Showing papers in "Spinal Cord in 2020"
TL;DR: Early surgical decompression of the injured spinal cord is one of few available interventions that can potentially alter the long-term recovery trajectory for this devastating condition.
Abstract: Traumatic spinal cord injuries (SCI) have devastating lifelong sequelae for affected individuals, caregivers, and society. Modest improvements in sensorimotor function can significantly enhance quality of life and decrease costs of care. Early surgical decompression of the injured spinal cord is one of few available interventions that can potentially alter the long-term recovery trajectory for this devastating condition [1]. Early decompression has a sound pathophysiologic rationale, clinical evidence of efficacy, and international guideline recommendations as a treatment option.
33 citations
TL;DR: Greater acceptance was consistently associated with greater global and psychological QOL, life satisfaction, sense of well-being, mental health, and with lower levels of depression and anxiety.
Abstract: Systematic review. To identify, critically appraise, and synthesize research findings on the associations between acceptance, quality of life (QOL), and mental health outcomes in individuals living with spinal cord injury (SCI). Five databases (PubMed, PsycINFO, Embase, Web of Science, and Scopus) were systematically searched. Studies were included if they provided findings on the association between acceptance and QOL, mental health outcomes, or both in an SCI population aged 16 years or older. Only peer-reviewed original quantitative and qualitative studies were included. Screening, quality assessment, and data extraction were conducted independently by two researchers. Findings were tabulated and synthesized by outcome. Forty-one studies were included. Greater acceptance was consistently associated with greater global and psychological QOL, life satisfaction, sense of well-being, mental health, and with lower levels of depression and anxiety. Inconsistent evidence was found with regards to social QOL and post-traumatic stress disorder. Acceptance was generally not associated with adjustment outcomes further than 2 years into the future. Study quality of the quantitative studies was mostly fair (n = 17) followed by good (n = 13), and poor (n = 9). Health-care professionals may regard acceptance as a psychological resource they can aim to support in improving QOL and mental health following SCI. A range of methodological and conceptual limitations were present in the research. Future studies should prioritize longitudinal designs, consider dyadic effects, explore subjective meaning(s) of acceptance, and investigate the effectiveness of therapeutic approaches that stimulate the acceptance process.
31 citations
TL;DR: The prescription rate of high dose methylprednisolone for acuteSCI is decreasing in South Korea but it is still high, and national health resources should be allocated to prevent acute SCI from occurring in older people.
Abstract: Retrospective population-based cohort study To evaluate the incidence of acute spinal cord injury (SCI) in South Korea, and the prescription rates and complications related to high dose methylprednisolone therapy. Health Insurance Review and Assessment Service (HIRA) data National database of the Korean HIRA between 2007 and 2017 was reviewed. To identify patients with acute SCI and the use of high dose methylprednisolone, International Classification of Disease revision codes, medical behavior codes and examination codes were used. Patients were grouped according to whether or not they received methylprednisolone therapy (MP group vs non-MP group). The average age-adjusted incidence of acute SCI per 1,000,000 persons was 26.4 and the peak incidence was in the 50s overall. The methylprednisolone prescription rate was highest in 2012 (76%) and continued to decrease thereafter, being lowest in 2017 (41%). The MP group showed higher complication rates in terms of pneumonia (OR 1.8, 95% CI, 1.62–2.0), GI bleeding (OR 1.2, 95% CI, 1.05–1.38), and UTI (OR 1.68, 95% CI, 1.53–1.84). The average length of hospitalization was longer in patients who received methylprednisolone (26.5 days vs. 24.4 days, p < 0.05). The average age-adjusted incidence of acute SCI for 11 years was 26.4 per 1,000,000 persons and highest in 50s. Strategies should be established, and national health resources should be allocated to prevent acute SCI from occurring in older people. The prescription rate of high dose methylprednisolone for acute SCI is decreasing in South Korea but it is still high.
30 citations
TL;DR: EAW training appeared to mitigate SCI-related bowel dysfunction and the potential benefits of EAW on bowel function after SCI is worthy or further study.
Abstract: Prospective, observational study. To explore the effects of exoskeletal-assisted walking (EAW) on bowel function in persons with spinal cord injury (SCI). Ambulatory research facility located in a tertiary care hospital. Individuals 18–65 years of age, with thoracic vertebrae one (T1) to T11 motor-complete paraplegia of at least 12 months duration were enrolled. Pre- and post-EAW training, participants were asked to report on various aspects of their bowel function as well as on their overall quality of life (QOL) as related to their bowel function. Ten participants completed 25–63 sessions of EAW over a period of 12–14 weeks, one participant was lost to follow up due to early withdrawal after ten sessions. Due to the small sample size, each participant’s results were presented descriptively in a case series format. At least 5/10 participants reported improvements with frequency of bowel evacuations, less time spent on bowel management per bowel day, fewer bowel accidents per month, reduced laxative and/or stool softener use, and improved overall satisfaction with their bowel program post-EAW training. Furthermore, 8/10 reported improved stool consistency and 7/10 reported improved bowel function related QOL. One participant reported worsening of bowel function post-EAW. Between 50 and 80% of the participants studied reported improvements in bowel function and/or management post-EAW training. EAW training appeared to mitigate SCI-related bowel dysfunction and the potential benefits of EAW on bowel function after SCI is worthy or further study.
26 citations
TL;DR: Transcutaneous SCS can be proposed as a promising candidate for a safer and more accessible SCS modality for some individuals with SCI.
Abstract: Systematic review. Over the past decade, an increasing number of studies have demonstrated that epidural spinal cord stimulation (SCS) can successfully assist with neurorehabilitation following spinal cord injury (SCI). This approach is quickly garnering the attention of clinicians. Therefore, the potential benefits of individuals undergoing epidural SCS therapy to regain sensorimotor and autonomic control, must be considered along with the lessons learned from other studies on the risks associated with implantable systems. Systematic analysis of literature, as well as preclinical and clinical reports. The use of SCS for neuropathic pain management has revealed that epidural electrodes can lose their therapeutic effects over time and lead to complications, such as electrode migration, infection, foreign body reactions, and even SCI. Several authors have also described the formation of a mass composed of glia, collagen, and fibrosis around epidural electrodes. Clinically, this mass can cause myelopathy and spinal compression, and it is only treatable by surgically removing both the electrode and scar tissue. In order to reduce the risk of encapsulation, many innovative efforts focus on technological improvements of electrode biocompatibility; however, they require time and resources to develop and confirm safety and efficiency. Alternatively, some studies have demonstrated similar outcomes of non-invasive, transcutaneous SCS following SCI to those seen with epidural SCS, without the complications associated with implanted electrodes. Thus, transcutaneous SCS can be proposed as a promising candidate for a safer and more accessible SCS modality for some individuals with SCI.
25 citations
TL;DR: Incomplete tetraplegia due to falling among elderly was overrepresented in the study population and alcohol-consumption preceded injury in nearly half of the cases in the younger population.
Abstract: Study design Prospective cohort study. Objectives To determine the incidence and evaluate the characteristics of newly injured patients admitted to two spinal cord injury (SCI) centers during a 4-year period. Setting Oulu and Tampere University Hospital, Finland. Methods A dedicated multidisciplinary team evaluated all of the patients with new traumatic SCI (TSCI). The data were recorded according to the International Spinal Cord Injury Core Data Sets. Results In a 4-year period, 346 new patients with TSCI were admitted to the study centers. In the Oulu and Tampere University Hospitals' catchment areas, the mean annual incidence of TSCI was 36.6 per million. The leading causes of injury were low-level falls (36.2%), high-level falls (25.5%), and transport-related accidents (19.2%). In the patients >60 years, 72.6% were injured by falling and the proportion of low-level falls was 49.7%. In the patients ≤60 years old, 47.4% were alcohol-related. The proportion of cervical injuries in the patients >60 years was 77.1%, while in the patients ≤60 years the proportion was 59.6%. The incidence of TSCI was higher during the Summer and Autumn months. Conclusion The mean annual incidence of TSCI was 36.6 per million corresponding to 200 new annual cases in Finland. Incomplete tetraplegia due to falling among elderly was overrepresented in the study population. Alcohol-consumption preceded injury in nearly half of the cases in the younger population. The prevention should focus on alcohol-related injuries and falls in the elderly.
25 citations
TL;DR: Overall, there was a significant effect of tDCS in improving motor functionality following iSCI, however, a small ES and the marginal p-value suggest that these results should be interpreted with caution.
Abstract: Systematic review and meta-analysis. We aimed to investigate the effects of anodal transcranial direct current stimulation (tDCS) against sham on muscle strength and motor functionality after incomplete spinal cord injury (iSCI). University of Sao Paulo, Brazil. A preplanned protocol was registered (PROSPERO, CRD42016050444). Pubmed, Embase, Web of Science, Cochrane Central Library and BVS databases were searched independently by two authors up to March 2018. Cochrane Collaboration’s Tool was used for the risk of bias assessments. Generic inverse variance and random-effects model were used to calculate pooled effect sizes (ES), 95% confidence intervals (CIs) and p-values in meta-analyses. Six randomized clinical trials met inclusion criteria (n = 78 iSCI individuals) and were included in the meta-analysis. Results showed a marginal significant pooled effect of active tDCS in improving motor functionality with a small ES (SMD = 0.26, 95% CI = −0.00 to 0.53, p = 0.05, I2 = 0%). On the other hand, the pooled effect of active tDCS on muscle strength did not reach statistical significance, in parallel with a small ES (SMD = 0.35, 95% CI = −0.21 to 0.92, p = 0.22, I2 = 0%) when compared with sham tDCS. No significant adverse events were reported. Overall, there was a significant effect of tDCS in improving motor functionality following iSCI. However, a small ES and the marginal p-value suggest that these results should be interpreted with caution. Further high-quality clinical trials are needed to support or refute the use of tDCS in daily clinical practice.
25 citations
TL;DR: The rigorous co-development process of a theory-based, physiotherapist-led PA intervention for people with SCI is described and serves as an example methodology for using theory to co-create a leisure-time physical activity behaviour change intervention tailored for peopleWith SCI.
Abstract: Cross-sectional survey, semi-structured interview, and randomized-controlled trial. Optimal spinal cord injury (SCI)-specific PA intervention strategies appropriate for the physiotherapist setting are unknown. The purpose of this paper is to describe the rigorous co-development process of a theory-based, physiotherapist-led PA intervention for people with SCI and assess its feasibility for implementation in the rehabilitation setting. Community. Co-development of the intervention included (1) a review of the literature; (2) key informant interviews with people with SCI (n = 26); (3) a national online survey of physiotherapists’ barriers, needs, and preferences (n = 239); (4) a review of the evidence and recommendations for the intervention from a stakeholder expert panel (n = 13); and (5) a randomized controlled trial of intervention training and its effects on implementation determinants amongst physiotherapists (n = 20). Almost 300 people with SCI and physiotherapists were engaged in the intervention development process. Optimal intervention delivery should be tailored and include (1) education on safety, PA guidelines, and behaviour change techniques, (2) referral to other peers, local programmes, and health professionals, and (3) adapted exercise prescriptions. Following intervention implementation training, physiotherapists demonstrated stronger tested and perceived knowledge, skills, resources, and confidence for promoting PA to people with SCI, ps < 0.05. This development process serves as an example methodology for using theory to co-create a leisure-time physical activity behaviour change intervention tailored for people with SCI.
25 citations
TL;DR: Variability in neurological examination timing within hours after acute traumatic SCI may influence observations of long-term neurological recovery, which could introduce bias or lead to errors in interpretation of studies of therapeutic interventions.
Abstract: Cohort study. It is widely accepted that the prediction of long-term neurologic outcome after traumatic spinal cord injury (SCI) can be done more accurately with neurological examinations conducted days to weeks post injury. However, modern clinical trials of neuroprotective interventions often require patients be examined and enrolled within hours. Our objective was to determine whether variability in timing of neurological examinations within 48 h after SCI is associated with differences in observations of follow-up neurologic recovery. Level I trauma hospital. An observational analysis testing for differences in AIS conversion rates and changes in total motor scores by neurological examination timing, controlling for potential confounders with multivariate stepwise regression. We included 85 patients, whose mean times from injury to baseline and follow-up examinations were 11.8 h (SD 9.8) and 208.2 days (SD 75.2), respectively. AIS conversion by 1+ grade was significantly more likely in patients examined at ≤4 h in comparison with later examination (78% versus 47%, RR = 1.66, p = 0.04), even after controlling for timing of surgery, age, and sex (OR 5.0, 95% CI 1.1–10, p = 0.04). We failed to identify any statistically significant associations for total motor score recovery in unadjusted or adjusted analyses. AIS grade conversion was significantly more likely in those examined ≤4 h of injury; the effect of timing on motor scores remains uncertain. Variability in neurological examination timing within hours after acute traumatic SCI may influence observations of long-term neurological recovery, which could introduce bias or lead to errors in interpretation of studies of therapeutic interventions.
23 citations
TL;DR: The GSDS-IT was found to have good internal consistency and test-retest reliability, and it showed positive and significant values for all the PSQI domains, and is a valid, reliable, and time-efficient tool for measuring sleep disturbances over the past week in a population with SCI.
Abstract: Psychometric study. This study sought to analyze the psychometric properties of the Italian version of the General Sleep Disturbance Scale (GSDS-IT) in a population of individuals with spinal cord injury (SCI). Italy. Its reliability was assessed using the Cronbach’s alpha and intraclass correlation coefficient (ICC), while its concurrent validity was assessed using the Pearson’s correlation coefficient in relation to the Pittsburgh Sleep Quality Index (PSQI). The obtained scores were compared with the cut-off score for the GSDS-IT among a healthy Italian population (38.5). The GSDS-IT was administered to 57 participants with SCI who were recruited from all over Italy. The GSDS-IT was found to have good internal consistency (Cronbach’s α of 0.76) and good test-retest reliability (ICC of 0.7), and it showed positive and significant values for all the PSQI domains. Based on the cut-off score of 38.5, 56% of participants tested positive for sleep disturbances upon admission (t0), while among the randomized participants submitted for the test-retest after 24 h (t1), 75% tested positive for sleep disturbances. The GSDS-IT is a valid, reliable, and time-efficient tool for measuring sleep disturbances over the past week in a population with SCI.
22 citations
TL;DR: The EAW programme with the new robotic exoskeleton provided potential meaningful improvements in mobility for individuals with SCI and had few adverse events.
Abstract: A pre-post observational study. To evaluate the safety and feasibility of a new rehabilitation robotic device for assisting individuals with lower extremity motor complete lesions following spinal cord injury (SCI). Three hospitals in Sichuan Province, China. Individuals aged 15–75 years with an SCI between vertebrae six (T6) and lumbar 1 (L1) and complete motor paralysis participated in an exoskeletal-assisted walking (EAW) programme (2 weeks, 5 days/week, 30 min/day). Data were collected pre-, mid- (week 1) and post-intervention (week 2). Twenty-eight individuals (mean age = 41.3, 71% males) participated in the EAW programme. The distance walked during the 6-min walking test (6MWT) increased relative to that at baseline, during week 1 (13.0 ± 5.3 m) and week 2 (16.2 ± 5.3 m) when wearing the exoskeleton. The walking speed during the 10-m walking test (10MWT) increased from 0.039 ± 0.016 to 0.045 ± 0.016 m/s. The Hoffer walking ability grade, the Spinal Cord Independence Measure (SCIM), and the Walking Index for SCI II (WISCI II) changed after 2 weeks of EAW. No improvement in lower extremity motor score (LEMS) was observed. The rates of adverse events and serious adverse events were 21% and 4%, respectively. The EAW programme with the new robotic exoskeleton provided potential meaningful improvements in mobility for individuals with SCI and had few adverse events.
TL;DR: Goal setting in SCI rehabilitation often directly reflects physical functioning goals set by the health professionals, which does not prepare persons with SCI for everyday life and emotional issues and there is lack of focus on goals addressing psychosocial components such as family issues and change of roles.
Abstract: Study design Systematic review of qualitative studies. Objective To synthesise qualitative research exploring the experiences and perspectives of persons with spinal cord injury (SCI), relatives and health professionals concerning goal setting in SCI rehabilitation. Methods Five electronic databases were searched. A search strategy was constructed with key concepts identified using PICo (Population, phenomena of Interest and Context). Peer reviewed studies complying with the inclusion criteria were selected. Interpretive Description methodology guided analysis and synthesis of the findings. Results The search yielded 427 records. Of 12 full text studies assessed for eligibility, four were included describing goal setting in SCI rehabilitation from the perspective of persons with SCI and health professionals. Persons with SCI described a need for goal setting to be related to their everyday life, whereas the health professionals tended to use the hospital setting as their point of reference. Persons with SCI emphasised the importance of being self-directed and taking an active role in goal setting and rehabilitation. No studies presented the perspective of relatives. Conclusions This review illuminates the divergence in the understanding of goal setting between persons with SCI and health professionals. Goal setting in SCI rehabilitation often directly reflects physical functioning goals set by the health professionals, which does not prepare persons with SCI for everyday life and emotional issues. There is lack of focus on goals addressing psychosocial components such as family issues and change of roles. A shared process with goal setting relevant to persons with SCI and their everyday life is needed.
TL;DR: It is believed cell-based transplantation translation remains in its infancy and that, although further robust clinical research is required, it is an important strategy to consider in the treatment of SCI.
Abstract: Spinal cord injury (SCI) is associated with significant and life-long disability. Yet, despite decades of research, no regenerative treatment has reached clinical practice. Cell-based therapies are one possible regenerative strategy beginning to transfer to human trials from a more extensive pre-clinical basis. We therefore conducted a scoping review to synthesise all cell-based trials in SCI to consider the current state of the field and the cell transplant type or strategy with greatest promise. A search strategy of MEDLINE returned 1513 results. All clinical trials including adult human patients with acute or chronic, compete or incomplete SCI and a recorded ASIA score were sought. Exclusion criteria included non-traumatic SCI, paediatric patients and animal studies. A total of 43 studies, treating 1061 patients, were identified. Most trials evaluated cells from the bone marrow (22 papers, 660 patients) or the olfactory bulb (10 papers, 245 patients). Cell transplantation does appear to be safe, with no serious adverse effects being reported in the short-term. 86% of trials described efficacy as a primary outcome. However, varying degrees of outcome reporting prevented meta-analysis. No emerging cell type or technique was identified. The majority of trials, 53%, took place in developing countries, which may suggest more stringent regulatory requirements within Western countries. We believe cell-based transplantation translation remains in its infancy and that, although further robust clinical research is required, it is an important strategy to consider in the treatment of SCI.
TL;DR: The MSISQ-15 is a valid, reliable, and useful questionnaire for investigating how often the symptoms of an SCI interfere with a person’s satisfaction or sexual activity.
Abstract: STUDY DESIGN Psychometric study. OBJECTIVE The aim of the study was to translate and culturally adapt the MSISQ-15 into Italian and to administer it to individuals with a spinal cord injury (SCI). SETTING Rome's Wheelchair Rugby Team and three spinal units in Italy. METHODS Translation and validation of the MSISQ-15 were performed based on international guidelines. The questionnaire, which was in a paper and online format, was administered with the Short Form-12 Health Survey (SF-12) and the Spinal Cord Independence Measure Self-Report. RESULTS Sixty-five participants were recruited. Internal consistency coefficient of MSISQ-15 scale, assessed by Cronbach's alpha, was 0.75. Test-retest reliability interclass correlations was, for example, 0.86. The construct validity was calculated and showed statistically significant results in relation to the mental health status investigated with the SF-12. CONCLUSIONS The MSISQ-15 is a valid, reliable, and useful questionnaire for investigating how often the symptoms of an SCI interfere with a person's satisfaction or sexual activity.
TL;DR: The modified Italian version of the SCI-SCS may represent a valuable instrument for the longitudinal assessment of the impact of secondary conditions in people with SCI.
Abstract: STUDY DESIGN Validation cross-sectional study. OBJECTIVE To adapt the Spinal Cord Injury Secondary Conditions Scale (SCI-SCS) to Italian and to assess the validity and reliability of this instrument. SETTING Multicentre study in outpatient clinics of three urban spinal units across Italy. METHODS After a five-step translation/validation process, the Italian SCI-SCS was administered in a toolset composed of a sociodemographic questionnaire, the Modified Barthel Index, the Short-Form 8, the Patient Health Questionnaire 9, and the General Anxiety Disorder 7. The Italian SCI-SCS construct validity was assessed through exploratory factor analysis (EFA). The internal consistency and test-retest reliability of the instrument were evaluated using Cronbach's α and the intraclass correlation coefficient (ICC) for the total scale and its subscales. Pearson's correlation coefficient with all administered instruments was calculated to evaluate the concurrent validity. RESULTS One-hundred fifty-six participants were recruited from February to October 2018. EFA suggested a three-factor structure explaining 45% of the total variance. After experts' consideration about the clinical relevance of its components, a final version of the Italian SCI-SCS with four different subscales and 15 items was proposed. The total scale Cronbach's α was 0.73. The ICC agreement for test-retest reliability was 0.91. Correlations of the Italian SCI-SCS with the administered instruments were statistically significant (p < 0.05), highlighting congruent hypothesized relations. CONCLUSION Findings of this study provided a first psychometric evaluation of the SCI-SCS. The modified Italian version of this tool may represent a valuable instrument for the longitudinal assessment of the impact of secondary conditions in people with SCI.
TL;DR: The current findings recommend the FTSST for ambulatory individuals with SCI using arms free by sides, with excellent rater and test–retest reliability and a modest to strong correlation with their physical ability.
Abstract: A psychometric study. To investigate the reliability and the concurrent validity of the five times sit-to-stand test (FTSST) during various arm placement conditions in ambulatory participants with spinal cord injury (SCI). In addition, the difficulty of the FTSST during various arm placement conditions was compared using the number, characteristics, and physical ability of those who could complete the conditions. Rehabilitation centers and communities in Thailand. Eighty-two participants were assessed for their physical ability and ability to complete the FTSST in four arm placement conditions, namely, arms on a walking device, arms on knees, arms free by sides, and arms crossed over the chest, according to their ability and in random order. The outcomes for all the FTSST conditions had excellent rater and test–retest reliability with a modest to strong correlation with their physical ability (ρ = −0.39 to −0.72), and it is especially high for the condition with arms by sides. All participants could complete the conditions with arms on a walking device, and two-thirds of them could execute the other conditions. The physical ability of these individuals was significantly better, with the number of those with mild lesion severity being greater than those who could execute the FTSST with arms on a walking device (p <0.01). Arm placements affected the psychometric properties and the ability to complete the FTSST of the participants. The current findings recommend the FTSST for ambulatory individuals with SCI using arms free by sides.
TL;DR: The first Covid-19 case at the Hospital Nacional de Parapléjicos of Toledo was confirmed on March 17, 2020, following close contact with an infected relative, and the institution immediately launched a contingency plan with the following objectives.
Abstract: For just over three months, our whole world has just been turned upside down. In late December 2019, an epidemic of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) started in Wuhan [1] and spread rapidly throughout the world. This pandemic reached us not silently but abruptly, even brutally. The World Health Organization (WHO) declared the 2019 coronavirus disease (Covid-19) a pandemic on March 11, 2020 and as of April 2, 2020, 1.002,159 cases were confirmed worldwide with 51,485 deaths [2]. The new coronavirus, responsible for the severe acute respiratory syndrome (SARSCoV-2), has brought higher levels of illness, death, and fear throughout the planet greater than the current generation has known until now [2]. As Spaniards we are a good example of how adversity brings out the true measure of a society. Since the first Covid-19 confirmed case in La Gomera (Canary Islands), our clinical role in the pandemic has been smoothly but constantly changing [3]. In this context, what about people with spinal cord injury (SCI)? SCI induces numerous chronic disorders that put these individuals at a high risk of severe Covid-19 prognosis. Specifically, the SCI population presents higher rates of hypertension, SCI-induced immunosuppression and, if the metameric level is T8 or above, respiratory failure with continuous or episodic hypoxemia due to respiratory muscle weakness. Sympathetic denervation following SCI compromises body temperature regulation, as a result of dysautonomia, which not only complicates the adequate early diagnosis of Covid-10 so that patients are at risk of a poor prognosis, but also makes it difficult to control infection transmission to other patients and/or healthcare staff. With so many potential patients on the horizon and so many brilliant clinicians and colleagues dealing with the consequences of Covid-19, how could we be of use for people/patients with SCI and to the medical community? The first Covid-19 case at the Hospital Nacional de Parapléjicos (HNP) of Toledo was confirmed on March 17, 2020, following close contact with an infected relative. As the HNP is the national SCI monographic hospital in Spain with 212 beds, classified as a long-term healthcare facility, our institution immediately launched a contingency plan with the following objectives: (1) avoid the spread of Covid19 among non-infected people/patients with SCI and healthcare staff; (2) treat adequately SCI Covid-19 confirmed cases; (3) design, create and apply the infrastructure to perform face–to–face and remote ongoing rehabilitation treatment using telemedicine support; (4) continue admission of new patients with acute SCI using enhanced hygiene protection conditions; and (5) make available all the clinical resources at its disposal to the Regional Public Health Service to help manage patients without SCI but with confirmed Covid-19 infection, in need of hospital admission. In order to avoid the spread of infection, one of our first goals was to decrease the traffic of people through the hallways and corridors: the physiotherapy and occupational therapy treatment rooms are temporarily closed, carrying out all the necessary rehabilitation treatment inside the patients’ rooms; those patients whose SCI is stable enough are sent home to quarantine, with periodic telephone follow-up by the hospital staff; and all visits to the inpatient area are forbidden. The seven people/patients with SCI diagnosed with a confirmatory RT-PCR test for Covid-19 infection were transferred to isolation zones in an inpatient area with adequate space, and cared for by healthcare personnel wearing personal protection equipment. This area is directly under the supervision of our Internal Medicine staff physicians. Hospitalized * Angel Gil-Agudo amgila@sescam.jccm.es
TL;DR: Compared with able-bodied women and men, individuals with chronic motor complete SCI showed considerably lower bone densitometry values and a higher historical fracture rate, which support the need for preventative and therapeutic strategies against bone loss in individuals with SCI.
Abstract: Cross-sectional study. To investigate the effect of chronic motor complete spinal cord injury (SCI) and sex on bone densitometry parameters of the hip, femoral neck, tibial epiphysis, and diaphysis and on long bone fractures. SCI rehabilitation center. Women and men with long-term (≥7 years) motor complete SCI were compared with able-bodied women and men. Dual-energy X-ray absorptiometry was used to assess bone densitometry parameters at the hip and femoral neck, whereas peripheral quantitative computed tomography was used for the tibial epiphysis and diaphysis. The data of 18 women and 25 men with SCI with a mean age of 54.7 ± 12.4 and 53.5 ± 8.6 years, respectively, were analyzed. As reference groups, 74 able-bodied women and 46 men with a mean age of 51.0 ± 13.1 and 50.9 ± 11.2 years were evaluated. Most bone densitometry values were significantly (p ≤ 0.033) lower in the SCI compared with the reference groups, including total bone mineral density at the distal tibial epiphysis (−58.0% in SCI women and −53.6% in SCI men). Fracture rates per 100 patient-years were 3.17 and 2.66 in women and men with SCI compared with 0.85 and 0.21 in able-bodied women and men, respectively. Compared with able-bodied women and men, individuals with chronic motor complete SCI showed considerably lower bone densitometry values and a higher historical fracture rate. These findings support the need for preventative and therapeutic strategies against bone loss in individuals with SCI.
TL;DR: The main concerns are: What is the real impact of COVID-19 in people with SCI and their caregivers?
Abstract: The global outbreak of coronavirus SARS-CoV-2 disease (COVID-19) in December 2019 has created an unprecedented challenge to the world and especially to the health system. All levels of medical attention are being affected: from emergency departments, intensive care units, and medical wards to postacute, outpatient, primary and home care settings. Some years ago, the World Health Organization established as a priority the need to help health providers and governments to ensure that people with disability such as spinal cord injury (SCI) could always access the healthcare services in emergency situations [1]. However, the current pandemic constitutes a major challenge that has forced the development of new specific recommendations [2]. In people with the impact of COVID-19 has not yet been completely evaluated but, in an unprecedented effort, the medical community has developed many proposals aimed at improving the care of this group and their caregivers [3]. Still with a very recent experience, some reflections are emerging that we believe could apply to other SCI units. The main concerns are: (1) What is the real impact of COVID-19 in people with SCI and their caregivers? and (2) What measures or changes in the circuits of care and in our structures will be necessary in the future? Problems derived from the reduced access to healthcare services and the reorganization of hospitals have been the norm for the past few months. Our department, provided with 20 beds in usual conditions, is the reference unit for SCI in Catalonia. It belongs to a tertiary hospital that, with 2300 COVID-19 admitted patients, has been one of those that has attended to a greater number of cases in Spain. This forced the hospital authorities to restructure the allocation of beds, increasing the number of critical care beds by five times. A similar reorganization has been reported in published works from Italy [4], Spain [5], or the USA [6]. In our unit, the number of beds was reduced to 50%, specific rehabilitation areas were closed and early hospital discharge and the use of remote systems in outpatient care were encouraged. The adopted contingency plan had urgent care for acute SCI and for serious complications in patients with chronic SCI as its main goal. Fortunately, the lockdown decreed on 14 March, 2020 in Spain, with a duration of almost 90 days, has led to a notable reduction in urgent consultation for SCI, as has been observed in other pathologies such as stroke [7] or ischemic heart disease [8]. During this period, the number of admissions for acute or chronic SCI has also decreased to a third of the usual rate of admissions in our unit. This phenomenon could be attributed to the reduced mobility of the population and consequently the risk of accidental trauma in the case of acute SCI and to a reluctance to consult in the case of people with chronic SCI as well. Among those admitted with acute SCI, only one patient upon admission had COVID-19. Interestingly, in this patient the infection was asymptomatic and was only detected through the polymerase chain reaction (PCR) screening protocol of all admitted patients established in our center since the start of the outbreak. This fact highlights the need for these screening protocols to reduce the possibility of in-hospital outbreaks. However, at the beginning of the pandemic, we had four patients who contracted nosocomial SARS-CoV-2 infection: one patient who suffered a trauma at home with an acute SCI and three patients with chronic SCI. The four patients were infected despite in-hospital control measures of COVID-19 which included, in addition to screening at admission, the preservation of non-COVID areas and the use of adequate personal protection equipment * Júlia Sampol jusampol@gmail.com
TL;DR: The NPSI demonstrated good psychometric properties in people with neuropathic pain after SCI and has utility for establishing pain symptom phenotypes.
Abstract: Cohort/psychometric study The primary objective was to determine the psychometric properties and the utility of the Neuropathic Pain Symptom Inventory (NPSI) in subgrouping people with moderate to severe neuropathic pain after spinal cord injury (SCI). University-based laboratory in Miami, FL USA. Seventy-two people with chronic SCI and neuropathic pain were included in this study. The NPSI, Numeric Rating Scale (NRS), Multidimensional Pain Inventory pain severity and perceived support subscales (MPI-PS and MPI-S, respectively), and the Coping Strategies Questionnaire were administered. The NPSI was administered twice, with a 2–4-week period between measurement sessions. The NPSI total score demonstrated good internal consistency with a Cronbach’s alpha of 0.70. The test–retest reliability (intraclass correlations) ranged from 0.65 to 0.73 for the NPSI subscores and 0.79 for the total NPSI score. Further, construct validity was supported by moderate and significant positive correlations with the pain intensity NRS and pain severity subscale of the MPI (MPI-PS) (r > 0.40). Cluster analysis of factor scores derived from NPSI subscales, NRS, and MPI-PS scores revealed three distinct subgroups: (1) low-moderate, (2) moderate, and (3) high pain symptom severity with mean NPSI sum scores of 7.1, 17.5, and 33.8, respectively. The NPSI demonstrated good psychometric properties in people with neuropathic pain after SCI. Moreover, it has utility for establishing pain symptom phenotypes.
TL;DR: Reactive stepping ability of individuals with incomplete SCI/D is impaired; however, this impairment is not explained by temporal parameters, and the findings suggest that reactive stepping should be targeted in the rehabilitation of ambulatory individuals with SCi/D.
Abstract: Cross sectional. To compare the reactive stepping ability of individuals living with incomplete spinal cord injury or disease (SCI/D) to that of sex- and age-matched able-bodied adults. A tertiary SCI/D rehabilitation center in Canada. Thirty-three individuals (20 with incomplete SCI/D) participated. Participants assumed a forward lean position in standing whilst 8–12% of their body weight was supported by a horizontal cable at waist height affixed to a rigid structure. The cable was released unexpectedly, simulating a forward fall and eliciting one or more reactive steps. Behavioral responses (i.e., single step versus non-single step) were compared using a Chi-square test. The following temporal parameters of reactive stepping were compared using t-tests: the onset of muscle activation in 12 lower extremity muscles (six per limb) and step-off, step contact and swing time of the stepping leg. Behavioral responses were significantly different between groups (χ2 = 13.9 and p < 0.01) with participants with incomplete SCI/D showing more non-single step responses (i.e., multi-steps and falls). The onsets of muscle activation were more variable in participants with incomplete SCI/D, but only the stepping tibialis anterior showed a significantly slower onset in this group compared with able-bodied adults (t = −2.11 and p = 0.049). Movement timing of the stepping leg (i.e., step-off, step contact, and swing time) was not significantly different between groups. Reactive stepping ability of individuals with incomplete SCI/D is impaired; however, this impairment is not explained by temporal parameters. The findings suggest that reactive stepping should be targeted in the rehabilitation of ambulatory individuals with SCI/D.
TL;DR: A variety of models aimed at supporting community integration in the immediate period following inpatient rehabilitation for SCI were found, and multi-disciplinary staffing and involvement of peer mentors was common to all services.
Abstract: Qualitative study using semi-structured interviews. To describe and compare models of service delivery intended to support community integration in the immediate period following inpatient rehabilitation for SCI, and describe the characteristics of these models or approaches. Spinal services from multiple international countries Semi-structured interviews were completed with 12 participants from a convenience sample of ten spinal services from developed economies. Interviews were audio-recorded, transcribed verbatim and thematically analysed. Three themes were identified, and are described with supporting quotations. These are: Theme One—Models of service delivery (sub-themes: staffing, peer mentors, facilitating community integration during inpatient rehabilitation; Theme Two—Services provided (sub-themes: telehealth, vocational services, groups); Theme Three—Facilitating self-efficacy and self-management. A variety of models aimed at supporting community integration in the immediate period following inpatient rehabilitation for SCI were found. Multi-disciplinary staffing and involvement of peer mentors was common to all services. The importance of vocational rehabilitation was acknowledged by all participants, although the approaches taken to this varied. Telehealth has the potential to assist in self-management, particularly for patients who live a long distance from the spinal unit or are confined to the home for health reasons, and could be further developed. Although service models are greatly influenced by the funding context, the findings from this study can be used to inform service planning in this area.
TL;DR: Hypertension as well as hypotension during surgery may impact the trajectory of recovery in individuals with SCI, and there may be a direct relationship between intraoperative MAP and motor recovery.
Abstract: Retrospective analysis. To assess the impact of mean arterial blood pressure (MAP) during surgical intervention for spinal cord injury (SCI) on motor recovery. Level-one Trauma Hospital and Acute Rehabilitation Hospital in San Jose, CA, USA. Twenty-five individuals with traumatic SCI who received surgical and acute rehabilitation care at a level-one trauma center were included in this study. The Surgical Information System captured intraoperative MAPs on a minute-by-minute basis and exposure was quantified at sequential thresholds from 50 to 104 mmHg. Change in International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor score was calculated based on physiatry evaluations at the earliest postoperative time and at discharge from acute rehabilitation. Linear regression models were used to estimate the rate of recovery across the entire MAP range. An exploratory analysis revealed that increased time within an intraoperative MAP range (70–94 mmHg) was associated with ISNCSCI motor score improvement. A significant regression equation was found for the MAP range 70–94 mmHg (F[1, 23] = 4.65, r2 = 0.168, p = 0.042). ISNCSCI motor scores increased 0.036 for each minute of exposure to the MAP range 70–94 mmHg during the operative procedure; this represents a significant correlation between intraoperative time with MAP 70–94 and subsequent motor recovery. Blood pressure exposures above or below this range did not display a positive association with motor recovery. Hypertension as well as hypotension during surgery may impact the trajectory of recovery in individuals with SCI, and there may be a direct relationship between intraoperative MAP and motor recovery.
TL;DR: Guided transdiagnostic ICBT programme is a feasible and acceptable treatment option for those with psychological needs following SCI and improvement in symptoms of depression and anxiety were seen after treatment.
Abstract: Observational pre-post study. Guided internet-delivered CBT (ICBT) offers an alternative approach for mental health service delivery in the community for those with spinal cord injury (SCI). The feasibility and acceptability of guided ICBT programme is available for various chronic health conditions; however, the evidence related to SCI is limited. The primary aim of the current study was to examine feasibility and acceptability of a guided transdiagnostic ICBT programme for persons with SCI. Community. In this single-group pre-post study, persons with SCI (n = 20) living in the community were provided with a guided 8-week transdiagnostic ICBT programme for overall well-being. Study feasibility was examined by the following outcomes: patient recruitment, engagement, and attrition. Acceptability of the programme was evaluated post-treatment. Reductions in symptoms of depression and anxiety were assessed at baseline, post-intervention, and at 3-month follow-up. Approximately 60% of eligible participants were recruited. The study found high rates of programme completion (90%) and outcome data were obtained from 90% of participants. Improvement in symptoms of depression (and anxiety) were seen after treatment. Gains were maintained at 3-month follow-up. Guided transdiagnostic ICBT programme is a feasible and acceptable treatment option for those with psychological needs following SCI.
TL;DR: The findings show that the needs of individuals with SCI are not fully met: outpatient and community care is often fragmented, mono-professional and non-specialized, while persons withSCI and HPs prefer coordinated, inter- professional and specialized services for preventing and treating PIs.
Abstract: Qualitative exploratory study. Pressure injuries (PIs) are a major secondary condition occurring after spinal cord injuries (SCI). Optimization of outpatient and community care may be a promising approach to better support community-dwelling individuals with SCI in preventing PIs. The aim of this study was to examine the experiences of individuals with SCI, family caregivers and health professionals (HPs) in using or providing outpatient and community services for early treatment and prevention of PIs in SCI. Switzerland. Semi-structured interviews with a sample of Swiss residents community-dwelling individuals with SCI (n = 20), family caregivers (n = 5) and HPs (n = 22) were analysed using thematic analysis. General practitioners (GPs), home care providers, SCI-specialized outpatient clinics and an SCI-specialized nursing service are involved in the prevention and early treatment of PIs. Our findings show that the needs of individuals with SCI are not fully met: outpatient and community care is often fragmented, mono-professional and non-specialized, while persons with SCI and HPs prefer coordinated, inter-professional and specialized services for preventing and treating PIs. Our findings also highlight the challenges faced by HPs in providing care to individuals with SCI in the community. Although there seems to be a gap in service provision, there is the potential for improvement by better integrating the different providers in a network and structuring their collaborations. Concrete suggestions are: systematizing knowledge transfer to home care providers and GPs; redefining the role of involved HPs and individuals with SCI and reinforcing the role of the SCI-specialized nursing service.
TL;DR: An overview of adaptive trial designs is provided, and how adaptive methods can address persistent challenges encountered by randomized controlled trials of people with spinal cord injury is described.
Abstract: Narrative review. To provide an overview of adaptive trial designs, and describe how adaptive methods can address persistent challenges encountered by randomized controlled trials of people with spinal cord injury (SCI). With few exceptions, adaptive methodologies have not been incorporated into clinical trial designs of people with SCI. Adaptive methods provide an opportunity to address high study costs, slow recruitment, and excessive amount of time needed to carry out the trial. The availability of existing SCI registries are well poised to support modeling and simulation, both of which are used extensively in adaptive trial designs. Eight initiatives for immediate advancement of adaptive methods in SCI were identified. Although successfully applied in other fields, adaptive clinical trial designs in SCI clinical trial programs have been narrow in scope and few in number. Immediate application of several adaptive methods offers opportunity to improve efficiency of SCI trials. Concerted effort is needed by all stakeholders to advance adaptive clinical trial design methodology in SCI.
TL;DR: A case fatality rate of 19% in Veterans with SCI/D can be compared with the rate in the overall US Veteran population enrolled for VHA health care, which has a similar proportion of individuals age 65 years or greater.
Abstract: Individuals with spinal cord injuries and disorders (SCI/D) have an elevated risk of death with community-acquired pneumonia [1], and there may be elevated risk with coronavirus disease 2019 (COVID-19). The Veterans Health Administration (VHA) SCI/D National Program Office oversees health care services received by over 24,000 Veterans with SCI/D at 170 medical centers and more than 1000 outpatient care sites. In coordination with the VHA Support Service Center, the National Program Office maintains the VHA SCI/D Registry, which identifies Veterans who have received health care services from the VHA SCI/D System of Care. To support outreach and prevention activities in the response to the current COVID19 pandemic, the National Program Office developed operational reports showing COVID-19 infection status as determined by occurrence of a positive laboratory test performed by VHA or by entry of a non-VHA lab result. Additional registry data including demographics, neurologic classifications, comorbidities, and geographic setting were used to determine a preliminary infection risk category and severity risk category for each SCI/D Veteran. These reports were developed in March 2020 and made available to VHA SCI/D Centers on April 7, 2020. The objective of this analysis was to describe case fatality of COVID-19 infection in Veterans with SCI/D as determined using these operational reports. Between March 9, 2020 and June 30, 2020, COVID-19 was identified in 140 of 17,452 Veterans with SCI/D, inclusive of traumatic and nontraumatic etiologies and excluding both multiple sclerosis and amyotrophic lateral sclerosis. The mean (SD) age of those with infection was 67 (12) years. The racial composition was White: 80 (57%), Black: 50 (36%), and other/declined/unknown 10 (7%). For those with neurologic classifications recorded (n= 82), the combined neurological level and American Spinal Injury Association Impairment Scale (AIS) categories were: C1–C4 tetraplegia AIS A–C: 13 (16)%; C5–C8 tetraplegia AIS A–C: 14 (17%); paraplegia AIS A–C: 15 (18%); all AIS D: 40 (49%). Infections were identified in Veterans from 63 VHA health care systems. Inpatient care was received by 67 of 140 (48%) Veterans in VHA hospitals and by an unknown number of Veterans in other inpatient settings. Of these 140 Veterans who tested positive for COVID19, 26 (19%; 95% CI, 13–26%) had died as of June 30, 2020, with all except one death occurring within 30 days of testing positive. For the 19 deceased Veterans who received VHA inpatient care, the median duration between positive test and death was 8 days. The case fatality rate of 19% in Veterans with SCI/D can be compared with the rate in the overall US Veteran population enrolled for VHA health care, which has a similar proportion of individuals age 65 years or greater (SCI/D: 54%; overall population: 49%) [2]. As of June 30, 2020, 7.7% of all non-SCI/D Veterans known to have COVID-19 had died: 1564 deaths in 20,369 infected individuals, calculated as overall Veteran population minus SCI/D Veteran subtotals [3]. The SCI/D Veteran case fatality rate with COVID-19 is 2.4 times the rate observed in the non-SCI/D Veteran population, with * Stephen P. Burns stephen.burns@va.gov
TL;DR: Cause-specific SMRs varied according to etiology, and cardiovascular disease, neoplasms, and infection, emerged as main causes of death following NTSCI and should thus be targets for future research and differential clinical management approaches.
Abstract: Observational cohort study. To benchmark all-cause and cause-specific mortality following NTSCI to the general population (GP). Specialized rehabilitation centers in Switzerland. Longitudinal data from the Swiss Spinal Cord Injury (SwiSCI) Medical Record study were probabilistically linked with cause of death (CoD) information from the Swiss National Cohort. Standardized mortality ratios (SMRs) were estimated for all-cause and cause-specific mortality. Competing risk frameworks were used to estimate the probability of death due to specific CoD. One thousand five hundred and one individuals were admitted for first rehabilitation with NTSCI between 1990–2011; CoD information was available for 454 individuals of the 525 individuals that died. Overall, the mortality rate for persons with NTSCI was 1.6 times greater than that of the GP. Deaths due to cardiovascular disease (39.8%), neoplasms (22%), and infection (9.9%) were most often reported. Individuals with an SCI due to a vascular etiology indicated the greatest burden of mortality from infection compared with the GP (SMR 5.4; 95% CI, 3.1 to 9.2). Cause-specific SMRs varied according to etiology. This supports the need for targeted clinical care and follow-up. Cardiovascular disease, neoplasms, and infection, emerged as main causes of death following NTSCI and should thus be targets for future research and differential clinical management approaches.
TL;DR: Acute changes in the supraspinatus and biceps tendon after fatiguing wheelchair propulsion may explain the high prevalence of tendon injuries in persons with spinal cord injury.
Abstract: A quasi-experimental, pretest–posttest design. To identify acute changes in the supraspinatus and biceps tendon following fatiguing wheelchair propulsion and to associate tendon changes with risk factors associated with shoulder pain in persons with spinal cord injury (SCI). Biomechanical laboratory Swiss Paraplegic Research. A population-based sample of 50 wheelchair users with SCI at lesion level T2 or below participated. Fatigue was measured by using the rate of perceived exertion and heart rate. Linear regression techniques were used to assess the association between the dependent and independent variables. Dependent variables included absolute differences in supraspinatus and biceps tendon thickness, contrast, and echogenicity ratio assessed with ultrasound before and after a fatiguing wheelchair propulsion intervention. Independent variables included susceptibility to fatigue (Yes/No), the acromio-humeral distance, sex, time since injury, activity levels, and body weight. A reduction in supraspinatus tendon thickness after fatiguing wheelchair propulsion (–1.39 mm; 95% CI: –2.28; –0.51) was identified after controlling for all potential confounders. Females who fatigued (n = 4) displayed a greater reduction in supraspinatus tendon thickness as compared with those who did not fatigue (n = 7). In contrast, higher body weight was associated with an increase in supraspinatus tendon thickness and a greater acromio-humeral distance before the intervention was associated with an increase in biceps tendon thickness. Acute changes in the supraspinatus and biceps tendon after fatiguing wheelchair propulsion may explain the high prevalence of tendon injuries in this population. Future research should determine the consequences of tendon changes and its relationship to tendinopathy.