Rehabilitation interventions to modify endocrine-metabolic disease risk in individuals with chronic spinal cord injury living in the community (RIISC): A systematic search and review of prospective cohort and case–control studies

Context:Endocrine-metabolic disease (EMD) is associated with functional disability, social isolation, hospitalization and even death in individuals living with a chronic spinal cord injury (SCI). There is currently very low-quality evidence that rehabilitation interventions can reduce EMD risk during chronic SCI. Non-randomized trials and alternative study designs are excluded from traditional knowledge synthesis.Objective:To characterize evidence from level 3–4 studies evaluating rehabilitation interventions for their effectiveness to improve EMD risk in community-dwelling adults with chronic SCI.Methods:Systematic searches of MEDLINE PubMed, EMBASE Ovid, CINAHL, Cochrane Database of Systematic Reviews, and PsychInfo were completed. All longitudinal trials, prospective cohort, case–control studies, and case series evaluating the effectiveness of rehabilitation/therapeutic interventions to modify/associate with EMD outcomes in adults with chronic SCI were eligible. Two authors independently selected studies and abstracted data. Mean changes from baseline were reported for EMD outcomes. The Downs and Black Checklist was used to rate evidence quality.Results:Of 489 articles identified, 44 articles (N = 842) were eligible for inclusion. Individual studies reported statistically significant effects of electrical stimulation-assisted training on lower-extremity bone outcomes, and the combined effects of exercise and dietary interventions to improve body composition and cardiometabolic biomarkers (lipid profiles, glucose regulation). In contrast, there were also reports of no clinically important changes in EMD outcomes, suggesting lower quality evidence (study bias, inconsistent findings).Conclusion:Longitudinal multicentre pragmatic studies involving longer-term exercise and dietary intervention and follow-up periods are needed to fully understand the impact of these rehabilitation approaches to mitigate EMD risk. Our broad evaluation of prospective cohort and case–control studies provides new perspectives on alternative study designs, a multi-impairment paradigm approach of studying EMD outcomes, and knowledge gaps related to SCI rehabilitation.     

Physical therapy after spinal cord injury: A systematic review of treatments focused on participation

Abstract

Context

Over the last four decades, the focus of spinal cord injury (SCI) rehabilitation has shifted from medical management to issues that affect quality of life and community participation. Physical therapists (PTs) need to design and implement interventions that result in maximal participation to provide an individual with SCI an effective rehabilitation program.

Objective

The aim of this review is to assess the extent, content, and outcomes of physical therapy (PT) interventions focused on improving the participation of individuals with SCI.

Methods

A search was conducted in Medline, Embase, CENTRAL, CINAHL, PEDro, and PsycINFO. We included studies, of all designs, focused on improving the participation of individuals with SCI using PT interventions.The primary author and a reviewer independently selected articles for inclusion, assessed articles quality, and extracted the data.

Results

Five studies met the inclusion criteria. The interventions applied were 9- and 12-month body weight-supported treadmill training in two studies, a supervised 9-month exercise program, a 12-week home exercise program, and a 10-week multidisciplinary cognitive behavioral program for coping with chronic neuropathic pain. Four of five PT interventions positively impacted the individual's perceived participation and satisfaction with participation.

Conclusion

The body of research by PTs on interventions to improve participation is limited. PTs must document the effects of interventions with a valid outcome tool to enable more research that examines participation. Expanding participation research will allow PTs to meet the needs of individuals with SCI and identify what interventions best facilitate integration into the community.     

Physiotherapy Secretion Removal Techniques in People With Spinal Cord Injury: A Systematic Review

Abstract

Objective: To address whether secretion removal techniques increase airway clearance in people with chronic spinal cord injury (SCI).

Data Sources and Study Selection: MEDLINE/PubMed, CINAHL, EMBASE, and PsyclNFO were searched from inception to May 2009 for population keywords (spinal cord injury, paraplegia, tetraplegia, quadriplegia) paired with secretion removal-related interventions and outcomes. Inclusion criteria for articles were a research study, irrespective of design, that examined secretion removal in people with chronic SCI published in English.

Review Methods: Two reviewers determined whether articles met the inclusion criteria, abstracted information, and performed a quality assessment using PEDro or Downs and Black criteria. Studies were then given a level of evidence based on a modified Sackett scale.

Results: Of 2,416 abstracts and titles retrieved, 24 met the inclusion criteria. Subjects were young (mean, 31 years) and 84% were male. Most evidence was level 4 or 5 and only 2 studies were randomized controlled trials. Three reports described outcomes for secretion removal techniques in addition to cough, whereas most articles examined the immediate effects of various components of cough. Studies examining insufflation combined with manual assisted cough provided the most consistent, high-level evidence. Compelling recent evidence supports the use of respiratory muscle training or electrical stimulation of the expiratory muscles to facilitate airway clearance in people with SCI.

Conclusion: Evidence supporting the use of secretion removal techniques in SCI, while positive, is limited and mostly of low level. Treatments that increase respiratory muscle force show promise as effective airway clearance techniques.     

Self-management of pain and depression in adults with spinal cord injury: A scoping review

Context: Pain and depression are two prevalent secondary complications associated with spinal cord injury (SCI) that negatively impact health and well-being. Self-management strategies are growing in popularity for helping people with SCI to cope with their pain and depression. However, there is still a lack of research on which approaches are best suited for this population.

Objective: The aim of this scoping review was to determine what is known about the self-management of pain and depression through the use of pharmacological and non-pharmacological therapies in adults with SCI.

Methods: Seven electronic databases were searched for articles published between January 1, 1990 and June 13, 2017. Grey literature was searched and additional articles were identified by manually searching the reference lists of included articles.

Results: Overall, forty-two articles met the inclusion criteria; with the majority reporting on the self-management of pain, rather than on depression or on both complications. Non-pharmacological interventions were more likely to include self-management strategies than pharmacological interventions. A limited number of studies included all of the core self-management tasks and skills.

Conclusions: There are significant knowledge gaps on effective self-management interventions for pain and depression post-SCI. There is a need to develop interventions that are multi-faceted, which include both pharmacological and non-pharmacological therapies to address multimorbidity.     

Systematic review of melatonin levels in individuals with complete cervical spinal cord injury

Context: Pineal melatonin production is mediated by afferent signaling pathways that navigate through the cervicothoracic spinal cord. Melatonin profiles in individuals with complete cervical spinal cord injury (SCI) have not been systematically reviewed despite this proposed pathway.

Objectives: The primary objective was to understand melatonin profiles in individuals with complete cervical SCI, as compared to healthy controls and those with thoracolumbar and incomplete cervical SCI. Secondary objectives were to understand the impact of injury chronicity and melatonin supplementation on melatonin values in adults with complete cervical SCI.

Methods: This review (PROSPERO ID: CRD42017073767) searched several databases and gray literature sources from January 1978 to August 2017. Studies were eligible if they evaluated melatonin levels (blood, saliva or urinary metabolite measurements) in adults with complete cervical SCI. 390 studies were screened and 12 studies met final selection criteria. Given the heterogeneity in study designs, a narrative analysis was performed.

Results: There is evidence that adults with complete cervical SCI have absent diurnal melatonin rhythms as compared to healthy controls and individuals with thoracolumbar SCI below T3. There is limited evidence comparing levels in individuals with incomplete tetraplegia. There is insufficient evidence describing profiles immediately (<2 weeks) after cervical SCI. Based on a limited number of studies, melatonin supplementation does not appear to improve sleep outcomes in adults with long-standing complete cervical SCI.

Conclusions: Future research should explore melatonin levels acutely after cervical SCI and the impact of supplementation on non-sleep outcomes.     

The Health Economics of the spinal cord injury or disease among veterans of war: A systematic review

Context: Information on health-care utilization and the economic burden of disease are essential to understanding service demands, service accessibility, and practice patterns. This information may also be used to enhance the quality of care through altered resource allocation. Thus, a systematic review of literature on the economic impact of caring for SCI/D veterans would be of great value.

Objective: To systematically review and critically appraise the literature on the economics of the management of veterans with SCI/D.

Methods: Medline, EMBASE and PsycINFO databases were searched for articles on economic impact of management of SCI/D veterans, published from 1946 to September/2016. The STROBE statement was used to determine publication quality.

Results: The search identified 1,573 publications of which 13 articles fulfilled the inclusion/exclusion criteria with 12 articles focused on costs of management of SCI/D veterans; and, one cost-effectiveness analysis. Overall, the health care costs for the management of SCI/D veterans are substantial ($30,770 to $62,563 in 2016 USD per year) and, generally, greater than the costs of caring for patients with other chronic diseases. The most significant determinants of the higher total health-care costs are cervical level injury, complete injury, time period (i.e. first year post-injury and end-of-life year), and presence of pressure ulcers.

Conclusions: There is growing evidence for the economic burden of SCI/D and its determinants among veterans, whereas there is a paucity of comparative studies on interventions including cost-effectiveness analyses. Further investigations are needed to fulfill significant knowledge gaps on the economics of caring for veterans with SCI/D.     

Clinical Taxonomy Development and Application in Spinal Cord Injury Research: The SCIRehab Project

Background/Objective: Applying practice-based evidence research methodology to spinal cord injury (SCI) rehabilitation requires taxonomy (typology or classification) of rehabilitation interventions provided by every discipline contributing to SCI rehabilitation. The rehabilitation field currently lacks such taxonomy. Methods: SCIRehab project researchers and clinicians representing 7 rehabilitation disciplines from 6 US inpatient SCI rehabilitation facilities worked in discipline groups during 2 face-to-face meetings and weekly discipline-specific teleconferences for 9 months to identify key contributions of each discipline to SCI rehabilitation and to develop a classification of treatment interventions used by each discipline. These clinician groups were charged with designing documentation systems that collected enough details to describe treatment adequately while not imposing an unrealistic data collection burden on clinicians. Completed documentation systems were programmed onto handheld personal digital assistants (PDAs) to facilitate data entry by clinicians at the point of care.

Results: Seven discipline-specific SCI rehabilitation taxonomies were developed that describe and quantify intervention activities (major categories of treatment offered by the discipline) and the activity-specific details (variables deemed important to fully describe the interventional process). Much treatment information is unique to each discipline; some is common across disciplines.

Conclusions: The taxonomies provide a format with which clinicians document actual interventions performed with or for patients. The SCIRehab project has developed the first comprehensive multidisci-plinary taxonomy for describing the details of the SCI rehabilitation process and designed a PDA-based documentation system based on that taxonomy that allows clinicians to describe the specifics of their interactions with their patients.     

Rehabilitation of the multiple injured patient with spinal cord injury: A systematic review of the literature

IntroductionPatients with multiple injuries including spinal cord injury (SCI) have low survivability. Little is known for the effect of SCI in their rehabilitation process.PurposeTo define differences in characteristics and outcomes during the rehabilitation of multiple injured patients with SCI compared to other polytrauma patients.Materials and methodsElectronic libraries provided 425 relevant articles. Applying the criteria, 6 articles were eligible for inclusion in this review.ResultsThe extracted data show that multiple injured patients with SCI have an increased length of stay (LOS) in rehabilitation. Initial functional levels, as also one- and two-years follow-up are also decreased. Similar results were found comparing SCI patients with or without multiple injuries: SCI patients with multiple injuries have an increased LOS and decreased functional levels compared with SCI patients. Finally, there was nota relevance between the circumstances of the injuries, like acts of terror, and the expected rehabilitation outcome.ConclusionDue to the rarity of eligible articles and the lack of homogenous accessing tools, a meta-analysis was not possible. There is a lack of a universal evaluation strategy or tool, for the severity of the multiple injured patients aiming at the rehabilitation outcome prognosis. Multiple-injured patients with SCI have longer rehabilitation LOS and functional outcomes compared to other polytrauma patients.Prospective studies are needed for evaluation of the differences according to the severity and the complexity of the injuries and the rehabilitation outcome depending on different rehabilitation methods and strategies.     

SCIRehab Project Series: The Speech Language Pathology Taxonomy

Introduction: Outcomes research for speech language pathology (SLP) interventions for acute traumatic spinal cord injury (SCI) rehabilitation in the US is difficult because of the lack of a treatment classification system (taxonomy).

Objective: To describe a taxonomy developed by speech language pathologists (SLPs) to examine the effects of SLP interventions on SCI rehabilitation outcomes.

Methods: The SCIRehab study uses practice-based evidence, a rigorous observational methodology that examines treatment processes without specifying or requiring specific therapeutic interventions. Speech language pathology lead clinicians and researchers at 6 US SCI centers developed a detailed SLP taxonomy documentation process that is comprehensive of SLP interventions for patients with SCI.

Results: The SLP taxonomy consists of 7 intervention categories that address deficits (speech production for patients with artificial airway, motor speech and voice, swallowing, cognitive-communication, and communication) and the associated exercises and tasks that patients perform. Time is recorded for each category, and supplementary information focuses on cueing needs and family involvement that helps to describe and guide intervention selection. The SCIRehab project is enrolling 1,500 patients with acute traumatic SCI at 6 inpatient rehabilitation facilities.

Conclusions: Speech language pathology taxonomy information is being captured for the SCIRehab patients who are referred for SLP services; this may be the first attempt to document the many details of the SLP rehabilitation process for patients with SCI in the US.     

Engaging in the prevention of pressure injuries in spinal cord injury: A qualitative study of community-dwelling individuals’ different styles of prevention in Switzerland

Context: Spinal cord injury (SCI) is a complex chronic condition with multiple self-management requirements and a high prevalence of complications. Pressure injuries (PIs) are among the most common ones and represent a frequent reason for re-hospitalization. This study aimed to identify styles of prevention that individuals with SCI adopt to deal with the risk of developing PIs.

Design: Qualitative explorative interview study. Data was collected through semi-structured interviews, which were transcribed verbatim and analyzed following the principles of thematic analysis.

Setting: Switzerland.

Participants: The participants were a purposive sample of community-dwelling Swiss residents with SCI for at least five years.

Interventions: Not applicable.

Outcome measures: Not applicable.

Results: Although all participants (N?=?20) showed at least a basic knowledge of prevention of PIs by describing some preventive measures, they had different prevention styles characterized by different behavioral patterns (i.e. complying with all recommended measures, performing only a selection of them or delegating them to others) and different beliefs and attitudes towards prevention.

Conclusion: By identifying the style of prevention of an individual, it is possible to develop tailored interventions that have an impact on the factors which seem to play a role in determining the adoption of preventive behaviors (i.e. perceived susceptibility to PIs, attitudes towards prevention, and self-efficacy). Such interventions would constitute a concrete effort to support individuals with SCI during their self-management. Besides alleviating a frequent and disabling medical complication and contributing to an enhanced quality of life, these interventions might also help decrease healthcare costs.     

SCIRehab Project Series: The Psychology Taxonomy

Context: The integration of psychologists as members of the rehabilitation team has occurred in conjunction with the evolution and adoption of interdisciplinary teams as the standard of care in spinal cord injury (SCI) rehabilitation. Although the value of psychological services during rehabilitation is endorsed widely, specific interventions and their association with patient outcomes have not been examined adequately.

Objective: To address this shortcoming, psychologists from 6 SCI centers collaborated to develop a psychology intervention taxonomy and documentation framework.

Methods: Utilizing an interactive process, the lead psychologists from 6 centers compiled an inclusive list of patient characteristics assessed and interventions delivered in routine psychological practice at the participating rehabilitation facilities. These were systematically grouped, defined, and compared.

Results: The resulting taxonomy became the basis of a documentation framework utilized by psychologists for the study. The psychology taxonomy includes 4 major clinical categories (assessment, psychotherapeutic interventions, psychoeducational interventions, and consultation) with 5 to 10 specific activities in each category.

Conclusions: Examination of psychological interventions and their potential association with positive outcomes for persons who sustain SCI requires the development of a taxonomy. Results of these efforts illustrate similarities and differences in psychological practice among SCI centers and offer the opportunity to blend research and clinical practice in an innovative approach to evidence-based practice improvement. The established taxonomy provides a basic framework for future studies on the effect of psychological interventions.     

A systematic review of the effectiveness of task-specific rehabilitation interventions for improving independent sitting and standing function in spinal cord injury

Context: Impaired balance function after a spinal cord injury (SCI) hinders performance of daily activities.

Objective: To assess the evidence on the effectiveness of task-specific training on sitting and standing function in individuals with SCI across the continuum of care.

Methods: A systematic search was conducted on literature published to June 2016 using people (acute or chronic SCI), task-specific interventions compared to conventional physical therapy, and outcome (sitting or standing balance function). The PEDro scale was used to investigate the susceptibility to bias and trial quality of the randomized controlled trials (RCTs). A standardized mean difference (SMD) was conducted to investigate the effect size for interventions with sitting or standing balance outcomes.

Results: Nineteen articles were identified; three RCTs, two prospective controlled trials, one cross-over study, nine pre-post studies and four prospective cohort studies. RCT and cross-over studies were rated from 6 to 8 indicating good quality on the PEDro scale. The SMD of task-specific interventions in sitting compared to active and inactive (no training) control groups was –0.09 (95% CI: –0.663 to 0.488) and 0.39 (95% CI: –0.165 to 0.937) respectively, indicating that the addition of task-specific exercises did not affect sit and reach test performance significantly. Similarly, the addition of BWS training did not significantly affect BBS compared to conventional physical therapy –0.36 (95% CI: –0.840 to 0.113). Task-specific interventions reported in uncontrolled trials revealed positive effects on sitting and standing balance function.

Conclusion: Few RCT studies provided balance outcomes, and those that were evaluated indicate negligible effect sizes. Given the importance of balance control underpinning all aspects of daily activities, there is a need for further research to evaluate specific features of training interventions to improve both sitting and standing balance function in SCI.