Development and preliminary validation of a tool measuring concordance and belief about performing pressure-relieving activities for pressure ulcer prevention in spinal cord injury.

OBJECTIVE: To develop and examine the reliability, and validity of a questionnaire measuring concordance for performing pressure-relief for pressure ulcer (PrU) prevention in people with Spinal Cord Injury (SCI). METHODS: Phase I included item development, content and face validity testing. In phase II, the questionnaire was evaluated for preliminary acceptability, reliability and validity among 48 wheelchair users with SCI. RESULTS: Thirty-seven items were initially explored. Item and factor analysis resulted in a final 26-item questionnaire with four factors reflecting concordance, perceived benefits, perceived negative consequences, and personal practical barriers to performing pressure-relief activities. The internal consistency reliability for four domains were very good (Cronbach's α = 0.75-.89). Pearson correlation coefficient on a test-retest of the same subjects yielded significant correlations in concordance (r2 = 0.91, p = .005), perceived benefit (r2 = 0.71, p < .04), perceived negative consequences (r2 = 0.98, p < .0001), personal barriers (r2 = 0.93, p= .002). Participants with higher levels of concordance reported a greater amount of pressure-relieving performed. Individuals viewing PrU as a threatening illness were associated with higher scores of concordance and tended to report a greater amount of pressure-relieving performance which provides evidence of criterion related validity. CONCLUSION: The new questionnaire demonstrated good preliminary reliability and validity in people with SCI. Further evaluation is necessary to confirm these findings using larger samples with follow-up data for predictive validity. Such a questionnaire could be used by clinicians to identify high risk of patients and to design individualised education programme for PrU prevention.

Understanding and modelling the economic impact of spinal cord injuries in the United Kingdom.

STUDY DESIGN: Economic modelling analysis. OBJECTIVES: To determine lifetime direct and indirect costs from initial hospitalisation of all expected new traumatic and non-traumatic spinal cord injuries (SCI) over 12 months. SETTING: United Kingdom (UK). METHODS: Incidence-based approach to assessing costs from a societal perspective, including immediate and ongoing health, rehabilitation and long-term care directly attributable to SCI, as well as aids and adaptations, unpaid informal care and participation in employment. The model accounts for differences in injury severity, gender, age at onset and life expectancy. RESULTS: Lifetime costs for an expected 1270 new cases of SCI per annum conservatively estimated as £1.43 billion (2016 prices). This equates to a mean £1.12 million (median £0.72 million) per SCI case, ranging from £0.47 million (median £0.40 million) for an AIS grade D injury to £1.87 million (median £1.95 million) for tetraplegia AIS A-C grade injuries. Seventy-one percent of lifetime costs potentially are paid by the public purse with remaining costs due to reduced employment and carer time. CONCLUSIONS: Despite the magnitude of costs, and being comparable with international estimates, this first analysis of SCI costs in the UK is likely to be conservative. Findings are particularly sensitive to the level and costs of long-term home and residential care. The analysis demonstrates how modelling can be used to highlight economic impacts of SCI rapidly to policymakers, illustrate how changes in future patterns of injury influence costs and help inform future economic evaluations of actions to prevent and/or reduce the impact of SCIs.

Women's experiences of sexuality after spinal cord injury: a UK perspective.

STUDY DESIGN: Cross-sectional phenomenological qualitative study. OBJECTIVES: To investigate women's experience of sexuality after spinal cord injury (SCI) with a focus on rehabilitation and manging practical impact. SETTING: Women with SCI living in the community in United Kingdom (UK). METHODS: Participants were recruited via three UK SCI centres, ensuring tetraplegia, paraplegia and cauda equina syndrome representation. Single semi-structured interviews exploring individual's experiences around sexuality following SCI were recorded and transcribed for thematic analysis. RESULTS: Twenty-seven women aged 21-72 years, sexually active since SCI were interviewed, each lasting 17-143 min (mean 55 min). Six key themes emerged: physical change, psychological impact, dependency, relationships and partners, post injury sexual life and sexuality rehabilitation. CONCLUSIONS: Sexuality remains an important, valued aspect of female identity following SCI; sexual activity continues and though altered remains enjoyable and rewarding. Sexuality rehabilitation should commence early, preparing women for altered sexual sensation, disclosure of altered sexual function to partners, and encouraging early self-exploration. Techniques optimising continence management in preparation for and during sex should be taught. Participants identified a need for women-only education and support groups, increased peer support, self-esteem, communication and social skills training and even fashion advice and pampering sessions during rehabilitation. Support and education for partners are needed. Staff require support to be knowledgeable and confident in addressing women's sexuality needs. Use of the Ex-PLISSIT model for psychosexual support could help staff to better meet these needs.

The Stanmore Nursing Assessment of Psychological Status (SNAPS): not just for spinal cord injury rehabilitation?

Spinal cord injury is an uncommon condition, potentially causing a wide range of consequences and requiring specialist rehabilitation to optimize health, activity and participation. Early psychological response to injury and relations with staff, as well as family, may set the foundations for long-term emotional adjustment, healthcare utilization and quality of life. The Stanmore Nursing Assessment of Psychological Status has been developed at the London Spinal Cord Injury Centre to empower nurses to adopt a consistently empathic approach to patient care, as part of a comprehensive range of rehabilitation team skills. Its use in other spinal cord injury centers and a broader range of clinical environments (hospital and community) should therefore be considered.

Results of the first interim analysis of the RAPPER II trial in patients with spinal cord injury: ambulation and functional exercise programs in the REX powered walking aid.

BACKGROUND: The RAPPER II study investigates the feasibility, safety and acceptability of using the REX self-stabilising robotic exoskeleton in people with spinal cord injury (SCI) who are obligatory wheelchair users. Feasibility is assessed by the completion of transfer into the REX device, competency in achieving autonomous control and completion of upper body exercise in an upright position in the REX device. Safety is measured by the occurrence of serious adverse events. Device acceptability is assessed with a user questionnaire. METHODS: RAPPER II is a prospective, multi-centre, open label, non-randomised, non-comparative cohort study in people with SCI recruited from neurological rehabilitation centres in the United Kingdom, Australia and New Zealand. This is the planned interim report of the first 20 participants. Each completed a transfer into the REX, were trained to achieve machine control and completed Timed Up and Go (TUG) tests as well as upper body exercises in standing in a single first time session. The time to achieve each task as well as the amount of assistance required was recorded. After finishing the trial tasks a User Experience questionnaire, exploring device acceptability, was completed. RESULTS: All participants could transfer into the REX. The mean transfer time was 439 s. Nineteen completed the exercise regime. Eighteen could achieve autonomous control of the REX, 17 of whom needed either no assistance or the help of just one therapist. Eighteen participants completed at least one TUG test in a mean time of 313 s, 15 with the assistance of just one therapist. The questionnaire demonstrated high levels of acceptability amongst users. There were no Serious Adverse Events. CONCLUSIONS: This first interim analysis of RAPPER II shows that it is feasible and safe for people with SCI to use the REX powered assisted walking device to ambulate and exercise in. Participants with tetraplegia and paraplegia could walk and perform a functional exercise program when standing needing only modest levels of assistance in most cases. User acceptability was high. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02417532 . Registered 11 April 2015.

A Quantitative, Pooled Analysis and Systematic Review of Controlled Trials on the Impact of Electrical Stimulation Settings and Placement on Pressure Ulcer Healing Rates in Persons With Spinal Cord Injuries.

Pressure ulcers (PrUs) are among the most common secondary complications following spinal cord injury (SCI). External electrical current applied to a wound is believed to mimic the body's natural bioelectricity and to restart and stimulate endogenous electrical fields to promote wound healing. A systematic review was conducted to critically appraise and synthesize updated evidence on the impact of electrical stimulation (ES) versus standard wound care (comprising cleansing, dressing, nutrition, and debridement as necessary) and/or sham stimulation on PrU healing rates in persons with SCIs. Medline, Embase, the Cumulative Index for Nursing and Allied Health Literature (CINAHL), PsycINFO, and Cochrane Central were searched using the terms spinal cord injury, electrical stimulation, and pressure ulcer in free text and MESH terms. Publications were limited to peer-reviewed, randomized controlled trials (RCTs) and non-RCTs (CCTs) published in English from 1985 to 2014. The methodological quality of the RCTs was evaluated using the Jadad scale; CCTs were assessed using the Downs and Black tool. Pooled analyses were performed to calculate the mean difference (MD) for continuous data, odds ratio (OR) for dichotomous data, and 95% confidence intervals (CI). A total of 8 trials were reviewed - 6 RCTs and 2 CCTs included a total of 517 SCI participants who had at least 1 PrU. The number of patients per study ranged from 7 to 150 and the number of wounds from 7 to 192. Comparison models included ES irrespective of current type and placement of electrodes against sham/no ES (7 trials), ES delivered by electrodes overlaid on the ulcer versus sham/no ES (4 trials), ES delivered by electrodes placed on intact skin around the ulcer versus sham/no ES (4 trials), ES delivered by electrodes overlaid on the wound bed versus placed on intact skin around the ulcer (1 trial), ES with pulsed current versus sham/no ES (6 trials), ES with constant current versus sham/no ES (2 trials), pulsed current ES versus constant current ES (1 trial), number of PrUs closed (2 trials), and incidence of PrU worsened by ES versus sham/no ES (2 trials). The overall quality of studies was moderate; 2 trials were rated as good quality, 2 were poor quality, and 4 were moderate. Evidence showed ES increased the rate of PrU healing in patients with SCI (MD 4.97, 95% CI 1.97-7.98, P = 0.00; N = 7 studies and 559 ulcers), and a higher proportion of ulcers healed (OR 2.68, 95% CI 1.17-6.14, P = 0.02; N = 2 studies and 226 ulcers). The data suggest pulsed current ES increased the healing rate (MD 6.27, 95% CI 2.77-9.78, P = 0.0005; N = 6 studies and 509 ulcers) more than constant current (MD 4.50, 95% CI 1.19-10.18, P = 0.12; N = 2 studies and 200 ulcers). In addition, wounds with electrodes overlaying the wound bed seemed to heal ulcer faster than wounds with electrodes placed on intact skin around the ulcer. Future preclinical, in vivo models and clinical trials examining the impact of electrodes configuration for PrU healing are warranted.

Identifying key experience-related differences in over-ground manual wheelchair propulsion biomechanics.

OBJECTIVES: The purpose of this study was to investigate technique differences between expert and novice manual wheelchair users during over-ground wheelchair propulsion. METHOD: Seven experts (spinal cord injury level between T5 and L1) and six novices (non-wheelchair users) pushed a manual wheelchair over level ground, a 2.5% cross slope and up a 6.5% incline (7.2 m length) and 12% incline (1.5 m length). Push rim kinetics, trunk and shoulder kinematics and muscle activity level were measured. RESULTS: During the level and cross slope tasks, the experts completed the tasks with fewer pushes by applying a similar push rim moment over a greater push arc, demonstrating lower muscle activity. During the incline tasks, the experts required fewer pushes and maintained a greater average velocity, generating greater power by applying a similar push rim moment over a greater push arc with greater angular velocity, demonstrating greater trunk flexion and higher shoulder muscle activity. CONCLUSIONS: This study identifies experience-related differences during over-ground manual wheelchair propulsion. These differences are particularly evident during incline propulsion, with the experts generating significantly greater power to maintain a higher velocity.

The interaction of cortico-spinal pathways and sacral sphincter reflexes in subjects with incomplete spinal cord injury: a pilot study.

AIMS: To reveal the effectiveness of corticospinal drive in facilitating the pudendal reflex in the anal sphincter muscle, as a surrogate marker for the urethral sphincter, in incomplete spinal cord injury (iSCI). METHODS: Three neurologically normal subjects and twenty-six subjects with incomplete, supra-sacral spinal cord injuries and symptoms of a neuropathic bladder were recruited. Incontinence was assessed using the International Consultation on Incontinence Modular Questionnaire (ICIQ). Electromyographic activity of the external anal sphincter was recorded. The pudendo-anal reflex (PAR) was elicited by electrical stimulation of the dorsal penile nerve (DPN). Motor cortical excitation was achieved using transcranial magnetic stimulation (TMS). RESULTS: Preliminary findings in normal and iSCI subjects showed facilitation of the PAR by prior TMS with an optimal interval of 20-40 msec. Of 23 iSCI subjects, 12 showed facilitation to TMS applied 30 msec before DPN stimulation. Eight of the 12, and a further five iSCI subjects, had an anal sphincter MEP in response to TMS alone. There was a weak tendency (r(2) = 0.22, P = 0.03) for those with higher ICIQ values to have larger PAR responses but no significant difference in ICIQ scores between those with (ICIQ = 4.9 ± 4.0 mean ± SD) and those without (ICIQ = 7.2 ± 4.7) cortical facilitation of the PAR. CONCLUSIONS: Cortical TMS was effective in facilitating the PAR in some iSCI subjects. The presence of cortical facilitation of the PAR was not related to the degree of urinary continence.

Linking wheelchair kinetics to glenohumeral joint demand during everyday accessibility activities.

The aim of the study was to investigate if push-rim kinetics could be used as markers of glenohumeral joint demand during manual wheelchair accessibility activities; demonstrating a method of biomechanical analysis that could be used away from the laboratory. Propulsion forces, trunk and upper limb kinematics and surface electromyography were recorded during four propulsion tasks (level, 2.5% cross slope, 6.5% incline and 12% incline). Kinetic and kinematic data were applied to an OpenSim musculoskeletal model of the trunk and upper limb, to enable calculation of glenohumeral joint contact force. Results demonstrated a positive correlation between propulsion forces and glenohumeral joint contact forces. Both propulsion forces and joint contact forces increased as the task became more challenging. Participants demonstrated increases in trunk flexion angle as the requirement for force application increased, significantly so in the 12% incline. There were significant increases in both resultant glenohumeral joint contact forces and peak and mean normalized muscle activity levels during the incline tasks. This study demonstrated the high demand placed on the glenohumeral joint during accessibility tasks, especially as the gradient of incline increases. A lightweight instrumented wheelchair wheel has potential to guide the user to minimize upper limb demand during daily activity.

Superior mesenteric artery syndrome - A rare presentation and challenge in spinal cord injury rehabilitation: A case report and literature review.

BACKGROUND: Obstruction of the third part of the duodenum (D3) is a very rare cause of gastric outflow obstruction. Rapid weight loss is the biggest risk factor. Patients seen in acute rehabilitation settings, not uncommonly, have a period of rapid weight loss. We report two cases of superior mesenteric artery (SMA) syndrome and review the literature. CLINICAL DETAILS: The patients presented differently, one with repeated, refractory autonomic dysreflexia and severe spasticity and one with nausea, abdominal discomfort, and vomiting. CT abdomen with contrast identified dynamic duodenal (D3) obstruction against the posterior structures by narrow angled SMA, gastric distension and, in one case, dilation of the left renal vein. Both patients responded well to optimizing nutrition in different ways. Surgery was successfully avoided. DISCUSSION: SMA syndrome is an atypical cause of high intestinal obstruction, frequently occurring in patients who have had rapid weight loss during spinal cord injury (SCI) rehabilitation. It may co-exist with left renal vein dilation "nutcracker phenomena". The associated neurogenic bowel dysfunction due to the nature of SCI could possibly contribute to delay in diagnosis. CONCLUSION: Clinicians should consider the risk of SMA syndrome in patients with SCI with rapid weight loss. Early diagnosis is possible by doing a CT abdomen with contrast and angiography if there is a high index of suspicion. SMA syndrome can be successfully treated by aggressive nutritional management. This may include total parenteral nutrition or feeding by a nasojejunal tube. Duodenojejunostomy could be required in refractory cases.

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.

Disability, atrophy and cortical reorganization following spinal cord injury.

The impact of traumatic spinal cord injury on structural integrity, cortical reorganization and ensuing disability is variable and may depend on a dynamic interaction between the severity of local damage and the capacity of the brain for plastic reorganization. We investigated trauma-induced anatomical changes in the spinal cord and brain, and explored their relationship to functional changes in sensorimotor cortex. Structural changes were assessed using cross-sectional cord area, voxel-based morphometry and voxel-based cortical thickness of T1-weighted images in 10 subjects with cervical spinal cord injury and 16 controls. Cortical activation in response to right-sided (i) handgrip; and (ii) median and tibial nerve stimulation were assessed using functional magnetic resonance imaging. Regression analyses explored associations between cord area, grey and white matter volume, cortical activations and thickness, and disability. Subjects with spinal cord injury had impaired upper and lower limb function bilaterally, a 30% reduced cord area, smaller white matter volume in the pyramids and left cerebellar peduncle, and smaller grey matter volume and cortical thinning in the leg area of the primary motor and sensory cortex compared with controls. Functional magnetic resonance imaging revealed increased activation in the left primary motor cortex leg area during handgrip and the left primary sensory cortex face area during median nerve stimulation in subjects with spinal cord injury compared with controls, but no increased activation following tibial nerve stimulation. A smaller cervical cord area was associated with impaired upper limb function and increased activations with handgrip and median nerve stimulation, but reduced activations with tibial nerve stimulation. Increased sensory deficits were associated with increased activations in the left primary sensory cortex face area due to median nerve stimulation. In conclusion, spinal cord injury leads to cord atrophy, cortical atrophy of primary motor and sensory cortex, and cortical reorganization of the sensorimotor system. The degree of cortical reorganization is predicted by spinal atrophy and is associated with significant disability.

MRSA colonisation in spinal cord injury: implications on patients rehabilitation.

MRSA has become a major cause of nosocomial and community acquired infections in the past few years. Our hypothesis is that MRSA colonisation affects the length of stay in hospital, thereby adding a strain on resources. Data from the last 20 patients admitted to the Spinal Injury Care Unit (SICU) who were MRSA positive (study group) have been analysed and then matched with data from 20 patients who were MRSA negative (control group) to compare their total hospital stay and the factors which affect the length of hospital stay. The mean age of the study group patients was 38.8 years. The average time between injury and admission in SICU was 76.5 days in the study group compared to 28.7 days in the control. The mean stay duration was 412.15 days in the study group as opposed to 187.2 days in the control group. Nearly 45% had developed pressure sores in the study group as compared to 25% in the control group. Our study indicates that MRSA colonisation in spinal injured patients leads to longer hospital stay, delay in admission to spinal care units, and development of pressure sores and further infection. These factors have adverse effects on patients' rehabilitation.

Ankylosing spondylitis and spinal cord injury.

Ankylosing spondylitis patients are reported to be at greater risk for vertebral fractures and spinal cord injury. We describe the case of a 72-year-old male with a long history of ankylosing spondylitis who sustained a vertebral fracture after minor trauma. The fracture was initially missed on conventional radiographs but was later diagnosed by magnetic resonance imaging after the development of new neurological symptoms. With this case report the authors outline the factors that increase the incidence of vertebral fractures and spinal cord injury in ankylosing spondylitis patients and discuss prevention strategies to avoid this devastating complication of the disease.

Chronic spinal cord injury: management of patients in acute hospital settings.

Spinal cord injury (SCI) is a lifelong condition affecting over 40,000 people in the UK. When an individual with established SCI is admitted to hospital for a procedure or because of illness, hospital teams need to manage both the acute condition and the spinal cord injury. These guidelines aim to assist in their assessment and management to avoid the common problems of hospital-acquired morbidity in this potentially vulnerable group of people. Key steps are: gaining an understanding of the common patho-physiological consequences of SCI; listening to the person and their family who are often expert in managing the condition; and maintaining close contact with the individual's regular team/specialist spinal cord injury centre.

Interface pressure and cutaneous hemoglobin and oxygenation changes under ischial tuberosities during sacral nerve root stimulation in spinal cord injury.

Noninvasive functional magnetic stimulation (FMS) of the sacral nerve roots can activate gluteal muscles. We propose the use of sacral anterior root stimulator (SARS) implants to prevent ischial pressure ulcers in the spinal cord injury (SCI) population. In this study, we (1) investigated the acute effects of sacral FMS on ischial pressure, skin blood content, and oxygenation changes in people with SCI and demonstrated the utility of FMS as an assessment tool, and (2) showed that similar effects are possible with electrical stimulation via a SARS implant. Results indicated that sacral nerve root stimulation, either by FMS or implanted electrical stimulation, induced sufficient gluteus maximus contraction to significantly change subjects' ischial pressures and cutaneous hemoglobin and oxygenation during sitting. In addition to these beneficial acute effects, chronic stimulation via a SARS implant may build gluteal muscle bulk and prevent or reduce pressure ulcers in the SCI population.

Pressure changes under the ischial tuberosities of seated individuals during sacral nerve root stimulation.

Neuromuscular stimulation via the sacral nerve roots is proposed for prevention of ischial pressure ulcers following a spinal cord injury (SCI). Acute effects of sacral functional magnetic stimulation (FMS) on seat interface pressure changes were investigated in five nondisabled volunteers. Similar effects were demonstrated with functional electrical stimulation in people with SCI who used a sacral anterior root stimulator implant. The results indicated that sacral nerve root stimulation, either by FMS or implanted electrical stimulation, induced gluteus maximus contraction and mild pelvic tilt sufficient for clinically significant reductions in ischial pressures during sitting.

Mangroves enhance the biomass of coral reef fish communities in the Caribbean.

Mangrove forests are one of the world's most threatened tropical ecosystems with global loss exceeding 35% (ref. 1). Juvenile coral reef fish often inhabit mangroves, but the importance of these nurseries to reef fish population dynamics has not been quantified. Indeed, mangroves might be expected to have negligible influence on reef fish communities: juvenile fish can inhabit alternative habitats and fish populations may be regulated by other limiting factors such as larval supply or fishing. Here we show that mangroves are unexpectedly important, serving as an intermediate nursery habitat that may increase the survivorship of young fish. Mangroves in the Caribbean strongly influence the community structure of fish on neighbouring coral reefs. In addition, the biomass of several commercially important species is more than doubled when adult habitat is connected to mangroves. The largest herbivorous fish in the Atlantic, Scarus guacamaia, has a functional dependency on mangroves and has suffered local extinction after mangrove removal. Current rates of mangrove deforestation are likely to have severe deleterious consequences for the ecosystem function, fisheries productivity and resilience of reefs. Conservation efforts should protect connected corridors of mangroves, seagrass beds and coral reefs.