Optimizing assessment of low frequency H-reflex depression in persons with spinal cord injury.

Considering the growing interest in clinical applications of neuromodulation, assessing effects of various modulatory approaches is increasingly important. Monosynaptic spinal reflexes undergo depression following repeated activation, offering a means to quantify neuromodulatory influences. Following spinal cord injury (SCI), changes in reflex modulation are associated with spasticity and impaired motor control. To assess disrupted reflex modulation, low-frequency depression (LFD) of Hoffman (H)-reflex excitability is examined, wherein the amplitudes of conditioned reflexes are compared to an unconditioned control reflex. Alternatively, some studies utilize paired-pulse depression (PPD) in place of the extended LFD train. While both protocols induce similar amounts of H-reflex depression in neurologically intact individuals, this may not be the case for persons with neuropathology. We compared the H-reflex depression elicited by PPD and by trains of 3-10 pulses to an 11-pulse LFD protocol in persons with incomplete SCI. The amount of depression produced by PPD was less than an 11-pulse train (mean difference = 0.137). When compared to the 11-pulse train, the 5-pulse train had a Pearson's correlation coefficient (R) of 0.905 and a coefficient of determination (R2) of 0.818. Therefore, a 5-pulse train for assessing LFD elicits modulation similar to the 11-pulse train and thus we recommend its use in lieu of longer trains.

Neurogenic heterotopic ossification of the hip: Magnetic resonance imaging versus computed tomography for pre-surgical assessment.

PURPOSE: Neurogenic heterotopic ossification (NHO) of the hip is a frequent complication of spinal cord injuries, often requiring surgical management. Pre-surgical imaging assessment is essential, usually with computed tomography (CT)-scan. We aimed to compare magnetic resonance imaging (MRI) and CT for pre-surgical imaging assessment of the NHO, particularly for their relationships with vessels and nerves. METHOD: This prospective study included consecutive patients who underwent surgery for NHO from July 2019 to April 2022. All patients had CT angiography and MRI including Zero Echo Time and TRICKS sequences. Radiologists used standardized reports for CT and MRI to evaluate NHO and their features, bone mineralization, and relation to the arteries, veins and nerves. Agreement between pre-surgical CT and MRI was evaluated. RESULTS: Twenty-four patients (mean age: 53.5 ± 12.2 years) were included, among which 7 had bilateral NHO (31 hips). NHO were anterior in 15/31 hips (48 %), multifragmented in 25/31 hips (81 %). Mild and significant demineralization was most frequent. Gutter and tunnel were reported in 11.1 % of the arteries. Nerves were more often identified in MRI than in CT-scan. Agreement coefficients between CT and MRI were excellent for NHO location (0.95) and implantation (0.92), good for fragmentation (0.70), contact with joint capsule (0.66), bone mineralization (0.74), and relation to arteries (0.85), veins (0.76), sciatic nerve (0.7) and moderate for femoral nerve (0.47). CONCLUSION: MRI exhibited a good agreement with CT for pre-surgical assessment of NHO of the hip, especially to evaluate their relationships with the arteries, veins and sciatic nerve. Femoral nerves were more often identified in MRI than in CT-scan.

Evaluation of the SCAT 5 tool in the assessment of concussion in Para athletes: a Delphi study.

OBJECTIVES: To investigate if the sport concussion assessment tool version 5 (SCAT5) could be suitable for application to Para athletes with a visual impairment, a spinal cord injury, or a limb deficiency. METHODS: A 16-member expert panel performed a Delphi technique protocol. The first round encompassed an open-ended questionnaire, with round 2 onwards being composed of a series of closed-ended statements requiring each expert's opinion using a five-point Likert scale. A predetermined threshold of 66% was used to decide whether agreement had been reached by the panel. RESULTS: The Delphi study resulted in a four-round process. After round 1, 92 initial statements were constructed with 91 statements obtaining the targeted level of agreement by round 4. The expert panellist completion rate of the full four-round process was 94%. In the case of athletes with a suspected concussion with either limb deficiencies or spinal cord injuries, the panel agreed that a baseline assessment would be needed on record is ideal before a modified SCAT5 assessment. With respect to visual impairments, it was conceded that some tests were either difficult, infeasible or should be omitted entirely depending on the type of visual impairment. CONCLUSION: It is proposed that the SCAT5 could be conducted on athletes with limb deficiencies or spinal cord injuries with some minor modifications and by establishing a baseline assessment to form a comparison. However, it cannot be recommended for athletes with visual impairment in its current form. Further research is needed to determine how potential concussions could be more effectively evaluated in athletes with different impairments.

Knowledge and awareness assessment of bone loss and fracture risk after spinal cord injury.

METHODS: A cross-sectional analysis was conducted on a convenience sample of 138 adults with SCI, who completed a survey regarding knowledge and awareness of post-SCI bone health as part of a larger study. Self-reported demographic information and assessments of bone health knowledge were analyzed. RESULTS: Approximately 20% (n = 28) of participants had never heard of bone mineral density (BMD), 25% (n = 34) only vaguely remembered that BMD was mentioned during their hospitalization/rehabilitation after SCI, 36% (n = 50) clearly remembered that BMD was mentioned during their hospitalization/rehabilitation, and 17% (n = 24) reported having an individual or group education session on causes and management of low BMD during rehabilitation. Only 30% (n = 42) of participants believed they had adequate knowledge on the subject, while 70% (n = 96) believed their knowledge was inadequate or were unsure. Most participants (73%, n = 101) reported being concerned about the risks of low BMD after SCI and were interested in learning more about prevention (76%, n = 105) and treatment options (78%, n = 108). CONCLUSIONS: While results suggest that most participants received some information regarding bone health in post-SCI care, over 70% of participants reported wanting more information about bone loss prevention and treatment, indicating bone health education is a patient priority in this population.

Type II odontoid fractures in the elderly presenting to the emergency department: an assessment of factors affecting in-hospital mortality and discharge to skilled nursing facilities.

BACKGROUND CONTEXT: Type II odontoid fractures (OF) are among the most common cervical spine injuries in the geriatric population. However, there is a paucity of literature regarding their epidemiology. Additionally, the optimal management of these injuries remains controversial, and no study has evaluated the short-term outcomes of geriatric patients presenting to emergency departments (ED). PURPOSE: This study aims to document the epidemiology of geriatric patients presenting to EDs with type II OFs and determine whether surgical management was associated with early adverse outcomes such as in-hospital mortality and discharge to skilled nursing facilities (SNF). STUDY DESIGN: This is a retrospective cohort study. PATIENT SAMPLE: Data was used from the 2016-2020 Nationwide Emergency Department Sample. Patient encounters corresponding to type II OFs were identified. Patients younger than 65 at the time of presentation to the ED and those with concomitant spinal pathology were excluded. OUTCOME MEASURES: The association between the surgical management of geriatric type II OFs and outcomes such as in-hospital mortality and discharge to SNFs. METHODS: Patient, fracture, and surgical management characteristics were recorded. A propensity score matched cohort was constructed to reduce differences in age, comorbidities, and injury severity between patients undergoing operative and nonoperative management. Additionally, to develop a positive control for the analysis of geriatric patients with type II OFs and no other concomitant spinal pathology, a cohort of patients that had been excluded due to the presence of a concomitant spinal cord injury (SCI) was also constructed. Multivariate regressions were then performed on both the matched and unmatched cohorts to ascertain the associations between surgical treatment and in-hospital mortality, inpatient length of stay, encounter charges, and discharge to SNFs. RESULTS: A total of 11,325 encounters were included. The mean total charge per encounter was $60,221. 634 (5.6%) patients passed away during their encounters. In total, 1,005 (8.9%) patients were managed surgically. Surgical management of type II OFs was associated with a 316% increase in visit charge (95% CI: 291%-341%, p<.001), increased inpatient length of stay (IRR: 2.87, 95% CI: 2.62-3.12, p<.001), and increased likelihood of discharge to SNFs (OR=2.62, 95% CI: 2.26-3.05, p<.001), but decreased in-hospital mortality (OR=0.32, CI: 0.21-0.45, p<.001). The propensity score matched cohort consisted of 2,010 patients, matching each of the 1,005 that underwent surgery to 1,005 that did not. These cohorts were well balanced across age (78.24 vs 77.91 years), Elixhauser Comorbidity Index (3.68 vs 3.71), and Injury Severity Score (30.15 vs 28.93). This matching did not meaningfully alter the associations determined between surgical management and in-hospital mortality (OR=0.34, CI=0.21-0.55, p<.001) or SNF discharge (OR=2.59, CI=2.13-3.16, p<.001). Lastly, the positive control cohort of patients with concurrent SCI had higher rates of SNF discharge (50.0% vs 42.6%, p<.001), surgical management (32.3% vs 9.7%, p<.001), and in-hospital mortality (28.9% vs 5.6%, p<.001). CONCLUSIONS: This study lends insight into the epidemiology of geriatric type II OFs and quantifies risk factors influencing adverse outcomes. Patient informed consent should include a discussion of the protective association between definitive surgical management and in-hospital mortality against potential operative morbidity, increased lengths of hospital stay, and increased likelihood of discharge to SNFs. This information may impact patient treatment selection and decision making.

An Economic Analysis of the Association Among Secondary Health Conditions, Health Care Costs, and Quality of Life for Persons With Spinal Cord Injury.

Background: A previous analysis using the Canadian Spinal Cord Injury (SCI) Community Survey data identified that there were individuals with a high number of secondary health conditions, high health care utilization, poor health outcomes, and unmet health care needs. Objectives: The objectives of this study were to estimate the annual health care costs of persons with SCI who report secondary health conditions, and to determine the association between these secondary health conditions with health care utilization and self-reported life satisfaction and quality of life. Methods: The survey respondents were divided into four groups: traumatic SCI (tSCI; those who said they received needed care and those who said they did not) and nontraumatic SCI (ntSCI; those who said they received needed care and those who said they did not). The average annual health care costs per respondent were estimated for each group. Using regression analysis, we estimated the change in average annual health care costs that were associated with an additional secondary health condition for respondents in each group. Results: Participants who reported not receiving needed care had on average 23% more secondary health conditions than those receiving needed care. The increase in average annual health care costs associated with one additional secondary health conditions was between $428 ($37-$820) (ntSCI, receiving needed care) and $1240 ($739-$1741) (tSCI, not receiving needed care). Conclusion: This study provides insight into potential cost savings associated with a reduction of secondary health conditions as well as an estimate of the reduction in health care costs associated with moving from not receiving all needed care to receiving needed care.

Improving Bowel Function Recovery and Quality of Life in Han Chinese Patients with Spinal Cord Injuries: A Quantitative Assessment-Based Nursing Intervention Study.

BACKGROUND Neurological bowel dysfunction (NBD) due to spinal cord injuries (SCIs) is common and significantly impacts patients' quality of life. This study evaluated the efficacy of quantitative assessment-based nursing interventions on bowel function recovery, quality of life, and caregivers' satisfaction with SCI patients with NBD. MATERIAL AND METHODS The study included 418 SCI patients with NBD. Patients were categorized into 3 cohorts: quantitative assessment-based nursing intervention (QN, n=114), conventional nursing intervention (CN, n=125), or no nursing intervention (DN, n=189). The 3 cohorts were followed over a 6-month period. RESULTS At 6 months post-intervention, patients in the QN and CN cohorts showed significant reductions in symptoms of fecal incontinence, constipation, and abdominal distension compared to the DN cohort. Additionally, defecation time decreased significantly in the QN and CN cohorts compared to both initial measures and the DN cohort. Notably, patients in the QN cohort demonstrated substantial improvement in overall quality of life scores compared to baseline, CN, and DN cohorts. The QN cohort also reported marked improvement in caregivers' satisfaction, surpassing that of caregivers in the CN and DN cohorts. CONCLUSIONS Six months of quantitative assessment-based nursing interventions significantly improved bowel function, quality of life, and caregiver satisfaction in SCI patients with NBD. This intervention appears beneficial for managing NBD in SCI patients and improving their quality of life and caregiver satisfaction.

Collaborative Care Versus Usual Care to Improve Quality of Life, Pain, Depression, and Physical Activity in Outpatients With Spinal Cord Injury: The SCI-CARE Randomized Controlled Clinical Trial.

Our goal was to test the effectiveness of collaborative care (CC) versus usual care (UC) to improve treatment of pain, depression, physical inactivity, and quality of life in outpatients with spinal cord injury (SCI). We conducted a single blind parallel group randomized controlled trial. The setting was two outpatient SCI rehabilitation clinics within a large academic medical center. Participants were 174 outpatients who were on average 47.7 years old, 76% male, 76% white, 8% Hispanic, 47% tetraplegic, 95% more than 1 year post-SCI, and 45% on Medicare. The intervention consisted of a mental health-trained collaborative care manager (CM) integrated into two SCI rehabilitation medicine clinics and supervised by content experts in pain and mental health treatment. The CM provided assessment, medical care coordination, adherence support, outcome monitoring, and decision support along with brief psychological interventions to the patients via up to 12 in-person or telephone sessions. Among all participants, 61% chose to focus on pain; 31% on physical activity and 8% on depression. The primary outcome was quality of life as measured by the World Health Organization Quality of Life-BREF at the end of treatment (4 months). Secondary outcomes were quality of life at 8 months and pain intensity and interference, depression severity, and minutes per week of moderate to vigorous physical activity at 4 and 8 months. A total of 174 participants were randomized 1:1 to CC (n = 89) versus UC (n = 85). The primary analysis, a mixed-effects linear regression adjusting for time since injury and sex, revealed a non-significant trend for greater improvement in quality of life in CC versus UC at 4 months (p = 0.083). Secondary analyses showed that those receiving CC reported significantly greater improvement in pain interference at 4- and 8-months and in depression at 4-months, but no significant effect on physical activity. We conclude that in an outpatient SCI care setting, CC is a promising model for delivering integrated medical and psychological care and improving management of common, chronic, disabling conditions such and pain and depression.

Assessment of high-risk opioid use metrics among individuals with spinal cord injury: A brief report.

OBJECTIVE: To examine high-risk opioid prescription metrics among individuals with chronic spinal cord injury (SCI) living in South Carolina. DESIGN: Cohort Study. SETTING: Two statewide population-based databases, an SCI Surveillance Registry and state prescription drug monitoring program (PDMP). PARTICIPANTS: Linked data was obtained for 503 individuals with chronic (>1year-post injury) SCI who were injured in 2013 or 2014 and who survived at least 3 years post-injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Opioid prescription metrics were obtained from the PDMP. Fill data during the period between January 1, 2014 and December 31, 2017 were analyzed to assess high-risk opioid use. Outcomes included: percentage of individuals prescribed chronic opioids, high-dose chronic opioid therapy (daily morphine milligram equivalents (MME) ≥50 and ≥90), and chronic concurrent opioids and benzodiazepines, sedatives, or hypnotics (BSH). RESULTS: Over half (53%) of the individuals filled an opioid in years 2-3 after injury. Of those, 38% had a concurrent BSH fill during the study period, 76% of which were for benzodiazepines. In any given quarter over the two-year timeframe, over half of the opioid prescriptions were for 60 days or more (chronic opioid prescriptions). Of those, roughly 40% of the individuals had high-dose chronic opioid prescriptions ≥50 MME/d and 25% were ≥90 MME/d. Over 33% had a concurrent BSH prescription for ≥60 days. CONCLUSIONS: While the number of individuals receiving high-risk opioid prescriptions may not be large, it is a concerning number of prescriptions. The findings suggest a need for more cautious opioid prescribing and monitoring of high-risk use in adults with chronic SCI.

Assessment of the incremental prognostic value from the modified frailty index-5 in complete traumatic cervical spinal cord injury.

Frailty, as measured by the modified frailty index-5 (mFI-5), and older age are associated with increased mortality in the setting of spinal cord injury (SCI). However, there is limited evidence demonstrating an incremental prognostic value derived from patient mFI-5. We conducted a retrospective cohort study to evaluate in-hospital mortality among adult complete cervical SCI patients at participating centers of the Trauma Quality Improvement Program from 2010 to 2018. Logistic regression was used to model in-hospital mortality, and the area under the receiver operating characteristic curve (AUROC) of regression models with age, mFI-5, or age with mFI-5 was used to compare the prognostic value of each model. 4733 patients were eligible. We found that both age (80 y versus 60 y: OR 3.59 95% CI [2.82 4.56], P < 0.001) and mFI-5 (score ≥ 2 versus < 2: OR 1.53 95% CI [1.19 1.97], P < 0.001) had statistically significant associations with in-hospital mortality. There was no significant difference in the AUROC of a model including age and mFI-5 when compared to a model including age without mFI-5 (95% CI Δ AUROC [- 8.72 × 10-4 0.82], P = 0.199). Both models were superior to a model including mFI-5 without age (95% CI Δ AUROC [0.06 0.09], P < 0.001). Our findings suggest that mFI-5 provides minimal incremental prognostic value over age with respect to in-hospital mortality for patients complete cervical SCI.

Prevalence of secondary health conditions and mental status in persons with long-term spinal cord injury in South Africa: Comparison between public and private healthcare sectors.

BACKGROUND: Spinal cord injuries typically result in a range of negative health outcomes and health states, which impacts overall functioning, health and well-being. It remains important to establish the prevalence (burden) of health outcomes to help with the development of optimal treatment strategies. OBJECTIVES: To determine the prevalence and treatment rates of secondary health conditions (SHCs) and mental health states in persons with long-term spinal cord injury (SCI) receiving public compared with private healthcare services in South Africa. METHODS: A cross-sectional survey included 200 community-dwelling persons with long-term SCI, 60% with paraplegia, 53% with complete injuries and 156 from the public and 44 from private healthcare sectors. The following modules of the International Spinal Cord Injury (InSCI) community survey were used: (i) demographic and injury characteristics; (ii) SHCs and treatment rates; and (iii) vitality and emotional well-being. All statistical analyses were stratified according to healthcare sector. RESULTS: Pain (47% v. 57), sexual dysfunction (59% v. 41%) and muscle spasms (54% v. 43%) were the most common SHCs in both cohorts, and the period prevalence was significantly higher for sleeping problems (41% v. 25%), sexual dysfunction (59% v. 41%) and contractures (42% v. 20%) in the public compared with the private cohort. Persons with SCI in the private cohort received treatment more often for sleeping problems (100% v. 45%), autonomic dysreflexia (75% v. 27%) and pain (56% v. 33%) than their counterparts with public insurance. Negative mental health states were prevalent in both groups. CONCLUSION: SHCs and negative mental health were common in persons with SCI in South Africa, while those with public insurance reporter a higher occurrence of sleep problems and contractures, as well as lower treatment rates. Overall, a need exists to better support persons with SCI in the long-term context to facilitate improved functioning and wellbeing.

Total Knee Arthroplasty in Patients with Spinal Cord Injury: Impact on Medical Complications, Hospital Costs and Length of Stay.

INTRODUCTION: Patients with spinal cord injury (SCI) with degenerative joint disease of the knee may require total knee arthroplasty (TKA). This study examines the demographic and immediate postoperative outcomes of patients with SCI who undergo TKA. METHODS: Admissions data for TKA and SCI were analyzed from the National Inpatient Sample database using International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. An extensive array of preoperative and postoperative variables was compared among SCI TKA patients and non-SCI TKA patients. An unmatched and matched analysis using a 1:1 propensity match algorithm was conducted to compare the two groups. RESULTS: Patients with SCI tend to be younger and have a 7.518 times greater risk of acute renal failure, 2.3 times greater risk of blood loss, and higher risk of local complications, including periprosthetic fracture and prosthetic infection. The average length of stay in the SCI cohort was 2.12 times greater, with a 1.58 times higher mean total incurred charge than the non-SCI group. CONCLUSION: SCI is associated with an increased risk of acute renal failure, blood loss anemia, periprosthetic fractures and infections, a longer length of stay, and greater incurred charges in TKA patients. STUDY DESIGN: Retrospective study.

[The neuro-urological expert opinion in statutory accident insurance : Consensual recommendations for diagnostics and for the assessment of reduction of earning capacity]. / Das neurourologische Gutachten in der gesetzlichen Unfallversicherung : Konsentierte Empfehlungen zur Diagnostik und zur Bewertung der Minderung der Erwerbsfähigkeit.

BACKGROUND: Previous assessment guidelines from standard sources for urologic expert opinions show considerable differences in the recommended percentages for the assessment of reduction of earning capacity (MdE) for accident sequelae in the neuro-urological specialty. OBJECTIVES: To develop a "revised and standardized version of the MdE assessments of neuro-urological accident sequelae (in tabular form) as a guideline/manual" for expert opinions in the legal area of the German and Austrian Statutory Accident Insurance ( www.dguv.de , www.auva.at ). MATERIALS AND METHODS: A working group of neuro-urologists from spinal cord injury centers of different BG ("Berufsgenossenschaft") clinics was formed within the working group Neuro-Urology of DMGP (German-speaking Medical Society for Paraplegiology; www.dmgp.de ). Between January 2017 and September 2022, a total of 7 working meetings and 2 video conferences were held. The consensus of the developed documents was reached by formal consensus finding in a nominal group process and in a final consensus conference. RESULTS: The necessary bases for a targeted, legally sound diagnosis of accident consequences in the neuro-urological field were elaborated and, based on the experience of many years of expert opinion activity, a "matrix" for a uniform, graduated assessment of the level of reduction of earning capacity in the (neuro-)urological field in the case of confirmed neuro-urological accident consequences was created. CONCLUSION: In the interest of equal treatment of all insured persons, it is of great importance to make a uniform and comprehensible assessment of the amount of the MdE on the basis of "table values" that reflect the available empirical values.

A cost-effectiveness analysis of bladder management strategies in neurogenic lower urinary tract dysfunction after spinal cord injury: A publicly funded health care perspective.

STUDY DESIGN: Economic evaluation study. OBJECTIVES: To investigate the long-term cost-effectiveness of clean intermittent catheterization (CIC) compared with suprapubic catheters (SPC) and indwelling urethral catheters (UC) among individuals with neurogenic lower urinary tract dysfunction (NLUTD) related to spinal cord injury (SCI) from a public healthcare perspective. SETTING: University affiliated hospital in Montreal, Canada. METHODS: A Markov model with Monte Carlo simulation was developed with a cycle length of 1 year and lifetime horizon to estimate the incremental cost per quality-adjusted life years (QALYs). Participants were assigned to treatment with either CIC or SPC or UC. Transition probabilities, efficacy data, and utility values were derived from literature and expert opinion. Costs were obtained from provincial health system and hospital data in Canadian Dollars. The primary outcome was cost per QALY. Probabilistic and one-way deterministic sensitivity analyses were performed. RESULTS: CIC had a lifetime mean total cost of $ 29,161 for 20.91 QALYs. The model predicted that a 40-year-old person with SCI would gain an additional 1.77 QALYs and 1.72 discounted life-years gained if CIC were utilized instead of SPC at an incremental cost savings of $330. CIC confer 1.96 QALYs and 3 discounted life-years gained compared to UC with an incremental cost savings of $2496. A limitation of our analysis is the lack of direct long-term comparisons between different catheter modalities. CONCLUSIONS: CIC appears to be a dominant and more economically attractive bladder management strategy for NLUTD compared with SPC and/or UC from the public payer perspective over a lifetime horizon.

Health Care Utilization and Cost Associated With Urinary Tract Infections in a Privately Insured Spinal Cord Injury Population.

Background: Urinary tract infections (UTIs) are the most common secondary medical complication following spinal cord injury (SCI), significantly impacting health care resource utilization and costs. Objectives: To characterize risk factors and health care utilization costs associated with UTIs in the setting of SCI. Methods: IBM's Marketscan Database from 2000-2019 was utilized to identify individuals with traumatic SCI. Relevant ICD-9 and ICD-10 codes classified individuals into two analysis groups: having ≥ 1 UTI episode or no UTI episodes within 2 years following injury. Demographics (age, sex), insurance type, comorbidities, level of injury (cervical, thoracic, lumbar/sacral), and health care utilization/payments were evaluated. Results: Of the 6762 individuals retained, 1860 had ≥ 1 UTI with an average of three episodes (SD 2). Younger age, female sex, thoracic level of injury, noncommercial insurance, and having at least one comorbidity were associated with increased odds of UTI. Individuals with a UTI in year 1 were 11 times more likely to experience a UTI in year 2. As expected, those with a UTI had a higher rate and associated cost of hospital admission, use of outpatient services, and prescription refills. UTIs were associated with 2.48 times higher cumulated health care resource use payments over 2 years after injury. Conclusions: In addition to bladder management-related causes, several factors are associated with an increased risk of UTIs following SCI. UTI incidence substantially increases health care utilization costs. An increased understanding of UTI-associated risk factors may improve the ability to identify and manage higher risk individuals with SCI and ultimately optimize their health care utilization.

A new balance assessment tool for quantifying balance impairment in patients with motor incomplete spinal cord injury: Pilot study.

OBJECTIVE: This study aimed to quantitatively and objectively evaluate the balance impairment in patients with motor incomplete spinal cord injury (SCI) using a new evaluation tool for balance and to assess its role in comprehensive balance assessment. DESIGN: Retrospective pilot study. SETTING: Rehabilitation hospital. PARTICIPANTS: 14 patients with motor incomplete spinal cord injury. INTERVENTIONS: None. OUTCOME MEASURES: We retrospectively compared and analyzed the results of 14 patients with motor incomplete SCI who underwent various balance assessments, including the FRA510S test, using correlation. RESULTS: The agreement between the FRA510S and existing balance assessment was confirmed through Bland-Altman plots; moreover, high degree of agreement was observed in Berg Balance Scale in the eye closed state and in Five Times Sit-to-Stand Test in the eye open state. CONCLUSIONS: It was confirmed that the FRA510S equipment provides quantitative values for balance function. Balance assessment using the FRA510S, along with neurological, electrophysiological, and clinical tests, may provide comprehensive additional information related to falls and gait rehabilitation in patients with SCI.

Clinical characteristics, hospital course, and disposition of patients with nontraumatic spinal cord injury in a large private health care system in the United States.

OBJECTIVES: To evaluate the clinical characteristics, hospital courses, outcomes after hospitalization, and factors associated with outcomes in patients with nontraumatic spinal cord injuries (NTSCI). DESIGN: Retrospective analysis. SETTING: A large for-profit United States health care system. PARTICIPANTS: 2807 inpatients with NTSCI between 2014 and 2020 were identified using International Classification of Disease codes. MAIN OUTCOME MEASURE: Demographic, clinical characteristics, hospital course, and disposition data collected from electronic health record. RESULTS: The mean age was 57.91 ± 16.41 years with 69.83% being male. Incomplete cervical level injury was the most common injury type, spinal stenosis was the most common diagnostic etiology and central cord syndrome was the most common clinical syndrome. The average length of stay was 9.52 ± 15.8 days, with the subgroup of 1308 (46.6%) patients who were discharged home demonstrating a shorter length of stay (6.42 ± 10.24 days). Falls were the most common hospital-acquired complication (n = 424, 15.11%) and 83 patients deceased. There were increased odds of non-home discharge among patients with the following characteristics: older age, Medicare insurance, non-black racial minority, increased Charlson Comorbidity Index (CCI), intensive care unit (ICU) stay, use of steroid or anticoagulant medications, and hospital-acquired pulmonary complications. Increased in-hospital mortality was observed in those with Medicaid insurance, ICU stay, increased CCI, diagnosis of degenerative spine disease, other unspecified level of injury, and hospital-acquired pulmonary complications. CONCLUSIONS: NTSCI in this sample were predominantly incomplete cervical central SCIs. Increased CCI, ICU stay, and hospital-acquired pulmonary complications were associated with poorer outcomes after acute care hospitalization among patients with NTSCI.

Optimization of Protocols Using Neuromuscular Electrical Stimulation for Paralyzed Lower-Limb Muscles to Increase Energy Expenditure in People With Spinal Cord Injury.

OBJECTIVE: The aim of this study was to evaluate whether using surface neuromuscular electrical stimulation (NMES) for paralyzed lower-limb muscles results in an increase in energy expenditure and whether the number of activated muscles and duty cycle affect the potential increase. DESIGN: This was a cross-sectional study. RESULTS: Energy expenditure during all NMES protocols was significantly higher than the condition without NMES (1.2 ± 0.2 kcal/min), with the highest increase (+51%; +0.7 kcal/min, 95% confidence interval, 0.3-1.2) for the protocol with more muscles activated and the duty cycle with a shorter rest period. A significant decrease in muscle contraction size during NMES was found with a longer stimulation time, more muscles activated, or the duty cycle with a shorter rest period. CONCLUSION: Using NMES for paralyzed lower-limb muscles can significantly increase energy expenditure compared with sitting without NMES, with the highest increase for the protocol with more muscles activated and the duty cycle with a shorter rest period. Muscle fatigue occurred significantly with the more intense NMES protocols, which might cause a lower energy expenditure in a longer protocol. Future studies should further optimize the NMES parameters and investigate the long-term effects of NMES on weight management in people with SCI.

Development and Assessment of SCI Model Systems Complicated UTI Consensus Guidelines: A Psychometrically Designed Mixed-Methods Protocol.

Background: Complicated UTI (cUTI) is highly prevalent among people with spinal cord injury and disease (SCI/D), but neither consistent nor evidence-based guidelines exist. Objectives: We propose a two-phase, mixed-methods study to develop consensus around diagnostic and decision-making criteria for cUTI among people with SCI/D and the clinicians who treat them. Methods: In phase 1 (qualitative), we will engage Spinal Cord Injury Model Systems (SCIMS) clinicians in focus groups to refine existing cUTI-related decision making using three reliable and validated Urinary Symptom Questionnaires for Neurogenic Bladder (USQNBs; intermittent catheterization, indwelling catheterization, and voiding) as points of departure, and then we will conduct a Delphi survey to explore and achieve consensus on cUTI diagnostic criteria among a nationally representative sample of clinicians from physical medicine and rehabilitation, infectious disease, urology, primary care, and emergency medicine. We will develop training materials based on these new guidelines and will deploy the training to both clinicians and consumers nationally. In phase 2 (quantitative), we will assess clinicians' uptake and use of the guidelines, and the impact of the guidelines training on consumers' self-management habits, engagement with the health care system, and antibiotic use over the 12 months after training. Results: The output of this study will be diagnostic guidelines for cUTI among people with neurogenic lower urinary tract dysfunction (NLUTD) due to SCI/D, with data on uptake (clinicians) and impact (patients). Conclusion: This mixed-methods protocol integrates formal psychometric methods with large-scale evidence gathering to derive consensus around diagnostic guidelines for cUTI among people with NLUTD due to SCI/D and provides information on uptake (clinicians) and impact (patients).

Spasticity following brain and spinal cord injury: assessment and treatment.

PURPOSE OF REVIEW: Spasticity is a common sequela of brain and spinal cord injury and contributes to disability, reduces quality of life, and increases economic burden. Spasticity is still incompletely recognized and undertreated. We will provide an overview of recent published data on the definition, assessment, and prediction, therapeutic advances, with a focus on promising new approaches, and telemedicine applications for spasticity. RECENT FINDINGS: Two new definitions of spasticity have been recently proposed, but operational criteria should be developed, and test-retest and inter-rater reliability should be explored. Cannabinoids proved to be effective in spasticity in multiple sclerosis, but evidence in other types of spasticity is lacking. Botulinum neurotoxin injection is the first-line therapy for focal spasticity, and recent literature focused on optimizing its efficacy. Several pharmacological, interventional, and nonpharmacological therapeutic approaches for spasticity have been explored but low-quality evidence impedes solid conclusions on their efficacy. The recent COVID-19 pandemic yielded guidelines/recommendations for the use of telemedicine in spasticity. SUMMARY: Despite the frequency of spasticity, robust diagnostic criteria and reliable assessment scales are required. High-quality studies are needed to support the efficacy of current treatments for spasticity. Future studies should explore telemedicine tools for spasticity assessment and treatment.