Incidence and Risk Factors of Pneumonia in Individuals With Acute Spinal Cord Injury: A Multi-national, Multi-center, Prospective Cohort Study.

OBJECTIVE: To describe the occurrence of pneumonia in individuals with acute spinal cord injury (SCI) and identify its key predictors. DESIGN: Multi-centric, longitudinal cohort study. SETTING: 10 specialized SCI rehabilitation units in Europe and Australia. PARTICIPANTS: Eligible were 902 men and women with acute SCI, aged 18 years or older, with cervical or thoracic lesions and not dependent on 24-hour mechanical ventilation; 503 participated in the study (N=503). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We assessed demographics and lesion related parameters at study entry, and any pneumonia events throughout inpatient rehabilitation. Respiratory function, decubitus, and urinary tract infections were assessed at 1, 3, and 6 months post injury as well as at discharge from inpatient rehabilitation. Time to event (pneumonia) analyses were done using the Kaplan-Meier method, and potential predictors for pneumonia were analyzed with multivariable survival models. RESULTS: Five hundred three patients with SCI were included, with 70 experiencing at least 1 pneumonia event. 11 participants experienced 2 or more events during inpatient rehabilitation. Most events occurred very early after injury, with a median of 6 days. Pneumonia risk was associated with tetraplegia (hazard ratio [HR]=1.78; 95% confidence interval [CI] 1.00-3.17) and traumatic etiology (HR=3.75; 95% CI 1.30-10.8) American Spinal Injury Impairment Scale (AIS) A (HR=5.30; 95% CI 2.28-12.31), B (HR=4.38; 95% CI 1.77-10.83), or C (HR=4.09; 95% CI 1.71-9.81) lesions. For every 10 cmH2O increase in inspiratory muscle strength, pneumonia risk was reduced by 13% (HR=0.87; 95% CI 0.78-0.97). CONCLUSION: Pneumonia is a major complication after SCI with the highest incidence very early after injury. Individuals with traumatic or AIS A, B, or C tetraplegia are at highest risk for pneumonia.

Management of sleep-disordered breathing in three spinal cord injury rehabilitation centres around the world: a mixed-methods study.

STUDY DESIGN: Mixed-methods observational study. OBJECTIVE: To describe the sleep-disordered breathing (SDB) management models of three spinal cord injury (SCI) rehabilitation centres that are screening, diagnosing and treating uncomplicated SDB, and to determine their common elements. SETTING: Three specialist SCI rehabilitation centres. METHODS: Data collection at each site included direct observations and interviews with lead clinical staff and an audit of SDB-related clinical practice in 2019. Detailed descriptions of the models of care, including process maps, were developed. A theory-based analysis of the common elements of the three care models was undertaken. RESULTS: At each centre a multidisciplinary team, consisting of medical, allied health and/or nursing staff, provided a comprehensive SDB management service that included screening, diagnosis and treatment. Inpatients with SCI were assessed for SDB with overnight oximetry and/or polygraphy. Further assessment of patient symptoms, respiratory function, and hypercapnia supported the diagnostic process. Treatment with positive airway pressure was initiated on the ward. Having a collaborative, skilled team with strong leadership and adequate resources were the key, common enablers to providing the service. CONCLUSION: It is feasible for multi-disciplinary SCI rehabilitation teams to independently diagnose and treat uncomplicated SDB without referral to specialist sleep services provided they are adequately resourced with equipment and skilled staff. Similar models of care could substantially improve access to SDB treatment for people with SCI. Further research is required to determine the non-inferiority of these alternatives to specialist care.

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.

Indications and effects of botulinum toxin A for obstetric brachial plexus injury: a systematic literature review.

AIM: To give an overview of indications for the use of botulinum toxin A (BoNT-A) treatment for children with obstetric brachial plexus injury (OBPI), and to present the best available evidence of the effectiveness of this treatment. METHOD: Searches were performed in Cinahl, Cochrane Library, Embase, PubMed, and Web of Science, using the keywords 'botulinum' and 'plexus', to identify articles reporting on the use of BoNT-A as a treatment for children with OBPI. Studies found through the references of related articles were also selected. RESULTS: Ten full-text papers and six congress abstracts were included, involving 343 children. Four groups of indications could be identified: internal rotation/adduction contracture of the shoulder, limited active elbow flexion, limited active elbow extension, and pronation contracture of the lower arm. Overall, positive results were reported for all except the indication for limited active elbow extension. However, only one study was comparative in nature; all others were classified as having a low level of evidence. There was a large variation in outcome measures. INTERPRETATION: To provide better evidence for the already partly promising results of BoNT-A treatment for children with OBPI, multicentre randomized controlled trials are needed.

Respiratory function and respiratory complications in spinal cord injury: protocol for a prospective, multicentre cohort study in high-income countries.

INTRODUCTION: Pneumonia is one of the leading complications and causes of death after a spinal cord injury (SCI). After a cervical or thoracic lesion, impairment of the respiratory muscles decreases respiratory function, which increases the risk of respiratory complications. Pneumonia substantially reduces patient's quality of life, may prolong inpatient rehabilitation time, increase healthcare costs or at worse, lead to early death. Respiratory function and coughing can be improved through various interventions after SCI, but the available evidence as to which aspect of respiratory care should be optimised is inconclusive. Furthermore, ability of respiratory function parameters to predict pneumonia risk is insufficiently established. This paper details the protocol for a large-scale, multicentre research project that aims to evaluate the ability of parameters of respiratory function to predict and understand variation in inpatient risk of pneumonia in SCI. METHODS AND ANALYSIS: RESCOM, a prospective cohort study, began recruitment in October 2016 across 10 SCI rehabilitation centres from Australia, Austria, Germany, the Netherlands and Switzerland. Inpatients with acute SCI, with complete or incomplete cervical or thoracic lesions, 18 years or older and not/no more dependent on 24-hour mechanical ventilation within the first 3 months after injury are eligible for inclusion. The target sample size is 500 participants. The primary outcome is an occurrence of pneumonia; secondary outcomes include pneumonia-related mortality and quality of life. We will use the longitudinal data for prognostic models on inpatient pneumonia risk factors. ETHICS AND DISSEMINATION: The study has been reviewed and approved by all local ethics committees of all participating centres. Study results will be disseminated to the scientific community through peer-reviewed journals and conference presentations, to the SCI community, other stakeholders and via social media, newsletters and engagement activities. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov NCT02891096.

The pedicled internal pudendal artery perforator (PIPAP) flap for ischial pressure sore reconstruction: Technique and long-term outcome of a cohort study.

BACKGROUND: The ischial region is the site most affected by pressure sores and has the highest recurrence and complication rates compared to other affected sites. We developed a practical and safe pedicled flap for reconstruction of ischial pressure sores based on the rich available perforators from the internal pudendal artery and the surplus of skin at the infragluteal fold. METHODS: A retrospective cohort study was conducted in all patients who underwent ischial pressure ulcer reconstruction using the PIPAP flap between March 2010 and March 2017. The skin flap was designed along the gluteal fold. The skin perforators of the pudendal artery were marked with a Doppler probe in the medial region of the gluteal fold. Surgery was performed in the jackknife position, and flaps were elevated in the suprafascial plane. Patients were assessed for minor (requiring no additional surgery) and major complications (requiring additional surgery). RESULTS: Twenty-seven patients (34 flaps) were identified. The median follow-up period was 38 months (IQR 37). Primary closure of the donor-site was achieved in all procedures, only one flap required muscle flap transposition in order to fill the dead space. The mean operating time was 60 ± 21 minutes. In six flaps (9%) wound healing problems were noted that did not require an additional operative procedure. Among the nine flaps (27%) that required a second procedure, 3 (9%) were necessary due to recurrent ulcers. CONCLUSIONS: The PIPAP flap is a safe and reliable alternative for ischial pressure sore reconstruction, certainly when compared to available techniques. Moreover, it has significant advantages over other techniques including minimal donor-site morbidity, preservation of posterior thigh skin, buttock-line integrity and reliable vascularity.

Effects of four-month handbike training under free-living conditions on physical fitness and health in wheelchair users.

PURPOSE: Recognizing the encouraging effect of challenging events, the HandbikeBattle (HBB) was created to promote exercise among wheelchair users. The purpose of this study was to reveal the effects on physical fitness and health outcomes of four-month handbike training under free-living conditions in preparation for the event. METHODS: In this prospective cohort study, 59 relatively inexperienced handyclists participated in the HBB of 2013 or 2014. Incremental exercise tests were conducted, respiratory function was tested and anthropometrics were measured before and after the preparation period. Main outcome measures were peak power output (POpeak), peak oxygen uptake (VO2peak) and waist circumference, of which the changes were tested using repeated measures ANOVA. To detect possible determinants of changes in physical fitness, a linear regression analysis was conducted with personal characteristics, executed training volume and upper-extremity complaints during the training period as independent variables. RESULTS: POpeak, VO2peak and waist circumference improved significantly with 17%, 7% and 4.1%, respectively. None of the included variables were significant determinants for the changes in POpeak found as a result of the training. CONCLUSION: A challenging event such as the HBB provokes training regimes among participants of sufficient load to realize substantial improvements in physical fitness and health outcomes. Implications for Rehabilitation Due to the often impaired muscle function in the lower-limbs and an inactive lifestyle, wheelchair users generally show considerably lower levels of fitness compared to able-bodied individuals. This prospective cohort study showed that four months of handbike training under free-living conditions in preparation for this event resulted in substantial improvements in physical fitness and health outcomes in wheelchair users. The creation of a challenging event such as the HandbikeBattle as part of a follow-up rehabilitation practice can therefore be a useful tool to help wheelchair users initiate or keep training to improve their physical fitness and health.

Wheelchair-specific fitness of inactive people with long-term spinal cord injury.

OBJECTIVES: To describe wheelchair-specific anaerobic work capacity, isometric strength and peak aerobic work capacity of physically inactive people with long-term spinal cord injury using outcomes of tests that are feasible for use in rehabilitation centres, and to determine associations among these fitness components. DESIGN: Cross-sectional study. PARTICIPANTS: Manual wheelchair users with spinal cord injury for at least 10 years, who were inactive based on a norm score of a physical activity questionnaire (n = 29; 22 men; 20 with paraplegia; median age 53 years). METHODS: Participants performed 3 exercise tests in their own wheelchair to determine: highest 5-s power output over 15-m overground sprinting (P5-15m); highest 3-s isometric push-force (Fiso); and peak power output (POpeak) and peak oxygen uptake (VO2peak) over a peak test. RESULTS: Median (interquartile range) was in P5-15m 16.1 W (9.4-20.9); in Fiso 399 N (284-610); in POpeak 40.9 W (19.1-54.9); and in VO2peak 1.26 l/min (0.80-1.67). Correlations among outcomes of fitness components were weak (r = 0.50-0.67, p < 0.01), except for P5-15m with POpeak (r = 0.79, p < 0.001). CONCLUSION: All fitness components measured in this sample were at relatively low levels, implying a specific need for interventions to improve wheelchair-specific fitness. The weak-to-moderate associations among components imply that separate tests should be used when monitoring wheelchair-specific fitness in rehabilitation centres.