Secondary health conditions in persons with a spinal cord injury for at least 10 years: design of a comprehensive long-term cross-sectional study

Bowel burdens: a systematic review and meta-analysis examining the relationships between bowel dysfunction and quality of life after spinal cord injury

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Many individuals with spinal cord injury (SCI) experience autonomic dysfunction, including profound impairments to bowel and cardiovascular function. Neurogenic bowel dysfunction (NBD) is emerging as a potential determinant of quality of life (QoL) after SCI. For individuals with high-level lesions ( > T6), bowel care-related autonomic dysreflexia (B-AD; profound episodic hypertension) further complicates bowel care. We aimed to evaluate the extent of bowel dysfunction after SCI, and the impact of bowel dysfunction on QoL after SCI.

METHODS

We searched five databases to identify research assessing the influence of NBD or B-AD on QoL after SCI. Metrics of bowel dysfunction (fecal incontinence [FI], constipation, time to complete, and B-AD) and QoL data were extracted and synthesised. Where possible, meta-analyses were performed.

RESULTS

Our search identified 2042 titles, of which 39 met our inclusion criteria. Individuals with SCI identified problems with NBD (74.7%), FI (56.9%), and constipation (54.6%), and 49.3% of individuals with SCI > T6 experienced B-AD. Additionally, 40.3% of individuals experienced prolonged defecation ( > 30 min). Moderate/severe deterioration in QoL due to NBD was reported by 55.5% of individuals with SCI, with negative impacts on physical, emotional, and social health-related QoL associated with inflexibility of bowel routines, fear of accidents, and loss of independence.

CONCLUSION

Bowel dysfunction and bowel care challenges are prevalent and disabling for individuals with SCI, with a profoundly negative impact on QoL. Improving bowel management is a key target to improve QoL for those living with SCI.

Obesity in wheelchair users with long-standing spinal cord injury: prevalence and associations with time since injury and physical activity

STUDY DESIGN

Secondary analysis of cross-sectional data from the ALLRISC cohort study.

OBJECTIVES

To investigate the prevalence of obesity and its association with time since injury (TSI) and physical activity (PA) in wheelchair users with long-standing (TSI > 10 years) spinal cord injury (SCI).

SETTING

Community, The Netherlands.

METHODS

Wheelchair users with SCI (N = 282) in TSI strata (10-19, 20-29, and ≥30 years) and divided in meeting SCI-specific exercise guidelines or not. Waist circumference (WC) and body mass index (BMI) were assessed. Participants were classified as being obese (WC > 102 cm for men, WC > 88 cm for women; BMI ≥ 25 kg/m2) or not. Logistic regression analyses were performed to investigate the associations between obesity and TSI and PA.

RESULTS

Almost half of the participants (45-47%) were classified as obese. TSI was significantly associated with obesity, the odds of being obese were 1.4 higher when having a 10 years longer TSI. Furthermore, the odds of being obese were 2.0 lower for participants who were meeting the exercise guidelines.

CONCLUSIONS

The prevalence of obesity is high in people with long-standing SCI. Those with a longer TSI and individuals who do not meet the exercise guidelines are more likely to be obese and need to be targeted for weight management interventions.

Relationships between cardiovascular disease risk, neuropathic pain, mental health, and autonomic function in chronic spinal cord injury

STUDY DESIGN

Multicentre, cross-sectional study.

OBJECTIVES

To determine if clinical measures of poor mental health (MH-) and neuropathic pain (NP) are related to increased CVD risk in individuals with chronic spinal cord injury (SCI), and further elucidate the relationships between CVD risk, autonomic function, NP, and MH-.

SETTING

Eight SCI rehabilitation centres in the Netherlands.

METHODS

Individuals (n = 257) with a traumatic, chronic (≥10 yrs) SCI, with age at injury between 18-35 years, completed a self-report questionnaire and a one-day visit to a rehabilitation centre for testing. CVD risk was calculated using Framingham risk score. NP was inferred using The Douleur Neuropathique 4 clinical examination, and MH- was assessed using the five-item Mental Health Inventory questionnaire. Cardiovascular autonomic function was determined from peak heart rate during maximal exercise (HRpeak).

RESULTS

There was a high prevalence of both NP (39%) and MH- (45%) following SCI. MH- was significantly correlated with an adverse CVD risk profile (r = 0.174; p = 0.01), increased the odds of adverse 30-year CVD risk by 2.2 (CI 0.92-2.81, p = 0.02), and is an important variable in determining CVD risk (importance=0.74, p = 0.05). Females (p = 0.05) and those with a higher HRpeak (p = 0.046) tended to be more likely to have NP.

CONCLUSIONS

Clinical measures of MH-, but not NP, are important factors for increased CVD risk following SCI. NP tended to be more prevalent in those with more preserved cardiovascular autonomic function. The interrelationships between secondary consequences of SCI are complex and need further exploration.

Dual utilization of Medicare and VA outpatient care among Veterans with spinal cord injuries and disorders

OBJECTIVE

Veterans with spinal cord injuries and disorders (SCI/D) utilizing Veterans Affairs healthcare facilities are also Medicare eligible. Use of multiple health care systems potentially duplicates or fragments care in this population; yet little is known about those using multiple systems. This study describes dual use of services paid for by VA and Medicare among Veterans with SCI/D.

DESIGN

Retrospective, cross-sectional, observational study.

PARTICIPANTS

Veterans with SCI/D (n = 13,902) who received healthcare services within the VA SCI System of Care and were eligible for or enrolled in Medicare in 2011.

INTERVENTIONS

N/A.

OUTCOME MEASURES

Patient characteristics, average number of visits and patient level frequencies of reasons for visits were determined for individuals within healthcare utilization (VA only, Medicare only, or dual VA/Medicare) groups. Multinomial logistic regression analyses were used to investigate associations of patient variables on dual use.

RESULTS

65.3% of Veterans with SCI/D were VA only users for outpatient encounters, 4.4% had encounters paid for by Medicare only, and 30.3% were dual users. Veterans were less likely to be VA only users if they were older than 69 and if they had been injured for greater than ten years. African American Veterans with SCI (compared to white) were more likely to be VA only users.

CONCLUSION

A substantial number (∼30%) of Veterans with SCI/D are dual users. These numbers highlight the importance of improved strategies to coordinate care and increase health information sharing across systems.

Associations between meeting exercise guidelines, physical fitness, and health in people with spinal cord injury

PURPOSE

(1) To estimate the proportion of Dutch wheelchair users with spinal cord injury (SCI) who meet different SCI exercise guidelines; (2) to evaluate which demographic and lesion characteristics are associated with meeting these guidelines; (3) whether meeting these guidelines is associated with physical fitness and health.

MATERIALS AND METHODS

Based on the PASIPD questionnaire items, participants were allocated to meeting two SCI aerobic exercise guidelines, which differ in exercise load. Differences in personal, lesion, fitness, and health characteristics between groups were tested with a one-way ANOVA. Multiple regression analyses were performed to evaluate if meeting guidelines was associated with better fitness and health. Statistical significance was accepted at p < 0.05.

RESULTS

Of the 358 included participants, 63.1% met at least one aerobic exercise guideline. Being female, older age, having tetraplegia, and lower educational level were associated with a lower likelihood to meet the aerobic exercise guidelines. Meeting aerobic exercise guidelines showed a positive association with all respiratory and exercise capacity parameters. Limited associations were found between meeting exercise guidelines and health.

CONCLUSIONS

Meeting exercise guidelines was associated with better respiratory functions and exercise capacity with additional fitness and some body composition benefits in higher exercise activity levels.IMPLICATIONS FOR REHABILITATIONMeeting SCI exercise guidelines are associated with better respiratory functions and exercise capacity with additional fitness and body composition benefits when higher exercising at higher activity levels, emphasizing the value and importance of regular exercise in individuals with SCI.

Modernization of a Large Spinal Cord Injuries and Disorders Registry: The Veterans Administration Experience

Since the 1990s, Veterans Health Administration (VHA) has maintained a registry of Veterans with Spinal Cord Injuries and Disorders (SCI/Ds) to guide clinical care, policy, and research. Historically, methods for collecting and recording data for the VHA SCI/D Registry (VSR) have required significant time, cost, and staffing to maintain, were susceptible to missing data, and caused delays in aggregation and reporting. Each subsequent data collection method was aimed at improving these issues over the last several decades. This paper describes the development and validation of a case-finding and data-capture algorithm that uses primary clinical data, including diagnoses and utilization across 9 million VHA electronic medical records, to create a comprehensive registry of living and deceased Veterans seen for SCI/D services since 2012. A multi-step process was used to develop and validate a computer algorithm to create a comprehensive registry of Veterans with SCI/D whose records are maintained in the enterprise wide VHA Corporate Data Warehouse. Chart reviews and validity checks were used to validate the accuracy of cases that were identified using the new algorithm. An initial cohort of 28,202 living and deceased Veterans with SCI/D who were enrolled in VHA care from 10/1/2012 through 9/30/2017 was validated. Tables, reports, and charts using VSR data were developed to provide operational tools to study, predict, and improve targeted management and care for Veterans with SCI/Ds. The modernized VSR includes data on diagnoses, qualifying fiscal year, recent utilization, demographics, injury, and impairment for 38,022 Veterans as of 11/2/2022. This establishes the VSR as one of the largest ongoing longitudinal SCI/D datasets in North America and provides operational reports for VHA population health management and evidence-based rehabilitation. The VSR also comprises one of the only registries for individuals with non-traumatic SCI/Ds and holds potential to advance research and treatment for multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), and other motor neuron disorders with spinal cord involvement. Selected trends in VSR data indicate possible differences in the future lifelong care needs of Veterans with SCI/Ds. Future collaborative research using the VSR offers opportunities to contribute to knowledge and improve health care for people living with SCI/Ds.

Safety and Feasibility of a Novel Exoskeleton for Locomotor Rehabilitation of Subjects With Spinal Cord Injury: A Prospective, Multi-Center, and Cross-Over Clinical Trial

Objective

To evaluate the safety, walking efficiency, physiological cost, don and doff time cost, and user satisfaction of Ai-robot.

Design

Prospective, multi-center, and cross-over trial.

Subjects

Paraplegic subjects (n = 40) with T6-L2 level spinal cord injury.

Methods

Subjects who could walk independently using Aiwalker, Ailegs, and hip knee ankle foot orthosis (HKAFO) for 6 min within 30 days of training underwent 10 sets of tests. In each set, they completed three 6-min walk test (6MWT) sessions using the three aids in random order.

Results

Skin lesions, pressure sores, and fractures, were the main adverse events, likely due to a lack of experience in using exoskeleton systems. The average 6MWT distances of the Aiwalker, Ailegs, and HKAFO groups were 134.20 ± 18.74, 79.71 ± 18.06, and 48.31 ± 19.87 m, respectively. The average heart rate increases in the Aiwalker (4.21 ± 8.20%) and Ailegs (41.81 ± 23.47%) groups were both significantly lower than that in the HKAFO group (62.33 ± 28.32%) (both p < 0.001). The average donning/doffing time costs for Ailegs and Aiwalker were significantly shorter than that of HKAFO (both p < 0.001). Satisfaction was higher in the Ailegs and Aiwalker groups (both p < 0.001).

Conclusion

Subjects with paraplegia below T6 level were able to ambulate safely and efficiently with Ai-robot. The use of Ai-robot should be learned under the guidance of experienced medical personnel.

Developing a consensus on the core educational content to be acquired by people with spinal cord injuries during rehabilitation: findings from a Delphi study followed by a Consensus Conference

STUDY DESIGN

Three-round Delphi study followed by a Consensus Conference with selected stakeholders.

OBJECTIVES

To identify a set of core educational content that people with spinal cord injury (SCI) need to acquire during rehabilitation.

SETTING

The Delphi study was performed electronically. The Consensus Conference was held at the Città della Salute e della Scienza University Hospital of Turin, Italy.

METHODS

A panel of 20 experts (healthcare professionals and SCI survivors) participated in a three-round Delphi study. In round 1, arguments for core educational content were solicited and reduced into items. In rounds 2 and 3, a five-point Likert scale was used to find consensus on and validate core educational content items (threshold for consensus and agreement: 60% and 80%, respectively). A Consensus Conference involving 32 stakeholders was held to discuss, modify (if appropriate) and approve the list of validated items.

RESULTS

The 171 arguments proposed in round 1 were reduced into 74 items; 67 were validated in round 3. The Consensus Conference approved a final list of 72 core educational content items, covering 16 categories, which were made into a checklist.

CONCLUSIONS

Consensus was achieved for a set of core educational content for people with SCI. The resultant checklist could serve as an assessment tool for both healthcare professionals and SCI survivors. It can also be used to support SCI survivors' education, streamline resource use and bridge the gap between information provided during rehabilitation and information SCI survivors need to function in the community.

Mobile App (WHEELS) to Promote a Healthy Lifestyle in Wheelchair Users With Spinal Cord Injury or Lower Limb Amputation: Usability and Feasibility Study

BACKGROUND

Maintaining a healthy lifestyle is important for wheelchair users' well-being, as it can have a major impact on their daily functioning. Mobile health (mHealth) apps can support a healthy lifestyle; however, these apps are not necessarily suitable for wheelchair users with spinal cord injury or lower limb amputation. Therefore, a new mHealth app (WHEELS) was developed to promote a healthy lifestyle for this population.

OBJECTIVE

The objectives of this study were to develop the WHEELS mHealth app, and explore its usability, feasibility, and effectiveness.

METHODS

The WHEELS app was developed using the intervention mapping framework. Intervention goals were determined based on a needs assessment, after which behavior change strategies were selected to achieve these goals. These were applied in an app that was pretested on ease of use and satisfaction, followed by minor adjustments. Subsequently, a 12-week pre-post pilot study was performed to explore usability, feasibility, and effectiveness of the app. Participants received either a remote-guided or stand-alone intervention. Responses to semistructured interviews were analyzed using content analysis, and questionnaires (System Usability Score [SUS], and Usefulness, Satisfaction, and Ease) were administered to investigate usability and feasibility. Effectiveness was determined by measuring outcomes on physical activity, nutrition, sleep quality (Pittsburgh Sleep Quality Index), body composition, and other secondary outcomes pre and post intervention, and by calculating effect sizes (Hedges g).

RESULTS

Sixteen behavior change strategies were built into an app to change the physical activity, dietary, sleep, and relaxation behaviors of wheelchair users. Of the 21 participants included in the pilot study, 14 participants completed the study. The interviews and questionnaires showed a varied user experience. Participants scored a mean of 58.6 (SD 25.2) on the SUS questionnaire, 5.4 (SD 3.1) on ease of use, 5.2 (SD 3.1) on satisfaction, and 5.9 (3.7) on ease of learning. Positive developments in body composition were found on waist circumference (P=.02, g=0.76), fat mass percentage (P=.004, g=0.97), and fat-free mass percentage (P=.004, g=0.97). Positive trends were found in body mass (P=.09, g=0.49), BMI (P=.07, g=0.53), daily grams of fat consumed (P=.07, g=0.56), and sleep quality score (P=.06, g=0.57).

CONCLUSIONS

The WHEELS mHealth app was successfully developed. The interview outcomes and usability scores are reasonable. Although there is room for improvement, the current app showed promising results and seems feasible to deploy on a larger scale.

Current State of Knowledge on Digital Rectal Stimulation in Individuals With Traumatic and Nontraumatic Spinal Cord Injury: A Scoping Review

OBJECTIVES

To map and characterize the nature of the evidence on the use of digital rectal stimulation for bowel management in individuals with spinal cord injury (SCI).

DATA SOURCES

Five electronic databases were searched (ie, MEDLINE, EMBASE, CINAHL, Cochrane CENTRAL, and Cochrane Incontinence Group) from 1990 to November 2019.

STUDY SELECTION

Articles that provided information on the use of digital rectal stimulation either alone or in combination with treatments were included. Title and abstract screening was split between 2 reviewers after reaching consensus on the first 100 studies screened. Full-texts were reviewed independently by 2 reviewers. Discrepancies were resolved by a third reviewer.

DATA EXTRACTION

The data extraction form was developed by 2 reviewers and piloted. Data were extracted by one reviewer and checked for accuracy by a second reviewer.

DATA SYNTHESIS

A total of 4841 studies were screened, including 425 full text articles; 33 articles were identified. Thirty-two studies focused solely on individuals with SCI and 1 study explored the experiences of caregivers of individuals with SCI. The majority of participants were aged between 30 and 59 years old. Most studies used quantitative methods (n=30, 91%). Fourteen of the studies (42%) were cross-sectional. Within experimental or quasiexperimental designs, digital rectal stimulation was commonly studied as an adjunct to other methods such as suppositories or enemas. Incontinence and defecation time were the most commonly examined outcomes.

CONCLUSION

There were few studies found that focus on digital rectal stimulation. Further studies examining experience, effectiveness, complications, and long-term outcomes are warranted.

Associations between post-traumatic growth and wisdom in people with long-term paraplegia - the role of disability appraisals and participation

PURPOSE

The number of people with long-term spinal cord injury (SCI) is growing but our knowledge about their successful functioning is still limited. The goal of this study was to investigate the correlations between posttraumatic growth (PTG) and wisdom in people with long-term paraplegia, exploring the mediating effect of disability appraisals, and participation/autonomy (P/A).

METHODS

One-hundred and sixty-six persons with paraplegia completed a set of questionnaires, which included: The three-dimensional Wisdom Scale; The Post-traumatic Growth Inventory; Appraisals of Disability Primary and Secondary Scale; Impact on Participation and Autonomy Questionnaire. Mediation was tested using bootstrapping and a multiple mediation model with two mediators.

RESULTS

Positive and significant correlations between PTG, disability appraisals (as determined resilience), P/A, and wisdom were found. PTG is associated with wisdom when disability appraisals and P/A are mediators. Higher PTG was related to higher determined resilience and smaller restrictions in participation, both of which were associated with higher wisdom.

CONCLUSIONS

The relationship between PTG and wisdom is complex and indirect in people with long-term paraplegia. The mediating variables of disability appraisals and P/A explained the variance in PTG, with P/A playing a more significant role. Findings suggest that long-term SCI may correlate with experiencing high levels of PTG and wisdom, and more positive disability appraisals.Implications for rehabilitationPTG is associated with life wisdom in people with long-term SCI, with a significant contribution of disability appraisal and P/A.Therapists can increase these people's awareness about the possibility of experiencing PTG and maintaining positive changes, despite long-term SCI.Therapists can support people with long-term SCI in maintaining or extending the possibilities of participation and autonomous decision-making about their daily activities, which in consequence may be important for increasing their life wisdom.

Prevalence of chronic pain after spinal cord injury: a systematic review and meta-analysis

BACKGROUND

The reported prevalence of chronic pain after spinal cord injury (SCI) varies widely due, in part, to differences in the taxonomy of chronic pain. A widely used classification system is available to describe subcategories of chronic pain in SCI, but the prevalence of chronic pain in SCI based on this system is unknown.

OBJECTIVE

The primary objective of this systematic review and meta-analysis is to determine the prevalence of chronic pain after SCI based on the International Spinal Cord Injury Pain (ISCIP) classification system.

EVIDENCE REVIEW

A comprehensive search of databases from January 1980 to August 2019 was conducted. The risk of bias was assessed using a modified tool developed for uncontrolled studies. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess certainty in prevalence estimates.

FINDINGS

A total of 1305 records were screened, and 37 studies met inclusion criteria. The pooled prevalence of overall chronic pain was 68% (95% CI 63% to 73%). The pooled prevalence of neuropathic pain in 13 studies was 58% (95% CI 49% to 68%); the pooled prevalence of musculoskeletal pain in 11 studies was 56% (95% CI 41% to 70%); the pooled prevalence of visceral pain in 8 studies was 20% (95% CI 11% to 29%) and the pooled prevalence of nociceptive pain in 2 studies was 45% (95% CI 13% to 78%). Meta-regression of risk of bias (p=0.20), traumatic versus non-traumatic etiology of injury (p=0.59), and studies where pain was a primary outcome (p=0.32) demonstrated that these factors were not significant moderators of heterogeneity. Certainty in prevalence estimates was judged to be low due to unexplained heterogeneity.

CONCLUSION

This systematic review and meta-analysis extends the findings of previous studies by reporting the prevalence of chronic pain after SCI based on the ISCIP classification system, thereby reducing clinical heterogeneity in the reporting of pain prevalence related to SCI.

Characterization of Telehealth Use in Veterans With Spinal Cord Injuries and Disorders

BACKGROUND

Individuals with spinal cord injuries and disorders (SCI/D) require frequent interdisciplinary health care to address impairments in mobility, autonomic function, and secondary complications. Telehealth has the capacity to substantially transform health care delivery and improve care by increasing access and communication. However, relatively little is known about telehealth use in this specific population. Here we attempt to fill part of this gap.

OBJECTIVE

To investigate the frequency and characteristics associated with telehealth use in Veterans with SCI/D.

DESIGN

Cross-sectional, descriptive project.

SETTING

Veterans Health Administration (VHA) facilities.

PARTICIPANTS

A total of 15 028 Veterans living with SCI/D who received services from the VHA SCI/D System of Care.

INTERVENTION

Not applicable.

OUTCOME MEASURES

Frequency and characteristics associated with VHA telehealth utilization.

RESULTS

Of the 15 028 Veterans with SCI/D included in the evaluation, 17% used some form of telehealth in VHA Fiscal Year (FY)2017. Veterans older than 65 years of age had lower odds (odds ratio [OR] = 0.88, P < .05, confidence interval [CI] 0.80-0.98) of using telehealth. Being Caucasian (OR = 1.29, P < .01, CI 1.09-1.52), living in rural areas (OR = 1.16, P < .01, CI 1.05-1.28), living greater distances away from the VHA (P < .01 for all distances), and being in priority group 8, meaning that Veterans have higher copayment requirements (OR = 1.46, P < .001, CI 1.19-1.81), were all significantly associated with greater odds of telehealth use. The most frequent types of telehealth used were real-time clinical video and store-and-forward between a provider and patient within the same hub network.

CONCLUSION

There are opportunities to increase telehealth adoption in the SCI/D arena. The findings from this project highlight which Veterans are currently using telehealth services, as well as gaps regarding telehealth adoption in this population.

Evaluation of cardiovascular disease risk in individuals with chronic spinal cord injury

STUDY DESIGN

Multicentre, cross-sectional study.

OBJECTIVES

To identify which markers of obesity, injury characteristics and autonomic function variables are related to cardiovascular disease (CVD) risk after spinal cord injury (SCI), and establish cut-points for detection and risk management.

SETTING

Eight SCI rehabilitation centres in the Netherlands.

METHODS

Individuals (n = 257) with a traumatic, chronic (≥10 years) SCI, with age at injury between 18 and 35 years, completed a self-report questionnaire and a one-day visit to a rehabilitation centre for testing. Three anthropometric measures were tested: body mass index (BMI); waist circumference (WC); and waist-to-height ratio (WHtR). Injury characteristics included: American Spinal Injury Association impairment scale (AIS); duration of injury (DOI); and neurological level of injury (LOI). Cardiovascular autonomic function was assessed from peak heart rate during maximal exercise (HR_peak). Systolic arterial pressure (SAP) and aerobic capacity (VO_2peak) were also determined. CVD risk was calculated using the Framingham risk score (FRS).

RESULTS

All anthropometric variables were associated with FRS, with WC showing the strongest correlation (r = 0.41, p < 0.001) and greatest area under the curve (0.73) for 10-year CVD risk (%). WC, DOI, SAP, HR_peak, LOI, and VO_2peak (variable importance: 0.81, 1.0, 0.98, 0.98, 0.66, 0.68, respectively) were important predictive variables for 10-year CVD risk in individuals with SCI.

CONCLUSIONS

We confirm that WC is a simple, practical measure of CVD risk, and along with DOI and markers of cardiovascular autonomic function, plays a role in the increased CVD risk following SCI.

Mortality and secondary complications four years after traumatic spinal cord injury in Cape Town, South Africa

STUDY DESIGN

A prospective, regional, population-based study.

OBJECTIVES

(1) Determine the mortality rate and factors associated with it 4 years after a TSCI and (2) The point prevalence of secondary medical complications of survivors at 4 years.

SETTING

Communities of the Cape metropolitan area, South Africa.

METHODS

All persons (n = 145) sustaining a TSCI from 15 September 2013 to 14 September 2014 were eligible for follow-up at 4 years. Participants were contacted after 4 years. The next of kin, via verbal autopsy, was used to establish cause of death. Those who were alive at 4 years were asked to indicate any secondary medical complications. Logistic regression techniques were used to identify independently associated risk indicators for death and development of secondary complications, respectively.

RESULTS

Of the initial 145 persons, 87 were included and accounted for. Of these, 21 (24%) had died, 55 (63%) were alive and completed the survey, and 11 (13%) were classified as alive but did not submit the survey. The main cause of death reported was septicaemia (n = 7; 33%), followed by unknown natural causes (n = 7; 33%), then pressure injuries (n = 5; 24%). Out of the 55 persons alive, 89% had at least one medical complication at the time of enquiry, while more than 50% experienced 6 or more complications. The most common complications were pain (80%), muscle spasms (76%), sleeping problems (56%), and bladder dysfunction (44%).

CONCLUSIONS

Almost one-quarter of persons with TSCI have died 4 years after injury. Also, secondary complications were found to be highly prevalent at 4 years. This information could be used to develop secondary complications prevention programmes to reduce premature deaths.

SPONSORSHIP

This study was funded by the Medical Research Council of South Africa within the Research Capacity Development Initiative.

The prevalence of pressure ulcers in Europe, what does the European data tell us: a systematic review

OBJECTIVE

The main aim of this systematic review was to establish the prevalence of pressure ulcers (PU) within published studies from Europe.

METHOD

Using systematic review methodology, quantitative design studies which explored prevalence data and/or the epidemiology of PUs in Europe were considered. The primary outcome was PU prevalence. The search, conducted in April 2019, using Cochrane, Medline, Embase, CINAHL, PubMed, Scopus and Web of Science databases, returned 3065 records, of which 79 met the inclusion criteria. Data were extracted using a pre-designed extraction tool, and validity analysis was undertaken using the Evidence-Based Librarianship (EBL) Critical Appraisal Checklist.

RESULTS

We included 79 articles in this review. Across the studies, the median prevalence was 10.8% (standard deviation: 7%; range: 4.6-27.2%). The highest PU prevalence reported was from the Netherlands (27.2%; n=17,494 participants), and the lowest was reported from Finland (4.6%; n=629 participants). Almost 32.4% (n=151,195) of the PUs were category I and the most common site for PUs was the sacrum.

CONCLUSION

The prevalence data is consistently high. These data indicate the continued need for further resource allocation into PU prevention and management.

The Relationship Between Psychological and Physical Secondary Conditions and Family Caregiver Burden in Spinal Cord Injury: A Correlational Study

Background: Caregiver burden (CB) is a consequence of providing care to people with spinal cord injury (SCI). However, there is a lack of clarity about the influence of secondary conditions of care recipients on family caregivers. Secondary conditions refer to the physical and psychological complications that can occur after SCI and lead to increased hospitalization and reduced functionality, quality of life, and social participation. Objective: To assess the impact of physical and psychological secondary conditions of people with SCI on the perceived burden of family caregivers. Methods: A multicenter, cross-sectional study of 56 dyads of family caregivers and individuals with SCI in two urban spinal units in Italy and Ireland. Care recipients completed a toolset consisting of demographic information and assessments of functional, physical, and psychological health. Caregivers completed a multidimensional measure of CB. Bivariate data analysis was used. Results: No significant differences between centers were identified. CB was found to be related to physical secondary conditions and functional independence but not to mental health of care recipients. Bladder dysfunction and urinary tract infections influenced all dimensions of CB, whereas pressure injuries influenced only the time-dependent dimension. Level and completeness of injury and duration of caregiving increased CB. Conclusion: Findings indicate the value of a reduction in secondary conditions not just for individuals with SCI but also for their family caregivers. To reduce the individual and family burden of secondary conditions, a two-pronged, multidimensional approach, focusing on self-management for care recipients and psychoeducational support for caregivers, is required.

Employment, health outcomes, and life satisfaction after spinal cord injury: comparison of veterans and nonveterans

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To explore differences between veterans and nonveterans with spinal cord injury (SCI) for employment, health, and satisfaction with life outcomes after controlling for demographic and injury characteristics.

SETTING

Hospitals in the Spinal Cord Injury Model System of care.

METHODS

A total of 9754 (85% nonveterans and 15% veterans) adults with traumatic SCI interviewed from 2000 and 2015 and completed follow-up years 1, 5, and 10 were included in this study. Employment status and the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF) measured employment. The SF-36 for self-perceived health status, CHART-SF, and rehospitalization determined health outcomes. Satisfaction with life was measured by the Satisfaction with Life Scale (SWLS). Secondary data analyses using χ2, t-tests, and generalized estimating equations (GEEs) model to determine group differences with control of demographic and injury characteristics.

RESULTS

There were no significant differences for employment and SWL between nonveterans and veterans. There were some differences in health outcomes; whereas, veterans had better physical independence and mobility compared with nonveterans.

CONCLUSION

Interventions for both groups should target adults with a disability from SCI, be customized for varying levels of injury that address differences in healthcare systems, demographic backgrounds, economic resources, disincentives, and motivation.

Effects of High-Intensity Interval Training Versus Moderate-Intensity Training on Cardiometabolic Health Markers in Individuals With Spinal Cord Injury: A Pilot Study

Background: Recent studies in nondisabled individuals have demonstrated that low-volume high-intensity interval training (HIIT) can improve cardiometabolic health similar to moderate-intensity training (MIT) despite requiring 20% of the overall time commitment. To date, there have been no studies assessing the effects of HIIT for improving cardiometabolic health in individuals with SCI. Objectives: The primary purpose of this pilot study was to compare the effects of 6 weeks of low-volume HIIT vs MIT using arm crank ergometer exercise to improve body composition, cardiovascular fitness, glucose tolerance, blood lipids, and blood pressure in a cohort of individuals with longstanding SCI. Methods: Participants were randomized to 6 weeks of HIIT or MIT arm crank exercise training. Aerobic capacity, muscular strength, blood lipids, glucose tolerance, blood pressure, and body composition were assessed at baseline and 6 weeks post training. Results: Seven individuals (6 male, 1 female; n = 3 in MIT and n = 4 in HIIT; mean age 51.3 ± 10.5 years) with longstanding SCI completed the study. The preliminary findings from this pilot study demonstrated that individuals with SCI randomized to either 6 weeks of HIIT or MIT displayed improvements in (a) insulin sensitivity, (b) cardiovascular fitness, and (c) muscular strength (p < .05). However, MIT led to greater improvements in arm fat percent and chest press strength compared to HIIT (p < .05). Conclusion: No differences between MIT and HIIT were observed. Both conditions led to improvements in insulin sensitivity, aerobic capacity, muscle strength, and blood lipids in individuals with SCI. Future larger cohort studies are needed to determine if the shorter amount of time required from HIIT is preferable to current MIT exercise recommendations.

Experienced sitting-related problems and association with personal, lesion and wheelchair characteristics in persons with long-standing paraplegia and tetraplegia

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To describe experienced sitting-related health and stability problems among persons with paraplegia (PP) or tetraplegia (TP) and to investigate associations with personal, lesion and wheelchair characteristics as well as satisfaction with sitting posture.

SETTING

Dutch community.

METHODS

A self-report questionnaire on seating was developed and completed by wheelchair-users living with Spinal Cord Injury (SCI) for ≥10 years (N = 264). Sitting-related problems and satisfaction with sitting posture were compared between participants with PP and TP using Chi-square and t-tests. Logistic regression analyses were performed to investigate associated characteristics.

RESULTS

Reported sitting-related problems comprised: sitting to be tiring (regularly to always) (33%), sitting to be painful (28%), pressure ulcers in the last three months (29%), instability while sitting (8%) and instability during reaching (33%). Except for instability during reaching, no differences in occurrence of sitting-problems were found between lesion-group. Persons with TP were more dissatisfied with their sitting posture than persons with PP: 51% vs 36% (p = 0.022) and 51% and 47% respectively thought their sitting posture could be improved (p = 0.670). 'Experienced lack of support in the wheelchair' was associated with most sitting-problems. Pain and instability were associated with dissatisfaction with sitting posture.

CONCLUSION

Sitting-related problems and dissatisfaction with sitting posture were frequently reported by persons with long-standing SCI. Sitting problems appeared to associate with lacking support in the wheelchair/seating. A comprehensive feedback from the wheelchair user and a stability check (reach task), as part of the wheelchair/seating-user fitting, may contribute to prevention of sitting-related problems.

Exercise self-efficacy is weakly related to engagement in physical activity in persons with long-standing spinal cord injury

Aims: Many people with a long-standing spinal cord injury have an inactive lifestyle. Although exercise self-efficacy is considered a key determinant of engaging in exercise, the relationship between exercise self-efficacy and physical activity remains unclear. Therefore, this study examines the relationship between exercise self-efficacy and the amount of physical activity in persons with long-standing spinal cord injury.Methods: This cross-sectional study included 268 individuals (aged 28-65 years) with spinal cord injury ≥ 10 years and using a wheelchair. Physical activity was measured with the Physical Activity Scale for Individuals with Physical Disabilities. Exercise self-efficacy was assessed with the Spinal cord injury Exercise Self-Efficacy Scale. Univariate and multivariable regression analyses were performed to test for the association between exercise self-efficacy and physical activity, controlling for supposed confounders.Results: Univariate regression analysis revealed that exercise self-efficacy was significantly related to the level of daily physical activity (β = 0.05; 95% CI 0.04-0.07; 15% explained variance; p < 0.001). In multivariable regression analysis exercise self-efficacy remained, explaining a significant additional amount of the variance (2%; p < 0.001) of physical activity.Conclusion: Exercise-self efficacy is a weak but independent explanatory factor of the level of physical activity among persons with long-standing spinal cord injury. Longitudinal trials are needed to study the impact of interventions targeting an increase of exercise self-efficacy on the amount of physical activity performed.Implications for rehabilitationPre-intervention levels of exercise-self-efficacy might mediate the effectiveness of interventions that aim at increasing physical activities in people with a long-standing spinal cord injury.Enhancing exercise-self efficacy may improve levels of physical activity, even in people with a long-standing spinal cord injury.When it comes to enhancing physical activity, efforts to enhance non-structured daily physical activities such as household activities and gardening might be as important as efforts to enhance sports and other physical exercise.

Description of Urological Surveillance and Urologic Ultrasonography Outcomes in a Cohort of Individuals with Long-Term Spinal Cord Injury

Background: Individuals with spinal cord injury (SCI) have an increased risk of developing urological complications. Therefore, long-term routine urological surveillance is recommended. Objective: To describe urological surveillance in individuals with long-term SCI and to determine factors associated with urologic ultrasonography (UU) outcome. Methods: Wheelchair-dependent individuals with an SCI for 10 years or more were included. A medical assessment was done in 8 participating rehabilitation centers. The International Lower Urinary Tract Function Basic SCI Data Set was used to assess bladder-emptying methods and previous surgical procedures on the urinary tract. We studied urological surveillance: whether participants had routine urological checkups (including UU) and when latest urodynamic study was performed. Latest UU (performed <1 year ago) was retrieved or, when lacking, UU was performed as part of our study. Results: Median time since injury (TSI) was 22.0 years. Overall, 39% of the 282 participants did not have routine urological checkups and 33% never had a urodynamic study performed. UU data (N = 243) revealed dilatation of the upper urinary tract (UUT) in 4.5% of the participants and urinary stones in 5.7%. Abnormal UU outcome was associated with increasing TSI, nontraumatic SCI, and previous surgical bladder or UUT stone removal. UU outcome was not associated with routine urological checkups or type of bladder-emptying method. Conclusions: Over one-third of Dutch individuals with long-term SCI did not receive routine urological surveillance. UU outcome was not associated with routine urological checkups or type of bladder-emptying method. Further research on the indication and frequency of urological surveillance is recommended.

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.

Degree of Contribution of Motor and Sensory Scores to Predict Gait Ability in Patients With Incomplete Spinal Cord Injury

Objective

To identify different contributions of motor and sensory variables for independent ambulation of patients with incomplete spinal cord injury (SCI), and reveal the most significant contributors among the variables.

Methods

The retrospective study included 30 patients with incomplete SCI and lesions were confirmed by magnetic resonance imaging. Motor and sensory scores were collected according to the International Standards for Neurological Classification of Spinal Cord Injury. The variables were analyzed by plotting ROC (receiver operating characteristic) curves to estimate their differential contributions for independent walking. The most significant functional determinant was identified through the subsequent logistic regression analysis.

Results

Motor and sensory scores were significantly different between the ambulators and non-ambulators. The majority was associated to the function of lower extremities. Calculation of area under ROC curves (AUC) revealed that strength of hip flexor (L2) (AUC=0.905, p<0.001) and knee extensor (L3) (AUC=0.820, p=0.006) contributed the greatest to independent walking. Also, hip flexor strength (L2) was the single most powerful predictor of ambulation by the logistic regression analysis (odds ratio=6.3, p=0.049), and the model fit well to the data.

Conclusion

The most important potential contributor for independent walking in patients with incomplete SCI is the muscle strength of hip flexors, followed by knee extensors compared with other sensory and motor variables.

Prevalence of parenthood in wheelchair-dependent persons with long-term spinal cord injury in the Netherlands

STUDY DESIGN

Multicenter  cross-sectional study.

OBJECTIVES

To determine the prevalence of parenthood in long-term wheelchair-dependent persons who sustained a spinal cord injury (SCI) during their reproductive years. Secondary aims were to (1) explore patient-specific and disease-related factors associated with parenthood after SCI; and (2) quantify fertility aids used by men with SCI.

SETTING

Eight specialized SCI rehabilitation centers in the Netherlands.

METHODS

Questionnaires and physical examination were applied in 255 persons with SCI. Prevalence rates of parenthood among the general Dutch population were used for comparison. Logistic regression analyses were used to explore factors associated with parenthood after SCI.

RESULTS

Prevalence of parenthood in SCI was 50% in men and 45% in women, which was significantly (P < 0.05) lower than rates in the general population (74% in men and 81% in women). Among the parents with SCI, most (66% of males and 72% of females) of them had children after SCI. Parenting children after SCI was associated with partnership (OR = 14.5, P < .001 [men]; OR = 3.7, P = .05 [women]), normal micturition (OR = 4.9, P = .02 [men]), incomplete lesion (OR = 5.4, P = .03 [women]), and paraplegia (OR = 7.3, P = .02 [women]). The most frequently used methods for ejaculation and fertilization were electroejaculation (29%) and intracytoplasmatic sperm injection (23%).

CONCLUSIONS

Prevalence of parenthood in SCI persons is low. However, half of the persons with SCI do become parents, with most doing so following SCI. Demographic and disease-related factors may contribute to this.

Ageing with neurogenic bowel dysfunction

STUDY DESIGN

Longitudinal study with postal survey.

OBJECTIVES

To describe changes in the patterns of neurogenic bowel dysfunction and bowel management in a population of people with spinal cord injury (SCI) followed for two decades.

SETTING

Members of the Danish SCI Association.

METHODS

In 1996, a validated questionnaire on bowel function was sent to the members of the Danish SCI Association (n=589). The same questionnaire was sent to all the surviving members in 2006 (n=284) and in 2015 (n=178). A total of 109 responded to both the 1996 and 2015 questionnaires.

RESULTS

Comparing data from 2015 with those from the exact same participants in 1996, the proportion of respondents needing more than 30 min for each defaecation increased from 21 to 39% (P<0.01), the use of laxatives increased (P<0.05) and the proportion considering themselves very constipated increased from 19 to 31% (P<0.01). In contrast, the proportion suffering from faecal incontinence remained stable at 18% in 1996 and 19% in 2015. During the 19-year period, there had been no significant change in the methods for bowel care, but 22 (20%) had undergone surgery for bowel dysfunction, including 11 (10%) who had some form of stoma.

CONCLUSION

Self-assessed severity of constipation increased but quality of life remained stable in a cohort of people with SCI followed prospectively for 19 years. Methods for bowel care remained surprisingly stable but a large proportion had undergone stoma surgery.

Surgical Neurostimulation for Spinal Cord Injury

Traumatic spinal cord injury (SCI) is a devastating neurological condition characterized by a constellation of symptoms including paralysis, paraesthesia, pain, cardiovascular, bladder, bowel and sexual dysfunction. Current treatment for SCI involves acute resuscitation, aggressive rehabilitation and symptomatic treatment for complications. Despite the progress in scientific understanding, regenerative therapies are lacking. In this review, we outline the current state and future potential of invasive and non-invasive neuromodulation strategies including deep brain stimulation (DBS), spinal cord stimulation (SCS), motor cortex stimulation (MCS), transcutaneous direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) in the context of SCI. We consider the ability of these therapies to address pain, sensorimotor symptoms and autonomic dysregulation associated with SCI. In addition to the potential to make important contributions to SCI treatment, neuromodulation has the added ability to contribute to our understanding of spinal cord neurobiology and the pathophysiology of SCI.

Sociotechnical Perspective on Implementing Clinical Video Telehealth for Veterans with Spinal Cord Injuries and Disorders

BACKGROUND

Real-time videoconferencing technology such as clinical video telehealth (CVT) offers a means to reach patient populations who face limited access to healthcare. The Veterans Health Administration has invested in CVT to improve care access for U.S. military veterans with spinal cord injuries and disorders (SCI/D); however, no studies have assessed the factors that influence implementation of this technology in clinical practice for individuals with SCI/D.

INTRODUCTION

Guided by a sociotechnical perspective, the purpose of this study was to identify factors that influence implementation of CVT for veterans with SCI/D.

MATERIALS AND METHODS

We conducted semistructured telephone interviews with 40 healthcare providers who use CVT to deliver services to veterans with SCI/D.

RESULTS

Factors related to workflow and communication were widely reported as implementation barriers. Coordinating logistics for CVT appointments was challenging, and effective communication between CVT team members across facilities was considered crucial. Providers also cited factors related to technical infrastructure, people, and organizational features, including the need for appropriate equipment, space, personnel, and support for using CVT equipment.

DISCUSSION

The implementation of CVT in the care of veterans with SCI/D was influenced by an interrelated set of social and technical factors. Key among them were social factors related to people, workflow, and communication, given that CVT supports healthcare teams interacting remotely in real time.

CONCLUSIONS

CVT implementation requires teams working together to negotiate a complex, distributed process across multiple sites. Such complexity places a premium on teamwork and communication among healthcare teams before, during, and after a CVT encounter.

Bladder-emptying methods, neurogenic lower urinary tract dysfunction and impact on quality of life in people with long-term spinal cord injury

OBJECTIVES

To describe bladder-emptying methods used by people with long-term spinal cord injury (SCI) and to determine usage differences in relation to time since injury, sex, lesion level and completeness of lesion. Furthermore, to evaluate the relationship between bladder-emptying methods and the impact of neurogenic lower urinary tract dysfunction (NLUTD) on quality of life (QoL).

DESIGN

Cross-sectional multicenter study.

SETTING

Dutch community.

PARTICIPANTS

Persons dependent on wheelchairs (N = 282) with traumatic or non-traumatic SCI for ≥10 years and age at injury of 18-35 years.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

The International Lower Urinary Tract Function Basic SCI Data Set and the Short-Form Qualiveen (SF-Qualiveen).

RESULTS

Median time since injury was 22.0 years (IQR: 16.8-30.3). Clean intermittent catheterization (CIC) was most commonly used (42.6%). Longer time since injury was associated with fewer continent urinary diversions and more transurethral catheter use. Transurethral catheter use and continent urinary diversions were more prevalent among women. Participants with tetraplegia were more likely to use reflex voiding or a suprapubic catheter, and participants with paraplegia were more likely to use CIC. Transurethral catheter users reported the highest impact of NLUTD on quality of life (SF-Qualiveen score: 1.9; SD = 0.8). Participants with a continent urinary diversion reported the lowest impact (SF-Qualiveen score: 0.9; SD = 0.6). Higher age and indwelling catheter use versus CIC were associated with a higher impact of NLUTD on QoL.

CONCLUSIONS

CIC is the most common bladder-emptying method in Dutch people with long-term SCI. Clinicians should be aware of the impact of NLUTD on QoL, especially for those using an indwelling catheter.

Risk of Dementia in Patients with Spinal Cord Injury: A Nationwide Population-Based Cohort Study

Spinal cord injury (SCI) can cause physical disability and psychological distress; however, whether SCI is a risk factor for dementia is unclear. This study evaluated the incidence of dementia in patients with SCI. Study participants were recruited from a nationwide cohort during 2004-2007 and categorized into SCI (patients diagnosed with SCI; n = 941) and non-SCI (age- and sex-matched controls; n = 5060) cohorts. Each participant was followed for 7 years until diagnosis of dementia or December 31, 2010, whichever occurred first. Data were subjected to Kaplan-Meier and Cox regression analyses. The incidence of dementia was significantly higher in the SCI cohort (1106 per 100,000 person-years) than in the non-SCI cohort (p < 0.001). Patients with SCI had a significantly higher risk of dementia than did those without SCI (crude hazard ratio [HR] = 2.14, 95% confidence interval [CI], 1.57-2.92, p < 0.001 vs. adjusted HR = 1.95, 95% CI, 1.43-2.67, p < 0.001). Further analysis found that there is no statistical significance of higher risk for developing Alzheimer's disease among SCI patients, but that SCI patients were at higher risk of developing other types of dementia than the control cohort (crude HR = 1.88, 95% CI, 1.33-2.63, p < 0.001 vs. adjusted HR = 1.90, 95% CI, 1.35-2.68, p < 0.001). In conclusion, patients with SCI are at high risk of dementia, and effective dementia prevention strategies are recommended for comprehensive SCI care.

Metabolic syndrome in people with a long-standing spinal cord injury: associations with physical activity and capacity

This study investigated (i) the prevalence of the metabolic syndrome (MetS) in people with a long-standing spinal cord injury (SCI); (ii) whether personal or lesion characteristics are determinants of the MetS; and (iii) the association with physical activity or peak aerobic capacity on the MetS. In a cross-sectional study, persons with SCI (N = 223; time since injury of ≥10 years) were tested. The individual components of the MetS were assessed together with the physical activity measured by the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD), while peak aerobic capacity was tested during a graded wheelchair exercise test on a treadmill. Thirty-nine percent of the participants had MetS. In a multivariate logistic regression analyses and after performing a backward regression analysis, only age and education were significant determinants of the MetS. A 10-year increase in age leads to a 1.5 times more chance to have the MetS. Furthermore, people with a low education will multiply the relative risk of MetS compared with people with high education by almost 2. With and without correcting for confounders, no significant relationship was found between PASIPD or peak aerobic capacity and the MetS. It can be concluded that the prevalence of the MetS is high (39%) in people with a long-standing SCI but is comparable to the general Dutch population. Older people and those with a lower education level are most at risk for the MetS. Physical activity and peak aerobic fitness were not related to the MetS in this group with a long-standing SCI.

The Impact Of Sports Activities On Quality Of Life Of Persons With A Spinal Cord Injury: VPLIV ŠPORTNIH AKTIVNOSTI NA KAKOVOST ŽIVLJENJA OSEB S POŠKODBO HRBTENJAČE

Objectives

Studying the quality of life of people with a spinal cord injury is of great importance as it allows the monitoring of both functioning and adaptation to disability. The aim of this study was to determine the difference between persons with a spinal cord injury involved in sports activities and those not involved in sports activities in relation to their quality of life and the presence of secondary health conditions (pressure ulcers, urinary infections, muscle spasms, osteoporosis, pain, kidney problems-infections, calculosis and poor circulation).

Methods

The study included a total of 44 participants with spinal cord injury-paraplegia of both genders; 26 of them were athletes and 18 were not athletes. The athletes were training actively for the last two years, minimally 2-3 times per week. A specially designed questionnaire, medical documentation and the Spinal Cord Injury Quality of Life Questionnaire (SCI QL-23) were used for research purposes. Chi-square test was used to analyze the differences between the groups, while multiple analysis of variance (MANOVA) was used to determine the differences between the sets of variables.

Results

Among the participants, the athletes perceived higher quality of life than the non-athletes (male gender p<0.001 and female gender p<0.05). Regarding secondary health conditions, the athletes reported the presence of less pain (p=0.034) and a subjective feeling of better circulation (p=0.023).

Conclusion

The implementation of sports activities significantly improves quality of life in the population of people with spinal cord injury-paraplegia. However, sports activities only partially affect secondary health conditions.

Oral health-related quality of life in Iranian patients with spinal cord injury: A case-control study

INTRODUCTION

The study aimed to compare the oral health variables, general, and oral health-related quality of life (QoL), depression, and anxiety between spinal cord injury (SCI) patients and healthy controls and also to determine the key factors related to the oral health-related quality of life (OHRQoL) in the SCI patients.

METHODS

A total of 203 SCI patients and 203 healthy controls were enrolled. Patients and healthy adults were invited to attend a dental clinic to complete the study measures and undergo oral clinical examinations. OHRQoL was assessed by the 14-item Oral Health Impact Profile (OHIP-14), and the general health-related quality of life (GHRQoL) was evaluated by SF-36. In SCI patients, depression and anxiety were recorded using the Hospital Anxiety and Depression Scale (HADS), while Functional Assessment Measure (FAM) was used to assess dependence and disability. All the subjects were examined for caries which was quantified using the decayed, missing, and filled Teeth (DMFT) index, gingival bleeding index (GI), plaque index, and periodontal status by community periodontal index (CPI).

RESULTS

The analysis of covariance (ANCOVA) revealed significant differences between the two groups in terms of oral health expressed in DMFT, oral hygiene, and periodontal status, controlled for age, gender, family income, and occupational status (p<0.001). Using the hierarchical linear regression analyses, in the final model, which accounted for 18% of the total variance (F(126.7), p<0.01), significant predictors of OHRQoL were irregular tooth brushing (β=1.23; 95% CI=1.06; 1.41), smoking (β=0.82; 95% CI=0.66; 0.97), dry mouth (β=0.37; 95% CI=-0.65 to 0.10) functional and motor functioning (β=0.32; 95% CI=-0.45 to 0.17), DMFT (β=0.06; 95% CI=0.02; 0.09), CPI (β=0.22; 95% CI=0.04; 0.04), physical component measure of GHRQoL (β=-0.275; 95% CI=-0.42 to 0.13), lesion level at the lumbar-sacral (β=-0.18; 95% CI=-0.29 to -0.06) and thoracic level (β=-0.09; 95% CI=-0.11 to -0.06).

CONCLUSION

SCI patients had poor oral hygiene practices, greater levels of plaque, gingival bleeding, and caries experience than the healthy controls. In addition, more number of SCI patients had periodontal pockets and dry mouth than the comparative group. SCI patients experienced more depression and anxiety, poor GHRQoL, and OHRQoL than the healthy control group. The factors that influenced OHRQoL in SCI patients were age, toothbrushing frequency, smoking, oral clinical status, depression, physical component of GHRQoL, and level of lesion.

Prevalence of hypertension and associated risk factors in people with long-term spinal cord injury living in the Netherlands

PURPOSE

To describe the prevalence of hypertension and associated risk factors in people with long-term spinal cord injury (SCI) and to compare the prevalence of high blood pressure and/or the use of antihypertensive drugs with the prevalence in the Dutch general population.

METHOD

Multicentre cross-sectional study (N = 282). Hypertension was defined as a systolic blood pressure (SBP) of ≥140 mmHg and/or a diastolic blood pressure (DBP) of ≥90 mmHg after ≥2 blood pressure measurements during ≥2 doctor visits. High blood pressure was defined as a single measurement of a SBP of ≥140 mmHg and/or a DBP of ≥90 mmHg.

RESULTS

The prevalence of hypertension was 21.5%. Significant predictors were: lesion level below C8 (T1-T6: OR =6.4, T7-L5: OR =10.1), history of hypercholesterolemia (OR =4.8), longer time since injury (OR =1.1), higher age (OR =1.1). The prevalence of high blood pressure and/or the use of antihypertensive drugs was higher in men (T1-T6 lesion: 48%; T7-L5 lesion: 57%) and women (T1-T6 lesion: 48%; T7-L5 lesion: 25%) with a SCI below C8 compared to Dutch able-bodied men (31%) and women (18%).

CONCLUSION

High blood pressure is common in people with SCI. Screening for hypertension during annual checkups is recommended, especially in those with a SCI below C8. Implications for Rehabilitation High blood pressure is common in people with long-term SCI living in the Netherlands and its prevalence is higher in both men and women with a spinal cord lesion level below C8 compared with the age-matched Dutch general population. It is recommended to screen for hypertension during annual checkups in people with SCI, especially in those with a higher risk of developing hypertension, e.g. those with a spinal cord lesion level below C8 and an age of ≥45 years or a time since injury of ≥20 years. When a high blood pressure is measured in people with SCI, they should receive a further assessment of the blood pressure according to the available guidelines for the general population, including ambulatory 24 h-blood pressure monitoring.

Functioning and disability analysis of patients with traumatic brain injury and spinal cord injury by using the world health organization disability assessment schedule 2.0

The purpose of this study is to compare traumatic brain injuries (TBI) and spinal cord injuries (SCI) patients’ function and disability by using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0); and to clarify the factors that contribute to disability. We analyzed data available between September 2012 and August 2013 from Taiwan’s national disability registry which is based on the International Classification of Functioning, Disability, and Health (ICF) framework. Of the 2664 cases selected for the study, 1316 pertained to TBI and 1348 to SCI. A larger percentage of patients with TBI compared with those with SCI exhibited poor cognition, self-care, relationships, life activities, and participation in society (all p < 0.001). Age, sex, injury type, socioeconomic status, place of residence, and severity of impairment were determined as factors that independently contribute to disability (all p < 0.05). The WHODAS 2.0 is a generic assessment instrument which is appropriate for assessing the complex and multifaceted disability associated with TBI and SCI. Further studies are needed to validate the WHODAS 2.0 for TBI and SCI from a multidisciplinary perspective.

Outcomes of neurogenic bowel management in individuals living with a spinal cord injury for at least 10 years

OBJECTIVE

To describe bowel management and its outcomes in individuals living with a spinal cord injury (SCI) for at least 10 years.

DESIGN

Cross-sectional multicenter study.

SETTING

Dutch community.

PARTICIPANTS

Individuals (N=258; age range, 28-65y) who acquired their SCI between 18 and 35 years of age, who were at least 10 years post-SCI, and who used a wheelchair for their daily mobility.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The International SCI Bowel Function Basic Data Set, the neurogenic bowel dysfunction (NBD) score, and a single item on satisfaction with bowel management.

RESULTS

Mean time since injury (TSI) was 24±9 years. Seventy-four percent used ≥1 conservative bowel management method, specifically digital evacuation (35%) and mini enemas (31%). Transanal irrigation (TAI) and surgical interventions were used by 11% and 8%, respectively. Perianal problems were reported by 45% of the participants. Severe NBD was present in 36% of all participants and in 40% of those using a conservative method. However, only 14% were (very) dissatisfied with their current bowel management. Dissatisfaction with bowel management was significantly associated with constipation and severe NBD. With increasing TSI, there was a nonsignificant trend observed toward a decline in dissatisfaction with bowel management and a significant decline in severe NBD.

CONCLUSIONS

Although satisfaction rates were high, more than a third of the participants reported severe NBD and perianal problems. Apart from severe NBD, there were no significant associations between bowel problems and TSI. Conservative methods were most often used, but some of these methods were also significantly associated with the presence of severe NBD. Longitudinal research is necessary to provide more knowledge concerning the course of NBD with increasing TSI.

An Exploratory Analysis of the Potential Association Between SCI Secondary Health Conditions and Daily Activities

BACKGROUND

Secondary health conditions (SHCs) are common following traumatic spinal cord injury (tSCI) and are believed to influence a person's ability to participate in daily activities (DAs). This association should be understood so that health care providers may target interventions with clarity and purpose to manage SHCs and facilitate DAs to maximal effect.

OBJECTIVE

To explore the association between SHCs and DAs expressed as the increased chance of not participating as much as wanted in a DA when an SHC is present.

METHODS

Community-dwelling persons with tSCI (n = 1,137) responded to the SCI Community Survey. The occurrence and frequency of 21 SHCs were determined. The extent of participation in 26 DAs was measured. The relative risk (RR) of not participating as much as wanted in a DA when a SHC is present was calculated.

RESULTS

When some SHC were present, the RR of not participating as much as wanted increased significantly (range, 15%-153%; P < .001). Certain SHCs (light-headedness/dizziness, fatigue, weight problems, constipation, shoulder problems) were associated with a greater chance of not participating in many DAs. No single SHC was associated with every DA and conversely not every DA was associated with an SHC.

CONCLUSIONS

Maximizing participation in DAs requires minimizing SHCs in every instance. Understanding the association between SHCs and DAs may facilitate targeted care resulting in less severe SHCs, greater participation in DAs, and benefits to both the individual and society.