Cognitive Impairment and Mood States after Spinal Cord Injury

The Role of Neuropsychology in the Management of Spinal Cord Injury: A Comprehensive Literature Review

Spinal cord injury (SCI) poses a complex set of physiological, psychological, and cognitive challenges that significantly affect an individual's quality of life. Analysis of longitudinal studies reveals that cognitive changes following SCI are often underestimated yet significantly impact patient's ability to adapt to their new circumstances. However, the role of neuropsychology in SCI management and rehabilitation is yet to be elucidated. This article offers an in-depth review of the role of neuropsychology in understanding and addressing the cognitive, emotional, and behavioral outcomes of SCI. Additionally, we delve into the emotional and psychological consequences of SCI, which can include increased stress, depression, anxiety, and potential changes in personality and social functioning. Neuropsychological assessment tools are highlighted as essential for diagnosing and monitoring these psychological shifts, aiding in the creation of personalized rehabilitation interventions. We also explore the role of neuroplasticity in cognitive rehabilitation post-SCI, emphasizing the potential of targeted cognitive training to alleviate cognitive deficits and improve adaptive functioning. The article further investigates the interplay between physical and cognitive recovery, underscoring the reciprocal relationship between motor function and cognitive improvement. In conclusion, this review emphasizes the crucial role of neuropsychology in understanding the multifaceted impact of SCI. By enhancing our comprehension of the intricate connections among neural integrity, cognitive function, and psychological well-being, neuropsychology provides valuable insights for developing holistic rehabilitation strategies that address both the cognitive and emotional challenges faced by individuals with SCI. As neurorehabilitation continues to advance, integrating neuropsychological principles offers promise for improving the overall recovery and quality of life for those affected by spinal cord injury.

Brain inflammation and cognitive decline induced by spinal cord injury can be reversed by spinal cord cell transplants

Spinal cord injuries (SCIs) impact between 250,000 and 500,000 people worldwide annually, often resulting from road accidents or falls. These injuries frequently lead to lasting disabilities, with the severity depending on the injury's extent and location. Emerging research also links SCIs to cognitive impairments due to brain inflammation. From a treatment perspective, various approaches, including cell therapy, have been investigated. One common mechanism across cellular transplant models is the modulation of inflammation at the injury site, though it remains uncertain if these effects extend to the brain. To explore this, we induced SCI in wild-type mice and treated them with either olfactory ensheathing cells or mesenchymal stem cells. Our findings reveal that both cell types can reverse SCI-induced cognitive deficits, reduce brain inflammation, and increase hippocampal neuronal density. This study is the first, to our knowledge, to demonstrate that cells transplanted into the spinal cord can influence brain inflammation and mitigate injury-induced effects on brain functions. These results highlight the intricate relationship between the spinal cord and brain in both health and disease.

The Sir Ludwig Guttmann lecture 2023: psychosocial factors and adjustment dynamics after spinal cord injury

STUDY DESIGN

Narrative review OBJECTIVES: Sir Ludwig Guttmann realised spinal cord injury (SCI) rehabilitation should incorporate more than a biomedical approach if SCI patients were to adjust to their injury and achieve productive social re-integration. He introduced components into rehabilitation he believed would assist his patients build physical strength as well as psychological resilience that would help them re-engage with their communities. We pay tribute to Sir Ludwig by presenting research that has focussed on psychosocial factors that contribute to adjustment dynamics after SCI.

SETTING

Not applicable.

METHODS

Five factors with a psychosocial source will be examined, featured in my research, namely psychological distress, cognitive impairment, pain catastrophizing, sleep disorder and fatigue. A multifactorial model of adjustment will be examined.

RESULTS

Evidence shows these factors can be significant barriers to adjustment and reciprocally related to self-efficacy and life decisions. A theoretical rehabilitation framework/model is presented called the SCI Adjustment Model (SCIAM), that explains the process of adjustment dynamics. It describes how multifactorial factors contribute to adjustment in a non-linear process over time.

CONCLUSIONS

Key clinical messages include: (i) adjustment dynamics will be enhanced if viewed through the lens of a multifactorial model that clarifies how multiple psychosocial factors can combine and act as barriers or facilitators to adjustment; (ii) judiciously using this information, assess and then strategize to reduce the influence of barriers or strengthen facilitators during SCI rehabilitation and beyond, and (iii) integrate psychosocial guidelines and a person-centred approach into SCI rehabilitation to achieve treatment goals.

Short- and long-term effects of transcutaneous spinal cord stimulation on autonomic cardiovascular control and arm-crank exercise capacity in individuals with a spinal cord injury (STIMEX-SCI): study protocol

INTRODUCTION

Individuals with higher neurological levels of spinal cord injury (SCI) at or above the sixth thoracic segment (≥T6), exhibit impaired resting cardiovascular control and responses during upper-body exercise. Over time, impaired cardiovascular control predisposes individuals to lower cardiorespiratory fitness and thus a greater risk for cardiovascular disease and mortality. Non-invasive transcutaneous spinal cord stimulation (TSCS) has been shown to modulate cardiovascular responses at rest in individuals with SCI, yet its effectiveness to enhance exercise performance acutely, or promote superior physiological adaptations to exercise following an intervention, in an adequately powered cohort is unknown. Therefore, this study aims to explore the efficacy of acute TSCS for restoring autonomic function at rest and during arm-crank exercise to exhaustion (AIM 1) and investigate its longer-term impact on cardiorespiratory fitness and its concomitant benefits on cardiometabolic health and health-related quality of life (HRQoL) outcomes following an 8-week exercise intervention (AIM 2).

METHODS AND ANALYSIS

Sixteen individuals aged ≥16 years with a chronic, motor-complete SCI between the fifth cervical and sixth thoracic segments will undergo a baseline TSCS mapping session followed by an autonomic nervous system (ANS) stress test battery, with and without cardiovascular-optimised TSCS (CV-TSCS). Participants will then perform acute, single-session arm-crank exercise (ACE) trials to exhaustion with CV-TSCS or sham TSCS (SHAM-TSCS) in a randomised order. Twelve healthy, age- and sex-matched non-injured control participants will be recruited and will undergo the same ANS tests and exercise trials but without TSCS. Thereafter, the SCI cohort will be randomly assigned to an experimental (CV-TSCS+ACE) or control (SHAM-TSCS+ACE) group. All participants will perform 48 min of ACE twice per week (at workloads corresponding to 73-79% peak oxygen uptake), over a period of 8 weeks, either with (CV-TSCS) or without (SHAM-TSCS) cardiovascular-optimised stimulation. The primary outcomes are time to exhaustion (AIM 1) and cardiorespiratory fitness (AIM 2). Secondary outcomes for AIM 1 include arterial blood pressure, respiratory function, cerebral blood velocity, skeletal muscle tissue oxygenation, along with concentrations of catecholamines, brain-derived neurotrophic factor and immune cell dynamics via venous blood sampling pre, post and 90 min post-exercise. Secondary outcomes for AIM 2 include cardiometabolic health biomarkers, cardiac function, arterial stiffness, 24-hour blood pressure lability, energy expenditure, respiratory function, neural drive to respiratory muscles, seated balance and HRQoL (eg, bowel, bladder and sexual function). Outcome measures will be assessed at baseline, pre-intervention, post-intervention and after a 6-week follow-up period (HRQoL questionnaires only).

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Wales Research Ethics Committee 7 (23/WA/0284; 03/11/2024). The recruitment process began in February 2024, with the first enrolment in July 2024. Recruitment is expected to be completed by January 2026. The results will be presented at international SCI and sport-medicine conferences and will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN17856698.

Depression-like behavior is associated with deficits in cognition and hippocampal neurogenesis in a subset of spinally contused male, but not female, rats

Depression and cognitive deficits present at higher rates among people with spinal cord injury (SCI) compared to the general population, yet these SCI comorbidities are poorly addressed. Sex and age appear to play roles in depression incidence, but consensus on the direction of their effects is limited. Systemic and cortical inflammation and disruptions in hippocampal neurogenesis have been identified as potential treatment targets, but a comprehensive understanding of these mechanisms remains elusive. We used a rodent SCI model to interrogate these gaps in knowledge. We examined post-injury depression-like behavior and cognitive deficits, as well as the association between affect, cognition, chronic hippocampal inflammation and hippocampal neurogenesis, in young and middle-aged male and female Sprague-Dawley rats. Depression-like behavior manifested in male and female subsets of SCI rats irrespective of age, at rates commensurate with the incidence of clinical depression. Changes in components of behavior were driven by sex and age, and affective outcomes were independent of common post-injury pathophysiological outcomes including locomotor functional deficits and spinal lesion severity. Interestingly, however, only male depression-like SCI rats exhibited deficits in hippocampal-associated spatial cognition. Neurogenesis was also disrupted in only SCI males in regions of the hippocampus responsible for affective outcomes. Decreased neurogenesis among middle-aged male subjects coincided with increases in numbers of the pro-inflammatory markers CD86 and iNOS, while middle-aged females had increased numbers of cells expressing Iba-1 and anti-inflammatory marker CD206. Overall, the present data suggest that post-SCI depression and cognition may be affected, in part, by sex- and age-dependent changes in hippocampal neurogenesis and inflammation. Hippocampal neurogenesis is a potential target to address psychological wellbeing after SCI, but therapeutic strategies must carefully consider sex and age as biological variables.

Improving the rehabilitation of individuals admitted to England's National Spinal Injuries Centre with traumatic brain injury

STUDY DESIGN

Mixed methods service improvement project. Retrospective analysis of clinical documentation and qualitative focus group with clinicians.

OBJECTIVES

Although traumatic brain injury (TBI) and spinal cord injury (SCI) often co-occur, many barriers have been found to identifying TBI in SCI rehabilitation and adapting treatment accordingly. This study aimed to compare the number of individuals with a TBI detected at England's National Spinal Injuries Centre to figures found in previous research and understand the barriers to adapting SCI rehabilitation in the presence of TBI.

SETTING

England's National Spinal Injuries Centre at Stoke Mandeville Hospital.

METHODS

This mixed methods study assessed the documentation at each stage of 88 patients' treatment where a TBI could be detected and used to inform rehabilitation, and subsequently, a focus group was conducted with staff to explore the barriers to detecting TBI and adapting SCI rehabilitation.

RESULTS

Results suggested that data related to TBI were inconsistently recorded, the number of individuals recorded as having a TBI at the centre was lower than a recent study, and several barriers were interpreted from the focus group.

CONCLUSIONS

TBI in SCI populations may be an invisible unmet need. Several barriers may exist which prevent clinicians from detecting TBI in this population and adapting rehabilitation accordingly. Findings have implications for rehabilitation for individuals with TBI and SCI admitted to the service.

Cognitive assessment during inpatient rehabilitation after spinal cord injury, a retrospective cross-sectional study

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Cognitive screening is underdeveloped in spinal cord injury (SCI). Therefore, the objectives of our study were: (1) to evaluate cognitive functioning of rehabilitation inpatients with recently acquired spinal cord injury (SCI) with the Montreal Cognitive Assessment (MoCA); (2) to analyse associations between patient and lesion characteristics and the MoCA scores and (3) to compare the MoCA with the cognitive domain of the Utrecht scale for Evaluation of Rehabilitation (USER).

SETTING

Inpatient rehabilitation in a specialized rehabilitation centre in the Netherlands.

METHODS

MOCA and USER data of inpatients between November 2020 and December 2021 were used. Correlation and regression analysis were used.

RESULTS

Included were 98 adults aged (median) 61.6 years (range 19.5-83.6), 66% male, 26.5% traumatic SCI, 63% persons with paraplegia. MoCA and USER scores were available for 83 and 92 individuals, respectively. In 44.6% of the participants, the MoCA score was below the cut-off. Age (r = 0.31, p = 0.005) and educational level (r = 0.54 P < 0.00) were significantly correlated to the MoCA score. The MoCA and the cognitive domain of the USER were moderately correlated (r = 0.25, p = 0.03).

CONCLUSIONS

Almost half of the inpatients scored below the cut-off score on the MoCA. Since the MoCA is a validated cognitive screening tool, the moderate correlation of the MoCA and the cognitive domain of the USER suggests that the USER alone is not sufficient in detecting cognitive deficits. We recommend to screen for cognitive deficits in all people with new SCI.

SPONSORSHIP

None.

Effects of 30-Day Midodrine Administration, Compared to Placebo, on Blood Pressure, Cerebral Blood Flow Velocity, and Cognitive Performance in Persons with SCI

Background

Individuals with spinal cord injury (SCI) at and above T6 experience impaired descending cortical control of the autonomic nervous system, which predisposes them to blood pressure (BP) disorders including persistent hypotension.

Objectives

The primary aim of this investigation was to determine the effects of midodrine, 10 mg, administered daily over a 30-day period in the home environment, compared to placebo, on laboratory assessments of BP, cerebral blood flow velocity (CBFv), and cognitive performance in hypotensive individuals with chronic SCI.

Methods

This prospective, randomized, placebo-controlled, double-blind, crossover trial was conducted in 15 individuals with tetraplegia. In the first 30-day period, five participants were randomized to midodrine and 10 were randomized to placebo; participants were then crossed over to the second 30-day period following a 14-day washout. Laboratory assessments of BP, CBFv, and cognitive performance were measured before and after each of the two study arms.

Results

Systolic BP (SBP) was significantly increased following midodrine administration compared to placebo (116 ± 23 mm Hg vs 94 ± 16 mm Hg; p = .002). In addition, diastolic CBFv was increased after midodrine administration compared to placebo (31.0 ± 11.2 vs 25.6 ± 9.1 cm/s; p = .04). However, there were no significant drug by time interaction effects for systolic or mean CBFv (p > .172) and cognitive performance (p = .689).

Conclusion

The results suggest significant increases in SBP and diastolic CBFv without appreciable effects on cognition after 30 days of midodrine administration. Further investigation is needed to identify effective antihypotensive treatment options that not only normalize BP but also improve CBFv and cognition.

Specific Alterations in Brain White Matter Networks and Their Impact on Clinical Function in Pediatric Patients With Thoracolumbar Spinal Cord Injury

BACKGROUND

The alternation of brain white matter (WM) network has been studied in adult spinal cord injury (SCI) patients. However, the WM network alterations in pediatric SCI patients remain unclear.

PURPOSE

To evaluate WM network changes and their functional impact in children with thoracolumbar SCI (TSCI).

STUDY TYPE

Prospective.

SUBJECTS

Thirty-five pediatric patients with TSCI (8.94 ± 1.86 years, 8/27 males/females) and 34 age- and gender-matched healthy controls (HCs) participated in this study.

FIELD STRENGTH/SEQUENCE

3.0 T/DTI imaging using spin-echo echo-planar and T1-weighted imaging using 3D T1-weighted magnetization-prepared rapid gradient-echo sequence.

ASSESSMENT

Pediatric SCI patients were evaluated for motor and sensory scores, injury level, time since injury, and age at injury. The WM network was constructed using a continuous tracing method, resulting in a 90 × 90 matrix. The global and regional metrics were obtained to investigate the alterations of the WM structural network. topology.

STATISTICAL TESTS

Two-sample independent t-tests, chi-squared test, Mann-Whitney U-test, and Spearman correlation. Statistical significance was set at P < 0.05.

RESULTS

Compared with HCs, pediatric TSCI patients displayed decreased shortest path length (Lp = 1.080 ± 0.130) and normalized Lp (λ = 5.020 ± 0.363), and increased global efficiency (Eg = 0.200 ± 0.015). Notably, these patients also demonstrated heightened regional properties in the orbitofrontal cortex, limbic system, default mode network, and several audio-visual-related regions. Moreover, the λ and Lp values negatively correlated with sensory scores. Conversely, nodal efficiency values in the right calcarine fissure and surrounding cortex positively correlated with sensory scores. The age at injury positively correlated with node degree in the left parahippocampal gyrus and nodal efficiency in the right posterior cingulate gyrus.

DATA CONCLUSION

Reorganization of the WM networks in pediatric SCI patients is indicated by increased global and nodal efficiency, which may provide promising neuroimaging biomarkers for functional assessment of pediatric SCI.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 5.

Potential role of hippocampal neurogenesis in spinal cord injury induced post-trauma depression

It has been reported both in clinic and rodent models that beyond spinal cord injury directly induced symptoms, such as paralysis, neuropathic pain, bladder/bowel dysfunction, and loss of sexual function, there are a variety of secondary complications, including memory loss, cognitive decline, depression, and Alzheimer's disease. The large-scale longitudinal population-based studies indicate that post-trauma depression is highly prevalent in spinal cord injury patients. Yet, few basic studies have been conducted to address the potential molecular mechanisms. One of possible factors underlying the depression is the reduction of adult hippocampal neurogenesis which may come from less physical activity, social isolation, chronic pain, and elevated neuroinflammation after spinal cord injury. However, there is no clear consensus yet. In this review, we will first summarize the alteration of hippocampal neurogenesis post-spinal cord injury. Then, we will discuss possible mechanisms underlie this important spinal cord injury consequence. Finally, we will outline the potential therapeutic options aimed at enhancing hippocampal neurogenesis to ameliorate depression.

Efficacy of Interventions to Improve Cognitive Function in Adults with Spinal Cord Injury: A Systematic Review

Cognitive impairment is a common complication following spinal cord injury (SCI) and imposes a significant negative impact on adjustment, functional independence, physical and mental health, and quality of life. It is unclear whether interventions for cognitive impairment following SCI are effective. A systematic review of controlled trials was performed to evaluate the effect of interventions on cognitive functions in adults with SCI using search engines: Embase, The Cochrane Library, MEDLINE, Scopus, CINAHL, and Web of Science up to December 2023. Two reviewers independently screened the articles, and study findings were synthesized and summarized. The risk of bias was evaluated using the Cochrane Risk of Bias 2.0 tool. Eight moderate-quality studies were found that investigated the effects of physical exercise/activity-based therapy plus cognitive training or intermittent hypoxia, diet modification and dietary supplements, tibial nerve or cortical stimulation, and drug therapy on cognitive function in SCI. Physical exercise/activity-based therapy plus cognitive training showed most promise for improving cognitive functions, while drug therapy, diet modification, and dietary supplements showed potential for improving cognitive function. However, about half of the participants experienced heightened instability in blood pressure following the administration of midodrine, and one participant reported gastrointestinal side effects after taking omega-3 fatty acids. There was no evidence of improvement in cognitive function for stimulation techniques. The current review highlights the scarcity of research investigating the effectiveness of interventions that target cognitive function after SCI. Further, the effects of these eight studies are uncertain due to concerns about the quality of designs and small sample sizes utilized in the trials, as well as the employment of insensitive neurocognitive tests when applied to adults with SCI. This review highlights a significant gap in knowledge related to SCI cognitive rehabilitation.

A Comprehensive Review of the Importance of the Main Comorbidities in Developing Cognitive Disorders in Patients With Spinal Cord Injuries

Spinal cord injuries (SCI) refer to lesions in the spinal cord due to direct trauma (traumatic SCI-TSCI), such as vehicle accidents, falls, and violent events, or other pathological conditions (non-traumatic SCI) such as metabolic disorders, inflammation, or degenerative disorders. Depending on the location of the injury, patients may experience movement and/or sense disabilities in their lower limbs, torso, or upper limbs. Even though poorly studied, it has been found that such patients have a higher risk of developing cognitive disorders, such as deficits in concentration, short and long memory, comprehension, and problem-solving, as well as mental deficits in the form of difficulty socializing and expressing emotions. The main contributing factor of cognitive impairment in patients with SCI has been identified as a traumatic brain injury (TBI), but other comorbidities play an important role. In spite of the correlation that has been found between certain comorbidities and cognitive impairment in patients with SCI, further investigation into the importance of these pathological states as well as future research into the approach of these patients is necessary.

Old age alters inflammation and autophagy signaling in the brain, leading to exacerbated neurological outcomes after spinal cord injury in male mice

Older patients with spinal cord injury (SCI) have different features with regard to neurological characteristics after injury. Recent large-scale longitudinal population-based studies showed that individuals with SCI are at a higher risk of developing dementia than non-SCI patients, indicating that SCI is a potential risk factor for dementia. Aging is known to potentiate inflammation and neurodegeneration at the injured site leading to impaired recovery from SCI. However, no research has been aimed at studying the mechanisms of SCI-mediated cognitive impairment in the elderly. The present study examined neurobehavioral and molecular changes in the brain and the underlying mechanisms associated with brain dysfunction in aged C57BL/6 male mice using a contusion SCI model. At 2 months post-injury, aged mice displayed worse performance in locomotor, cognitive and depressive-like behavioral tests compared to young adult animals. Histopathology in injured spinal cord tissue was exacerbated in aged SCI mice. In the brain, transcriptomic analysis with NanoString neuropathology panel identified activated microglia and dysregulated autophagy as the most significantly altered pathways by both age and injury. These findings were further validated by flow cytometry, which demonstrated increased myeloid and lymphocytes infiltration at both the injured site and brain of aged mice. Moreover, SCI in aged mice altered microglial function and dysregulated autophagy in microglia, resulting in worsened neurodegeneration. Taken together, our data indicate that old age exacerbates neuropathological changes in both the injured spinal cord and remote brain regions leading to poorer functional outcomes, at least in part, through altered inflammation and autophagy function.

Neuromuscular electrical stimulation to combat cognitive aging in people with spinal cord injury: protocol for a single case experimental design study

INTRODUCTION

Individuals with spinal cord injury (SCI) can experience accelerated cognitive aging. Myokines (factors released from muscle cells during contractions), such as brain-derived neurotrophic factor (BDNF), are thought to have beneficial effects on cognition. Neuromuscular electrical stimulation (NMES) was shown to elicit a large release of myokines. However, the effects of NMES on cognitive function have not been studied.

OBJECTIVE

To present the study protocol for a clinical trial evaluating the effects of NMES aimed at improving cognition and BDNF.

METHODS

A replicated randomized three-phases single-case experimental design (SCED) with sequential multiple baseline time series and a single-armed prospective trial will be conducted with 15 adults with chronic SCI (> 12 months after injury) above L1 neurological level undergoing 30-min quadriceps NMES, 3 days per week for 12 weeks.

MAIN STUDY ENDPOINTS

Primary endpoint is cognitive performance (assessed by a smartphone test) conducted three times per week during the baseline phase with random duration of 3 to 8 weeks, the intervention phase of 12 weeks, and the follow-up phase of 3 weeks after a no measurement rest period of 12 weeks. Secondary endpoints are changes in BDNF levels and cognitive performance measured before the baseline period, before and after intervention and after a 12 weeks follow-up.

CONCLUSION

This will be the first study investigating the effects of 12 weeks NMES on both cognition and BDNF levels in individuals with SCI. The SCED results provide information on individual treatment effect courses which may direct future research.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05822297, 12/01/2023).

Delayed cerebrovascular reactivity in individuals with spinal cord injury in the right inferior parietal lobe: a breath-hold functional near-infrared spectroscopy study

Cerebrovascular reactivity (CVR) reflects the ability of blood vessels to dilate or constrict in response to a vasoactive stimulus, and allows researchers to assess the brain's vascular health. Individuals with spinal cord injury (SCI) are at an increased risk for autonomic dysfunction in addition to cognitive impairments, which have been linked to a decline in CVR; however, there is currently a lack of brain-imaging studies that investigate how CVR is altered after SCI. In this study, we used a breath-holding hypercapnic stimulus and functional near-infrared spectroscopy (fNIRS) to investigate CVR alterations in individuals with SCI (n = 20, 14M, 6F, mean age = 46.3 ± 10.2 years) as compared to age- and sex-matched able-bodied (AB) controls (n = 25, 19M, 6F, mean age = 43.2 ± 12.28 years). CVR was evaluated by its amplitude and delay components separately by using principal component analysis and cross-correlation analysis, respectively. We observed significantly delayed CVR in the right inferior parietal lobe in individuals with SCI compared to AB controls (linear mixed-effects model, fixed-effects estimate = 6.565, Satterthwaite's t-test, t = 2.663, p = 0.008), while the amplitude of CVR was not significantly different. The average CVR delay in the SCI group in the right inferior parietal lobe was 14.21 s (sd: 6.60 s), and for the AB group, the average delay in the right inferior parietal lobe was 7.08 s (sd: 7.39 s). CVR delays were also associated with the duration since injury in individuals with SCI, in which a longer duration since injury was associated with a shortened delay in CVR in the right inferior parietal region (Pearson's r-correlation, r = -0.59, p = 0.04). This study shows that fNIRS can be used to quantify changes in CVR in individuals with SCI, and may be further used in rehabilitative settings to monitor the cerebrovascular health of individuals with SCI.

The role of clinical and demographic predictors for understanding the cognitive impairment in Spinal Cord Injury (SCI) patients

STUDY DESIGN

Using a cross-sectional design, we extracted sociodemographic and clinical data from 488 Spinal Cord Injury (SCI) patients during their initial assessment before receiving intensive rehabilitation treatment.

OBJECTIVES

The primary objectives of this study were to ascertain the prevalence of cognitive impairment in the study sample and specify the key clinical and demographic predictors of cognitive functioning in SCI patients.

SETTING

Lucy Montoro Rehabilitation Institute (LMRI), University of Sao Paulo, Sao Paulo, Brazil.

METHODS

We utilized independent univariate and multivariate regression models with the Montreal Cognitive Assessment (MoCA) scale, adapted for individuals with visual impairment. Moreover, we consider scores from the execution tasks (visuospatial/executive) as the dependent variable.

RESULTS

Our findings demonstrate that approximately 80% of the evaluated study sample exhibited cognitive impairment. Through the multivariate regression models, we show that several factors, including age, education, depression levels, and the use of analgesics and/or opioids, are significant predictors of total cognitive scores. These factors are independent of the clinical features associated with SCI, such as age, sex, education, and time since the injury.

CONCLUSIONS

The results indicate a high prevalence of significant cognitive impairment within the sample, with age, education, depression levels, and the use of analgesics and/or opioids emerging as the primary predictors of total cognitive scores, independent of the clinical features correlated to SCI. These findings hold significant implications for both clinical research and practice, offering valuable guidance for comprehensive management throughout hospitalization and rehabilitation.

Anorexigenic neuropeptides as anti-obesity and neuroprotective agents: exploring the neuroprotective effects of anorexigenic neuropeptides

Since 1975, the incidence of obesity has increased to epidemic proportions, and the number of patients with obesity has quadrupled. Obesity is a major risk factor for developing other serious diseases, such as type 2 diabetes mellitus, hypertension, and cardiovascular diseases. Recent epidemiologic studies have defined obesity as a risk factor for the development of neurodegenerative diseases, such as Alzheimer's disease (AD) and other types of dementia. Despite all these serious comorbidities associated with obesity, there is still a lack of effective antiobesity treatment. Promising candidates for the treatment of obesity are anorexigenic neuropeptides, which are peptides produced by neurons in brain areas implicated in food intake regulation, such as the hypothalamus or the brainstem. These peptides efficiently reduce food intake and body weight. Moreover, because of the proven interconnection between obesity and the risk of developing AD, the potential neuroprotective effects of these two agents in animal models of neurodegeneration have been examined. The objective of this review was to explore anorexigenic neuropeptides produced and acting within the brain, emphasizing their potential not only for the treatment of obesity but also for the treatment of neurodegenerative disorders.

Participation and autonomy, independence in activities of daily living and upper extremity functioning in individuals with spinal cord injury

Improvements in care and rehabilitation have resulted in a higher proportion of people living with spinal cord injury (SCI), which calls for an increased focus on participation and autonomy. This observational cross-sectional study investigated the impact of SCI on autonomy and how it correlates to activity performance and upper extremity functioning. A total of 25 adults (mean age 58 years) with chronic cervical or thoracic SCI were included. Self-perceived autonomy was measured with Impact on Participation and Autonomy questionnaire, independence in activities of daily living (ADL) with Spinal Cord Independence Measure, upper extremity functioning with Action Research Arm Test (ARAT) and kinematic measures of the drinking task. The results showed that most participants perceived injury-related restrictions in outdoor autonomy (80%), family role (76%), and in indoor autonomy (72%). Independence in self-care (r = 0.72), mobility (r = 0.59) and upper extremity kinematics of movement time (r = 0.63) and smoothness (r = 0.49) were correlated to indoors autonomy. Social life autonomy was correlated to self-care (r = 0.50) and ARAT (r = 0.41). In conclusion, autonomy was perceived restricted after SCI in several major life areas and correlated with independence in ADL and upper extremity functioning. The aspects of autonomy should be considered more in goal setting and clinical decision-making.

Cognitive, behavioral and psychiatric symptoms in patients with spinal cord injury: a scoping review

Spinal Cord Injury (SCI) is a condition where the spinal cord is damaged and experiences partial or complete loss of motor and/or sensory function, which is typically less than normal. After SCI, patients may exhibit more severe psychiatric symptoms and experience cognitive impairments, including reduced speed and attention processing capacity, as well as difficulties with executive function and episodic memory retention. Among the behavioral and psychiatric symptoms, depression, anxiety, substance use disorder, and posttraumatic stress disorder are the most common. This review aims to investigate the cognitive, behavioral, or psychiatric symptoms of the patient with SCI and their influence on the rehabilitation process. Studies were identified from an online search of PubMed, Web of Science, Cochrane Library, and Embase databases. Studies published between 2013-2023 were selected. This review has been registered on OSF (n) 3KB2U. We have found that patients with SCI are at high risk of cognitive impairment and experience a wide range of difficulties, including tasks based on processing speed and executive function. This clinical population may experience adjustment disorders with depression and anxiety, as well as other psychiatric symptoms such as fatigue, stress, and suicidal ideation. This review has demonstrated that SCI patients may experience psychiatric symptoms and cognitive impairments that affect their functioning. At the same time, these patients may be more prone to various adjustment and mood disorders. Moreover, these two aspects may interact with each other, causing a range of symptoms, increasing the risk of hospitalization, and delaying the rehabilitation process.

Brain activation during the N-back working memory task in individuals with spinal cord injury: a functional near-infrared spectroscopy study

Cognitive impairments have frequently been reported in individuals with spinal cord injury (SCI) across different domains such as working memory, attention, and executive function. The mechanism of cognitive impairment after SCI is not well understood due to the heterogeneity of SCI sample populations, and may possibly be due to factors such as cardiovascular dysfunction, concomitant traumatic brain injury (TBI), hypoxia, sleep disorders, and body temperature dysregulation. In this study, we implement the Neuropsychiatric Unit Cognitive Assessment Tool (NUCOG) to assess cognitive differences between individuals with SCI and age-matched able-bodied (AB) controls. We then use an N-back working memory task and functional near-infrared spectroscopy (fNIRS) to elucidate the neurovascular correlates of cognitive function in individuals with SCI. We observed significant differences between the SCI and AB groups on measures of executive function on the NUCOG test. On the N-back task, across the three levels of difficulty: 0-back, 2-back, and 3-back, no significant differences were observed between the SCI and AB group; however, both groups performed worse as the level of difficulty increased. Although there were no significant differences in N-back performance scores between the two groups, functional brain hemodynamic activity differences were observed between the SCI and AB groups, with the SCI group exhibiting higher maximum oxygenated hemoglobin concentration in the right inferior parietal lobe. These findings support the use of fNIRS to study cognitive function in individuals with SCI and may provide a useful tool during rehabilitation to obtain quantitative functional brain activity metrics.

Improving Outcomes in People with Spinal Cord Injury: Encouraging Results from a Multidisciplinary Advanced Rehabilitation Pathway

Spinal cord injury (SCI) consists of damage to any segment of the spinal cord extending to potential harm to nerves in the cauda equina. Rehabilitative efforts for SCI can involve conventional physiotherapy, innovative technologies, as well as cognitive treatment and psychological support. The aim of this study is to evaluate the feasibility of a dedicated, multidisciplinary, and integrated intervention path for SCI, encompassing both conventional and technological interventions, while observing their impact on cognitive, motor, and behavioral outcomes and the overall quality of life for individuals with SCI. Forty-two patients with SCI were included in the analysis utilizing electronic recovery system data. The treatment regimen included multidisciplinary rehabilitation approaches, such as traditional physiotherapy sessions, speech therapy, psychological support, robotic devices, advanced cognitive rehabilitation, and other interventions. Pre-post comparisons showed a significant improvement in lower limb function (Fugl Meyer Assessment-FMA < 0.001), global cognitive functioning (Montreal Cognitive Assessment-MoCA p < 0.001), and perceived quality of life at both a physical and mental level (Short Form-12-SF-12 p < 0.001). Furthermore, we found a significant reduction in depressive state (Beck Depression Inventory-BDI p < 0.001). In addition, we assessed patient satisfaction using the Short Form of the Patient Satisfaction Questionnaire (PSQ), offering insights into the subjective evaluation of the intervention. In conclusion, this retrospective study provides positive results in terms of improvements in motor function, cognitive functions, and quality of life, highlighting the importance of exploring multidisciplinary approaches.

Microstructural alterations of major thalamic nuclei in the chronic pediatric spinal cord injured population

Background

The brain undergoes reorganization following spinal cord injury (SCI), but little is known about how the thalamus is affected in pediatric SCIs.

Purpose

To characterize microstructural alterations in the thalamus after SCI with diffusion tensor imaging (DTI) metrics.

Methods

18 pediatric participants with chronic SCI (8-20 years) were stratified using the American Spinal Injury Association Impairment Scale (AIS) into groups: A, B, and C/D. DTI of the brain used a 3 T Siemens Verio MRI using the parameters: 20 directions, number of averages = 3, b = 1000 s/mm2, voxel size = 1.8 mm × 1.8 mm, slice thickness = 5 mm, TE = 95 ms, TR = 4300 ms, 30 slices, FOV = 230 × 230 mm2, matrix = 128 × 128, acquisition time = 4:45 min. Diffusion data was processed to generate DTI metrics FA, MD, AD, and RD.

Data analysis

DTI metrics were acquired by superimposing the AAL3 thalamic atlas onto participant diffusion images registered to MNI152 space. We utilized a multiple Mann-Whitney U-test to compare between AIS groups, considering values of p ≤ 0.05 as significant.

Results

FA, AD, RD, and MD significantly differed in thalamic nuclei between AIS groups A vs B and B vs C/D. Significant nuclei include the right ventral anterior, left intralaminar, bilateral lateral pulvinar, and right lateral geniculate.

Conclusion

Our findings suggest the presence of microstructural alterations based on SCI severity in pediatric patients. These results are encouraging and warrant further study.

The Clinical Relevance of Autonomic Dysfunction, Cerebral Hemodynamics, and Sleep Interactions in Individuals Living With SCI

A myriad of physiological impairments is seen in individuals after a spinal cord injury (SCI). These include altered autonomic function, cerebral hemodynamics, and sleep. These physiological systems are interconnected and likely insidiously interact leading to secondary complications. These impairments negatively influence quality of life. A comprehensive review of these systems, and their interplay, may improve clinical treatment and the rehabilitation plan of individuals living with SCI. Thus, these physiological measures should receive more clinical consideration. This special communication introduces the under investigated autonomic dysfunction, cerebral hemodynamics, and sleep disorders in people with SCI to stakeholders involved in SCI rehabilitation. We also discuss the linkage between autonomic dysfunction, cerebral hemodynamics, and sleep disorders and some secondary outcomes are discussed. Recent evidence is synthesized to make clinical recommendations on the assessment and potential management of important autonomic, cerebral hemodynamics, and sleep-related dysfunction in people with SCI. Finally, a few recommendations for clinicians and researchers are provided.

Heart Rate Variability Biofeedback in Adults with a Spinal Cord Injury: A Laboratory Framework and Case Series

Heart rate variability biofeedback (HRV-F) is a neurocardiac self-regulation therapy that aims to regulate cardiac autonomic nervous system activity and improve cardiac balance. Despite benefits in various clinical populations, no study has reported the effects of HRV-F in adults with a spinal cord injury (SCI). This article provides an overview of a neuropsychophysiological laboratory framework and reports the impact of an HRV-F training program on two adults with chronic SCI (T1 AIS A and T3 AIS C) with different degrees of remaining cardiac autonomic function. The HRV-F intervention involved 10 weeks of face-to-face and telehealth sessions with daily HRV-F home practice. Physiological (HRV, blood pressure variability (BPV), baroreflex sensitivity (BRS)), and self-reported assessments (Fatigue Severity Scale, Generalised Anxiety Disorder Scale, Patient Health Questionnaire, Appraisal of Disability and Participation Scale, EuroQol Visual Analogue Scale) were conducted at baseline and 10 weeks. Participants also completed weekly diaries capturing mood, anxiety, pain, sleep quality, fatigue, and adverse events. Results showed some improvement in HRV, BPV, and BRS. Additionally, participants self-reported some improvements in mood, fatigue, pain, quality of life, and self-perception. A 10-week HRV-F intervention was feasible in two participants with chronic SCI, warranting further investigation into its autonomic and psychosocial effects.

Autonomic Cardiovascular Control, Psychological Well-Being, and Cognitive Performance in People With Spinal Cord Injury

PURPOSE

To examine associations between parameters of psychological well-being, injury characteristics, cardiovascular autonomic nervous system (ANS) control, and cognitive performance in persons with spinal cord injury (SCI) compared with age-matched uninjured controls. This is an observational, cross-sectional study including a total of 94 participants (52 with SCI and 42 uninjured controls: UIC). Cardiovascular ANS responses were continuously monitored at rest and during administration of the Paced Auditory Serial Addition Test (PASAT). Self-report scores on the SCI-Quality of Life questionnaires are reported for depression, anxiety, fatigue, resilience, and positive affect. Participants with SCI performed significantly more poorly on the PASAT compared with the uninjured controls. Although not statistically significant, participants with SCI tended to report more psychological distress and less well-being than the uninjured controls. In addition, when compared with uninjured controls, the cardiovascular ANS responses to testing were significantly altered in participants with SCI; however, these responses to testing did not predict PASAT performance. Self-reported levels of anxiety were significantly related to PASAT score in the SCI group, but there was no significant relationship between PASAT and the other indices of SCI-Quality of Life. Future investigations should more closely examine the relationship among cardiovascular ANS impairments, psychological disorders, and cognitive dysfunction to better elucidate the underpinnings of these deficits and to guide interventions aimed at improving physiological, psychological, and cognitive health after SCI. Tetraplegia, paraplegia, blood pressure variability, cognitive, mood.

What Is the Pathway to the Best Model of Care for Traumatic Spinal Cord Injury? Evidence-Based Guidance

Introduction

People with traumatic spinal cord injury (tSCI) experience lifelong physical and emotional health impacts, needing specialized care that is complex to navigate. The non-standardized care pathways used by different jurisdictions to address these needs lead to care inequities and poor health outcomes.

Purpose

To develop an evidence-based integrated tSCI Care Pathway, from time of injury to life in the community.

Methods and Analysis

Eighty key partners engaged in planning, providing, and receiving tSCI care (1) identified existing guidelines, pathways, and care models; (2) created the tSCI Care Pathway with key elements or building blocks ("the what"), not specific recommendations ("the how") for each care stage (Acute, Rehabilitation, and Community), with elements highlighting the role of primary care and equity considerations on the pathway; (3) identified regional gaps in the tSCI Pathway and prioritized them for implementation; and (4) developed quality indicators.

Outcomes

The tSCI Pathway was drafted in overarching and detailed formats. For Acute Care, building blocks focused on appropriate assessment, initial management, and transition planning; for Rehabilitation, building blocks focused on access to specialized rehabilitation and assessment and planning of community needs; for Community, building blocks focused on follow-up, mechanisms for re-access, and holistic support for persons and families; and for equity considerations, building blocks focused on those at-risk or requiring complex supports. Team-based primary care and navigation supports were seen as crucial to reduce inequities.

Conclusion

This is the first comprehensive care pathway for tSCI. The Pathway is grounded in person-centred care, integrated care and services, and up-to-date clinical practice guidelines. The tSCI Care Pathway is flexible to regional realities and individual needs to ensure equitable care for all.

Cognitive Failure in Adults with Spinal Cord Injury: A Valuable Adjunct Measure for Enhancing Cognitive Assessment and Rehabilitation Outcomes

Cognitive impairment is common in persons with spinal cord injury (SCI), impacting their daily functioning and rehabilitation. This study assesses the extent of self-reported cognitive failures in everyday life in persons with SCI and its relationships with objective neurocognitive measures and psychosocial factors, including depressive mood, anxiety, perceived control, and fatigue. The differences between forty-one adults with a chronic SCI and forty-one able-bodied controls were examined. The participants completed the Cognitive Failures Questionnaire (CFQ) to assess cognitive failure and neurocognitive tests assessing attention and executive functions, as well as a psychosocial assessment. The SCI group reported higher cognitive failure rates than the able-bodied group (31.7% versus 19%, p > 0.05). Objective neurocognitive tests did not significantly correlate with the CFQ scores in either group. However, the CFQ scores were positively associated with most psychosocial factors, even after controlling for covariates. The CFQ scores were significantly associated with depressive mood in persons with SCI. These findings highlight the importance of incorporating self-reported cognitive measures into neurocognitive assessments and rehabilitation planning for adults with SCI. Self-reports capture everyday cognitive challenges that objective tests may miss. Additionally, this study highlights the strong connections between cognitive failures and psychosocial issues, particularly mood disorders, emphasizing the need for comprehensive rehabilitation and psychosocial support post-SCI, addressing both cognitive and emotional wellbeing.

Pulse rate variability: An alternative to heart rate variability in adults with spinal cord injury

Pulse rate variability (PRV) is often used as an alternative to heart rate variability (HRV) to measure psychophysiological function. However, its validity to do so is unclear, especially in adults with spinal cord injury (SCI). This study compared PRV and HRV in adults with higher-level SCI (SCI-H, n = 23), lower-level SCI (SCI-L, n = 22), and able-bodied participants (AB n = 44), in a seated position as a function of performance in a reactivity task (Oxford Sleep Resistance Test: OSLER). PRV and HRV was measured using reflective finger-based photoplethysmography (PPG) and electrocardiography, respectively, at baseline, immediately post-OSLER, and after five-minute recovery. Agreement between PRV and HRV was determined by Bland-Altman analysis and differences between PRV and HRV over time by linear mixed effects model (LMM) analysis. Concurrent validity was assessed through correlation analyses between PRV and HRV. Additional correlation analyses were performed with psychosocial factors. Results indicated insufficient to moderate agreement between PRV and HRV. LMM analyses indicated no differences over time for standard deviation of normal-to-normal intervals and low-frequency power but significant differences for root mean square of successive differences and high frequency power. Nevertheless, PRV and HRV were highly correlated (Median r = .878 (.675-.990)) during all assessment periods suggesting sufficient concurrent validity. Similar correlation patterns were also found for PRV and HRV with psychosocial outcomes. While differences existed, results suggest PRV derived from reflective finger-based PPG is a valid proxy of HRV in tracking psychophysiological function in adults with SCI and could therefore be used as a more accessible monitoring tool.

Massive body-brain disconnection consequent to spinal cord injuries drives profound changes in higher-order cognitive and emotional functions: A PRISMA scoping review

Spinal cord injury (SCI) leads to a massive disconnection between the brain and the body parts below the lesion level representing a unique opportunity to explore how the body influences a person's mental life. We performed a systematic scoping review of 59 studies on higher-order cognitive and emotional changes after SCI. The results suggest that fluid abilities (e.g. attention, executive functions) and emotional regulation (e.g. emotional reactivity and discrimination) are impaired in people with SCI, with progressive deterioration over time. Although not systematically explored, the factors that are directly (e.g. the severity and level of the lesion) and indirectly associated (e.g. blood pressure, sleeping disorders, medication) with the damage may play a role in these deficits. The inconsistency which was found in the results may derive from the various methods used and the heterogeneity of samples (i.e. the lesion completeness, the time interval since lesion onset). Future studies which are specifically controlled for methods, clinical and socio-cultural dimensions are needed to better understand the role of the body in cognition.

Sexually dimorphic extracellular vesicle responses after chronic spinal cord injury are associated with neuroinflammation and neurodegeneration in the aged brain

BACKGROUND

Medical advances have made it increasingly possible for spinal cord injury (SCI) survivors to survive decades after the insult. But how SCI affects aging changes and aging impacts the injury process have received limited attention. Extracellular vesicles (EVs) are recognized as critical mediators of neuroinflammation after CNS injury, including at a distance from the lesion site. We have previously shown that SCI in young male mice leads to robust changes in plasma EV count and microRNA (miR) content. Here, our goal was to investigate the impact of biological sex and aging on EVs and brain after SCI.

METHODS

Young adult age-matched male and female C57BL/6 mice were subjected to SCI. At 19 months post-injury, total plasma EVs were isolated by ultracentrifugation and characterized by nanoparticle tracking analysis (NTA). EVs miR cargo was examined using the Fireplex® assay. The transcriptional changes in the brain were assessed by a NanoString nCounter Neuropathology panel and validated by Western blot (WB) and flow cytometry (FC). A battery of behavioral tests was performed for assessment of neurological function.

RESULTS

Transcriptomic changes showed a high number of changes between sham and those with SCI. Sex-specific changes were found in transcription networks related to disease association, activated microglia, and vesicle trafficking. FC showed higher microglia and myeloid counts in the injured tissue of SCI/Female compared to their male counterparts, along with higher microglial production of ROS in both injured site and the brain. In the latter, increased levels of TNF and mitochondrial membrane potential were seen in microglia from SCI/Female. WB and NTA revealed that EV markers are elevated in the plasma of SCI/Male. Particle concentration in the cortex increased after injury, with SCI/Female showing higher counts than SCI/Male. EVs cargo analysis revealed changes in miR content related to injury and sex. Behavioral testing confirmed impairment of cognition and depression at chronic time points after SCI in both sexes, without significant differences between males and females.

CONCLUSIONS

Our study is the first to show sexually dimorphic changes in brain after very long-term SCI and supports a potential sex-dependent EV-mediated mechanism that contributes to SCI-induced brain changes.

Clinical trial of home blood pressure monitoring following midodrine administration in hypotensive individuals with spinal cord injury

BACKGROUND

Individuals with spinal cord injury (SCI) above thoracic level-6 (T6) experience impaired descending cortical control of the autonomic nervous system which predisposes them to blood pressure (BP) instability, including includes hypotension, orthostatic hypotension (OH), and autonomic dysreflexia (AD). However, many individuals do not report symptoms of these BP disorders, and because there are few treatment options that have been proven safe and effective for use in the SCI population, most individuals remain untreated.

OBJECTIVE

The primary aim of this investigation was to determine the effects of midodrine (10 mg) prescribed TID or BID in the home environment, compared to placebo, on 30-day BP, study withdrawals, and symptom reporting associated with OH and AD in hypotensive individuals with SCI.

DESIGN/METHODS

Participants were randomly assigned to received midodrine/placebo or placebo/midodrine, with a 2-weeks washout period in between, and both the participants and investigators were blinded to randomization order. Study medication was taken 2 or 3 times/day, depending on their sleep/wake schedule, BP, and any related symptoms were recorded before and 1 h after each dosage and periodically throughout the day.

RESULTS

Nineteen individuals with SCI were recruited; however, 9 withdrew prior to completion of the full protocol. A total of 1892 BP recordings (75 ± 48 recordings/participant/30-day period) were collected in the 19 participants over the two 30-day monitoring periods. Average 30-day systolic BP was significantly increased with midodrine compared to placebo (114 ± 14 vs. 96 ± 11 mmHg, respectively; P = 0.004), and midodrine significantly reduced the number of hypotensive BP recordings compared to placebo (38.7 ± 41.9 vs. 73.3 ± 40.6, respectively; P = 0.01). However, compared to placebo, midodrine increased fluctuations in BP, did not improve symptoms of OH, but did significantly worsen the intensity of symptoms associated with AD (P = 0.03).

CONCLUSION

Midodrine (10 mg) administered in the home environment effectively increases BP and reduces the incidence of hypotension; however these beneficial effects come at the expense of worsened BP instability and AD symptom intensity.

Cognitive Reserve and Its Association with Cognitive and Mental Health Status following an Acute Spinal Cord Injury

BACKGROUND

Mild cognitive impairment (MCI) is a common secondary condition associated with spinal cord injury (SCI). Cognitive reserve (CR) is believed to protect against cognitive decline and can be assessed by premorbid intelligence (pmIQ). Despite the potential utility of pmIQ as a complementary metric in the evaluation of MCI in SCI, this approach has been infrequently employed. The purpose of this study was to examine the association between MCI and pmIQ in adults with SCI with the aim of exploring the potential value of pmIQ as a marker of CR in this population.

METHODS

Cognitive function was assessed on three occasions in adults with SCI over a 12-month period post-injury, and pmIQ was assessed once at baseline. Demographic and mental health measures were also collected, and logistic regression was conducted to determine the strength of association between pmIQ and MCI while adjusting for factors such as mental health and age.

RESULTS

The regression analysis revealed that at the time of admission to SCI rehabilitation, the MCI assessed by a valid neurocognitive screen was strongly associated with pmIQ. That is, if a person has MCI, there was 5.4 greater odds (p < 0.01) that they will have poor pmIQ compared to a person without MCI after adjustment for age and mental health.

CONCLUSIONS

The assessment of CR is an important area that should be considered to improve the process of diagnosing MCI in adults with an acute SCI and potentially facilitate earlier intervention to slow or prevent cognitive decline.

Neuropathic Pain and Spinal Cord Injury: Management, Phenotypes, and Biomarkers

Chronic neuropathic pain after a spinal cord injury (SCI) continues to be a complex condition that is difficult to manage due to multiple underlying pathophysiological mechanisms and the association with psychosocial factors. Determining the individual contribution of each of these factors is currently not a realistic goal; however, focusing on the primary mechanisms may be more feasible. One approach used to uncover underlying mechanisms includes phenotyping using pain symptoms and somatosensory function. However, this approach does not consider cognitive and psychosocial mechanisms that may also significantly contribute to the pain experience and impact treatment outcomes. Indeed, clinical experience supports that a combination of self-management, non-pharmacological, and pharmacological approaches is needed to optimally manage pain in this population. This article will provide a broad updated summary integrating the clinical aspects of SCI-related neuropathic pain, potential pain mechanisms, evidence-based treatment recommendations, neuropathic pain phenotypes and brain biomarkers, psychosocial factors, and progress regarding how defining neuropathic pain phenotypes and other surrogate measures in the neuropathic pain field may lead to targeted treatments for neuropathic pain after SCI.

Different macaque brain network remodeling after spinal cord injury and NT3 treatment

Graph theory-based analysis describes the brain as a complex network. Only a few studies have examined modular composition and functional connectivity (FC) between modules in patients with spinal cord injury (SCI). Little is known about the longitudinal changes in hubs and topological properties at the modular level after SCI and treatment. We analyzed differences in FC and nodal metrics reflecting modular interaction to investigate brain reorganization after SCI-induced compensation and neurotrophin-3 (NT3)-chitosan-induced regeneration. Mean inter-modular FC and participation coefficient of areas related to motor coordination were significantly higher in the treatment animals than in the SCI-only ones at the late stage. The magnocellular part of the red nucleus may reflect the best difference in brain reorganization after SCI and therapy. Treatment can enhance information flows between regions and promote the integration of motor functions to return to normal. These findings may reveal the information processing of disrupted network modules.

Magnetic resonance spectroscopy investigation in the right human hippocampus following spinal cord injury

Objective

Preclinical studies have shown that cognitive impairments following spinal cord injury (SCI), such as impaired spatial memory, are linked to inflammation, neurodegeneration, and reduced neurogenesis in the right hippocampus. This cross-sectional study aims to characterize metabolic and macrostructural changes in the right hippocampus and their association to cognitive function in traumatic SCI patients.

Methods

Within this cross-sectional study, cognitive function was assessed in 28 chronic traumatic SCI patients and 18 age-, sex-, and education-matched healthy controls by a visuospatial and verbal memory test. A magnetic resonance spectroscopy (MRS) and structural MRI protocol was performed in the right hippocampus of both groups to quantify metabolic concentrations and hippocampal volume, respectively. Group comparisons investigated changes between SCI patients and healthy controls and correlation analyses investigated their relationship to memory performance.

Results

Memory performance was similar in SCI patients and healthy controls. The quality of the recorded MR spectra was excellent in comparison to the best-practice reports for the hippocampus. Metabolite concentrations and volume of the hippocampus measured based on MRS and MRI were not different between two groups. Memory performance in SCI patients and healthy controls was not correlated with metabolic or structural measures.

Conclusion

This study suggests that the hippocampus may not be pathologically affected at a functional, metabolic, and macrostructural level in chronic SCI. This points toward the absence of significant and clinically relevant trauma-induced neurodegeneration in the hippocampus.

Cannabis health survey on usage in women with spinal cord injury and knowledge among physicians: A cross-sectional study

OBJECTIVE

Individuals with spinal cord injury (SCI) report using cannabis to self-manage chronic pain and spasticity. However, its safety and efficacy are not well understood. As more women with SCI are pursuing motherhood, clinicians must consider the possibility of maternal cannabis use and its impact on fetal development. Moreover, due to the lack of current evidence for cannabis, it is important to characterize the perceptions and knowledge of physicians towards both recreational and synthetic cannabinoids.

DESIGN

Two anonymous surveys (10-items each) were conducted.

SETTING AND PARTICIPANTS

Women with SCI (n = 20) completed an anonymous, online survey regarding cannabis use. Physicians at a Canadian SCI rehabilitation center (n = 15) completed a survey on their knowledge of recreational and synthetic cannabinoids among individuals with SCI.

OUTCOME MEASURES

Survey 1 evaluated cannabis use patterns and perceptions before/after SCI in women, including during pregnancy and breastfeeding. The aim of Survey 2 was to understand the perception and current knowledge of physicians regarding recreational cannabis and synthetic cannabinoid use by patients with SCI.

RESULTS

At the time of survey, 7 women with SCI reported use of cannabis, only 4 of them used prior to injury. Managing tone/spasticity (n = 5) was the major reported benefit of cannabis use. Women used cannabis during pregnancy and/or breastfeeding as a sleep aid or relief for morning sickness (n = 1 pregnancy, n = 1 breastfeeding, n = 1 both). The most-reported challenge with cannabis use was difficulty obtaining consistent, desirable effects (n = 5). Almost all physicians (n = 13) described their knowledge on recreational cannabis products as "none, very little or poor", with greater overall comfort and knowledge of synthetic cannabinoids.

CONCLUSION

Due to the reported use of cannabis during pregnancy/breastfeeding and current impoverishment of physicians' knowledge (particularly regarding recreational cannabis products), it is imperative to further investigate the safety and efficacy of cannabis use in women with SCI.

Myokines may target accelerated cognitive aging in people with spinal cord injury: A systematic and topical review

Persons with spinal cord injury (SCI) can suffer accelerated cognitive aging, even when correcting for mood and concomitant traumatic brain injury. Studies in healthy older adults have shown that myokines (i.e. factors released from muscle tissue during exercise) may improve brain health and cognitive function. Myokines may target chronic neuroinflammation, which is considered part of the mechanism of cognitive decline both in healthy older adults and SCI. An empty systematic review, registered in PROSPERO (CRD42022335873), was conducted as proof of the lack of current research on this topic in people with SCI. Pubmed, Embase, Cochrane and Web of Science were searched, resulting in 387 articles. None were considered eligible for full text screening. Hence, the effect of myokines on cognitive function following SCI warrants further investigation. An in-depth narrative review on the mechanism of SCI-related cognitive aging and the myokine-cognition link was added to substantiate our hypothetical framework. Readers are fully updated on the potential role of exercise as a treatment strategy against cognitive aging in persons with SCI.

Hydralazine plays an immunomodulation role of pro-regeneration in a mouse model of spinal cord injury

Spinal cord injury (SCI) results in severe motor and sensory dysfunction with no effective therapy. Spinal cord debris (sp) from injured spinal cord evokes secondary SCI continuously. We and other researchers have previously clarified that it is mainly bone marrow derived macrophages (BMDMs) infiltrating in the lesion epicenter to clear sp, rather than local microglia. Unfortunately, the pro-inflammatory phenotype of these infiltrating BMDMs is predominant which impairs wound healing. Hydralazine, as a potent vasodilator and scavenger of acrolein, has protective effects in many diseases. Hydralazine is also confirmed to promote motor function and hypersensitivity in SCI rats through scavenging acrolein. However, few studies have explored the effects of hydralazine on immunomodulation, as well as spontaneous pain and emotional response, the important syndromes in clinical patients. It remains unclear whether hydralazine affects infiltrating BMDMs after SCI. In this study, we targeted BMDMs to explore the influence of hydralazine on immune cells in a mouse model of SCI, and also investigated the contribution of polarized BMDMs to hydralazine-induced neurological function recovery after SCI in male mice. The adult male mice underwent T10 spinal cord compression. The results showed that in addition to improving motor function and hypersensitivity, hydralazine relieved SCI-induced spontaneous pain and emotional response, which is a newly discovered function of hydralazine. Hydralazine inhibited the recruitments of pro-inflammatory BMDMs and educated infiltrated BMDMs to a more reparative phenotype involving in multiple biological processes associated with SCI pathology, including immune/inflammation response, neurogenesis, lipid metabolism, oxidative stress, fibrosis formation, and angiogenesis, etc. As an overall effect, hydralazine-treated BMDMs loaden with sp partially rescued neurological function after SCI. It is concluded that hydralazine plays an immunomodulation role of educating pro-inflammatory BMDMs to a more reparative phenotype; and hydralazine-educated BMDMs contribute to hydralazine-induced improvement of neurological function in SCI mice, which provides support for drug and cell treatment options for SCI therapy.

Assessing Depression and Cognitive Impairment Following Stroke and Neurotrauma: Behavioral Methods for Quantifying Impairment and Functional Recovery

Rodent models of stroke and neural injury are reliable and useful tools for testing new interventions and therapeutics. In addition to physical (motor) impairment, cognitive deficits and depressive behaviors are often observed due to neurotrauma. Proper experimental design of pre- and post-assessments of these behaviors that reduce or minimize the confounding effects of motor impairment are essential for determining markers of progression of impairment or recovery. This chapter provides step-by-step laboratory protocols for assessing cognition using the Barnes maze and the novel object recognition test (NORT) and depressive-like behaviors using the sucrose preference test, the three-chambered sociability approach test, and the burrowing test.

Higher serum β2-microglobulin is a predictive biomarker for cognitive impairment in spinal cord injury

Objective

Recent studies have suggested that high levels of β2-microglobulin are linked to cognitive deterioration; however, it is unclear how this connects to spinal cord injury (SCI). This study sought to determine whether there was any association between cognitive decline and serum β2-microglobulin levels in patients with SCI.

Methods

A total of 96 patients with SCI and 56 healthy volunteers were enrolled as study participants. At the time of enrollment, specific baseline data including age, gender, triglycerides (TG), low-density lipoprotein (LDL), systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting blood glucose (FBG), smoking, and alcohol use were recorded. Each participant was assessed by a qualified physician using the Montreal cognitive assessment (MoCA) scale. Serum β2-microglobulin levels were measured using an enzyme-linked immunosorbent assay (ELISA) reagent for β2-microglobulin.

Results

A total of 152 participants were enrolled, with 56 in the control group and 96 in the SCI group. There were no significant baseline data differences between the two groups (p > 0.05). The control group had a MoCA score of 27.4 ± 1.1 and the SCI group had a score of 24.3 ± 1.5, with the difference being significant (p < 0.05). The serum ELISA results revealed that the levels of β2-microglobulin in the SCI group were considerably higher (p < 0.05) than those in the control group (2.08 ± 0.17 g/mL compared to 1.57 ± 0.11 g/mL). The serum β2-microglobulin level was used to categorize the patients with SCI into four groups. As serum β2-microglobulin levels increased, the MoCA score reduced (p < 0.05). After adjustment of baseline data, further regression analysis showed that serum β2-microglobulin level remained an independent risk factor for post-SCI cognitive impairment.

Conclusions

Patients with SCI had higher serum levels of β2-microglobulin, which may be a biomarker for cognitive decline following SCI.

Psychological and Psychiatric Aspects of Brain and Spinal Cord Tumors

Central nervous system (CNS) tumors are mainly diagnosed by physical symptoms such as paralysis, visual field defect, seizure, and loss of consciousness. The psychological and psychiatric background of CNS tumors, whether in preoperative or postoperative period, has long been a neglected topic; however, lately, many authors and researchers have paid more attention to these manifestations. Neurocognition is a subset of parameters, including attention, memory, mood, emotions, language production, personality, executive function, problem-solving, calculation, and spatial cognition, making up the patient's cognitive performance. Also, it is worthy to say that neurocognition is considered a parameter of quality of life (QoL). Currently, we know that neurocognitive disorders are a group of symptoms presenting by the patients. These symptoms may be the first picture of CNS lesions, which result in incorrect treatment, a higher financial burden on the patient and health system, and finally, poorer QoL and performance scale if they are not diagnosed early. Psychological and psychiatric problems such as depression, anxiety, and phobia following the CNS tumors have two aspects. These may present before any treatment resulting from the tumoral mass effect, peritumoral edema, or cerebral tissue disruption due to the space-occupying lesion. On the other hand, we can see these features after a kind of therapy such as surgery, medical therapy, or adjuvant therapy. Sometimes, the CNS tumors lead to psychosocial complications postoperatively. Indeed, considering tumor surgery complications, some patients may find various degrees of deficits that make the patient isolated either socially or professionally. Obviously, the improvement rate and outcome of this specific situation depend on the mechanism of occurrence and its causes. For instance, postoperative symptom relief would be expected when the symptoms are related to the tumoral mass effect. Getting familiar with this constellation of the symptoms, realizing them, and then localizing them to the correct area of the CNS are very crucial. Accordingly, because of their importance in QoL, their influence on patient's survival even more than the extent of resection of the tumor, and somehow their ignorance, we will discuss different neurocognitive manifestations related to CNS tumors in this chapter.

Factors Associated With Fatigue in People With Spinal Cord Injury: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the association between fatigue and clinical and demographic variables in people with spinal cord injury (SCI).

DATA SOURCES

Five databases (MEDLINE, Physiotherapy Evidence Database, Cochrane, Google Scholar, Cumulative Index to Nursing and Allied Health) were searched up to November 2021.

STUDY SELECTION

Observational studies that reported the association between fatigue and clinical and demographic variables in English or Spanish were eligible. Reviews, qualitative research studies, and nonoriginal articles were excluded. Twenty-three of the 782 identified studies met the inclusion criteria for the meta-analysis.

DATA EXTRACTION

Two researchers independently extracted the data. The strength of the association between each factor and fatigue was determined by the effect size. When the results of the effect size were expressed with different statistics, the correlation coefficient was the preferred estimation. The risk of bias was assessed using the Appraisal Tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale.

DATA SUMMARY

A pooled analysis of the associations between fatigue and 17 factors was performed. A direct association was found between fatigue and 9 factors (sorted by effect size): anxiety (r=0.57; 95% CI, 0.29-0.75), stress (r=0.54; 95% confidence interval [CI], 0.26-0.74), depression (r=0.47; 95% CI, 0.44-0.50), pain (r=0.34; 95% CI, 0.16-0.50), analgesic medication (r=0.32; 95% CI, 0.28-0.36), assistive devices (r=0.23; 95% CI, 0.17-0.29), lesion level (r=0.15; 95% CI, 0.07-0.23), incomplete SCI (r=0.13; 95% CI, 0.05-0.22), and medication (r=0.12; 95% CI, 0.01-0.23). An inverse association was found with 3 factors (sorted by effect size): self-efficacy (r=-0.63; 95% CI, -0.81 to -0.35), participation (r=-0.32; 95% CI, -0.58 to -0.001), and physical activity (r=-0.17; 95% CI, -0.28 to -0.05). No association was found with age, sex, educational level, time since injury, and spasticity.

CONCLUSIONS

Several factors were associated with fatigue in people with SCI, with those related to mental health showing the strongest associations. These results should be interpreted with caution because of the high heterogeneity observed in some factors.

Rehabilitation of People With Chronic Spinal Cord Injury Using a Laparoscopically Implanted Neurostimulator: Impact on Mobility and Urinary, Anorectal, and Sexual Functions

OBJECTIVES

This study aimed to assess the impact of the laparoscopic implantation of neuromodulation electrodes (Possover-LION procedure) on mobility and on sexual, urinary, and anorectal functions of people with chronic spinal cord injury (SCI).

MATERIAL AND METHODS

Longitudinal analysis of 30 patients with chronic SCI (21 ASIA impairment scale (AIS) A, eight AIS B, and one AIS C) submitted to the Possover-LION procedure for bilateral neuromodulation of femoral, sciatic, and pudendal nerves. Assessments were performed before the surgical procedure and at 3, 6, and 12 months postoperatively. The primary outcome was evolution in walking, measured by the Walking Index for Spinal Cord Injury score, preoperatively and at 12 months. Secondary outcomes were changes in overall mobility (Mobility Assessment Tool for Evaluation of Rehabilitation score), urinary function and quality of life (Qualiveen questionnaire), and bowel (time for bowel emptying proceedings and Wexner's Fecal Incontinence Severity Index [FISI]) and sexual functions (International Index of Erectile Function for men and Female Sexual Function Index for women). Surgical time, intraoperative bleeding, and perioperative complications were also recorded.

RESULTS

Qualitatively, 18 of 25 (72%) patients with thoracic injury and 3 of 5 (60%) patients with cervical injury managed to establish a walker-assisted gait at one-year follow-up (p < 0.0001). A total of 11 (47.8%) have improved in their urinary incontinence (p < 0.0001), and seven (30.4%) improved their enuresis (p = 0.0156). The FISI improved from a median of 9 points preoperatively to 5.5 at 12 months (p = 0.0056). Of note, 20 of 28 (71.4%) patients reported an improvement on genital sensitivity at 12 months postoperatively (p < 0.0001), but this was not reflected in sexual quality-of-life questionnaires.

CONCLUSIONS

Patients experienced improved mobility and genital sensitivity and a reduction in the number of urinary and fecal incontinence episodes. By demonstrating reproducible outcomes and safety, this study helps establish the Possover-LION procedure as an addition to the therapeutic armamentarium for the rehabilitation of patients with chronic SCI.

CLINICAL TRIAL REGISTRATION

This study was registered at the WHO Clinical Trials Database through the Brazilian Registry of Clinical Trials-REBEC (Universal Tracking Number: U1111-1261-4428).

Improving Assessment of Cognitive Impairment after Spinal Cord Injury: Methods to Reduce the Risk of Reporting False Positives

Adults with spinal cord injury (SCI) are reported to have heightened risk of cognitive impairment, notably mild cognitive impairment (MCI). Reports of increased risk of MCI are almost exclusively based on cross-sectional assessments of cognitive function using norm-referenced scores. Norm-referenced single-point assessments do not reflect cognitive decline at the individual level but rather represent between group differences in cognitive function. The practice of relying solely on norm-referenced assessment to study MCI after SCI is therefore problematic as it lends to potential misclassification of MCI. Premorbid intelligence estimates permit comparison of people's actual versus expected cognitive function and thereby can be used to validate the presence of genuine cognitive decline. These are not utilized in the assessment of MCI after SCI. This study simulated data for 500,000 adults with SCI to compare norm-referenced and premorbid-intelligence methods of screening for MCI to examine the potential extent of MCI misclassification after SCI resulting from the overreliance on norm-referenced methods and exclusion of premorbid intelligence methods. One in five to one in 13 simulated adults with SCI were potentially misclassified as having MCI showing that measures of premorbid cognitive function must be included in assessment of cognitive function after SCI.

Acute submaximal exercise does not impact aspects of cognition and BDNF in people with spinal cord injury: A pilot study

Objective

To investigate the effect of acute submaximal exercise, based on the spinal cord injury (SCI) Exercise Guidelines, on cognition and brain-derived neurotrophic factor (BDNF) in people with SCI.

Design

Eight adults (7 males) with traumatic SCI volunteered in this pre-registered pilot study. In randomized order, participants completed submaximal intensity arm cycling (60% of measured peak-power output at 55–60 rpm) for 30 min or time-matched quiet rest (control condition) on separate days. Blood-borne BDNF was measured in serum and plasma at pre-intervention, 0 min and 90 min post-intervention. Cognition was assessed using the Stroop Test and Task-Switching Test on an electronic tablet pre- and 10 min post-intervention.

Results

Submaximal exercise had no effect on plasma [F(2,12) = 1.09; P = 0.365; η² = 0.069] or serum BDNF [F(2,12) = 0.507; P = 0.614; η² = 0.024] at either 0 min or 90 min post-intervention. Similarly, there was no impact of exercise on either Stroop [F(1,7) = 2.05; P = 0.195; η² = 0.065] or Task-Switching performance [F(1,7) = 0.016; P = 0.903; η² &lt; 0.001] compared to the control condition. Interestingly, there was a positive correlation between years since injury and resting levels of both plasma (r = 0.831; P = 0.011) and serum BDNF (r = 0.799; P = 0.023). However, there was not relationship between years since injury and the BDNF response to exercise.

Conclusions

Acute guideline-based exercise did not increase BDNF or improve aspects of cognition in persons with SCI. This work establishes a foundation for continued investigations of exercise as a therapeutic approach to promoting brain health among persons with SCI.

Cognitive Impairment in Individuals With Spinal Cord Injury: Findings of a Systematic Review With Robust Variance and Network Meta-analyses

BACKGROUND AND OBJECTIVES

Estimates of the prevalence (10%-60%) of cognitive impairment in individuals with spinal cord injury (SCI) are too broad, and which domains of cognition are most affected is unclear. We performed a meta-analysis to investigate impairments across domains of cognitive functioning to provide a nuanced picture of research conducted to date into cognitive impairment after SCI.

METHODS

Results of peer-reviewed studies published in English between 1980 and 2021 comparing ≥20 participants with SCI with able-bodied controls were synthesized using meta-analysis. The primary outcomes were neurocognitive test scores categorized into 5 cognitive domains as listed in the Diagnostic and Statistical Manual of Mental Disorders: Complex Attention, Executive Functioning, Learning and Memory, Language, and Perceptual Motor Function. Two researchers independently assessed and verified extracted data to comply with meta-analytic reporting guidelines. Robust variance estimation meta-analysis was conducted to determine an overall pooled effect size across all cognitive domains using data extracted from studies. Using network meta-analysis, we synthesized eligible studies and made comparisons with the 5 domains of cognitive functioning serving as the outcomes and SCI as the condition.

RESULTS

Of 4,783 potential studies, 13 met final inclusion criteria. Studies met 6 of 8 quality assessment criteria generally. Results suggested that adults with SCI experience reduced cognitive functioning (effect size: -0.84; 95% CI -1.24 to -0.44, p < 0.001) compared with able-bodied individuals, with deficits mostly in attention (g = -0.64; 95% CI -0.92 to -0.38) and executive functioning (g = -0.61, 95% CI -0.89 to -0.04). Publication bias and high heterogeneity (I2: 86%) qualify these findings and highlight the need to improve research methods in this area.

DISCUSSION

Adults with SCI seem more likely than adults who are able-bodied to display cognitive impairments mostly in areas of attention and executive functioning. Research practices must become consistent to reduce heterogeneity so that the validity and reliability of the results of future studies into cognitive impairment after SCI improves.

A Narrative Review of Research on Adjustment to Spinal Cord Injury and Mental Health: Gaps, Future Directions, and Practice Recommendations

Spinal cord injury (SCI) results in autonomic, motor, and sensory impairments that can compromise mental health. Guidelines directing the management of mental health following SCI presently address clinical anxiety, depression, post-traumatic stress, substance use disorders, and suicide. However, evidence suggests that perhaps as many as 70% of individuals with SCI do not develop a clinically diagnosable mental health disorder. Therefore, the authors contend that understanding non-clinical cognitive and psychological aspects of adjustment post-SCI is paramount and that the application of this knowledge to the formulation of adjustment-enhancing interventions is crucial. To assist with this endeavour, we examine existing mental health guidelines targeting SCI, and present a narrative review of research on the under-represented topics of adjustment, coping, grief, and resilience. We include mild cognitive impairment, which reflects a common factor that can compromise adjustment. Loss and stress trigger processes of adjustment, coping, grief, and resilience. SCI involves loss and stress triggering these processes, arguably without exception. Our study applied a narrative review methodology searching Google Scholar and PsychInfo databases for terms adjustment, coping, grief, resilience, and cognitive impairment. Qualitative studies and quantitative studies were selected to capture bottom-up and top-down perspectives. Reference lists of retrieved papers were searched as appropriate. Reviewed literature suggested that existing guidelines concerning mental health following SCI neglect positive processes of adjustment and suggest this neglect contributes to a deficits-based view of mental health following SCI. Research into "positive" or adjustment-enhancing processes is mostly cross-sectional, heterogenous, and poorly positioned to inform future guideline-development. Researchers should achieve consensus over the operationalisation of essential processes and overcome a fixation with "outcomes" to better inform management of mental health after SCI.

Investigating Dynamics of the Spinal Cord Injury Adjustment Model: Mediation Model Analysis

Spinal cord injury (SCI) is a severe neurological injury that results in damage to multiple bodily systems. SCI rehabilitation requires a significant focus on improving adjustment to the injury. This paper presents a detailed description of the Spinal Cord Injury Adjustment Model (SCIAM), which clarifies how individuals adjust to SCI and contends that adjustment to SCI is a multifactorial process involving non-linear dynamic adaptation over time. Evidence supporting SCIAM is also discussed. Mediation analyses were conducted to test the mediator dynamics proposed by the model. The analyses tested the relationship between two moderators (self-care and secondary health conditions), mediators (two self-efficacy items and appraisal of quality of life or QoL), and positive versus negative vitality/mental health as outcomes. Results showed that higher self-efficacy and perceived QoL was related to greater independence in self-care and reduced negative impacts of secondary health conditions. This study supported the mediation role of self-efficacy and other appraisals such as perceived QoL in enhancing self-care and buffering the negative impact of health challenges. In conclusion, it is important to employ a holistic model such as SCIAM to conceptualise and increase understanding of the process of adjustment following a severe neurological injury such as SCI.