A Patient With Acute Cervical Cord Injury and COVID-19: A First Case Report

Evidence-based position paper on physical and rehabilitation medicine professional practice for persons with COVID-19, including post COVID-19 condition: the European PRM position (UEMS PRM Section)

Although multiple factors still pose challenges to inpatient/outpatient rehabilitation for survivors of COVID-19, rehabilitation plays a key role for this patient population. This study aimed to improve Physical and Rehabilitation Medicine (PRM) physician's professional practice for persons with COVID-19-related functioning limitations, to promote functional recovery and reduce activity limitations and/or participation restrictions. A systematic review of the scientific literature was performed from December 2019 to August 2022, followed by production of recommendations through 5 Delphi rounds, by consensus among the delegates of all European countries represented in the Union of European Medical Specialists PRM Section. The systematic literature review is reported together with thirty-two recommendations resulting from the Delphi procedure. The PRM physician's role for persons with COVID-19-related limitations of functioning is to develop, foster, and monitor the implementation of an individual rehabilitation project tailored to the patient's age, previous medical and functional status, current comorbidities and complications, activity limitations and participation restrictions and personal and environmental factors. This is done by applying the concept of a multi-specialty integrated service model with multi-professional/interdisciplinary teams, providing care at all stages of COVID-19 illness. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section.

Neuromuscular rehabilitation interventions and COVID-19 management in a case of incomplete paraplegia with neurogenic bladder, post T3-T5 ependymoma

Spinal ependymomas are a group of mostly slow-growing tumors that can cause non-traumatic spinal cord injury with insidious clinical symptomatology ranging from neck or back pain to as-sociated sensory-motor impairment. Due to their neurological and systemic frailty, patients with spinal cord injury might be especially vulnerable to the effects of SARS-CoV-2 infection and the resulting respiratory impairment. CASE PRESENTATION: We present the case of a 66 year old women admitted in our Neuromuscular Rehabilitation Clinic Division for severe in-complete paraplegia and neurogenic bladder. She was previously diagnosed in the Neurosurgi-cal Ward with a thoracic grade II (classic) ependymoma and underwent a gross tumor resection. During the neurorehabilitation program the patient was diagnosed with COVID-19. The multi-drug related treatments were associated with supportive oxygen therapy and neuromuscular and respiratory rehabilitation techniques. RESULTS: Despite of the patient’s favorable rehabili-tation, consisting of walking abilities with support in a walking frame on short distances, her prognosis may be worsened by resting neurogenic bladder symptoms. COVID-19 has led to im-portant acute respiratory morbidity in our patient, regardless of the mild course of the disease, and might further cause a post-infectious respiratory impairment. ONCLUSION: Spinal cord in-jury remains a life-long condition and emphasizes the necessity of supporting the affected pati-ents on the long run. Keywords: students, balance, postural stability, physical exercise, progress, motor skills

Challenges of Patients with Spinal Cord Injury During the COVID-19 Pandemic: A Qualitative Study

Background: Spinal cord injury (SCI) is a chronic condition leading to physical and psychological problems along with numerous economic burdens for patients. In late 2019, an unknown disease called COVID-19 broke out, which quickly spread throughout the world. Objectives: The aim of the present study was to determine the challenges of SCI patients during the COVID-19 pandemic. Methods: This was a qualitative study performed among SCI patients after obtaining the code of ethics from the Research Ethics Committee of Ilam University of Medical Sciences in 2021. Data were collected using semi-structured, face-to-face individual interviews, in accordance with health protocols, in a safe environment without stress until reaching data saturation. Data were saturated after interviewing nine patients; to ensure data saturation, two additional interviews were conducted. Each interview lasted between 30 and 45 minutes, depending on the condition of each patient. The written files of the interviews were analyzed using MAXQDA software. Results: The mean age of the participants was 54 years, and 68% of the participants were male. After analyzing the data obtained from in-person interviews, three main themes, including expectations (need for financial support, need for social support, and need for physical support), concerns (fear of loneliness and fear of death), and health needs (health literacy, access to services and how to transmit the disease), were extracted. Conclusions: Considering the challenges in the three areas of expectations, concerns, and health care, it is necessary to take some measures to reduce these challenges.

COVID-19 and Acute Cervical Spinal Cord Injury-Case Report of 2 Patients: Do We Need to Rethink Our Standard Treatment Strategy?

STUDY DESIGN

This was a case series.

OBJECTIVE

The authors sought to examine the high-risk population of COVID-positive patients with acute cervical spinal cord injury (SCI) in a large level 1 trauma and tertiary referral center.

SUMMARY OF BACKGROUND DATA

There are limited studies regarding the surgical management of patients with acute SCI in the setting of the recent coronavirus pandemic.

METHODS

The authors describe the cases of 2 patients who died from COVID-related complications after acute cervical SCI.

RESULTS

Patients with SCI are at increased risk of pulmonary complications. COVID-19 infection represents a double hit in this patient population, increasing potential morbidity and mortality in the perioperative time frame. Careful consideration must be made regarding the timing of potential surgical intervention in the treatment of acute SCI.

CONCLUSIONS

Nationwide database of COVID-positive patients with acute spinal cord injury should be collected and analyzed to better understand how to manage acute SCI in the COVID-19 era. The authors recommend preoperative discussion in patients with acute cervical SCI with COVID-19, specifically emphasizing the increased risk of respiratory complications and mortality.

Clinical features and prognosis of COVID-19/SARS-CoV-2 infections in persons with spinal cord injury: a review of current literature

Study design

Focused literature review.

Objectives

Objective of the study was to perform a literature search and summarise the clinical features and prognosis of persons with spinal cord injury (SCI) infected with COVID-19 from the published articles.

Setting

India.

Methods

PubMed, CENTRAL and MEDLINE were systematically searched using specific keywords. The study assessed 2747 scientific studies involving COVID-19 and SCI for possible inclusion in a meta-analysis of SCI and SARS-COV-2. Studies involving persons with SCI who were tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the nasopharyngeal or throat swab polymerase chain reaction were included.

Results

Out of 2747 articles, 11 articles (206 participants), including six case reports, were included in this review. Fever was the most frequently observed symptom of COVID-19 infection in the SCI population. C-reactive protein (CRP) and lymphocytopenia were common abnormal laboratory parameters. The most common radiological finding in COVID-19 infection was ground glass opacities in lung fields. Prophylactic/therapeutic anticoagulation was given in a significant number of SCI persons infected with COVID-19. Persons with SCI who were diagnosed early showed good outcomes.

Conclusions

Based on the few studies published on COVID-19 and SCI populations since 2019, this study determined fever, elevated CRP, lymphocytopenia and ground glass opacities, which indicated inflammation, compromised immune response, and lung edema, as the main clinical features of COVID-19 infection in SCI population. Though COVID-19 infection reported an increased number of deaths in few studies, a significant number of SCI populations with positive RT-PCR were treated successfully and discharged at home.

COVID-19 Presentation in an Acute Motor Incomplete Spinal Cord Injury in Inpatient Rehabilitation

ABSTRACT

Spinal cord injuries lead to impairment of the central regulation of respiratory muscle activity. This impairs the cough response, which can increase the risk of complications if infected with coronavirus disease 2019. This case describes a 32-yr-old man with an acute traumatic motor incomplete spinal cord injury, C4 American Spinal cord Injury Association Impairment Scale D D, in an inpatient rehabilitation facility who presented with only a fever. Initial infectious workup was negative, and he continued to have elevated temperatures with no other symptoms. He was then tested for coronavirus disease 2019 and found to be positive. This is the first documented case that identifies this potentially lethal disease in an acute motor incomplete spinal cord injury in an inpatient rehabilitation setting. We further discuss how physiatrists need to be aware of milder presentation of coronavirus disease 2019 in patients with spinal cord injuries. Inability to recognize this disease can lead to delayed diagnosis and asymptomatic spread in an inpatient rehabilitation setting.

COVID-19 and Spinal Cord Injury: Clinical Presentation, Clinical Course, and Clinical Outcomes: A Rapid Systematic Review

Persons living with spinal cord injury (SCI) are potentially at risk for severe COVID-19 disease given that they often have decreased lung capacity and may lack the ability to effectively evacuate their lungs. Known risk factors for negative outcomes after COVID-19, such as obesity, diabetes, and cardiovascular disease, disproportionally affect people with SCI and raise concerns for the mortality risk among persons with SCI. A rapid systematic review of English, Spanish, Portuguese, and Chinese literature on COVID-19 and SCI was performed using the keywords "spinal cord injury" and "COVID-19." We included studies that provided information on clinical presentation, characteristics, course, and outcomes of COVID-19 disease in SCI. We excluded studies on patients who did not have an SCI before severe acute respiratory syndrome coronavirus-2 infection or did not report clinical information. We included 10 studies in total: nine studies with a total of 171 patients and a survey study of 783 healthcare professionals. Fever (74%), cough (52%), and dyspnea (33%) were the most frequently reported symptoms, and 63% showed abnormalities on X-ray imaging. In the included case series and reports (N = 31), only 1 patient required mechanical ventilation, but 3 patients died (10%). The mortality rate in a large registry study (N = 140) was 19%. Clinical presentation of COVID-19 in SCI patients was similar to the general population, and though adverse events and intensive care unit admission were low, the mortality rate was high (10-19%). No prognostic factors for severe disease or mortality could be identified. Registration (PROSPERO): CRD42020196565.

Initial assessment and management of respiratory infections in persons with spinal cord injuries and disorders in the COVID-19 era

As the COVID-19 pandemic unfolds, emergency department (ED) personnel will face a higher caseload, including those with special medical needs such as persons living with spinal cord injuries and disorders (SCI/D). Individuals with SCI/D who develop COVID-19 are at higher risk for rapid decompensation and development of acute respiratory failure during respiratory infections due to the combination of chronic respiratory muscle paralysis and autonomic dysregulation causing neurogenic restrictive/obstructive lung disease and chronic immune dysfunction. Often, acute respiratory infections will lead to significant mucus production in individuals with SCI/D, and aggressive secretion management is an important component of successful medical treatment. Secretion management techniques include nebulized bronchodilators, chest percussion/drainage techniques, manually assisted coughing techniques, nasotracheal suctioning, and mechanical insufflation-exsufflation. ED professionals, including respiratory therapists, should be familiar with the significant comorbidities associated with SCI/D and the customized secretion management procedures and techniques required for optimal medical management and prevention of respiratory failure. Importantly, protocols should also be implemented to minimize potential COVID-19 spread during aerosol-generating procedures.

Pulmonary Embolism After Acute Spinal Cord Injury and COVID-19

The coronavirus virus disease 2019 (COVID-19) is best known for its pulmonary sequelae. Understanding of the disease process is rapidly growing and the medical community already appreciates a hypercoagulable state associated with COVID-19. Acute spinal cord injury (SCI) has an inherent increased risk for venous thromboembolism (VTE). In this case report the patient presented with bilateral lower extremity weakness and sensory loss secondary to thoracic disc herniation. Incidentally, at the same time as the initial presentation, the patient was also found to have COVID-19 without significant respiratory symptoms. During hospitalization, the patient developed extensive bilateral lower extremity deep vein thrombosis (DVT) despite chemoprophylaxis. Therapeutic anticoagulation was initiated, yet several days later he developed pleuritic chest pain. Computed tomography (CT) angiography revealed bilateral pulmonary emboli. This case highlights the need for clinicians to have elevated vigilance in regards to screening and treatment for VTE in high-risk patients, such as SCI with a concurrent diagnosis of COVID-19.

A case for inspiratory muscle training in SCI: potential role as a preventative tool in infectious respiratory diseases like COVID-19

INTRODUCTION

Respiratory complications (RC) are a leading cause of death after spinal cord injury (SCI) due to compromised immune function and respiratory muscle weakness. Thus, individuals with SCI are at high risk of developing COVID-19 related RC. Results of a SCI clinical trial showed a supervised respiratory muscle training (RMT) program decreased risk of developing RC. The feasibility of conducting unsupervised RMT is not well documented. Four publications (n = 117) were identified in which unsupervised RMT was performed. Significant improvements in respiratory outcomes were reported in two studies: Maximal Inspiratory and Expiratory Pressure (MIP40% and MEP25%, respectively), Peak Expiratory Flow (PEF9%), seated and supine Forced Vital Capacity (FVC23% and 26%, respectively), and Peak Cough Flow (28%). This review and case report will attempt to show that an inspiratory muscle training (IMT) home exercise program (HEP) is feasible and may prepare the respiratory system for RC associated with COVID-19 in patients with SCI.

CASE PRESENTATION

A 23-year-old with tetraplegia (P1), history of mechanical ventilation, and hospitalization for RC, completed 27 IMT HEP sessions in one month. MIP and sustained MIP (SMIP) increased from baseline by 28% and 26.5%, respectively. Expiratory volumes and rates also improved (FVC, FEV1, and PEF: 11.7%, 8.3%, and 14.2%, respectively).

DISCUSSION

The effects of COVID-19 on patients with SCI remains inconclusive, but recent literature and the results of this case suggest that unsupervised IMT is feasible and may limit the severity of RC in patients with SCI who contract COVID-19.

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review

INTRODUCTION

This paper improves the methodology of the first edition of the rapid living systematic review started in April 2020, with the aim to gather and present the current evidence informing rehabilitation of patients with COVID-19 and/or describing the consequences due to the disease and its treatment.

EVIDENCE ACQUISITION

The Cochrane methodology for a rapid living systematic review was applied. Primary research papers, published from 1 January to 30 June 2020, reporting patients' data, with no limits of study design were included. Studies were categorized for study design, research question, COVID-19 phase, limitations of functioning (disability) of rehabilitation interest and type of rehabilitation service involved. Methodological quality assessment was based on the Cochrane Risk of Bias tools, and the level of evidence table (OCEBM 2011) for all the other studies.

EVIDENCE SYNTHESIS

Thirty-six, out of 3703 papers, were included. One paper was of level 2 (RCT), 7 were of level 3 (2 cohort studies, 2 cross-sectional studies and 3 case-control studies), and 28 papers of level 4 (descriptive studies); 61% of papers reported epidemiological data on clinical presentations, 5 investigated natural history/determining factors, 1 searched prevalence, 2 studies reported on intervention efficacy (though not on harms), and 5 studies looked at health service organization.

CONCLUSIONS

Main issues emerging from the review: it is advised to test for COVID-19 people with neurological disorders presenting with symptom changes; dysphagia is a frequent complication after oro-tracheal intubation in COVID-19 patients admitted to the ICU; after discharge, COVID-19 survivors may report persistent restrictive ventilatory deficits regardless of disease severity; there is only sparse and low quality evidence concerning the efficacy of any rehabilitation intervention to promote functional recovery; a substantial increase in resource (staff and equipment) is needed for rehabilitation.