Movement repetitions in physical and occupational therapy during spinal cord injury rehabilitation.

STUDY DESIGN: Longitudinal observational study. OBJECTIVE: To quantify the amount of upper- and lower-extremity movement repetitions (that is, voluntary movements as part of a functional task or specific motion) occurring during inpatient spinal cord injury (SCI), physical (PT) and occupational therapy (OT), and examine changes over the inpatient rehabilitation stay. SETTING: Two stand-alone inpatient SCI rehabilitation centers. METHODS: Participants: A total of 103 patients were recruited through consecutive admissions to SCI rehabilitation. INTERVENTIONS: Trained assistants observed therapy sessions and obtained clinical outcome measures in the second week following admission and in the second to last week before discharge. MAIN OUTCOME MEASURES: PT and OT time, upper- and lower-extremity repetitions and changes in these outcomes over the course of rehabilitation stay. RESULTS: We observed 561 PT and 347 OT sessions. Therapeutic time comprised two-thirds of total therapy time. Summed over PT and OT, the median upper-extremity repetitions in patients with paraplegia were 7 repetitions and in patients with tetraplegia, 42 repetitions. Lower-extremity repetitions and steps primarily occurred in ambulatory patients and amounted to 218 and 115, respectively (summed over PT and OT sessions at discharge). Wilcoxon-signed rank tests revealed that most repetition variables did not change significantly over the inpatient rehabilitation stay. In contrast, clinical outcomes for the arm and leg improved over this time period. CONCLUSIONS: Repetitions of upper- and lower-extremity movements are markedly low during PT and OT sessions. Despite improvements in clinical outcomes, there was no significant increase in movement repetitions over the course of inpatient rehabilitation stay.

Knowledge translation and implementation in spinal cord injury: a systematic review.

OBJECTIVE: To conduct a systematic review examining the effectiveness of knowledge translation (KT) interventions in changing clinical practice and patient outcomes. METHODS: MEDLINE/PubMed, CINAHL, EMBASE and PsycINFO were searched for studies published from January 1980 to July 2012 that reported and evaluated an implemented KT intervention in spinal cord injury (SCI) care. We reviewed and summarized results from studies that documented the implemented KT intervention, its impact on changing clinician behavior and patient outcomes as well as the facilitators and barriers encountered during the implementation. RESULTS: A total of 13 articles featuring 10 studies were selected and abstracted from 4650 identified articles. KT interventions included developing and implementing patient care protocols, providing clinician education and incorporating outcome measures into clinical practice. The methods (or drivers) to facilitate the implementation included organizing training sessions for clinical staff, introducing computerized reminders and involving organizational leaders. The methodological quality of studies was mostly poor. Only 3 out of 10 studies evaluated the success of the implementation using statistical analyses, and all 3 reported significant behavior change. Out of the 10 studies, 6 evaluated the effect of the implementation on patient outcomes using statistical analyses, with 4 reporting significant improvements. The commonly cited facilitators and barriers were communication and resources, respectively. CONCLUSION: The field of KT in SCI is in its infancy with only a few relevant publications. However, there is some evidence that KT interventions may change clinician behavior and improve patient outcomes. Future studies should ensure rigorous study methods are used to evaluate KT interventions.

An evidence-based review on the influence of aging with a spinal cord injury on subjective quality of life.

STUDY DESIGN: Systematic review. OBJECTIVES: To identify changes in subjective quality of life (QoL) as one ages with a spinal cord injury (SCI). SETTING: Vancouver, Canada. METHODS: Electronic databases were searched for studies reporting on age-related QoL changes over time. Data from relevant studies were transcribed into data extraction forms and analyzed by years post injury (YPI) and chronologic age. Each study was assigned a level of evidence based on a modified Sackett scale. RESULTS: In all, 21 studies, each with a low level of evidence, were included for review. The results indicated that regardless of chronologic age, individuals with relatively new SCI have the potential to improve their QoL. Among individuals with advanced YPI, overall QoL is consistently reported as good or excellent over time, however, with variations in different QoL domains. CONCLUSION: The QoL of individuals aging with a SCI has the potential to improve, and remain high and stable over time. As the identified studies provide low levels of evidence, more longitudinal research with greater methodological and measurement rigor is needed to corroborate the findings and conclusions of this review.

An evidence-based review of aging of the body systems following spinal cord injury.

STUDY DESIGN: Systematic review. OBJECTIVE: To systematically review evidence on aging of the body systems after spinal cord injury (SCI). SETTING: Toronto, Ontario and Vancouver, British Columbia, Canada. METHODS: Electronic databases (MEDLINE/PubMed, CINAHL, EMBASE and PsycINFO), were searched for studies published between 1980 and 2009. The search was augmented by reviewing the reference lists of relevant papers. Non-intervention studies that were longitudinal or cross-sectional with able-bodied controls that were at minimum matched on chronological age were included for review. Levels of evidence were assigned to the study design using a modified Sackett scale. RESULTS: Of the 74 studies selected for inclusion, 16 were longitudinal in design. The hypothesis that SCI represents a model for premature aging is supported by a large proportion of level 5 evidence for the cardiovascular and endocrine systems, level 2, 4 and 5 evidence for the musculoskeletal system, and limited level 5 evidence for the immune system. Only a few level 4 and 5 studies for the respiratory system were found. The evidence on the genitourinary system, gastrointestinal system, and for skin and subcutaneous tissues provide level 4 and 5 evidence that premature aging may not be occurring. The evidence on the nervous system does not provide evidence of premature aging as a result of SCI. CONCLUSIONS: Premature aging appears to occur in some systems after SCI. Additional longitudinal studies are required to confirm these findings.

Compromised bone strength index in the hemiparetic distal tibia epiphysis among chronic stroke patients: the association with cardiovascular function, muscle atrophy, mobility, and spasticity.

SUMMARY: The purpose of this study was to identify the determinants of the bone strength index of the distal tibia epiphysis in chronic stroke patients. The results showed that lower cardiovascular fitness, more muscle atrophy, poorer mobility, and more severe spasticity were independently associated with lower tibial bone strength index. INTRODUCTION: To identify the determinants of the bone strength index (BSI) at the distal tibia in chronic stroke patients METHODS: Sixty-three chronic stroke survivors underwent scanning of the distal tibia at the 4% site on both sides using peripheral quantitative computed tomography. The primary outcomes were trabecular bone mineral density (BMD; milligram per cubic centimeter), total BMD (milligram per cubic centimeter), total bone area (square millimeter), and BSI (square gram per centimeter to the power of four). Cardiovascular fitness, leg lean mass, gait velocity, and spasticity were also measured. RESULTS: Scans from 45 subjects were deemed to have acceptable quality and were included for subsequent analysis. The paretic side had significantly lower trabecular BMD, total BMD, and BSI than the nonparetic side (p < 0.05). However, the total bone area demonstrated no significant side-to-side difference (p > 0.05). After adjusting for relevant biological factors, peak oxygen consumption, leg muscle mass, and gait velocity remained positively associated with tibial BSI on both sides (R (2) change = 6.9-14.2%), whereas spasticity of the paretic leg was negatively associated with tibial BSI on the same side (R (2) change = 4.8%). CONCLUSIONS: Cardiovascular function, muscle atrophy, mobility, and spasticity are independently associated with BSI of the distal tibia epiphysis among chronic stroke patients.

Neurogenic bowel management after spinal cord injury: a systematic review of the evidence.

STUDY DESIGN: Randomized-controlled trials (RCTs), prospective cohort, case-control, pre-post studies, and case reports that assessed pharmacological and non-pharmacological intervention for the management of the neurogenic bowel after spinal cord injury (SCI) were included. OBJECTIVE: To systematically review the evidence for the management of neurogenic bowel in individuals with SCI. SETTING: Literature searches were conducted for relevant articles, as well as practice guidelines, using numerous electronic databases. Manual searches of retrieved articles from 1950 to July 2009 were also conducted to identify literature. METHODS: Two independent reviewers evaluated each study's quality, using Physiotherapy Evidence Database scale for RCTs and Downs and Black scale for all other studies. The results were tabulated and levels of evidence assigned. RESULTS: A total of 2956 studies were found as a result of the literature search. On review of the titles and abstracts, 57 studies met the inclusion criteria. Multifaceted programs are the first approach to neurogenic bowel and are supported by lower levels of evidence. Of the non-pharmacological (conservative and non-surgical) interventions, transanal irrigation is a promising treatment to reduce constipation and fecal incontinence. When conservative management is not effective, pharmacological interventions (for example prokinetic agents) are supported by strong evidence for the treatment of chronic constipation. When conservative and pharmacological treatments are not effective, surgical interventions may be considered and are supported by lower levels of evidence in reducing complications. CONCLUSIONS: Often, more than one procedure is necessary to develop an effective bowel routine. Evidence is low for non-pharmacological approaches and high for pharmacological interventions.

Bone geometric response to chronic disuse following stroke: a pQCT study.

OBJECTIVES: The objectives of this study were to 1) assess volumetric bone geometry and density at the distal radius of individuals with chronic stroke and 2) assess whether bone strength is associated with measures of muscle strength and impairment. MATERIAL AND METHODS: Cross-sectional study of bone and muscle parameters in 15 community-dwelling people living with the residual effects of a stroke (between 1 and 9 years post-incident stroke). RESULTS: The 4% site of the distal radius had significantly lower bone mineral content and density on the paretic side (p<0.006). There was a significant difference in pQCT measures of bone cortical density (p<0.03), area (p<0.05) and bone strength [Stress-Strain Index; SSI] (p<0.01) (lower on the paretic side) at the 30%. We found significant correlations between composite muscle strength score of the upper extremities and pQCT-generated bone strength. CONCLUSIONS: This cross-sectional study highlights lower bone strength on the paretic limb and an adaptive response to disuse.

Reliability of surface EMG during sustained contractions of the quadriceps.

The purpose of this study was to determine test-retest reliability for median frequency (MDF) and amplitude of surface EMG during sustained fatiguing contractions of the quadriceps. Twenty-two healthy subjects (11 males and 11 females) were tested on two days held one week apart. Surface EMG was recorded from rectus femoris (RF), vastus lateralis (VL) and vastus medialis (VM) during sustained isometric contractions at 80% and 20% of maximal voluntary contraction (MVC) held to exhaustion. Quadriceps fatigue was described using four measures for both MDF and amplitude of EMG: initial, final, normalized final and slope. For both MDF and amplitude, the initial, final and normalized EMG showed moderate to high reliability for all three muscle groups at both contraction levels (ICC=0.59-0.88 for MDF; ICC=0.58-0.99 for amplitude). Slope of MDF and amplitude was associated with a large degree of variability and low ICCs for the 80% but not the 20% MVC. MDF and amplitude of EMG during sustained contractions of the quadriceps are reproducible; normalized final values of MDF and amplitude show better reliability than slope.

Kinetic analysis of the lower limbs during walking: what information can be gained from a three-dimensional model?

Kinetic analyses (joint moments, powers and work) of the lower limbs were performed during normal walking to determine what further information can be gained from a three-dimensional model over planar models. It was to be determined whether characteristic moment and power profiles exist in the frontal and transverse planes across subjects and how much work was performed in these planes. Kinetic profiles from nine subjects were derived using a three-dimensional inverse dynamics model of the lower limbs and power profiles were then calculated by a dot product of the angular velocities and joint moments resolved in a global reference system. Characteristic joint moment profiles across subjects were found for the hip, knee and ankle joints in all planes except for the ankle frontal moment. As expected, the major portion of work was performed in the plane of progression since the goal of locomotion is to support the body against gravity while generating movements which propel the body forward. However, the results also showed that substantial work was done in the frontal plane by the hip during walking (23% of the total work at that joint). The characteristic joint profiles suggest defined motor patterns and functional roles in the frontal and transverse planes. Kinetic analysis in three dimensions is necessary particularly if the hip joint is being examined as a substantial amount of work was done in the frontal plane of the hip to control the pelvis and trunk against gravitational forces.

Intralimb dynamics simplify reactive control strategies during locomotion.

The utilization of passive dynamics to control the swing trajectory is one mechanism which serves to minimize energy costs during locomotion, in addition to reducing the complexity of the neural control. In a reactive situation (e.g. trip or slip during walking), the energy cost may not be a major determinant of the locomotor activity as there is a need for quick corrective action under the threat of a fall. Therefore, we addressed the following question: does the nervous system utilize passive dynamics during the reactive control of locomotion? An unexpected mechanical perturbation was applied to the foot during early and late swing during walking. Video data were input into an inverse dynamics routine to obtain the joint moment and mechanical power profiles and to partition the joint moments into active and passive components. The nervous system still utilized the passive dynamics of the effector system; active control of a single joint, the knee joint, passively facilitated the flexor action at the proximal hip and distal ankle joint following the early swing perturbation. The minimization of the mechanical energy cost was not a major determinant for this task since the total mechanical work during the perturbed steps was greater than during normal steps. A neuromuscular constraint was observed following the late swing perturbation; the active control of the hip and knee joints were increased but the magnitude of the hip extensor/knee flexor moment was invariant and equal to 1.6. The intralimb dynamics identified during these responses may serve to simplify the complexity of the active control of the nervous system.

The effect of soft foot orthotics on three-dimensional lower-limb kinematics during walking and running.

BACKGROUND AND PURPOSE: Although foot orthotics are often prescribed to alter the lower-extremity mechanics during the stance period of gait, there is little documentation of the actual effect of foot orthotics on the movement of the lower-extremity joints during walking and running. This study examined the effect of foot orthotics on the range of motion of the talocrural/subtalar joint and the knee joint in three dimensions during walking and running. SUBJECTS: Ten female adolescent subjects, aged 13 to 17 years (X = 14.4, SD = 1.1) who were diagnosed with patellofemoral pain syndrome and exhibited forefoot varus greater than 6 degrees and/or calcaneal valgus greater than 6 degrees participated in the study. METHODS: Thirty strides of walking and running on a treadmill were recorded for each of the orthotic and nonorthotic conditions for each subject using an optoelectronic recording technique. Analyses of variance for repeated measures were performed on the range of motion of the talocrural/subtalar joint and knee joint for each plane of motion (ie, six separate analyses). The main factors of each analysis were the effect of the orthotic (orthotic condition versus nonorthotic condition), mode of ambulation (walking and running), and phase of the stance period (contact, mid-stance, and propulsion). RESULTS: No differences were found in sagittal-plane movements. Reductions of 1 to 3 degrees occurred with orthotic use for the talocrural/subtalar joint during walking and running in the frontal and transverse planes. The orthotics reduced knee motion in the frontal plane during the contact and mid-stance phases of walking, but increased the motion during the contact and mid-stance phases of running. CONCLUSIONS AND DISCUSSION: This study shows that corrections to the static position of forefoot varus and calcaneal valgus can result in changes in transverse- and frontal-plane motion of the foot and knee during walking and running.

Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome.

BACKGROUND AND PURPOSE: The effectiveness of soft foot orthotics in the treatment of patients who have patellofemoral pain syndrome was investigated. SUBJECTS: Subjects were 20 adolescent female patients, aged 13 to 17 years (mean = 14.8, SD = 1.2), who were diagnosed with patellofemoral pain syndrome and who exhibited excessive forefoot varus or calcaneal valgus. METHODS: Subjects were randomly assigned to one of two groups: a control group (n = 10), which took part in an exercise program, or a treatment group (n = 10), which used soft foot orthotics in addition to participating in the exercise program. The exercise program consisted of quadriceps femoris and hamstring muscle strengthening and stretching exercises. A visual analogue scale was used to assess the level of pain of the subjects over an 8-week period. RESULTS: Both the treatment and control groups demonstrated a significant decrease in the level of pain, but the improvement of the treatment group was significantly greater than that of the control group. CONCLUSION AND DISCUSSION: The results suggest that in addition to an exercise program, the use of soft foot orthotics is an effective means of treatment for the patient with patellofemoral pain syndrome.

Use of prolonged standing for individuals with spinal cord injuries.

BACKGROUND AND PURPOSE: Prolonged standing in people with spinal cord injuries (SCIs) has the potential to affect a number of health-related areas such as reflex activity, joint range of motion, or well-being. The purpose of this study was to document the patterns of use of prolonged standing and their perceived effects in subjects with SCIs. SUBJECTS: The subjects were 152 adults with SCIs (103 male, 49 female; mean age=34 years, SD=8, range=18-55) who returned mailed survey questionnaires. METHODS: A 17-item self-report survey questionnaire was sent to the 463 members of a provincial spinal cord support organization. RESULTS: Survey responses for 26 of the 152 respondents were eliminated from the analysis because they had minimal effects from their injuries and did not need prolonged standing as an extra activity. Of the 126 remaining respondents, 38 respondents (30%) reported that they engaged in prolonged standing for an average of 40 minutes per session, 3 to 4 times a week, as a method to improve or maintain their health. The perceived benefits included improvements in several health-related areas such as well-being, circulation, skin integrity, reflex activity, bowel and bladder function, digestion, sleep, pain, and fatigue. The most common reason that prevented the respondents from standing was the cost of equipment to enable standing. DISCUSSION AND CONCLUSION: Considering the many reported benefits of standing, this activity may be useful for people with SCI. This study identified a number of body systems and functions that may need to be investigated if clinical trials of prolonged standing in people with SCI are undertaken.

Biomechanics of reaching: clinical implications for individuals with acquired brain injury.

PURPOSE: Outline the biomechanics of reaching both in healthy individuals and in individuals with acquired brain injury (ABI), and to discuss the clinical implications for using valid biomechanical models to assess reaching. METHODS: A review of current literature, including a MEDLINE search using keywords of reaching, ABI, stroke, biomechanics and motor control. RESULTS: Current assessments of the upper extremity in ABI are focused on single-joint characteristics of range of motion, strength and spasticity. However, reaching is a functional multijoint task requiring interjoint coordination in addition to feedback and feedforward control to position the hand optimally at a desired location so that it may interact with the environment. From the literature, biomechanical measures of reaching such as movement time, movement distance and interjoint coordination have been shown to discriminate changes to hand path quality following brain injury. These measures have also been shown to correlate with measures of sensorimotor function (e.g. Fugl-Meyer) in the upper extremity. CONCLUSIONS: Further development of reliable and valid multi-joint biomechanical evaluations is required, particularly for natural and goal-oriented reaching movements. The biomechanical assessment of reaching in ABI can provide an understanding of the specific deficits in physiological structures or motor planning underlying altered reaching ability, assist in the evaluation of new therapies, and characterize the recovery process following ABI.

Effects of isokinetic strength training on walking in persons with stroke: a double-blind controlled pilot study.

OBJECTIVES: The goal most often stated by persons with stroke is improved walking function. The purpose of this study was to determine the effects of isokinetic strength training on walking performance, muscle strength, and health-related quality of life in survivors of chronic stroke. METHODS: Twenty participants (age, 61.2 +/- 8.4 years) with chronic stroke were randomized into 2 groups. The experimental group undertook maximal concentric isokinetic strength training, whereas the control group received passive range of motion of the paretic lower extremity 3 times a week for 6 weeks. The Kin-Com Isokinetic Dynamometer (Chattanooga Group Inc., TN) was used for both the strengthening and passive range of motion exercises. The Mann-Whitney U test was used to compare the changes in scores (postintervention minus baseline) between the control and experimental groups for a composite lower extremity strength score, walking speed (level-walking and stair-walking) and health-related quality of life measure (36-Item Short Form Health Survey [SF-36]). RESULTS: Both the experimental and control groups increased their strength and walking speed postintervention; however, there were no differences in the changes in walking speed between the groups. There was a trend (P = .06) toward greater strength improvement in the experimental group compared with the control group. No changes in SF-36 scores were found in either group. CONCLUSIONS: Intervention aimed at increasing strength did not result in improvements in walking. The results of this study stress the importance of controlled clinical trials in determining the effect of specific treatment approaches. Strength training in conjunction with other task-related training may be indicated.

Participation and Well-Being Among Older Adults Living with Chronic Conditions.

This study explored the unique contribution of participation (daily activities and social roles) in explaining well-being of older adults living with chronic conditions and examined which aspect of participation (accomplishment of participation or satisfaction with participation) was more important in describing their well-being. Two hundred older adults with chronic conditions completed the following assessments: Satisfaction with Life Scale to measure well-being; Assessment of Life Habits to evaluate two aspects of participation: (a) accomplishment of daily activities and social roles and (b) level of satisfaction with participation; Interpersonal Support Evaluation List to assess level of social support and Affect Balance scale to measure level of balance confidence. In addition, participants' level of mobility was assessed using the Timed Up and Go test. Regression analysis was performed. Results indicated that number of chronic conditions, social support and satisfaction with participation had a significant contribution to well-being and altogether explained 31% of its variance whereas accomplishment of participation did not play as significant role in the model. In conclusion, participation has a unique contribution to older adults' well-being where satisfaction with participation rather than the accomplishment of activities is of importance. Additional aspects of participation and level of disability are key factors identified for further inquiry.

Falls in people with chronic obstructive pulmonary disease: an observational cohort study.

STUDY OBJECTIVE: To investigate incidence, risk factors and impact of falls on health related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD). DESIGN: Observational cohort study. METHODS: Patients completed these questionnaires at baseline and at 6-months: Medical Outcomes Study Short Form 36 (SF-36), Chronic Respiratory Questionnaire (CRQ), Activities Balance Confidence (ABC) Scale and a form to record demographic data, medications, co-morbidities, oxygen use, acute exacerbations, fall history and assistive device use. Physical activity was measured with the Physical Activity Scale for the Elderly (PASE) only at baseline. Fall incidence was monitored through monthly fall diaries. Patients were categorized as non-fallers (0 falls) or fallers (≥ 1 falls). RESULTS: Data from 101 patients with a forced expiratory volume in 1 s of 46.4 ± 21.6% predicted were analyzed. Thirty-two patients (31.7%) reported at least one fall during the 6-months. Fall incidence rate was 0.1 (95% CI: 0.06-0.14) falls per person-month. Fallers tended to be older (p = 0.04), female (p = 0.04) and oxygen dependent (p = 0.02), have a history of previous falls (p < 0.001), more co-morbidities (p = 0.007) and take more medications (p = 0.001). Previous falls (OR = 7.36; 95% CI: 2.39-22.69) and diagnosis of coronary heart disease (OR = 7.07; 95% CI: 2.14-23.36) were the most important predictors of falls. The Dyspnea Domain of the CRQ declined significantly more (p = 0.02) in the fallers group at 6-months. CONCLUSIONS: Patients with COPD have a high susceptibility to falls, which is associated with a worsening of dyspnea perception as related to HRQoL. Fall prevention programs in COPD are recommended.

Postural Control Is Impaired in People with COPD: An Observational Study.

PURPOSE: We investigated deficits in postural control and fall risk in people with chronic obstructive pulmonary disease (COPD). METHOD: Twenty people with moderate to severe COPD (mean age 72.3 years, standard deviation [SD] 6.7 years) with a mean forced expiratory volume in 1 second (FEV(1)) of 46.7% (SD 13%) and 20 people (mean age 68.2 years, SD 8.1) who served as a comparison group were tested for postural control using the Sensory Organization Test (SOT). A score of zero in any trial of the SOT was registered as a fall. On the basis of the SOT results, participants were categorized as frequent fallers (two or more falls) or as fallers (one fall). To explore the potential influence of muscle weakness on postural control, knee extensors concentric muscle torque was assessed with an isokinetic dynamometer. Physical activity level was assessed with the Physical Activity Scale for the Elderly. RESULTS: People with COPD showed a 10.8% lower score on the SOT (p=0.016) and experienced more falls (40) than the comparison group (12). The proportion of frequent fallers and fallers during the SOT was greater (p=0.021) in the COPD group (four of 10) than in the comparison group (two of seven). People with COPD showed deficits in knee extensors muscle strength (p=0.01) and a modest trend toward reduced physical activity level. However, neither of these factors explained the deficits in postural control observed in the COPD group. CONCLUSIONS: People with COPD show deficits in postural control and increased risk of falls as measured by the SOT. The deficits in postural control appear to be independent of muscle weakness and level of physical activity. Postural control interventions and fall risk strategies in the pulmonary rehabilitation of COPD are recommended.

Physiatrists' opinions and practice patterns for bone health after SCI.

STUDY DESIGN: Self-report survey. OBJECTIVE: To ascertain physiatrists' opinions and current practice patterns for bone health management after spinal cord injury (SCI). PARTICIPANTS: Physiatrists who work in teaching rehabilitation centers in Canada. METHODS: A 4-page 17-question survey (available in French and English) was sent to working physiatrists in all major Canadian SCI rehabilitation centers. RESULTS: We had an 85% response rate (22 responses). Physiatrists reported that they should be managing bone health issues after SCI in conjunction with family physicians, and most respondents assess and treat for bone health after SCI. However, just over one-third of the physiatrists reported that the current treatment options are not effective for low bone mass; there was more support for pharmacological treatments than there was for rehabilitation modalities. CONCLUSION: Bone health after SCI is an important health concern that is being managed by physiatrists; however, more discussion and research is needed to ascertain the effectiveness of assessment and treatment options for low bone mass.

Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: a correlational study.

STUDY DESIGN: This was a prospective cross-sectional study for people with chronic spinal cord injury (SCI). OBJECTIVES: To (1) evaluate the intensity level and nature of physical activity in community-dwelling individuals living with SCI, and (2) explore the relation between descriptive individual variables (for example, lesion level), secondary complications and participation in physical activity. SETTING: Urban community setting. METHODS: A total of 49 subjects with SCI who used a manual wheelchair for primary mode of mobility (mean years since injury, 11.8; mean age, 43.7 years; 67% paraplegia) completed the physical activity recall assessment for people with SCI (PARA-SCI). RESULTS: Approximately 50% of reported physical activity among individuals with SCI is due to activities of daily living. The amount of physical activity was not related to lesion level, age, body mass index or waistline size. Greater heavy-intensity activity was related to lower levels of pain and fatigue and higher levels of self-efficacy, whereas higher amounts of mild-intensity activity and total activity were related to less depressive symptoms. CONCLUSIONS: Activities of daily living are a large component for physical activity among individuals with SCI. It appears that greater physical activity is associated with less secondary complications (pain, fatigue and depression) in individuals with SCI.