American Spinal Injury Association A (sensory and motor complete) is not different from American Spinal Injury Association B (sensory incomplete,motor complete) in gunshot-related spinal cord injury

Background Context

We receive a large number of patients with spinal cord injury (SCI) due to penetrating gunshot wounds (GSW) at our national rehabilitation center. Although many patients are labeled American Spinal Injury Association (ASIA) B sensory incomplete because of sensory sparing, especially deep anal pressure, with purported prognostic value, we have not observed a clinical difference from patients labeled ASIA A complete. We hypothesized that sensory sparing, if meaningful, should reduce the occurrence of pressure ulcers.

A systematic review of electrical stimulation for pressure ulcer prevention and treatment in people with spinal cord injuries

Context

Electrical stimulation (ES) can confer benefit to pressure ulcer (PU) prevention and treatment in spinal cord injuries (SCIs). However, clinical guidelines regarding the use of ES for PU management in SCI remain limited.

Objectives

To critically appraise and synthesize the research evidence on ES for PU prevention and treatment in SCI.

Method

Review was limited to peer-reviewed studies published in English from 1970 to July 2013. Studies included randomized controlled trials (RCTs), non-RCTs, prospective cohort studies, case series, case control, and case report studies. Target population included adults with SCI. Interventions of any type of ES were accepted. Any outcome measuring effectiveness of PU prevention and treatment was included. Methodological quality was evaluated using established instruments.

Results

Twenty-seven studies were included, 9 of 27 studies were RCTs. Six RCTs were therapeutic trials. ES enhanced PU healing in all 11 therapeutic studies. Two types of ES modalities were identified in therapeutic studies (surface electrodes, anal probe), four types of modalities in preventive studies (surface electrodes, ES shorts, sacral anterior nerve root implant, neuromuscular ES implant).

Conclusion

The methodological quality of the studies was poor, in particular for prevention studies. A significant effect of ES on enhancement of PU healing is shown in limited Grade I evidence. The great variability in ES parameters, stimulating locations, and outcome measure leads to an inability to advocate any one standard approach for PU therapy or prevention. Future research is suggested to improve the design of ES devices, standardize ES parameters, and conduct more rigorous trials.     

Comprehensive management of pressure ulcers in spinal cord injury: Current concepts and future trends

Abstract

Pressure ulcers in spinal cord injury represent a challenging problem for patients, their caregivers, and their physicians. They often lead to recurrent hospitalizations, multiple surgeries, and potentially devastating complications. They present a significant cost to the healthcare system, they require a multidisciplinary team approach to manage well, and outcomes directly depend on patients' education, prevention, and compliance with conservative and surgical protocols. With so many factors involved in the successful treatment of pressure ulcers, an update on their comprehensive management in spinal cord injury is warranted. Current concepts of local wound care, surgical options, as well as future trends from the latest wound healing research are reviewed to aid medical professionals in treating patients with this difficult problem.     

Intermittent fasting in mice does not improve hindlimb motor performance after spinal cord injury

Previously, we reported that every-other-day-fasting (EODF) in Sprague-Dawley rats initiated after cervical spinal cord injury (SCI) effectively promoted functional recovery, reduced lesion size, and enhanced sprouting of the corticospinal tract. More recently, we also showed improved behavioral recovery with EODF after a moderate thoracic contusion injury in rats. In order to make use of transgenic mouse models to study molecular mechanisms of EODF, we tested here whether this intermittent fasting regimen was also beneficial in mice after SCI. Starting after SCI, C57BL/6 mice were fed a standard rodent chow diet either with unrestricted access or feeding every other day. Over a 14-week post-injury period, we assessed hindlimb locomotor function with the Basso Mouse Scale (BMS) open-field test and horizontal ladder, and the spinal cords were evaluated histologically to measure white and grey matter sparing. EODF resulted in an overall caloric restriction of 20% compared to animals fed ad libitum (AL). The EODF-treated animals exhibited a ～ 14% reduction in body weight compared to AL mice, and never recovered to their pre-operative body weight. In contrast to rats on an intermittent fasting regimen, mice exhibited no increase in blood ketone bodies by the end of the second, third, and fourth day of fasting. EODF had no beneficial effect on tissue sparing and failed to improve behavioral recovery of hindlimb function. Hence this observation stands in stark contrast to our earlier observations in Sprague-Dawley rats. This is likely due to the difference in the metabolic response to intermittent fasting as evidenced by different ketone levels during the first week of the EODF regimen.     

Prevalence of upper motor neuron vs lower motor neuron lesions in complete lower thoracic and lumbar spinal cord injuries

OBJECTIVE: To determine the incidence and etiology of lower motor neuron (LMN) vs upper motor neuron (UMN) lesions in patients with complete thoracic and lumbar spinal cord injuries (SCI). DESIGN: Retrospective chart review. SETTING: A regional Model Spinal Cord Injury System center. METHODS: A consecutive sample of medical records of patients with lower thoracic and upper lumbar (T7-L3) complete SCI admitted from 1979 through 1996 was systematically reviewed. Of the 306 patients evaluated, 156 subjects met inclusion criteria. The incidence and etiology of LMN vs UMN lesions were determined for the following neurologic levels: T7-T9, T10-T12, L1-L3. Lesions were classified as LMN, UMN, or mixed on the basis of the presence or absence of (1) the bulbocavernosus reflex, (2) lower limb deep tendon reflexes below the neurologic level of injury, and (3) the Babinski sign. RESULTS: The incidences of LMN, UMN, and mixed lesions in the T7-T9, T10-T12, and L1-L3 groups were as follows: T7-T9 group (7.3% LMN, 85.5% UMN, 7.3% mixed), T10-T12 group (57% LMN, 17.7% UMN, 25.3% mixed),L1-L3 group (95.5% LMN, 0.0% UMN, 4.5% mixed). Etiology of injury did not significantly influence the likelihood of a LMN lesion. CONCLUSIONS: One cannot determine the type of lesion (UMN vs LMN) on the basis of the neurological level of injury. A detailed clinical examination, including sacral reflexes, is required. This has important prognostic and therapeutic implications for bowel, bladder, and sexual function, as well as mobility. Distinguishing UMN lesions from LMN lesions is also essential for evaluating new interventions in clinical trials for UMN pathology.     

Pressure changes in spinal canal and evaluation of spinal cord injuries in spinal section subjected to impact

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The average cost of pressure ulcer management in a community dwelling spinal cord injury population

Pressure ulcers (PUs) are a common secondary complication experienced by community dwelling individuals with spinal cord injury (SCI). There is a paucity of literature on the health economic impact of PU in SCI population from a societal perspective. The objective of this study was to determine the resource use and costs in 2010 Canadian dollars of a community dwelling SCI individual experiencing a PU from a societal perspective. A non‐comparative cost analysis was conducted on a cohort of community dwelling SCI individuals from Ontario, Canada. Medical resource use was recorded over the study period. Unit costs associated with these resources were collected from publicly available sources and published literature. Average monthly cost was calculated based on 7‐month follow‐up. Costs were stratified by age, PU history, severity level, location of SCI, duration of current PU and PU surface area. Sensitivity analyses were also carried out. Among the 12 study participants, total average monthly cost per community dwelling SCI individual with a PU was $4745. Hospital admission costs represented the greatest percentage of the total cost (62%). Sensitivity analysis showed that the total average monthly costs were most sensitive to variations in hospitalisation costs.     

Pressure ulcers and acute risk factors in individuals with traumatic spinal fractures with or without spinal cord injuries: A prospective analysis of the National Spinal Column/Cord Injury Registry of Iran (NSCIR-IR) data

PurposeTo identify risk factors for developing pressure ulcers (PUs) in the acute care period of traumatic spinal fracture patients with or without spinal cord injuries (SCIs).MethodsData were collected prospectively in participating the National Spinal column/Cord Injury Registry of Iran (NSCIR-IR) from individuals with traumatic spinal fractures with or without SCIs, inclusive of the hospital stay from admission to discharge. Trained nursing staff examined the patients for the presence of PUs every 8 h during their hospital stay. The presence and grade of PUs were assessed according to the European Pressure Ulcer Advisory Panel classification. In addition to PU, following data were also extracted from the NSCIR-IR datasets during the period of 2015 – 2021: age, sex, Glasgow coma scale score at admission, having SCIs, marital status, surgery for a spinal fracture, American Spinal Injury Association impairment scale (AIS), urinary incontinence, level of education, admitted center, length of stay in the intensive care unit (ICU), hypertension, respiratory diseases, consumption of cigarettes, diabetes mellitus and length of stay in the hospital. Logistic regression models were used to estimate the unadjusted and adjusted odds ratio (OR) with 95% confidence intervals (CI).ResultsAltogether 2785 participants with traumatic spinal fractures were included. Among them, 87 (3.1%) developed PU during their hospital stay and 392 (14.1%) had SCIs. In the SCI population, 63 (16.1%) developed PU during hospital stay. Univariate logistic regression for the whole sample showed that marital status, having SCIs, urinary incontinence, level of education, treating center, number of days in the ICU, age, and Glasgow coma scale score were significant predictors for PUs. However, further analysis by multiple logistic regression only revealed the significant risk factors to be the treating center, marital status, having SCIs, and the number of days in the ICU. For the subgroup of individuals with SCIs, marital status, AIS, urinary incontinence, level of education, the treating center, the number of days in the ICU and the number of days in the hospital were significant predictors for PUs by univariate analysis. After adjustment in the multivariate model, the treating center, marital status (singles vs. marrieds, OR = 3.06, 95% CI: 1.55 – 6.03, p = 0.001), and number of days in the ICU (OR = 1.06, 95% CI: 1.04 – 1.09, p < 0.001) maintained significance.ConclusionsThese data confirm that individuals with traumatic spinal fractures and SCIs, especially single young patients who suffer from urinary incontinence, grades A-D by AIS, prolonged ICU stay, and more extended hospitalization are at increased risk for PUs; as a result strategies to minimize PU development need further refinement.     

A pilot study evaluating protein abundance in pressure ulcer fluid from people with and without spinal cord injury

Abstract

Objective

To determine whether the biochemistry of chronic pressure ulcers differs between patients with and without chronic spinal cord injury (SCI) through measurement and comparison of the concentration of wound fluid inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases.

Design

Survey.

Setting

Tertiary spinal cord rehabilitation center and skilled nursing facilities.

Participants

Twenty-nine subjects with SCI and nine subjects without SCI (>18 years) with at least one chronic pressure ulcer Stage II, III, or IV were enrolled.

Outcome measures

Total protein and 22 target analyte concentrations including inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases were quantified in the wound fluid and blood serum samples. Blood samples were tested for complete blood count, albumin, hemoglobin A1c, total iron binding capacity, iron, percent (%) saturation, C-reactive protein, and erythrocyte sedimentation rate.

Results

Wound fluid concentrations were significantly different between subjects with SCI and subjects without SCI for total protein concentration and nine analytes, MMP-9, S100A12, S100A8, S100A9, FGF2, IL-1b, TIMP-1, TIMP-2, and TGF-b1. Subjects without SCI had higher values for all significantly different analytes measured in wound fluid except FGF2, TGF-b1, and wound fluid total protein. Subject-matched circulating levels of analytes and the standardized local concentration of the same proteins in the wound fluid were weakly or not correlated.

Conclusions

The biochemical profile of chronic pressure ulcers is different between SCI and non-SCI populations. These differences should be considered when selecting treatment options. Systemic blood serum properties may not represent the local wound environment.     

A pilot study evaluating protein abundance in pressure ulcer fluid from people with and without spinal cord injury

Objective

To determine whether the biochemistry of chronic pressure ulcers differs between patients with and without chronic spinal cord injury (SCI) through measurement and comparison of the concentration of wound fluid inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases.

Design

Survey.

Setting

Tertiary spinal cord rehabilitation center and skilled nursing facilities.

Participants

Twenty-nine subjects with SCI and nine subjects without SCI (>18 years) with at least one chronic pressure ulcer Stage II, III, or IV were enrolled.

Outcome measures

Total protein and 22 target analyte concentrations including inflammatory mediators, growth factors, cytokines, acute phase proteins, and proteases were quantified in the wound fluid and blood serum samples. Blood samples were tested for complete blood count, albumin, hemoglobin A1c, total iron binding capacity, iron, percent (%) saturation, C-reactive protein, and erythrocyte sedimentation rate.

Results

Wound fluid concentrations were significantly different between subjects with SCI and subjects without SCI for total protein concentration and nine analytes, MMP-9, S100A12, S100A8, S100A9, FGF2, IL-1b, TIMP-1, TIMP-2, and TGF-b1. Subjects without SCI had higher values for all significantly different analytes measured in wound fluid except FGF2, TGF-b1, and wound fluid total protein. Subject-matched circulating levels of analytes and the standardized local concentration of the same proteins in the wound fluid were weakly or not correlated.

Conclusions

The biochemical profile of chronic pressure ulcers is different between SCI and non-SCI populations. These differences should be considered when selecting treatment options. Systemic blood serum properties may not represent the local wound environment.     

Anatomical changes in human motor cortex and motor pathways following complete thoracic spinal cord injury

A debilitating consequence of complete spinal cord injury (SCI)is the loss of motor control. Although the goal of most SCItreatments is to re-establish neural connections, a potentialcomplication in restoring motor function is that SCI may resultin anatomical and functional changes in brain areas controllingmotor output. Some animal investigations show cell death inthe primary motor cortex following SCI, but similar anatomicalchanges in humans are not yet established. The aim of this investigationwas to use voxel-based morphometry (VBM) and diffusion tensorimaging (DTI) to determine if SCI in humans results in anatomicalchanges within motor cortices and descending motor pathways.Using VBM, we found significantly lower gray matter volume incomplete SCI subjects compared with controls in the primarymotor cortex, the medial prefrontal, and adjacent anterior cingulatecortices. DTI analysis revealed structural abnormalities inthe same areas with reduced gray matter volume and in the superiorcerebellar cortex. In addition, tractography revealed structuralabnormalities in the corticospinal and corticopontine tractsof the SCI subjects. In conclusion, human subjects with completeSCI show structural changes in cortical motor regions and descendingmotor tracts, and these brain anatomical changes may limit motorrecovery following SCI.     

Biomarkers for recurrent pressure injury risk in persons with spinal cord injury

Objective: To investigate potential linkages between pressure injury (PrI) recurrence following spinal cord injury (SCI) and muscle-based and circulatory biomarkers, specifically fatty metabolites and inflammatory cytokines.

Design: Observational study.

Setting: Tertiary Care Center.

Participants: 30 individuals with complete or incomplete SCI. Study participants either had never developed a PrI (Group I) or had a history of recurrent PrI (Group II).

Interventions: Not applicable.

Outcome Measures: Gluteal muscle histology, immunohistochemistry, muscle-based and circulatory fatty metabolites and inflammatory cytokines.

Results: Gluteal intramuscular adipose tissue (IMAT) was greater than 15% in most Group II (83%) individuals. Muscle tissue histology confirmed intramuscular structural differences. Fatty acid binding protein 4 (FABP4) and fatty acid binding protein 3 (FABP3) were reliably detected in muscle and blood and significantly correlated with IMAT (P?<?0.001). FABP4 was significantly higher in Group II muscle and blood (P?<?0.05). FABP3 was significantly higher in Group I muscle (P?<?0.05). Circulatory FABP3 levels were lower for Group I. Inflammatory biomarkers were more reliably detected in blood. Colony-Stimulating Factor-1 was slightly higher in Group II muscle. Circulatory interleukin-13 was significantly higher (P?<?0.01) in Group I. Vascular endothelial growth factor (VEGF-A) was significantly increased (P?<?0.05) in Group I muscle and blood.

Conclusion: Identifying individuals with SCI at highest risk for recurrent PrI may impact patient management. IMAT content evaluation illustrates that muscle quality is a key biomarker. Low circulatory inflammatory biomarker expression potentially limits clinical significance for between group differences. Circulatory levels of FABP4 hold great potential as a recurrent PrI risk biomarker.     

冲击载荷造成椎管内压力变化与脊髓损伤程度的评估

目的 观察脊柱遭受轴向撞击时椎管内的压力变化,从撞击－压力变化－脊髓损伤的角度分析脊柱骨折类型与脊髓损伤程度间的关系,为脊髓损伤程度的早期评估提供实验依据。方法 应用ＢＩＭ－Ｉ型立式生物撞击机高速准静态轴向加载和应力遮挡技术建立脊椎爆裂型骨折模型,观察８具新鲜尸体的脊柱标本Ｔ１０￣Ｌ４节段受垂直撞击瞬间椎管内的压力变化,将大体解剖观察与放射影像学技术相结合,记录脊柱骨折类型及脊柱损伤程度。结果 发     

大腿剔骨皮瓣修复脊髓损伤患者髋关节周围难治性压疮

目的:探讨修复脊髓损伤患者髋关节周围危及生命难治性压疮的方法和疗效。方法:2012年3月至2015年6月,采用高位股骨截骨或髋离断形成血供丰富的大腿剔骨肌皮瓣修复8例脊髓损伤患者髋关节周围危及生命的难治性压疮。其中男7例,女1例;年龄35~68岁,平均(52.0±2.6)岁。病程10个月~7年,平均(2.9±0.2)年。所有患者为包括2个部位以上的复杂压疮,除1例未引起髋关节感染外,其余7例压疮均合并同侧髋关节内感染。单个压疮表面面积最小3 cm×3 cm,最大12 cm×15 cm。术后观察感染控制,创面愈合,营养状况改善和生活质量提高情况。结果:8例患者均获得随访,随访时间3个月~2年,平均1.3年。所有患者皮瓣成活,其中5例创面Ⅰ期愈合,2例皮瓣愈合不良,经扩创缝合后Ⅱ期愈合。1例远段小块皮瓣坏死,经换药愈合。术中尿道损伤1例,经尿道修补痊愈。所有创面得到有效覆盖,局部感染控制,营养情况及生活质量较术前明显改善,随访期间,无创面感染及皮瓣覆盖部位压疮复发病例。结论:大腿剔骨肌皮瓣能有效修复脊髓损伤患者髋关节周围危及生命的难治性压疮创面。虽以失去整个下肢为代价,但在没有其他更好的办法时,它仍然是一种挽救生命的好方法。     

Diagnostic dilemma of sacral abscess presented with seizure and altered conscious level in a patient with spinal cord injury

Context: Infection and septicaemia may clinically presented with seizure and altered conscious level. In spinal cord injury (SCI) population, they are at risk of having pressure ulcer which can be complicated further with infection and septicaemia.

Findings: A 40-year-old man with complete T4 SCI and multiple clean and non-healing pressure ulcers at sacral and bilateral ischial tuberosity regions was initially admitted for negative pressure wound therapy (NPWT) dressing. He had an episode of seizure and subsequently had fluctuating altered conscious level before the diagnosis of deep-seated sacral abscess was made and managed. Prior investigations to rule out common possible sources of infections and management did not resolve the fluctuating event of altered consciousness.

Clinical relevance: We presented an unusual case presentation of septicemia in a patient with SCI with underlying chronic non-healing pressure ulcer. He presented with seizure and fluctuating altered conscious level. Even though a chronic non-healing ulcer appeared clinically clean, a high index of suspicion for deep seated abscess is warranted as one of the possible sources of infection, especially when treatment for other common sources of infections fails to result in clinical improvement.     

Complications in patients with spinal cord injuries sustained in an earthquake in Northern Pakistan

BACKGROUND: Spinal cord injury (SCI) is a devastating trauma suffered by many of the victims of an earthquake that struck Northern Pakistan on October 8, 2005. It rendered approximately 600 patients paraplegic, which is the highest number ever reported in any disaster. This study was conducted to evaluate the risk of complications. METHODS: The cross-sectional retrospective study covering a 2-month period was conducted on 194 patients admitted to the surgical/neurosurgical wards of Rawalpindi Medical College and allied hospitals (Holy Family Hospital, Rawalpindi General Hospital, and District Headquarter Hospital) and Melody Relief and Rehabilitation Center, Islamabad. RESULTS: The male-to-female ratio was approximately 1:3 (n = 50 [26%] and n = 144 [74%], respectively). The majority (78% [n = 151]) were 16 to 39 years of age; 62% (n = 120) had lumbar-level injuries, 25% (n = 48) had thoracic-level injuries, 9% (n = 18) had thoracolumbar-level injuries, and a few had cervical- or sacral-level injuries. Forty-six percent (n = 90) had American Spinal Injury Association type A injuries; 4% (n = 8) were graded B, 11% (n = 21) were graded C, 9% (n = 18) were graded D, and 14% (n = 27) were graded E. Twenty percent (n = 39) developed pressure ulcers, of which 38% (n = 15) had grade 1, 36% (n = 14) had grade 2, 23% (n = 9) had grade 3, and 3% (n = 1) had grade 4. All patients developed urinary tract infections; 15% (n = 30) had bowel complaints; 2% (n = 3) developed deep-vein thrombosis (1 died of pulmonary embolism); and 0.05% (n = 1) developed wound infection. CONCLUSION: Awareness of potential complications in patients with paraplegia is essential to care planning in the disaster setting. The priorities include skin, bowel, and bladder care and provision of prophylactic heparin. SCI post-disaster care requires comprehensive long-term planning.     

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.     

Comparing 4- and 6-week post-flap protocols in patients with spinal cord injury

Objective: For patients with spinal cord injury (SCI) who undergo flap surgery to treat pressure injuries (PIs), the optimal duration of post-operative bedrest to promote healing and successful remobilization to sitting is unknown. At the study center, the minimum duration of post-operative bedrest was changed from 4 to 6 weeks. The purpose of this study is to compare outcomes of patients who underwent flap surgery using bedrest protocols of different duration.Design: This was a retrospective review of all flap procedures completed at VA Puget Sound Health Care System from 1997 to 2016 to treat PIs in patients with SCI. Surgeries were excluded if they were not a flap (i.e. primary skin closure or graft), involved a non-pelvic region, or were a same-hospitalization revision of a prior surgery. The primary outcome of this investigation was the number of days between surgery and the first time the patient mobilized to sitting out of bed for 2 h with an intact surgical incision.Methods: 190 patients received a total of 286 flap surgeries from 1994 to 2016. A chart review of each case was completed to determine the planned duration of bedrest (4- vs 6-weeks), first date of successful mobilization out of bed for 2 h, length of stay post-surgery, and occurrence of complications such as dehiscence or need for operative revisions.Results: Among 286 primary surgeries, 171 surgeries used the 4-week protocol and 115 used the 6-week protocol. When compared to the 4-week protocol, patients treated with the 6-week protocol were slightly older, more likely to have a diagnosis of diabetes, and less likely to be current smokers. Healing was never achieved after 4 surgeries in the 4-week group and 2 surgeries in the 6-week group. With the analysis restricted to a single surgery per subject who achieved healing (109 treated with 4-week protocol and 75 with 6-week protocol), there was a significant difference in days until 2-h sitting: median 54 days for the 4-week protocol compared to 60 days for the 6-week protocol (p = 0.041). Up to about 60 days post-operatively, the 4-week protocol produced a greater proportion remobilized to sitting, and thereafter the proportion of patients successfully remobilized did not differ between protocols.Conclusions: The 6-week protocol was not associated with improved remobilization outcomes (reduced rates of dehiscence or surgical revisions), and the 4-week protocol resulted in a significantly shorter time to remobilization to sitting for 2 h as well as a shorter length of stay. We did not identify any subgroup of patients that benefited from the longer protocol.