Non-invasive spinal cord electrical stimulation for arm and hand function in chronic tetraplegia: a safety and efficacy trial.

Cervical spinal cord injury (SCI) leads to permanent impairment of arm and hand functions. Here we conducted a prospective, single-arm, multicenter, open-label, non-significant risk trial that evaluated the safety and efficacy of ARCEX Therapy to improve arm and hand functions in people with chronic SCI. ARCEX Therapy involves the delivery of externally applied electrical stimulation over the cervical spinal cord during structured rehabilitation. The primary endpoints were safety and efficacy as measured by whether the majority of participants exhibited significant improvement in both strength and functional performance in response to ARCEX Therapy compared to the end of an equivalent period of rehabilitation alone. Sixty participants completed the protocol. No serious adverse events related to ARCEX Therapy were reported, and the primary effectiveness endpoint was met. Seventy-two percent of participants demonstrated improvements greater than the minimally important difference criteria for both strength and functional domains. Secondary endpoint analysis revealed significant improvements in fingertip pinch force, hand prehension and strength, upper extremity motor and sensory abilities and self-reported increases in quality of life. These results demonstrate the safety and efficacy of ARCEX Therapy to improve hand and arm functions in people living with cervical SCI. ClinicalTrials.gov identifier: NCT04697472 .

Effects of Adaptations in an Interdisciplinary Follow-Up Clinic for People with Spinal Cord Injury in the Chronic Phase: A Prospective Cohort Study.

People with spinal cord injury (SCI) often experience secondary health conditions (SHCs), which are addressed during interdisciplinary follow-up clinics. We adapted the design of our clinic, by introducing a questionnaire concerning functioning and SHCs, additional measurements of blood pressure and saturation, and participants were seen by either a specialized nurse or rehabilitation physician. In this study, we investigated the effects of these adaptations and the experienced satisfaction of the participants. The results showed an increased number of recommendations in the adapted design, compared to the initial design. Further, the nature of the recommendations shifted from somatic issues to recommendations regarding psychosocial functioning and regarding (the use of) devices. The added measurements revealed an average high systolic blood pressure, which led to more referrals to the general practitioner. The clinical weight and pulmonary functions stayed stable over time. The current adaptations in design expanded and optimized the number and nature of recommendations regarding SHCs to participants. The questionnaire helps the participant to prepare for the clinic and the professionals to tailor their recommendations, resulting in highly satisfied participants.

Improved walking capacity after complementary ankle-foot surgery and gait training in a person with an incomplete tetraplegia; a case report.

INTRODUCTION: The population of people with a spinal cord injury (SCI) is changing to a diverse population with an increasing number of incomplete lesions. Often, these individuals have the capacity to walk, but experience disabling gait impairments. CASE PRESENTATION: The course of a 34-year-old male with a chronic incomplete traumatic cervical SCI who initially could walk no more than a few steps with supervision or a wheeled walker is described. He participated in a clinical trial with Targeted Epidural Spinal Stimulation (TESS). After this trial, he was able to walk with a wheeled walker and bilateral orthosis over a distance of 100 meters. Despite these improvements, his main complaints were (1) difficulty to correctly preposition the feet, and (2) pain in his toe and calf muscles. An interdisciplinary approach and the use of structured gait analysis formed the basis for shared decision-making with the team and the patient to perform ankle-foot surgery followed by 2-month gait training with a body weight support system. After this trajectory his walking distance increased to 250 meters, with a wheeled walker; but now without orthosis and with an increased walking speed compared to pre-surgery. Additionally, there was reduction of pain and he experienced no disturbances during sleeping, washing and clothing anymore. DISCUSSION: This case shows that surgical interventions can improve the gait capacity even in case of chronic incomplete SCI. Furthermore, training with a body weight support system after medical-technical interventions is useful to utilize the full potential of these interventions.

Walking naturally after spinal cord injury using a brain-spine interface.

A spinal cord injury interrupts the communication between the brain and the region of the spinal cord that produces walking, leading to paralysis1,2. Here, we restored this communication with a digital bridge between the brain and spinal cord that enabled an individual with chronic tetraplegia to stand and walk naturally in community settings. This brain-spine interface (BSI) consists of fully implanted recording and stimulation systems that establish a direct link between cortical signals3 and the analogue modulation of epidural electrical stimulation targeting the spinal cord regions involved in the production of walking4-6. A highly reliable BSI is calibrated within a few minutes. This reliability has remained stable over one year, including during independent use at home. The participant reports that the BSI enables natural control over the movements of his legs to stand, walk, climb stairs and even traverse complex terrains. Moreover, neurorehabilitation supported by the BSI improved neurological recovery. The participant regained the ability to walk with crutches overground even when the BSI was switched off. This digital bridge establishes a framework to restore natural control of movement after paralysis.

Needs and wishes for the future lower limb exoskeleton: an interview study among people with spinal cord injury with community-based exoskeleton experience.

PURPOSE: Exoskeleton use by people with complete spinal cord injury (SCI) in daily life is challenging. To optimize daily exoskeleton use, a better understanding of the purpose of use and the accompanying improvements are needed. The perspective of experienced exoskeleton users could guide design improvements. METHODS: Face-to-face semi-structured interviews were held with 13 people with SCI with exoskeleton experience. Interviews were audio-taped, transcribed, and analysed thematically. RESULTS: Participants expressed three future purposes of exoskeleton use: for daily activities (e.g., stair climbing), exercise (e.g., staying healthy), and social interaction (e.g., standing at parties). Exoskeleton use during daily activities was the ultimate goal. Therefore, the future exoskeleton should be: easy to use, small and lightweight, tailor made, safe, comfortable, less distinctive, durable, and affordable. Improving the ease of use was relevant for all purposes, for all participants. The other suggestions for improvement varied depending on the purpose of use and the participant. CONCLUSION: Increasingly more advanced improvements are needed to transition from an exercise purpose to social interaction, and ultimately use during daily activities. In the current study, detailed suggestions for improvements have been made. Only when multiple of these suggestions are adjusted, can the exoskeleton be used to its full potential.IMPLICATIONS FOR REHABILITATIONThe use of an exoskeleton by people with a complete spinal cord injury in daily life is still in its infancy.To optimize daily exoskeleton use, a better understanding of the purpose of use and exoskeleton improvements is needed.More advanced improvements to future exoskeletons are needed to make a transition from use as an exercise device to use during social interaction and daily activities.Improving the ease of use of future exoskeletons is considered a priority by experienced users, followed by making the exoskeleton small, lightweight, and tailor made.

Improvement of quality of life after 2-month exoskeleton training in patients with chronic spinal cord injury.

OBJECTIVE: To examine changes in quality of life (QoL) after an eight-week period of robotic exoskeleton training in a homogeneous group of patients with chronic complete spinal cord injury (SCI). DESIGN: Prospective single-group pre-post study. SETTING: Rehabilitation center. PARTICIPANTS: Patients with a chronic (>6 months) motor complete SCI (T1-L1). INTERVENTION: Twenty-four training sessions with the ReWalk exoskeleton over an eight-week period. MAIN OUTCOME MEASURE: QoL, assessed with the sum score of the Short Form-36 with Walk Wheel modification (SF-36ww). Secondary outcome measures were the eight SF-36ww subdomains, satisfaction with bladder and bowel management, lower extremity joint passive range of motion (pROM), and lower extremity spasticity. RESULTS: Twenty-one participants completed the training. QoL significantly improved after the training period (average SF-36 sum score 621 ± 90) compared to baseline (571 ± 133) (t(20)=-2.5, P=.02). Improvements were seen on the SF-36ww subdomains for pain (P=.003), social functioning (P=.03), mental health (P=.02), and general health perception (P=.01). Satisfaction with bladder management (range 1-5) improved from median 3 at baseline to 4 after exoskeleton training (P=0.01). No changes in satisfaction with bowel management (P=.11), pROM (hip-extension (P=.49), knee-extension (P=.36), ankle dorsiflexion (P=.69)), or spasticity (P=.94) were found. CONCLUSION: Even in patients with chronic motor complete SCI and a relatively high level of QoL at baseline, a short-term exoskeleton training improved their QoL, pain and satisfaction with bladder management; findings that warrant further controlled studies in this specific SCI population.

Standard set of network outcomes for traumatic spinal cord injury: a consensus-based approach using the Delphi method.

STUDY DESIGN: Consensus study. OBJECTIVES: The purpose of this study is to define a standardized (network) outcomes set for traumatic spinal cord injury (t-SCI), covering the patient journey from acute to chronic rehabilitation phase, including patient-relevant outcomes, adequate measurement instruments, as well as case-mix and risk factors. SETTING: Acute Spinal Cord Injury (ASCI) Unit Nijmegen, the Netherlands. METHODS: A modified Delphi method was performed, including a multidisciplinary panel of 19 health-care professionals with experience in t-SCI management. Formal consensus was reached after two web-based surveys, a face-to-face meeting, and a final confirmation round (threshold consensus: 70%). RESULTS: In the first two Delphi rounds, 18/19 invited panelists (94.7%) responded and 10 panelists participated in the final meeting. The prefinal set was confirmed by all panelists. The standard set encompasses the three-tiered outcome hierarchy and consists of patient-reported and clinician-reported outcome domains and measurement instruments. Consensus was reached to include survival, degree of health or recovery, time to recovery, and return to normal activities, disutility of care or treatment process, sustainability of health and nature of recurrences, and long-term consequences of therapy. A measurement schedule was defined as well as for proposed casemix and risk factors, including demographics, clinical status, and treatment process. CONCLUSION: A standard set of network outcomes is developed that could be implemented in hospitals and rehabilitation centers involved in the treatment of t-SCI. Using this standard set, comparison of the quality of care is possible and prognostic prediction of outcomes of treatment is feasible, so that each patient receives the right care at the right time in the right place.

[Autonomic dysreflexia in spinal cord injury patients: recognition is vital]. / Autonome dysreflexie bij dwarslaesiepatiënten.

Depending on the level and severity of spinal cord injury (SCI), SCI patients may suffer from loss of autonomic nervous system function besides the well-known motor and sensory function loss. Changes in the autonomic control of the cardiovascular system can lead to the life-threatening phenomenon of autonomic dysreflexia (AD), especially in patients with cervical or high thoracic SCI. AD is defined as a sudden increase in systolic blood pressure of at least 20 mmHg above baseline. It results from an uncontrolled reaction of the sympathetic nervous system to a stimulus below the neurological SCI level. The characteristic symptoms above the neurological level are caused by vasodilation (headache, flushing, sweating, nasal congestion) whereas the symptoms below the neurological level are caused by vasoconstriction (piloerection). Recognition and appropriate management of AD are essential in preventing life-threatening complications of hypertensive crisis as well as identifying underlying disease requiring further treatment.

Learning self-care skills after spinal cord injury: a qualitative study.

BACKGROUND: People with a recent spinal cord injury (SCI) often follow intensive rehabilitation. Learning appropriate self-care, deal with their impairments and prevent secondary health conditions (SHCs), is highly important during rehabilitation. To date it is not clear how self-care skills are taught to people with SCI. The objective of this study was to understand how people with SCI experienced the learning of appropriate self-care skills during inpatient rehabilitation, including the role of the rehabilitation team. METHODS: Individual semi-structured interviews were conducted with 15 people with SCI, recently discharged from initial inpatient rehabilitation. Interviews were audio-taped, transcribed and analyzed thematically. RESULTS: Two main themes and seven sub-themes were identified. Participants stated that the contribution of the rehabilitation team to learning self-care, including prevention of SHCs, was mostly made by optimizing opportunities to learn through experience. For preventing SHCs, education and lessons learned from the professionals during therapy and the formal educational program, was experienced as especially important. Further, the motivational attitude of the professionals which participants found stimulating and was based on respect, combined with their positive contribution as one team, were seen as essentials elements for learning appropriate self-care. However participants did not recognize the contribution of the nursing staff as part of their rehabilitation, although it was seen as very important. An important aspect of the participants' own contribution was challenging oneself to learn self-care. This was done in different ways by the participants. Further, their own mental adjustment was considered important in the learning process. The gaining of confidence was by most participants seen as personal characteristic, although they also recognized the importance of the team effort and the experiences they underwent. CONCLUSIONS: Learning appropriate self-care was mostly done through experience, by challenging themselves, and making use of the opportunities given by the members of the rehabilitation team. The same strategies used by the rehabilitation team to teach people with SCI to perform appropriate self-care, were also helpful for the participants to gain confidence. Explicit attention for self-care training as an important goal in SCI rehabilitation may strengthen the nursing staff's role and stimulate interdisciplinary working.

Interdisciplinary follow-up clinic for people with spinal cord injury: a retrospective study of a carousel model.

STUDY DESIGN: Explorative retrospective cohort study. OBJECTIVE: Secondary health conditions (SHCs) are common in people with spinal cord injury (SCI). To date, little is known about the effectiveness of long-term follow-up care in preventing SHCs. The objective of this study was to explore the therapeutic content of an interdisciplinary follow-up clinic by retrospective analyses of provided recommendations and collected data concerning SHCs. SETTING: Rehabilitation center Sint Maartenskliniek, The Netherlands. METHODS: All people with SCI, who visited one or more outpatient interdisciplinary follow-up clinics between January 2012 and October 2020 were included in this study. Treatment information was retrieved from their medical records. RESULTS: The 264 participants of the follow-up clinic received, after their first visit, an average of 3.9 recommendations regarding SHCs. Most recommendations were preventive in nature (43%), and were related to physical SHCs (61%). Most recommendations were followed by the participants (34% out of 40% that could be determined) and half of the underlying problems were solved (31% out of 62%). The bodyweight and respiratory function remained stable over time. CONCLUSION: Participants of the interdisciplinary follow-up clinics received extensive recommendations on a variety of subjects, which most likely, reflects the interdisciplinary approach. Recommendations were followed-up to a large extent, resulting in solving half of the underlying SHCs. This way, worse SHCs were prevented by the recommendations. This findings, together with the stability of respiratory function and bodyweight, suggests the added value of the interdisciplinary follow-up clinic to usual care. More prospective research is necessary to investigate the (cost-)effectiveness.

Trajectories of Self-Efficacy, Depressed Mood, and Anxiety From Admission to Spinal Cord Injury Rehabilitation to 1 Year After Discharge.

OBJECTIVE: Self-efficacy (SE) is an important determinant for the psychological adjustment of people with spinal cord injury (SCI). However, little is known about the course of SE during inpatient rehabilitation up to 1 year after discharge. The aim of this study was to determine latent trajectory classes of SE, depressive mood, and anxiety in people with SCI, as well as the interrelationships between these trajectories. DESIGN: Longitudinal inception cohort study. SETTING: Eight specialized SCI rehabilitation centers. PARTICIPANTS: The participants (N=268) were mainly men 183 of 268 (68.3%) with a mean age of 55.6 years. Almost half had a traumatic SCI 135 of 268 (50.4%) and tetraplegia (53.7%), and the minority had a motor complete SCI (32.2%). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: SE was measured using the University of Washington Self-Efficacy Scale. In addition, the Hospital Anxiety and Depression Scale was used to asses distress and perform dual trajectory modeling analyses. RESULTS: Three trajectories of SE, indicating low, middle, and high SE, could be distinguished. Furthermore, a 2-class trajectory solution for depressive mood and a 4-class solution for anxiety were found to be most suitable. All trajectories were stable over time. Developmental connections between SE and depressive mood and between SE and anxiety were revealed. In particular, participants who adjusted well, reporting low scores on depressive mood and anxiety, could be identified by their high SE scores. However, the group of participants with high depressive mood scores and anxiety scores could not always be identified based on their SE trajectory. CONCLUSIONS: In accordance with our hypotheses, distinct trajectories of SE, depressive mood, and anxiety were identified and high probabilities that SE trajectories were interrelated to the trajectories from depressive mood and anxiety were confirmed. Concurrent screening for SE and distress might best detect people at risk for adjustment problems.

Assessment of the Shank-to-Vertical Angle While Changing Heel Heights Using a Single Inertial Measurement Unit in Individuals with Incomplete Spinal Cord Injury Wearing an Ankle-Foot-Orthosis.

Previous research showed that an Inertial Measurement Unit (IMU) on the anterior side of the shank can accurately measure the Shank-to-Vertical Angle (SVA), which is a clinically-used parameter to guide tuning of ankle-foot orthoses (AFOs). However, in this context it is specifically important that differences in the SVA are detected during the tuning process, i.e., when adjusting heel height. This study investigated the validity of the SVA as measured by an IMU and its responsiveness to changes in AFO-footwear combination (AFO-FC) heel height in persons with incomplete spinal cord injury (iSCI). Additionally, the effect of heel height on knee flexion-extension angle and internal moment was evaluated. Twelve persons with an iSCI walked with their own AFO-FC in three different conditions: (1) without a heel wedge (refHH), (2) with 5 mm heel wedge (lowHH) and (3) with 10 mm heel wedge (highHH). Walking was recorded by a single IMU on the anterior side of the shank and a 3D gait analysis (3DGA) simultaneously. To estimate validity, a paired t-test and intraclass correlation coefficient (ICC) between the SVAIMU and SVA3DGA were calculated for the refHH. A repeated measures ANOVA was performed to evaluate the differences between the heel heights. A good validity with a mean difference smaller than 1 and an ICC above 0.9 was found for the SVA during midstance phase and at midstance. Significant differences between the heel heights were found for changes in SVAIMU (p = 0.036) and knee moment (p = 0.020) during the midstance phase and in SVAIMU (p = 0.042) and SVA3DGA (p = 0.006) at midstance. Post-hoc analysis revealed a significant difference between the ref and high heel height condition for the SVAIMU (p = 0.005) and knee moment (p = 0.006) during the midstance phase and for the SVAIMU (p = 0.010) and SVA3DGA (p = 0.006) at the instant of midstance. The SVA measured with an IMU is valid and responsive to changing heel heights and equivalent to the gold standard 3DGA. The knee joint angle and knee joint moment showed concomitant changes compared to SVA as a result of changing heel height.

Predictors of exoskeleton motor learning in spinal cord injured patients.

PURPOSE OF THE ARTICLE: Learning to use an exoskeleton is time consuming and diverse between users. Knowledge about trainability of exoskeleton skills is relevant for planning and expectation management. The objective was to assess predictors of exoskeleton skill performance during and after exoskeleton training. MATERIALS AND METHODS: Twenty-four participants with a motor complete spinal cord injury were given 24 training sessions in 8 weeks. Nine potential predictors were identified: lesion level, age, gender, age at injury, time since injury, BMI, sport, active lifestyle, and anxiety. Univariate and multivariate linear regression analyses were performed to examine predictors of skill performance after 2, 4, 6, and 8 weeks. RESULTS AND CONCLUSIONS: Twenty participants completed the training. Univariate analysis revealed that positive predictors were: low lesion level and more active lifestyle after 2 weeks, whereas low age at injury, low BMI, and more active lifestyle were positive predictors after 6 weeks. Multivariate regression model explained 65% of the performance after 2 weeks (predictors: lesion level, anxiety, active lifestyle) and 66% after 6 weeks (predictors: BMI, active lifestyle, age). Lesion level was a predictor during the first 4 weeks, but did not influence participants' final skill level. BMI, age, and active lifestyle were predictors toward the end of the training period.Implications for rehabilitationWith the help of wearable exoskeletons people with a complete spinal cord injury can regain their standing and walking mobility.Learning to use an exoskeleton is time consuming and the number of training sessions required to walk independently differs greatly between users.This study shows that lesion level was an important predictor of exoskeleton motor learning in the first 4 weeks of training.BMI, age, and active lifestyle were predictors of exoskeleton skill performance toward the end of the 8 week training period.

Enhancing our conceptual understanding of state and trait self-efficacy by correlational analysis of four self-efficacy scales in people with spinal cord injury.

BACKGROUND: Self-efficacy is an important determinant of adjustment following spinal cord injury. Self-efficacy is defined as the belief that one can successfully execute behavior required to produce the desired outcomes. In its original conceptualization, self-efficacy refers to the confidence that people have in their ability to accomplish specific tasks and behaviors within a specific context. Over the years these situation specific aspects have been unconfined and multiple constructs of self-efficacy have been proposed. The most common is a division in trait and state self-efficacy. Another used division that is utilized is between general, domain-specific and task-specific self-efficacy. The scientific support for these constructs is to date still unclear. The objective of this study was to enhance the understanding of the self-efficacy construct by comparing four self-efficacy scales designed to measure three aspects of self-efficacy (general versus domain-specific versus task-specific) in people with spinal cord injury. METHODS: Dutch and Australian adults with spinal cord injury (N = 140) completed four frequently used self-efficacy scales; the Moorong Self-efficacy Scale, General Self-efficacy Scale, University of Washington Self-efficacy Scale and a Self-care Self-efficacy Scale approximately 6 months after their inpatient rehabilitation. Pearson correlations examined inter-relationships between the scales. RESULTS: Hypothesized strong correlations between scales measuring similar aspects of self-efficacy were found (correlations 0.50-0.65). However, the hypothesized weak to moderate correlations between scales measuring diverging aspects of self-efficacy were only partly found (correlations 0.31-0.74), with 7 out of 12 correlations being strong instead of moderate. CONCLUSIONS: The expected distinctions between the three aspects of self-efficacy was not demonstrated. All four scales measure a common latent construct, most likely general self-efficacy aspects. Further research is necessary to find ways to improve the measurement of domain-specific and task-specific aspects of SE, so that they are sensitive enough to capture change over time, and thus enhance clinical outcomes of people with SCI as they adjust to their disability.

Exoskeleton home and community use in people with complete spinal cord injury.

A consequence of a complete spinal cord injury (SCI) is the loss of gait capacity. Wearable exoskeletons for the lower extremity enable household and community ambulation in people with SCI. This study assessed the amount, purpose, and location of exoskeleton use in the home and community environment, without any restrictions. The number of steps taken was read from the exoskeleton software. Participants kept a daily logbook, and completed two user experience questionnaires (Quebec User Evaluation of Satisfaction with assistive Technology (D-QUEST) and System Usability Scale (SUS)). Fourteen people with a complete SCI used the ReWalk exoskeleton a median of 9 (range [1-15]) out of 16 ([12-21]) days, in which participants took a median of 3,226 ([330-28,882]) steps. The exoskeleton was mostly used for exercise purposes (74%) and social interaction (20%). The main location of use was outdoors (48%). Overall, participants were satisfied with the exoskeleton (D-QUEST 3.7 ± 0.4) and its usability (SUS 72.5 [52.5-95.0]). Participants with complete SCI report satisfaction with the exoskeleton for exercise and social interaction in the home and community, but report limitations as an assistive device during daily life.

Physical Activity and Sedentary Behavior From Discharge to 1 Year After Inpatient Rehabilitation in Ambulatory People With Spinal Cord Injury: A Longitudinal Cohort Study.

OBJECTIVE: To evaluate changes in duration of physical activity (PA) and sedentary behavior (SB) from discharge to 1 year after inpatient rehabilitation in ambulatory people with spinal cord injury (SCI). DESIGN: Longitudinal cohort study with objective measurements of physical behavior at discharge and at 6 and 12 months post discharge. SETTING: Three rehabilitation centers and the participant's home environment. PARTICIPANTS: Participants (N=47) with ambulatory function were consecutively recruited from the self-management and self-efficacy in patients with SCI cohort (age 18 years or older, recent SCI, expected inpatient stay ≥4wk). Mean age was 54.5±12.9 years, all had incomplete lesions, 53% were men, 49% had tetraplegia, and 51% were community ambulators at discharge. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Duration (min) of PA (summed duration of walking, cycling, running, and wheeling) and SB (sitting/lying). RESULTS: Mean duration of PA increased by 21 min/d (95% confidence interval, 7-35) and SB decreased by 64 min/d (95% confidence interval, -94 to -35) from discharge to 6 months after inpatient rehabilitation. No changes were found in the second half-year. One year after discharge mean PA was 116±59 min/d and mean SB was 665±121 min/d. The increase in PA was the result of an almost doubling of time spent walking. Variability in physical behavior and its change was large. Older age and lower ambulation level were associated with lower PA, lower ambulation level with higher SB, and tetraplegia was associated with a reduced increase in PA. CONCLUSIONS: At group level, duration of PA and SB improved following inpatient rehabilitation in ambulatory people with SCI. However, there were large differences between individuals. Levels 1 year after discharge were still unfavorable, particularly regarding SB.

Self-Efficacy Predicts Personal and Family Adjustment Among Persons With Spinal Cord Injury or Acquired Brain Injury and Their Significant Others: A Dyadic Approach.

OBJECTIVES: To investigate whether the combination of self-efficacy levels of individuals with spinal cord injury (SCI) or acquired brain injury (ABI) and their significant others, measured shortly after the start of inpatient rehabilitation, predict their personal and family adjustment 6 months after inpatient discharge. DESIGN: Prospective longitudinal study. SETTING: Twelve Dutch rehabilitation centers. PARTICIPANTS: Volunteer sample consisting of dyads (N=157) of adults with SCI or ABI who were admitted to inpatient rehabilitation and their adult significant others. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-efficacy (General Competence Scale) and personal and family adjustment (Hospital Anxiety and Depression Scale and McMaster Family Assessment Device General Functioning). RESULTS: In 20 dyads, both individuals with SCI or ABI and their significant others showed low self-efficacy at baseline. In 67 dyads, both showed high self-efficacy. In the low-self-efficacy dyads, 61% of the individuals with SCI or ABI and 50% of the significant others showed symptoms of anxiety 6 months after discharge, vs 23% and 30%, respectively, in the high-self-efficacy dyads. In the low-self-efficacy dyads, 56% of individuals with SCI or ABI and 50% of the significant others reported symptoms of depression, vs 20% and 27%, respectively, in the high-self-efficacy dyads. Problematic family functioning was reported by 53% of the individuals with SCI or ABI and 42% of the significant others in the low-self-efficacy dyads, vs 4% and 12%, respectively, in the high-self-efficacy dyads. Multivariate analysis of variance analyses showed that the combination of levels of self-efficacy of individuals with SCI or ABI and their significant others at the start of inpatient rehabilitation predict personal (V=0.12; F6,302=2.8; P=.010) and family adjustment (V=0.19; F6,252=4.3; P<.001) 6 months after discharge. CONCLUSIONS: Low-self-efficacy dyads appear to be more at risk for personal and family adjustment problems after discharge. Screening for self-efficacy may help healthcare professionals to identify and support families at risk for long-term adjustment problems.

Coping Flexibility as Predictor of Distress in Persons With Spinal Cord Injury.

OBJECTIVES: Examine whether coping flexibility at admission to first spinal cord injury (SCI) rehabilitation was predictive of distress 1 year after discharge. DESIGN: Longitudinal inception cohort study. SETTING: Rehabilitation center. PARTICIPANTS: Of the 210 people admitted to their first inpatient SCI rehabilitation program, 188 met the inclusion criteria. n=150 (80%) agreed to participate; the data of participants (N=113) with a complete dataset were used in the statistical analysis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Coping flexibility was operationalized by (1) flexible goal adjustment (FGA) to given situational forces and constraints and (2) tenacious goal pursuit (TGP) as a way of actively adjusting circumstances to personal preference. The Assimilative-Accommodative Coping Scale was used to measure FGA and TGP. The Hospital Anxiety and Depression Scale was used to assess distress. RESULTS: Scores on FGA and TGP measured at admission were negatively associated with the scales depression (r= -.33 and -.41, respectively) and anxiety (r= -.23 and -.30, respectively) 1 year after discharge. All demographic and injury-related variables at admission together explained a small percentage of the variance of depression and anxiety. FGA, TGP, and the interaction term together explained a significant additional 16% of the variance of depression and 10% of anxiety. CONCLUSIONS: The tendency to pursue goals early postonset of the injury seems to have a protecting effect against distress 1 year after discharge. People with low TGP may experience protection against distress from high FGA.

Self-Management and Self-Efficacy in Patients With Acute Spinal Cord Injuries: Protocol for a Longitudinal Cohort Study.

BACKGROUND: People with recently acquired spinal cord injury (SCI) experience changes in physical, social and psychological aspects of their lives. In the last decades, attention has grown for aspects of self-management and self-efficacy in SCI research. However, we still do not know what the self-management and self-efficacy outcomes of first rehabilitation are and whether utilizing these skills may prevent secondary health conditions (SHCs) and increase participation and psychological adjustment early after SCI. OBJECTIVE: To describe the course and determinants of self-management and self-efficacy during and after first SCI rehabilitation; and to determine theory-based associations between self-management and self-efficacy with SHCs, participation and psychological adjustment. METHODS: Multicenter prospective longitudinal cohort study. All people with a newly acquired SCI admitted to one of the 8 specialized SCI rehabilitation centers in the Netherlands will be considered for inclusion in this study. Main assessments will take place during the first and last week of admission and 3, 6 and 12 months after discharge. The target sample is 250 participants. The primary outcomes are self-management (knowledge and execution of self-care) and self-efficacy (confidence in the ability to manage the consequences of SCI and of self-care). Secondary outcome measures are SHCs, participation and psychological adjustment to SCI. RESULTS: The first results with the complete set of data are expected in June 2019. CONCLUSIONS: This protocol describes the SELF-SCI cohort study investigating self-management and self-efficacy of initial inpatient SCI rehabilitation. Second, associations will be investigated with SHCs, participation and psychological adjustment early after onset of SCI, until 1 year after discharge. The results will be used to test theories about motivation to perform health-promoting behaviors and adjustment to SCI.

Associations Between Self-Efficacy and Secondary Health Conditions in People Living With Spinal Cord Injury: A Systematic Review and Meta-Analysis.

OBJECTIVE: To describe the association between self-efficacy and secondary health conditions (SHCs) in people living with spinal cord injury (SCI). DATA SOURCES: PubMed, EMBASE, the Cochrane Library, and CINAHL were systematically searched from database inception to September 2016. STUDY SELECTION: Studies describing patients living with SCI in which self-efficacy was measured by a standardized questionnaire and an association was made with somatic or psychological SHCs. DATA EXTRACTION: An independent extraction by multiple observers was performed based on the Strengthening the Reporting of Observational Studies in Epidemiology statements checklist. A meta-analysis concerning the association between self-efficacy and SHCs in people with SCI was performed if a minimum of 4 comparable studies were available. DATA SYNTHESIS: Of 670 unique articles screened, 22 met the inclusion criteria. Seven of these 22 studies investigated associations between self-efficacy and somatic SHCs. Only a trend toward an association between higher self-efficacy and less pain, fatigue, number of SHCs, and limitations caused by SHCs was found. Twenty-one studies described the association between self-efficacy and psychological SHCs. All correlations of higher self-efficacy with fewer depressive (18 studies) and anxiety symptoms (7 studies) were significant, and meta-analysis showed a strong negative correlation of -.536 (-.584 to -.484) and -.493 (-.577 to -.399), respectively. A small number of studies (2) showed a trend toward a positive correlation between self-efficacy and quality of life. CONCLUSIONS: Self-efficacy is negatively associated with depressive and anxiety symptoms in SCI. Therefore, self-efficacy seems an important target in the rehabilitation of patients living with SCI. More research is necessary to clarify the associations between self-efficacy and somatic SHCs. Future research should also focus on different types of self-efficacy and their association with SHCs.