Cost-utility analysis and impact on the environment of videoconference in pressure injury. A randomized controlled trial in individuals with spinal cord injury.

STUDY DESIGN: A prospective randomized controlled trial (RCT) in persons with spinal cord injury (SCI) and ongoing pressure injury (PI). OBJECTIVES: The main aim was to perform a cost-utility analysis (CUA) alongside the RCT comparing regular care to regular care with additional videoconference consultations. Secondary aims were to assess costs and greenhouse gas emission related to transportation in the two study groups. SETTING: Two spinal cord units in Norway. METHODS: Participants were allocated to a regular care group (RCG) and a regular care group with additional videoconference (VCG), in a 1-year follow-up between 2016 and 2018. Costs were prospectively collected, and health-related quality of life (HRQoL) data were collected at baseline and 12 months. The outcome was quality-adjusted life years (QALYs), derived from the EQ-5D-5L questionnaire. Results are reported as incremental cost-effectiveness ratio (ICER), expressed as the cost per additional QALY gained. Transportation related costs and environmental emissions were compared by t-tests. RESULTS: There were 56 participants included, 28 in each group. Of these 27 in the VCG and 26 in the RCG completed. Three participants died. The mean cost per patient was € 8819 in the VCG and € 3607 in the RCG, with 0.1 QALYs gained in the VCG. No significant differences were identified regarding HRQoL or secondary outcomes. CONCLUSION: The VCG costs € 5212 more for an additional 0.1 QALYs, giving an ICER of € 52,120 per QALY. No significant differences were found regarding transportation-related costs, or emission of greenhouse gases. TRIAL REGISTRATION: www. CLINICALTRIALS: gov ; NCT02800915, TeleSCIpi. CRISTIN.no. https://app.cristin.no/projects/show.jsf?id=545284 . Sunnaas Rehabilitation hospital's web page, available at https://www.sunnaas.no/fag-og-forskning/fagstoff/sar .

Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research.

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Climate Change and Physiatry: A Call to Proportional and Prospective Action.

ABSTRACT: Through increased temperature-related illness, exposure to wildfire smoke and air pollutants, and more frequent and intense natural disasters, climate change is disproportionately affecting the health of people with disabilities. Although the evidence behind the health effects of climate change is growing, there remain critical research gaps in the physiatric literature that must be addressed. Increased education throughout the medical-education continuum is also needed to prepare physiatrists to address the climate-related health effects impacting their patient populations. Physiatrists and their member organizations should advocate for policies that address climate change with a focus on the unique needs of their patient population and the inclusion of people with disabilities in the policy making process.

Videoconferencing in Pressure Injury: Randomized Controlled Telemedicine Trial in Patients With Spinal Cord Injury.

BACKGROUND: Geographical, financial and travel-related barriers may impact access to necessary health care for people in need of long-term follow-up. OBJECTIVE: The goal of the research was to perform a nonblinded, randomized, controlled trial on health-related quality of life (HRQoL), healing, interaction, and satisfaction of patients with spinal cord injury (SCI) and PI receiving multidisciplinary videoconference consultations from a wound clinic to the participant's home versus regular outpatient care. The multidisciplinary team consisted of a medical doctor, a wound nurse, and an occupational therapist. In both groups, district nurses attended the consultations at the participant's home. METHODS: A total of 56 participants, 28 in each group, were randomized to a videoconference group (VCG) or a regular care group (RCG). Validated questionnaires were used to measure and compare the follow-up effect on HRQoL. Percentage reduction of wound volume was measured at end of the follow-up. A Likert scale was used to measure the satisfaction of the patients and district nurses regarding the interaction between different modalities of care in the 2 groups. RESULTS: The HRQoL did not show significant differences between the 2 groups (P values ranging from .09 to .88) or the rate of PI healing, experienced interaction, and satisfaction in the groups. A total of 67% (37/55) of all PIs healed, 64% (18/28) in the VCG and 70% (19/27) in the RCG. Mean reduction in ulcer volume was 79% in the VCG and 85% in the RCG (P=.32). A Kaplan-Meier plot with a logrank test regarding time to healing did not show any significant difference between the 2 groups. CONCLUSIONS: Videoconference-based care seems to be a safe and efficient way to manage PIs in terms of HRQoL, healing, interaction, and satisfaction compared to conventional care for people with SCI. This should be considered when planning for future care. SCI has a huge impact on the individual, the family, and the health care system. There is an urgent need to improve systems of care so that individuals who live far from specialists and require long-term follow-up for conditions such as PI can get optimal treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT02800915; https://clinicaltrials.gov/ct2/show/NCT02800915 and Current Research Information System in Norway (CRISTIN) 545284; https://app.cristin.no/projects/show.jsf?id=545284.

It's Corona Calling: Time for Telerehabilitation!

The Covid-19 pandemic has caused a disproportionate impact on people with disabilities and the elderly. Moreover, the pandemic can be likened to disasters caused by catastrophic weather events which will increase in the future in response to climate change. To forestall these threats, rehabilitation professionals must to come together internationally to prepare and proactively educate their peers and patients. This can be done through observance of such times as Day for Tomorrow. Moreover, rehabilitation professionals need to transition to greener forms of healthcare in order to assure that in the future we all sustain our abilities.

Correction: International spinal cord injury male sexual function and female sexual and reproductive function basic data sets-version 2.0.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

COVID-19 and spinal cord injury and disease: results of an international survey.

STUDY DESIGN: An online survey. OBJECTIVES: To query the international spinal cord medicine community's engagement with and response to the novel coronavirus (COVID-19) pandemic and to assess pandemic-specific information needs and patient concerns. SETTING: An international collaboration of authors and participants. METHODS: Two near-identical surveys (one English and one Spanish language) were distributed via the internet. Responses from those questions shared between the surveys were pooled then analyzed; four questions' responses (those not shared) were analyzed separately. RESULTS: A total of 783 responses were submitted from six continents. Few participants (5.8%) had tested their outpatients with SCI/D for COVID-19; only 4.4% reported having a patient with SCI/D with the virus. Of respondents who worked at an inpatient facility, 53.3% reported that only individuals with symptoms were being screened and 29.9% said that no screening was occurring. Participants relayed several concerns offered by their patients with SCI/D, including vulnerability to infection (76.9%) and fragility of caretaker supply (42%), and those living in countries with guaranteed health care were more likely to report widespread availability of COVID-19 testing than were those living in countries without universal care, χ2 (3, N = 625) = 46.259, p < 0.001. CONCLUSION: There is substantial variability in the rehabilitation medicine community in COVID-19 screening practices and availability of screening kits. People living with SCI/D are expressing legitimate and real concerns about their vulnerability to COVID-19. More and rapid work is needed to address these concerns and to standardize best-practice protocols throughout the rehabilitation community.

Spinal cord injury and development of pressure injury during acute rehabilitation in Norway: a national retrospective cross-sectional study.

STUDY DESIGN: A national, retrospective, cross-sectional study. OBJECTIVES: To analyze the prevalence of pressure injury (PI), and characteristics associated with PI development in the hospitalized population of persons with a newly acquired spinal cord injury (SCI) between 2004 and 2014. SETTING: All three specialized Spinal Cord Units in Norway. METHODS: Demographic data related to prevalence and potential risk factors were retrieved from the electronic medical record (EMR). Statistical analyses were performed, using IBM SPSS Statistics, version 23. RESULTS: We identified 1012 individuals with a new SCI. Mean age at injury was 48 years (SD 19). The period prevalence of PI was 16% (95% CI = 0.14-0.19), and identified PI associations were complete SCI (OR = 0.1), being injured abroad (OR = 2.4), bowel (OR = 13), and bladder (OR = 9.2) dysfunction; comorbidities like diabetes mellitus 1 (OR = 7.9), diagnosed depression (OR = 3.8), ventilator support (OR = 3.0), drug abuse (OR = 3.0), and concurrent traumatic brain injury (OR = 1.7). Individuals in the age group of 15-29 years had higher odds of PI compared with middle-aged individuals (45-59 years). CONCLUSION: PI is a serious complication after SCI. The association between depression or comorbidity and PI occurrence should be investigated more thoroughly. We recommend implementation of a simple follow-up program regarding observation and prevention of PI. Increased awareness of factors that could contribute to PI will help to focus on better prevention and early recognition of PI. This will contribute to more optimal rehabilitation.

The sacral exam-what is needed to best care for our patients?

Sacral reflexes are important to allow the SCI practitioner to gain information about the state of the sacral spinal cord segments. The presence of the bulbocavernosus and/or the anal wink reflex indicate an intact spinal reflex arc and reflex conal autonomic function (as part of the upper motor neuron syndrome); their absence defines a lower motor neuron syndrome. The assessment of sacral reflexes helps predict the type of bladder, bowel and sexual functions and the related therapeutic interventions. We suggest adding the sacral component of the International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI) to the International Standards for the Neurologic Classification of Spinal Cord Injury (ISNCSCI) examination so there can be a detailed description of these important functions. As an alternative, the performance of sacral reflexes should be routinely required as part of the neurologic examination after SCI. Whether the sacral motor neuron system is classified as upper or lower motor neuron injury is also quite useful and as such should be present in the ISCNSCI.

A bellweather for climate change and disability: educational needs of rehabilitation professionals regarding disaster management and spinal cord injuries.

Study design: Cross-sectional survey. Objective: Persons with disabilities are disproportionately impacted by extreme weather disasters and climate change. Individuals with spinal cord injury (SCI) are especially at risk due to inability to control their body temperature and mobility concerns. We surveyed rehabilitation professionals in the field of SCI to determine their experiences, concerns and educational needs regarding natural disasters, climate change and sustainability and the effects on their clientele. Setting: Online survey available to an international cohort. Methods: The survey was developed by the authors and conducted in 2019. It was distributed amongst various international health care organizations whose members care for persons with SCI. Descriptive statistics and chi-square test for association were performed using Microsoft Excel 2016. Results: Of 125 respondents, 50% were from Europe, 18% from North America, and 18% from Asia; 74% were physicians and 13% physical therapists. In total 57.6% believed climate change had impacted their client's health and well-being. Respondents from North America were significantly less likely to report climate change had an impact on their patient's health than those from Asia or Europe (p < 0.01). In total 82.5% of respondents thought professionals should be concerned with sustainability and 85.5% were interested in further education. Conclusions: Most respondents acknowledged a need for more information related to the disasters, climate change, and disability. Results underscore the need for further research, professional, and consumer education.

Pulse article: opioid prescription for pain after spinal cord damage (SCD), differences from recommended guidelines, and a proposed algorithm for the use of opioids for pain after SCD.

Study design: Online questionnaire of spinal cord injury (SCI) physicians. Objectives: The objective of this study is to characterize the approach to opioid prescription for persons with spinal cord damage (SCD). Setting: An international online questionnaire. Methods: A survey was posted online and circulated among international societies within the field of SCI medicine from August to November 2018. Results: One hundred and twenty-three physicians responded to the survey. Of these, 107 (92%) managed pain for persons with SCD. Most (82%) felt that opioid prescription was appropriate for uncontrolled acute pain, but fewer (67%) felt it was appropriate for chronic pain. Of those who felt opioids had a role in the treatment of neuropathic pain, 46% did not think there should be a specific upper limit of opioid dose. The majority (85%) would continue prescribing high doses (250 morphine milligram equivalent (MME) doses/day) if that dose were effective. Tramadol was the most common opioid prescribed first line. Conclusion: Most physicians who responded to this survey prescribe opioids for intractable pain after SCD. A significant proportion of respondents believed that there should not be a specific upper limit of opioid dose prescribed if the drug is tolerated; this does not align with current recommendations. Most physicians do not feel influenced in their prescribing habits by regulatory bodies. If physicians decide to taper an opioid that is being tolerated well, it is most commonly related to a fear of the patient developing an opioid-use disorder. The authors propose an algorithm that may help align practice patterns with current recommended practice guidelines.

Improving quality of life after spinal cord injury in India with telehealth.

Introduction: Despite adequate inpatient rehabilitation, a number of spinal cord injury (SCI) individuals suffer from difficulties at home and in their local environments. This is mainly prevalent in low-middle-income countries (LMIC) due to a lack of qualified personal caregivers. This issue could be addressed with the help of telehealth technology, which may be used in LMICs without economic concerns. Case presentations: A 44-year-old male with C3 AIS C SCI and a 35-year-old female with T12 AIS A SCI were discharged after successful rehabilitation from a tertiary care spinal center. The patients demonstrated gradual loss in their independence, which was evident by monitoring their home activities biweekly for 4 weeks via a combination of telephone calls, live video chat, and WhatsApp. Subsequently after 4 weeks of consistent guidance, pre-post scores after teletherapy were analyzed for the self-care and mobility subcomponents of the self-reported SCIM III. Discussion: After consistent supervised guidance via telehealth, self-care scores improved in the C3 AIS C case from 3 to 15 and in the T12 AIS A case from 4 to 15, while mobility scores respectively improved from 14 to 27 and 4 to 16. Identification of individual competencies, performance, and capacity in activities of daily living and participation, self-assessment, caregiver training, and home integration contributed toward successful community integration. This case series documents the benefits of using telehealth and home goal planning in the aftercare of SCI individuals, in order to improve quality of life in their local environment.