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).     

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.     

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.     

Predicting complicated outcomes in spinal cord injury patients with urinary tract infection: Development and internal validation of a risk model

Context/objective: Patients with chronic SCI hospitalized for UTI can have significant morbidity. It is unclear whether SIRS criteria, SOFA score, or quick SOFA score can be used to predict complicated outcome.

Design: Retrospective cohort study. A risk prediction model was developed and internally validated using bootstrapping methodology.

Setting: Urban, academic hospital in St. Louis, Missouri.

Participants: 402 hospitalizations for UTI between October 1, 2010 and September 30, 2015, arising from 164 patients with chronic SCI, were included in the final analysis.

Outcome/measures: An a priori composite complicated outcome defined as: 30-day hospital mortality, length of hospital stay >4 days, intensive care unit (ICU) admission, and hospital revisit within 30 days of discharge.

Results: Mean age of patients was 46.4?±?12.3 years; 83.6% of patient-visits involved males. The primary outcome occurred in 278 (69.2%) hospitalizations. In multivariate analysis, male sex was protective (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.18-0.99; P?=?0.048) while Gram-positive urine culture (OR 3.07; 95% CI, 1.05-9.01; P?=?0.041), urine culture with no growth (OR, 1.69; 95% CI, 1.02-2.80; P?=?0.041), and greater SOFA score (for one-point increments, OR, 1.41; 95% CI, 1.18-1.69; P?<?0.001) were predictive for complicated outcome. SIRS criteria and qSOFA score were not associated with complicated outcome. Our risk prediction model demonstrated good overall performance (Brier score, 0.19), fair discriminatory power (c-index, 0.72), and good calibration during internal validation.

Conclusion: Clinical variables present on hospital admission with UTI may help identify SCI patients at risk for complicated outcomes and inform future clinical decision-making.     

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).     

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     

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.     

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.     

Surgical management of lower limb fractures in patients with spinal cord injury less associated with complications than non-operative management: A retrospective series of cases

Objectives: To evaluate the difference in terms of overall complications between surgical and non-surgical management of lower limb fractures in patients with chronic spinal cord injury (SCI).

Design: A 13-year retrospective study including patients with chronic spinal cord lesion admitted for sublesional lower limb fractures.

Setting: University hospital SCI reference departments (Rehabilitation department and orthopedic department).

Participants: Forty patients with SCI were included, 24 men and 16 women. Fifty-six distinct fracture occurrences were responsible for a total of 59 lower limb fractures. We compared the number of overall complications between surgical and non-surgical management of fractures.

Results: Non-surgical management was realized for 19 fractures and surgery for 40. Characteristics of operated and non-operated patients at the time of each fracture occurrence did not differ concerning age (P?=?0.430), sex (P?=?0.890), lesion levels (P?=?0.410) and AIS classification (P?=?0.790). Data analysis highlighted 20 complications directly due to the fracture site for 16 distinct fractures. Seven medical complications were found in 5 distinct fracture events. Only 10 (25.0%) of 40 surgical managements had at least one medical or post-surgical complication, whereas 12 (63.2%) of 19 non-operative managements had at least one complication. Therefore, the overall rate of complications was significantly higher after non-surgical treatment (P?=?0.044).

Conclusion: Lower extremity fractures due to osteoporosis in patients with SCI are responsible for local and general complications. When possible, surgery may be the best management to propose because of fewer overall complications.     

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.     

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.     

Non-infectious Fever After Acute Spinal Cord Injury in the Intensive Care Unit

Objective: The aim of the present study is to evaluate the frequency, etiology, risk factors and clinical outcomes in acute traumatic SCI patients who develop fever and to evaluate the relationship between fever and mortality.

Design: Retrospective data were collected between January 2007 and August 2016 from patients diagnosed with persistent fever from SCI cases observed in the ICU.

Participants: Among 5370 intensive care patients, 435 SCI patients were evaluated for the presence of fever. A total of 52 patients meeting the criteria were evaluated.

Outcome measures: Fever characteristics were evaluated by dividing the patients into two groups: infectious (group-1) and non-infectious (group-2) fever. Demographic and clinical data, ICU and hospital stay, and mortality were evaluated.

Results: In the patients with noninfectious fever, mortality was significantly higher compared to the group with infectious fever (P < 0.001). Of 52 acute SCI cases, 25 (48.1%) had neurogenic fever that did not respond to treatment in intensive care follow-up, and 22 (88%) of these patients died. Maximal fever was 39.10 ± 0.64 °C in Group-1 and 40.22 ± 1.10 ° C in Group-2 (P?=?0.001). There was a significant difference in the duration of ICU stay and hospital stay between the two groups (P?=?0.005, P?=?0.001, respectively), while there was no difference in the duration of mechanical ventilation between the groups (P?=?0.544).

Conclusion: This study demonstrates that patients diagnosed with neurogenic fever following SCI had higher average body temperature and higher rates of mortality compared to patients diagnosed with infectious fever.     

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.     

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.     

Enhancing health care professionals’ and trainees’ knowledge of physical activity guidelines for adults with and without SCI

Background: Health care providers (HCPs) are preferred sources of physical activity (PA) information; however, minimal research has explored HCPs’ knowledge of spinal cord injury (SCI) PA guidelines, and no research has examined HCP trainees’ PA guideline knowledge.

Objective: The current study explored HCPs’ and trainees’ initial knowledge of PA guidelines for both adults with SCI and the general population, and the utility of an event-based intervention for improving this knowledge.

Methods: Participants (HCPs n?=?129; trainees n?=?573) reported guideline knowledge for both sets of guidelines (SCI and general population) immediately after, one-month, and six-months following the intervention. Frequencies determined guideline knowledge at each timepoint, while chi-squared tests examined differences in knowledge of both guidelines, as well as knowledge differences in the short- and long-term.

Results: Results demonstrated that HCPs and trainees lack knowledge of PA guidelines, particularly guidelines for adults with SCI. The results further suggest that a single event-based intervention is not effective for improving long-term guideline knowledge.

Conclusion: Suggestions are made for future research with the aim of improving interventions that target HCP and HCP trainees’ long-term guideline knowledge for adults with SCI and the general population.     

Trehalose attenuates spinal cord injury through the regulation of oxidative stress,inflammation and GFAP expression in rats

Objective: Inflammation and oxidative stress are implicated in pathogenesis of spinal cord injury (SCI). Trehalose, a nonreducing disaccharide, exhibits anti-inflammatory and antioxidant effects. The present study investigated the therapeutic efficacy of trehalose in the SCI model.

Design and setting: An experimental study was designed using 120 male Wistar rats which were randomly divided into three groups including SCI, SCI?+?phosphate buffer saline (vehicle) and SCI?+?trehalose. All rats were subjected to SCI. Immediately after SCI, vehicle and trehalose groups received intrathecal injection of buffer and trehalose, respectively.

Outcome measures: The level of tissue TNFα, IL-1β, nitric oxide, malondialdehyde, myeloperoxidase, glial fibrillary acidic protein (GFAP) as well as hindlimb function were assessed at 4 hours, 1, 3 and 7 days post-SCI.

Results: Data indicated an early significant decrease in inflammatory and oxidative responses following SCI in trehalose treated group. Moreover, trehalose reduced GFAP expression as soon as 1-day post-trauma. Furthermore, trehalose treatment increased the score of hindlimb function.

Conclusion: Our results indicated that treatment with trehalose reduces the development of secondary injury associated with SCI. This effect likely underlies improved neurological function.     

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.