Self-reported effects of warm seasonal temperatures in persons with spinal cord injury

OBJECTIVE

Spinal cord injury (SCI) interrupts motor, sensory, and autonomic pathways, impairing mobility and increasing heat storage during warm seasonal temperatures due to compromised autonomic control of vasodilation and sweating and recognition of body temperature. Thus, persons with SCI are more vulnerable to hyperthermia and its adverse effects. However, information regarding how persons with SCI perceive warmer seasons and whether thermal discomfort during warmer seasons restricts routine activities remains anecdotal.

DESIGN

Cross-sectional, self-report surveys.

SETTING

VA Medical Center and Kessler Institute for Rehabilitation.

PARTICIPANTS

Three groups of 50 participants each: tetraplegia, paraplegia, and matched non-SCI controls.

OUTCOME MEASURES

Tetraplegia, paraplegia, and control groups responded "yes" or "no" when asked whether warm seasonal temperatures adversely affected comfort or participation in routine activities.

RESULTS

The percentage of responses differed among tetraplegia, paraplegia, and control groups when asked if they required ≥20 min to cool down once overheated (44 vs. 20 vs. 12%; X2 = 14.7, P < 0.001), whether heat-related discomfort limited their ability to go outside (62 vs. 34 vs. 32%; X2 = 11.5, P = 0.003), if they needed to use a water-mister because of the heat (70 vs. 44 vs. 42%; X2 = 9.8, P = 0.008), and if heat-related discomfort limited participation in social activities (40 vs. 20 vs. 16%; X2 = 8.7, P = 0.01).

CONCLUSION

Warmer seasonal temperatures had a greater negative impact on reported comfort and daily activities of persons with SCI than non-SCI controls. Those with tetraplegia were most adversely affected. Our findings warrant increasing awareness and identifying interventions to address the vulnerability of persons with SCI to hyperthermia.

Cardiometabolic risk factor clustering in persons with spinal cord injury: A principal component analysis approach

CONTEXT/OBJECTIVE

To identify cardiometabolic (CM) measurements that cluster to confer increased cardiovascular disease (CVD) risk using principal component analysis (PCA) in a cohort of chronic spinal cord injury (SCI) and healthy non-SCI individuals.

APPROACH

A cross-sectional study was performed in ninety-eight non-ambulatory men with chronic SCI and fifty-one healthy non-SCI individuals (ambulatory comparison group). Fasting blood samples were obtained for the following CM biomarkers: lipid, lipoprotein particle, fasting glucose and insulin concentrations, leptin, adiponectin, and markers of inflammation. Total and central adiposity [total body fat (TBF) percent and visceral adipose tissue (VAT) percent, respectively] were obtained by dual x-ray absorptiometry (DXA). A PCA was used to identify the CM outcome measurements that cluster to confer CVD risk in SCI and non-SCI cohorts.

RESULTS

Using PCA, six factor-components (FC) were extracted, explaining 77% and 82% of the total variance in the SCI and non-SCI cohorts, respectively. In both groups, FC-1 was primarily composed of lipoprotein particle concentration variables. TBF and VAT were included in FC-2 in the SCI group, but not the non-SCI group. In the SCI cohort, logistic regression analysis results revealed that for every unit increase in the FC-1 standardized score generated from the statistical software during the PCA, there is a 216% increased risk of MetS (P = 0.001), a 209% increased risk of a 10-yr. FRS ≥ 10% (P = 0.001), and a 92% increase in the risk of HOMA2-IR ≥ 2.05 (P = 0.01).

CONCLUSION

Application of PCA identified 6-FC models for the SCI and non-SCI groups. The clustering of variables into the respective models varied considerably between the cohorts, indicating that CM outcomes may play a differential role on their conferring CVD-risk in individuals with chronic SCI.

Clinical trial of home blood pressure monitoring following midodrine administration in hypotensive individuals with spinal cord injury

BACKGROUND

Individuals with spinal cord injury (SCI) above thoracic level-6 (T6) experience impaired descending cortical control of the autonomic nervous system which predisposes them to blood pressure (BP) instability, including includes hypotension, orthostatic hypotension (OH), and autonomic dysreflexia (AD). However, many individuals do not report symptoms of these BP disorders, and because there are few treatment options that have been proven safe and effective for use in the SCI population, most individuals remain untreated.

OBJECTIVE

The primary aim of this investigation was to determine the effects of midodrine (10 mg) prescribed TID or BID in the home environment, compared to placebo, on 30-day BP, study withdrawals, and symptom reporting associated with OH and AD in hypotensive individuals with SCI.

DESIGN/METHODS

Participants were randomly assigned to received midodrine/placebo or placebo/midodrine, with a 2-weeks washout period in between, and both the participants and investigators were blinded to randomization order. Study medication was taken 2 or 3 times/day, depending on their sleep/wake schedule, BP, and any related symptoms were recorded before and 1 h after each dosage and periodically throughout the day.

RESULTS

Nineteen individuals with SCI were recruited; however, 9 withdrew prior to completion of the full protocol. A total of 1892 BP recordings (75 ± 48 recordings/participant/30-day period) were collected in the 19 participants over the two 30-day monitoring periods. Average 30-day systolic BP was significantly increased with midodrine compared to placebo (114 ± 14 vs. 96 ± 11 mmHg, respectively; P = 0.004), and midodrine significantly reduced the number of hypotensive BP recordings compared to placebo (38.7 ± 41.9 vs. 73.3 ± 40.6, respectively; P = 0.01). However, compared to placebo, midodrine increased fluctuations in BP, did not improve symptoms of OH, but did significantly worsen the intensity of symptoms associated with AD (P = 0.03).

CONCLUSION

Midodrine (10 mg) administered in the home environment effectively increases BP and reduces the incidence of hypotension; however these beneficial effects come at the expense of worsened BP instability and AD symptom intensity.

Preliminary observations on the administration of a glucagon-like peptide-1 receptor agonist on body weight and select carbohydrate endpoints in persons with spinal cord injury: A controlled case series

CONTEXT/OBJECTIVE

To describe the effect of semaglutide, a glucagon-like peptide-1 (GLP-1) agonist, to reduce body weight and improve glycemic control in overweight or obese individuals with spinal cord injury (SCI).

DESIGN

Open-label, randomized drug intervention case series.

SETTING

This study was performed at James J. Peters VA Medical Center (JJP VAMC) and Kessler Institute for Rehabilitation (KIR).

PARTICIPANTS

Five individuals with chronic SCI meeting criteria for obesity and abnormal carbohydrate metabolism.

INTERVENTION

Administration of semaglutide (subcutaneously once per week) versus no treatment (control) for 26 weeks.

OUTCOME MEASURES

Change in total body weight (TBW), fat tissue mass (FTM), total body fat percent (TBF%), and visceral adipose tissue volume (VAT_vol) was determined at baseline and after 26 weeks using Dual energy X-ray absorptiometry; fasting plasma glucose (FPG) concentration and serum glycated hemoglobin (HbA1C) values were obtained at the same two time points.

RESULTS

In 3 participants, after 26 weeks of semaglutide administration, TBW, FTM, TBF%, and VAT_vol decreased, on average, by 6, 4.4 kg, 1.7%, and 674 cm³, respectively. In addition, values for FPG and HbA1c decreased by 17 mg/dl and 0.2%, respectively. After 26 weeks of observation in the 2 control participants, TBW, FTM, TBF% and VAT_vol increased on average by 3.3 , 4.5 kg, 2.5%, and 991 cm³, respectively. The average values for FPG and HbA1c also increased by 11 mg/dl and 0.3%, respectively.

CONCLUSIONS

Administration of semaglutide for 26 weeks resulted in favorable changes in body composition and glycemic control, suggesting a reduced risk for the development of cardiometabolic disease in obese individuals with SCI.Trial registration: ClinicalTrials.gov identifier: NCT03292315.

The International Standards for Neurological Classification of Spinal Cord Injury: Classification Accuracy and Challenges

Background

Successful utilization of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) requires a comprehensive understanding of its rules, terminology, and several complex concepts. There have been no studies investigating classification accuracy since the newest ISNCSCI revision (2019).

Objectives

To evaluate classification accuracy of SCI professionals using the 2019 ISNCSCI edition, identify common mistakes and areas of confusion, and assess associations between experience in ISNCSCI classification and performance.

Methods

Members of the International Spinal Cord Society (ISCoS) and attendees of the ISCoS Annual Scientific Meeting 2021 were invited to complete an online survey that included six ISNCSCI cases to classify.

Results

A total of 107 persons completed the survey, with overall classification accuracy of 74.6%. Accuracy was highest for injury completeness (95.3%) and sensory level (91.1%) and lowest for motor zone of partial preservation (ZPP; 54.7%) and ASIA Impairment Scale (AIS) grade (57.3%). Newer concepts, including the appropriate documentation of non-SCI conditions and classification of ZPP in incomplete injuries, contributed to several common errors. There was a significant association between overall classification accuracy and self-rated experience in the ISNCSCI classification (p = .017). Experience with the ISNCSCI examination, experience in SCI medicine, and occupation were not found to be significantly associated with overall classification accuracy.

Conclusion

Classification accuracy of an international cohort of SCI professionals was modest but greater than previous reports. Knowledge deficits about the 2019 ISNCSCI updates are prevalent and contribute to common classification errors. Further training in the utilization of the ISNCSCI is needed.

Loss of lower extremity bone mineral density 1 year after denosumab is discontinued in persons with subacute spinal cord injury

Twelve months following discontinuation of denosumab, the percent decrease in mean bone mineral density (BMD) values at the hip and knee regions were similar between both the denosumab and placebo groups. These findings emphasize the need for additional trials to understand the effect of continued administration of denosumab after subacute spinal cord injury (SCI) to avoid this demineralization.

OBJECTIVE

To determine changes in BMD 1 year after denosumab was discontinued in participants with subacute SCI who had drug treatment initiated within 90 days post SCI and continued for 1 year.

METHODS

Fourteen participants who completed a randomized, double-blinded, placebo-controlled drug trial (parent study: denosumab 60 mg (Prolia, Amgen Inc., n = 8) or placebo (n = 6); administered at baseline, 6, and 12 months) were followed 12 months after the 18 months from baseline primary end point was completed. The BMD of skeletal regions below the SCI at higher risk of fracture was measured [total hip, distal femur epiphysis (DFE), distal femur metaphysis (DFM), and proximal tibia epiphysis (PTE)] by dual energy X-ray absorptiometry.

RESULTS

The percent decreases in mean BMD values at all regions of the hip and knee from 18 to 30 months were similar in both the denosumab and placebo groups. However, at 30 months, the absolute values for mean BMD remained significantly higher in the drug treatment than that of the placebo group at the DFM (p = 0.03), DFE (p = 0.04), and PTE (p = 0.05).

CONCLUSIONS

In persons with SCI who initiated denosumab treatment during the subacute injury phase and maintained treatment for 1 year, the discontinuation of drug resulted in percent loss of mean BMD similar to that of the placebo group, with absolute mean BMD values at the knee regions at the 12-month follow-up visit significantly higher in the drug treatment than those in the placebo group. These data underscore the need to study continued administration of denosumab after subacute SCI to avoid marked demineralization in the sublesional skeleton upon discontinuation of this agent.

Generation of a Reference Dataset to Permit the Calculation of T-scores at the Distal Femur and Proximal Tibia in Persons with Spinal Cord Injury

Persons with traumatic spinal cord injury (SCI) have severe bone loss below the level of lesion with the distal femur (DF) and proximal tibia (PT) being the skeletal regions having the highest risk of fracture. While a reference areal bone mineral density (aBMD) database is available at the total hip (TH) using the combined National Health and Nutrition Examination Survey (NHANES) III study and General Electric (GE) combined (GE/NHANES) to calculate T-score (T-score_GE/NHANES), no such reference database exists for aBMD of the DF, and PT. The primary objectives of this study were (1) to create a reference dataset of young-healthy able-bodied (YHAB) persons to calculate T-score (T-score_YHAB) values at the DF and PT, (2) to explore the impact of time since injury (TSI) on relative bone loss in the DF and PT regions using the two computation models to determine T-score values, and (3) to determine agreement between T-score values for a cohort of persons with SCI using the (T-score_YHAB) and (T-score_GE/NHANES) reference datasets. A cross-sectional prospective data collection study. A Department of Veterans Affairs Medical Center and a Private Rehabilitation Hospital. A normative reference aBMD database at the DF and PT was collected in 32 male and 32 female Caucasian YHAB participants (n=64) and then applied to calculate T-score values at the DF and PT in 105 SCI participants from a historical cohort. The SCI participants were then grouped based on TSI epochs (E-I: TSI < 1y, E-II: TSI 1-5y, E-III: TSI 6-10y, E-IV: TSI 11-20y, E-V: TSI > 20y). N/A. The knee and hip aBMD values were obtained by dual energy X-ray absorptiometry (GE Lunar iDXA) using standard clinical software for proximal femur orthopedic knee software applications. There were no significant differences in mean aBMD values across the four YHAB age subgroups (21-25, 26-30, 31-35, and 36-40 yr of age) at the TH, DF, and PT; mean aBMD values were higher in men compared to the women at all skeletal regions of interest. Using the mean YHAB aBMD values to calculate T-score values at each TSI epoch for persons with SCI, T-score values decreased as a function of TSI, and they continued to decline for 11-20 yr. Moderate kappa agreement was noted between the YHAB and the GE/NHANES reference datasets for the T-score cutoff criteria accepted to diagnose osteoporosis (i.e., SD <-2.5). A homogeneous reference dataset of YHAB aBMD values at the DF and PT was applied to calculate T-score values in persons with chronic SCI. There was a moderate level of agreement at the TH between the YHAB and GE/NHANES reference datasets when applying the conventional T-score cutoff value for the diagnosis of osteoporosis.

The PITCH study: pitcher injuries during the first 30 days of the coronavirus disease 2019 halted Major League Baseball season

Background

Major League Baseball (MLB) was among the first professional team sports leagues to resume play in the United States after public health measures related to the appearance of coronavirus disease 2019 caused interruptions to preseason training and major alterations to regular season play. There was a high level of concern that these athletes were ill-prepared for competition and would experience an increased risk of injury under the restricted play rules.

Methods

The data in our study were compiled using publicly accessible records of players placed on injured lists from 2015 to 2020. These records came from 4 open access websites: rotoworld.com, fangraphs.com, foxsports.com, and spotrac.com. All injuries were confirmed using the transaction database found on the official MLB website (mlb.com).

Results

A greater proportion of pitchers were injured during the first 30 days of the 2020 season compared to the first 30 days of any of the 5 prior seasons (29.74% vs. 11.72%, n=2190, P<.001). There was a demonstrated increase in injury risk in 2020 for the following anatomic locations: back and trunk, shoulder, upper arm and elbow, forearm and wrist, and hand and finger (P=.02; confidence interval [0.497-5.783]). When dividing the first month of play in 2020 into equal halves (15 days each), the number of relief pitcher injuries increased with time (60% vs. 78%, P=.04). Lastly, there was no proportional difference in placement on the short-term vs. long-term injured list.

Conclusion

A significantly large increase in soft tissue injuries in 2020 compared to the prior 5 seasons predominantly affected the trunk and the upper extremity of pitchers in the first 30 days of play. Alterations to preseason training and regular season play in the 2020 MLB season due to coronavirus disease 2019 may have been particularly disadvantageous to professional pitchers who are positioned at baseline, the most injury prone position.

Surveillance for Pressure Injuries on Admission to Inpatient Rehabilitation Hospitals During the COVID-19 Pandemic

Objective

To determine if the incidence of pressure injuries (PIs) on admission to an inpatient rehabilitation hospital (IRH) system of care was increased during the early coronavirus disease 2019 (COVID-19) pandemic period.

Design

Retrospective survey chart review of consecutive cohorts. Admissions to 4 acute IRHs within 1 system of care over the first consecutive 6-week period of admitting patients positive for COVID-19 during the initial peak of the COVID-19 pandemic, April 1-May 9, 2020. A comparison was made with the pre–COVID-19 period, January 1-February 19, 2020.

Setting

Four acute IRHs with admissions on a referral basis from acute care hospitals.

Participants

A consecutive sample (N=1125) of pre–COVID-19 admissions (n=768) and COVID-19 period admissions (n=357), including persons who were COVID-19–positive (n=161) and COVID-19–negative (n=196).

Main Outcome Measures

Incidence of PIs on admission to IRH.

Results

Prevalence of PIs on admission during the COVID-19 pandemic was increased when compared with the pre–COVID-19 period by 14.9% (P<.001). There was no difference in the prevalence of PIs in the COVID-19 period between patients who were COVID-19–positive and COVID-19–negative (35.4% vs 35.7%). The severity of PIs, measured by the wound stage of the most severe PI the patient presented with, worsened during the COVID-19 period compared with pre–COVID-19 (χ² 32.04%, P<.001). The length of stay in the acute care hospital before transfer to the IRH during COVID-19 was greater than pre–COVID-19 by 10.9% (P<.001).

Conclusions

During the early part of the COVID-19 pandemic time frame, there was an increase in the prevalence and severity of PIs noted on admission to our IRHs. This may represent the significant burden placed on the health care system by the pandemic, affecting all patients regardless of COVID-19 status. This information is important to help all facilities remain vigilant to prevent PIs as the pandemic continues and potential future pandemics that place strain on medical resources.

Predicting Cardiometabolic Risk From Visceral Abdominal Adiposity in Persons With Chronic Spinal Cord Injury

Persons with spinal cord injury (SCI) have increased adiposity that may predispose to cardiovascular disease compared to those who are able-bodied (AB). The purpose of this study was to determine the relationships between dual energy X-ray absorptiometry (DXA)-derived visceral adipose tissue (VAT) and biomarkers of lipid metabolism and insulin resistance in persons with chronic SCI. A prospective observational study in participants with chronic SCI and age- and gender-matched AB controls. The study was conducted at a Department of Veterans Affairs Medical Center and Private Rehabilitation Hospital. The quantification of DXA-derived VAT volume (VAT_vol) and blood-derived markers of lipid and carbohydrate metabolism were determined in 100 SCI and 51 AB men. The VAT_vol was acquired from a total body DXA scan and analyzed using iDXA enCore CoreScan software (GE Lunar). Blood samples were collected for the serum lipid profile and plasma and glucose concentrations, with the latter two values used to calculate a measure of insulin resistance. In the SCI and AB groups, VAT% was significantly correlated with most cardiometabolic biomarkers. The results of the binary logistic regression analysis revealed that participants who had a VAT_vol above the cutoff value of 1630 cm³ were 3.1-, 4.8-, 5.6-, 19.2-, and 16.7-times more likely to have high serum triglycerides (R²_N= 0.09, p = 0.014), low serum high density lipoprotein cholesterol (R²_N = 0.16, p < 0.001), HOMA2-IR (R²_N = 0.18, p < 0.001), metabolic syndrome (R²_N = 0.25, p < 0.001), and a 10-yr Framingham Risk Score ≥ 10% (R²_N = 0.16, p = 0.001), respectively, when compared to participants below this VAT_vol cutoff value. Our findings reveal that persons with chronic SCI have a higher VAT_vol than that of AB controls, and VAT_vol correlates directly with biomarkers of lipid and carbohydrate metabolism that are strong predictors of cardiometabolic disorders.

Screening for Deep Vein Thrombosis in Persons With COVID-19 Upon Admission to an Inpatient Rehabilitation Hospital

OBJECTIVE

The aim of the study was to determine the prevalence of deep venous thrombosis detected by duplex screening and risk factors associated with deep venous thrombosis in patients with COVID-19 upon admission to an inpatient rehabilitation hospital.

DESIGN

This is a retrospective review.

SETTING

The setting is three freestanding inpatient rehabilitation hospitals operating as one system.

PARTICIPANTS

The participants are consecutive patients with a diagnosis of COVID-19 admitted to an inpatient rehabilitation hospital without a diagnosis of deep venous thrombosis or screening duplex ultrasound prior to transfer.

INTERVENTIONS

A duplex ultrasound of lower limbs was performed upon admission to inpatient rehabilitation hospital.

OUTCOME MEASURES

Primary outcome was the percentage of admission patients with a lower limb deep venous thrombosis. Secondary factors included potential risk factors for a positive screen for deep venous thrombosis.

RESULTS

A lower limb deep venous thrombosis was diagnosed in 22% (25/113) of the patients tested, with eight patients (7.1%) having a proximal deep venous thrombosis. Risk factors for screening positive for a deep venous thrombosis included being male, younger, and having been on a ventilator during the acute illness.

CONCLUSIONS

The high rate of deep venous thrombosis observed in these patients suggests that the risk of venous thromboembolic disorders after severe COVID-19 illness is considerable and surveillance measures of such patients should be undertaken.

Relationships between T-scores at the hip and bone mineral density at the distal femur and proximal tibia in persons with spinal cord injury

Objective: To identify T-score values at the total hip (TH) and femoral neck (FN) that correspond to the cutoff value of <0.60 g/cm² for heightened risk of fracture at the distal femur (DF) and proximal tibia (PT).Design: Retrospective analysis of data in a research center's database. Setting: Community-based individuals with spinal cord injury (SCI). Participants: 105 unique individuals with SCI. Outcome Measurements: DXA derived areal BMD (aBMD) and T-score of the DF, PT, TH, and FN. Results: The aBMD at the DF and PT regions were predictors of T-scores at the TH (R² = 0.63, P < 0.001 and R² = 0.65, P < 0.001) and FN (R² = 0.55, P < 0.001 and R² = 0.58, P < 0.001). Using the DF and PT aBMD of 0.60 g/cm² as a value below which fractures were more likely to occur, the predicted T-score was -3.1 and -3.5 at the TH and -2.6 and -2.9 at the FN, respectively. However, when the predicted and observed T-score values disagree outside the 95% limit of agreement, the predicted T-score values are lower than the measured T-score values, overestimating the measured values between -2.0 and -4.0 SD. Conclusion: The DF and PT cutoff value for aBMD of 0.60 g/cm² was a moderate predictor of T-score values at the TH and FN, with considerable inaccuracies outside the clinically acceptable limits of agreement. As such, the direct measurement of knee aBMD in persons with SCI should be performed, whenever possible, prior to prescribing weight bearing upright activities, such as robotic exoskeletal-assisted walking.

Reliability of S3 pressure sensation and voluntary hip adduction/toe flexion and agreement with deep anal pressure and voluntary anal contraction in classifying persons with traumatic spinal cord injury

Context/Objective: The sacral examination components of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), namely deep anal pressure (DAP) and voluntary anal sphincter contraction (VAC), are often difficult to perform. We evaluated whether pressure sensation at the S3 dermatome (S3P), and voluntary hip adductor or toe flexor contraction (VHTC) are tenable alternatives. Here we report test-retest reliability and agreement of these components at 1 month after spinal cord injury (SCI), and impact of disagreement on American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades. Design: Longitudinal cohort. ISNCSCI examination, S3P and VHTC conducted at 1-month post-injury; retest of the sacral exam, S3P and VHTC within 3 days. Follow-up examinations performed at 3, 6, and 12 months. Setting: Five Spinal Cord Injury Model System Centers. Participants: Subjects with acute traumatic SCI, neurological levels T12 and above, AIS grades A-C. Interventions: None. Outcome Measures: ISNCSCI exam, AIS grades. Results: Fifty-one subjects had 1-month data, and 39 had at least one follow-up examination. Test-retest reliability indicated perfect agreement (kappa = 1.0) for all data except S3P (kappa = 0.96). The agreement was almost perfect between S3P and DAP (kappa = 0.84) and between VHTC and VAC (kappa = 0.81). VHTC and VAC differed more often with neurologic levels below T10, possibly due to root escape in conus medullaris injuries. Conclusion: S3P and VHTC show promise as alternatives to DAP and VAC for determining sacral sparing in persons with neurologic levels T10 and above. Reliability and agreement should be evaluated at earlier timepoints and in children with SCI.

Screening Testing for SARS-CoV-2 upon Admission to Rehabilitation Hospitals in a High COVID-19 Prevalence Community

Background

While planning for the care of coronavirus disease 2019 (COVID‐19) patients during the pandemic crisis has dominated the focus of leaders of inpatient rehabilitation facilities (IRFs), patients with injuries/illnesses unrelated to COVID‐19 continue to need inpatient rehabilitation admission. To maintain a safe environment for all patients and staff, we established an admission screening plan of testing for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) to determine the presence of asymptomatic patients who were infected with the virus upon admission.

Objective

To determine the prevalence of patients who test positive for SARS‐CoV‐2 but were presumed to be COVID‐19 negative at the time of admission to IRF in New Jersey.

Design

Retrospective analysis of SARS‐CoV‐2 testing results.

Setting

Four freestanding IRFs in New Jersey operated as one system.

Patients

All (N = 103) patients sequentially admitted from 4 to 27 April 2020 with no symptoms or evidence of COVID‐19 disease at the time of transfer from the acute hospital.

Interventions

Specimens were collected for SARS‐CoV‐2 analysis at the time of admission to the IRF and patients were monitored for subsequent symptom development over the next 14 days.

Main Outcome Measures

Results of SARS‐CoV‐2 testing upon admission and evidence of development of clinical signs or symptoms of COVID‐19.

Results

Seven asymptomatic persons (6.8% of admissions) without clinical signs/symptoms of COVID‐19 tested positive on admission. Of these, five developed symptoms of COVID‐19, with a mean onset of 3.2 (range of 2‐5) days. Five additional patients became symptomatic and tested positive within the next 3 to 10 days (mean of 5.2 days). Overall, 11.6% of admissions (12/103) had a positive test within 14 days of admission.

Conclusions

Admission testing to postacute centers for SARS‐CoV‐2 can help identify presymptomatic or asymptomatic individuals, especially in areas where COVID‐19 is prevalent. Negative results, however, do not preclude COVID‐19 and should not be used as the sole basis for patient management decisions.

Administration of Denosumab Preserves Bone Mineral Density at the Knee in Persons With Subacute Spinal Cord Injury: Findings From a Randomized Clinical Trial

Persons with neurologically motor-complete spinal cord injury (SCI) have a marked loss of bone mineral density (BMD) of the long bones of the lower extremities, predisposing them to fragility fractures, especially at the knee. Denosumab, a commercially available human monoclonal IgG antibody to receptor activator of nuclear factor-κB ligand (RANKL), may provide an immunopharmacological solution to the rapid progressive deterioration of sublesional bone after SCI. Twenty-six SCI participants with subacute motor-complete SCI were randomized to receive either denosumab (60 mg) or placebo at baseline (BL), 6, and 12 months. Areal bone mineral density (aBMD) by dual energy x-ray absorptiometry (DXA) at 18 months at the distal femur was the primary outcome and aBMD of the proximal tibia and hip were the secondary outcomes analyzed in 18 of the 26 participants (denosumab, n = 10 and placebo, n = 8). The metrics of peripheral QCT (pQCT) were the exploratory outcomes analyzed in a subsample of the cohort (denosumab, n = 7 and placebo n = 7). The mean aBMD (±95% CI) for the denosumab versus the placebo groups demonstrated a significant group × time interactions for the following regions of interest at BL and 18 months: distal femoral metaphysis = mean aBMD 1.187; 95% CI, 1.074 to 1.300 and mean aBMD 1.202; 95% CI, 1.074 to 1.329 versus mean aBMD 1.162; 95% CI, 0.962 to 1.362 and mean aBMD 0.961; 95% CI, 0.763 to 1.159, respectively (p < 0.001); distal femoral epiphysis = mean aBMD 1.557; 95% CI, 1.437 to 1.675 and mean aBMD 1.570; 95% CI, 1.440 to 1.700 versus mean aBMD 1.565; 95% CI, 1.434 to 1.696 and mean aBMD 1.103; 95% CI, 0.898 to 1.309, respectively (p = 0.002); and proximal tibial epiphysis = mean aBMD 1.071; 95% CI, 0.957 to 1.186 and mean aBMD 1.050; 95% CI, 0.932 to 1.168 versus mean aBMD 0.994; 95% CI, 0.879 to 1.109 and mean aBMD 0.760; 95% CI, 0.601 to 0.919, respectively (p < 0.001). Analysis of pQCT imaging revealed a continued trend toward significantly greater loss in total volumetric BMD (vBMD) and trabecular vBMD at the 4% distal tibia region, with a significant percent loss for total bone mineral content. Thus, at 18 months after acute SCI, our findings show that denosumab maintained aBMD at the knee region, the site of greatest clinical relevance in the SCI population. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

SUN-396 Denosumab Preserves Bone Mineral Density at the Knee in Persons with Subacute Spinal Cord Injury

Despite clinical strides in the treatment of osteoporosis in several diverse medical conditions, the ability to maintain bone has proven to be exceedingly difficult in individuals with severe immobilization. Fifty to 60% of bone mineral density (BMD) at the epiphyseal and metaphyseal regions of the long-bones of the lower extremities may be lost over the first couple of years after spinal cord injury (SCI). Once a large amount of bone has been lost, it would be challenging to restore BMD, trabecular architectural integrity, and mechanical strength to provide protection against long-bone fractures of the lower extremities. Persons with neurologically complete forms of SCI have marked loss of BMD of the lower extremities, predisposing to fracture, especially at the knee. Denosumab, a commercially available human monoclonal antibody of the IgG₂ immunoglobulin isotype with a high affinity and specificity for binding RANKL to antagonize its action, may provide an immunopharmacological solution to the rapid progressive deterioration of sublesional bone after SCI. Twenty-six patients with motor-complete SCI [International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) grade A and B] were randomized to receive denosumab or placebo at baseline (BL), 6, and 12 months. Ten participants in the denosumab group and 8 participants in the placebo group completed the 18-month clinical trial [ClinicalTrials.gov (NCT01983475)]. Dual energy x-ray absorptiometry (DXA; Lunar Prodigy Advance, all software version 12.20.023; EnCORE, GE Medical Systems, Madison, WI) and peripheral quantitative computed tomography (pQCT; Stratec XCT 3000; STIM designs, Carmel, CA) imaging were performed. Within group paired analysis revealed a significant decrease for areal BMD (aBMD) from BL in the placebo group that started at month 3 for the distal femoral epiphysis (DFE), distal femoral metaphysis (DFM), and total hip (TH) and at month 6 for the femoral neck (FN), and at month 12 for the proximal tibial epiphysis (PTE); the loss in aBMD progressed to 18 months for all the skeletal regions of interest (ROI). At 18 months, the percent change at the ROI for the denosumab vs. placebo groups were: DFE (1.1% ± 7.5 vs. -30.0% ± 11.9, respectively, p<0.001 and p<0.001), DFM (1.2% ± 6.4 vs. -17.2% ± 14.2, p<0.01), TH (3.3% ± 8.7 vs. -25.6% ± 7.6, p < 0.001), and PTE (-1.7% ± 8.2 vs. -24.1% ± 12.3, p<0.001). At 18 months, pQCT at the 4% tibial region confirmed the DXA findings at proximal tibial; at the 38% tibial region, a trend toward loss of total volumetric BMD (vBMD) was observed (-0.7% ± 4.5 vs. -16.9% ± 20.0, p<0.09), but cortical vBMD was similar between the denosumab and placebo groups, suggesting trabecular loss at the tibial shaft. In summary, the findings suggest that denosumab, if treatment is initiated within 3 months of acute SCI, appears to be an efficacious approach to maintain BMD at the knee and hip regions.

Measurement of Visceral Adipose Tissue in Persons With Spinal Cord Injury by Magnetic Resonance Imaging and Dual X-Ray Absorptiometry: Generation and Application of a Predictive Equation

PURPOSE

Dual energy X-ray absorptiometry (DXA) and magnetic resonance imaging (MRI) permits quantification of visceral adipose tissue (VAT). However, DXA has not been validated against MRI in persons with chronic spinal cord injury (SCI). A predictive equation was generated from the measurement of VAT by MRI, a "gold" standard to quantitate VAT, compared to that of DXA, a method with several practical advantages.

METHOD

DXA and MRI scans were performed in 27 participants with SCI. MRI multiaxial images were captured for VAT analysis. DXA-VAT was quantified at the android region (DXA-VAT_ANDROID-VOL) using enCore software. Android regions of DXA and MRI were matched using android height. Volumes of multiaxial MRI-VAT and subcutaneous adipose tissue (SAT) were quantified for the android region (MRI-VAT_ANDROID-VOL, MRI-SAT_ANDROID-VOL) and total trunk (MRI-VAT_ANDROID-VOL). Linear regression analysis was used to establish the proposed predication equations. The prediction equations were then applied to an independent sample that consisted of 98 participants with SCI. Bland-Altman analysis was used to determine the limits of agreement.

RESULTS

DXA-VAT_ANDROID-VOL predicted 92% of the variance in MRI-VAT_ANDROID-VOL (SEE = 252.5, p < 0.0005) and 85% of the variance in MRI-VAT_TRUNK-VOL (SEE = 1526.9, p < 0.0005). DXA-SAT_ANDROID-VOL predicted 81.5% of the variance in MRI-SAT_ANDROID-VOL (SEE = 458.2, p < 0.0005). Bland-Altman analysis revealed a high level of agreement between MRI-VAT_ANDROID-VOL and DXA-VAT_ANDROID-VOL (mean bias = 58.45 cm³). A predicted mean DXA-VAT_ANDROID-VOL of 995.2 cm³ was estimated as the population-specific cut-off point for high levels of VAT.

CONCLUSION

DXA-VAT_ANDROID-VOL may accurately predict MRI-VAT_ANDROID-VOL in persons with SCI. The ability of DXA to detect VAT changes in longitudinal studies in persons with SCI should be performed.

A Four Month Randomized Controlled Trial on the Efficacy of Once-daily Fenofibrate Monotherapy in Persons with Spinal Cord Injury

An open-label, randomized clinical trial of once-daily fenofibrate monotherapy administered for 2- (Mo2) and 4- (Mo4) months using modified intervention thresholds for triglyceride (TG) was performed in persons with chronic spinal cord injury (SCI). Fenofibrate (145 mg tablet) was self-administered daily in 10 persons with SCI for 4 months with monthly blood testing to quantify the lipoprotein profile (e.g., serum TG, LDL-C, and HDL-C concentrations). Eight SCI participants were control subjects. In comparison to the control group, the treatment group at Mo2 had a 40% (±12%; p < 0.05) reduction in serum TG concentration, a 28% (±21%; p < 0.05) increase in HDL-C and 14% (±20%; p < 0.05) decline in LDL-C. In the same comparison at Mo4, the treatment group maintained a 40% (±20%; p < 0.05) reduction in serum TG concentration, had an 18% in reduction in LDL-C (±12%; p < 0.05) and a 23% (±23%; p < 0.05) increase in HDL-C. Fenofibrate monotherapy for Mo2 and Mo4 initiated in persons with SCI resulted in a robust and favorable change in the serum lipoprotein profile and ratios, suggesting reduced risk for cardiovascular disease.

Blood Pressure Instability in Persons With SCI: Evidence From a 30-Day Home Monitoring Observation

BACKGROUND

To determine the degree of blood pressure instability over a 30-day home observation in participants with spinal cord injury grouped by level of injury pertaining to cardiovascular autonomic regulation.

METHODS

This is an observational study completed at the Kessler Foundation and James J. Peters Veterans Medical Center. Seventy-two participants with tetraplegia (C1-T1), 13 with high thoracic (T2-T4), and 28 with low thoracic (T5-T12) injury participated in this study. Participants were asked to record their blood pressure using an ambulatory blood pressure monitor three times a day for 30 days.

RESULTS

The number of blood pressure fluctuations was significantly increased in the tetraplegia group compared with the paraplegia groups. Age and duration of injury contributed to an increase in the observation of 30-day blood pressure instability; however, completeness of injury did not.

CONCLUSION

The data indicate significant blood pressure instability that may not be exclusive to persons with tetraplegia; in fact, individuals with low thoracic injuries demonstrated severe blood pressure fluctuations. The use of a monitor at home for an extended period may help document dangerous and extreme fluctuations in blood pressure and should be considered an important adjunctive clinical practice for tracking of the secondary consequences in the spinal cord injury population.

Progressive Sublesional Bone Loss Extends into the Second Decade After Spinal Cord Injury

OBJECTIVE

The rate of areal bone mineral density (aBMD) loss at the knee (distal femur (DF) and proximal tibia ) and hip (femoral neck (FN) and total hip (TH)) was determined in persons with traumatic spinal cord injury (SCI) who were stratified into subgroups based on time since injury (TSI).

DESIGN

Cross-sectional retrospective review.

SETTING

Department of Veterans Affairs Medical Center and Private Rehabilitation Hospital.

PARTICIPANTS

Data on 105 individuals with SCI (TSI ≤12 months, n = 19; TSI 1-5 years, n = 35; 6-10 years, n = 19; TSI 11-20 years, n = 16; TSI >20 years, n = 15) and 17 able-bodied reference (AB_ref) controls.

INTERVENTIONS

NA Main Outcome Measures: The knee and hip aBMD values were obtained by dual energy X-ray absorptiometry (GE Lunar iDXA) using standard clinical software for the proximal femur employed in conjunction with proprietary research orthopedic knee software applications. Young-normal (T-score) and age-matched (Z-scores) standardized scores for the FN and TH were obtained using the combined GE Lunar/National Health and Nutrition Examination Survey (NHANES III) combined reference database.

RESULTS

When groups were stratified and compared as epochs of TSI, significantly lower mean aBMD and reference scores were observed as TSI increased, despite similar mean ages of participants among the majority of TSI epoch subgroups. Loss in aBMD occurred at the distal femur (DF), proximal tibia (PT), FN, and TH with 46%, 49%, 32%, and 43% of the variance in loss, respectively, described by the exponential decay curves with a time to steady state (t_ss) occurring at 14.6, 11.3, 14, and 6.2 years, respectively, after SCI.

CONCLUSIONS

Sublesional bone loss after SCI was marked and occurred as an inverse function of TSI. For aBMD at the hip and knee, t_ss extended into the second decade after SCI.

Establishing a threshold to predict risk of cardiovascular disease from the serum triglyceride and high-density lipoprotein concentrations in persons with spinal cord injury

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

This report identified the serum triglyceride (TG) concentrations in persons with spinal cord injury (SCI) and able-bodied (AB) individuals that the serum high-density lipoprotein cholesterol (HDL-C) equaled 40 mg/dl, a concentration below which is an independent risk factor for coronary artery disease.

METHODS

Retrospective analysis was performed on 578 participants: 223 with SCI at or proximal to the 4th thoracic vertebrae (↑T4), 178 with SCI at or distal to the 5th thoracic vertebrae (↓T5), and 177 AB. Different statistical modeling approaches identified the intersecting serum TG concentration with a serum HDL-C concentration equal to 40 mg/dl. Participants were dichotomized into subgroups by TG concentration exceeding (supra) or falling below (sub) the intersecting value and the TG/HDL-C ratios were compared.

RESULTS

Linear regression analysis revealed that the serum TG concentration that intersects with serum HDL-C concentration at 40 mg/dl was 121 mg/dl in SCI ↑T4 and 137 mg/dl in SCI ↓T5 group. A ROC curve identified the optimal TG concentration as 115 mg/dl in SCI ↑T4 and 137 mg/dl in SCI ↓T5 group with the latter concentration being similar to the AB group (e.g., 137 mg/dl). The TG/HDL-C ratios in the respective ↑T4, ↓T5, and AB supra and subgroups were similar within each group.

CONCLUSIONS

A lower TG concentration appears to be associated with dyslipidemia in persons with SCI than AB individuals. These findings should prompt clinicians to screen for and consider instituting lifestyle or pharmacological interventions at lower TG concentrations to reduce risk of CVD.

Challenging questions regarding the international standards

Objective/Context To highlight questions with regards to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and provide historical perspectives to help SCI professionals gain fuller insights into the classification system. Methods Frequently asked questions to the ISNCSCI were collected and a review of literature and personal communications with International Standards committee members and Chairs were undertaken. Results Background and explanations for nine questions, detailing decision processes and challenging classification rules are presented. Conclusion While the ISNCSCI can be challenging, this background and historical explanation may provide a greater understanding and the ability to critically analyze this classification system.

Exploring detailed characteristics of autonomic dysreflexia

OBJECTIVES

Identify clinical and pathophysiologic insights into autonomic dysreflexia (AD) in patients with spinal cord injury (SCI).

STUDY DESIGN

Analysis of prospectively gathered AD dataset.

SETTING

Inpatient Veterans Affairs SCI unit.

PARTICIPANTS

78 male patients with SCI who experienced AD.

METHODS

Statistical methods were utilized to identify the frequency of relative bradycardia vs. tachycardia during AD, the effectiveness of supplemental opioids in managing suspected nociceptive pain mediated AD, the effect of chronicity of SCI on response to pharmacological management of AD, and the response to nitroglycerin ointment in suspected bladder related AD.

RESULTS

445 episodes of AD were analyzed. The frequency of relative bradycardia and tachycardia with AD were 0.3% and 68.0% respectively. The addition of opioids to an antihypertensive medication protocol did not significantly decrease AD episode duration or magnitude of systolic blood pressure (SBP) change. A strongly matched positive linear correlation was identified between the duration of pharmacologically treated AD episodes and chronicity of SCI (R2=0.83). Bladder related AD episodes treated with nitroglycerin ointment had a faster onset of action (10.8 minutes vs. 15.9 minutes), faster time to reach a safe target blood pressure (16.5 minutes vs 20.9 minutes), and greater decrease in SBP (84.3mmHg vs. 68.6mmHg) than non-bladder related episodes (P=0.19, 0.23, and 0.02 respectively).

CONCLUSIONS

AD may commonly occur with relative tachycardia. While further investigation is needed on the effects of chronicity of SCI and pharmacologic management, this study raises multiple directions for future research to understand clinical signs and treatment variables of AD following SCI.

Quantifying and Reducing Retained Botulinum Toxin Postinjection

BACKGROUND

Retained botulinum toxin solution may be visible in vials and syringe tips after mixing and presumed complete injections, leaving patients without the full prescribed dose.

OBJECTIVE

To quantify the mean amount of retained toxin within vials, syringes, and needles following spasticity injections (phase 1) and to design/test a targeted intervention for reduced retained toxin (phase 2).

DESIGN

Prospective cohort quality assurance study.

SETTING

Outpatient spasticity program in a rehabilitation facility.

PARTICIPANTS

Nine physicians specializing in physical medicine and rehabilitation, performing successive mixing and injections for spasticity with onabotulinumtoxinA or incobotulinumtoxinA.

METHODS

After initial review (phase 1), recommendations were made (phase 2) including not inverting the vial to withdraw medication unless needed, favoring 2-mL dilutions when possible, and decapping of vials for more complete medication withdrawal.

MAIN OUTCOME MEASUREMENTS

Retained volume of toxin solution that was not injected and estimated retained units of toxin.

RESULTS

A total of 157 vials of botulinum toxin A were tested. Of the 82 initial, phase 1, preintervention vials (8200 units), 5.5% (∼452 units) of toxin solution was retained following mixing and injections. One and 3-mL syringe tips contained a mean of 3.32 and 1.44 units of toxin respectively. Within vials, saline dilutions with 2 mL contained less mean retained toxin (1.89 vs 3.31 units) relative to 1-mL dilution. Awareness of monitoring significantly decreased retained solution in vials (0.035 mL vs 0.069 mL for naïve group, P = .002). Phase 2, postintervention testing of 75 vials demonstrated that withdrawing toxin from the inferior edge from a non-inverted vial reduced the retained toxin by 32.8% (P < .001). Decapping the vial further reduced the mean retained toxin to 0.42 units per vial (81.9% reduction, P < .001).

CONCLUSIONS

A potentially clinically significant amount of botulinum toxin solution is retained following mixing and injections. Implementation of guidelines significantly decreased wasted botulinum toxin.

LEVEL OF EVIDENCE

III.

Research progress from the SCI Model Systems (SCIMS): An interactive discussion on future directions

CONTEXT/OBJECTIVE

To describe current and future directions in spinal cord injury (SCI) research.

DESIGN

The SCI Model Systems (SCIMS) programs funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) during the 2011 to 2016 cycle provided abstracts describing findings from current research projects. Discussion among session participants generated ideas for research opportunities.

SETTING/PARTICIPANTS

Pre-conference workshop before the 2016 American Spinal Injury Association (ASIA) annual meeting. A steering committee selected by the SCIMS directors that included the moderators of the sessions at the ASIA pre-conference workshop, researchers presenting abstracts during the session, and the audience of over 100 attending participants in the pre-conference workshop.

METHODS/RESULTS

Group discussion followed presentations in 5 thematic areas of (1) Demographics and Measurement; (2) Functional Training; (3) Psychosocial Considerations; (4) Assistive Technology; and (5) Secondary Conditions. The steering committee reviewed and summarized discussion points on future directions for research and made recommendations for research based on the discussion in each of the five areas.

CONCLUSION

Significant areas in need of research in SCI remain, the goal of which is continued improvement in the quality of life of individuals with SCI.

Administration of increasing doses of gonadotropin-releasing hormone in men with spinal cord injury to investigate dysfunction of the hypothalamic-pituitary-gonadal axis

STUDY DESIGN

Prospective.

OBJECTIVES

To determine the optimum gonadotropin-releasing hormone (GnRH) dose to identify dysfunction of the hypothalamic-pituitary-gonadal axis in men with spinal cord injury (SCI).

SETTING

Metropolitan Area Hospitals, New York and New Jersey, USA.

METHODS

SCI men (16 hypogonadal (HG = serum testosterone <12.1 nmol/l) and 14 eugonadal (EG)) and able-bodied (AB) men (27 HG and 11 EG) were studied. GnRH (10, 50, and 100 μg) was randomly administered intravenously on three separate visits. Blood samples were collected post-GnRH for serum-luteinizing hormone (LH) and follicular-stimulating hormone (FSH).

RESULTS

HG and EG men had a similar proportion of clinically acceptable gonadotropin responses to all three GnRH doses. The incremental gonadotropin responses to GnRH were not significantly different across the groups. However, in the SCI-HG group, GnRH of 100 μg resulted in the greatest integrated FSH response, and in the SCI-EG group, GnRH of 50 μg resulted in the greatest integrated LH response compared with the AB groups. A consistent, but not significant, absolute increase in gonadotropin release was observed in the SCI groups at all GnRH doses.

CONCLUSIONS

Lower doses of GnRH did not improve the ability to identify the clinical dysfunction of the hypothalamic-pituitary-gonadal axis. However, the absolutely higher SCI-HG FSH response to GnRH of 100 μg and a higher SCI-EG LH response to GnRH of 50 μg, along with a higher gonadotropin release at all GnRH doses, albeit not significant, suggests a hypothalamic-pituitary dysfunction in persons with SCI.

Testicular responses to hCG stimulation at varying doses in men with spinal cord injury

STUDY DESIGN

Prospective.

OBJECTIVES

To test whether provocative stimulation of the testes identifies men with chronic spinal cord injury (SCI), a population in which serum testosterone concentrations are often depressed, possibly due to gonadal dysfunction. To accomplish this objective, conventional and lower than the conventional doses of human chorionic gonadotropin (hCG) were administered.

METHODS

Thirty men with chronic SCI (duration of injury >1 year; 18 and 65 years old; 16 eugonadal (>12.1 nmol l-1) and 14 hypogonadal (⩽12.1 nmol l-1)) or able-bodied (AB) men (11 eugonadal and 27 hypogonadal) were recruited for the study. Stimulation tests were performed to quantify testicular responses to the intramuscular administration of hCG at three dose concentrations (ithat is, 400, 2000 and 4000 IU). The hCG was administered on two consecutive days, and blood was collected for serum testosterone in the early morning prior to each of the two injections; subjects returned on day 3 for a final blood sample collection.

RESULTS

The average gonadal response in the SCI and AB groups to each dose of hCG was not significantly different in the hypogonadal or eugonadal subjects, with the mean serum testosterone concentrations in all groups demonstrating an adequate response.

CONCLUSIONS

This work confirmed the absence of primary testicular dysfunction without additional benefit demonstrated of provocative stimulation of the testes with lower than conventional doses of hCG. Our findings support prior work that suggested a secondary testicular dysfunction that occurs in a majority of those with SCI and depressed serum testosterone concentrations.

Self-reported effects of cold temperature exposure in persons with tetraplegia

OBJECTIVE

Cervical spinal cord injury (tetraplegia) is known to interrupt sympathetic vasculature control, thereby preventing shunting of blood from the periphery to central organs when exposed to cold temperatures. As a result, persons with tetraplegia are at risk to develop hypothermia. However, information regarding the discomfort experienced during the cooler months (late fall, winter, early spring) is overwhelmingly anecdotal. It is not known, with any certainty, how those with tetraplegia perceive cold and if discomfort in colder environments restricts them from performing activities that they routinely would perform.

DESIGN

Prospective, two-group, self-report surveys.

SETTING

VA Medical Center and Kessler Institute for Rehabilitation.

PARTICIPANTS

Forty-four subjects with tetraplegia; 41 matched non-SCI controls.

OUTCOME MEASURES

Tetraplegic and control groups responded "yes" or "no" when asked whether cold seasonal temperatures allowed comfort or negatively affected participation in routine activities.

RESULTS

Percentage of responses of tetraplegia compared to controls was different as to whether they felt cold when others in the same room were comfortable (82 vs. 24%; χ² = 28.2, P < 0.0001), felt comfortable outdoors (17 vs. 43%; χ² = 6.8, P = 0.009), or whether cold negatively affected bathing routines (55 vs. 15%; χ² = 14.8, P = 0.0001), keeping physician appointments (46 vs. 12%; χ² = 11.3, P = 0.0008), thinking clearly (41 vs. 7%; χ² = 12.9, P = 0.0003), and completing usual work duties (46 vs. 10%; χ² = 13.3, P = 0.0003).

CONCLUSION

Cold seasonal temperatures have a reported greater negative impact on personal comfort and ability to perform vital activities in persons with tetraplegia than that of non-SCI controls. These findings highlight the need to address thermoregulatory impairment in persons with tetraplegia.

Bone loss at the distal femur and proximal tibia in persons with spinal cord injury: imaging approaches, risk of fracture, and potential treatment options

Persons with spinal cord injury (SCI) undergo immediate unloading of the skeleton and, as a result, have severe bone loss below the level of lesion associated with increased risk of long-bone fractures. The pattern of bone loss in individuals with SCI differs from other forms of secondary osteoporosis because the skeleton above the level of lesion remains unaffected, while marked bone loss occurs in the regions of neurological impairment. Striking demineralization of the trabecular epiphyses of the distal femur (supracondylar) and proximal tibia occurs, with the knee region being highly vulnerable to fracture because many accidents occur while sitting in a wheelchair, making the knee region the first point of contact to any applied force. To quantify bone mineral density (BMD) at the knee, dual energy x-ray absorptiometry (DXA) and/or computed tomography (CT) bone densitometry are routinely employed in the clinical and research settings. A detailed review of imaging methods to acquire and quantify BMD at the distal femur and proximal tibia has not been performed to date but, if available, would serve as a reference for clinicians and researchers. This article will discuss the risk of fracture at the knee in persons with SCI, imaging methods to acquire and quantify BMD at the distal femur and proximal tibia, and treatment options available for prophylaxis against or reversal of osteoporosis in individuals with SCI.

Clinical interpretation of the Spinal Cord Injury Functional Index (SCI-FI)

OBJECTIVE

To provide validation of functional ability levels for the Spinal Cord Injury - Functional Index (SCI-FI).

DESIGN

Cross-sectional.

SETTING

Inpatient rehabilitation hospital and community settings.

PARTICIPANTS

A sample of 855 individuals with traumatic spinal cord injury enrolled in 6 rehabilitation centers participating in the National Spinal Cord Injury Model Systems Network.

INTERVENTIONS

Not Applicable.

MAIN OUTCOME MEASURES

Spinal Cord Injury-Functional Index (SCI-FI).

RESULTS

Cluster analyses identified three distinct groups that represent low, mid-range and high SCI-FI functional ability levels. Comparison of clusters on personal and other injury characteristics suggested some significant differences between groups.

CONCLUSIONS

These results strongly support the use of SCI-FI functional ability levels to document the perceived functional abilities of persons with SCI. Results of the cluster analysis suggest that the SCI-FI functional ability levels capture function by injury characteristics. Clinical implications regarding tracking functional activity trajectories during follow-up visits are discussed.

Motor levels in high cervical spinal cord injuries: Implications for the International Standards for Neurological Classification of Spinal Cord Injury

CONTEXT/OBJECTIVE

To verify the hypothesis that motor levels (ML) inferred from sensory levels in the upper cervical segments C2-C4 according to the current version of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) are counterintuitive in cases where the most rostral myotomes C5 and C6 are graded as intact.

DESIGN

Prospective cohort study of ISNCSCI instructional course participants completing a post-test after the workshop to determine the MLs in two variants of a complete, high cervical spinal cord injury (SCI) case scenario. Both variants were based on the same ISNCSCI sensory and MLs of C2. In the first variant myotomes C5 and C6 were bilaterally graded as intact, while in variant 2 only active movements against gravity were possible (grade 3).

SETTING

Eight ISNCSCI instructional courses conducted during the study period from November 2012 until March 2015 in the framework of the European Multicenter Study on Human Spinal Cord Injury (EMSCI- http//emsci.org ).

PARTICIPANTS

Ninety-two clinicians from twenty-two SCI centers. Most of the attendees were physicians (58.7%) or physical therapists (33.7%) and had less than one year (44.6%) experience in SCI medicine.

INTERVENTIONS

Not applicable.

OUTCOME MEASURE

The classification performance described as percentage of correctly determined MLs by the clinicians.

RESULTS

Variant 2 (89.13%) was significantly (P < 0.0001) better classified than variant 1 (65.76%). In variant 1 with intact myotomes at C5 and C6, C6 was incorrectly classified as the ML by the clinicians in 33.15% of all cases, whereas in variant 2 with non-intact C5 / C6 myotomes, C6 was rarely chosen (2.17%).

CONCLUSIONS

Sensory level deferred MLs in the high cervical region of C2-C4 are counterintuitive whenever the most rostral cervical myotomes are intact. An adjustment of the ML definition in ISNCSCI may be needed.

International standards for neurological classification of spinal cord injury: impact of the revised worksheet (revision 02/13) on classification performance

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

Comparison of the classification performance between the worksheet revisions of 2011 and 2013 of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI).

SETTINGS

Ongoing ISNCSCI instructional courses of the European Multicenter Study on Human Spinal Cord Injury (EMSCI). For quality control all participants were requested to classify five ISNCSCI cases directly before (pre-test) and after (post-test) the workshop.

PARTICIPANTS

One hundred twenty-five clinicians working in 22 SCI centers attended the instructional course between November 2011 and March 2015. Seventy-two clinicians completed the post-test with the 2011 revision of the worksheet and 53 with the 2013 revision.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

The clinicians' classification performance assessed by the percentage of correctly determined motor levels (ML) and sensory levels, neurological levels of injury (NLI), ASIA Impairment Scales and zones of partial preservations.

RESULTS

While no group differences were found in the pre-tests, the overall performance (rev2011: 92.2% ± 6.7%, rev2013: 94.3% ± 7.7%; P = 0.010), the percentage of correct MLs (83.2% ± 14.5% vs. 88.1% ± 15.3%; P = 0.046) and NLIs (86.1% ± 16.7% vs. 90.9% ± 18.6%; P = 0.043) improved significantly in the post-tests. Detailed ML analysis revealed the largest benefit of the 2013 revision (50.0% vs. 67.0%) in a case with a high cervical injury (NLI C2).

CONCLUSION

The results from the EMSCI ISNCSCI post-tests show a significantly better classification performance using the revised 2013 worksheet presumably due to the body-side based grouping of myotomes and dermatomes and their correct horizontal alignment. Even with these proven advantages of the new layout, the correct determination of MLs in the segments C2-C4 remains difficult.

Provocative stimulation of the hypothalamic-pituitary-testicular axis in men with spinal cord injury

STUDY DESIGN

Prospective study.

OBJECTIVE

To determine the integrity of the hypothalamic-pituitary-testicular axis in healthy men with spinal cord injury (SCI).

METHODS

Thirty healthy men with chronic SCI (37±10 years) and thirty-eight able-bodied (AB) controls (36±10 years) participated. Gonadotropin-releasing hormone (GnRH; 100 μg IV) was administered to determine gonadotropin release, and human chorionic gonadotropin (hCG; 4000 IU IM) was administered to determine testosterone (T) secretion. Responses to stimulation were categorized as 'responder' or 'non-responder' by clinical criteria. Single factor ANOVA with repeated measures was performed to identify group differences.

RESULTS

The proportion of responders to pituitary GnRH stimulation was similar in the SCI group (22 subjects (73%) for the follicular-stimulating hormone (FSH) and 23 subjects (76%) for the luteinizing hormone (LH) to that of the AB group. The SCI-responder group had an increased FSH response after stimulation compared with the AB-responder group (P<0.05). The SCI-responder group had a greater LH area under the curve to GnRH stimulation than the AB-responder group (P=0.06). The peak FSH response was at 60 min and the peak LH response at 30 min, regardless of group designation. All groups had similar increases in serum T concentration to hCG stimulation.

CONCLUSIONS

The pituitary response to stimulation in healthy men with SCI revealed an augmented FSH response; LH response only trended higher. The testicular response to provocative stimulation was similar in hypogonadal and eugondal subjects and in GnRH responders and non-responders. These findings suggest a lack of hypothalamic drive of pituitary gonadotropin release in healthy people with chronic SCI.

Patterns of Sacral Sparing Components on Neurologic Recovery in Newly Injured Persons With Traumatic Spinal Cord Injury

OBJECTIVE

To assess the patterns of sacral sparing and recovery in newly injured persons with traumatic spinal cord injury (SCI).

DESIGN

Retrospective analysis of data from the national Spinal Cord Injury Model Systems (SCIMS) database for patients enrolled from January 2011 to February 2015.

SETTING

SCIMS centers.

PARTICIPANTS

Individuals (N=1738; age ≥16y) with traumatic SCI admitted to rehabilitation within 30 days after injury with follow-up at discharge, at 1 year, or both.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

International Standards for Neurological Classification of Spinal Cord Injury examination results at admission and follow-up (discharge or 1y, or both).

RESULTS

Conversion from an initial American Spinal Injury Association Impairment Scale (AIS) grade A to incomplete status was 20% at rehabilitation discharge and 27.8% at 1 year, and was greater in cervical and low paraplegia levels (T10 and below) than in high paraplegia level injuries (T1-9). Conversion from AIS B to motor incomplete was 33.9% at discharge and 53.6% at 1 year, and the initial sparing of all sacral sensory components was correlated with the greatest conversion to motor incomplete status at discharge and at 1 year. For patients with initial AIS C, the presence of voluntary anal contraction (VAC) in association with other sacral sparing was most frequently observed to improve to AIS D status at discharge. However, the presence of VAC alone as the initial sacral sparing component had the poorest prognosis for recovery to AIS D status. At follow-up, regaining sacral sparing components correlated with improvement in conversion for patients with initial AIS B and C.

CONCLUSIONS

The components of initial and follow-up sacral sparing indicated differential patterns of neurologic outcome in persons with traumatic SCI. The more sacral components initially spared, the greater the potential for recovery; and the more sacral components gained, the greater the chance of motor recovery. Consideration of whether VAC should remain a diagnostic criterion sufficient for motor incomplete classification in the absence of other qualifying sublesional motor sparing is recommended.

Breaking the news: A pilot study on patient perspectives of discussing prognosis after traumatic spinal cord injury

OBJECTIVE/BACKGROUND

In spinal cord injury (SCI) medicine, informing a patient with a neurologically complete SCI of the poor prognosis ("bad news") for significant neurological recovery (e.g. ambulation) is difficult. Few guidelines exist for clinicians and the wishes of patients in receiving this information are currently not known. The goal of this pilot study was to determine when, by whom, and in what setting persons with neurologically complete traumatic SCI want to hear of their prognosis.

METHODS

Subjects with a >3 months motor complete SCI above T10 were recruited to complete an online survey, from three geographically different acute rehabilitation centers, to obtain retrospective information on their experiences of receiving poor prognosis. A mixed methods approach was used to obtain data on individual experiences and a combination of quantitative and qualitative analyses was used to assess patterns in individual responses.

RESULTS

60 individuals were recruited for the study and 56 participants completed the survey. Most heard their prognosis from a physician, in the acute care hospital (61%), with the patient initiating the conversation (64%). Patient recommendations reveal that most individuals with traumatic SCI prefer to be given the poor prognosis for neurological recovery by a physician and early after injury. There were no differences in patient experience nor recommendations based on demographic background (i.e. sex, age, race, or education level).

CONCLUSION

The majority of patients surveyed report wanting to know their prognosis early after injury and to hear the information by a physician in a clear and sensitive manner. This study marks the first step towards defining how and when to break the news regarding poor prognosis for neurological recovery including ambulation after severe (neurological complete) traumatic SCI from the patients' perspective.

Visceral adiposity in persons with chronic spinal cord injury determined by dual energy X-ray absorptiometry

OBJECTIVE

To determine visceral adipose tissue (VAT) volume (VATvol) by dual energy X-ray absorptiometry (DXA) in spinal cord injured (SCI) and able-bodied (AB) participants and to explore the relationships between VATvol and routine anthropometric measures.

METHODS

Sixty-three subjects with SCI and 126 healthy male AB controls were stratified as low risk [LR: waist circumference (WC) < 102 cm] and moderate to high risk (MHR: WC ≥ 102 cm) for identification of risk for cardiometabolic disease: AB-LR, SCI-LR, AB-MHR, and SCI-MHR. Anthropometrics and standard body composition measurements by DXA with analysis to derive VATvol were performed.

RESULTS

Comparison of the four subgroups demonstrated the highest subcutaneous adipose tissue volume (SATvol) in the AB-MHR group (P < 0.01), and the highest VATvol in the SCI-MHR group (P < 0.01). Furthermore, when compared to the AB group, participants with SCI had a 27% increase in VATvol for every centimeter increase in WC and a 20% increase in VATvol for every unit increase in BMI.

CONCLUSIONS

Because cutoff values for the routine surrogate measures of adiposity underestimate visceral adiposity in persons with SCI, the risk of adverse metabolic consequences would also be underestimated, which necessitates adjustment of the these cutoff values or, preferably, to perform its direct measurement.

Lipoprotein heterogeneity in persons with Spinal Cord Injury: a model of prolonged sitting and restricted physical activity

BACKGROUND

Persons with spinal cord injury (SCI) often have low levels of physical activity, which predispose to increased adiposity and decreased high density lipoprotein cholesterol (HDL-C) concentrations, and, generally, normal low density lipoprotein cholesterol (LDL-C) concentrations. In spite of the mixed lipoprotein profile, the SCI population has been reported to have an elevated risk of cardiovascular-related morbidity and mortality. Nuclear magnetic resonance spectroscopy may permit a more precise quantification of lipoprotein particle (P) species, enabling a more accurate inference of risk for cardiovascular disease (CVD) in the SCI population.

METHODS

Fasting blood samples were obtained on 83 persons with chronic SCI and 62 able-bodied (AB) subjects. Fasting plasma insulin (FPI), triglycerides (TG), and P number and size of VLDL (very low density lipoprotein), LDL, and HDL subclasses were determined. AB and SCI subjects were stratified based on HDL-C (i.e., Low <40 and Normal ≥ 40 mg/dl): AB-Normal (n = 48), AB-Low (n = 14), SCI-Normal (n = 49), and SCI-Low (n = 34). Factorial analyses of variance were performed to identify group differences in lipoprotein measurements. Pearson correlations were performed between the number of P by lipoprotein subclass, size, FPI, and TG.

RESULTS

The SCI-Normal group was not significantly different from the AB-Normal group for body composition, FPI, TG or LP-IR and had negligible differences in the lipoprotein P profile, except for fewer number and smaller size of HDL-P. The SCI-Low group had a similar lipoprotein profile to that of the AB-Low group, but with a lipid P composition associated with a heightened atherogenic risk and greater tendency toward insulin resistance by the Lipoprotein-Insulin Resistance (LP-IR) score. In the SCI-Low group, the decreased number and reduced size of lipoprotein P were more prevalent and may be associated with increased waist circumference (i.e., abdominal adiposity), relatively elevated TG values (compared to the other subgroups), and an underlying subclinical state of insulin resistance.

CONCLUSIONS

Prolonged sitting and restricted physical activity in individuals with SCI had the most profound effect on the HDL-C and its lipoprotein P subclasses, but not on LDL-C, however its P subclasses were also unfavorably affected but not to the same degree. The quantification of lipoprotein P characteristics may be a potent tool for the determination of risk for CVD in persons with SCI.

Zoledronic acid administration failed to prevent bone loss at the knee in persons with acute spinal cord injury: an observational cohort study

After acute spinal cord injury (SCI), rapid depletion of the sublesional skeleton occurs, particularly at the distal femur and proximal tibia. Subsequently, fragility fractures of the knee may occur. We determined the efficacy of zoledronic acid to prevent sublesional bone mineral density (BMD) loss at 6 and 12 months after acute SCI. Thirteen subjects with acute motor-complete SCI were prospectively studied: 6 patients received zoledronic acid (5 mg) and 7 subjects did not receive the drug (controls). Zoledronic acid was administered intravenously within 16 weeks of acute injury. Areal BMD was performed by dual energy X-ray absorptiometry at baseline, 6, and 12 months after administration of drug. The treatment group demonstrated sparing of BMD at the total hip at month 6 (p < 0.0006) and at month 12 (p < 0.01). In contrast to the findings at the hip, the treatment group had a greater loss of BMD compared to the control group at the distal femur and proximal tibia at month 6 (-7.9% ± 3.4 vs.-2.7% ± 5.0, respectively, p = 0.054; and -10.5% ± 6.4 vs. -4.8% ± 6.8, respectively, p = NS) and at month 12 (-18.5% ± 3.9 vs. -8.4% ± 7.2, respectively, p = 0.01; and -20.4% ± 8.8 vs.-7.9% ± 12.3, respectively, p = 0.06). A single dose of zoledronic acid administered soon after acute SCI reduced the %BMD loss at the hip, but appeared to have no effect to prevent %BMD loss at the knee, the site where fracture risk is greatest in persons with SCI.

Development and psychometric characteristics of the SCI-QOL Pressure Ulcers scale and short form

OBJECTIVE

To develop a self-reported measure of the subjective impact of pressure ulcers on health-related quality of life (HRQOL) in individuals with spinal cord injury (SCI) as part of the SCI quality of life (SCI-QOL) measurement system.

DESIGN

Grounded-theory based qualitative item development methods, large-scale item calibration testing, confirmatory factor analysis (CFA), and item response theory-based psychometric analysis.

SETTING

Five SCI Model System centers and one Department of Veterans Affairs medical center in the United States.

PARTICIPANTS

Adults with traumatic SCI.

MAIN OUTCOME MEASURES

SCI-QOL Pressure Ulcers scale.

RESULTS

189 individuals with traumatic SCI who experienced a pressure ulcer within the past 7 days completed 30 items related to pressure ulcers. CFA confirmed a unidimensional pool of items. IRT analyses were conducted. A constrained Graded Response Model with a constant slope parameter was used to estimate item thresholds for the 12 retained items.

CONCLUSIONS

The 12-item SCI-QOL Pressure Ulcers scale is unique in that it is specifically targeted to individuals with spinal cord injury and at every stage of development has included input from individuals with SCI. Furthermore, use of CFA and IRT methods provide flexibility and precision of measurement. The scale may be administered in its entirety or as a 7-item "short form" and is available for both research and clinical practice.

Development and psychometric characteristics of the SCI-QOL Bladder Management Difficulties and Bowel Management Difficulties item banks and short forms and the SCI-QOL Bladder Complications scale

OBJECTIVE

To describe the development and psychometric properties of the Spinal Cord Injury--Quality of Life (SCI-QOL) Bladder Management Difficulties and Bowel Management Difficulties item banks and Bladder Complications scale.

DESIGN

Using a mixed-methods design, a pool of items assessing bladder and bowel-related concerns were developed using focus groups with individuals with spinal cord injury (SCI) and SCI clinicians, cognitive interviews, and item response theory (IRT) analytic approaches, including tests of model fit and differential item functioning.

SETTING

Thirty-eight bladder items and 52 bowel items were tested at the University of Michigan, Kessler Foundation Research Center, the Rehabilitation Institute of Chicago, the University of Washington, Craig Hospital, and the James J. Peters VA Medical Center, Bronx, NY.

PARTICIPANTS

Seven hundred fifty-seven adults with traumatic SCI.

RESULTS

The final item banks demonstrated unidimensionality (Bladder Management Difficulties CFI=0.965; RMSEA=0.093; Bowel Management Difficulties CFI=0.955; RMSEA=0.078) and acceptable fit to a graded response IRT model. The final calibrated Bladder Management Difficulties bank includes 15 items, and the final Bowel Management Difficulties item bank consists of 26 items. Additionally, 5 items related to urinary tract infections (UTI) did not fit with the larger Bladder Management Difficulties item bank but performed relatively well independently (CFI=0.992, RMSEA=0.050) and were thus retained as a separate scale.

CONCLUSION

The SCI-QOL Bladder Management Difficulties and Bowel Management Difficulties item banks are psychometrically robust and are available as computer adaptive tests or short forms. The SCI-QOL Bladder Complications scale is a brief, fixed-length outcomes instrument for individuals with a UTI.

Orthostatic responses to anticholinesterase inhibition in spinal cord injury

INTRODUCTION

Acetylcholine (Ach) is the pre-synaptic neurotransmitter of the sympathetic nervous system. Increased pre-synaptic Ach may augment post-synaptic release of norepinephrine, thereby increasing systemic blood pressure (BP).

OBJECTIVES

The primary objective of this investigation was to determine the hemodynamic effect of pyridostigmine bromide (PYRIDO: 60 mg), an Ach inhibitor (AchI), compared to no-drug (NO-D) during head-up tilt (HUT) in individuals with spinal cord injury (SCI). Secondarily, we aimed to determine the effects of PYRIDO compared to NO-D on symptoms of orthostatic intolerance (OI) and adverse event reporting (AE).

METHODS

Ten individuals with SCI (C4-C7) were studied on two occasions: visit (1) NO-D and visit (2) PYRIDO. On each visit subjects underwent a progressive HUT maneuver to 15°, 25°, 35° for 5 min at each angle and 45 min at 45°. Supine and orthostatic heart rate (HR), systolic and diastolic BP (SBP and DBP), as well as monitored and symptoms of OI and AE were monitored and recorded.

RESULTS

Supine hemodynamics did not differ between the trials. The significant fall in SBP during the NO-D trial was diminished with PYRIDO, and five subjects had an increased DBP during HUT with PYRIDO compared to the NO-D trial. Individuals that responded to PYRIDO with an increase in orthostatic BP had significantly lower resting HR than non-responders (p < 0.01), which suggests increased levels of pre-synaptic Ach. Subjective symptoms of OI and AE reporting did not differ between the two trials.

CONCLUSIONS

These preliminary data suggest that PYRIDO is safe and may be effective at ameliorating the orthostatic fall in BP in select individuals with SCI.

Lean tissue mass and energy expenditure are retained in hypogonadal men with spinal cord injury after discontinuation of testosterone replacement therapy

OBJECTIVE

To determine whether favorable changes to lean tissue mass (LTM), resting energy expenditure (REE), and testosterone (T) that occurred with 12 months of physiological testosterone replacement therapy (TRT) were retained 6 months after discontinuing treatment.

DESIGN

Prospective, open-label, controlled drug intervention trial.

SETTING

Metropolitan area hospitals.

SUBJECTS

Eugonadal (n = 11) and hypogonadal (n = 13) men with chronic spinal cord injury (SCI).

INTERVENTIONS

Hypogonadal subjects received a 5 or 10 mg transdermal T patch daily for 12 months, with adjustment of the dose to normalize the serum T concentration; TRT was discontinued after 12 months (TRT-12M) and subjects were followed for an additional 6 months and re-evaluated (Post-TRT). Total body dual energy X-ray absorptiometry and blood draws were performed at baseline (BL) prior to TRT, TRT-12M, and Post-TRT. Eugonadal subjects did not receive treatment and were evaluated at comparable time points.

RESULTS

There were no significant differences between groups prior to TRT at BL for any of the study endpoints. In the hypogonadal group, a significant increase in LTM was observed from BL to TRT-12M (50.2 ± 7.4 vs. 52.9 ± 6.8 kg, P < 0.01), which persisted Post-TRT compared to BL (52.2 ± 7.8 kg, P < 0.05). The increase in REE from BL to TRT-12M (1283 ± 246 vs. 1410 ± 250 kcal/day) was also retained at Post-TRT (1393 ± 220 kcal/day). These sustained improvements in LTM and REE after termination of anabolic hormonal therapy may be associated with persistent beneficial effects on health and physical function of hypogonadal men with chronic SCI.

International standards for neurological classification of spinal cord injury: cases with classification challenges

The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) is routinely used to determine levels of injury and to classify the severity of the injury. Questions are often posed to the International Standards Committee of the American Spinal Injury Association (ASIA) regarding the classification. The committee felt that disseminating some of the challenging questions posed, as well as the responses, would be of benefit for professionals utilizing the ISNCSCI. Case scenarios that were submitted to the committee are presented with the responses as well as the thought processes considered by the committee members. The importance of this documentation is to clarify some points as well as update the SCI community regarding possible revisions that will be needed in the future based upon some rules that require clarification.

A survey of protective cushion usage in individuals with spinal cord injury while traveling in a motor vehicle and on a commercial airliner

OBJECTIVE

While there are specific recommendations for pressure relieving cushions when seated in a wheelchair, there is a paucity of information regarding prescribed wheelchair cushions for persons with spinal cord injury (SCI) when traveling and not in their wheelchair seat. A questionnaire was designed to ascertain if individuals with SCI who are primarily wheelchair users utilize a prescribed wheelchair cushion when traveling in a motor vehicle (MV) or on a commercial airliner, as not utilizing one may be a causative factor in developing pressure ulcers.

DESIGN AND SETTING

Survey design in an outpatient SCI rehabilitation setting.

PARTICIPANTS

Full-time wheelchair users, with chronic (>1 year) SCI.

RESULTS

Forty-two participants completed the survey, with a mean age of 39 years old and time post-injury of 10.4 years. All subjects used a prescribed wheelchair cushion when seated in their wheelchair. Twenty-seven subjects reported transferring to a MV seat (59.5% of sample), with 25 (92.6%) reporting not using a prescribed wheelchair cushion when sitting directly on the MV seat. For subjects who traveled on an airplane (n = 23-54.8%), 19 (82.6%) reported that they do not sit on a prescribed specialty cushion.

CONCLUSION

Persons with chronic SCI, who are primary wheelchair users, utilize prescribed wheelchair cushions when sitting in their wheelchair, but most do not utilize a prescribed wheelchair cushion when seated in a MV (if they transfer out of their chair) or on a airplane seat. Studies to determine the pressures over the bony prominences on their travel surfaces may need to be undertaken to see whether the pressures are appropriate, as they may be a source of skin breakdown.

The relationship between the postprandial lipemic response and lipid composition in persons with spinal cord injury

OBJECTIVE

To determine the influence of lipid concentration, lipid particle size, and total abdominal fat (TAF) on postprandial lipemic response (PPLr) in persons with spinal cord injury (SCI).

METHODS

Thirty-five persons with SCI (17 paraplegia, 18 tetraplegia) and 18 able-bodied (AB) individuals participated. Following a 10-hour fast, blood was drawn for lipids, apolipoprotein (apo) A1 and B concentrations, and low-density (LSP) and high-density (HSP) lipoprotein particle sizes. A high-fat milkshake was consumed (∼1.3 g fat/kg). Blood was drawn at 2, 4, and 6 hours to determine PPLr, (triglyceride (TG) area under the curve). TAF and visceral (VF) fat were measured by ultrasonography; total body fat (TBF) by dual-energy X-ray absorptiometry. Differences between the groups were determined by independent sample t-tests. Pearson correlation coefficients determined the relationship among PPLr and lipids, and TAF.

RESULTS

There were no significant differences in fasting TG, low-density lipoprotein (LDL), apoB, TAF, or PPLr values between the groups. In SCI, PPLr significantly correlated with: apoB (r = 0.63, P < 0.01, LSP (r = 0.57, P < 0.01), and TAF (r = 0.36, P < 0.01). After controlling for age and duration of injury, PPLr significantly correlated with apoB (r = 0.66, P = 0.001), TBF (r = 0.45, P = 0.03), VF (r = 0.66, P = 0.02), and TAF (r = 0.56, P = 0.007).

CONCLUSIONS

Although concentrations of LDL cholesterol and apoB were not different between SCI and AB groups, LSP, apoB, and TAF correlated with PPLr in persons with SCI. ApoB was associated with a greater PPLr in those with motor complete SCI, after controlling for age and duration of injury.