Are Comorbid Pain and Depressive Symptoms Associated with Rehabilitation of Individuals with Spinal Cord Injury?

Predicting Duration of Outpatient Physical Therapy Episodes for Individuals with Spinal Cord Injury Based on Locomotor Training Strategy

OBJECTIVE

To characterize individuals with spinal cord injuries (SCI) who use outpatient physical therapy or community wellness services for locomotor training and predict the duration of services, controlling for demographic, injury, quality of life, and service and financial characteristics. We explore how the duration of services is related to locomotor strategy.

DESIGN

Observational study of participants at 4 SCI Model Systems centers with survival. Weibull regression model to predict the duration of services.

SETTING

Rehabilitation and community wellness facilities at 4 SCI Model Systems centers.

PARTICIPANTS

Eligibility criteria were SCI or dysfunction resulting in motor impairment and the use of physical therapy or community wellness programs for locomotor/gait training. We excluded those who did not complete training or who experienced a disruption in training greater than 45 days. Our sample included 62 participants in conventional therapy and 37 participants in robotic exoskeleton training.

INTERVENTIONS

Outpatient physical therapy or community wellness services for locomotor/gait training.

MAIN OUTCOME MEASURES

SCI characteristics (level and completeness of injury) and the duration of services from medical records. Self-reported perceptions of SCI consequences using the SCI-Functional Index for basic mobility and SCI-Quality of Life measurement system for bowel difficulties, bladder difficulties, and pain interference.

RESULTS

After controlling for predictors, the duration of services for the conventional therapy group was an average of 63% longer than for the robotic exoskeleton group, however each visit was 50% shorter in total time. Men had an 11% longer duration of services than women had. Participants with complete injuries had a duration of services that was approximately 1.72 times longer than participants with incomplete injuries. Perceived improvement was larger in the conventional group.

CONCLUSIONS

Locomotor/gait training strategies are distinctive for individuals with SCI using a robotic exoskeleton in a community wellness facility as episodes are shorter but individual sessions are longer. Participants' preferences and the ability to pay for ongoing services may be critical factors associated with the duration of outpatient services.

Relationship Between Serum Fibrinogen Level and Depressive Symptoms in an Adult Population with Spinal Cord Injury: A Cross-Sectional Study

PURPOSE

Depression is associated with an inflammatory immune response. There are minimal data regarding the association of inflammatory markers with depression in patients with spinal cord injury (SCI). We aimed to investigate the association of inflammatory markers with depression in middle-aged and elderly SCI patients.

METHODS

Data were obtained from the Midlife in the United States (MIDUS) study, a longitudinal study of a representative sample of the adult population. We analyzed the associations of serum levels of fibrinogen, interleukin-6, tumor necrosis factor-ɑ, and C-reactive protein with depressive symptoms.

RESULTS

The median participant age was 52.5 years; 44.9% of participants were men. Multivariate linear regression analyses showed that an increased serum fibrinogen level (Sβ = 0.114, p = 0.005) was associated with higher Centre for Epidemiological Studies-Depression (CES-D) scores after adjustment for age, sex, body mass index (BMI), ethnicity, education, marital status, smoking, alcohol use, exercise, perceived stress score, and cardiovascular disease (CVD). Multivariate logistic regression analysis showed that an increased serum fibrinogen level was independently associated with a history of depression (odds ratio [OR] = 1.240, 95% confidence interval [CI] = 1.103-1.997, p = 0.012) and depressive symptoms (OR = 1.884, 95% CI = 1.165-2.499, p < 0.001; CES-D score ≥ 16) after adjustment for confounding factors. Stratified analysis revealed that the association between serum fibrinogen level and depressive symptoms was affected by antidepressant use.

CONCLUSION

Serum fibrinogen level had a significantly positive association with depressive symptoms in middle-aged and elderly patients with SCI. Future longitudinal cohort studies should evaluate the possible use of serum fibrinogen for diagnosis of depression in SCI patients.

Co-Located or Freestanding Multi-Trauma Orthopedic Rehabilitation

INTRODUCTION

Multi-trauma rehabilitation is delivered in a variety of hospital settings. However, it is unclear whether the proximity of rehabilitation to acute services has an effect on rehabilitation outcomes.

OBJECTIVE

To evaluate whether the primary outcomes of an inpatient multi-trauma rehabilitation program (functional outcome and length of rehabilitation stay) are impacted when rehabilitation is delivered in a unit co-located in an acute hospital compared with a unit located in a freestanding hospital. To also compare these outcomes at a national level using data provided by the Australasian Rehabilitation Outcomes Centre (AROC).

DESIGN

Observational, retrospective audit study.

SETTING

An inpatient, orthopedic, multi-trauma rehabilitation unit that re-located from an acute co-located facility to a freestanding facility.

PATIENTS

Patients following multi-trauma injury admitted to the co-located rehabilitation unit (n = 216) or after its relocation to the freestanding rehabilitation unit (n = 186).

METHODS

Data were audited from the patients' hospital medical records including demographics, injury characteristics, and rehabilitation outcome measures (Functional Independence Measure [FIM] and length of rehabilitation stay).

OUTCOME MEASURES

The primary outcome variables were motor FIM change (change in function between admission and discharge), FIM efficiency (functional gain per inpatient day), and length of rehabilitation stay.

RESULTS

There were no statistically significant differences between the two settings in terms of motor FIM change (adjusted for admission motor FIM score) and motor FIM efficiency. In general, there was no statistically significant difference in length of rehabilitation stay between settings (median: 26 vs 27 days). At a national level, the majority of facilities offering inpatient multi-trauma rehabilitation are co-located. Nationally, freestanding units resulted in a slightly greater motor FIM change (difference between median changes adjusted for baseline = -.5, 95% confidence interval [CI] = -2.5, -0.6, P = .0012).

CONCLUSIONS

There were no differences observed in outcomes between multidisciplinary rehabilitation programs in either setting. Optimizing the individual components of a rehabilitation program and improving staff skill sets should be a focus going forward.

Spinal cord injury by clip-compression induces anxiety and depression-like behaviours in female rats: The role of the inflammatory response

Traumatic spinal cord injury (SCI) promotes long-term disability that affects mobility and functional independence. The spinal cord inflammatory response after the initial mechanical insult substantially impacts locomotor impairment and development of neuropsychiatric disorders, including anxiety and depression. However, these psychiatric events are scarcely investigated in females. This study investigated the anxiety/depression-like behaviours and inflammatory responses related to the production/release of pro- and anti-inflammatory cytokines in female adult Wistar rats submitted to severe clip-compression SCI. Data showed that SCI impaired the locomotor performance assessment by the BBB scale, but did not alter exploratory activity in open-field test. Animals' locomotor impairment was associated with anxious and depressive-like behaviours characterised by a decreased amount of time in the open arms of the elevated plus-maze test, and the motivational reduction of social interaction and anhedonia assessed by social exploration and sucrose preference tests. By contrast, SCI decreased the immobility time in the forced swimming test. Moreover, SCI caused a significant increase in local and systemic proinflammatory cytokines (TNF-α, INF-γ, IL-1β, and IL-6) and a reduction in the anti-inflammatory cytokine IL-10. Finally, there were significant negative correlations between depression-like behaviour, but not anxiety, and increased plasma concentrations of TNF-α, IL-1β, IL-6, and INF-γ. Additionally, the laminectomy procedure provoked the inflammatory response associated with reduced sucrose intake in Sham animals, although less expressively than in the SCI group. Collectively, these results indicate that SCI by clip-compression in female rats promotes a neuropsychiatric-like profile associated with an imbalance in the production/release of pro- and anti-inflammatory cytokines.