Implementation of a Standardized Dataset for Collecting Information on Patients With Spinal Cord Injury

The effect of breathing exercises and mindset with or without cold exposure on mental and physical health in persons with a spinal cord injury-a protocol for a three-arm randomised-controlled trial

STUDY DESIGN

A three-arm randomized controlled trial.

OBJECTIVES

To investigate the effects of the Wim Hof Method (WHM), with (WHM-C) and without cold exposure (WHM-NC), on mental and physical health in persons with chronic spinal cord injury (SCI).

SETTING

Rehabilitation centre (assessments and once-weekly intervention sessions) and home-based (daily intervention sessions).

METHODS

Sixty adults with chronic SCI will be randomised (1:1:1) to one of three groups: participants in the intervention groups (i.e., WHM-C and WHM-NC) will engage in a 7-week intervention, with one weekly practice session at the rehabilitation centre and a daily WHM session at home. WHM-NC will consist of breathing exercises and mindset, while participants in WHM-C will partake in breathing exercises, mindset and cold exposure. Participants allocated to usual care (UC) will not receive the WHM intervention. The primary outcome is mental health reported via the Mental Health Inventory (MHI)-5, while secondary outcomes include circulating inflammatory and metabolic marker concentration, pulmonary function, body composition, sleep quality, spasticity, chronic pain and psychological stress.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the medical ethics committee of the Máxima Medical Centre (Veldhoven, the Netherlands; identifier: w22.069). If shown efficacious in improving mental health, as well as physical health, in persons with chronic SCI, the low cost and accessibility of the WHM allows it to be directly implemented in SCI rehabilitation.

TRIAL REGISTRATION NUMBER

NCT05704322.

The social dimension of quality of life following spinal cord injury or disease: an international ICF-linking study

STUDY DESIGN

International Classification of Functioning, Disability and Health (ICF) linking study.

OBJECTIVE

Analyze cognitive interview data using the ICF as an analytic framework, to examine aspects of social life relevant to quality of life (QoL) according to people with spinal cord injury or disease (SCI/D). This study builds upon results of an international study about the cross-cultural validity of the International SCI QoL Basic Data Set (QoL-BDS).

SETTING

Four specialized outpatient clinics in SCI/D rehabilitation, from the US, Brazil and Australia.

METHODS

Analysis of qualitative data from 39 cognitive interviews with SCI/D patients at least one year post onset. Participants were asked to define their concept of QoL, overall life satisfaction, physical health and psychological health, and other relevant matters. Four independent researchers coded text fragments related to the items, and fragments were linked to ICF chapters d6-d9, following established linking rules.

RESULTS

The proportion of text referring to social life was 35.8% (definition QoL), 24.9% (QoL life as whole), 6.0% (physical health) and 34.9% (psychological health). The most frequent ICF categories were d760 Family relationships, d770 Intimate relationships and d920 Recreation and leisure. Most frequent responded social topics to the 'other issues' item were d770 Intimate relationships, d760 Formal relationships, and d870 Economic self-sufficiency.

CONCLUSION

The importance of social life aspects to the QoL was highlighted based on responses of SCI/D patients, clearly demonstrated through the ICF linking process. Adding a satisfaction with social life item to the QoL-BDS has made this instrument a more comprehensive measure.

The international spinal cord injury pain basic data set (version 3.0)

STUDY DESIGN

Expert opinion, feedback, revisions, and final consensus.

OBJECTIVES

To update the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS version 2.0) and incorporate suggestions from the SCI pain clinical and research community with respect to overall utility.

SETTING

International.

METHODS

The ISCIPBDS working group evaluated these suggestions and made modifications. The revised ISCIPBDS (Version 3.0) was then reviewed by members of the International SCI Data Sets Committee, the American Spinal Injury Association (ASIA) Board, the International Spinal Cord Society (ISCoS) Executive and Scientific Committees, individual reviewers and societies, and posted on the ASIA and ISCoS websites for 1 month to elicit comments before final approval by ASIA and ISCoS.

RESULTS

The ISCIPBDS (Version 3.0) was updated to make the dataset more flexible and useful: 1. The assessment can be based on the patient's perception of several of his/her "worst" pain(s) or based on the International SCI Pain (ISCIP) Classification-defined or other pain types, depending on the specific research questions or clinical needs. 2. Pain interference should usually be rated for overall pain but may also be used for specific pain problems if needed. 3. An optional pain drawing was added to complement the check box documentation of pain location. 4. Data categories consistent with the Extended Pain Dataset list of current treatments were added. 5. Several new training cases were added.

The Effect of Mindset and Breathing Exercises on Physical and Mental Health in Persons with Spinal Cord Injury-A Pilot Feasibility Study

This study investigated the feasibility and efficacy of mindset and breathing exercises (Wim Hof Method (WHM)) on physical and mental health in persons with spinal cord injury (SCI). Ten individuals with SCI participated in this pilot study. These ten participants followed a 4-week WHM intervention, with one weekly group session in the rehabilitation center and daily practice at home using the WHM app. An in-person exit-interview was conducted post-intervention to collect qualitative information on participants' experiences, regarding the feasibility and effects of the intervention. Furthermore, tests and questionnaires were administered pre- and post-intervention to assess physical and mental health outcomes. Adherence to the weekly in-person meetings was excellent and no adverse events occurred. Physical and mental health outcomes in this small sample size showed some pre-post differences. This pilot feasibility study provides preliminary evidence supporting the feasibility and efficacy of the WHM, including mindset and breathing exercises, on physical and mental health of people with SCI. These results warrant a randomized-controlled trial, including cold exposure, of this novel intervention in people with SCI.

Effective bowel management in spinal cord injury during inpatient rehabilitation: data from the Dutch spinal cord injury database

STUDY DESIGN

Retrospective Observational Study.

OBJECTIVES

To describe bowel management in individuals with a recently acquired spinal cord injury (SCI) both at admittance and discharge from first inpatient rehabilitation, and to determine factors that contribute to effective bowel management (EBM) at discharge.

SETTING

Specialized rehabilitation centers in the Netherlands.

METHODS

Data from the Dutch Spinal Cord Injury Database (DSCID) collected between 2015 and 2019 was used. EBM was defined by the variables of stool frequency and fecal incontinence. After univariate analysis, a multivariate regression analysis was conducted.

RESULTS

Of 1,210 participants, 818 (68%) did not have EBM at admittance. At discharge, 308 (38%) did still not have EBM (in total 33% of all participants). The odds of having EBM at discharge was 2.82 times higher for participants with ASIA Impairment Scale (AIS) D compared to those with AIS-A (95% CI: 1.38-5.78). Participants with non-traumatic SCI had higher odds of having EBM than those with traumatic SCI (OR: 0.59, 95% CI 0.38-0.91). Use of suppositories, small enema, medication influencing bowel function, and oral laxatives at admittance did not influence EBM significantly at discharge.

CONCLUSIONS

Bowel management improves during first inpatient rehabilitation. However, realizing EBM after a recently acquired SCI is a challenge. This endorses the importance of bowel management during inpatient rehabilitation, especially for people with AIS-A and non-traumatic etiology.

Computer International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) algorithms: a review

STUDY DESIGN

Literature review and survey.

OBJECTIVES

To provide an overview of existing computerized International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) algorithms and to evaluate the use of the current algorithms in research and clinical care.

SETTING

Not applicable.

METHODS

Literature review according to three organizing concepts for evaluation of Health Information Products (reach, usefulness, and use) was conducted.

RESULTS

While the use of computerized ISNCSCI algorithms has been around for many years, many were developed and used internally for specific projects or not maintained. Today the International SCI community has free access to algorithms from the European Multicenter Study about Spinal Cord Injury (EMSCI) and the Praxis Spinal Cord Institute. Both algorithms have been validated in large datasets and are used in different SCI registries for quality control and education purposes. The use of the Praxis Institute algorithm by clinicians was highlighted through the Praxis User Survey (n = 76) which included participants from 27 countries. The survey found that over half of the participants using the algorithm (N = 69) did so on a regular basis (51%), with 54% having incorporated it into their regular workflow.

CONCLUSIONS

Validated computerized ISNCSCI classification tools have evolved substantially and support education, clinical documentation, communication between clinicians and their patients, and ISNCSCI data quality around the world. They are not intended to replace well-trained clinicians, but allow for reclassification of ISNCSCI datasets with updated versions of the ISCNSCI, and support rapid classification of large datasets.

Standard set of network outcomes for traumatic spinal cord injury: a consensus-based approach using the Delphi method

STUDY DESIGN

Consensus study.

OBJECTIVES

The purpose of this study is to define a standardized (network) outcomes set for traumatic spinal cord injury (t-SCI), covering the patient journey from acute to chronic rehabilitation phase, including patient-relevant outcomes, adequate measurement instruments, as well as case-mix and risk factors.

SETTING

Acute Spinal Cord Injury (ASCI) Unit Nijmegen, the Netherlands.

METHODS

A modified Delphi method was performed, including a multidisciplinary panel of 19 health-care professionals with experience in t-SCI management. Formal consensus was reached after two web-based surveys, a face-to-face meeting, and a final confirmation round (threshold consensus: 70%).

RESULTS

In the first two Delphi rounds, 18/19 invited panelists (94.7%) responded and 10 panelists participated in the final meeting. The prefinal set was confirmed by all panelists. The standard set encompasses the three-tiered outcome hierarchy and consists of patient-reported and clinician-reported outcome domains and measurement instruments. Consensus was reached to include survival, degree of health or recovery, time to recovery, and return to normal activities, disutility of care or treatment process, sustainability of health and nature of recurrences, and long-term consequences of therapy. A measurement schedule was defined as well as for proposed casemix and risk factors, including demographics, clinical status, and treatment process.

CONCLUSION

A standard set of network outcomes is developed that could be implemented in hospitals and rehabilitation centers involved in the treatment of t-SCI. Using this standard set, comparison of the quality of care is possible and prognostic prediction of outcomes of treatment is feasible, so that each patient receives the right care at the right time in the right place.

Evaluation of the International Spinal Cord Injury Bowel Function Basic Data Set Version 2.0 in Children and Youth With Spinal Cord Injury

OBJECTIVES

To establish the utility and feasibility of the International Spinal Cord Injury/Dysfunction (SCI/D) Bowel Function Basic Data Set Version 2.0 in pediatric SCI populations.

METHODS

This was a noninterventional, repeated measure design conducted in Pennsylvania, Maryland, Illinois, Kentucky, and South Carolina. The International Spinal Cord Injury/Dysfunction (SCI/D) Bowel Function Basic Data Set Version 2.0 was administered repeatedly, twice at the point of care and once over the phone. Time to complete the data set was recorded. Inter- and intrarater reliability was examined by intraclass correlation coefficients (ICC) with 95% confidence intervals (CI), and agreement between the bowel function basic data set variables and medical records was calculated using percentages. Intrarater reliability involved the same person administering the data once at the point of care and once over the phone.

RESULTS

Forty-one children/youth ages 1 to 20 years participated in this study. Average time to complete the data set was 5.17 minutes. Interrater reliability was good to excellent (ICC ≥ 0.75) for most variables. Five variables had moderate interrater reliability (ICC = 0.05-0.74) and three had poor interrater reliability (ICC < 0.05). With the exception of one variable that had poor intrarater reliability (constipating agent, ICC = 0.00) and one that approached moderate reliability (digital evacuation, ICC = 0.74), intrarater reliability was good to strong for every bowel variable (ICC = 0.88-1.00). Only 12 (32%) medical records had explicit documentation of one or more of the variables on the Basic Bowel Function Basic Data Set V2.0.

CONCLUSION

The results support future research with a larger and more diverse sample of children with SCI to build upon the psychometric work described herein.

An evaluation of the representativeness of a national spinal cord injury registry: a population-based cohort study

STUDY DESIGN

Population-based cohort study for the western part of Quebec.

OBJECTIVES

To determine the impact of declining to participate in a national spinal cord injury (SCI) registry on patient outcomes and continuum of care.

SETTING

Level-1 trauma center specialized in SCI care in Montreal, Canada.

METHODS

This cohort study compared the outcomes of 444 patients who were enrolled in the Rick Hansen SCI registry and 140 patients who refused. Logistic regression analyses were performed to assess the association between voluntary participation and the outcomes, while adjusting for confounding factors. The main outcomes were: attendance to follow-up 6- to 12-month post injury, 1-year mortality, and the occurrence of pressure injury during acute care.

RESULTS

Declining to be enrolled in the registry was a significant predictor of lower attendance to specialized follow-up (adjusted odds ratio [OR] 0.04, 95% confidence interval [CI] 0.02-0.08). It was also associated with a higher 1-year mortality rate (OR 12.50, CI 4.50-33.30) and higher occurrence of pressure injury (OR 2.56, CI 1.56-4.17).

CONCLUSIONS

This study sheds invaluable insight on individuals that researchers and clinicians are usually blind to in SCI cohort studies. This study suggests that decline to participate in a registry during the care hospitalization may be associated with worsened health, poorer outcomes, and reduced follow-up to specialized care. Declining the enrollment to voluntary registry could represent a potential prognostic factor for future research.

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

Study protocol of a double-blind randomised placebo-controlled trial on the effect of a multispecies probiotic on the incidence of antibiotic-associated diarrhoea in persons with spinal cord injury

STUDY DESIGN

Multi-centre, double-blind randomised placebo-controlled study.

OBJECTIVE

To investigate whether the use of a multispecies probiotic can prevent antibiotic-associated diarrhoea in people with spinal cord injury (SCI).

SETTING

Three Dutch SCI rehabilitation centres.

METHODS

Fifty-six people aged 18-75 years with SCI during inpatient rehabilitation, who require antibiotics, will be given probiotics or placebo randomly assigned (T0). After cessation of the antibiotics (T1), the participants will use probiotics/placebo for 3 more weeks (T2). Defaecation, assessed by the Bristol Stool Scale, and bowel management will be monitored daily until 2 weeks after cessation of probiotics/placebo intake (T3). Also, the degree of nausea and information on quality of life will be collected at T0, T1, T2 and T3.

MAIN OUTCOME MEASURES

The difference between the incidence of antibiotic-associated diarrhoea between people with SCI using probiotics compared to those using a placebo at the moment the antibiotics stops, the probiotics stops and two weeks thereafter.

SECONDARY OUTCOME MEASURES

The time to reach effective bowel management, degree of nausea and quality of life.

REGISTRATION

The Dutch Trial Register- NTR 5831.

Relationship between Movement Quality, Functional Ambulation Status, and Spatiotemporal Gait Parameters in Children with Myelomeningocele

AIMS

We investigated relationships among the Pediatric Neuromuscular Recovery Scale (Peds NRS), modified Hoffer Scale, and spatiotemporal gait parameters in children with myelomeningocele (MMC).

METHODS

21 children with MMC, age 5.3 years (SD = 2.6), were assessed by three clinicians using the Peds NRS and modified Hoffer Scale. In eight children, gait parameters were also measured.

RESULTS

The Peds NRS summary score demonstrated good correlation with modified Hoffer Scale score (r = -0.64, p = 0.002) that accounted for 41% of variation in summary score. Six Peds NRS seated/standing items exhibited good relationships with modified Hoffer Scale (r = -0.51 to -0.70, p ≤ 0.023), and the sit-to-stand item demonstrated an excellent relationship (r = -0.85, p < 0.001). Sit-to-stand and three standing/walking items exhibited excellent associations with cadence (R_s = 0.81 to 0.88, p ≤ 0.014), and swing and stance time (both R_s = -0.83 to -0.90, p ≤ 0.01). Two Peds NRS standing items and modified Hoffer Scale score demonstrated good correlations with velocity (R_s = 0.71, p = 0.047; R_s = -0.73, p = 0.04, respectively).

CONCLUSIONS

Our findings suggest that children with MMC who exhibit greater movement quality and trunk control are likely to be functional ambulators with more optimal spatiotemporal gait parameters.

Reproducibility of the international spinal cord injury quality of life basic data set: an international psychometric study

STUDY DESIGN

Psychometric study.

OBJECTIVES

To examine the reproducibility of the international spinal cord injury quality of life basic data set (QoL-BDS) in an international sample of community-dwelling adults with spinal cord injury or disease (SCI/SCD) and in subgroups with respect to age (< 50 vs. ≥ 50 years) and etiology.

SETTING

Outpatient rehabilitation clinics and community.

METHODS

Participants were people living with SCI/D in four countries, at least 1 year post onset and at least 18 years of age. The QoL-BDS consists of three items on satisfaction with life as a whole, physical health and psychological health rated on a 0-10 numerical rating scale. A fourth item on satisfaction with social life was included based on feedback from participants.

RESULTS

A total of 79 people were included. Median age was 52 years. Most participants (69.6%) had SCI, paraplegia (53%), and 40.5% reported a motor complete injury. Median time between tests was 14 days (range 4-27). Intra-class correlation (ICC) values of the items ranged from 0.66 to 0.80. ICC values of the three-item and four-item total scores were identical and good (0.83; 95% CI 0.75-0.89). Subgroup analyses showed ICC values ranging from 0.76 to 0.83. Bland-Altman plots suggested no bias for the three-item total score, but some bias for the four-item total score. The limits of agreement of both scores were similar, wide at individual level and small at group level.

CONCLUSIONS

This study provides evidence of reproducibility of the current version of the QoL-BDS. When adding a fourth item, reproducibility was maintained.

International Spinal Cord Injury Lower Urinary Tract Function Basic Data Set (version 2.0)

STUDY DESIGN

Revision, review, and presentation of the International Spinal Cord Injury (SCI) Lower Urinary Tract (LUT) Function Basic Data Set (version 2.0).

OBJECTIVES

Describe the revision and review and present the data set.

SETTING

International.

METHODS

The first version of the data set was revised according to new knowledge and suggestions. The review included International SCI Data Sets Committee, American Spinal Injury Association (ASIA) board, International Spinal Cord Society (ISCoS) executive and scientific committees, major organizations, and interested individuals. The data set was also on ASIA and ISCoS websites. All replies were answered and appropriate adjustments made. Finally, the data set was endorsed by ASIA board, and ISCoS executive and scientific committees.

RESULTS

Among revisions are adoptions of new terminology by the International Continence Society. For most variables, advice for collection of information from pediatric patients stated. For the variable 'Bladder emptying', is in the data collection form to the response category 'Normal voiding' expanded. 'Sacral Anterior Root Stimulator' is deleted as response category. For the variable 'Any involuntary urine leakage (incontinence) within the last 4 weeks' 'last 4 weeks' has replaced 'last 3 months'. The response categories have been adjusted to: 'Daily', 'Once or more per week (but not daily)', 'Less than once per week', 'Never', 'Not applicable' and 'Unknown'. For the variable 'Any drugs for the urinary tract within the last four weeks' 'last four weeks' has replaced 'last year'.

CONCLUSIONS

The International SCI LUT Function Basic Data Set (version 2.0) with its complete syllabus is available from http://www.iscos.org.uk/international-sci-data-sets.

Progress of the Dutch Spinal Cord Injury Database: Completeness of Database and Profile of Patients Admitted for Inpatient Rehabilitation in 2015

Background: In the Dutch International Spinal Cord Injury (SCI) Data Sets project, we translated all International SCI Data Sets available in 2012 and created a Dutch SCI Database (NDD). Objective: To describe the number of included patients and completeness of the NDD, and to use the NDD to provide a profile of people with traumatic SCI (T-SCI) and non-traumatic SCI (NT-SCI) in the Netherlands. Methods: The NDD includes patients admitted for their first inpatient rehabilitation after onset of SCI to 1 of the 8 rehabilitation centers with a specialty in SCI rehabilitation in the Netherlands. Data of patients admitted in 2015 were analyzed. Results: Data for 424 patients were available at admission; for 310 of these patients (73.1%), discharge data were available. No significant differences were found between patients with and without data at discharge. Data were nearly complete (>90%) for lower urinary tract, bowel, pain, and skin. Data on sexual function has the lowest completion rate. Complete neurological and functional data were available for 41.7% and 38%, respectively. Most patients were male (63.4%), had NT-SCI (65.5%), and had incomplete SCI (58.4% D). Patients with T-SCI differed from patients with NT-SCI on most characteristics, and they stayed considerably longer in the rehabilitation center (112 days vs 65 days, p < .001). Place of discharge was not different between both groups. Conclusion: With the NDD, we collect important data on the majority of Dutch SCI patients, although much work needs to be done to improve the completeness of the data collection.