Quality of life of people with spinal cord injury in Northern India

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIALS REGISTRATION

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

Quality of life after traumatic thoracolumbar spinal cord injury: a North Indian perspective

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To determine the Quality of Life (QOL) in individuals with traumatic Spinal Cord Injury (SCI) of thoracolumbar region in Indian population, the factors affecting QOL and to compare this to other SCI populations.

SETTING

Tertiary level hospital in low-middle income country.

METHODS

93 individuals with SCI of minimum 1 year duration since injury were included in the study. Baseline demographics, socioeconomic parameters, and incidence of complications were ascertained. World Health Organisation Quality of Life-BREF (WHOQOL-BREF) score was used for measurement of QOL and was then compared to healthy Indian population and other SCI studies. Subgroup analysis was done to find out impact of variables on different domains of WHOQOL-BREF.

RESULTS

The median (IQR) age of the study participants was 35 (25, 45) with a male predominance. The median (IQR) duration since injury in the study population was 50 (26, 70) months. Lowest mean (SD) score was observed in the psychological domain -50.3 (12.1) and comparison to healthy Indian and high-income SCI populations revealed drastically decreased scores across all domains (p < 0.01). Employed individuals and housewives had significantly higher scores across all domains than unemployed individuals (p < 0.05). American Spinal Injury Association Impairment Scale (AIS) grade, socioeconomic status, pain and presence of complications all had significant impact on domain scores (p < 0.05). Multiple regression analysis revealed that mobilisation status and pain had the greatest effect on QOL.

CONCLUSION

Individuals with SCI have low QOL scores as compared to general Indian population as well as SCI individuals from a high resource setting. Pain and dependent mobilisation were found to be most significant predictors of poor WHOQOL-BREF domain scores. Housewives were found to have domain scores comparable to employed individuals. Presence of complications negatively impacts QOL.

Telerehabilitation for individuals with spinal cord injury in low-and middle-income countries: a systematic review of the literature

STUDY DESIGN

Systematic review.

OBJECTIVE

To systematically review the evidence for the effectiveness of telerehabilitation as an intervention for people with spinal cord injury (SCI) in low-and middle-income countries (LMICs).

SETTING

Not applicable.

METHODS

MEDLINE (Ovid), Embase (Ovid), Pubmed and Global Health databases were used to identify studies published between 1946-2020 meeting the following criteria: (1) patients with SCI diagnosis; (2) in LMIC; (3) an outcome measuring clinical functional ability, quality of life or all-cause mortality reduction. The risk of bias in studies was graded using revised Cochrane risk-of-bias tool in randomised trials (RoB 2) and risk-of-bias tool in non-randomised trials (ROBINS-I). Evidence levels were graded with Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

RESULTS

In total, 107 articles were identified from the initial search. After screening, five studies were included. Some significant improvements to quality of life and pressure ulcer management were observed, alongside some improvement in functional ability with suggested improvement to depression scores. Telerehabilitation alleviated participants' sense of social isolation, improved satisfaction scores and assisted them to remember techniques for SCI management. Telerehabilitation was valued by health professionals. There was no reduction in all-cause mortality.

CONCLUSION

There is insufficient evidence to recommend telerehabilitation as an intervention to treat and manage SCI in LMICs, although there is an indication of potential patient benefit. Further research is required to better understand the causal mechanisms underpinning the use of telerehabilitation and establish its efficacy, in the context of resource-limited settings.

Prognostic Factors of the Inability to Bear Self-Weight at Discharge in Patients with Fragility Femoral Neck Fracture: A 5-Year Retrospective Cohort Study in Thailand

An inability to bear self-weight is one of the unfavorable results in geriatric hip fracture, which needs to be prevented. This study determines pre-operative, intra-operative, and post-operative prognostic factors of the inability to bear self-weight at discharge in patients with fragility femoral neck fracture. This retrospective study was conducted at Chiang Mai University (CMU) hospital with an observational cohort design. Electronic medical records of patients aged ≥ 50 years old with fragility femoral neck fractures between 1 January 2015 and 31 December 2019 were reviewed. Pre-, intra-, and post-operative factors were collected. Ambulation status at discharge time was classified into either ability or inability to bear self-weight. Analysis of prognostic factors was done using multivariable risk ratio regression. In total, 269 patients were recruited in this study. Significantly prognostic factors of inability to bear self-weight at discharge were end-stage renal disease (ESRD), cirrhosis, cerebrovascular disease, pre-fracture ambulatory status, having associated fractures, increasing intra-operative blood loss, and having pressure sore. These prognostic factors could be used to predict patients’ outcomes at discharge. Proper management could then be offered to the patients by the multidisciplinary care team to enhance surgical outcomes.

Respiratory morbidity and mortality of traumatic cervical spinal cord injury at a level I trauma center in India

STUDY DESIGN

Descriptive retrospective.

OBJECTIVES

To evaluate the burden of respiratory morbidity in terms of ventilator dependence (VD) days and length of stay in neurotrauma ICU (NICU) and hospital, and to determine mortality in patients with traumatic cervical spinal cord injury (CSCI) in a low middle-income country (LMIC).

SETTING

Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India.

METHODS

A total of 135 patients admitted with CSCI in the NICU between January 2017 to December 2018 were screened. Information regarding age, gender, American Spinal Injury Association (ASIA) impairment scale (AIS), level of injury, duration of VD, length of NICU, hospital stay, and outcome in terms of mortality or discharge from the hospital were obtained from the medical records.

RESULTS

A total of 106 CSCI patients were analyzed. The mean (SD) age of patients was 40 (±16) years and male: female ratio was 5:1. The duration of VD, duration of NICU, and hospital stay was a median of 8 days (IQR 1127), 6 days (IQR 1118), and 15 days (IQR 3127) respectively. Mortality was 19% (20/106). The mortality was significantly associated with poorer AIS score, VD, and duration of ICU and hospital stay. All patients were discharged to home only after they became ventilator-free.

CONCLUSIONS

The ventilator burden, hospital stay, and mortality are high in patients with CSCI in LMICs. Poor AIS scores, prolonged VD, ICU and hospital stay are associated with mortality. There is a need for comprehensive CSCI rehabilitation programs in LMICs to improve outcome.

A multiscript gaze-based assistive virtual keyboard

The recent development of inexpensive and accurate eye-trackers allows the creation of gazed based virtual keyboards that can be used by a large population of disabled people in developing countries. Thanks to eye-tracking technology, gaze-based virtual keyboards can be designed in relation to constraints related to the gaze detection accuracy and the considered display device. In this paper, we propose a new multimodal multiscript gaze-based virtual keyboard where it is possible to change the layout of the graphical user interface in relation to the script. Traditionally, virtual keyboards are assessed for a single language (e.g. English). We propose a multiscript gaze based virtual keyboard that can be accessed for people who communicate with the Latin, Bangla, and/or Devanagari scripts. We evaluate the performance of the virtual keyboard with two main groups of participants: 28 people who can communicate with both Bangla and English, and 24 people who can communicate with both Devanagari and English. The performance is assessed in relation to the information transfer rate when participants had to spell a sentence using their gaze for pointing to the command, and a dedicated mouth switch for commands selection. The results support the conclusion that the system is efficient, with no difference in terms of information transfer rate between Bangla and Devanagari. However, the performance is higher with English, despite the fact it was the secondary language of the participants.

Mortality and health-related quality of life following injuries and associated factors: a cohort study in Chandigarh, North India

INTRODUCTION

Injuries are among the 10 leading causes of deaths worldwide. In recent years, the quality and reporting of injury mortality has improved but little or no data are available on the morbidity burden and impact of non-fatal injuries in India. This study evaluates health recovery status postinjury, identifying predictors of recovery in North India.

METHODS

Prospective cohort study recruiting patients from one tertiary-level and two secondary-level hospitals in North India between April and June 2014 hospitalised due to any injury. Health-related quality of life was assessed at baseline and at 1-month, 2-month, 4-month and 12-month postinjury using the EuroQol five-dimensional (EQ-5D-5L) questionnaire. Multivariable linear regressions with generalised estimating equations were used to examine the relationship between sociodemographic and injury-related factors with the EQ-5D-5L single utility score and the visual analogue scale (VAS) score.

RESULTS

A total of 2416 eligible patients aged ≥18 years were enrolled in the study. Of these, 2150 (74%) completed baseline and all four follow-up EQ-5D-5L questionnaires. Almost 7% (n=172) patients died by the first follow-up and the overall mortality at 12 months was 9% (n=176). Both EQ-5D-5L utility and VAS scores dropped significantly at 1-month postinjury but gradually improved at 2, 4 and 12 months. Severe injuries, defined as those requiring a hospital stay of ≥7 days, were associated with lower utility scores at 1-month, 2-month and 4-month follow-ups (p<0.001).

CONCLUSION

This is the first study to examine health outcomes following injuries in India. The findings highlight the need to understand the social, psychological and biological factors influencing recovery outcomes. High mortality following discharge emphasises the need to invest in secondary and tertiary injury prevention in India.

Standardization of a spinal cord lesion model and neurologic evaluation using mice

OBJECTIVE

To standardize a spinal cord lesion mouse model.

METHODS

Thirty BALB/c mice were divided into five groups: four experimental groups and one control group (sham). The experimental groups were subjected to spinal cord lesion by a weight drop from different heights after laminectomy whereas the sham group only underwent laminectomy. Mice were observed for six weeks, and functional behavior scales were applied. The mice were then euthanized, and histological investigations were performed to confirm and score spinal cord lesion. The findings were evaluated to prove whether the method of administering spinal cord lesion was effective and different among the groups. Additionally, we correlated the results of the functional scales with the results from the histology evaluations to identify which scale is more reliable.

RESULTS

One mouse presented autophagia, and six mice died during the experiment. Because four of the mice that died were in Group 5, Group 5 was excluded from the study. All the functional scales assessed proved to be significantly different from each other, and mice presented functional evolution during the experiment. Spinal cord lesion was confirmed by histology, and the results showed a high correlation between the Basso, Beattie, Bresnahan Locomotor Rating Scale and the Basso Mouse Scale. The mouse function scale showed a moderate to high correlation with the histological findings, and the horizontal ladder test had a high correlation with neurologic degeneration but no correlation with the other histological parameters evaluated.

CONCLUSION

This spinal cord lesion mouse model proved to be effective and reliable with exception of lesions caused by a 10-g drop from 50 mm, which resulted in unacceptable mortality. The Basso, Beattie, Bresnahan Locomotor Rating Scale and Basso Mouse Scale are the most reliable functional assessments, and but the horizontal ladder test is not recommended.

The Burden of Spine Fractures in India: A Prospective Multicenter Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

The objectives of this study were (1) to determine the characteristics of patients sustaining spinal trauma in India and (2) to explore the association between patient or injury characteristics and outcomes after spinal trauma.

METHODS

In affiliation with the ongoing INternational ORthopaedic MUlticentre Study (INORMUS), 192 patients with spinal injuries were recruited during an 8-week period (November 2011 to June 2012) from 14 hospitals in India and followed for 30-days. The primary outcome was a composite of mortality, complications, and reoperation. This was regressed on a set of 13 predictors in a multiple logistic regression model.

RESULTS

Most patients were middle-aged (mean age = 51.0 years; median age = 55.5 years; range = 18.0 to 72.0 years), male (60.4%), injured from falls (72.4%), and treated in a private setting (59.9%). Fractures in the lumbar region (51.0%) were most common, followed by thoracic (30.7%) and cervical (18.2%). More than 1 in 5 (21.6%) patients experienced a treatment delay greater than 24 hours, and 36.5% arrived by ambulance. Thirty-day mortality and complication rates were 2.6% and 10.0%, respectively. Care in the public hospital system (odds ratio [OR] = 6.7, 95% CI = 1.1-41.6), chest injury (OR = 11.1, 95% CI = 1.8-66.9), and surgical intervention (OR = 4.8, 95% CI = 1.2-19.6) were independent predictors of major complications.

CONCLUSIONS

Treatment in the public health care system, increased severity of injury, and surgical intervention were associated with increased risk of major complications following spinal trauma. The need for a large-scale, prospective, multicenter study taking into account spinal stability and neurologic status is feasible and warranted.

Physical Activity and Quality of Life among Adults with Paraplegia in Odisha, India

OBJECTIVES

The complete rehabilitation of patients with spinal cord injuries (SCI) comprises both physical and psychosocial factors. This study therefore aimed to assess physical activity and quality of life (QOL) among paraplegic patients with SCI in Odisha, India.

METHODS

This cross-sectional prospective study was conducted between March 2010 and December 2013. All paraplegic patients treated at the Swami Vivekanand National Institute of Rehabilitation Training & Research in Odisha, India, during the study period who met the inclusion criteria were invited to participate in the study (n = 364). Structured face-to-face interviews were held with participants and QOL and physical activity were assessed using the abbreviated World Health Organization QOL instrument and the Physical Activity Scale for Individuals with Physical Disabilities, respectively.

RESULTS

A total of 84 people participated in the study (response rate: 23.1%). The mean age was 32.54 ± 10.75 years and 90.5% of the participants were male. Participants had a low mean metabolic equivalent score (18.18 ± 10.68 hours/day). Additionally, low mean scores were noted for the physical health, psychological well-being, social relationships and environment QOL domains (49.76 ± 18.74, 48.57 ± 17.04, 57.88 ± 17.04 and 49.85 ± 17.77, respectively). There was a strong positive association between levels of physical activity and all QOL domains (P <0.050). Physical activity and employment status were significant predictors of all QOL domains (P <0.001).

CONCLUSION

Low physical activity levels and QOL were noted among the paraplegic subjects. Interventions promoting physical activity and employment may help to improve QOL among this patient group.

Community-based InterVentions to prevent serIous Complications (CIVIC) following spinal cord injury in Bangladesh: protocol of a randomised controlled trial

INTRODUCTION

In low-income and middle-income countries, people with spinal cord injury (SCI) are vulnerable to life-threatening complications after they are discharged from hospital. The aim of this trial is to determine the effectiveness and cost-effectiveness of an inexpensive and sustainable model of community-based care designed to prevent and manage complications in people with SCI in Bangladesh.

METHODS AND ANALYSIS

A pragmatic randomised controlled trial will be undertaken. 410 wheelchair-dependent people with recent SCI will be randomised to Intervention and Control groups shortly after discharge from hospital. Participants in the Intervention group will receive regular telephone-based care and three home visits from a health professional over the 2 years after discharge. Participants in the Control group will receive standard care, which does not involve regular contact with health professionals. The primary outcome is all-cause mortality at 2 years. Recruitment started on 12 July 2015 and the trial is expected to take 5 years to complete.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Institutional Ethics Committee at the site in Bangladesh and from the University of Sydney, Australia. The study will be conducted in compliance with all stipulations of its protocol, the conditions of ethics committee approval, the NHMRC National Statement on Ethical Conduct in Human Research (2007), the Note for Guidance on Good Clinical Practice (CPMP/ICH-135/95) and the Bangladesh Guidance on Clinical Trial Inspection (2011). The results of the trial will be disseminated through publications in peer-reviewed scientific journals and presentations at scientific conferences.

TRIAL REGISTRATION NUMBERS

ACTRN12615000630516, U1111-1171-1876.

Improvisations in classic and modified techniques of flap surgery to improve the success rate for pressure ulcer healing in patients with spinal cord injury

The recurrence of pressure ulcers (PrUs) and dehiscence of reconstructive flap have always been a problem. The present study aimed to evaluate the results of reconstructive flap surgeries in patients with spinal cord injury (SCI) having PrUs, using classic and modified flaps with improvisations to decrease wound dehiscence, flap necrosis and tension in flap. This is a prospective clinical study. The setting was a tertiary care centre in northern India. Thirty-five patients with SCI having 37 stage III and IV PrUs. PrUs were treated using classic and modified flaps with improvisations. The outcome was evaluated using criteria of wound dehiscence, flap necrosis and recurrence. The results of flap surgery were excellent in 32 (86·48%) patients, good in 4 (10·81%) patients and poor in 1 (2·7%) patient. Partial flap necrosis (2·7%), low incidence of PrU recurrence rate at flap site (5·4%) and overall PrU recurrence (11·4%) were the complications observed. Improvisation of classic and modified techniques of flap surgeries along with reinforcement of general care principles of paraplegia can be effective in minimising complications often associated with PrU reconstructive surgery thus improving the ultimate outcome.

Avaliação do emprego do GM1 após lesão medular experimental em ratos

OBJETIVO: Avaliar a eficácia do GM1, administrado por via intraperitoneal, após lesão medular experimental em ratos. MÉTODOS: Foram utilizados 20 ratos da raça Wistar machos, adultos jovens, com média de idade de 20 semanas, pesando em torno de 350 g, divididos em dois grupos de 10 animais. No grupo 1 foi administrado apenas soro fisiológico por via intraperitoneal. Ao grupo 2, administraram-se 30 mg/kg de GM1 diariamente por essa mesma via. As lesões foram produzidas seguindo-se o protocolo internacional MASCIS (Multicenter Animal Spinal Cord Injury Study), com o sistema NYImpactor. Os animais foram avaliados funcionalmente pela escala BBB nos dias 14, 28 e 42 após a lesão. O potencial evocado foi realizado em todos os animais, no 42º dia após o trauma. RESULTADOS: Utilizou-se um modelo de variância de dois fatores (ANOVA) e o teste t de Student. As avaliações funcionais e por meio de potencial evocado não demonstraram diferença estatisticamente significante entre os dois grupos. CONCLUSÃO: O emprego de GM1 intraperitoneal não demonstrou resultados satisfatórios após lesão medular experimental.

Surgery for pressure ulcers improves general health and quality of life in patients with spinal cord injury

STUDY DESIGN

Prospective clinical study.

BACKGROUND

Pressure ulcers interfere with the rehabilitation process in patients with spinal cord injury (SCI) and are a significant deterrent to participation in activities that contribute to independent, productive, and satisfying life.

OBJECTIVE

To evaluate the effect of surgery for pressure ulcers on general health and quality of life in patients with SCI.

SETTING

Tertiary care center in northern India.

METHODS

Various types of flap surgery were performed on 30 patients with SCI and 32 pressure ulcers (stages III and IV). Outcome was evaluated using general improvement in health (hemoglobin, serum proteins, and general well-being), patient satisfaction, and global quality of life scores (according to the visual analog scale).

RESULTS

At admission, the mean values of global quality of life, hemoglobin, serum albumin, and total serum proteins were 50.15 (range, 30-65), 8.75 g/dL (range, 6-12 g/dL), 3.12 g/dL (range, 2.9-4.3 g/dL), and 5.21 (range, 5-6.2 g/dL), respectively. At 6-month follow up, mean values of global quality of life score, hemoglobin, serum albumin, and total serum proteins were 87.36 (range, 44-96), 10.85 g/dL (range, 8.2-13.5 g/dL), 3.89 g/dL (range, 3.2-4.5 g/dL), and 6.43 g/dL (range, 5.85-6.70 g/dL), respectively. The overall rise in quality of life scores, hemoglobin, serum albumin, and total serum proteins was statistically significant. Most of the patients (76.7%) reported improvement in subjective well-being, and 83.3% were satisfied with the ultimate outcome of the surgery.

CONCLUSION

Results suggest that surgery for stages III and IV pressure ulcers offers the greatest benefit to the patients in terms of improvement in general health (anemia, hypoproteinemia, and general well-being) and quality of life.

Bilateral hip disarticulation in paraplegics

Background: Decubitus ulcers are severe challenges to paraplegic patients, as well as to the medical providers caring for such disabled persons. Severe, chronic infection often can lead to death, especially in developing countries. Sometimes, hip disarticulation is the most appropriate surgical response to chronic ulceration. Objective: Report the results of bilateral disarticulations in 3 patients, one in Cambodia, and two in Australia. Methods: Chart reviews, examinations, and interviews with the patients were conducted to identify appropriate details of the indications and results. Results: Severe decubitus ulcers were successfully treated using the technique, without undue surgical complications. The general health of the patients was much improved. Conclusion: Bilateral hip disarticulations were performed as last stage salvage operations in three patients, who expressed satisfaction with the results, even though some problems with balance and recurrent ulceration persisted.