Age-related variation in mobility independence among wheelchair users with spinal cord injury: A cross-sectional study

Change in mobility independence over 5 years for persons with chronic spinal cord injury

OBJECTIVES

To evaluate change in mobility independence (MI) in community dwelling persons with spinal cord injury (SCI).

PARTICIPANTS

Community Survey.

DESIGN

Cohort study. Rasch analysis was applied to the mobility subscale of the Spinal Cord Independence Measure - Self-Report data from years 2012 to 2017, resulting in a Rasch Mobility Independence Score (RMIS). We employed multilevel modeling to examine RMIS and its change over 5 years, adjusting for demographics and SCI severity; random forest regression was applied to determine the impact of modifiable factors (e.g. environmental factors, home-support) on its change.

RESULTS

The analysis included 728 participants. The majority (≈85%) of participants demonstrated little or no change in RMIS from 2012 to 2017; however, a smaller proportion (15%) showed considerably large change of more than 10 on the 100-point scale. A mixed-effects model with random slopes and intercepts described the dataset very well (conditional R2 of 0.95) in terms of demographics and SCI severity. Age was the main predictor of change in RMIS. Considering SCI severity, change in RMIS was related to age for the subgroup with paraplegia, and to time since injury for the subgroup with tetraplegia. No impact of modifiable factors was found.

CONCLUSION

RMIS in persons with SCI changes over a period of 5 years, especially in elder patients with paraplegia and persons with incomplete tetraplegia with more than 15 years of time since injury. During routine follow-up change in mobility independence should be assessed in order to timely intervene and prevent mobility loss and participation limitations.

Association Between the Availability of Mobility Assistive Products and Participation Outcomes in Individuals With Spinal Cord Injury in Switzerland

Objectives

This study investigated the association between the reported availability of mobility assistive products and the perceived frequency, restriction, and satisfaction of participation in individuals with spinal cord injury in Switzerland.

Methods

This study was based on a cross-sectional analysis based on questionnaire data collected from the Swiss SCI Cohort Study community survey in 2012 (N = 492). The availability of 12 mobility assistive products were analyzed as the main predictor variable. The outcomes of interest were the frequency, restriction, and satisfaction of participation scales as measured by the 32-item Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). The association between availability of mobility assistive products and participation was investigated using linear regressions analyses. All mobility assistive products were ranked in terms of relevance to improve participation by means of an importance performance plot.

Results

The availability of a sports wheelchair or a hand bike were both significant in reducing the restriction to participation. Having an adapted car increased the frequency of participation.

Conclusion

The availability of a sports wheelchair or a hand bike was significantly associated with less restriction in participation. With an unmet need of up to 36%, the known health benefits of regular physical activity and thereby cost-saving potential for the health care system, external support in the acquiring or use of these sports-related mobility assistive products could be an easy target for intervention.

Exercise and aerobic capacity in individuals with spinal cord injury: A systematic review with meta-analysis and meta-regression

BACKGROUND

A low level of cardiorespiratory fitness [CRF; defined as peak oxygen uptake ([Formula: see text]O2peak) or peak power output (PPO)] is a widely reported consequence of spinal cord injury (SCI) and a major risk factor associated with chronic disease. However, CRF can be modified by exercise. This systematic review with meta-analysis and meta-regression aimed to assess whether certain SCI characteristics and/or specific exercise considerations are moderators of changes in CRF.

METHODS AND FINDINGS

Databases (MEDLINE, EMBASE, CENTRAL, and Web of Science) were searched from inception to March 2023. A primary meta-analysis was conducted including randomised controlled trials (RCTs; exercise interventions lasting >2 weeks relative to control groups). A secondary meta-analysis pooled independent exercise interventions >2 weeks from longitudinal pre-post and RCT studies to explore whether subgroup differences in injury characteristics and/or exercise intervention parameters explained CRF changes. Further analyses included cohort, cross-sectional, and observational study designs. Outcome measures of interest were absolute (A[Formula: see text]O2peak) or relative [Formula: see text]O2peak (R[Formula: see text]O2peak), and/or PPO. Bias/quality was assessed via The Cochrane Risk of Bias 2 and the National Institute of Health Quality Assessment Tools. Certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Random effects models were used in all meta-analyses and meta-regressions. Of 21,020 identified records, 120 studies comprising 29 RCTs, 67 pre-post studies, 11 cohort, 7 cross-sectional, and 6 observational studies were included. The primary meta-analysis revealed significant improvements in A[Formula: see text]O2peak [0.16 (0.07, 0.25) L/min], R[Formula: see text]O2peak [2.9 (1.8, 3.9) mL/kg/min], and PPO [9 (5, 14) W] with exercise, relative to controls (p < 0.001). Ninety-six studies (117 independent exercise interventions comprising 1,331 adults with SCI) were included in the secondary, pooled meta-analysis which demonstrated significant increases in A[Formula: see text]O2peak [0.22 (0.17, 0.26) L/min], R[Formula: see text]O2peak [2.8 (2.2, 3.3) mL/kg/min], and PPO [11 (9, 13) W] (p < 0.001) following exercise interventions. There were subgroup differences for R[Formula: see text]O2peak based on exercise modality (p = 0.002) and intervention length (p = 0.01), but there were no differences for A[Formula: see text]O2peak. There were subgroup differences (p ≤ 0.018) for PPO based on time since injury, neurological level of injury, exercise modality, and frequency. The meta-regression found that studies with a higher mean age of participants were associated with smaller changes in A[Formula: see text]O2peak and R[Formula: see text]O2peak (p < 0.10). GRADE indicated a moderate level of certainty in the estimated effect for R[Formula: see text]O2peak, but low levels for A[Formula: see text]O2peak and PPO. This review may be limited by the small number of RCTs, which prevented a subgroup analysis within this specific study design.

CONCLUSIONS

Our primary meta-analysis confirms that performing exercise >2 weeks results in significant improvements to A[Formula: see text]O2peak, R[Formula: see text]O2peak, and PPO in individuals with SCI. The pooled meta-analysis subgroup comparisons identified that exercise interventions lasting up to 12 weeks yield the greatest change in R[Formula: see text]O2peak. Upper-body aerobic exercise and resistance training also appear the most effective at improving R[Formula: see text]O2peak and PPO. Furthermore, acutely injured, individuals with paraplegia, exercising for ≥3 sessions/week will likely experience the greatest change in PPO. Ageing seemingly diminishes the adaptive CRF responses to exercise training in individuals with SCI.

REGISTRATION

PROSPERO: CRD42018104342.

Moving forward: A review of continuous kinetics and kinematics during handcycling propulsion

Wheelchair users (WCUs) face high rates of shoulder overuse injuries. As exercise is recommended to reduce cardiovascular disease prevalent among WCUs, it is becoming increasingly important to understand the mechanisms behind shoulder soft-tissue injury in WCUs. Understanding the kinetics and kinematics during upper-limb propulsion is the first step toward evaluating soft-tissue injury risk in WCUs. This paper examines continuous kinetic and kinematic data available in the literature. Attach-unit and recumbent handcycling are examined and compared. Athletic modes of propulsion such as recumbent handcycling are important considering the higher contact forces, speed, and power outputs experienced during these activities that could put users at increased risk of injury. Understanding the underlying kinetics and kinematics during various propulsion modes can lend insight into shoulder loading, and therefore injury risk, during these activities and inform future exercise guidelines for WCUs.

MRI evaluation of shoulder pathologies in wheelchair users with spinal cord injury and the relation to shoulder pain

OBJECTIVE

To describe the number, specifics and co-occurrence of shoulder pathologies detected by MRI in manual wheelchair users with spinal cord injury and to evaluate the association between shoulder pathologies and presence of shoulder pain.

DESIGN

Cross-sectional observation study.

SETTING

Community.

PARTICIPANTS

Fifty-one wheelchair-dependent persons with spinal cord injury (44 males, 7 females, median age 50 years (IQR 14), median time since injury 24 years (IQR 16)) were allocated to pain or no-pain group based on the Wheelchair User Shoulder Pain Index.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

All persons underwent shoulder MRI. Pathologies were scored blinded by two experienced radiologists. Participant characteristics, number and severity of shoulder pathologies were analyzed descriptively. Logistic regression was performed to evaluate the association between MRI findings and shoulder pain.

RESULTS

The median number of co-occurring MRI findings per person ranged from 0 to 19 (out of 31 possible findings). The cluster of MRI findings occurring most often together were tendon tears of supraspinatus (present in 84%), subscapularis (69%) and biceps (67%) and osteoarthritis of acromioclavicular joint (80%). When correcting for age and time since injury, the logistic regression showed no statistically significant correlation between the individual pathologies and shoulder pain.

CONCLUSION

MRI findings of shoulder pathology are very frequent in persons with and without shoulder pain. Therefore, when diagnosing the cause of shoulder pain and planning interventions, health care professionals should keep this finding in mind and MRI should not be interpreted without careful consideration of clinical history and functional testing.

Understanding the Global Challenges to Accessing Appropriate Wheelchairs: Position Paper

Introduction: Appropriate wheelchairs are often essential for the health and wellbeing of people with mobility impairments to enhance fundamental freedoms and equal opportunity. To date, provision has mainly focused on just delivering the wheelchair instead of following an evidence-based wheelchair service delivery process. In addition, many governments have not committed to a national wheelchair provision policy. Approach: To prepare this position paper, a systemic development model, founded on the sustainable human security paradigm, was employed to explore the global challenges to accessing appropriate wheelchairs. Positions: I: Consideration of key perspectives of wheelchair provision across the life course is essential to meet the needs to children, adults, older people and their families; II: Comprehensive wheelchair service delivery processes and a competent workforce are essential to ensure appropriate wheelchair service provision; III: Evaluations on wheelchair product quality development, performance and procurement standards are key as wheelchair product quality is generally poor; IV: Understanding the economic landscape when providing wheelchairs is critical. Wheelchair funding systems vary across jurisdictions; V: Establishing wheelchair provision policy is a key priority, as specific policy is limited globally. Conclusion: The vision is to take positive action to develop appropriate and sustainable wheelchair service provision systems globally, for me, for you, for us.

Functional independence of persons with long-standing motor complete spinal cord injury in the Netherlands

Context/Objective: Since life expectancy of persons with spinal cord injury (SCI) has improved, it is relevant to know whether this group is able to maintain functional abilities many years after onset of SCI. Objectives of this study were (1) to examine associations between time since injury (TSI) and functional independence in persons with long-standing SCI and (2) to explore associations between functional independence and level of injury, comorbidities, mental health, waist circumference and secondary health conditions (SHCs).Design: TSI-stratified cross-sectional study. Strata were 10-19, 20-29 and 30+ years.Setting: Community.Participants: 226 persons with long-standing SCI. Inclusion criteria: motor complete SCI; age at injury 18-35 years; TSI ≥ 10 years; current age 28-65 years; wheelchair dependency.Interventions: Not applicable.Outcome measures: The Spinal Cord Independence Measure III (SCIM) was administered by a trained research assistant. Level of injury, comorbidities, mental health, waist circumference and SHCs were assessed by a rehabilitation physician.Results: Mean TSI was 23.6 (SD 9.1) years. No significant differences in SCIM scores were found between TSI strata. SCIM scores were lower for persons with tetraplegia, autonomic dysreflexia, hypotension, more than four SHCs and a high waist circumference. In linear regression analyses, TSI nor age was associated with the SCIM total score. Only level of injury (β = -0.7; P < .001) and waist circumference (β = -0.1; P = .042) were independent determinants (explained variance 55%).Conclusion: We found no association between TSI and functional independence in persons with long-standing motor complete SCI. This study confirms the possible effect of overweight on functional independence.

Availability and need of home adaptations for personal mobility among individuals with spinal cord injury

OBJECTIVE

To identify the availability and unmet need of home adaptations (HAs) among the Swiss population with spinal cord injury (SCI).

DESIGN

Cross-sectional study.

SETTING

Swiss Spinal Cord Injury Community Survey 2012.

PARTICIPANTS

Individuals aged 16 or older with chronic SCI living in Switzerland.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

The availability of ten HAs (self-report) was analyzed by sex, age, living situation, indoor mobility, SCI severity, SCI etiology and time since SCI. The unmet need (self-report of not having a HA but needing it) of HAs was analyzed by financial hardship.

RESULTS

Among the 482 study participants (mean age 55.2 years, standard deviation 15.0 years, 71.6% males), 85.1% had at least one HA. The most frequent HA was a wheelchair accessible shower (62.7%). Availability of HAs markedly varied with indoor mobility (e.g. 38.4% of participants using a wheelchair had a stair lift compared to 17.4% of those walking) and with SCI severity (e.g. 54.8% of those with complete paraplegia had a wheelchair accessible kitchen worktop compared to 26.0% of those with incomplete paraplegia). Unmet need was highest for adjustable kitchen worktops (78.7% of those with a need) and adjustable kitchen cabinets (75.7%) and lowest for wheelchair accessible showers (9.4%) and grab bars next to the toilet (8.5%). No significant differences in unmet need were found when stratifying for financial hardship.

CONCLUSION

Availability of HAs is dependent on indoor mobility and SCI severity. There is a considerable degree of unmet need for selected HAs, which couldn't be explained by financial hardship.