Can targeted job-information for adults with spinal cord dysfunction be effectively delivered online? A pilot study

Objective: To pilot a novel email-based information package (Work and SCI) for job-seekers with an acquired spinal cord injury (SCI) or spinal cord dysfunction (SCI/D).

Study design: Prospective, non-randomized, repeated measures trial.

Setting: Community dwelling cohort in Australia.

Participants: Five people with SCI (mean age 46.4 years, SD?=?10.2; 4 female) initially reviewed Work and SCI. Twenty-four with SCI/D subsequently enrolled, of whom 16 (mean age 46.4 years, SD?=?11.1; 7 female), completed the intervention.

Intervention: Intervention participants accessed Work and SCI over a 4-week period.

Outcome measures: Individual changes in pre-post scores for the My Vocational Situation Scale, Job Procurement Self-Efficacy Scale, Patient Health Questionnaire-9 and Life Orientation Test-Revised were examined.

Results: Reliable change in pre-post scores across outcomes were reported by 38% (n?=?6) of participants. Favorable comments on the Work and SCI resource were provided in addition to suggestions for improvement.

Conclusions: Preliminary data suggest that Work and SCI may help to establish vocational interests among job-seekers with a SCI/D, however further work is needed to enhance participant compliance. This might include moderator support to promote and maintain participation. A controlled design will also help to identify factors that influence engagement with the Work and SCI resource.     

Contextualizing the lived experience of quality of life for persons with spinal cord injury: A mixed-methods application of the response shift model

Objective: The objective of this study was to gain greater insight into individuals’ quality of life (QOL) definitions, appraisals, and adaptations following spinal cord injury (SCI).

Design: A mixed-methods design, applying the Schwartz and Sprangers response shift (RS) model. RS is a cognitive process wherein, in response to a change in health status, individuals change internal standards, values, or conceptualization of QOL

Setting: Community-dwelling participants who receive medical treatment at a major Midwestern medical system and nearby Veterans’ Affairs hospital.

Participants: A purposive sample of participants with SCI (N?=?40) completed semi-structured interviews and accompanying quantitative measures.

Interventions: Not applicable.

Outcome Measures: Qualitative data were analyzed using content analysis to identify themes. Analysis of variance were performed to detect differences based on themes and QOL, well-being, and demographic and injury characteristics.

Results: Four RS themes were identified, capturing the range of participant perceptions of QOL. The themes ranged from complete RS, indicating active engagement in maintaining QOL, to awareness and comparisons redefining QOL, to a relative lack of RS. Average QOL ratings differed as a function of response shift themes. PROMIS Global Health, Anxiety, and Depression also differed as a function of RS themes.

Conclusion: The RS model contextualizes differences in QOL definitions, appraisals, and adaptations in a way standardized QOL measures alone do not.     

Exercise testing protocol using a roller system for manual wheelchair users with spinal cord injury

Objective: Determine the validity and reliability of an exercise testing protocol to evaluate cardiorespiratory measures in manual wheelchair users (MWUs) with spinal cord injury (SCI) using a roller-based (RS) wheelchair system.

Design: Repeated measures within-subject design.

Setting: Community-based research laboratory.

Participants: Ten adults with SCI requiring the use of a manual wheelchair.

Interventions: Not applicable.

Outcome measures: Cardiorespiratory measures (peak oxygen consumption [VO₂peak], respiratory exchange ratio [RER], pulmonary ventilation [VE], energy expenditure [EE], heart rate [HR], accumulated kilocalories [AcKcal]) and perceived exertion (RPE) were measured during three separate maximal exercise tests using an arm crank ergometer (ACE) and an RS.

Results: At maximal exertion, there were no significant differences in variables between groups, with moderate-to-strong correlations (P?<?0.05, r?=?0.79–0.90) for VO₂, HR, RPE, AcKcal, and rate of EE between RS and ACE trials. Significant moderate-to-strong correlations existed between RS trials for VO₂, AcKcal, rate of EE, and peak power output (P?<?0.01, r?=?0.77–0.97).

Conclusions: VO_2peak was highly correlated between ACE and RS trials and between the two RS trials, indicating the RS protocol to be reliable and valid for MWUs with SCI. Differences in perceived exertion and efficiency at submaximal workloads and maximal pulmonary ventilation at peak workloads indicated potential advantages to using the RS.     

Lifestyle intervention for adults with spinal cord injury: Results of the USC–RLANRC Pressure Ulcer Prevention Study

Context/Objective: Medically serious pressure injuries (MSPrIs), a common complication of spinal cord injury (SCI), have devastating consequences on health and well-being and are extremely expensive to treat. We aimed to test the efficacy of a lifestyle-based intervention designed to reduce incidence of MSPrIs in adults with SCI.

Design: A randomized controlled trial (RCT), and a separate study wing involving a nonrandomized standard care control group.

Setting: Rancho Los Amigos National Rehabilitation Center, a large facility serving ethnically diverse, low income residents of Los Angeles County.

Participants: Adults with SCI, with history of one or more MSPrIs over the past 5 years: N=166 for RCT component, N=66 in nonrandomized control group.

Interventions: The Pressure Ulcer Prevention Program, a 12-month lifestyle-based treatment administered by healthcare professionals, largely via in-home visits and phone contacts.

Outcome Measures: Blinded assessments of annualized MSPrI incidence rates at 12 and 24 months, based on: skin checks, quarterly phone interviews with participants, and review of medical charts and billing records. Secondary outcomes included number of surgeries and various quality-of-life measures.

Results: Annualized MSPrI rates did not differ significantly between study groups. At 12 months, rates were .56 for intervention recipients, .48 for randomized controls, and .65 for nonrandomized controls. At follow-up, rates were .44 and .39 respectively for randomized intervention and control participants.

Conclusions: Evidence for intervention efficacy was inconclusive. The intractable nature of MSPrI threat in high-risk SCI populations, and lack of statistical power, may have contributed to this inability to detect an effect.

Trial Registration: ClinicalTrials.gov NCT01999816     

Usefulness of classical homeopathy for the prophylaxis of recurrent urinary tract infections in individuals with chronic neurogenic lower urinary tract dysfunction

Context/Objective: to investigate the usefulness of classical homeopathy for the prevention of recurrent urinary tract infections (UTI) in patients with spinal cord injury (SCI).

Design: prospective study.

Setting: rehabilitation center in Switzerland.

Participants: patients with chronic SCI and ≥3 UTI/year.

Interventions: Participants were treated either with a standardized prophylaxis alone or in combination with homeopathy.

Outcome measures: The number of UTI, general and specific quality of life (QoL), and satisfaction with homeopathic treatment were assessed prospectively for one year.

Results: Ten patients were in the control group; 25 patients received adjunctive homeopathic treatment. The median number of self-reported UTI in the homeopathy group decreased significantly, whereas it remained unchanged in the control group. The domain incontinence impact of the KHQ improved significantly (P?=?0.035), whereas the general QoL did not change. The satisfaction with homeopathic care was high.

Conclusions: Adjunctive homeopathic treatment lead to a significant decrease of UTI in SCI patients. Therefore, classical homeopathy could be considered in SCI patients with recurrent UTI.

Trial registration: ClinicalTrials.gov. (NCT01477502).     

The association between the etiology of a spinal cord injury and time to mortality in the United States: A 44-year investigation

Objective: To determine the association between spinal cord injury (SCI) etiology categories and mortality, and examine the association between etiology sub-categories and mortality.

Design: Prospective cohort study.

Setting: Model Systems and Shriners Hospital SCI units.

Participants: Data were analyzed from 42,627 cases in the SCI Model System Collaborative Survival Study Database from 1973 to 2017. Those with SCI etiologies categorized as vehicular, violent, sports, falls, pedestrian, and medical were included.

Interventions: Not applicable.

Outcome Measure: Time to mortality after SCI.

Results: Relative to the sports related etiology category, those with medical, pedestrian, violence, falls, and vehicular related SCIs had a 2.00 (95% confidence intervals (CIs): 1.79–2.24), 1.57 (CIs: 1.34–1.83), 1.54 (CIs: 1.41–1.68), 1.35 (CIs: 1.25–1.45), and 1.26 (CIs: 1.17–1.35) higher hazard for mortality, respectfully. Persons with SCIs from automobile crashes had a 1.38 (CIs: 1.23–1.56) higher hazard for mortality, whereas those with SCIs from motorcycle crashes had a 1.21 (CIs: 1.04–1.39) higher hazard for mortality, relative to other etiologies within the vehicular category. Those with SCIs from diving had a 1.37 (CIs: 1.18–1.59) higher hazard for mortality relative to other etiologies within the sports category.

Conclusions: Injury etiology categories and certain sub-categories were associated with a higher risk for early mortality. Understanding how additional factors such as socioeconomic status, co-occurring injuries, medical co-morbidities, and environmental aspects interact with SCI etiologies may provide insights for how etiology of injury impacts survival. These findings may serve as a development for extending long-term life expectancy by informing SCI prevention programs and care post-injury.     

Hybrid assistive limb (HAL) treatment for patients with severe thoracic myelopathy due to ossification of the posterior longitudinal ligament (OPLL) in the postoperative acute/subacute phase: A clinical trial

Context/Objective: The hybrid assistive limb (HAL) is a wearable exoskeleton robot that assists walking and lower limb movements via real-time actuator control. Our aim was to clarify the safety and feasibility of using the HAL robotic suit for rehabilitation in patients with severe thoracic myelopathy due to ossification of the posterior longitudinal ligament (T-OPLL).

Design: Uncontrolled case series; pre- and post-intervention measurement.

Setting: In-patient rehabilitation unit.

Intervention: HAL training was provided in 60-minuts session, 2–3 sessions per week, for a total of 10 sessions. HAL training was initiated on average 27.5 days post-surgery.

Patients: Eight patients (four males and four females; mean age, 60.9?±?10.2 years) with severe myelopathy, who had undergone posterior decompression with instrumented fusion, were enrolled.

Outcome Measures: Gait speed, step length and cadence were measured along a 10-m walkway every session. The American Spinal Injury Association (ASIA) motor score (lower extremities) and Walking Index for Spinal Cord Injury (WISCI) II were also evaluated at baseline and after 10 sessions. The Japanese Orthopaedic Association (JOA) score was calculated over time after surgery.

Results: All participants completed the 10 training sessions, with no serious adverse effect noted. Gait speed, step length and cadence improved over time. Both the WISCI-II and ASIA motor (lower extremities) scores improved from baseline after 10 sessions. The JOA score improved over time post-surgery.

Conclusion: HAL training can be feasibly initiated in the early postoperative period, without severe adverse events in patients, with T-OPLL-related severe gait disturbance.     

Peer-led,transformative learning approaches increase classroom engagement in care self-management classes during inpatient rehabilitation of individuals with spinal cord injury

Objective: Evaluate effects of revised education classes on classroom engagement during inpatient rehabilitation for individuals with spinal cord injury/disease (SCI/D).

Design: Multiple-baseline, quasi-experimental design with video recorded engagement observations during conventional and revised education classes; visual and statistical analysis of difference in positive engagement responses observed in classes using each approach.

Participants/Setting: 81 patients (72% male, 73% white, mean age 36 SD 15.6) admitted for SCI/D inpatient rehabilitation in a non-profit rehabilitation hospital, who attended one or more of 33 care self-management education classes that were video recorded. All study activities were approved by the host facility institutional review board.

Intervention: Conventional nurse-led self-management classes were replaced with revised peer-led classes incorporating approaches to promote transformative learning. Revised classes were introduced across three subject areas in a step-wise fashion over 15 weeks.

Outcome Measure: Positive engagement responses (asking questions, participating in discussion, gesturing, raising hand, or otherwise noting approval) were documented from video recordings of 14 conventional and 19 revised education classes.

Results: Significantly higher average (per patient per class) positive engagement responses were observed in the revised compared to conventional classes (p=0.008).

Conclusion: Redesigning SCI inpatient rehabilitation care self-management classes to promote transformative learning increased patient engagement. Additional research is needed to examine longer term outcomes and replicability in other settings.     

Associations between vitamin D and pulmonary function in chronic spinal cord injury

Context/Objective: Individuals with chronic spinal cord injury (SCI) have an increased risk of morbidity and mortality attributable to respiratory diseases. Previous studies in non-SCI populations suggest that vitamin D may be a determinant of respiratory health. Therefore, we sought to assess if lower vitamin D levels were associated with decreased pulmonary function in persons with chronic SCI.

Design: Cross-sectional study.

Setting: Veterans Affairs Medical Center.

Participants: 312 participants (260 men and 52 women) with chronic SCI recruited from VA Boston and the community participating in an epidemiologic study to assess factors influencing respiratory health.

Methods: Participants provided a blood sample, completed a respiratory health questionnaire, and underwent spirometry. Linear regression methods were used to assess cross-sectional associations between plasma 25-hydroxyviatmin D and spirometric measures of pulmonary function.

Outcome Measures: Forced expiratory volume in one second (FEV₁), forced vital capacity (FVC), and FEV₁/FVC.

Results: Adjusted and unadjusted for a number of confounders, there was no significant association between plasma vitamin D levels and FEV₁, FVC, or FEV₁/FVC. For example, in fully adjusted models, each 10?ng/ml increase in vitamin D was associated with a 4.4?ml (95%CI ?64.4, 73.2, P?=?0.90) ml change in FEV_1.

Conclusion: There was no significant cross-sectional association between plasma vitamin D and FEV₁, FVC, or FEV₁/FVC in this cohort of individuals with chronic SCI.     

The protection of acute spinal cord injury by subarachnoid space injection of Danshen in animal models

Context/Objective: Following acute spinal cord injury (ASCI) in rabbits, subarachnoid space injection of Danshen was performed to protect the neurological damage. In this study, we established rabbit models of spinal cord injury using a modified Allen’s method.

Design: After the operation introducing the injuries, the rabbits were randomized into two different groups, control group (normal saline, NS) and Danshen, a component extracted from Chinese herb, treatment group. Each rabbit was supplied with either the drug or placebo at 0.3?ml/kg each day through subarachnoid cavity.

Setting: Rabbit model of acute spinal cord injury were used for the response to Danshen treatment.

Participants: Total 48 Chinese rabbits aged four～ five months old provided by Experimental Animal Center of Hubei Province were used for this study.

Interventions: Danshen drug or placebo was administered via a silicon tube embedded under the spinal dura mater to administer the drugs into subarachnoid cavity.

Outcome Measures: After the treatment, damage indicators including cell apoptosis, morphological changes and oxidative damages were assessed.

Results: We found out that cell apoptosis was decreased after Danshen injection as determined by downregulation of apoptosis index (AI) by TUNEL analysis as well as propidium iodide (PI) percentage by FACS analysis. In the meanwhile, we observed cells after the treatment have increased numbers of BCL-2 positive cells, this indicated the antiapoptotic gene expression is increased after Danshen treatment. When we check the oxidative damage indicators, we found superoxide dismutase (SOD) was increased and malondiadehyde (MDA) levels were decreased after the treatment.

Conclusion: Danshen can protect ASCI through inhibition of oxidative damage in the injured cells and thus reduce the subsequent cell apoptosis in the spinal.     

Inconsistencies with screening for traumatic brain injury in spinal cord injury across the continuum of care

Objective: Explore how traumatic brain injury (TBI) is screened among spinal cord injury (SCI) patients across the continuum of care.

Design: Retrospective chart review

Setting: Emergency department, trauma, inpatient rehabilitation

Participants: 325 patients with SCI from inpatient rehabilitation facility (IRF) between March 1, 2011 and December 31, 2014 were screened. 49 eligible subjects had traumatic SCI and received care in adjoining acute care (AC) hospital.

Outcome Measures: Demographic characteristics and variables that capture diagnosis of TBI/SCI included documentation from ambulance, emergency department, AC, and IRF including ICD-9 codes, altered mental status, loss of consciousness (LOC), Glasgow Coma Score, Post Traumatic Amnesia (PTA), neuroimaging, and cognitive assessments.

Results: Participants were male (81%), white (55%), privately insured (49%), and aged 39.3±18.0 years with 51% paraplegic and 49% tetraplegic. Mechanisms of injury were gunshot wound (31%), fall (29%), and motor vehicle accident (20%). TBI occurred in 65% of SCI individuals, however documentation of identification of TBI, LOC, and CT imaging results varied in H&P, discharge notes, and ICD-9 codes across the continuum. Cognitive assessments were performed on 16% of subjects.

Conclusions: Documentation showed variability between AC and IRF and among disciplines. Imaging and GCS were more consistently documented than LOC and PTA. It is necessary to standardize screening processes between AC and IRF to identify dual diagnosis.     

Inspiratory muscle training is feasible and safe for patients with acute spinal cord injury

Objective: To investigate the feasibility and safety and, to a lesser extent efficacy, of inspiratory muscle training (IMT) for patients with acute complete cervical or thoracic spinal cord injury (SCI).

Design: Prospective, observational pilot study comprising a series of case reports.

Setting: Tertiary care, public hospital.

Participants: Seven adult subjects with an acute complete cervical or thoracic SCI.

Interventions: Participants received IMT as soon as their respiratory condition was stable. A high-resistance, low-repetition program of IMT using a POWERbreathe KH1 device was instituted. Training comprised 3–6 sets of 6 breaths, commenced at 50% maximum inspiratory pressure with the training load progressively increased.

Outcome measures: Feasibility (number of sessions when the criteria to participate in IMT were met/not met), safety (symptoms and physiological stability) before, during and after IMT sessions and efficacy (lung function) were measured.

Results: There were 50 sessions in total where participants met the criteria to receive IMT, with a mean (range) of 7.1 (3–11) IMT sessions per participant delivered over 10.7 (4–17) days. IMT was feasible, with all 50 planned sessions of IMT able to be delivered, and safe, with stable physiological parameters and no adverse symptoms or events recorded before, during or after IMT. Maximal inspiratory pressure increased for four participants and forced vital capacity increased for three participants over the duration of their IMT sessions.

Conclusion: A high-resistance, low-repetition program of IMT was feasible and safe in adults with an acute complete cervical or thoracic SCI whose respiratory status was stable.

Trial registration: Australian New Zealand Clinical Trials Registry (ACTRN 12614000975695).     

Sex dimorphism in the distribution of adipose tissue and its influence on proinflammatory adipokines and cardiometabolic profiles in motor complete spinal cord injury

Objective: We aimed to examine the influence of sex on the distribution of adipose tissue, as well as proinflammatory adipokine and cardiometabolic profiles, in chronic motor complete spinal cord injury (SCI).

Design: Cross-sectional and correlational study.

Setting: Academic rehabilitation hospital.

Participants: Forty-seven individuals with chronic motor complete SCI classified according to sex (males: age 44.0?±?10.9 y, body mass index (BMI) 27.2?±?5.8, level of injury (LOI) C4 - L1; females: 42.0?±?13.5 y, BMI 27.8?±?6.6, LOI C4 - T11).

Intervention: Not applicable.

Outcome Measures: Visceral (VAT), subcutaneous (SAT), and total trunk (TTAT) adipose tissue volumes were assessed utilizing magnetic resonance imaging and a VAT:SAT ratio was calculated. Proinflammatory adipokines (tumor neurosis factor-α, interleukin-6, plasminogen activator inhibitor-1, thrombin-activatable fibrinolysis inhibitor, and high sensitivity c-reactive protein) and cardiovascular, carbohydrate, and lipid profiles were evaluated according to standard techniques.

Results: VAT and VAT:SAT ratio were significantly greater in male participates with SCI (P?≤?0.002), while SAT volume was significantly greater in female participants with SCI (P?=?0.001). No difference was noted in TTAT between groups (P?=?0.341). Male participants with SCI demonstrated lower high-density lipoprotein-cholesterol (HDLC) profiles and an elevated total cholesterol to HDLC ratio (P?≤?0.003) compared with females. No other significant differences were found between groups concerning cardiometabolic profiles or proinflammatory adipokines; however, males exhibited poorer profiles overall. Proinflammatory adipokines significantly correlated with adipose tissue depots by sex (P?<?0.05).

Conclusion: The results show that sex influences the distribution of adipose tissue, and may influence proinflammatory and cardiometabolic profiles following SCI. The findings of this study highlight the need for further research with dietary modification and exercise to decrease health risks.     

Healthcare utilization following spinal cord injury: Objective findings from a regional hospital registry

Objective: The purpose was to describe the prevalence and characteristics of healthcare utilization among individuals with spinal cord injury (SCI) from a Level I trauma center.

Design: Retrospective data analysis utilizing a local acute trauma registry for initial hospitalization and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year.

Setting: Dallas, TX, USA.

Participants: Six hundred and sixty four patients were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty five patients that expired during initial hospitalization and 18 patients with unspecified SCI (defined by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591.

Outcome Measures: Data included demographic and clinical characteristics, charges, and healthcare utilization.

Results: Mean age was 46.1?years (±18.9?years), the majority of patients were male (74%), and Caucasian (58%). Of the 591 patients, 345 (58%) had additional inpatient or emergency healthcare utilization accounting for 769 additional visits (median of 3 visits per person). Of the 769 encounters, 534 (69%) were inpatient and 235 (31%) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension, and tobacco use.

Conclusion: Individuals with SCI experience high levels of healthcare utilization which are costly and may be preventable. Increasing our understanding of the prevalence and causes for healthcare utilization after acute SCI is important to target preventive strategies.     

Plasma fatty acids as markers for desaturase and elongase activities in spinal cord injured males

Objective: To investigate the use of surrogate plasma fatty acid analysis to provide further insights into the underlying adiposity and the development of metabolic syndrome in men with spinal cord injury (SCI).

Design: Case-control, cross-sectional study.

Setting: Community-based individuals with spinal cord injury and healthy controls.

Participants: Twenty men with SCI age, height and weight matched with 20 able-bodied controls.

Outcome Measures: Lean tissue (LTM) and fat mass (FM) were determined using dual energy X-ray absorptiometry. Fasting blood samples were taken for analysis of fatty acids, adiponectin, insulin, glucose and leptin. Enzymatic indices were calculated using relevant fatty acids.

Results: Total FM, leptin, stearoyl coenzyme A desaturase (SCD) Δ9 (SCD-16, 16:1/16:0, and SCD-18, 18:1/18:0) indices and Δ6 desaturase index were significantly higher (P < 0.05) in the SCI group than the controls. Significant differences between the groups was observed for several individual fatty acids. Correlational analysis revealed a different pattern between blood biomarkers and indices of SCDs, de novo lipogenesis and elongase. Associations between the desaturase and elongase indices and biomarkers in the controls followed those reported elsewhere for able bodied participants; the same associations were not observed in the SCI group.

Conclusion: We have identified disturbances in fatty acid biosynthesis in SCI individuals likely associated with the development of adipose tissue below the lesion and a decrease in LTM. Loss of LTM may disturb the normal skeletal muscle-fatty acid metabolic processes leading to the disruption of metabolic homeostasis, previously identified in persons with SCI.     

Pain profiles in a community dwelling population following spinal cord injury: a national survey

Context: While as many as 60% of patients with spinal cord injury (SCI) develop chronic pain, limited data currently exists on the prevalence and profile of pain post-SCI in community dwelling populations.

Study Design: A cross-sectional population survey.

Setting: Primary care.

Participants: Community dwelling adults with SCI.

Methods: Following ethical approval members registered to a national SCI database (n=1,574) were surveyed. The survey included demographic and SCI characteristics items, the International Spinal Cord Injury Pain Basic Data Set (version 1) the Douleur Neuropathique 4 questionnaire (interview) and questions relating to health care utilisation. Data were entered into the Statistical Package for the Social Sciences (version 20) Significance was set P < 0.05 for between group comparisons.

Results: In total 643 (41%) surveys were returned with 458 (71%) respondents experiencing pain in the previous week. Neuropathic pain (NP) was indicated in 236 (37%) of responses and nociceptive pain in 206 (32%) Common treatments for pain included medications n=347 (76%) massage n=133 (29%) and heat n=115 (25%). Respondents with NP reported higher pain intensities and increased healthcare service utilisation (P= < 0.001) when compared to those with nociceptive pain presentations. A higher proportion of females than males reported pain (P?=?0.003) and NP (P?=?0.001) and those unemployed presented with greater NP profiles compared with those in education or employment (P?=?0.006).

Conclusion: Pain, in particular NP post SCI interferes with daily life, increases health service utilisation and remains refractory to current management strategies. Increased availability of multi-disciplinary pain management and further research into management strategies is warranted.     

The effect of level of injury and physical activity on heart rate variability following spinal cord injury

Objective/Background: To assess frequency domain heart rate variability (HRV) parameters at rest and in response to postural autonomic provocations in individuals with spinal cord injury (SCI) and investigate the autonomic influences on the heart of different physical activities.

Design: Cross-sectional study.

Methods: Ten subjects with complete cervical SCI and fourteen subjects with complete low thoracic SCI were prospectively recruited from the community and further divided in sedentary and physically active groups, the latter defined as regular weekly 4 hour physical activity for the preceding 3 months. Sixteen healthy individuals matched for sex and age were recruited to participate in the control group. The Low Frequency (LF), High Frequency (HF) powers and the LF/HF ratio of HRV were measured from continuous electrocardiogram (ECG) recordings at rest and after sitting using a fast Fourier transformation.

Outcome measures: The LF,HF, and the LF/HF ratio at rest and after sitting.

Results: A significant decrease in all HRV parameters in patients with SCI was found compared to controls. The change in HF, LF and LF/HF following sitting maneuver was significantly greater in controls as compared with the SCI group and greater in subjects with paraplegia as compared to subjects with tetraplegia. Better HRV values and enhanced vagal activity appears to be related to the type of physical activity in active subjects with paraplegia.

Conclusion: In this cohort of subjects spectral parameters of HRV were associated with the level of the injury. Passive standing was associated with higher HRV values in subjects with paraplegia.     

Impact of interdisciplinary rounds in the spinal cord injury unit on relational coordination for patients with pressure injury: A pilot study

Context/Objective: Multiple medical specialties are often involved in the management of patients with both spinal cord injuries (SCI) and pressure injuries (PIs), sometimes leading to inadequate communication. Our Veterans Affairs (VA) hospital has an interdisciplinary team for PI patients in the SCI unit. This team conducts monthly bedside rounds and journal clubs; there is no similar team for patients with PIs outside the SCI unit. This pilot study aims to determine whether such an interdisciplinary team improves care coordination among practitioners.

Design: Survey-based study.

Setting: VA hospital.

Participants: Healthcare providers who participate in interdisciplinary SCI rounds and who also care for patients with PIs outside the SCI unit.

Interventions: Interdisciplinary rounds, including monthly bedside rounds and journal clubs with variety of specialists take place within the SCI unit. There are no similar interdisciplinary rounds for patients with PIs outside of the SCI unit.

Outcome Measures: The Relational Coordination (RC) survey is a validated tool for gauging team performance. Survey results quantified relational dynamics inside and outside the SCI unit across four communication domains (frequent communication, timely communication, accurate communication, and problem-solving communication) and three relationship domains (shared knowledge, mutual respect, and shared goals).

Results: Interdisciplinary rounds in the SCI unit was associated with significantly better RC with hospitalists, surgical specialists, infectious diseases, nursing, and pharmacy. This effect was primarily due to improvements in communication domains, without significant difference in relationship domains.

Conclusions: Interdisciplinary rounds in the SCI unit significantly improves RC in the care of PI patients.     

At-home genital nerve stimulation for individuals with SCI and neurogenic detrusor overactivity: A pilot feasibility study

Objective: Neurogenic bladder dysfunction, including neurogenic detrusor overactivity (NDO) is one of the most clinically significant problems for persons with spinal cord injury (SCI), affecting health and quality of life. Genital nerve stimulation (GNS) can acutely inhibit NDO-related reflex bladder contractions and increase bladder capacity. However, it is unknown if GNS can improve urinary continence or help meet individuals’ bladder management goals during sustained use, which is required for GNS to be clinically effective.

Design: Subjects maintained voiding diaries during a one-month control period without stimulation, one month with at-home GNS, and one month after GNS. Urodynamics and quality of life assessments were conducted after each treatment period, and a satisfaction survey was taken at study completion.

Setting: Subject screening and clinical procedures were conducted at the Louis Stokes Cleveland VA Medical Center. Stimulation use and voiding diary entries were conducted in subjects’ homes.

Participants: Subjects included five men with SCI and NDO.

Interventions: This study tested one month of at-home portable non-invasive GNS.

Outcome Measures: The primary outcome measure was leakage events per day. Secondary outcome measures included self-reported subject satisfaction, bladder capacity, and stimulator use frequency.

Results: GNS reduced the number of leakage events from 1.0?±?0.5 to 0.1?±?0.4 leaks per day in the four subjects who reported incontinence data. All study participants were satisfied that GNS met their bladder goals; wanted to continue using GNS; and would recommend it to others.

Conclusions: Short term at-home GNS reduced urinary incontinence and helped subjects meet their bladder management goals. These data inform the design of a long-term clinical trial testing of GNS as an approach to reduce NDO.