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

STUDY DESIGN

Retrospective Observational Study.

OBJECTIVES

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

SETTING

Specialized rehabilitation centers in the Netherlands.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cohort profile: Netherlands Longitudinal Study on Hearing (NL-SH)

PURPOSE

The Netherlands Longitudinal Study on Hearing (NL-SH) was set up to examine associations of hearing ability with psychosocial, work and health outcomes in working age adults.

PARTICIPANTS

Inclusion started in 2006 and is ongoing. Currently the sample comprises 2800 adults with normal and impaired hearing, aged 18-70 years at inclusion. Five-year follow-up started in 2011, 10-year follow-up in 2016 and 15-year follow-up in 2021. All measurements are web-based. Participants perform a speech-in-noise recognition test to measure hearing ability and fill out questionnaires about their hearing status, hearing aid use, self-reported hearing disability and coping, work status and work-related outcomes (work performance, need for recovery), physical and psychosocial health (depression, anxiety, distress, somatisation, loneliness), healthcare usage, lifestyle (smoking, alcohol), and technology use.

FINDINGS TO DATE

The NL-SH has shown the vast implications of reduced hearing ability for the quality of life and health of working-age adults. A selection of results published in 27 papers is presented. Age-related deterioration of hearing ability accelerates after the age of 50 years. Having a history of smoking is associated with a faster decline in hearing ability, but this relationship is not found for other cardiovascular risk factors. Poorer hearing ability is associated with increased distress, somatisation, depression and loneliness. Adults with impaired hearing ability are more likely to be unemployed or unfit for work, and need more time to recuperate from work effort.

FUTURE PLANS

Participant data will be linked to a national database to enable research on the association between hearing ability and mortality. Linking to environmental exposure data will facilitate insight in relations between environmental factors, hearing ability and psychosocial outcomes. The unique breadth of the NL-SH data will also allow for further research on other functional problems, for instance, hearing ability and fall risk.

TRIAL REGISTRATION NUMBER

NL12015.029.06.

Faecal Microbiota in Patients with Neurogenic Bowel Dysfunction and Spinal Cord Injury or Multiple Sclerosis-A Systematic Review

Background: Neurogenic bowel dysfunction (NBD) frequently occurs in patients with spinal cord injury (SCI) and multiple sclerosis (MS) with comparable symptoms and is often difficult to treat. It has been suggested the gut microbiota might influence the course of NBD. We systematically reviewed the literature on the composition of the gut microbiota in SCI and MS, and the possible role of neurogenic bowel function, diet and antibiotic use. Methods: A systematic search was conducted in PubMed and Embase, which retrieved studies on the gut microbiota in SCI and MS. The Newcastle–Ottawa Quality Assessment Scale (NOS) was used to assess methodological quality. Results: We retrieved fourteen papers (four on SCI, ten on MS), describing the results of a total of 479 patients. The number of patients per study varied from 13 to 89 with an average of 34. Thirteen papers were observational studies and one study was an intervention study. The studies were case control studies in which the gut microbiota composition was determined by 16S rRNA gene sequencing. The methodological quality of the studies was mostly rated to be moderate. Results of two studies suggested that alpha diversity in chronic SCI patients is lower compared to healthy controls (HC), whereas results from five studies suggest that the alpha diversity of MS patients is similar compared to healthy subjects. The taxonomic changes in MS and SCI studies are diverse. Most studies did not account for possible confounding by diet, antibiotic use and bowel function. Conclusion: Based on these 14 papers, we cannot draw strong conclusions on the composition of the gut microbiota in SCI and MS patients. Putatively, alpha diversity in chronic SCI patients may be lower compared to healthy controls, while in MS patients, alpha diversity may be similar or lower compared to healthy controls. Future studies should provide a more detailed description of clinical characteristics of participants and of diet, antibiotic use and bowel function in order to make valid inferences on changes in gut microbiota and the possible role of diet, antibiotic use and bowel function in those changes.

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

STUDY DESIGN

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

OBJECTIVE

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

SETTING

Three Dutch SCI rehabilitation centres.

METHODS

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

MAIN OUTCOME MEASURES

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

SECONDARY OUTCOME MEASURES

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

REGISTRATION

The Dutch Trial Register- NTR 5831.

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

Background: Over the last decade, the International Spinal Cord Injury Data Sets project developed a number of International Spinal Cord Injury Data Sets (ISCIDS) that can be used to collect standardized information on patients with SCI. Objective and Methods: The aim of this article is to describe the process of translating the ISCIDS into Dutch and reaching consensus on a Dutch National SCI Data Set (NDD). The interrater reliability of the NDD and implementation of the NDD at eight rehabilitation centers with a specialty in rehabilitation after SCI in the Netherlands are described. Results: NDD was implemented successfully at all eight centers. Some adaptations were made to the ISCIDS, especially to the core data set. The reliability coefficients of the NDD items were at least sufficient (mean kappa per data set ranged between .68 and .91), and mean agreement per data set ranged from 66% to 97%. Experiences from the participating centers were mainly positive as well. The main obstacle for use was thought to be the absence of a link between the local patient files and the national database, which necessitates double data entry. Conclusion: Although the results on interrater reliability are based on a small sample size and the assessment situation is different from the normal clinical situation, this study showed the NDD to be a useful instrument to collect standardized information on patients with SCI in the Netherlands. In the future, a connection between systems or another way to centrally collect the data is recommended to prevent double data entry and to guarantee continuation of administration of the NDD.

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

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

Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso Bionics

STUDY DESIGN

Prospective quasi-experimental study, pre- and post-design.

OBJECTIVES

Assess safety, feasibility, training characteristics and changes in gait function for persons with spinal cord injury (SCI) using the robotic exoskeletons from Ekso Bionics.

SETTING

Nine European rehabilitation centres.

METHODS

Robotic exoskeleton gait training, three times weekly over 8 weeks. Time upright, time walking and steps in the device (training characteristics) were recorded longitudinally. Gait and neurological function were measured by 10 Metre Walk Test (10 MWT), Timed Up and Go (TUG), Berg Balance Scale (BBS), Walking Index for Spinal Cord Injury (WISCI) II and Lower Extremity Motor Score (LEMS).

RESULTS

Fifty-two participants completed the training protocol. Median age: 35.8 years (IQR 27.5-52.5), men/women: N = 36/16, neurological level of injury: C1-L2 and severity: AIS A-D (American Spinal Injury Association Impairment Scale). Time since injury (TSI) < 1 year, N = 25; > 1 year, N = 27. No serious adverse events occurred. Three participants dropped out following ankle swelling (overuse injury). Four participants sustained a Category II pressure ulcer at contact points with the device but completed the study and skin normalized. Training characteristics increased significantly for all subgroups. The number of participants with TSI < 1 year and gait function increased from 20 to 56% (P = 0.004) and 10MWT, TUG, BBS and LEMS results improved (P < 0.05). The number of participants with TSI > 1 year and gait function, increased from 41 to 44% and TUG and BBS results improved (P < 0.05).

CONCLUSIONS

Exoskeleton training was generally safe and feasible in a heterogeneous sample of persons with SCI. Results indicate potential benefits on gait function and balance.

Predictors of physical independence at discharge after stroke rehabilitation in a Dutch population

The aim of this study was to identify predictors, available at admission, of physical independence at discharge from inpatient rehabilitation. Secondary aims were to identify predictors of functional gain and length of stay (LOS). We included 1310 adult stroke patients who were admitted for inpatient rehabilitation in five Dutch rehabilitation centres. Data on the Utrecht Scale for Evaluation of Clinical Rehabilitation at admission and discharge (physical and cognitive independence, mood, pain and fatigue), age, sex and in a subsample stroke characteristics as well were collected. A prediction model was created using random coefficient analysis. None of the stroke characteristics were independently associated with physical independence or functional gain at discharge, or LOS. Higher physical and cognitive independence scores and severe pain at admission were predictors of higher physical independence scores at discharge. Furthermore, lower physical independence scores, higher cognitive independence scores, less pain at admission and younger age predicted more functional gain. Finally, lower physical and cognitive independence scores at admission and younger age predicted longer LOS. Physical independence at admission was the most robust predictor for rehabilitation outcome in a Dutch rehabilitation setting. To a lesser extent, age, cognitive independence and pain predicted rehabilitation outcome after stroke. Treatment of cognition and pain should be taken into account during rehabilitation. Further work needs to be carried out to establish whether focusing on these factors improves outcome after rehabilitation.

Can a prediction model combining self-reported symptoms, sociodemographic and clinical features serve as a reliable first screening method for sleep apnea syndrome in patients with stroke?

OBJECTIVE

To determine whether a prediction model combining self-reported symptoms, sociodemographic and clinical parameters could serve as a reliable first screening method in a step-by-step diagnostic approach to sleep apnea syndrome (SAS) in stroke rehabilitation.

DESIGN

Retrospective study.

SETTING

Rehabilitation center.

PARTICIPANTS

Consecutive sample of patients with stroke (N=620) admitted between May 2007 and July 2012. Of these, 533 patients underwent SAS screening. In total, 438 patients met the inclusion and exclusion criteria.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We administered an SAS questionnaire consisting of self-reported symptoms and sociodemographic and clinical parameters. We performed nocturnal oximetry to determine the oxygen desaturation index (ODI). We classified patients with an ODI ≥15 as having a high likelihood of SAS. We built a prediction model using backward multivariate logistic regression and evaluated diagnostic accuracy using receiver operating characteristic analysis. We calculated sensitivity, specificity, and predictive values for different probability cutoffs.

RESULTS

Thirty-one percent of patients had a high likelihood of SAS. The prediction model consisted of the following variables: sex, age, body mass index, and self-reported apneas and falling asleep during daytime. The diagnostic accuracy was .76. Using a low probability cutoff (0.1), the model was very sensitive (95%) but not specific (21%). At a high cutoff (0.6), the specificity increased to 97%, but the sensitivity dropped to 24%. A cutoff of 0.3 yielded almost equal sensitivity and specificity of 72% and 69%, respectively. Depending on the cutoff, positive predictive values ranged from 35% to 75%.

CONCLUSIONS

The prediction model shows acceptable diagnostic accuracy for a high likelihood of SAS. Therefore, we conclude that the prediction model can serve as a reasonable first screening method in a stepped diagnostic approach to SAS in stroke rehabilitation.

Hearing Ability and its Relationship with Psychosocial Health, Work-Related Variables, and Health Care Use: The National Longitudinal Study on Hearing

Worldwide, more than 250 million people experience problems with hearing (Mathers et al. 2003)[...]