Electrodiagnosis for mitigating false-negative non-responsiveness in electrical evoked contractions: A case series exploring probable polyneuromyopathy induced by nonuse.

INTRODUCTION: The revised international standards for neurological classification of spinal cord injury (ISNCSCI) have facilitated the documentation of non-spinal cord injury-related impairments, such as chronic peripheral nerve injuries and muscle weakness due to immobility. This advancement addresses potential biases in muscle strength examinations. Utilizing electrically evoked contractions from paralyzed muscles, enhanced by electrodiagnosis, holds promise in identifying false-negative diagnoses of non-responsiveness to neuromuscular electrical stimulation. This concept prompts the exploration of polyneuromyopathy arising from nonuse in paralyzed muscles. CASE SERIES PRESENTATION: To substantiate our hypothesis, we recruited nine participants for a case series aimed at elucidating the potential benefits of incorporating the stimulus electrodiagnostic test (SET) to mitigate non-responsiveness during preparation for functional electrical stimulation (FES)-assisted cycling. In our convenience sample (n = 5), we conducted neurological mapping based on ISNCSCI and applied SET on the quadriceps. The SET guided optimal dosimetry for evoking contractions and revealed responses similar to those observed in peripheral neuropathies, with α coefficients equal to or lower than 2.00. This observation is likely attributable to nonuse of paralyzed muscles, indicative of an ongoing polyneuropathy in individuals with chronic spinal cord injury (SCI). DISCUSSION: Among the nine initially recruited subjects, seven exhibited responsiveness to neuromuscular electrical stimulation (78% responsiveness), with two participants excluded based on exclusion criteria. In the final five reported cases, all displayed α coefficient values indicating impaired neuromuscular accommodation, and one presented no α coefficient within the normal range. The inclusion of electrodiagnosis appears effective in averting non-responsiveness, suggesting the presence of ongoing polyneuropathies in paralyzed muscles.

A novel approach to the epidemiology of people living with spinal cord injuries in France based on an original algorithm from public health insurance data.

INTRODUCTION: French Public Health Insurance gathers health, demographic and economic data based on codes from the 10th version of the international classification of diseases (ICD-10), specific nomenclature for each health-care (medical or surgical) procedures, medical expenses and justifications for full coverage of medical care. We aimed to build an algorithm that could identify the French population of people living with spinal cord injury (SCI) relying on public health insurance metadata. MATERIAL AND METHODS: The SNDS (in French, Système National des Données de Santé) was searched for the time-period 2012-2019, looking for: full-coverage motives, ICD-10 codes, and health-therapeutic procedures specific of our population of interest. We built a step-by-step algorithm that identified i)including codes, ii)excluding codes, iii)codes needing confirmation. A group of 3 physicians recognized as experts in this field contributed with data scientists to the selection of pertinent codes and their association. Including codes were ALD-20 (full-coverage 'paraplegia', in French, Affection de Longue Durée), G114 (spastic paraplegia), Q05.x (spina bifida), spinal cord trauma (S14.x; S24.x), vascular myelopathy (G951), degenerative myelopathies (M47.x). Autoimmune, other disabling neurological diseases with a specific ICD code, and oncologic patients were excluded. Neurological symptoms (G82.x) needed confirmation. We identified 6 categories of SCI regarding their etiology, based on ICD-10 code combinations (congenital, genetic, tumoral, traumatic, acquired and symptomatic) Finally antibiotics consumption and hospitalizations of persons identified as SCI were compared to a control sample from overall population (with a 1:5 ratio). RESULTS: Among almost 245 000 persons with putative SCI, we identified 133 849 living individuals with SCI aged>16 (55.8% men, age 57 yo [44;70]) by 2019. Confirmed traumatic SCI were 21 459 (67% were men, age 53 yo [39;67]), acquired non-traumatic were the most frequent (n=62 561, 46.7%). SCI consumed 1.5 to 3-times more antibiotics and were 4-fold more hospitalized than controls. Also, when hospitalized, they remained twice longer in rehabilitation facilities and 3-times longer in acute care. CONCLUSION: Using multiple code entries, our algorithm allowed an exhaustive identification of the French adult SCI population, with an updated epidemiology. This innovative method opens the field for large-scale studies regarding medical history of persons living with SCI by the prism of medical expenses and habits.

Balance Interventions to Improve Upright Balance Control and Balance Confidence in People with Motor-Incomplete Spinal Cord Injuries or Diseases: A Systematic Review and Meta-Analysis.

OBJECTIVES: To assist with clinical decision-making, evidence syntheses are needed to demonstrate the efficacy of available interventions, and examine the intervention components and dosage parameters. This systematic review and meta-analysis describes the efficacy, components and dosage of interventions targeting upright balance control, balance confidence and/or falls in adults with motor incomplete spinal cord injuries/diseases (SCI/D). DATA SOURCES: A search strategy following the PICO framework was developed. Six databases were searched: APA PsychInfo, CINAHL, Embase, Emcare Nursing, Web of Science CC, and Medline. STUDY SELECTION: Title, abstract and full-text screening were conducted by two researchers independently. Inclusion criteria included: 1) adults with chronic, motor-incomplete SCI/D; 2) physical intervention targeting upright postural control; and 3) clinical and/or biomechanical measures of upright balance control and/or balance confidence and/or documentation of falls. DATA EXTRACTION: Participant characteristics, balance intervention details, adverse events and study results were extracted. The Downs and Black Checklist assessed methodological quality. Meta-analyses on pre-post intervention outcomes and a meta-regression of dosage were completed. The GRADE approach was used to evaluate the quality of the evidence. DATA SYNTHESIS: The search returned 1,664 unique studies; 26 were included. Methodological quality was moderate to good. Participants were 500 individuals with SCI/D, aged 18-74 years (males: females = 2.4:1). Minor adverse events were reported in eight studies (e.g. muscle soreness, fatigue). Walking interventions and upright balance training with visual feedback had clinically meaningful and significant pooled effects on improving standing balance control. Only walking interventions had a significant pooled effect on improving balance confidence. There were no significant findings on dosage response. Few studies evaluated the effects of balance interventions on the occurrence of falls. CONCLUSIONS: Walking interventions and upright balance training with visual feedback had greater effects on upright balance control than conventional physiotherapy; however, the quality of the evidence was very low.

How Can We Treat If We Do Not Measure: A Systematic Review of Neurogenic Bowel Objective Measures.

Background: Guidelines fail to recommend objective measures to assist with treatment of neurogenic bowel dysfunction (NBD) in spinal cord injury (SCI). Objectives: The main objective was to review the literature to identify the objective measures used in all NBD populations and to present their results and any correlations performed to validated subjective measures. Methods: A systematic review of the literature was performed in accordance with PRISMA (2020) guidelines, including all records from January 2012 to May 2023 with MeSH terms like "neurogenic bowel" indexed in the following databases: PubMed, EMBASE, CINAHL, Cochrane Central Trials Register, and ClinicalTrials.gov. Abstracts were excluded if they did not include objective measures or if they only mentioned the esophagus, stomach, and/or small bowel. Records were screened independently by at least two collaborators, and differences were resolved by unanimous agreement. Results: There were 1290 records identified pertaining to NBD. After duplicates were removed, the remaining records were screened for a total of 49 records. Forty-one records (82%) included subjective measures. Two-thirds of the articles involved the population with SCI/disease (n = 552) and one-third were non-SCI NBD (n = 476). Objective measures were categorized as (1) transit time, (2) anorectal physiology testing, and (3) miscellaneous. Of the 38 articles presenting results, only 16 (42%) performed correlations of objective measures to subjective measures. Conclusion: There is an abundance of literature supporting the use of objective outcome measures for NBD in SCI. Strong correlations of subjective measures to objective outcome measures were generally lacking, supporting the need to use both measures to help with NBD management.

Reduction of Overactive Bladder Medications in Spinal Cord Injury With Self-Administered Neuromodulation; a Randomized Trial.

PURPOSE: To evaluate if self-administered bladder neuromodulation with transcutaneous tibial nerve stimulation can safely replace overactive bladder medications in people with spinal cord injury. MATERIALS AND METHODS: We performed a 3-month, randomized, investigator-blinded, tibial nerve stimulation vs sham-control trial in adults with spinal cord injury and neurogenic bladder performing intermittent catheterization and taking overactive bladder medications. The primary outcome was a reduction in bladder medications while maintaining stable bladder symptoms and quality of life based on pre-post Neurogenic Bladder Symptom Score and the Incontinence-QOL questionnaire, respectively. Secondary outcomes included changes in pre-post cystometrogram, 2-day voiding diaries, and an anticholinergic medication side effect survey. RESULTS: Fifty people consented to the study, with 42 completing the trial. No dropouts were due to stimulation issues. All baseline demographics and surveys were comparable at baseline. Cystometrogram parameters were also comparable at baseline, except the stimulation group had a higher proportion of loss of bladder compliance compared to the control group. At the end of the trial, a significantly greater percentage of the tibial nerve stimulation group were able to reduce medications (95% v 68%), by a 26.2% difference in medication reduction (95% confidence interval 1.17%-51.2%). Function and quality of life surveys and cystometrograms at the end of the trial were alike between groups. Transcutaneous tibial nerve stimulation satisfaction surveys and adherence to protocol were high. CONCLUSIONS: In people with chronic spinal cord injury performing intermittent catheterization, transcutaneous tibial nerve stimulation can be an option to reduce or replace overactive bladder medications.

Adiponectin in spinal cord injury: What is the role of nutrition in serum adiponectin concentration?

Objectives: The study aimed to analyze the relationship between serum adiponectin concentration, Mediterranean diet (MD) adherence, and Dietary Approaches to Stop Hypertension (DASH) diet adherence in patients with spinal cord injury (SCI). Patients and methods: Thirty-three SCI patients (21 males, 12 females; median age: 33 years; range, 18 to 65 years) and 33 age-, sex-, and body mass index-matched healthy controls (21 males, 12 females; median age: 33 years; range, 18 to 64 years) were included in this cross-sectional study between March 2021 and March 2022. Serum adiponectin concentrations of all participants were measured. Body weight, height, and neck, hip, waist, and mid-upper arm circumferences were measured. Twenty-four-hour dietary records were obtained by the researchers for evaluation of the nutritional status. The DASH diet score and MD score were measured for each participant. Results: Most of the cases of SCI were due to motor vehicle collisions (n=12, 36.4%) and complete paraplegic. Mid-upper arm circumference, waist circumference, hip circumference, and neck circumference of the patient group were significantly higher than the control group (p=0.020, p=0.002, p=0.042, and p<0.001, respectively). Mediterranean diet scores and DASH diet scores of the patient group were significantly higher than the control group (p<0.001 and p=0.031, respectively). Serum adiponectin concentration of patients was significantly higher than the control group (p=0.049). No correlation was detected between adiponectin concentration, MD score, and DASH diet score in both groups. Conclusion: Although correlation analysis in the current research did not show significant relation between nutrition and adiponectin concentrations, nutrition of patients with SCI, as demonstrated by higher adherence to MD and DASH, may have provided positive effects on adiponectin concentrations. Future studies focused on the effect of a healthy diet intervention on serum adiponectin concentration is warranted.

Developing a mobile exercise program for individuals with Spinal Cord Injury: Stakeholder perceptions of app features and implementation determinants.

BACKGROUND: Individuals with Spinal Cord Injury (SCI) often experience physical deconditioning, leading to long-term health challenges. While regular exercise can offer substantial health benefits, adherence to exercise guidelines among individuals with SCI is hindered by barriers such as inaccessibility. Exercise programs using the mobile application (App) tailored to individual needs present a promising solution for promoting exercise adherence among individuals with SCI. OBJECTIVE: This study aimed to identify factors contributing to the successful implementation of an app-based home exercise program for individuals with SCI and gather user feedback on app preferences, functionality, and features. METHODS: Guided by the Consolidated Framework for Implementation Research (CFIR), twenty-six clinicians completed an expert panel survey to rank factors influencing the implementation of an app-based intervention for increasing exercise adherence for individuals with SCI. CFIR-selected factors and app quality features obtained from the Mobile Application Rating Scale (MARS) framework were discussed in seven focus groups with 23 individuals with SCI, 6 caregivers, and 6 clinicians. RESULTS: The expert survey identified adaptability, complexity, evidence strength/quality, relative advantage, knowledge/beliefs about the initiative, and execution as the key CFIR factors that affected the intervention's success. Major themes emerging from focus groups with individuals with SCI and caregivers included usability, instruction and guidelines, user-friendly interface, and clinician interaction. In contrast, clinicians mentioned themes such as the representation of the SCI population, time commitment, accessibility, and equipment. CONCLUSIONS: The study highlights the significance of incorporating these determinants into future designs to develop app-based home exercise interventions for individuals with SCI.

Relationships of self-reported opioid and benzodiazepine use with health-related quality of life among adults with spinal cord injury.

BACKGROUND: There is limited understanding of the relationships between prescription opioid and benzodiazepine use and indices of health-related quality of life (HRQOL) among those with spinal cord injuries (SCI). OBJECTIVE: To identify the relationships between self-reported prescription opioid and benzodiazepine use and two indicators of HRQOL, number of days in poor physical health and poor mental health in the past 30 days among adults with SCI. METHODS: A cross-sectional cohort study of 918 adults with chronic (>1 year), traumatic SCI living in the Southeastern United States was conducted. Participants completed a self-report assessment (SRA). RESULTS: In the preliminary model, both opioid and benzodiazepine use were associated with a greater number of days in poor physical health and poor mental health in the past month. After controlling for health conditions (pain intensity, spasticity, anxiety and perceived sleep insufficiency), opioid use was associated with 2.04 (CI = 0.69; 3.39) additional poor physical health days in the past 30 days, and benzodiazepine use was associated with 2.18 (CI = 0.70; 3.64) additional days of poor mental health. Age was associated with greater number of poor physical health days and fewer poor mental health days. Lower income was associated with poor mental health days. Most of the health conditions were significantly related to the number of past month poor physical and mental health days. CONCLUSIONS: Opioid and benzodiazepine use are associated with poor physical and mental HRQOL, even after controlling for health conditions. Treatment strategies should consider potential unanticipated negative consequences of pharmacological interventions.

Epidemiology of traumatic spinal cord injury in Spain: A ten-year analysis of trend of clinical and demographic characteristics.

CONTEXT: The study of epidemiological changes of traumatic spinal cord injury (TSCI) is needed due to its highly variable incidence. OBJECTIVE: To determine the incidence of TSCI in Spain and to describe the trend of clinical and demographic characteristics according to age group during a 10-year period. METHODS: A prospective cohort study was conducted. A multidisciplinary team evaluated all individuals with new TSCI. The data were recorded according to the International Spinal Cord Injury Core Data Sets. RESULTS: In a 10-year period, 933 new patients with TSCI were admitted to the hospital. The annual incidence of TSCI was 6.2 per million. The leading causes of injury were traffic accidents (38.5%), low-level falls (20.6%), and high-level falls (19.1%). Males, age group of 31-45 years, and cervical level of injury were the most common profiles of TSCI. In patients over 60 years,71.5% were injured following a fall, particularly low-level falls (47.2%). In patients under 60 years old, the leading cause of SCI was traffic accidents (46%). The proportion of tetraplegia in patients above 60 years was 68.3%, compared to 43.7% in patients under 60 years of age. Patients in the age group above 60 years were hospitalized with a shorter duration of rehabilitation compared to younger age group. CONCLUSIONS: Compared with globally estimated data reported in previous studies, this research demonstrated a low incidence of TSCI in Spain, suggesting a decrease in the last years. Falls and traffic accidents were the most common causes of TSCI in elderly and youth, respectively. Prevention programs should focus on these issues.

Reproductive characteristics and success rate of intracytoplasmic sperm microinjection in spinal cord injury infertile men: Retrospective cohort study.

BACKGROUND: Thanks to modern methods of assisted reproduction (ART), parenthood has become an attainable goal for couples in which the male partner has experienced spinal cord injury (SCI). OBJECTIVE: The aim of our study was to determine the success of the treatment of infertile patients with SCI with intracytoplasmic sperm injection (ICSI) of cryopreserved sperm obtained by the testicular sperm aspiration (TESA) procedure. METHODS: In this retrospective study 156 infertile couples were included, in which the male partner is primarily infertile due to azoospermia. Infertile couples were divided into two groups. The first group (n= 82) includes men with SCI, and the second (n= 74) men with obstructive azoospermia (OA) as the cause of infertility. All infertile men were examined and processed in the diagnostic procedure, and based on the urological findings, surgical extraction of sperm from the testicles was indicated. Exclusion criteria were the age of women over 40 and men over 45. RESULTS: We found that the quality of sperm was worse in the group with SCI, compared to the group with OA, but without statistical significance. Zenica and Johnsen score (p= 0.001; p= 0.000) showed worse semen characteristics in the group with SCI.     There were no significant differences in the average number of embryos (p= 0.698), pregnancy rates per cycle (p= 0.979) and pregnancy rates per embrio transfer (ET), clinical pregnancy rates per ET (p= 0.987) and delivery rates per ET (p= 0.804) in couples with SCI, compared to couples with OA. CONCLUSION: Based on the results of this research, the TESA and ICSI procedures can be recommended as a successful method in the treatment of male infertility caused by azoospermia due to SCI.

Pilot Study of Home-Based Virtual Reality Fitness Training in Post-Discharge Rehabilitation for Patients with Spinal Cord Injury: A Randomized Double-Blind Multicenter Trial.

Spinal cord injury (SCI) patients require continuous rehabilitation post-discharge to ensure optimal recovery. This study investigates the effectiveness of home-based virtual reality fitness training (VRFT) as a convenient and accessible rehabilitation method for SCI patients. This randomized, double-blind, multicenter trial will enroll 120 participants, assigning them to either an 8-week VRFT program (exercise group) or a control group engaging in regular daily activities. The outcomes measured include muscle function, cardiopulmonary fitness, body composition, and physical performance. Our study will determine the safety and feasibility of VRFT in a home setting for SCI patients and evaluate whether these patients can effectively participate in such a program post-discharge. The results of this study are expected to inform future exercise protocols for SCI rehabilitation, offering valuable insights into the utility of VRFT as a therapeutic tool.

Long-Term Pulmonary Function Post-Spinal Cord Injury.

OBJECTIVE: To investigate mean values of pulmonary function tests at specific time points to assess long-term progression in patients with spinal cord injury (SCI). DESIGN: Retrospective cohort study from 1997 to 2022. SETTING: National rehabilitation hospital, providing scheduled admission for potential SCI-related issues. Follow-up assessments are recommended annually, guiding the observation period into consecutive one-year intervals. PARTICIPANTS: This study included 1,394 adult patients who were admitted at least twice to the National Rehabilitation Center between 1997 and 2022, selected from an initial pool of 1,510. Overall, 116 patients were excluded due to the absence of any pulmonary function test (PFT) results. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Changes in PFT values over time, specifically assessing for a potential two-phase pattern post-injury. The hypothesis that PFT values would initially improve before declining was formulated based on existing literature. RESULTS: Significant changes in pulmonary function were noted among 1,394 adults with SCI. FVC and FEV1 initially increased within the first 1-2 years post-injury but declined to below baseline levels after 6 years. Pronounced changes occurred between <1 year and 1-2 years post-injury (FVC: Δ = 4.89, SE = 0.87, p < 0.001; FEV1: Δ = 4.28, SE = 1.09, p = 0.002) and 1-2 years to >6 years (FVC: Δ = -5.83, SE = 0.94, p < 0.001; FEV1: Δ = -6.49, SE = 1.18, p < 0.001). No significant changes in the FEV1/FVC ratio. Motor completeness was significantly associated with the increase and decline phase, showing a steeper increase and less decline compared to the motor-incomplete group. CONCLUSIONS: Pulmonary function in SCI initially increases but declines over time, falling below initial levels by 6 years. Further evaluation with more complete datasets is warranted to elucidate factors influencing these changes.

Evaluating soft collars in pre-hospital cervical spine immobilisation: A cohort study on neurological outcomes, patient comfort and paramedic perspectives.

OBJECTIVE: Cervical spinal immobilisation procedures often include rigid cervical collars which, despite associated complications, may provide less immobilisation than previously thought. The present study reports the incidence of worsening neurological outcomes following soft collar application, and additionally reports patient comfort, compliance with spinal immobilisation, and paramedic perspectives on usage. METHODS: This was an observational cohort study conducted in selected metropolitan and regional areas of NSW Ambulance between 1 May 2022 and 31 March 2023. Soft collars were used exclusively in place of rigid collars. The SPEED (SPinal Emergency Evaluation of Deficits) tool was used to evaluate new or worsening neurological deficits following pre-hospital soft collar application. Secondary outcomes included patient-reported comfort of the device, and paramedic assessment of efficacy. RESULTS: Overall, 2098 soft collars were applied, of which 74 patients (3.5%) were subsequently found to have a cervical spine injury. Eight patients had a spinal cord injury, of which two experienced a worsening neurological deficit after soft collar application. In both instances, comprehensive case reviews determined that this was unlikely to have been attributable to the soft collar. The majority of patients found the soft collar comfortable, and they were well-tolerated by patients who generally complied with immobility directions. Paramedics found the collar easy to apply, and felt it assisted in minimising patient movement. CONCLUSIONS: Pre-hospital use of soft collars does not appear to increase the risk of significant injury. Patients found these devices relatively comfortable, and clinicians reported overall ease of use with good patient compliance with immobility directives.

Disparities Based on Demographic Features in the Intensity and Treatment of Chronic Pain in US Patients With Spinal Cord Injury.

OBJECTIVE: Informed by Minority Stress Theory, to investigate disparities in pain intensity, interference, and care in patients with spinal cord injuries (SCI) based on demographic features. DESIGN: Cross-sectional survey. SETTING: Outpatient SCI clinics in 2 academic medical centers in the northwestern United States. PARTICIPANTS: Sample of 242 SCI clinic patients who endorsed SCI-related pain, were ≥18-years-of-age, English-fluent, not diagnosed with bipolar or psychotic disorders, and able to make their own medical decisions. Participants were 74.8% men, an average of 48.5 years (range 18.1-89.8 years), 76.2% White, 31.9% privately insured, and 64.7% making <$50,000 per year. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Exploratory analyses of screening data from a randomized controlled trial for pain treatment. Primary outcomes included pain intensity, pain interference, and the patient report of recommended pain treatments by a medical provider, tried by the patient, or that the patient would be willing to try. RESULTS: More treatments recommended was associated with younger age (ρ=-0.14, 95% confidence interval [CI]: -0.01 to -0.27, P=.03) and private insurance (ρ=-0.15, 95% CI: 0.02-0.27, P=.03), whereas more treatments tried was associated with private insurance alone (ρ=0.20, 95% CI: 0.07-0.32, P=.003). Number of treatments willing to be tried was associated with lower income (ρ=-0.15, 95% CI: -0.02 to -0.28, P=.03). SCI patients of color (PoC) reported higher pain intensity (Cohen's d=0.41, 95% CI: 0.11-0.71) and greater odds of receiving psychotherapy for pain (odds ratio: 7.12, 95% CI: 1.25-40.46) than their White peers. CONCLUSIONS: These exploratory findings indicate differences in SCI-related pain intensity based on identifying as PoC, and differences in SCI-related pain treatment modalities based on identifying as PoC, age, insurance type, and income. Further work exploring differences in SCI-related pain care based on patient social identities is warranted.

Robot-Assisted Gait Training in Individuals With Spinal Cord Injury: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Spinal cord injury (SCI) rehabilitation emphasizes locomotion. Robotic-assisted gait training (RAGT) is widely used in clinical settings because of its benefits; however, its efficacy remains controversial. We conducted a systematic review and meta-analysis to investigate the efficacy of RAGT in patients with SCI. We searched international and domestic databases for articles published until April 18, 2024. The meta-analysis employed a random effects model to determine the effect size as either mean difference (MD) or standardized MD (SMD). Evidence quality was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Twenty-three studies with a total of 690 participants were included in the final analysis. The overall pooled effect size for improvement in activities of daily living was 0.24, with SMD (95% confidence interval [95% CI], 0.04-0.43; GRADE: high) favoring RAGT over conventional rehabilitation. Muscular strength (MD, 0.23; 95% CI, 0.02-0.44; GRADE: high), walking index for SCI (MD, 0.31; 95% CI, 0.07-0.55; GRADE: moderate) and 6 min walk test distance (MD, 0.38; 95% CI, 0.14-0.63; GRADE: moderate) showed significant improvement in the robot group. Subgroup analysis revealed that subacute patients and intervention periods >2 months were more effective. This meta-analysis revealed that RAGT significantly improved activities of daily living, muscular strength, and walking abilities. Additional studies are needed to identify the optimal treatment protocol and specific patient groups for which the protocol is most effective.

Effects of Botulinum Toxin-A for Spasticity and Nociceptive Pain in Individuals with Spinal Cord Injury: A Systematic Review and Meta-Analysis.

We conducted a systematic review and meta-analysis to examine the protective effects of botulinum toxin-A (Botox-A) on spasticity and nociceptive pain in individuals with spinal cord injuries (SCIs). PubMed, Embase, and Cochrane Library databases were searched from inception to July 2023. The primary outcome of interest was spasticity and nociceptive pain. We pooled the available data using the generic inverse variance method, and we used a fixed-effect/random-effects model. We then calculated standardized mean difference (SMD) and 95% confidence intervals (95% CIs) to estimate the effect size. A total of fourteen studies meeting the inclusion criteria comprised two randomized controlled trials, five pre-post studies, and seven case reports. Across the various study designs, the majority of trials were assessed to have fair to high quality. The meta-analysis shows that Botox-A significantly decreased spasticity (SMD, -1.73; 95% CI, -2.51 to -0.95; p<0.0001, I2=48%) and nociceptive pain (SMD, -1.79; 95% CI, -2.67 to -0.91; p<0.0001, I2=0%) in SCI patients. Furthermore, Botox-A intervention improved motor function, activities of daily living (ADL), and quality of life. Our study suggests that Botox-A may alleviate spasticity and nociceptive pain in SCI patients. Moreover, the observed improvements in motor function, ADL, and overall quality of life following Botox-A intervention underscore its pivotal role in enhancing patient outcomes.

Urinary Tract Infections in Relation to Bladder Emptying in Patients with Spinal Cord Injury.

Background/Objectives: Spinal cord injuries are debilitating conditions with significant impacts on physical function and patient quality of life. The high incidence of urinary tract infections in these patients can be attributed to neurogenic bladder-a major complication of spinal cord injuries. The aim of this study is to investigate the incidence of urinary tract infections in patients with spinal cord injuries and their relation to the method of bladder emptying. Methods: A retrospective analysis on 560 patients admitted for rehabilitation at the Clinic for Rehabilitation "Dr Miroslav Zotovic" from December 2009 to January 2023 was conducted. Patients over 18 years old who were inpatients for longer than 30 days without any symptoms of urinary tract infection on admission were included. Patient demographics, injury details, and bladder emptying methods were recorded. Results: In our study, 402 (71.8%) participants developed a urinary tract infection during their rehabilitation. Urinary tract infections were significantly more common in patients with traumatic spinal cord injuries, lower ASIA scores, and thoracic-level injuries. The highest incidence of urinary tract infections was observed in intermittent self-catheterization patients (62.7%), with Escherichia coli and Proteus mirabilis being the most frequently isolated pathogens. Conclusions: The method of bladder emptying significantly impacted the incidence of urinary tract infection in patients with spinal cord injuries. Despite guidelines favoring intermittent catheterization, this study found it to be associated with the highest infection rates. These findings suggest a need for personalized bladder management strategies to reduce the risk of urinary tract infections and improve outcomes for spinal cord injury patients.

Lesion characteristics are associated with bowel, bladder, and overall independence following cervical spinal cord injury.

CONTEXT/OBJECTIVE: There is a growing global interest in quantifying spinal cord lesions and spared neural tissue using magnetic resonance imaging (MRI) in individuals with spinal cord injury (SCI). The primary objective of this study was to assess the relationships between spinal cord lesion characteristics assessed on MRI and bowel, bladder, and overall independence following SCI. DESIGN: Retrospective, exploratory study. PARTICIPANTS: 93 individuals with cervical SCI who were enrolled in a local United States Model Systems SCI database from 2010 to 2017. METHODS: Clinical and MRI data were obtained for potential participants, and MRIs of eligible participants were analyzed. Explanatory variables, captured on MRIs, included intramedullary lesion length (IMLL), midsagittal ventral tissue bridge width (VTBW), midsagittal dorsal tissue bridge width (DTBW), and axial damage ratio (ADR). OUTCOME MEASURES: Bowel and bladder management scale of the Functional Independence Measure (FIM) and FIM total motor score. RESULTS: When accounting for all four variables, only ADR was significantly associated with bowel independence (OR = 0.970, 95% CI: 0.942-0.997, P = 0.030), and both ADR and IMLL were strongly associated with bladder independence (OR = 0.967, 95% CI: 0.936-0.999, P = 0.046 and OR = 0.948, 95% CI: 0.919-0.978, P = 0.0007, respectively). 32% of the variation in overall independence scores were explained by all four predictive variables, but only ADR was significantly associated with overall independence after accounting for all other predictive variables (ß = -0.469, 95% CI: -0.719, -0.218, P = 0.0004). CONCLUSIONS: Our results suggest that the MRI-measured extent of spinal cord lesion may be predictive of bowel, bladder, and overall independence following cervical SCI.

Rehabilitation Professionals' Perspectives on Human Rights, Disability, and Science: A Qualitative Study.

Objective: To investigate the attitudes and knowledge of rehabilitation professionals concerning human rights within the context of disability, science, and technology access. Design: A qualitative study using in-depth semi-structured interviews. Setting: A large, urban, academically-affiliated rehabilitation research center. Participants: We conducted semi-structured interviews with rehabilitation professionals who specialize in spinal cord injury (SCI) care, including 6 physicians, 3 physical therapists, 2 occupational therapists, 2 nurses, 1 rehabilitation engineer, and 1 rehabilitation psychologist (N=15). Participants were purposively recruited through e-mail letters to members of the American Spinal Injury Association. Efforts were made to recruit a diverse cohort of rehabilitation professionals based on profession, sex, age, and race. Interviews were conducted in person during the 2018 annual meeting or by phone after the meeting. Interventions: Not applicable. Main Outcome Measures: Interviews were recorded, transcribed verbatim, and coded to identify emerging themes within and across participants' content. Results: Primary findings show that most respondents were unaware of disability-relevant human rights doctrine. None was aware of the right to science as articulated in Article 15 of the International Covenant on Economic, Social, and Cultural Rights. Only 2 respondents had previously considered injustices experienced by their clients as human rights violations, yet nearly all were intrigued by framing access difficulties within the right to science paradigm. Overall, participants reported they would find value in implementing human rights in their work. Conclusions: Rehabilitation professionals are receptive to a human rights framework. Further research is needed to identify actionable steps for implementing principles of human rights to increase access to technology by individuals with SCI.

Individuals With Prior Chronic Pain and Long-Term Opioid Treatment May Experience Persistence of That Pain Even After Subsequent Complete Cervical Spinal Cord Injury: Suggestions From a Prospective Case-Controlled Study.

Objective: To determine whether chronic pain persists after complete spinal cord injury (SCI). Design: Prospective observational study regarding the outcome of pre-existent chronic pain of inpatients admitted with new clinically diagnosed complete cervical SCI. For patients who acknowledged chronic pain of ≥3 years duration before the SCI, further questions explored whether they still experienced that pain, whether they were experiencing current posttraumatic pain, and whether they had any past exposure to opioids. The included patients were identified during the initial consultation in the trauma center for treatment of the SCI. Setting: Level I trauma center. Participants: From a total of 49 participants with acute cervical SCI with clinically diagnosed complete motor and sensory tetraplegia admitted between 2018 and 2020, 7 were selected on the basis of a history of chronic pain. Intervention: Collected complete history and performed physical examination with serial follow-ups during the acute hospital stay until death or discharge. Main Outcome Measures: The primary outcome was a finding of chronic pain experienced before new clinical diagnosis of complete SCI, compared with whether or not that pain continued after the SCI injury. The secondary outcome was the relation of persistent pain with opioid use; it was formulated after data collection. Results: Among 49 patients with clinically diagnosed complete cervical SCIs, 7 had experienced prior chronic pain. Four participants experienced a continuation of the prior pain after their complete tetraplegia (4/7), whereas 3 participants did not (3/7). All the participants with continued pain had been previously treated with opioids, whereas those whose pain ceased had not received chronic opioid therapy. Conclusions: There may be a unique form of chronic pain that is based in the brain, irrespective of peripheral pain or spinal mechanisms. Otherwise healthy people with longstanding antecedent chronic pain whose pain persists after acute clinically complete SCI with tetraplegia may provide a new model for evaluation of brain-based pain. Opioids may be requisite for this type of pain.