Safety and feasibility of exoskeleton-assisted walking during acute/sub-acute SCI in an inpatient rehabilitation facility: A single-group preliminary study

Abstract

Context/objective: Information on the safety and feasibility of lower extremity powered exoskeletons for persons with acute/sub-acute spinal cord injury (SCI) is limited. Understanding the safety and feasibility of employing powered exoskeletons in acute/sub-acute (<6 months post injury) at a SCI acute inpatient rehabilitation (SCI-AIR) facility could guide clinical practice and provide a basis for larger clinical trials on efficacy and effectiveness.

Design: Single group observational study.

Setting: SCI-AIR.

Participants: Participants (n?=?12; age: 28–71 years; 58% AIS D; 58% male) with neurological levels of injuries ranging from C2 to L3.

Interventions: Up to 90?min of exoskeleton-assisted locomotor training was provided up to three times per week during SCI-AIR.

Outcome measures: Safety of device use during inpatient locomotor training was quantified as the number of adverse events (AE) per device exposure hour. Feasibility of device use was defined in terms of protocol compliance, intensity, and proficiency.

Results: Concerning safety, symptomatic hypotension was the most common AE reported at 111-events/exoskeleton-hours. Protocol compliance had a mean (SD) of 54% (30%). For intensity, 77% of participants incorporated variable assistance into at least 1 walking session; 70% of participants' sessions were completed with a higher RPE than the physical therapist. In proficiency, 58% achieved at least minimal assistance when walking with the device.

Conclusion: Exoskeleton training in SCI-AIR can be safe and feasible for newly injured individuals with SCI who have clinically defined ambulatory goals. Nonetheless, sufficient controls to minimize risks for AEs, such as hypotensive events, are required.     

External cues benefit walking ability of ambulatory patients with spinal cord injury

Abstract

Background/objectives

Sensorimotor dysfunction following spinal cord injury (SCI) reduces ability of the patients to perceive information and control movements. They may need alternative sources of input to optimize their walking ability. This study investigated effects of external cues on walking ability in 33 independent ambulatory participants with SCI.

Methods

Participants’ walking ability was cross-sectionally assessed under three conditions including self-determined fastest walking speed (uncued condition), and fastest walking speed with the use of external cues (visual cue and visuotemporal cue conditions). Walking ability was measured in terms of walking speed, stride length, cadence, and percent step symmetry. Findings of the three conditions were compared using the one-way analysis of variance with repeated measures.

Results

When using external cues particularly the visuotemporal cue, participants showed a significant increase in walking speed, stride length, and cadence as compared with those of the uncued condition (P < 0.005). The increment of walking speed was demonstrated even in participants at a chronic stage of injury (post-injury time ≥12 months), with severe SCI (American Spinal Injury Association Impairment Scale C), or who required a walking device.

Conclusion

The results suggested the benefit of external cues, particularly the visuotemporal cues, as a potential rehabilitation tool to improve walking speed of individuals with SCI.     

Visuotemporal cues clinically improved walking ability of ambulatory patients with spinal cord injury within 5 days

Background/Objective: The human movement system uses a variety of inputs to produce movements. The concurrent use of external information, specifically visutemporal cues, while walking could promote the walking ability of ambulatory patients with spinal cord injury (SCI). This study explored the use of visutemporal cues in rehabilitation training by subjecting ambulatory individuals with SCI to walking training with or without visuotemporal cues and then assessing the effects on their functional ability.

Design: Quasi-experimental study.

Setting: A tertiary rehabilitation center.

Participants: Thirty-two participants were randomly assigned to the experimental or control groups using stage of injury, severity of SCI, and baseline walking ability as criteria for group arrangement (16 participants/group).

Interventions: The participants were trained to walk over level ground at their fastest safe speed with or without a visuotemporal cue, 30 minutes/day, for 5 consecutive days.

Outcome Measures: The 10-meter walk test, 6-minute walk test, timed up and go test, and five times sit-to-stand test.

Results: The participants demonstrated significant improvement in all functional tests after the 5 days of training (P?<?0.001). In addition, the improvement in the group trained using the visuotemporal cue was significantly better than that trained without using the cue.

Conclusions: Most of these participants were at a chronic stage of SCI, so the findings supported a benefit for incorporating visuotemporal cues in rehabilitation practice, particularly today when the length of rehabilitation has dramatically decreased.     

A clinically meaningful training effect in walking speed using functional electrical stimulation for motor-incomplete spinal cord injury

Context/Objective: The study aimed to investigate the presence of a training effect for rehabilitation of walking function in motor-incomplete spinal cord injury (SCI) through daily use of functional electrical stimulation (FES).

Setting: A specialist FES outpatient centre.

Participants: Thirty-five participants (mean age 53, SD 15, range 18-80; mean years since diagnosis 9, range 5 months - 39 years) with drop foot and motor-incomplete SCI (T12 or higher, ASIA Impairment Scale C and D) able to ambulate 10 metres with the use of a walking stick or frame.

Interventions: FES of the peroneal nerve, glutei and hamstrings as clinically indicated over six months in the community.

Outcome Measures: The data was analysed for a training effect (difference between unassisted ten metre walking speed at baseline and after six months) and orthotic effects (difference between walking speed with and without FES) initially on day one and after six months. The data was further analysed for a minimum clinically important difference (MCID) (>0.06 m/s).

Results: A clinically meaningful, significant change was observed for initial orthotic effect (0.13m/s, CI: 0.04-0.17, P?=?0.013), total orthotic effect (0.11m/s, CI: 0.04-0.18, P?=?0.017) and training effect (0.09m/s, CI: 0.02-0.16, P?=?0.025).

Conclusion: The results suggest that daily independent use of FES may produce clinically meaningful changes in walking speed which are significant for motor-incomplete SCI. Further research exploring the mechanism for the presence of a training effect may be beneficial in targeting therapies for future rehabilitation.     

Neuromechanical adaptations during a robotic powered exoskeleton assisted walking session

Objective: To evaluate gait parameters and neuromuscular profiles of exoskeleton-assisted walking under Max Assist condition during a single-session for; (i) able bodied (AB) individuals walking assisted with (EXO) and without (non-EXO) a powered exoskeleton, (ii) non-ambulatory SCI individuals walking assisted with a powered exoskeleton.

Design: Single-session.

Setting: Motion analysis laboratory.

Participants: Four AB individuals and four individuals with SCI.

Interventions: Powered lower extremity exoskeleton.

Outcome Measures: Temporal-spatial parameters, kinematics, walking velocity and electromyography data.

Results: AB individuals in exoskeleton showed greater stance time and a significant reduction in walking velocity (P < 0.05) compared to non-EXO walking. Interestingly, when the AB individuals voluntarily assisted the exoskeleton movements, they walked with an increased velocity and lowered stance time to resemble that of slow walking. For SCI individuals, mean percent stance time was higher and walking velocity was lower compared to all AB walking conditions (P < 0.05). There was muscle activation in several lower limb muscles for SCI group. For AB individuals, there were similarities among EXO and non-EXO walking conditions however there were differences in several lower limb EMGs for phasing of muscle activation.

Conclusion: The data suggests that our AB individuals experienced reduction in walking velocity and muscle activation amplitudes while walking in the exoskeleton and moreover with voluntary control there is a greater temporal-spatial response of the lower limbs. Also, there are neuromuscular phasic adaptions for both AB and SCI groups while walking in the exoskeleton that are inconsistent to non-EXO gait muscle activation.     

Factors Related to Obstacle Crossing in Independent Ambulatory Patients With Spinal Cord Injury

Abstract

Background/Objectives: To evaluate factors related to the ability of ambulatory patients with spinal cord injury (SCI) to walk over small obstacles.

Study Design: Cross-sectional study.

Methods: Thirty-four patients with SCI (ASIA impairment scale [AIS] D) who were able to walk independently at least 10 m with or without walking devices were recruited for the study. Participants were required to walk over small obstacles (1,4, and 8 cm in height or width; total of 6 conditions). A “fail” was recorded when either the lower limbs or the walking device contacted the obstacle. Multiple logistic regression models were applied to determine the effects of walking devices (presence or absence), SCI levels (tetraparesis or paraparesis), and SCI stages (acute or chronic) on the ability of obstacle crossing.

Results: Fifteen participants (44%) failed to adequately clear the foot or walking device over obstacles in at least one condition (range 1–3 conditions). After adjusting for covariates, the chance of failure on obstacle crossing was greatly increased with the use of walking devices (odds ratio = 8.50; 95% CI = 0.85?75.03)

Conclusions: Gait safety in independent ambulatory participants with SCI remains threatened. Participants who walked with walking devices encountered a greater chance of failing to walk over obstacles as a result of inefficiently moving the foot or walking device over small obstacles. Thus, instead of training in an empty/ quiet room, rehabilitation procedures should incorporate contextual conditions that patients encounter at home and in the community in order to minimize risk of injury and prepare patients to be more independent after discharge.     

A Prediction Model for Determining Over Ground Walking Speed After Locomotor Training in Persons With Motor Incomplete Spinal Cord Injury

Background/Objective: To develop and test a clinically relevant model for predicting the recovery of over ground walking speed after 36 sessions of progressive body weight-supported treadmill training (BWSTT) in individuals with motor incomplete spinal cord injury (SCI).

Design: A retrospective review and stepwise regression analysis of a SCI clinical outcomes data set.

Setting: Outpatient SCI laboratory.

Subjects: Thirty individuals with a motor incomplete SCI who had participated in locomotor training with BWSTT. Eight individuals with similar diagnoses were used to prospectively test the prediction model.

Main Outcome Measures: Over ground walking speed was assessed using the 10-m walking test.

Methods: The locomotor training program consisted of 36 sessions of sequential comprehensive training comprised of robotic assisted BWSTT, followed by manual assisted BWSTT, and over ground walking. The dose of locomotor training was standardized throughout the protocol.

Results: Clinical characteristics with predictive value for walking speed were time from injury onset, the presence or absence of voluntary bowel and bladder voiding, a functional spasticity assessment, and over ground walking speed before locomotor training. The model identified that these characteristics accounted for 78.3% of the variability in the actual final over ground walking speed after 36 sessions of locomotor training. The model was successful in prospectively predicting over ground walking speed in the 8 test participants within 4.15 ± 2.22 cm/s in their recovered walking speed.

Conclusions: This prediction model can identify individuals who are most likely to experience success using locomotor training by determining an expected magnitude of training effect, thereby allowing individualized decisions regarding the use of this intensive approach to rehabilitation.     

The effects of robot assisted gait training on temporal-spatial characteristics of people with spinal cord injuries: A systematic review

Context: Robotic assisted gait training (RAGT) technology can be used as a rehabilitation tool or as an assistive device for spinal cord injured (SCI) individuals. Its impact on upright stepping characteristics of SCI individuals using treadmill or overground robotic exoskeleton systems has yet to be established.

Objective: To systematically review the literature and identify if overground or treadmill based RAGT use in SCI individuals elicited differences in temporal-spatial characteristics and functional outcome measures.

Methods: A systematic search of the literature investigating overground and treadmill RAGT in SCIs was undertaken excluding case-studies and case-series. Studies were included if the primary outcomes were temporal-spatial gait parameters. Study inclusion and methodological quality were assessed and determined independently by two reviewers. Methodological quality was assessed using a validated scoring system for randomized and non-randomized trials.

Results: Twelve studies met all inclusion criteria. Participant numbers ranged from 5-130 with injury levels from C2 to T12, American Spinal Injuries Association A-D. Three studies used overground RAGT systems and the remaining nine focused on treadmill based RAGT systems. Primary outcome measures were walking speed and walking distance. The use of treadmill or overground based RAGT did not result in an increase in walking speed beyond that of conventional gait training and no studies reviewed enabled a large enough improvement to facilitate community ambulation.

Conclusion: The use of RAGT in SCI individuals has the potential to benefit upright locomotion of SCI individuals. Its use should not replace other therapies but be incorporated into a multi-modality rehabilitation approach.     

Acute Effects Of Locomotor Training on Overground Walking Speed and H-Reflex Modulation in Individuals with Incomplete Spinal Cord Injury

Abstract

Objective: The purpose of this study was to assess the effect of a single bout of a locomotor-training paradigm on overground walking speed and H-reflex modulation of individuals with incomplete spinal cord injury (SCI).

Methods: Self-selected and maximum walking speeds and soleus H-reflexes (H/M ratios) during standing and stance and swing phases of walking (self-selected velocity) were obtained from 4 individuals with American Spinal Injury Association impairment classification D. Data were collected immediately before and after a single bout of locomotor training with body weight support on a treadmill. The pretraining H/M ratios of the SCI subjects were also compared with values from 4 able-bodied subjects who did not receive the intervention. Maximum H/M ratios while standing and during midstance and midswing phases of overground walking were considerably greater in the SCI subjects than in the control subjects.

Results: After the single bout of training, self-selected and maximum overground walking speeds of the subjects with SCI increased by 26% and 25%, respectively. Furthermore, H-reflexes were significantly more depressed in the SCI subjects during overground walking (28% less during stance, 34% less during swing).

Conclusions: Although preliminary, these findings indicate that a single bout of locomotor training produced immediate increases in walking velocity and acute neurophysiologic changes in individuals with incomplete SCI.     

Associations of Mode of Locomotion and Independence in Locomotion With Long-Term Outcomes After Spinal Cord Injury

Background/Objective: To explore the association of mode of locomotion (ambulation vs wheelchair use) and independence in locomotion (independent vs require assistance) with health, participation, and subjective well-being (SWB) after spinal cord injury (SCI).

Research Design: Secondary analysis was conducted on survey data collected from 2 rehabilitation hospitals in the Midwest and a specialty hospital in the southeastern United States. The 1,493 participants were a minimum of 18 years of age and had traumatic SCI of at least 1 year duration at enrollment.

Main Outcome Measures: Three sets of outcome measures were used: SWB, participation, and health. SWB was measured by 8 scales and a measure of depressive symptoms, participation by 3 items, health by general health ratings, days in poor health, hospitalizations, and treatments.

Results: Small but significant associations were observed between independence in locomotion and every outcome. Ambulation was associated with greater participation but a mixed pattern of favorable and unfavorable health and SWB outcomes. Supplemental analyses were conducted on those who ambulated but who were dependent on others to do so (n = 117), because this group reported poor outcomes in several areas. Individuals who were independent in wheelchair use reported substantially better outcomes than nonwheelchair users and those dependent on others in wheelchair use.

Conclusions: Although ambulation is often a recovery goal, individuals with SCI who ambulate do not uniformly report better outcomes than wheelchair users, and those who depend on others for assistance with ambulation may experience a unique set of problems.     

Outcome of Functional Electrical Stimulation in the Rehabilitation of a Child with C-5 Tetraplegia

Abstract

Hand function was provided for a six-year-old child with C-5 American Spinal Injuries Association (ASIA) classification-A tetraplegia through a percutaneous intramuscular (IM) functional electrical stimulation (FES) system. In conjunction with implantation of 10 percutaneous IM electrodes for provision of grasp and release of her right hand, reconstructive surgery was performed to provide upper extremity positioning to optimize hand use. The subject participated in FES training over a nine-week period for approximately five hours weekly, with an additional five hours each week dedicated to exercise and conditioning of her arm muscles.

Physical and functional assessments included range of motion (ROM), manual muscle testing (MMT), activities of daily living (ADL) abilities and the Canadian Occupational Performance Measure (COPM), used to evaluate the effect of stimulated hand function and surgical reconstruction on functional ability. These were conducted prior to FES and surgery and repeated after rehabilitation training.

With rehabilitation and training, the child was able to control her FES system. Physical assessments revealed increased strength of both shoulders and more useful range of arm movement. Functional assessments show that the FES system enabled her to perform age-appropriate ADL that previously were achievable only with physical assistance. Her overall level of independence in ADL ability increased, as (lit) self-rated levels of satisfaction and performance on chosen activities. Positive gains demonstrated here suggest the need for further studies of FES systems in young children with SCI. () Spin.il Cord Med 1999;22:107–113)     

Ability of walking without a walking device in patients with spinal cord injury as determined using data from functional tests

Abstract

Background/Objectives

More than half of independent ambulatory patients with spinal cord injury (SCI) need a walking device to promote levels of independence. However, long-lasting use of a walking device may introduce negative impacts for the patients. Using a standard objective test relating to the requirement of a walking device may offer a quantitative criterion to effectively monitor levels of independence of the patients. Therefore, this study investigated (1) ability of the three functional tests, including the five times sit-to-stand test (FTSST), timed up and go test (TUGT), and 10-meter walk test (10MWT) to determine the ability of walking without a walking device, and (2) the inter-tester reliability of the tests to assess functional ability in patients with SCI.

Methods

Sixty independent ambulatory patients with SCI, who walked with and without a walking device (30 subjects/group), were assessed cross-sectionally for their functional ability using the three tests. The first 20 subjects also participated in the inter-tester reliability test.

Results

The time required to complete the FTSST <14 seconds, the TUGT < 18 seconds, and the 10MWT < 6 seconds had good-to-excellent capability to determine the ability of walking without a walking device of subjects with SCI. These tests also showed excellent inter-tester reliability.

Conclusions

Methods of clinical evaluation for walking are likely performed using qualitative observation, which makes the results difficult to compare among testers and test intervals. Findings of this study offer a quantitative target criterion or a clear level of ability that patients with SCI could possibly walk without a walking device, which would benefit monitoring process for the patients.     

A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on walking competency

Background

Multi-channel surface functional electrical stimulation (FES) for walking has been used to improve voluntary walking and balance in individuals with spinal cord injury (SCI).

Objective

To investigate short- and long-term benefits of 16 weeks of thrice-weekly FES-assisted walking program, while ambulating on a body weight support treadmill and harness system, versus a non-FES exercise program, on improvements in gait and balance in individuals with chronic incomplete traumatic SCI, in a randomized controlled trial design.

Methods

Individuals with traumatic and chronic (≥18 months) motor incomplete SCI (level C2 to T12, American Spinal Cord Injury Association Impairment Scale C or D) were recruited from an outpatient SCI rehabilitation hospital, and randomized to FES-assisted walking therapy (intervention group) or aerobic and resistance training program (control group). Outcomes were assessed at baseline, and after 4, 6, and 12 months. Gait, balance, spasticity, and functional measures were collected.

Results

Spinal cord independence measure (SCIM) mobility sub-score improved over time in the intervention group compared with the control group (baseline/12 months: 17.27/21.33 vs. 19.09/17.36, respectively). On all other outcome measures the intervention and control groups had similar improvements. Irrespective of group allocation walking speed, endurance, and balance during ambulation all improved upon completion of therapy, and majority of participants retained these gains at long-term follow-ups.

Conclusions

Task-oriented training improves walking ability in individuals with incomplete SCI, even in the chronic stage. Further randomized controlled trials, involving a large number of participants are needed, to verify if FES-assisted treadmill training is superior to aerobic and strength training.     

Trunk Function and Ischial Pressure Offloading in Individuals with Spinal Cord Injury

Objective: To determine if there is a relationship between trunk function and offloading of the ischial tuberosities in individuals with Spinal Cord Injury (SCI).

Design: Prospective cross-sectional evaluation.

Setting: Sub-acute rehabilitation hospital.

Participants: Fifteen non-ambulatory participants with complete or incomplete traumatic and non-traumatic SCI, American Spinal Injury Association Impairment Scale (AIS), Classification A-D.

Outcome Measures: Isometric trunk strength using a hand held dynamometer, the ability to reach using the multidirectional reach test and offloading times of the ischial tuberosities using a customized pressure mat.

Results: Participants who were able to engage in the multidirectional reach test were defined as “Reachers”, whereas individuals who were unable to engage in the multidirectional reach test were defined as “Non-Reachers”. Trunk strength was significantly higher in Reachers compared with Non-Reachers (P < 0.05). Offloading times over the left and right ischial tuberosities were lower in Non-Reachers when compared with Reachers, however the results were statistically significant only for offloading over the right ischial tuberosity (P < 0.05). There was no correlation between trunk strength and pressure offloading times for both groups.

Conclusions: Regardless of an individual's ability to engage in a reaching task, participants with spinal cord injury spent more time offloading the left ischial tuberosity compared with the right ischial tuberosity. The study highlights the need to identify factors that may contribute to offloading behavior in individuals with spinal cord injury who lack sufficient trunk strength.     

Association between 25(OH)-vitamin D and testosterone levels: Evidence from men with chronic spinal cord injury

Objective: As an independent linear association between 25-hydroxyvitamin D (25(OH)D) and testosterone levels is controversial, this study aimed to explore this topic in men with chronic spinal cord injury (SCI), who exhibit a high prevalence of both androgen and vitamin D deficiency.

Design: Forty-nine men with chronic SCI consecutively admitted to a rehabilitation program underwent clinical/biochemical evaluations.

Results: Deficiency of 25(OH)D (<20?ng/mL) was found in 36 patients (73.5%). They exhibited significantly lower total testosterone and free testosterone levels, higher parathyroid hormone (PTH) and HOMA-IR, a poorer functional independence degree, and were engaged in poorer weekly leisure time physical activity (LTPA). Significant correlates of 25(OH)D levels were: total testosterone, free testosterone, PTH, functional independence degree and weekly LTPA. At the linear regression models, lower 25(OH)D levels were associated with both lower total and free testosterone after adjustment for age, smoking, alcohol consumption, comorbidities and HOMA-IR. However, after full adjustment, also including functional independence degree, BMI and LTPA, only the association of lower 25(OH)D with lower free testosterone was still significant.

Conclusion: In men with SCI, 25(OH)D correlates with total and free testosterone and exhibits an independent linear association with free testosterone. Regardless of this independent link, hypovitaminosis D and androgen deficiency are markers of poor health, sharing common risk factors to take into account in the rehabilitative approach to patients with SCI.     

Functional independence of persons with long-standing motor complete spinal cord injury in the Netherlands

Context/Objective: Since life expectancy of persons with spinal cord injury (SCI) has improved, it is relevant to know whether this group is able to maintain functional abilities many years after onset of SCI. Objectives of this study were (1) to examine associations between time since injury (TSI) and functional independence in persons with long-standing SCI and (2) to explore associations between functional independence and level of injury, comorbidities, mental health, waist circumference and secondary health conditions (SHCs).

Design: TSI-stratified cross-sectional study. Strata were 10–19, 20–29 and 30+ years.

Setting: Community.

Participants: 226 persons with long-standing SCI. Inclusion criteria: motor complete SCI; age at injury 18–35 years; TSI?≥?10 years; current age 28–65 years; wheelchair dependency.

Interventions: Not applicable.

Outcome measures: The Spinal Cord Independence Measure III (SCIM) was administered by a trained research assistant. Level of injury, comorbidities, mental health, waist circumference and SHCs were assessed by a rehabilitation physician.

Results: Mean TSI was 23.6 (SD 9.1) years. No significant differences in SCIM scores were found between TSI strata. SCIM scores were lower for persons with tetraplegia, autonomic dysreflexia, hypotension, more than four SHCs and a high waist circumference. In linear regression analyses, TSI nor age was associated with the SCIM total score. Only level of injury (β?=?–0.7; P?<?.001) and waist circumference (β?=?–0.1; P?=?.042) were independent determinants (explained variance 55%).

Conclusion: We found no association between TSI and functional independence in persons with long-standing motor complete SCI. This study confirms the possible effect of overweight on functional independence.     

Nerve transfer rehabilitation in tetraplegia: Comprehensive assessment and treatment program to improve upper extremity function before and after nerve transfer surgery,a case report

ContextA 28-year-old male, sustained a traumatic Spinal Cord Injury (SCI) in January 2015, and was classified as AIS A, neurological level of injury (NLI) C4. As an inpatient at the SCI rehabilitation unit, he underwent multidisciplinary assessment involving SCI specialists, peripheral nerve surgeons, psychologists, occupational and physical therapists. Team consensus determined he was a candidate for nerve transfer surgery to improve upper extremity function. The patient undertook a pre-surgical neurorehabilitation program of 3 months duration. Surgery was performed bilaterally at 11 and 13 months after SCI (right and left arm respectively).FindingsUpon completion of surgical procedures, the patient underwent an intensive post-surgical rehabilitation program based on established goals, with follow-up every 3 months, up to 24 months after the surgery. Notable improvements were wheelchair propulsion, the ability to relieve pressure, grasp, pinch, and release an object. Standardized measures for SCI individuals (SCIM-III, CUE-Q, LiSAT-9 and UEMS) showed significant improvements.Clinical RelevanceNerve transfers in tetraplegia are an underused technique. The benefits of surgery along with an intensive neurorehabilitation program, can improve independence and function in daily living activities for a properly selected group of individuals.     

Earthquakes and Rehabilitation Needs: Experiences From Bam,Iran

Abstract

Background: In December 2003, a devastating earthquake destroyed Bam and surrounding areas in Iran, leaving many people with residual deficits and disabilities, of which approximately 240 patients had spinal cord injury (SCI).

Methods: As an independent volunteer working in outpatient clinics, I visited the patients as part of a mobile team and set up a short educational course in spinal cord medicine.

Results: I visited 34 patients with SCI in the first 3 months. Eight months after the disaster, I visited 54 patients with SCI, 29 female (53.7%) and 25 male (46.3%). Postdisaster problems were identified, including need for accurate data collection, identification of patients' conditions, attention paid to psychosocial issues, ethical dilemmas, and research needs.

Conclusion: Disaster preparedness for earthquakes should include first aid and injury prevention, coordination of relief efforts, basic education and medical care, and short-and long-term rehabilitation needs. The major focus of rehabilitation medicine specialists' should be education of the general and professional population toward integrating the concept of rehabilitation.     

Problematic secondary health conditions among adults with spinal cord injury and its impact on social participation and daily life

Objective: This exploratory study describes the problematic secondary health conditions among adults with a spinal cord injury (SCI) and the impact these health concerns have on social participation and daily life.

Design: Cross-sectional survey design.

Setting: A community-based rehabilitation program within the United States.

Participants: Fifty-six adults (33 males and 23 females; age 18 to 73 [M?=?39.4, SD?=?12.7]) with SCI participating in the community-based rehabilitation program.

Methods: Subjects identified the top five problematic secondary health conditions related to his/her SCI, belief about the impact these conditions have on social participation and daily life, and if they believed the secondary health condition(s) were avoidable.

Results: The top problematic areas identified were bladder control, pain, bowel control, and pressure ulcers, and 73% felt these problems were unavoidable. In addition, more than 66% had each of these problems continuously during the last 12 months. When examining the impact of the problematic secondary health conditions, 75% identified that the primary problem had a significant impact on social participation and 64% identified it significantly impacted daily life.

Conclusion: Although the majority of the participants were actively participating in a community-based rehabilitation wellness program, it appears that they thought engagement in social participation and daily life were negatively impacted by the secondary health conditions and unavoidable. The results suggested unfulfilled goals despite the emphasized efforts of medical providers to help manage the secondary conditions. Future research should examine why individuals with SCI still have a difficult time managing secondary health conditions.