Manual wheelchair skills capacity predicts quality of life and community integration in persons with spinal cord injury.

OBJECTIVES: To determine wheelchair (WC) skills success rates for manual WC users with spinal cord injury (SCI), to determine subject characteristics associated with the lowest success rates of WC skills, and to characterize the relationship between WC skills and measures of community integration and quality of life (QOL). DESIGN: Cross-sectional multisite study. SETTING: Six Spinal Cord Injury Model Systems (SCIMS) centers. PARTICIPANTS: Individuals with SCI (N=214) who were at least 11 months postinjury, treated at an SCIMS center, and who used a manual WC as their primary means of mobility. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Wheelchair Skills Test (WST) and questionnaires of demographics and characteristics, QOL, and community participation. RESULTS: Of the 31 skills in the WST assessed, success rates ranged from 19.6% to 100%. Eight skills had success rates of ≤75%: folding/unfolding the WC (71.5%), ascending (19.6%) and descending (47.2%) a 15-cm curb, ascending (23.2%) and descending (26.5%) stairs, transferring from ground to WC (40.6%), turning 180° in wheelie position (55.2%), and holding a 30-second stationary wheelie (59.9%). Male sex, paraplegia, employed status, lower education, younger age at injury, and white race were among the participant characteristics bivariately associated with higher success rates of several WC skills. After controlling for covariates, higher success rates of several WC skills and a higher total WST score predicted better self-perceived health, higher life satisfaction, and more community participation. CONCLUSIONS: For people with SCI who use a manual WC as their primary means of mobility, their ability to perform manual WC skills is associated with higher community participation and life satisfaction. Factors contributing to low success rates need to be investigated, and interventions to improve these rates are needed.

Vitamin B(12) deficiency as a cause of delirium in a patient with spinal cord injury.

A man with spinal cord injury (SCI) and multiple medical comorbidities had new-onset delirium during his 14th month of hospitalization. Diagnostic workup did not elicit an obvious etiology for mental status changes. Delirium persisted despite psychiatry intervention, and he was unable to be weaned from the ventilator because of prolonged agitation. Routine anemia workup revealed a possible untreated vitamin B(12) deficiency, although laboratory values were inconclusive. Empiric treatment with cyanocobalamin injections was initiated, and his delirium remarkably resolved after 3 weeks of treatment. We provide a concise review of the etiologies and varied clinical presentations of vitamin B(12) deficiency. As illustrated in this case, classic laboratory findings may not appear, and neurologic impairments from SCI can obscure the physical signs of deficiency, making diagnosis difficult. Empiric treatment may be indicated in cases of neuropsychiatric abnormalities not explained by other causes.

Management of thoracic spinal cord injury in a professional American football athlete: illustrative case.

BACKGROUND: A case of catastrophic thoracic spinal cord injury (SCI) sustained by a professional American football player with severe scoliosis is presented. OBSERVATIONS: A 25-year-old professional football player sustained an axial loading injury while tackling. Examination revealed a T8 American Spinal Injury Association Impairment Scale grade A complete SCI. Methylprednisolone and hypothermia protocols were initiated. Computed tomography scan of the thoracic spine demonstrated T8 and T9 facet fractures on the left at the apex of a 42° idiopathic scoliotic deformity. Magnetic resonance imaging (MRI) demonstrated T2 spinal cord hyperintensity at T9. He regained trace movement of his right lower extremity over 12 hours, which was absent on posttrauma day 2. Repeat MRI revealed interval cord compression and worsening of T2 signal change at T7-T8 secondary to hematoma. Urgent decompression and fusion from T8 to T10 were performed. Additional treatment included high-dose omega-3 fatty acids and hyperbaric oxygen therapy. A 2-month inpatient spinal cord rehabilitation program was followed by prolonged outpatient physical therapy. He currently can run and jump with minimal residual distal left lower limb spasticity. LESSONS: This is the first known football-related thoracic SCI with idiopathic scoliosis. Aggressive medical and surgical intervention with intensive rehabilitation formed the treatment protocol, with a favorable outcome achieved.

Narrative Review of Clinical Practice Guidelines for Rehabilitation of People With Spinal Cord Injury: 2010-2020.

ABSTRACT: Clinical practice guidelines provide reliable, vetted, and critical information to bring research to practice. Some medical specialties (e.g., physical medicine and rehabilitation) provide multidomain treatment for various conditions. This presents challenges because physical medicine and rehabilitation is a small specialty, a diverse patient base in terms sociodemographics and diagnosis, treatments are difficult to standardize, and rehabilitation research is underfunded. We wished to identify quality and applicability of clinical practice guidelines and searched "Spinal Cord Injury AND Clinical Practice Guidelines AND Rehabilitation" and vetting process.Three hundred fifty-nine articles were identified of which 58 met all criteria for full-text review of which 13 were included in the final selection. Additional publications were accessed from a nondatabase search. Five articles addressed postacute care, community treatment. Nine articles had no recorded vetting process but addressed rehabilitation as an outcome and were included separately. Many of the clinical practice guidelines were developed without evidence from randomized controlled trials, one had input from stakeholders, and some are out of date and do not address important aspects of changes in demographics of the affected population and the use of newer technologies such as sensors and robotics and devices. Identification of these gaps may help stimulate treatment that is clinically relevant, accessible, and current.

Assessment of primary care services and perceived barriers to care in persons with disabilities.

OBJECTIVE: To determine what percentage of persons with disabilities have a primary care provider, participate in routine screening and health maintenance examinations, and identify perceived physical or physician barriers to receiving care. DESIGN: A total of 344 surveys, consisting of 66 questions, were collected from adults with disabilities receiving care at an outpatient rehabilitation clinic. RESULTS: A total of 89.5% (95% CI 86.3%-92.8%) of participants reported having a primary care physician. Younger persons (P < 0.0001), men (P < 0.02), persons with brain injury (P < 0.05), or persons with amputations (P < 0.05) were less likely to have a primary care physician. Participant report of screening for alcohol, nonprescription drug use, and safety with relationships at home ranged from 26.6% to 37.5% compared with screening for depression, diet, exercise, and smoking (64.5%-70%). Completion rates of age- and gender-appropriate health maintenance examinations ranged from 42.4% to 90%. A total of 2.67% of participants reported problems with physical access at their physician's office, and 36.4% (95% CI 30.8%-42.1%) of participants reported having to teach their primary care physician about their disability. CONCLUSIONS: Most persons with disabilities have a primary care physician. In general, completion rates for routine screening and health maintenance examinations were high. Perceived deficits in primary care physicians' knowledge of disability issues seem more prevalent than physical barriers to care.