Functional recovery measures for spinal cord injury: an evidence-based review for clinical practice and research

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

Matched case-control study.

SETTING

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

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURE(S)

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

RESULTS

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

CONCLUSIONS

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

Correlates of metabolic syndrome in people with chronic spinal cord injury

PURPOSE

We aimed at identifying clinical risk factors or early markers of metabolic syndrome (MetS) in people with spinal cord injury (SCI) that would facilitate a timely diagnosis and implementation of preventive/therapeutic strategies.

METHODS

One hundred sixty-eight individuals with chronic (> 1 year) SCI underwent clinical and biochemical evaluations. MetS was diagnosed according to modified criteria of the International Diabetes Federation validated in people with SCI. Wilcoxon rank-sum test and χ2 test were used to compare variables between groups with and without MetS. Multiple logistic regression analysis was performed to reveal independent associations with MetS among variables selected by univariate linear regression analyses.

RESULTS

MetS was diagnosed in 56 of 132 men (42.4%) and 17 of 36 women (47.2%). At univariate regression analyses, putative predictors of MetS were an older age, a higher number of comorbidities, a lower insulin-sensitivity, the presence and intensity of pain, a shorter injury duration, a poorer leisure time physical activity (LTPA) and an incomplete motor injury. At the multiple logistic regression analysis, a significant independent association with MetS only persisted for a poorer LTPA in hours/week (OR: 0.880, 95% CI 0.770, 0.990) and more severe pain symptoms as assessed by the numeral rating scale (OR: 1.353, 95% CI 1.085, 1.793).

CONCLUSION

In people with chronic SCI, intense pain symptoms and poor LTPA may indicate a high likelihood of MetS, regardless of age, SCI duration, motor disability degree, insulin-sensitivity and comorbidities.

Harnessing Artificial Neural Networks for Spinal Cord Injury Prognosis

Background: Prediction of neurorehabilitation outcomes after a Spinal Cord Injury (SCI) is crucial for healthcare resource management and improving prognosis and rehabilitation strategies. Artificial neural networks (ANNs) have emerged as a promising alternative to conventional statistical approaches for identifying complex prognostic factors in SCI patients. Materials: a database of 1256 SCI patients admitted for rehabilitation was analyzed. Clinical and demographic data and SCI characteristics were used to predict functional outcomes using both ANN and linear regression models. The former was structured with input, hidden, and output layers, while the linear regression identified significant variables affecting outcomes. Both approaches aimed to evaluate and compare their accuracy for rehabilitation outcomes measured by the Spinal Cord Independence Measure (SCIM) score. Results: Both ANN and linear regression models identified key predictors of functional outcomes, such as age, injury level, and initial SCIM scores (correlation with actual outcome: R = 0.75 and 0.73, respectively). When also alimented with parameters recorded during hospitalization, the ANN highlighted the importance of these additional factors, like motor completeness and complications during hospitalization, showing an improvement in its accuracy (R = 0.87). Conclusions: ANN seemed to be not widely superior to classical statistics in general, but, taking into account complex and non-linear relationships among variables, emphasized the impact of complications during the hospitalization on recovery, particularly respiratory issues, deep vein thrombosis, and urological complications. These results suggested that the management of complications is crucial for improving functional recovery in SCI patients.

Correlation of bilateral M1 hand area excitability and overall functional recovery after spinal cord injury: protocol for a prospective cohort study

BACKGROUND

After spinal cord injury (SCI), a large number of survivors suffer from severe motor dysfunction (MD). Although the injury site is in the spinal cord, excitability significantly decreases in the primary motor cortex (M1), especially in the lower extremity (LE) area. Unfortunately, M1 LE area-targeted repetitive transcranial magnetic stimulation (rTMS) has not achieved significant motor improvement in individuals with SCI. A recent study reported that the M1 hand area in individuals with SCl contains a compositional code (the movement-coding component of neural activity) that links matching movements from the upper extremities (UE) and the LE. However, the correlation between bilateral M1 hand area excitability and overall functional recovery is unknown.

OBJECTIVE

To clarify the changes in the excitability of the bilateral M1 hand area after SCI and its correlation with motor recovery, we aim to specify the therapeutic parameters of rTMS for SCI motor rehabilitation.

METHODS

This study is a 12-month prospective cohort study. The neurophysiological and overall functional status of the participants will be assessed. The primary outcomes included single-pulse and paired-pulse TMS. The second outcome included functional near-infrared spectroscopy (fNIRS) measurements. Overall functional status included total motor score, modified Ashworth scale score, ASIA Impairment Scale grade, spinal cord independence measure and modified Barthel index. The data will be recorded for individuals with SCI at disease durations of 1 month, 2 months, 4 months, 6 months and 12 months. The matched healthy controls will be measured during the same period of time after recruitment.

DISCUSSION

The present study is the first to analyze the role of bilateral M1 hand area excitability changes in the evaluation and prediction of overall functional recovery (including motor function and activities of daily living) after SCI, which will further expand the traditional theory of the predominant role of M1, optimize the current rTMS treatment, and explore the brain-computer interface design for individuals with SCI.

TRIAL REGISTRATION NUMBER

ChiCTR2300068831.

Leisure time physical activity in middle-aged and older adults aging with long-term spinal cord injury: Changes over six years

BACKGROUND

Regular leisure time physical activity (LTPA) has beneficial health effects in people with spinal cord injury (SCI). Yet, participation in LTPA is low, and little is known about changes many years after injury.

OBJECTIVES

To determine changes in LTPA in middle-aged and older adults with long-term SCI over six years, investigate associations with gender, age, injury characteristics and changes in secondary health conditions and activity limitations, and investigate factors related to being physically active or sedentary.

METHODS

Part of the Swedish Aging with Spinal Cord Injury Study (SASCIS). LTPA was assessed twice over a six-year period with the Physical Activity Recall Assessment for people with Spinal Cord Injury (n = 75; 32% women, mean age 67 years, mean time since injury 31 years, injury levels C1-L3, AIS A-D). Changes were assessed with paired t-tests, McNemar test and Wilcoxon signed-rank test, associations with multivariable regression and group comparisons with Mann-Whitney U test and Chi Square test.

RESULTS

On group level participation in LTPA did not change, but the variability was substantial on individual level. There were no significant associations between changes in LTPA and the investigated variables. Among sedentary participants, higher level and severity of injury were overrepresented and the activity limitations were greater.

CONCLUSIONS

Our findings indicate stability in LTPA over time, but with a large individual variation. In many participants LTPA was insufficient to reach positive health effects. Promoting participation in LTPA is therefore an important part of the long-term management of middle-aged and older adults aging with long-term SCI.

Quantification of hand functional recovery in spinal cord injury patients

STUDY DESIGN

A prospective cohort study.

OBJECTIVES

To examine the use of a circle-tracing task in quantifying hand functional recovery in cervical spinal cord injury patients.

METHODS

Ten cervical spinal cord injury (SCI) patients and 10 healthy age-matched controls performed a circle-tracing task, using a computerized tablet at the beginning of the study and after 4 weeks. Data relative to performance accuracy as well as pen pressure throughout the performances were collected, and clinical assessment for all patients was performed at the beginning and at the end of the study.

RESULTS

Significant differences were found in pen pressure profiles in the SCI patients between the initial assessment and after 4 weeks of assessment. SCI patients, when compared with controls, apply less pressure during the execution, though no significant differences were found for the other parameters. Examination of pen pressure profiles of both controls and SCI patients reveals that, in addition to the lower pressure registered, SCI patients present a more oscillating pressure profile which is direction-dependent. No significant correlations were found between clinical assessments and pen pressure, both within the initial assessment as well as after 4 weeks.

CONCLUSIONS

This study emphasizes the potential of simple computerized means for quantifying upper limb functions in SCI patients. These results of this study could be helpful for both highlighting specific functional deficits in patients as well tailoring specific interventions.

Age-Adjusted Modified Frailty Index: Association With Hip Fracture Discharge Functional Dependence

INTRODUCTION

Hip fractures are a common traumatic injury that carry significant morbidity and mortality, and prognostication of functional outcome is becoming increasingly salient. Across multiple surgical specialties, the five-item and 11-item Modified Frailty Index (mFI-5 and mFI-11) have been found to be convenient, quick, and sensitive tools for identifying patients at risk for perioperative complications. A prior study described the superiority of an Age-Adjusted Modified Frailty Index (aamFI) for predicting perioperative complications compared to the mFI-5 in an elective hip surgery. We sought to externally validate the aamFI in a multicenter hip fracture cohort and hypothesize that these risk scores would not only predict functional dependence (FD) at discharge, but that the aamFI would outperform the mFI-5 and mFI-11.

METHODS

The Pennsylvania Trauma Systems Foundation registry was queried from 2010 to 2020 for CPT codes, ICD-9 and ICD-10 codes pertaining to hip fracture patients. Patients with missing locomotion and transfer mobility data were excluded. FD status was determined by discharge locomotion and transfer mobility scores per existing methodology. Univariable and Multivariable analysis as well as receiver operator characteristic curves were used to evaluate and compare the three indices for prediction of functional status at discharge. P value < 0.05 was considered significant.

RESULTS

Twelve thousand seven hundred and forty patients met inclusion criteria (FD: 8183; functional independent 4557). On univariable logistic regression analysis, the mFI-11 (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.47-1.58, P < 0.05), mFI-5 (OR 1.57, 95% CI 1.51-1.63), and aamFI (OR 1.57, 95% CI 1.52-1.62, P < 0.05) were associated with FD. On multivariable logistic regression analysis for predictors of FD, when controlling for age (for the mFI-11 and mFI-5), sex, injury severity score, and admission vitals (systolic blood pressure and respiratory rate), higher mFI-11 and mFI-5 scores independently predicted FD at discharge (OR 1.23, 95% CI 1.18-1.28, P < 0.05 and OR 1.23, 95% CI 1.18-1.29P < 0.05 respectively). Higher aaMFI scores had superior association with functional dependence (OR 1.59, 95% CI 1.54-1.64, P < 0.05). Receiver operator characteristic curves for the mFI-11, mFI-5, and aaMFI showed comparable diagnostic strength (area under curve [AUC] = 0.63 95% CI 0.62-0.64, P < 0.05; AUC = 0.63 95% CI 0.62-0.64, P < 0.05; and AUC = 0.67 95% CI 0.65-0.67, P < 0.05 respectively).

CONCLUSIONS

The mFI-11, mFI-5, and aamFI are predictive of functional outcome following hip fracture. By including age, the aamFI retains the ease of use of the mFI-5 while improving its prognostic utility for functional outcome.

Comparison of One-Year Postinjury Mobility Outcomes Between Locomotor Training and Usual Care After Motor Incomplete Spinal Cord Injury

Objectives

To compare 1-year mobility outcomes of individuals with traumatic motor incomplete spinal cord injury (miSCI) who participated in standardized locomotor training (LT) within the first year of injury to those who did not.

Methods

This retrospective case-control analysis conducted with six US rehabilitation hospitals used SCI Model Systems (SCIMS) data comparing 1-year postinjury outcomes between individuals with miSCI who participated in standardized LT to those who received usual care (UC). Participants were matched on age, gender, injury year, mode of mobility, and rehabilitation center. The primary outcome is the FIM Total Motor score. Other outcomes include the FIM Transfer Index, FIM Stairs, and self-reported independence with household mobility, community mobility, and stairs.

Results

LT participants reported significantly better FIM Total Motor (difference = 2.812, 95% confidence interval [CI] = 5.896, 17.282) and FIM Transfer Index scores (difference = 0.958, 95% CI = 0.993, 4.866). No significant between-group differences were found for FIM Stairs (difference = 0.713, 95% CI = -0.104, 1.530) or self-reported household mobility (odds ratio [OR] = 5.065, CI = 1.435, 17.884), community mobility (OR = 2.933, 95% CI = 0.868, 9.910), and stairs (OR = 5.817, 95% CI = 1.424, 23.756) after controlling for multiple comparisons.

Conclusion

LT participants reported significantly greater improvements in primary and secondary measures of mobility and independence (FIM Total Motor score; FIM Transfer Index) compared to UC participants. Self-reported mobility outcomes were not significant between groups.

Reliability and validity of the Greek adaptation of the Modified Barthel Index in neurorehabilitation patients

BACKGROUND

The Modified Barthel Index (MBI) (Shah version) is a widely used functional assessment measure with greater sensitivity and improved reliability compared to the original Barthel Index.

AIM

The aim of this study was to adapt the MBI for use in Greece and measure its reliability and validity on a Greek neuro-rehabilitation population.

DESIGN

Observational study.

SETTING

KAT Hospital Rehabilitation Clinic and National Rehabilitation Centre in Athens, Greece.

POPULATION

A total of 100 rehabilitation inpatients and outpatients consisting of 50 stroke and 50 spinal cord injury (SCI) patients were evaluated.

METHODS

The MBI underwent the proper translation and cultural adaptation procedure as required by the World Health Organization and was administered to 100 rehabilitation patients. For criterion validity evaluation all patients were also assessed with the Katz Index of Independence in Activities of Daily Living (Katz Index) and the 36-Item Short Form Survey (SF-36) physical functioning subscale, both questionnaires having been validated for use in Greece.

RESULTS

The unidimensionality solution was rejected and a two- factor solution was adopted based on exploratory and confirmatory factor analysis (Factor 1 - Transfers and Activities of Daily Living, Factor 2 - Mobility). Very high correlation was presented between the Katz Index score and the Greek MBI Factor 1 (r=0.888, P<0.001) and total score (r=0.873 P<0.001) respectively and high with MBI Factor 2 (r=0.561, P<0.001). High correlation was observed between the SF-36 physical functioning subscale score with MBI Factor 1 (r=0.522, P<0.001), MBI Factor 2 (r=0.590, P<0.001) and MBI Total score (r=0.580, P<0.001). The internal consistency of the MBI Factor 1, Factor 2 and Total score was 0.920, 0.860 and 0.923 respectively. Test-retest reliability was remarkably consistent (total score 0.994, P<0.001).

CONCLUSIONS

The Greek version of the Modified Barthel Index has been found to exhibit satisfactory levels of reliability and validity.

CLINICAL REHABILITATION IMPACT

The Greek MBI adaptation is an adequate and useful instrument for use on Greek neuro-rehabilitation patients.

Can the Initial Parameters of Functional Scales Predict Recovery in Patients with Complete Spinal Cord Injury? A Retrospective Cohort Study

Regaining greater independence in performing daily activities constitutes a priority for people with tetraplegia following spinal cord injury (SCI). The highest expectations are connected with the improvement of hand function. Therefore, it is so important for the clinician to identify reliable and commonly applicable prognostic factors for functional improvement. The aim of this study was to conduct an analysis to assess the impact of initial functional factors on the clinical improvement in patients during early neurological rehabilitation (ENR). This study assessed 38 patients with complete SCI aged 17-78 who underwent ENR in 2012-2022. The analysis included the motor score from the AIS (MS), the Barthel Index (BI) and the SCIM scale values at the beginning of the ENR program and after its completion. During ENR, patients achieved a statistically significant improvement in MS, BI and SCIM. The initial MS and the level of neurological injury constituted the predictors of functional improvement during ENR. Significant statistical relationships were observed primarily in the correlations between the initial MS and BI, and the increase in the analyzed functional scales of SCI patients. Higher initial MS may increase the chances of a greater and faster functional improvement during ENR.

Determination of cut-off points in the Trunk control test for spinal cord injury to assess the ability to perform different activities of daily living

STUDY DESIGN

Observational, comparative, and transversal study.

OBJECTIVE

To identify the cut-off points in the Trunk Control Test (TCT) for individuals with Spinal Cord Injury (SCI) to determine the ability to perform independently the different activities of daily living (ADL) according to the Spinal Cord Independence Measure-III (SCIM-III).

SETTING

National Institute of Rehabilitation, Mexico City.

METHODS

Individuals with SCI of any neurologic level and severity according to ISNCSCI, in sub-acute and chronic phases were included. Receiver Operating Characteristic (ROC) curves were made to identify the cut-off points on the TCT that discriminate the individuals that can independently perform each of the ADL described in the SCIM-III.

RESULTS

A total of 604 participants were evaluated, 70.7% male; mean age of 34 (± 14) years; time since injury was 134 ± 360 days; predominating motor complete injury (50.1%). It was demonstrated through ROC curves, that there are different cut-off points in the TCT that are sensitive and specific to discriminate individuals that can independently perform the majority of the items of the SCIM-III of those who perform it with assistance. Domains that do not depend on an adequate trunk control (respiration and sphincter management) had poor areas under the curve, with low sensitivity and specificity.

CONCLUSIONS

The application of the TCT in individuals with SCI allows to discriminate between individuals who perform the different ADL independently of those who do not, at this subject institute. These results can guide the management of individuals with SCI, helping to establish short term goals.

Independent association of hypovitaminosis d with non-alcoholic fatty liver disease in people with chronic spinal cord injury: a cross-sectional study

PURPOSE

Non-alcoholic fatty liver disease (NAFLD) and hypovitaminosis D are highly prevalent in people with spinal cord injury (SCI) and could exert an unfavorable influence on cardiovascular profile and rehabilitation outcomes. We aimed to assess the independent association between low 25-hydroxy vitamin D (25(OH)D) levels and NAFLD in people with chronic (> 1 year) SCI.

METHODS

One hundred seventy-three consecutive patients with chronic SCI (132 men and 41 women) admitted to a rehabilitation program underwent clinical/biochemical evaluations and liver ultrasonography.

RESULTS

NAFLD was found in 105 patients (60.7% of the study population). They were significantly older and exhibited a poorer leisure time physical activity (LTPA) and functional independence in activities of daily living, a greater number of comorbidities and a higher prevalence of metabolic syndrome (MetS) and its correlates, including lower HDL and higher values of body mass index (BMI), systolic blood pressure, HOMA-index of insulin resistance and triglycerides. 25(OH)D levels were significantly lower in NAFLD (median: 10.6 ng/ml, range: 2.0-31.0) than in non-NAFLD group (22.5 ng/ml, 4.2-51.6). When all these variables were included in a multiple logistic regression analysis, a significant independent association with NAFLD only persisted for lower 25(OH)D levels, a greater number of comorbidities and a poorer LTPA. The ROC analysis revealed that 25(OH)D levels < 18.25 ng/ml discriminated patients with NAFLD with a sensitivity of 89.0% and a specificity of 73.0% (AUC: 85.7%; 95%CI: 79.6-91.7%). NAFLD was exhibited by 83.9% of patients with 25(OH)D levels < 18.25 ng/ml and by 18% of those with 25(OH)D levels ≥ 18.25 ng/ml (p < 0.0001).

CONCLUSION

In people with chronic SCI, 25(OH)D levels < 18.25 ng/ml may represent a marker of NAFLD independent of MetS-related features. Further studies are warranted to define the cause-effect relationships of this association.

Comparison of 5-Item and 11-Item Modified Frailty Index as Predictors of Functional Independence in Patients With Spinal Cord Injury

STUDY DESIGN

Retrospective Cohort Study.

INTRODUCTION

The 11-item modified Frailty index (mFI-11) by the ACS-NSQIP database was used to predict which patients are high risk for complications and inpatient mortality. ACS-NSQIP now has switched to the 5-item MFI. However, there are no studies on how these frailty indices fare against each other and their prognostic value of functional independence in patients with spinal cord injury (SCI).

OBJECTIVE

To compare the mFI-5 and mFI-11 in order to standardize frailty assessment in the SCI population.

METHODS

Retrospective analysis of 272,174 patients with SCI from 2010 to 2020 from the Pennsylvania Trauma Systems Foundation (PTSF) registry. Multivariable logistic regression was used to determine the predictive value of mFI for functional independence as determined by locomotion and transfer mobility.

RESULTS

A total of 1907 patients were included with a mean age of 46.9 ± 15.1 years. The 3 most common MFI factors were hypertension (32.2%), diabetes mellitus (13.7%) and chronic obstructive pulmonary disease (8.5%). Multivariable logistic regression analyses using MFI-5 and MFI-11 showed that a higher frailty score in MFI-5 (OR 1.375, P < .001) and in MFI-11 (OR 1.366, P < .001) were each predictive of poor functional status at discharge. ROC curves for the MFI-5 (AUC = .818, P < .001) and MFI-11 (AUC = .819, P < .001) demonstrated excellent diagnostic accuracy.

CONCLUSION

The new MFI-5 is equivalent to its predecessor, the MFI-11, and predictive of functional outcomes in patients with SCI. MFI-5 can serve as the preferred frailty index at the point of care and in research contexts.

Impact of Robotic-Assisted Gait Training in Subacute Spinal Cord Injury Patients on Outcome Measure

The improvement of walking ability is a primary goal for spinal cord injury (SCI) patients. Robotic-assisted gait training (RAGT) is an innovative method for its improvement. This study evaluates the influence of RAGT vs. dynamic parapodium training (DPT) in improving gait motor functions in SCI patients. In this single-centre, single-blinded study, we enrolled 105 (39 and 64 with complete and incomplete SCI, respectively) patients. The investigated subjects received gait training with RAGT (experimental S1-group) and DPT (control S0-group), with six training sessions per week over seven weeks. The American Spinal Cord Injury Association Impairment Scale Motor Score (MS), Spinal Cord Independence Measure, version-III (SCIM-III), Walking Index for Spinal Cord Injury, version-II (WISCI-II), and Barthel Index (BI) were assessed in each patient before and after sessions. Patients with incomplete SCI assigned to the S1 rehabilitation group achieved more significant improvement in MS [2.58 (SE 1.21, p < 0.05)] and WISCI-II [3.07 (SE 1.02, p < 0.01])] scores in comparison with patients assigned to the S0 group. Despite the described improvement in the MS motor score, no progression between grades of AIS (A to B to C to D) was observed. A nonsignificant improvement between the groups for SCIM-III and BI was found. RAGT significantly improved gait functional parameters in SCI patients in comparison with conventional gait training with DPT. RAGT is a valid treatment option in SCI patients in the subacute phase. DPT should not be recommended for patients with incomplete SCI (AIS-C); in those patients, RAGT rehabilitation programs should be taken into consideration.

Standardized administration and scoring guidelines for the Spinal Cord Independence Measure Version 3.0 (SCIM-III)

STUDY DESIGN

Qualitative studies.

OBJECTIVE

To develop clear and specific administration and scoring procedures for the Spinal Cord Independence Measure Version 3.0 as a performance-based and interview assessment.

SETTING

Research lab.

METHODS

Modified Delphi Technique survey methods were used in this study. Previously developed SCIM-III administration and scoring procedures for performance-based and interview versions were presented to clinicians experienced in SCI and SCIM-III using the Qualtrix (Qualtrics, Provo, UT) online survey platform. Summary and descriptive statistics were used to assess the percent agreement survey responses.

RESULTS

Three survey rounds were necessary to achieve 80% agreement or above for the performance-based version. Two survey rounds were necessary to achieve 80% agreement or above on the interview version.

CONCLUSIONS

This study describes the development of standardized administration and scoring procedures for the self-care and mobility sub-scales of the SCIM-III as a performance-based and interview version.

Long-term prediction of functional independence using adjusted and unadjusted single items of the functional independence measure (FIM) at discharge from rehabilitation

CONTEXT

Being able to survive in the long-term independently is of concern to patients with spinal cord injury (SCI), their relatives, and to those providing or planning health care, especially at rehabilitation discharge. Most previous studies have attempted to predict functional dependency in activities of daily living within one year after injury.

OBJECTIVES

(1) build 18 different predictive models, each model using one FIM (Functional Independence Measure) item, assessed at discharge, as independent predictor of total FIM score at chronic phase (3-6 years post-injury) (2) build three different predictive models, using in each model an item from a different FIM domain with the highest predictive power obtained in objective (1) to predict "good" functional independence at chronic phase and (3) adjust the 3 models from objective (2) with known confounding factors.

METHODS

This observational study included 461 patients admitted to rehabilitation between 2009 and 2019. We applied regression models to predict total FIM score and "good" functional independence (FIM motor score ≥ 65) reporting adjusted R², odds ratios, ROC-AUC (95% CI) tested using 10-fold cross-validation.

RESULTS

The top three predictors, each from a different FIM domain, were Toilet (adjusted R² = 0.53, Transfers domain), Toileting (adjusted R² = 0.46, Self-care domain), and Bowel (adjusted R² = 0.35, Sphincter control domain). These three items were also predictors of "good" functional independence (AUC: 0.84-0.87) and their predictive power increased (AUC: 0.88-0.93) when adjusted by age, paraplegia, time since injury, and length of stay.

CONCLUSIONS

Discharge FIM items accurately predict long-term functional independence.

Independence and upper extremity functioning after spinal cord injury: a cross-sectional study

Upper extremity functioning is important for achieving independence in activities of daily living (ADL). A better understanding of relationships between different aspects of independence in ADL after spinal cord injury (SCI) and upper extremity functioning is required to guide rehabilitation practices. To determine which aspects of independence in ADL are correlated with upper extremity functioning in individuals with cervical or thoracic SCI. A total of 25 adults (mean age 58.4 years, 72% men) with established cervical or thoracic SCI were recruited. Independence in ADL was assessed by Spinal Cord Independence Measure (SCIM-III) and upper extremity functioning by kinematic measures (movement time, smoothness, and wrist angle during drinking task), grip strength, Upper Extremity Motor and Sensory Score, Box and Block Test (BBT), Action Research Arm Test (ARAT), and Upper Extremity Basic Data Set (ISCI-Hand and ISCI-Shoulder). Spearman correlation coefficients were used for data analyses. The SCIM-self-care subscale, particularly the feeding and dressing items, correlated moderately (r ≥ 0.5) with movement time and smoothness, grip strength, ARAT, BBT, and ISCI-Hand. The SCIM-respiration/sphincter subscale and the SCIM-mobility showed very low and low correlations with upper extremity assessments. However, at item level, respiration and bed/wheelchair mobility showed moderate correlations. Independence in self-care as domain and feeding/dressing, respiration and bed/wheelchair mobility as separate items were dependent on upper extremity functioning in individuals with cervical or thoracic SCI. Movement time and smoothness along with BBT, grip strength, ARAT, and ISCI-Hand can be used as indicators of independence in ADL. These findings can provide guidance to clinical practice in selection of upper extremity assessments in the context for ADL in individuals with SCI.

Changes over 6 years in secondary health conditions and activity limitations in older adults aging with long-term spinal cord injury

BACKGROUND

The number of individuals aging with long-term spinal cord injury (SCI) is increasing. Still, there is limited knowledge about changes in secondary health conditions (SHCs) and activity limitations over time.

OBJECTIVES

To determine changes in SHCs and activity limitations in older adults aging with long-term SCI over 6 years, and to investigate how changes in SHCs and activity limitations are associated with gender, age, and injury characteristics.

DESIGN

Longitudinal cohort study from the Swedish Aging with Spinal Cord Injury Study (SASCIS).

SETTING

Community settings, Sweden.

PARTICIPANTS

From the initial 123 participants in the SASCIS: 78 individuals (32% women); mean age 68 years; mean time since injury 31 years; injury levels C1-L3, AIS A-D.

INTERVENTIONS

Not applicable MAIN OUTCOME MEASURE: Bowel and bladder function and problems, pain, spasticity, and the Spinal Cord Independence Measure (SCIM III).

RESULTS

Over 6 years, bowel-related problems increased (31% to 47%, p = .015) and the occurrence of constipation doubled to 24% (p = .013). There were increases in frequent urinary tract infections (10% to 26%, p = .004), use of indwelling urinary catheters (15% to 23%, p = .031), and other bladder-related problems (4% to 22%, p < .001). The occurrence of pain was high (85%), with no significant change. Spasticity increased from 41% to 62% (p < .001). Activity limitations increased (SCIM III total score mean 67 to 61, p < .001, with significant decreases in all subscales). The increase in bowel-related problems was greater in males, and the deterioration in self-care was greater in participants with longer time since injury and with traumatic injuries.

CONCLUSIONS

These findings support the notion that SHCs and activity limitations increase over time in older adults aging with long-term SCI. The results can inform clinicians and call for a proactive, holistic approach in the long-term follow-up to support healthy and active aging.

Superiority of Brain and Spinal Injury Center Score for Assessing Injury Severity and Predicting Prognosis in Patients with Acute Traumatic Spinal Cord Injury

PURPOSE

The goal of this study was to evaluate the interrelationship between different magnetic resonance (MR) imaging measures and their validity in assessing the severity of acute traumatic spinal cord injury (tSCI) and predicting neurological outcomes.

METHODS

We performed a preoperative multicenter cohort study of 89 patients with acute tSCI and preoperative MR imaging within 24 h after injury. We assessed several MR imaging measures of injury, including axial grade (Brain and Spinal Injury Center [BASIC] score), sagittal grade, length of injury, maximum canal compromise (MCC), and maximum spinal cord compression (MSCC). Principal component analysis (PCA) was applied to evaluate the interrelationship between different MR imaging measures. Spearman correlation and regression analyses were applied to assess injury severity and predict neurological impairment. The severity was assessed by the American Spinal Injury Association Impairment Scale (AIS) at admission, while neurological outcome was defined by AIS grade change at 6 weeks, AIS grade and SCIM score at 1 year after surgery.

RESULTS

The PCA identified 2 clusters of MR imaging variables related to 1) measures of intrinsic cord signal abnormality (BASIC score, sagittal grade and length of injury) and 2) measures of extrinsic cord compression (MCC and MSCC). Neurological outcome and injury severity were best accounted for by MR imaging measures of intrinsic cord signal abnormalities, with the BASIC score representing the most accurate predictor of short-term and long-term neurological outcomes.

CONCLUSION

We determined the superior significance of the BASIC score in assessing injury severity, predicting early AIS improvement, AIS grade and SCIM score at 1 year compared with other MR imaging measures.

Use and evaluation of assistive technologies for upper limb function in tetraplegia

CONTEXT

More than half of all spinal cord injuries (SCI) occur at the cervical level leading to loss of upper limb function, restricted activity and reduced independence. Several technologies have been developed to assist with upper limb functions in the SCI population.

OBJECTIVE

There is no clear clinical consensus on the effectiveness of the current assistive technologies for the cervical SCI population, hence this study reviews the literature in the years between 1999 and 2019.

METHODS

A systematic review was performed on the state-of-the-art assistive technology that supports and improves the function of impaired upper limbs in cervical SCI populations. Combinations of terms, covering assistive technology, SCI, and upper limb, were used in the search, which resulted in a total of 1770 articles. Data extractions were performed on the selected studies which involved summarizing details on the assistive technologies, characteristics of study participants, outcome measures, and improved upper limb functions when using the device.

RESULTS

A total of 24 articles were found and grouped into five categories, including neuroprostheses (invasive and non-invasive), orthotic devices, hybrid systems, robots, and arm supports. Only a few selected studies comprehensively reported characteristics of the participants. There was a wide range of outcome measures and all studies reported improvements in upper limb function with the devices.

CONCLUSIONS

This study highlighted that assistive technologies can improve functions of the upper limbs in SCI patients. It was challenging to draw generalizable conclusions because of factors, such as heterogeneity of recruited participants, a wide range of outcome measures, and the different technologies employed.

TEleRehabilitation Nepal (TERN) for People With Spinal Cord Injury and Acquired Brain Injury: A Feasibility Study

BACKGROUND

Spinal Cord Injury (SCI) or Acquired Brain Injury (ABI) leads to disability, unemployment, loss of income, decreased quality of life and increased mortality. The impact is worse in Low-and Middle-Income Countries (LMICs) due to a lack of efficient long-term rehabilitative care. This study aims to explore the feasibility and acceptability of a telerehabilitation programme in Nepal.

METHODS

Prospective cohort feasibility study in a community setting following discharge from a specialist rehabilitation centre in Nepal. Patients with SCI or ABI who had previously accessed specialist rehabilitation were connected to a specialist Multidisciplinary Team (MDT) in the centre through a video conference system for comprehensive remote assessments and virtual individualised interventions. Data were captured on recruitment, non-participation rates, retention, acceptability (via end-of-study in-depth interviews with a subset of participants) and outcome measures including the Modified Barthel Index (MBI), Depression Anxiety Stress Scale (DASS) and EuroQol-5D (EQ-5D), completed pre- and post-programme.

RESULTS

97 participants with SCI (n = 82) or ABI (n = 15) discharged from the centre during an 18-month period were approached and enrolled on the study. The telerehabilitation programme facilitated the delivery of support around multiple aspects of rehabilitation care, such as spasticity treatments and pain management. Outcome measures indicated a significant improvement in functional independence (P < .001), depression, anxiety and stress (P < .001) and quality of life (P < .001). Qualitative interviews (n = 18) revealed participants found the programme acceptable, valuing regular contact and input from MDT professionals and avoiding expensive and lengthy travel.

CONCLUSION

This is the first study in Nepal to identify telerehabilitation as a feasible and acceptable approach to augment the provision of specialist rehabilitation. Future research is needed to assess the suitability of the programme for other conditions requiring specialist rehabilitation and determine the mechanisms underpinning improved outcomes for people with SCI or ABI.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04914650.

Impact of Rehabilitation Nutrition and Healthy Weight Maintenance in Motor-Complete Tetraplegia Patients

Cachexia and low muscle mass in motor-complete tetraplegia are associated with poor outcomes. This study aimed to document anthropometric, body composition, and nutritional indices in patients and to assess the effect of a comprehensive rehabilitation nutrition program in cachexia and low muscle mass. For 34 motor-complete tetraplegia in the subacute phase, a comprehensive rehabilitation nutrition program was provided for 8 to 9 weeks. Risk of malnutrition, anthropometric and body composition indices, as well as laboratory tests were assessed upon admission and at discharge. A body mass index of less than 20.2 kg/m2 was used as the cut-off value for obesity. Upon admission, 73.5% of patients were classified as obese, half were at risk of malnutrition, and 29.4% were compatible with cachexia. Compared to the premorbid state, the non-obese group showed greater weight reduction (p < 0.01) and higher prevalence of low muscle mass (p = 0.004) than the obese group. Disease duration was different between groups (p < 0.01). After rehabilitation, malnutrition risk, protein levels, and hemodynamic results improved in both groups (p < 0.05). A significant time × group interaction was observed for muscle mass, skeletal muscle mass, and appendicular lean mass index (p < 0.05). Muscle mass was maintained while fat components increased in both groups. Functional improvement was negatively correlated with an increase in fat components (p < 0.05). A personalized rehabilitation nutrition intervention improved the nutritional status, body composition, and functional outcomes in motor-complete tetraplegia. The increase in muscle mass was associated with functional gain; healthy weight gain or maintenance may improve the level of independence. Further studies to endorse this beneficial evidence of rehabilitation nutrition in the maintenance of muscle component are needed.

Cardiometabolic risk profiling during spinal cord injury rehabilitation: A longitudinal analysis from Swiss Spinal Cord Injury cohort (SwiSCI)

BACKGROUND

Early screening is important in individuals with spinal cord injury (SCI) as they were deemed high-risk for cardiometabolic diseases. Few studies explored changes in cardiometabolic risk profile in the early phase of the injury. Thus, it remains unclear how early the cardiometabolic status deteriorates after injury.

OBJECTIVE

We determined the longitudinal changes in the cardiometabolic risk profile and examined the association between injury characteristics and cardiometabolic status in subacute SCI.

SETTING

Multicenter Swiss Spinal Cord Injury Cohort.

PARTICIPANTS

Adults with traumatic SCI without history of cardiovascular disease or type 2 diabetes.

MAIN OUTCOME MEASURES

Blood pressure (BP), lipid profile, fasting glucose, waist circumference (WC), weight, body mass index (BMI) and Framingham risk score (FRS) were compared across time and according to the injury characteristics.

RESULTS

We analyzed the data of 258 individuals with traumatic SCI (110 tetraplegia and 148 paraplegia, 122 motor complete and 136 incomplete). The median age was 50 years (IQR 32-60), with 76.36% (n=197) of the population being male. The median rehabilitation duration was 5.5 months (IQR 3.2-7.1). At admission to rehabilitation, fully-adjusted linear regression models showed higher baseline weight (β 0.06, 95% CI 0.005, 0.11), systolic BP (β 0.05, 95% CI 0.008, 0.09), diastolic BP (β 0.05 95% CI 0.004, 0.10), and triglycerides (β 0.27 95% CI 0.13, 0.42) in paraplegia than tetraplegia. Systolic BP, diastolic BP, HDL-C were higher in incomplete than complete injury. In our main analysis, we observed an increase in cholesterol and HDL-C and lipid ratio when comparing the beginning and end of rehabilitation. Individuals with paraplegia had a higher increase in BMI than tetraplegia, while no differences in other cardiometabolic risk factors were detected when comparing motor incomplete and complete injury. Trajectories of each participant showed that the majority of individuals with SCI decreased FRS score at follow-up compared to baseline and no significant changes in prevalence of cardiometabolic syndrome were observed. At discharge, one-third of study participants were classified as moderate to high risk of CVD, 64% were overweight, and 39.45% had cardiometabolic syndrome.

CONCLUSION

We observed a modest improvement in lipid profile and FRS during the first inpatient rehabilitation hospitalization. Injury characteristics, such as level and completeness, were not associated with changes in cardiometabolic risk factors in the subacute phase of the injury. Despite this, a significant proportion of study participants remained at risk of cardiometabolic disease at discharge, suggesting that early cardiometabolic preventive strategies may be initiated as early as during the first inpatient rehabilitation hospitalization. This article is protected by copyright. All rights reserved.

[Respiratory and physical recovery in cervical spinal cord injury. Seventeen years' experience in a weaning and rehabilitation center: An observational study]

INTRODUCTION AND OBJECTIVES

Spinal cord injury (SCI) is a devastating entity that generates substantial disability. The outcome of respiratory and motor features has an impact in human and social well-being. We analyzed demographic characteristics, motor and respiratory outcomes, and determined equipment needs at discharge in a weaning and rehabilitation center.

MATERIAL AND METHOD

Observational, descriptive and retrospective study of medical records between January 2002 and December 2018. Tracheostomised cervical SCI patients with invasive mechanical ventilation were included. Forced vital capacity (upright and supine), maximal inspiratory and expiratory pressures, ASIA and Spinal Cord Independence MeasureIII (SCIMIII) were obtained.

RESULTS

Of 1603 patients, 3.5% had SCI, and 28 met the inclusion criteria. The most frequent level of injury was C4-C5 (17/28), 21/28 had ASIAA classification, and 19 showed no change in either the ASIA or the SCIM score. In all, 22/28 patients were weaned, while 15/28 were decannulated. Twenty four patients were discharged to home. The most relevant change in SCIMIII was in the 5th component of respiration and sphincter subscale, related to weaning and tracheostomy. At discharge, 23/24 patients needed both respiratory and motor aids.

CONCLUSIONS

The admission rate of SCI patients was low in our weaning and rehabilitation center, with almost all being admitted for traumatic causes. Severity remained unchanged in most ASIAA patients. Respiratory recovery was more clinically significant than recovery of motor function. Upon discharge, most of our patients had to be equipped with both respiratory and motor aids.

A Rasch-Based Comparison of the Functional Independence Measure and Spinal Cord Independence Measure for Outcome and Quality in the Rehabilitation of Persons with Spinal Cord Injury

Objective

The Functional Independence Measure (FIM™) and spinal cord injury (SCI)-specific Spinal Cord Independence Measure (SCIM) are commonly used tools for outcome measurement and quality reporting in rehabilitation. The objective of this study was to investigate the psychometric properties of FIM™ and SCIM and to equate the 2 scales.

Methods

First, content equivalence of FIM™ and SCIM was established through qualitative linking with the International Classification for Functioning, Disability and Health (ICF). Secondly, a Rasch analysis of overlapping contents determined the metric properties of the scales and provided the empirical basis for scale equating. Furthermore, a transformation table for FIM™ and SCIM was created and evaluated.

Subjects

Patients with SCI in Swiss inpatient rehabilitation in 2017–18.

Results

The ICF linking and a separate Rasch analysis of FIM™ restricted the analysis to the motor scales of FIM™ and SCIM. The Rasch analysis of these scales showed good metric properties. The co-calibration of FIM™ and SCIM motor scores was supported with good fit to the Rasch model. The operational range of SCIM is larger than for FIM™ motor scale.

Discussion

This study supports the advantage of using SCIM compared with FIM™ for assessing the functional independence of patients with SCI in rehabilitation.

Influence of body weight-supported treadmill training with voluntary-driven exoskeleton on the quality of life of persons with chronic spinal cord injury: a pilot study

The aim of this study was to investigate whether body weight-supported treadmill training with voluntary-driven exoskeleton body weight-supported treadmill training (VDE-BWSTT) improves the quality of life (QOL) of persons with chronic spinal cord injury (SCI). Nineteen individuals with chronic SCI with walking limitation underwent a total of 20 sessions of VDE-BWSTT using the hybrid assistant limb. The QOL was measured using the Short Form-36v2 (SF-36v2) questionnaire at preintervention and postintervention. The Walking Index for SCI-II (WISCI-II), Functional Independence Measure (FIM) motor score, and Neuropathic Pain Symptom Inventory (NPSI) self-questionnaire were also administered/completed. In SF-36v2, the mean values of all subscales in our participants were lower than those in healthy individuals. None of the measures showed significant improvement, even in individuals with some residual walking ability (baseline WISCI-II score of 6 or higher). In the correlation analysis between the baselines WISCI-II, FIM, or NPSI values and the mean SF-36v2 subscale changes throughout the training, the baseline FIM motor score was positively correlated with the mean changes in Role Emotional and Mental Health. In addition, NPSI was negatively correlated with the mean change in Vitality and Mental Health. In our protocol, although VDE-BWSTT did not improve the QOL of persons with chronic SCI, those with higher functional independence or lower pain at preintervention likely improved. Further study with combination of task-specific training or pain-targeting treatment with more patients should be considered to more effectively improve their QOL.

Overview of the Spinal Cord Injury-Functional Index (SCI-FI): Structure and Recent Advances

The Spinal Cord Injury - Functional Index is a system of patient reported outcomes (PRO) measures of functional activities developed specifically with and for individuals with spinal cord injury (SCI). The SCI-FI was designed to overcome limitations in measurement of the full range of activities and breadth of content of physical functioning commonly used in SCI research. Generic measurement tools of physical function (i.e., those focused on the general population) tend to overemphasize mobility and do not contain enough items at the lower end of the functional range (e.g., appropriate for individuals with tetraplegia). The SCI-FI consists of nine item response theory (IRT)-calibrated item banks that represent relevant and meaningful item content for individuals with SCI, span a wide range of functional abilities, and subdivide physical functioning into important subdomains, including basic mobility, self-care, and fine motor function. Since the original publication of the SCI-FI in 2012, there have been significant advances in and publications on the reliability and psychometric properties of the measures. The manuscripts presented in this special section clarify the SCI-FI structure and present new research on the SCI-FI measurement system.

Reliability validity and responsiveness of the spinal cord independence measure 4th version in a multicultural setup

OBJECTIVE

To examine the fourth version of the Spinal Cord Independence Measure for reliability and validity.

DESIGN

Partly blinded comparison with the criterion standard Spinal Cord Independence Measure III, and between examiners and examinations.

SETTING

A multicultural cohort from 19 spinal cord injury units in 11 countries.

PARTICIPANTS

Six hundred and forty-eight patients with spinal cord injury.

INTERVENTION

Assessment with Spinal Cord Independence Measure (SCIM IV) and Spinal Cord Independence Measure (SCIM III) on admission to inpatient rehabilitation and before discharge.

MAIN OUTCOME MEASURES

SCIM IV interrater reliability, internal consistency, correlation with and difference from SCIM III, and responsiveness.

RESULTS

Total agreement between examiners was above 80% on most SCIM IV tasks. All Kappa coefficients were above 0.70 and statistically significant (p<0.001). Pearson's coefficients of the correlation between the examiners were above 0.90, and intraclass correlation coefficients were above 0.90. Cronbach's alpha was above 0.96 for the entire SCIM IV, above 0.66 for the subscales, and usually decreased when an item was eliminated. Reliability values were lower for the subscale of respiration and sphincter management, and on admission than at discharge. SCIM IV and SCIM III mean values were very close, and the coefficients of Pearson correlation between them were 0.91-0.96 (p<0.001). The responsiveness of SCIM IV was not significantly different from that of SCIM III in most of the comparisons.

CONCLUSIONS

The validity, reliability, and responsiveness of SCIM IV, which was adjusted to assess specific patient conditions or situations that SCIM III does not address, and which includes more accurate definitions of certain scoring criteria, are very good and quite similar to those of SCIM III. SCIM IV can be used for clinical and research trials, including international multi-center studies, and its group scores can be compared with those of SCIM III.

The value of the whole picture: rehabilitation outcome measurement using patient self-report and clinician-based assessments after spinal cord injury

STUDY DESIGN

This is a retrospective longitudinal study.

OBJECTIVES

To explore the relative impact and contribution of using both the Spinal Cord Independence Measure III (SCIM) and Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) to assess rehabilitation outcome following an acute spinal cord injury (SCI).

SETTING

The study was performed at National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK.

METHODS

A patient self-report SMS-NAC and clinician-rated SCIM were administered on admission and discharge from the NSIC as part of standardised care. This paper presents a retrospective analysis of the rehabilitation outcomes of 195 people with spinal cord injury (PwSCI) following their first admission.

RESULTS

In both measures, PwSCI improved from admission to discharge. Individuals with higher SCI obtained lower scores in both measures, at both admission and discharge. The SMS-NAC demonstrated the greatest increase in knowledge and skill for PwSCI who had higher and more complete injuries. On the SCIM, PwSCI who had lower and less complete injuries demonstrated the greatest increase in outcome.

CONCLUSIONS

Overall, both measures demonstrated responsiveness to change during SCI rehabilitation and enable clinicians to systematically determine areas to focus rehabilitation effort. The relative strengths and contribution to delivering person-centred care for each are identified. The SMS-NAC enables clinicians to record, for people with higher injuries, their subjective self-report of skill and knowledge gains from rehabilitation that may be missed with other measures. Consequently, using both is encouraged in appreciation of the value of recording verbal (instructional) independence as well as functional (physical) independence.

Rehabilitation length of stay and functional improvement among patients with traumatic spinal cord injury

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Investigate the association between rehabilitation length of stay (LOS) and motor FIM^® (mFIM) between rehabilitation admission and discharge among patients with traumatic spinal cord injury (SCI).

SETTING

Seventeen SCI Model Systems (SCIMS) centers in the United States.

METHODS

A total of 3386 patients with traumatic SCI enrolled in the SCIMS Database from 2011 to 2018. The main outcome measure was the mean change in mFIM (12 items) between rehabilitation admission and discharge by twelve neurological categories (C1-C4 American Spinal Injury Association impairment scale (AIS) A-B, AIS C, AIS D, and C5-C8 AIS A-B, AIS C, AIS D, and T1-T10 AIS A-B, AIS C, AIS D, and T11-S3 AIS A-B, C, D). Linear regression models were applied to estimate changes across rehabilitation LOS groups (shortest LOS, quarter2, quarter3, and longest LOS) after adjusting for covariables for each neurological category.

RESULTS

The mean age of study patients was 44.5 years. Patients were predominantly men (78.5%), non-Hispanic white (64.8%), and had private insurance (57.1%). The median LOS was 42 days across the entire sample. Longer LOS was associated with a higher mFIM score compared to the shortest LOS among patients with C1-C4 AIS D; C5-C8 AIS D; T1-T10 AIS A-B; and T11-S3 AIS A-B, C, and D after adjusting for demographics and clinical characteristics.

CONCLUSION

Among patients with C1-C4 AIS D; C5-C8 AIS D; T1-T10 AIS A-B; and T11-S3 AIS A-B, C, and D injuries, those with longer rehabilitation stays tended to have more motor function improvement.

Development and Validation of Crosswalks Between FIM® and SCIM III for Voluntary Musculoskeletal Movement Functions

Background. In spinal cord injury, there are multiple databases containing information on functional recovery, but data cannot be pooled or compared due to differences in how function is measured. A crosswalk is needed to link or convert scores between instruments. Objectives. To create a crosswalk between the voluntary musculoskeletal movement items in the Functional Independence Measure (FIM®) and the Spinal Cord Independence Measure III (SCIM III) for spinal cord injury. Methods. Retrospective datasets with FIM® and SCIM III on the same people were used to develop (Swiss dataset, n = 662) and validate (US, n = 119, and Canadian datasets, n = 133) the crosswalks. Three different crosswalk methods (expert panel, equipercentile, and Rasch analysis) were employed. We used the correlation between observed scores on FIM® and SCIM III to crosswalked scores as the primary criterion to assess the strength of the crosswalk. Secondary criteria such as score distributions, Cohen's effect size, point differences, and subgroup invariance were also evaluated. Results. All three methods resulted in strong correlation coefficients, exceeding the primary criterion value of r = .866 (.897-.972). Assessment of secondary criteria suggests the equipercentile and Rasch methods produced the strongest crosswalks. Conclusions. The Rasch FIM®/SCIM III crosswalk is recommended because it is based on co-calibration of linearized measures, allowing for more sophisticated parametric analyses. The crosswalk will allow comparisons of voluntary musculoskeletal functional recovery across international databases using different functional measures, as well as different systems of care and rehabilitation approaches.

Reliability and validity of the international standards for neurological classification of spinal cord injury in patients with non-traumatic spinal cord lesions

STUDY DESIGN

Prospective, observational study.

OBJECTIVES

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) represent the gold standard for the assessment of patients with spinal cord injury (SCI) and their measurement properties have been evaluated in patients with traumatic lesions. Albeit the ISNCSCI are widely used also for the assessment and prognosis of patients with non-traumatic SCI, a validation of this grading system in this sample has never been performed. Therefore, the aim of this study is to evaluate the measurement properties of the ISNCSCI in a population of persons with non-traumatic SCI.

SETTING

Three Italian rehabilitation hospitals.

METHODS

The sample included 140 patients with non-traumatic SCI of different etiology, level and grade, for a total of 169 evaluations performed by two examiners. Cronbach's Alpha was used to evaluate the internal consistency of the ISNCSCI various components. The agreement between two examiners of each center in the definition of different components was used to assess the inter-rater reliability. The construct validity was evaluated through the correlation of the ISNCSCI with the Spinal Cord Independence Measure (SCIM).

RESULTS

The ISNCSCI showed substantial internal consistency, and substantial inter-rater agreement for AIS grade, cumulative motor and sensory scores. The motor scores for upper and lower extremity showed fair to moderate correlation with SCIM self-care and motility subscores, respectively. The ISNCSCI total motor score correlated with the total SCIM score.

CONCLUSIONS

Our study demonstrates that the ISNCSCI are a valid and reliable tool for the assessment of patients with non-traumatic SCI.

The potential of prediction models of functioning remains to be fully exploited: A scoping review in the field of spinal cord injury rehabilitation

OBJECTIVE

The study aimed to explore existing prediction models of functioning in spinal cord injury (SCI).

STUDY DESIGN AND SETTING

The databases PubMed, EBSCOhost CINAHL Complete, and IEEE Xplore were searched for relevant literature. The search strategy included published search filters for prediction model and impact studies, index terms and keywords for SCI, and relevant outcome measures able to assess functioning as reflected in the International Classification of Functioning, Disability and Health (ICF). The search was completed in October 2020.

RESULTS

We identified seven prediction model studies reporting twelve prediction models of functioning. The identified prediction models were mainly envisioned to be used for rehabilitation planning, however, also other possible applications were stated. The method predominantly used was regression analysis and the investigated predictors covered mainly the ICF-components of body functions and activities and participation, next to characteristics of the health condition and health interventions.

CONCLUSION

Findings suggest that the development of prediction models of functioning for use in clinical practice remains to be fully exploited. By providing a comprehensive overview of what has been done, this review informs future research on prediction models of functioning in SCI and contributes to an efficient use of research evidence.

Differences in functional improvement based on history of substance abuse and pain severity following spinal cord injury

Background: This study explored the relationship between history of substance abuse and pain severity during inpatient rehabilitation following traumatic spinal cord injury (SCI). Methods: Secondary analysis of a prospective longitudinal study. An adjusted general linear model was used to examine differences in functional improvement based on history of substance abuse and pain severity. Results: Over 50% of the sample had a history of substance abuse, and 94% reported moderate or severe pain. There was a significant interaction between the history of substance abuse and pain severity (p = 0.01, partial η² = 0.012). A difference in functional improvement was found among individuals who reported low pain; those with a history of substance abuse achieved less functional improvement than those without a history of substance abuse, M = 5.32, SE = 1.95, 95% CI 0.64-10.01. Conclusions: A history of substance abuse and post-injury pain are prevalent among individuals with SCI in rehabilitation, and there may be a meaningful relationship between these two patient characteristics and functional improvement. The results provide potential new insights into the characteristics of vulnerable subpopulations during SCI rehabilitation. Furthering our understanding of these results warrants future investigation to prevent and minimize poor outcomes among vulnerable SCI patients.

Erectile Dysfunction Is the Main Correlate of Depression in Men with Chronic Spinal Cord Injury

Depression is the most prevalent psychological issue after a spinal cord injury (SCI) and is associated with noticeable disability, mortality and health expenditure. As SCI mainly occurs in sexually active men at a young age, and can lead to them suffering from an organic neurogenic erectile dysfunction (ED), we supposed that ED could be a major correlate of depressive status in men with SCI. As documented by a Beck Depression Inventory-II (BDI-II) score ≥14, depression was reported in 17 out of 57 men with a chronic SCI (29.8%). They exhibited a significantly higher prevalence of ED and a more severe bowel and bladder dysfunction when compared to the group without depression. At the multiple logistic regression analysis, depression showed a significant independent association with ED (OR = 19.0, 95% CI: 3.1, 203.3; p = 0.004) and, to a lesser extent, with a severe impairment of bowel and bladder function (OR = 0.84; 95% CI: 0.72, 0.94; p = 0.01). Depression was observed in 43.7% of men with ED and only in 12.0% of those without ED (p = 0.002). In conclusion, healthcare providers should give the right level of importance to the management of ED in men with SCI, as this represents a major independent correlate of depression, which, in turn, might hinder physical rehabilitation and exacerbate physical health issues related to SCI.

Identification of Classes of Functioning Trajectories and Their Predictors in Individuals With Spinal Cord Injury Attending Initial Rehabilitation in Switzerland

Objectives

To identify classes of functioning trajectories in individuals with spinal cord injury (SCI) undergoing initial rehabilitation after injury and to examine potential predictors of class membership to inform clinical planning of the rehabilitation process.

Design

Longitudinal analysis of the individual's rehabilitation stay using data from the Inception Cohort of the Swiss Spinal Cord Injury Cohort Study (SwiSCI).

Setting

Initial rehabilitation in specialized centers in Switzerland.

Participants

Individuals with newly acquired SCI (N=748; mean age, 54.66±18.38y) who completed initial rehabilitation between May 2013 and September 2019. The cohort was primarily composed of men (67.51%), persons with paraplegia (56.15%), incomplete injuries (67.51%), and traumatic etiologies (55.48%).

Interventions

Not applicable.

Main Outcome Measures

Functioning was operationalized with the interval-based sum score of the Spinal Cord Independence Measure version III (SCIM III). For each individual, the SCIM III sum score was assessed at up to 4 time points during rehabilitation stay. The corresponding time of assessment was recorded by the difference in days between the SCIM III assessment and admission to the rehabilitation program.

Results

Latent process mixed model analysis revealed 4 classes of functioning trajectories within the present sample. Class-specific predicted mean functioning trajectories describe stable high functioning (n=307; 41.04%), early functioning improvement (n=39; 5.21%), moderate functioning improvement (n=287; 38.37%), and slow functioning improvement (n=115; 15.37%), respectively. Out of 12 tested factors, multinomial logistic regression showed that age, injury level, injury severity, and ventilator assistance were robust predictors that could distinguish between identified classes of functioning trajectories in the present sample.

Conclusions

The current study establishes a foundation for future research on the course of functioning of individuals with SCI in initial rehabilitation by identifying classes of functioning trajectories. This supports the development of specifically tailored rehabilitation programs and prediction models, which can be integrated into clinical rehabilitation planning.

Hip-Spine Syndrome in Patients With Spinal Cord Injuries: Hyperlordosis Associated With Severe Hip Flexion Contracture

Aim: Spinal cord injury (SCI)-related flaccid paralysis may result in a debilitating hyperlordosis associated with a progressive hip flexion contracture. The aim of this study was to evaluate the correction of hip flexion contractures and lumbar hyperlordosis in paraplegic patients that had a history of spinal cord injuries. Methods: A retrospective review was performed on 29 hips of 15 consecutive patients who underwent corrective surgeries for severe hip flexion deformity from 2006 to 2018. The mean age at surgery was 10.1 years (2.7 to 15.8), and the mean follow-up was 68 months (7 to 143). Relevant medical, surgical, and postoperative information was collected from the medical records and radiographs. Results: Improvements were seen in the mean hip flexion contracture (p < 0.001) with 100% hip correction at surgery and 92.1% at the latest follow-up. Mean lumbar lordosis decreased (p = 0.029) while the mean Cobb angle increased (p = 0.001) at the latest follow up. Functional score subdomains of the Spinal Cord Independence Measure, Functional Independence Measure, and modified Barthel activities of daily living (ADL) scores remained the same at the final follow-up. Conclusion: For paraplegic SCI patients, we found an association between treating the hip flexion contracture and indirect correction of their lumbar hyperlordosis. We recommend the surgeon carefully examine the hip pathology when managing SCI-related spinal deformities, especially increased lumbar lordosis.

[Factors associated with functional improvement in patients with cervical spinal cord injuries]

OBJECTIVE

To determine the factors influencing functional improvement of cervical spinal cord injuries during hospital admission.

MATERIAL AND METHODS

We performed a retrospective study of patients with an acute cervical spinal cord injury who had completed a rehabilitation programme in the Spinal Cord Injuries Unit of the Canary Islands between 2001 and 2018. To measure functional improvement, we administered the Spinal Cord Independence Measure III (SCIM III) on admission and at discharge.

RESULTS

Of the 141 patients in our sample, 88% were men. Worse functional results were observed in older patients, those with a history of alcohol consumption, complete lesions and those with more severe lesions on the ASIA scale. Factors significantly associated with functional improvement were the interval between injury and admission to the unit, length of hospital stay, and the interval between injury and hospital discharge.

CONCLUSIONS

Older patients, as well as those with a history of alcohol intake, complete lesions and greater severity on the ASIA scale, had worse functional outcomes. In contrast, early admission was crucial to obtain better functional outcomes and was associated with shorter hospital stays.

Combined botulinum toxin type A and electrical stimulation in individuals with C5-C6 and C6-C7 tetraplegia: a pilot study

STUDY DESIGN

Single-blind pilot study.

OBJECTIVES

(1) To evaluate combined BoNT-A injection of spastic antagonistic muscles and ES of wrist extensors in order to improve hand function in incomplete cervical SCI patients. (2) To identify prognostic indicators of hand improvements, as a function of motor levels of injury.

SETTING

Ten incomplete asymmetric SCI tetraplegics admitted to San Camillo Hospital (Venezia, Italy), who were not able to perform automatic grasping, were enrolled in the study. A better motor level (BML) C6-C7 and worse motor level (WML) C5-C6 were assigned to take into account asymmetric motor strength.

METHODS

Administration of 100-200 UI BoNT-A per limb into flexor carpi radialis (FCR), extensor digitorum communis (EDC), brachial biceps (BB), and pectoralis major (PM) was performed. This was in conjunction with 6 weeks of 30-min ES sessions repeated three times a day for 6 days a week in wrist extensor muscles, and 6 weeks of 30-min hand rehabilitation for 6 days a week. Assessments included wrist Range of Motion (w-RoM), Modified Ashworth Score (MAS), Functional Independence Measure motor scores (FIM motor), and Nine Hole Peg Test (NHPT).

RESULTS

Treatments produced a significant reduction in motor spasticity (MAS) and better dexterity (NHPT) in the C6-C7 BML with respect to the WML cases (p level = 0.007; p = 0.01, respectively). FIM motor scores improved more in BML (median: 20; range 20/22) than in WML (median: 10; range 8/17).

CONCLUSIONS

Hand function improvement, determined by combined BONT-A and ES, was better in C6-C7 than in C5-C6 SCI patients.

Development of the spinal cord injury pressure sore onset risk screening (SCI-PreSORS) instrument: a pressure injury risk decision tree for spinal cord injury rehabilitation

STUDY DESIGN

Psychometric study based on retrospectively collected data.

OBJECTIVE

Development of a pressure injury (PI) risk screening instrument for use during spinal cord injury (SCI) rehabilitation.

SETTING

Tertiary rehabilitation center.

METHODS

Medical charts of 807 inpatients participating in SCI rehabilitation were reviewed. Two models (recursive partitioning and logistic regression) were developed with demographic and Functional Independence Measure (FIM) variables and compared with the SCI Pressure Ulcer Scale (SCIPUS, n = 603) and Braden scale (n = 100) using modeling (n = 615) and validation (n = 192) datasets. Sensitivity and specificity analyses were completed for each model. Models yielding high sensitivity and area under the curve (AUC), while minimizing false negatives (FN < 0.5%) were preferred.

RESULTS

In the modeling dataset, a single dichotomized FIM variable, Bed/Chair Transfers <4, was predictive of PI incidence (sensitivity = 97%, AUC = 74%, FN = 0.49%) and had similar metrics as the logistic regression model (sensitivity = 97%, AUC = 76%, FN = 0.49%). The recursive partitioning model had fewer FN (sensitivity = 98%, AUC = 75%, FN = 0.33%). When applied to the validation dataset, both models performed similarly. The SCIPUS performed poorly (AUC < 70%). When analyses were limited to cases with available Braden data and no admission PI, recursive partitioning outperformed the other methods for PI risk screening.

CONCLUSION

A recursive partitioning model, named the SCI-PreSORS (SCI Pressure Sore Onset Risk Screening), demonstrated promise for PI risk screening during inpatient SCI rehabilitation. Prospective validation of the new model is warranted.

Acute Traumatic and Ischemic Spinal Cord Injuries Have a Comparable Course of Recovery

Background. The relative rarity of ischemic compared with traumatic spinal cord injury (SCI) has limited a comparison of the outcomes of these conditions. Objective. To investigate the neurological and functional recovery of ischemic compared with traumatic acute SCI. Methods. Data were derived from the European Multicenter Study Spinal Cord Injury database. Patients with ischemic (iSCI) or traumatic SCI (tSCI), aged 18 years or older were evaluated at different time points from incidence: at about 1 month, 3 months, and 6 months. The neurological status was assessed at each time point by the International Standards for Neurological Classification of Spinal Cord Injury and the functional status by the Spinal Cord Independence Measure. Walking ability was evaluated by Walking Index for Spinal Cord Injury, 10-Meter Walk Test, and 6-Minute Walk Test. Because of the imbalances of the 2 groups in respect to size and lesion severity, a matching procedure according to age, neurological level, and severity of injury was performed. Outcomes evaluation was performed by means of a 2-way repeated-measures ANOVA. Results. The matching procedure resulted in 191 pairs. Both groups significantly improved from about 15 days after the lesion to 6 months. No differences were found in the course of neurological and functional recovery of iSCI compared with tSCI. Conclusions. This analysis from a representative cohort of participants revealed that from 15 days following the cord damage onward, the outcomes after iSCI and tSCI are comparable. This finding supports the potential enrolment of patients with acute iSCI into clinical trials from that point in time after the event and an evaluation up to 6 months afterward.

Characterization of pain syndromes in patients with neuromyelitis optica

BACKGROUND

Pain is common and refractory in spinal cord injury (SCI). Currently, most studies evaluated pain in male-predominant traumatic-SCI. Also, concomitant secondary pain syndromes and its temporal evolution were seldom reported.

METHODS

We aimed to prospectively describe the main and secondary pain and its associated factors in inflammatory-SCI evaluating neuromyelitis optica (NMO) patients. In-remission NMO patients underwent neurological, imaging and autoantibody evaluations. Questionnaires detailing main and secondary pains, functional state, mood, catastrophizing, quality of life (QoL) and "non-motor symptoms" were used at two time points.

RESULTS

Pain was present in 53 (73.6%) of the 72 patients included. At-level neuropathic pain was the most common main pain syndrome, affecting 32 subjects (60.4% of those with pain). Over 70% (n = 38) of this cohort reported two pain syndromes. Those without pain were significantly younger (26.1 ± 12.7 y.o. in those without pain and 40.1 ± 12.5, 37.2 ± 11.4 y.o. in those whose main pain was neuropathic and non-neuropathic, respectively, p = .001), and no differences in the inflammatory status were observed between groups. On follow-up, one-fifth (n = 11) had a different main pain syndrome from the first visit. Pain impacted QoL as much as disability and motor strength.

CONCLUSION

Pain is a prevalent and disabling non-motor symptom in NMO-SCI. Most patients experience more than one pain syndrome which can change in time even in the absence of clinical relapse. Age of the inflammatory-SCI was a major determinant of pain. Acknowledging temporal changes and multiplicity of pain syndromes in NMO-SCI may give insights into more precise designs of clinical trials and general management of pain in SCI.

SIGNIFICANCE

In this longitudinal study with NMO-related SCI, pain affected almost three-quarters of patients with NMO. Over 70% have more than one pain syndrome and at-level neuropathic pain is the most common type of pain syndrome. Patients without pain were significantly younger but had the same burden of inflammatory lesions than those with pain. During follow-up, up to one fifth of patients presented with changes in the main pain syndromes, which can occur even in the absence of clinical activity of the inflammatory disease. In this cohort, Pain affected quality of life as much as disability or motor strength.

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

Independent Association of Erectile Dysfunction and Low Testosterone Levels With Life Dissatisfaction in Men With Chronic Spinal Cord Injury

BACKGROUND

The loss of global functional independence, along with bladder, bowel, and sexual dysfunctions, may contribute to psychological distress and life dissatisfaction after spinal cord injury (SCI).

AIM

To explore the relationship of erectile function and androgenic status with life satisfaction, independently from confounders recognizable in spinal cord-injured men.

METHODS

100 consecutive men (49 ± 17 years) admitted to a rehabilitation program because of chronic SCI (≥1 year) underwent clinical/biochemical evaluations, including the assessment of life and sexual satisfaction using the Life-Satisfaction Questionnaire-9 (LiSat-9), erectile function using the International Index of Erectile Function-5 (IIEF-5), global and bowel-bladder functional independence using the Spinal Cord Independence Measure (SCIM) and measurement of total testosterone (TT) levels. The free testosterone level was calculated using the Vermeulen formula.

OUTCOMES

The outcomes include the relationship between sexual health and life satisfaction in men with SCI.

RESULTS

A LiSat-9 score <4, suggestive for life dissatisfaction, was exhibited by 49% of men. When compared with the life-satisfied group, a significantly higher percentage of them had sexual dissatisfaction and erectile dysfunction (ED); they also exhibited significantly lower levels of TT and calculated free testosterone (cFT) and a more severe impairment of bowel-bladder function. The life satisfaction degree correlated with sexual satisfaction degree, IIEF-5 score, TT, cFT, and bowel-bladder function degree. At the logistic regression model, including sexual LiSat-9 subscore and bowel-bladder SCIM subscore, only the former exhibited a significant negative association with life dissatisfaction. In a further logistic regression model, including the putative key determinants of sexual satisfaction, erectile function, and cFT levels, a higher odd of life dissatisfaction was independently associated both with a lower IIEF-5 score (OR: 0.93; 95% CI: 0.88, 0.98) and lower cFT levels (OR: 0.98; 95% CI: 0.98, 0.99).

CLINICAL IMPLICATIONS

In men with chronic SCI, assessment of erectile function and testosterone levels can help to predict life satisfaction.

STRENGTHS & LIMITATIONS

This is the first demonstration of the independent association of androgen deficiency and ED with life satisfaction in men with SCI. Prospective studies are warranted to clarify the cause-effect relationships.

CONCLUSIONS

In men with SCI, ED and low testosterone levels exhibit a significant independent association with life dissatisfaction; longitudinal intervention studies could explore possible effects of their treatment in improving sexual and life satisfaction in this population. D'Andrea S, Minaldi E, Castellini C, et al. Independent Association of Erectile Dysfunction and Low Testosterone Levels With Life Dissatisfaction in Men With Chronic Spinal Cord Injury. J Sex Med 2020;17:911-918.

Development of 3D-printed myoelectric hand orthosis for patients with spinal cord injury

BACKGROUND

Spinal cord injury (SCI) is a severe medical condition affecting the hand and locomotor function. New medical technologies, including various wearable devices, as well as rehabilitation treatments are being developed to enhance hand function in patients with SCI. As three-dimensional (3D) printing has the advantage of being able to produce low-cost personalized devices, there is a growing appeal to apply this technology to rehabilitation equipment in conjunction with scientific advances. In this study, we proposed a novel 3D-printed hand orthosis that is controlled by electromyography (EMG) signals. The orthosis was designed to aid the grasping function for patients with cervical SCI. We applied this hand exoskeleton system to individuals with tetraplegia due to SCI and validated its effectiveness.

METHODS

The 3D architecture of the device was designed using computer-aided design software and printed with a polylactic acid filament. The dynamic hand orthosis enhanced the tenodesis grip to provide sufficient grasping function. The root mean square of the EMG signal was used as the input for controlling the device. Ten subjects with hand weakness due to chronic cervical SCI were enrolled in this study, and their hand function was assessed before and after wearing the orthosis. The Toronto Rehabilitation Institute Hand Function Test (TRI-HFT) was used as the primary outcome measure. Furthermore, improvements in functional independence in daily living and device usability were evaluated.

RESULTS

The newly developed orthosis improved hand function of subjects, as determined using the TRI-HFT (p < 0.05). Furthermore, participants obtained immediate functionality on eating after wearing the orthosis. Moreover, most participants were satisfied with the device as determined by the usability test. There were no side effects associated with the experiment.

CONCLUSIONS

The 3D-printed myoelectric hand orthosis was intuitive, easy to use, and showed positive effects in its ability to handle objects encountered in daily life. This study proved that combining simple EMG-based control strategies and 3D printing techniques was feasible and promising in rehabilitation engineering.

TRIAL REGISTRATION

Clinical Research Information Service (CRiS), Republic of Korea. KCT0003995. Registered 2 May 2019 - Retrospectively registered.

The effect of arm-crank exercise training on power output, spirometric and cardiac function and level of autonomy in persons with tetraplegia

Studies on the effects of exercise training in persons with cervical spinal cord injury (CSCI) are scarce. The aim of this study was to determine the effect of an 8-week stationary arm-crank exercise (ACE) training programme on the level of autonomy, exercise performance, pulmonary functional parameters and resting heart rate variability (HRV) in persons with CSCI. Quadriplegia Index of Function (QIF), arm-crank peak power output (Ppeak), spirometric variables, and HRV indices were measured before and after the training programme in a group of 11 persons with CSCI. ACE training increased Ppeak in both groups (p < 0.05), whereas maximum voluntary ventilation (MVV) and low frequency HRV (LF) improved only in the lower CSCI group (p < 0.05). Moreover, QIF and Ppeak were significantly correlated before (r = 0.88; p < 0.01) and after (r = 0.86; p < 0.01) the training period. However, no significant changes were found in the level of autonomy (QIF) as a result of the intervention. Therefore, stationary ACE training appears to be a feasible and effective method for aerobic exercise in persons with tetraplegia and a short-term intervention is able to significantly improve exercise capacity, cardiac autonomic regulation and respiratory muscle endurance, regardless of the absence of significant immediate changes in the level of autonomy.

Recommendations for evaluation of bladder and bowel function in pre-clinical spinal cord injury research

Objective: In order to encourage the inclusion of bladder and bowel outcome measures in preclinical spinal cord injury (SCI) research, this paper identifies and categorizes 1) fundamental, 2) recommended, 3) supplemental and 4) exploratory sets of outcome measures for pre-clinical assessment of bladder and bowel function with broad applicability to animal models of SCI.Methods: Drawing upon the collective research experience of autonomic physiologists and informed in consultation with clinical experts, a critical assessment of currently available bladder and bowel outcome measures (histological, biochemical, in vivo functional, ex vivo physiological and electrophysiological tests) was made to identify the strengths, deficiencies and ease of inclusion for future studies of experimental SCI.Results: Based upon pre-established criteria generated by the Neurogenic Bladder and Bowel Working Group that included history of use in experimental settings, citations in the literature by multiple independent groups, ease of general use, reproducibility and sensitivity to change, three fundamental measures each for bladder and bowel assessments were identified. Briefly defined, these assessments centered upon tissue morphology, voiding efficiency/volume and smooth muscle-mediated pressure studies. Additional assessment measures were categorized as recommended, supplemental or exploratory based upon the balance between technical requirements and potential mechanistic insights to be gained by the study.Conclusion: Several fundamental assessments share reasonable levels of technical and material investment, including some that could assess bladder and bowel function non-invasively and simultaneously. Such measures used more inclusively across SCI studies would advance progress in this high priority area. When complemented with a few additional investigator-selected study-relevant supplemental measures, they are highly recommended for research programs investigating the efficacy of therapeutic interventions in preclinical animal models of SCI that have a bladder and/or bowel focus.

Effects of Combined Upper Limb Robotic Therapy in Patients With Tetraplegic Spinal Cord Injury

OBJECTIVE

To confirm the effects of combined upper limb robotic therapy (RT) as compared to conventional occupational therapy (OT) in tetraplegic spinal cord injury (SCI) patients and to suggest the optimized treatment guidelines of combined upper limb RT.

METHODS

After subject recruitment and screening for eligibility, the baseline evaluation for outcome measures were performed. We evaluated the Graded and Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP), the American Spinal Injury Association upper extremity motor score, grip and pinch strength, and the Spinal Cord Independence Measurement III (SCIM-III). In this study, the pre-tested participants were divided randomly into the RT and OT group. The utilized interventions included combined upper limb RT using ArmeoPower and Amadeo (RT group), or conventional OT (OT group) in addition to daily inpatient rehabilitation program. The participants underwent 40 minutes×3 sessions×5 weeks of interventions.

RESULTS

A total of 30 tetraplegic SCI patients completed entire study program. After 5 weeks of intervention, both groups demonstrated increases in GRASSP-strength and SCIM-III. The manual muscle test scores of elbow flexion, elbow extension, 2-5th metacarpophalangeal extension, and SCIM-III subscores of bathing-upper, dressing-upper, and grooming as well as the GRASSP-qualitative prehension score were noted to have been significantly increased in the RT group as evaluated. The OT group showed improvements in the GRASSP-quantitative prehension score and some items in grip and pinch strength. There was no significant difference between the two groups in almost all measurements except for the SCIM-III bathing-upper subscore.

CONCLUSION

Combined upper limb RT demonstrated beneficial effects on the upper limb motor function in patients with tetraplegic SCI, which were comparable with conventional OT.