Active Conservative Management of Primary Spinal Syringomyelia: A Scoping Review and Perspectives for an Activity-based Clinical Approach.

OBJECTIVE: This scoping review aimed to identify and synthesize existing research on active conservative management of primary spinal syringomyelia and associated symptoms and to discuss perspectives for clinical application using an activity-based approach. METHODS: PubMed, Embase, Scopus, and Web of Science were systematically searched for empirical studies of conservative management or therapies of adults with primary spinal syringomyelia from inception to April 2021. In addition, abstracts from relevant conferences were searched. Study characteristics and key findings were extracted, and findings descriptively synthesized. RESULTS: Of 1,186 studies screened, 7 studies met the eligibility criteria (4 single case studies and 3 cohort studies, a total of 90 individuals). The interventions were primarily physiotherapeutic, mostly by posture correction and exercises, and effects were alleviation of pain, improved physical function, improved activities of daily living and quality of life. Analysis of factors triggering symptoms and rationale for choice of intervention based upon these was limited. CONCLUSION: Evidence of active conservative management of primary spinal syringomyelia and associated symptoms is limited. Many variations and limitations in the existing research limit the conclusions. High-quality research is needed to enable healthcare professionals to apply evidencebased active conservative interventions.

Temporal changes in demographic and injury characteristics of traumatic spinal cord injuries in Nordic countries - a systematic review with meta-analysis.

STUDY DESIGN: Systematic review with meta-analysis. OBJECTIVES: To explore temporal changes in incidence rates, demographic and injury characteristics of incident traumatic spinal cord injury (TSCI) in Nordic countries. METHODS: Peer-reviewed publications and periodic reports about epidemiology of TSCI in the Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) are identified, reviewed and included in the meta-analysis. Data are stratified into 20-year intervals to allow for chronological comparisons. Pooled estimates are derived using random effects meta-analysis. RESULTS: Twenty-three data sources are included presenting a total of 5416 cases. The pooled incidence rate for 2001-2020 is 15.4 cases/million/year compared to 17.6 and 18.3 cases/million/year during the two previous 20-year intervals. The proportion of cases with TSCI in the 15-29 age-group decreases from 50% (1961-1980) to 20% (2001-2020), while it increases from 9% to 35% in 60+ age-group. Transportation-related injuries decrease from 44% (1961-1980) to 27% (2001-2020). Conversely, fall-related injuries increase from 32% (1961-1980) to 46% (2001-2020). The proportion of individuals with incomplete tetraplegia increases from 31% (1961-1980) to 43% (2001-2020), while complete paraplegia decreases from 25% to 16%. CONCLUSION: The characteristics of TSCI in the Nordic countries have changed drastically over the last six decades, in line with clinical experiences, and limited research evidence from other countries. These changes indicate the need for adapting research focus, prevention strategies, design and provision of care, rehabilitation and community services towards older individuals, fall-related injuries, and incomplete injuries in Nordic countries and other settings internationally where such changes occur.

Translation and validation of two International Spinal Cord Injury (SCI) Data Sets-a modified process.

Study design: A descriptive design was used of a reflective process of problem solving among individuals working together to improve the process of translating. Setting: Sweden. Objectives: The aim of this study was to describe a modified process for translation and validation of the International Spinal Cord Injury (SCI) Quality of Life (QoL) and Activity and Participation (A&P) Basic Data Sets from English into Swedish. Methods: The process of translation followed the Executive Committee for the International SCI Standards and Data Sets (ECSCI) recommendations. The initial translation was performed by translators. Experts in SCI were then assembled to scrutinize the translations and to reach a consensus for defining a final version. Results: The whole process was time consuming. To save time in future translations, the start-up planning is of great importance. To identify appropriate participants with knowledge and interest to be part of the project is crucial. In addition, the consensus meetings, when scrutinizing the translated International SCI Data Sets, should be well prepared and structured. We identified a few steps that could make the process more efficient. Conclusions: By adding a few steps as well as defining the role of a project coordinator, we believe that future translations of the International SCI Data Sets for non-English-speaking countries could be facilitated.

Exoskeleton gait training after spinal cord injury: An exploratory study on secondary health conditions.

OBJECTIVE: To explore changes in pain, spasticity, range of motion, activities of daily living, bowel and lower urinary tract function and quality of life of individuals with spinal cord injury following robotic exoskeleton gait training. DESIGN: Prospective, observational, open-label multicentre study. METHODS: Three training sessions per week for 8 weeks using an Ekso™ GT robotic exoskeleton (EKSO Bionics). Included were individuals with recent (<1 year) or chronic (>1 year) injury, paraplegia and tetraplegia, complete and incomplete injury, men and women. RESULTS: Fifty-two participants completed the training protocol. Pain was reported by 52% of participants during the week prior to training and 17% during training, but no change occurred longitudinally. Spasticity decreased after a training session compared with before the training session (p <0.001), but not longitudinally. Chronically injured participants increased Spinal Cord Independence Measure (SCIM III) from 73 to 74 (p = 0.008) and improved life satisfaction (p = 0.036) over 8 weeks of training. Recently injured participants increased SCIM III from 62 to 70 (p < 0.001), but no significant change occurred in life satisfaction. Range of motion, bowel and lower urinary function did not change over time. CONCLUSION: Training seemed not to provoke new pain. Spasticity decreased after a single training session. SCIM III and quality of life increased longitudinally for subsets of participants.

Bladder irrigation with Chlorhexidine reduces bacteriuria in persons with spinal cord injury.

OBJECTIVE: To explore whether bladder irrigation with chlorhexidine: (i) can reduce bacteriuria, and (ii) is a practically feasible option in subjects with spinal cord injury practicing intermittent self-catheterization. DESIGN: A prospective, non-controlled, open, multi-centre study. METHODS: Fifty patients with spinal cord injury, practicing intermittent self-catheterization, with a history of recurrent urinary tract infections were screened for bacteriuria at follow-up visits to 4 spinal cord injury centres in Sweden. Twenty-three patients had a positive urine culture (> 105 CFU/ml of > 1 bacterial species), of which 19 completed the study. Subjects proceeded with bladder irrigation, using 120 ml of 0.2% chlorhexidine solution twice daily for up to 7 days. Urine samples were taken twice daily. Response to treatment was defined as reduction in bacterial counts to < 103 CFU/ml. RESULTS: Fourteen of 19 subjects reduced their bacterial counts to or below the set limit. Subsequent return of above-endpoint bacteriuria was seen in most of the subjects. However, there were significantly fewer subjects with bacteriuria after treatment (p <0.005). CONCLUSION: Bladder irrigation with chlorhexidine, using intermittent self-catheterization, reduced bacteriuria in the majority of subjects with spinal cord injury and bacteriuria. The addition of bladder irrigation was practically feasible in the short time-frame of this study.

Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso Bionics.

STUDY DESIGN: Prospective quasi-experimental study, pre- and post-design. OBJECTIVES: Assess safety, feasibility, training characteristics and changes in gait function for persons with spinal cord injury (SCI) using the robotic exoskeletons from Ekso Bionics. SETTING: Nine European rehabilitation centres. METHODS: Robotic exoskeleton gait training, three times weekly over 8 weeks. Time upright, time walking and steps in the device (training characteristics) were recorded longitudinally. Gait and neurological function were measured by 10 Metre Walk Test (10 MWT), Timed Up and Go (TUG), Berg Balance Scale (BBS), Walking Index for Spinal Cord Injury (WISCI) II and Lower Extremity Motor Score (LEMS). RESULTS: Fifty-two participants completed the training protocol. Median age: 35.8 years (IQR 27.5-52.5), men/women: N = 36/16, neurological level of injury: C1-L2 and severity: AIS A-D (American Spinal Injury Association Impairment Scale). Time since injury (TSI) < 1 year, N = 25; > 1 year, N = 27. No serious adverse events occurred. Three participants dropped out following ankle swelling (overuse injury). Four participants sustained a Category II pressure ulcer at contact points with the device but completed the study and skin normalized. Training characteristics increased significantly for all subgroups. The number of participants with TSI < 1 year and gait function increased from 20 to 56% (P = 0.004) and 10MWT, TUG, BBS and LEMS results improved (P < 0.05). The number of participants with TSI > 1 year and gait function, increased from 41 to 44% and TUG and BBS results improved (P < 0.05). CONCLUSIONS: Exoskeleton training was generally safe and feasible in a heterogeneous sample of persons with SCI. Results indicate potential benefits on gait function and balance.

Clinical fMRI of language function in aphasic patients: reading paradigm successful, while word generation paradigm fails.

BACKGROUND: In fMRI examinations, it is very important to select appropriate paradigms assessing the brain function of interest. In addition, the patients' ability to perform the required cognitive tasks during fMRI must be taken into account. PURPOSE: To evaluate two language paradigms, word generation and sentence reading for their usefulness in examinations of aphasic patients and to make suggestions for improvements of clinical fMRI. MATERIAL AND METHODS: Five patients with aphasia after stroke or trauma sequelae were examined by fMRI. The patients' language ability was screened by neurolinguistic tests and elementary pre-fMRI language tests. RESULTS: The sentence-reading paradigm succeeded to elicit adequate language-related activation in perilesional areas whereas the word generation paradigm failed. These findings were consistent with results on the behavioral tests in that all patients showed very poor performance in phonemic fluency, but scored well above mean at a reading comprehension task. CONCLUSION: The sentence-reading paradigm is appropriate to assess language function in this patient group, while the word-generation paradigm seems to be inadequate. In addition, it is crucial to use elementary pre-fMRI language tests to guide the fMRI paradigm decision.

Long-term follow up of factual knowledge after a single, randomised problem-based learning course.

BACKGROUND: The long-term effect of problem-based learning (PBL) on factual knowledge is poorly investigated. We took advantage of a previous randomised comparison between PBL and traditional teaching in a 3rd year course to follow up factual knowledge of the students during their 4th and 5th year of medical school training. METHODS: 3rd year medical students were initially randomized to participate in a problem-based (PBL, n = 55), or a lecture-based (LBL, n = 57) course in basic pharmacology. Summative exam results were monitored 18 months later (after finishing a lecture-based course in clinical pharmacology). Additional results of an unscheduled, formative exam were obtained 27 months after completion of the first course. RESULTS: Of the initial sample of 112 students, 90 participated in the second course and exam (n = 45, 45). 32 (n = 17 PBL, n = 15 LBL) could be exposed to the third, formative exam. Mean scores (+/- SD) were 22.4 +/- 6.0, 27.4 +/- 4.9 and 20.1 +/- 5.0 (PBL), or 22.2 +/- 6.0, 28.4 +/- 5.1 and 19.0 +/- 4.7 (LBL) in the first, second and third test, respectively (maximum score: 40). No significant differences were found between the two groups. CONCLUSION: A small-scale exposure to PBL, applied under randomized conditions but in the context of a traditional curriculum, does not sizeably change long-term presence of factual knowledge within the same discipline.

A follow-up of medical graduates of a problem-based learning curriculum.

INTRODUCTION: There is little information available on the effects of problem-based undergraduate curricula on doctors and their performances after graduation. Therefore, we conducted a questionnaire study of all graduates of the new medical programme at the Faculty of Health Sciences, Linköping University. METHODS: All 446 medical students who had graduated from the new programme were asked to fill in a questionnaire about selected activities during their studies and their careers after graduation. They were also asked to evaluate the quality of their undergraduate education retrospectively. Statistical analysis was performed using descriptive, multivariate and bivariate approaches. RESULTS: A total of 77% of the graduates responded. They showed a high degree of overall contentment with their undergraduate education and felt well prepared for professional life during their preregistration period and specialist education (mean = 4.0 on a 6-point Likert scale ranging from 0 to 5). They felt especially well prepared in terms of skills for communication with patients, collaboration with other health professionals and development of critical thinking/scientific attitudes. The students' age at the beginning of their studies correlated positively with their contentment as graduates, especially in terms of preparation for patient communication and collaboration with other health professionals. No differences between students originally admitted via a local admission procedure and those admitted via a national procedure were detected concerning retrospective evaluation of undergraduate medical education. CONCLUSION: Graduates of the new curriculum showed a high degree of satisfaction with their undergraduate education and its preparation of them for medical practice. Specifically, they were very content with the particular emphases of the new curriculum.

Cognitive impairment in patients with chronic whiplash-associated disorder--a matched control study.

AIM: To verify the occurrence of cognitive impairment in patients with chronic whiplash-associated disorder (WAD) and to provide a more detailed description of the impairment's character and context. METHODS: Thirty (30) patients with chronic WAD and 30 matched healthy controls completed a cognitive test battery. Four computerised tests were used: a) two different types of cognitive tasks (reaction time vs. working memory) and b) two types of information processing (verbal vs. spatial). Before testing and after every randomised subtest, subjects rated their pain level on a visual analogue scale. RESULTS: A worse overall performance among patients with WAD and, specifically, worse results concerning working memory tasks were found. Post-hoc testing revealed a statistically significant difference concerning the single variable "verbal reaction time". Pain intensity among patients increased significantly during testing. Pain intensity after the subtest for verbal mental reaction time (independent of test sequence) was significantly correlated with results in this subtest, the more pain, the more time was needed. CONCLUSION: Compared to healthy controls, patients performed worse overall. Concerning verbal reaction time, the impairment was correlated with pain intensity. The findings support the hypothesis that pain might be one important factor leading to cognitive impairment in patients with chronic WAD.

The influence of tutor qualification on the process and outcome of learning in a problem-based course of basic medical pharmacology.

Limited access to expert tutors is a problem that can be addressed by using tutors from different stages of medical or non-medical (under-, post-) graduate education. To address whether such differences in qualification affect the results of process evaluation by participants or their learning outcome (exam results), we analysed the data of a 4-year prospective study performed with 787 3rd-year medical students (111 groups of 5-10 participants) taking an obligatory problem-based learning (PbL)-course of basic pharmacology. We compared peer tutors (undergraduate medical students, >/=4th year), non-expert (junior) staff tutors (physicians, pharmacists, veterinarians, biologists, or chemists during postgraduate education), and expert (senior) staff tutors (completed postgraduate education). Evaluation scores related to PbL gave the highest values for senior staff-led groups. The tutor's performance score of peer-led groups did not differ from those of staff-led groups, but the score obtained from groups tutored by junior staff was lower than that obtained with senior staff tutors. Students' weekly preparation time tended to be lower in peer-led groups, while learning time spent specifically on exam preparation seemed to be increased compared to PbL-groups of staff tutors. As a putative confounding variable, tutors' experience in coaching PbL-groups was also investigated. Groups led by experienced tutors, defined as tutors with at least one term of previous PbL tutoring, were found to have significantly higher evaluation scores. Interestingly, neither tutors' subject-matter expertise (peer students, junior staff, or senior staff) nor their teaching-method expertise showed any influence on PbL-groups' mean test scores in a written exam. This indicates that the effect of tutor expertise on the learning process is not associated with a difference in learning outcome when just factual knowledge is assessed by traditional methods.