Rehabilitation (SCIRehab) study.

Setting

Six rehabilitation centers in the U.S. that participated in the SCIRehab study. Participants: Individuals with traumatic SCI (N=1371) who were consecutively enrolled in the SCIRehab study.

Outcome measures

The primary outcome was all-cause hospital readmission within 1 year of discharge from a rehabilitation center. The patient-level and clinical factors include employment status, depression, caregiver support, state-funded insurance, functional status, and rehabilitation services.

Results

Of the 1170 participants included in the study, 228 were readmitted once and 120 were readmitted multiple times. In our study, 34.2% and 10.8% were readmitted more than once due to genitourinary and respiratory conditions, respectively. Lower utilization of rehabilitation services, lower functional status, unemployment, and depression were associated with higher odds of being readmitted multiple times within one year of discharge from inpatient rehabilitation facility.

Conclusion

Psychosocial and clinical factors were associated with increased risk for multiple readmissions in individuals with SCI. In order to reduce recurrent readmissions in individuals with SCI, further research is necessary to maximize efficacy of risk factor modification and prevention strategies.

Feedback improves compliance of pressure relief activities in wheelchair users with spinal cord injury

STUDY DESIGN

Prospective cross-sectional pre-post pilot study.

OBJECTIVES

This pilot study aimed to evaluate the potential for improving pressure relief behaviour in wheelchair users with spinal cord injury (SCI) using a novel feedback system based on textile pressure sensor technology.

SETTING

In- and out-patient clinic of the Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.

METHODS

Nine wheelchair users with SCI (3 females, 50 ± 12 years of age, 2 tetra- and 7 paraplegics) were equipped with a feedback system (sensomativewheelchair) for three continuous weeks. The system consists of a textile pressure mat and a mobile smartphone application that reminds participants to perform missing pressure reliefs during regular and unobserved wheelchair usage in a customized manner. Pressure reliefs were detected using a subject-specific random forest classifier. Improvements of relief quality, duration and frequency were analysed by comparing week 1 (baseline) with no feedback, i.e., only pressure data recorded, against week 2 (with feedback). Carry-over effects of improved relief behaviour were studied in week 3 (no feedback, pressure data only recorded).

RESULTS

All participants increased their relief frequency and performed in median 82% (IQRs: 55%-99%) of the required reliefs while using the feedback system, whereas the median relief frequency was only 11% (IQRs: 10%-31%) during the baseline condition. Every participant who did not perform reliefs of sufficient duration (based on the recommendations of the therapist) during week 1 showed a significant improvement while using the feedback system.

CONCLUSION

Subject-specific feedback using the novel feedback system may have the potential for improving the regularity of an individual's relief activities, and may ultimately be an instrument for reducing the risk of developing pressure ulcers.

Association of Secondary Health Conditions With Future Chronic Health Conditions Among Persons With Traumatic Spinal Cord Injury

BACKGROUND

Secondary health conditions (SHC) are physical and mental health conditions that are causally related to disabilities. Studies have found that SHC increase risk of negative health outcomes among people with traumatic spinal cord injury (TSCI). However, little has been done to assess the association of SHC with the risk of chronic health conditions (CHC) after TSCI.

OBJECTIVES

To identify the prevalence of CHC in adults with TSCI, changes in CHC at follow-up, and the associations of baseline SHC with future CHC.

METHODS

Participants included 501 adults with TSCI of at least 1-year duration, identified through a population-based surveillance system. Baseline and follow-up self-report assessments were completed. We measured seven SHC: fatigue, spasticity, pain, pressure ulcers, subsequent injury, fracture, and anxiety disorder, and measured seven CHC: diabetes, heart attack, coronary artery disease, stroke, cancer, hypertension, and high blood cholesterol. Control variables included gender, race/ethnicity, age at injury, years post injury, injury severity, smoking status, binge drinking, and taking prescription medication. We implemented a Poisson regression model for the multivariate analyses.

RESULTS

The total number of CHC, the percentage of participants having at least one CHC, and prevalence of three individual CHC (diabetes, cancer, and high cholesterol) increased from baseline to follow-up. After controlling for demographic, injury characteristics, and behavioral factors, pain interference and anxiety disorder at baseline were associated with the total number of CHC at follow-up.

CONCLUSION

CHC are common among adults with TSCI and increase significantly over time. Pain and anxiety disorders appear to be risk factors for future CHC.

The gut-brain axis and beyond: Microbiome control of spinal cord injury pain in humans and rodents

Spinal cord injury (SCI) is a devastating injury to the central nervous system in which 60 to 80% of patients experience chronic pain. Unfortunately, this pain is notoriously difficult to treat, with few effective options currently available. Patients are also commonly faced with various compounding injuries and medical challenges, often requiring frequent hospitalization and antibiotic treatment. Change in the gut microbiome from the "normal" state to one of imbalance, referred to as gut dysbiosis, has been found in both patients and rodent models following SCI. Similarities exist in the bacterial changes observed after SCI and other diseases with chronic pain as an outcome. These changes cause a shift in the regulation of inflammation, causing immune cell activation and secretion of inflammatory mediators that likely contribute to the generation/maintenance of SCI pain. Therefore, correcting gut dysbiosis may be used as a tool towards providing patients with effective pain management and improved quality of life.

The Damaged Spinal Cord Is a Suitable Target for Stem Cell Transplantation

Background. Given individuals with spinal cord injury (SCI) approaching 2 million, viable options for regenerative repair are desperately needed. Human central nervous system stem cells (HuCNS-SC) are self-renewing, multipotent adult stem cells that engraft, migrate, and differentiate in appropriate regions in multiple animal models of injured brain and spinal cord. Preclinical improved SCI locomotor function provided rationale for the first-in-human SCI clinical trial of HuCNS-SC cells. Evidence of feasibility and long-term safety of cell transplantation into damaged human cord is needed to foster translational progression of cellular therapies. Methods. A first-ever, multisite phase I/IIa trial involving surgical transplantation of 20 million HuCNS-SC cells into the thoracic cord in 12 AIS A or B subjects (traumatic, T2-T11 motor-complete, sensory-incomplete), aged 19 to 53 years, demonstrated safety and preliminary efficacy. Six-year follow-up data were collected (sensory thresholds and neuroimaging augmenting clinical assessments). Findings. The study revealed short- and long-term surgical and medical safety (well-tolerated immunosuppression in population susceptible to infections). Preliminary efficacy measures identified 5/12 with reliable sensory improvements. Unfortunately, without thoracic muscles available for manual muscle examination, thoracic motor changes could not be measured. Lower limb motor scores did not change during the study. Cervical cord imaging revealed, no tumor formation or malformation of the lesion area, and secondary supralesional structural changes similar to SCI control subjects. Interpretation. Short- and long-term safety and feasibility support the consideration of cell transplantation for patients with complete and incomplete SCI. This report is an important step to prepare, foster, and maintain the therapeutic development of cell transplantation for human SCI.

Investigation of Bowel Function with Anorectal Manometry in a Rat Spinal Cord Contusion Model

Bowel dysfunction after chronic spinal cord injury (SCI) is a common source of morbidity and rehospitalization. Typical complications include constipation, fecal impaction, incontinence, abdominal distention, autonomic dysreflexia, and the necessity of interventions (i.e., suppositories, digital stimulation) to defecate. Numerous surveys have confirmed that the remediation of bowel complications is more highly valued for quality of life than improvements in walking. Much of what is known about bowel function after SCI for diagnosis and research in humans has been gained using anorectal manometry (ARM) procedures. However, ARM has been underutilized in pre-clinical animal work. Therefore, a novel combination of outcome measures was examined in the current study that incorporates functional output of the bowel (weekly fecal measurements), weight gain (pre-injury to terminal weight), and terminal ARM measurement with external anal sphincter electromyography under urethane anesthesia. The results indicate higher fecal output after contusion during the sub-acute period (4-7 days) post-injury, changes in the composition of the feces, and functionally obstructive responses in a specific section of the rectum (increased baseline pressure, increased frequency of contraction, and reduced ability to trigger a giant contraction to a distension stimulus). These results demonstrate significant bowel dysfunction in the rodent SCI contusion model that is consistent with data from human research. Thus, the combined measurement protocol enables the detection of changes and can be used, with minimal cost, to assess effectiveness of therapeutic interventions on bowel complications.

Gastrointestinal vascular permeability changes following spinal cord injury

BACKGROUND

Gastrointestinal (GI) dysfunction is observed clinically after spinal cord injury (SCI) and contributes to the diminished long-term quality of life. Our study examined the acute and chronic GI vascular changes that occur following SCI. We demonstrated that the GI vascular tract in SCI mice becomes compromised during the acute phase of injury and persists into the chronic phase of injury.

METHODS

Gastrointestinal vasculature permeability was measured using dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) at 48 hours, and 2 and 4 weeks following contusion spinal cord injury. Angiopoietin-1, a vascular stabilizing protein, was administered intravenously following injury. Intestinal contractile activity assessments were performed following the last imaging session.

KEY RESULTS

Our results indicated that a single administration of Ang-1 reduced vascular permeability at 48 hours but the effect was only transient. However, when the treatment paradigm was changed from a single administration to multiple administrations of Ang-1 following contusion injury, our DCE MRI data indicated a significant decrease in GI vascular permeability 4 weeks after injury compared with vehicle control treated animals. This improved GI vascular permeability was associated with improved sustained intestinal contractile activity. We also demonstrated that Ang-1 reduced the expression of sICAM-1 in the ileum compared with the saline-treated group.

CONCLUSIONS AND INFERENCES

We show that the GI vasculature is compromised in the acute and chronic phase of injury following spinal contusion. Our results also indicate that multiple administrations of Ang-1 can attenuate GI vascular permeability, possibly reduce inflammation, and improve sustained agonist-induced contraction compared with saline treatment.

Diminished enteric neuromuscular transmission in the distal colon following experimental spinal cord injury

Neurogenic bowel following spinal cord injury (SCI) leads to decreased colonic motility, remodeling of the neuromuscular compartment and results in chronic evacuation difficulties. The distal colon of the rat serves a dual role for fluid absorption and storage that is homologous to the descending colon of humans. Dysmotility of the descending colon is one component of neurogenic bowel. We investigated the integrity of the enteric neuromuscular transmission responsible for the generation of excitatory and inhibitory junction potentials (EJPs and IJPs, respectively) in the distal colon of rats. We previously demonstrated a chronic reduction in colonic enteric neurons from rats with acute and chronic high-thoracic (T3) SCI and hypothesized that neurogenic bowel following T3-SCI results from diminished enteric neuromuscular transmission. Immunohistochemical labeling for myenteric neuronal nitric oxide synthase (nNOS) and choline acetyltransferase (ChAT) neurons demonstrated a significant loss of presumptive nitric oxide (NO) and acetylcholine (ACh) immunoreactive neurons in both 3-day and 3-week injured animals. Colonic neuromuscular transmission in response to transmural electrical stimulation of the colon was significantly reduced 3-days and 3-weeks following SCI in male rats. Specifically, cholinergic-mediated excitatory junction potentials (EJPs) and nitrergic-mediated slow inhibitory junction potentials (IJPs) were significantly reduced while ATP-mediated fast IJPs remained unaffected. We conclude that a reduction in excitatory and inhibitory enteric neuromuscular transmission contributes to neurogenic bowel observed following SCI, and that these loss-of-function changes involve enteric-mediated cholinergic and nitrergic pathways.

Treatment of Lower Extremity Fractures in Chronic Spinal Cord Injury: A Systematic Review of the Literature

OBJECTIVE

To review the literature regarding outcomes of surgical and nonsurgical management of lower extremity (LE) fractures in chronic spinal cord injury (SCI). TYPE: Systematic review.

LITERATURE SURVEY

Medline (PubMed), Embase, Cochrane Database of Systemic Reviews, Cochrane Central, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, International Clinical Trials Registry Platform, and International Standard Randomized Controlled Trials were searched from January 1, 1966, to March 1, 2019.

METHODOLOGY

Search was restricted to English language and adults (age ≥ 18 yr). Titles and abstracts were reviewed for relevance to study topics for inclusion. Case reports, reviews, non-SCI population studies, and studies examining fractures at the time of acute SCI were excluded. References of included articles from the original search and task force and external submissions yielded two additional articles that were included in the review after voting by task force members. Data extraction was performed by four task force members using a data extraction form, glossary, and instructions created in Microsoft Excel. Quality assessment was performed by three methodologists using prespecified criteria.

SYNTHESIS

Twenty-three articles were included. Use of surgery to treat LE fractures in chronic SCI has increased, though nonoperative management was still more frequently reported. Regardless of type of management, amputations, nonunion/malunion, and pressure injuries were among the most commonly reported complications. Functional and quality of life outcomes were less frequently reported.

CONCLUSIONS

There is insufficient evidence to support operative versus nonoperative management as best practice for management of LE fracture of SCI. Existing literature was limited by small sample sizes, lack of randomization or matched study designs, significant heterogeneity in populations and treatment strategies studied, and variability in defining and reporting outcomes of interest. The field would benefit from future research to address study design issues and standardization of outcome reporting to facilitate comparison of outcomes of operative versus nonoperative management.

The association between participation and quality of life indicators with hospitalizations in ambulatory adults with spinal cord injury

STUDY DESIGN

Statistical modeling of self-report assessments (SRA) as predictors of future hospitalizations, measured by administrative billing data.

OBJECTIVES

To examine the relationships between self-reported participation and quality of life (QOL) indicators and future hospital admissions among ambulatory adults with chronic spinal cord injury (SCI).

SETTING

Data were collected from participants living in and utilizing hospitals in the state of South Carolina.

METHODS

Participants were identified through the South Carolina SCI Surveillance System Registry. Between 2011 and 2015, 615 ambulatory adults (>18 years old) with chronic (>1-year), traumatic SCI completed mailed SRA. Participant socio-demographic, injury, health, participation, and QOL indicators were assessed using self-report data. Administrative billing data were used to measure hospital utilization in nonfederal, South Carolina hospitals in the year following the SRA.

RESULTS

Prior year discharges, current pressure ulcers, number of chronic conditions, walking 150 feet more often (never, less than once per week, at least once per week, once or twice per day, or several times per day), and greater home life satisfaction were associated with an increased risk of subsequent hospitalization. Walking 10 feet more frequently and greater global satisfaction were associated with a decreased risk of hospital admission.

CONCLUSIONS

Specific participation and QOL items may increase the risk of hospitalization in ambulatory adults with SCI. Further study is necessary to understand better the relationships between walking distance and frequency, home life and global satisfaction, and inpatient admissions.

Engaging in the prevention of pressure injuries in spinal cord injury: A qualitative study of community-dwelling individuals' different styles of prevention in Switzerland

Context: Spinal cord injury (SCI) is a complex chronic condition with multiple self-management requirements and a high prevalence of complications. Pressure injuries (PIs) are among the most common ones and represent a frequent reason for re-hospitalization. This study aimed to identify styles of prevention that individuals with SCI adopt to deal with the risk of developing PIs.Design: Qualitative explorative interview study. Data was collected through semi-structured interviews, which were transcribed verbatim and analyzed following the principles of thematic analysis.Setting: Switzerland.Participants: The participants were a purposive sample of community-dwelling Swiss residents with SCI for at least five years.Interventions: Not applicable.Outcome measures: Not applicable.Results: Although all participants (N = 20) showed at least a basic knowledge of prevention of PIs by describing some preventive measures, they had different prevention styles characterized by different behavioral patterns (i.e. complying with all recommended measures, performing only a selection of them or delegating them to others) and different beliefs and attitudes towards prevention.Conclusion: By identifying the style of prevention of an individual, it is possible to develop tailored interventions that have an impact on the factors which seem to play a role in determining the adoption of preventive behaviors (i.e. perceived susceptibility to PIs, attitudes towards prevention, and self-efficacy). Such interventions would constitute a concrete effort to support individuals with SCI during their self-management. Besides alleviating a frequent and disabling medical complication and contributing to an enhanced quality of life, these interventions might also help decrease healthcare costs.

Pressure ulcer knowledge, beliefs and practices in a group of South Africans with spinal cord injury

Study design

A quantitative, descriptive study using a cross-sectional survey.

Objectives

To describe the pressure ulcer knowledge, beliefs and practices amongst persons with SCI, who received rehabilitation at a Cape Town rehabilitation centre.

Setting

A rehabilitation centre for clients with physical disabilities in Cape Town, South Africa.

Methods

A quantitative, descriptive study, that employed consecutive sampling, was done. Participants included inpatients (n = 30), outpatients (n = 33) and peer supporters (n = 8). Data were collected during April and March 2015 with a questionnaire developed through collating existing questionnaires and adapting it for the study context. This rendered a knowledge score and data on beliefs and practices. The Fisher's exact test was used for comparative analysis (p < 0.05).

Results

The mean combined knowledge score was 42.7%. The majority of participants (88.7%) believed pressure ulcers to be serious and 45% thought they were likely to develop a PU. They believed daily skin checks (80.3%), weight shifting (86%) and limiting sitting time (80.3%) could prevent PU development. Study participants indicated that they did not regularly follow guideline recommended practices like regular pressure relief (51%) (36 participants) or daily skin inspection (38%) (27 participants) and 37% (26 participants) reported being current smokers.

Conclusion

Participants showed a lack of knowledge, which might have affected their pressure ulcer prevention practices negatively. The study findings can be used to assist with the development of a contextually relevant training programme on pressure care.

Gastrointestinal dysfunction after spinal cord injury

The gastrointestinal tract of vertebrates is a heterogeneous organ system innervated to varying degrees by a local enteric neural network as well as extrinsic parasympathetic and sympathetic neural circuits located along the brainstem and spinal axis. This diverse organ system serves to regulate the secretory and propulsive reflexes integral to the digestion and absorption of nutrients. The quasi-segmental distribution of the neural circuits innervating the gastrointestinal (GI) tract produces varying degrees of dysfunction depending upon the level of spinal cord injury (SCI). At all levels of SCI, GI dysfunction frequently presents life-long challenges to individuals coping with injury. Growing attention to the profound changes that occur across the entire physiology of individuals with SCI reveals profound knowledge gaps in our understanding of the temporal dimensions and magnitude of organ-specific co-morbidities following SCI. It is essential to understand and identify these broad pathophysiological changes in order to develop appropriate evidence-based strategies for management by clinicians, caregivers and individuals living with SCI. This review summarizes the neurophysiology of the GI tract in the uninjured state and the pathophysiology associated with the systemic effects of SCI.

Associations between health behaviour, secondary health conditions and quality of life in people with spinal cord injury

Background

The development of secondary health conditions (SHCs) after spinal cord injury (SCI) is common and can affect an individual’s emotional well-being, and his or her health-related quality of life (QOL). Little is known about relationships between performing health-benefiting behaviours and the presence (or absence) of SHCs and QOL, particularly in South Africa.

Objectives

This research study was conducted in order to determine the associations between health behaviour, SHCs and QOL in people with SCI (PWSCI).

Method

This cross-sectional study included 36 PWSCI discharged from a private rehabilitation facility in Pretoria, South Africa. The PWSCI completed questionnaires pertaining to lifestyle, independence, presence of SHCs, social support and QOL. Data were analysed using descriptive and inferential statistics such as correlation tests and chi-square test of independence (x²) using the SPSS v25. Moderate, moderately high and high correlations are reported (Pearson r ≥ 0.4). Results were significant if p < 0.05.

Results

Participation in health-benefiting behaviour was associated with increased QOL (r = 0.457, p < 0.01) and increased social support from family and friends (r = 0.425, p < 0.01), which was associated with increased QOL (r = 0.671, p < 0.001). Not participating in specific neuromusculoskeletal health behaviours was found to be associated with the overall presence of SHCs (r = -0.426, p < 0.01).

Conclusions

Participating in health-benefiting behaviour can reduce the development of SHCs and subsequently increase QOL in PWSCI. Health professionals must focus on minimising the development of SHCs by providing specific education on good health-benefiting behaviour.

Electroceutical Targeting of the Autonomic Nervous System

Autonomic nerves are attractive targets for medical therapies using electroceutical devices because of the potential for selective control and few side effects. These devices use novel materials, electrode configurations, stimulation patterns, and closed-loop control to treat heart failure, hypertension, gastrointestinal and bladder diseases, obesity/diabetes, and inflammatory disorders. Critical to progress is a mechanistic understanding of multi-level controls of target organs, disease adaptation, and impact of neuromodulation to restore organ function.