Bowel burdens: a systematic review and meta-analysis examining the relationships between bowel dysfunction and quality of life after spinal cord injury.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: Many individuals with spinal cord injury (SCI) experience autonomic dysfunction, including profound impairments to bowel and cardiovascular function. Neurogenic bowel dysfunction (NBD) is emerging as a potential determinant of quality of life (QoL) after SCI. For individuals with high-level lesions ( > T6), bowel care-related autonomic dysreflexia (B-AD; profound episodic hypertension) further complicates bowel care. We aimed to evaluate the extent of bowel dysfunction after SCI, and the impact of bowel dysfunction on QoL after SCI. METHODS: We searched five databases to identify research assessing the influence of NBD or B-AD on QoL after SCI. Metrics of bowel dysfunction (fecal incontinence [FI], constipation, time to complete, and B-AD) and QoL data were extracted and synthesised. Where possible, meta-analyses were performed. RESULTS: Our search identified 2042 titles, of which 39 met our inclusion criteria. Individuals with SCI identified problems with NBD (74.7%), FI (56.9%), and constipation (54.6%), and 49.3% of individuals with SCI > T6 experienced B-AD. Additionally, 40.3% of individuals experienced prolonged defecation ( > 30 min). Moderate/severe deterioration in QoL due to NBD was reported by 55.5% of individuals with SCI, with negative impacts on physical, emotional, and social health-related QoL associated with inflexibility of bowel routines, fear of accidents, and loss of independence. CONCLUSION: Bowel dysfunction and bowel care challenges are prevalent and disabling for individuals with SCI, with a profoundly negative impact on QoL. Improving bowel management is a key target to improve QoL for those living with SCI.

Barriers and facilitators to changing bowel care practices after spinal cord injury: a Theoretical Domains Framework approach.

BACKGROUND: Improvement to autonomic processes such as bladder, bowel and sexual function are prioritised by individuals with spinal cord injury (SCI). Bowel care is associated with high levels of dissatisfaction and decreased quality of life. Despite dissatisfaction, 71% of individuals have not changed their bowel care routine for at least 5 years, highlighting a disconnect between dissatisfaction with bowel care and changing routines to optimise bowel care. OBJECTIVE: Using an integrated knowledge translation approach, we aimed to explore the barriers and facilitators to making changes to bowel care in individuals with SCI. METHODS: Our approach was guided by the Behaviour Change Wheel and used the Theoretical Domains Framework (TDF). Semi-structured interviews were conducted with individuals with SCI (n = 13, mean age 48.6 ± 13.1 years) and transcribed verbatim (duration 31.9 ± 7.1 min). Barriers and facilitators were extracted, deductively coded using TDF domains and inductively analysed for themes within domains. RESULTS: Changing bowel care after SCI was heavily influenced by four TDF domains: environmental context and resources (workplace flexibility, opportunity or circumstance, and access to resources); beliefs about consequences; social influences (perceived support and peer mentorship); and knowledge (knowledge of physiological processes and bowel care options). All intervention functions and policy categories were considered viable intervention options, with human (61%) and digital (33%) platforms preferred. CONCLUSIONS: Modifying bowel care is a multi-factorial behaviour. These findings will support the systematic development and implementation of future interventions to both enable individuals with SCI to change their bowel care and to facilitate the optimisation of bowel care approaches.

Integrated Knowledge Translation Guiding Principles for Conducting and Disseminating Spinal Cord Injury Research in Partnership.

OBJECTIVE: To address a gap between spinal cord injury (SCI) research and practice by rigorously and systematically co-developing integrated knowledge translation (IKT) guiding principles for conducting and disseminating SCI research in partnership with research users. DESIGN: The process was guided by the internationally accepted The Appraisal of Guidelines for REsearch & Evaluation (AGREE) II Instrument for evaluating the development of clinical practice guidelines. SETTING: North American SCI research system (ie, SCI researchers, research users, funders). PARTICIPANTS: The multidisciplinary expert panel (n=17) and end users (n=35) included individuals from a North American partnership of SCI researchers, research users, and funders who have expertise in research partnerships. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clarity, usefulness, and appropriateness of the principles. RESULTS: Data regarding 125 principles of partnered research were systematically collected from 4 sources (review of reviews, scoping review, interviews, Delphi consensus exercise). A multidisciplinary expert panel held a 2-day meeting to establish consensus, select guiding principles, and draft the guidance. The panel reached 100% consensus on the principles and guidance document. The final document includes a preamble, 8 guiding principles, and a glossary. Survey data showed that the principles and guidance document were perceived by potential end users as clear, useful, and appropriate. CONCLUSIONS: The IKT Guiding Principles represent the first rigorously co-developed, consensus-based guidance to support meaningful SCI research partnerships. The principles are a foundational tool with the potential to improve the relevance and impact of SCI research, mitigate tokenism, and advance the science of IKT.

Clinical recommendations for use of lidocaine lubricant during bowel care after spinal cord injury prolong care routines and worsen autonomic dysreflexia: results from a randomised clinical trial.

STUDY DESIGN: Clinical trial. OBJECTIVE: Spinal cord injury (SCI) impacts autonomic function and bowel management. Bowel care is a potential trigger for autonomic dysreflexia (AD; paroxysmal hypertension elicited by sensory stimuli below the level of lesion). AD can be life threatening so strategies to minimise AD are prioritised after SCI. Lidocaine lubricant is recommended during bowel care with the rationale to minimise the sensory stimulus, reducing AD. The objective of this study was to assess whether lidocaine lubricant (Xylocaine 2%) ameliorates AD during at-home bowel care compared with standard lubricant (placebo). SETTING: Community. METHOD: Participants (n = 13; age 44.0 ± 3.3 years) with high-level SCI (C3-T4) performed their normal at-home bowel care on two days, each time using a different lubricant, with continuous non-invasive cardiovascular monitoring. Injury to spinal autonomic (sympathetic) nerves was determined from low-frequency systolic arterial pressure (LF SAP) variability. RESULTS: Participants displayed reduced autonomic function (LF SAP 3.02 ± 0.84 mmHg2), suggesting impaired autonomic control. Bowel care duration was increased with lidocaine (79.1 ± 10.0 min) compared to placebo (57.7 ± 6.3 min; p = 0.018). All participants experienced AD on both days, but maximum SAP was higher with lidocaine (214.3 ± 10.5 mmHg) than placebo (196.7 ± 10.0 mmHg; p = 0.046). Overall, SAP was higher for longer with lidocaine (6.5 × 105 ± 0.9 × 105 mmHg • beat) than placebo (4.4 × 105 ± 0.6 × 105 mmHg • beat; p = 0.018) indicating a higher burden of AD. Heart rate and rhythm disturbances were increased during AD, particularly with lidocaine use. CONCLUSIONS: At-home bowel care was a potent trigger for AD. Our findings contradict recommendations for lidocaine use during bowel care, suggesting that anaesthetic lubricants impair reflex bowel emptying, resulting in longer care routines with an increased burden of AD.

Translating the international scientific spinal cord injury exercise guidelines into community and clinical practice guidelines: a Canadian evidence-informed resource.

STUDY DESIGN: Knowledge translation (KT) study. OBJECTIVES: To demonstrate how to use systematic, community-engaged methods to (1) translate the international scientific spinal cord injury (SCI) exercise guidelines into community and clinical practice guidelines, and (2) develop supporting resources. SETTING: Canada. METHODS: An expert panel of SCI researchers and stakeholders translated the guidelines and developed a supporting resource, using a KT process guided by an adapted version of the Appraisal of Guidelines, Research and Evaluation (AGREE) II Instrument. Pilot tests with end-users were conducted throughout. RESULTS: The panel recommended (1) the two scientific exercise guidelines be combined and presented in a single message titled "The Canadian SCI physical activity guidelines"; (2) development of an online supporting resource, with educational and motivational information presented in "layers" to address the needs and preferences of diverse end-users. The top layer presents and explains the Canadian SCI physical activity guidelines. The deeper layers include information on benefits, overcoming barriers, activity examples, safety tips, and links to existing resources. Interviews with adults with SCI (n = 8) and survey-data from end-users (n = 90) showed that the guidelines and supporting resource were perceived as clear, useful, and appropriate. CONCLUSION: Using community-engaged methods, the two scientific SCI exercise guidelines were combined into one single physical activity guideline message. This KT process provides a template for groups in other countries to translate the scientific SCI exercise guidelines to their local settings using a similar systematic, community-engaged approach. SPONSORSHIP: Rick Hansen Institute; Social Sciences and Humanities Research Council of Canada.

Community acquired pressure injuries in a work-related spinal cord injury population: Problem characterization and assessment of a working solution.

BACKGROUND: To characterize the problem of community-acquired pressure injuries (CAPIs) in a work-related spinal cord injury (SCI) population in Canada and assess the benefits of a person-centered solution. Characterization of the problem and a solution, albeit in an insured Worker's Compensation Board of British Columbia (WorkSafeBC) cohort, may inform the supply of solutions in the larger SCI population with disparate access to healthcare. METHODS: For this observational study, data on 244 WorkSafeBC clients, who received an intervention featuring pressure injury (PI) assessment between 2011 and 2015, were used to characterize the problem. Data on observed injuries, risk, referrals, and outcomes were linked to healthcare service claims. Employing an activity-based costing methodology, total expenditures on attributed services were calculated for clients with 1 or more PIs. Intervention cost and benefits from the insurer's perspective are considered. RESULTS: 84 of 244 clients had 1 or more PIs at assessment, with attributed mean cost of $56,092 in 2015 Canadian dollars (CAD). Mean cost by PI severity range from $9580 to $238,736. At an intervention cost of $820,618, detection of less severe injuries provided an opportunity to prevent progression and achieve $3 million in cost avoidance. Follow-up data suggest reasonable returns. Reductions in the incidence, number, and risk of pressure injuries were also observed. CONCLUSIONS: The analysis establishes the cost of CAPIs in a Canadian-based work-related SCI population and suggests preventative and early intervention is not only feasible but also practical. Results are relevant to decisions regarding the use of proactive prevention-based treatment models as opposed to reactive, solutions in the larger SCI population.

COVID-19 and Spinal Cord Injury: Clinical Presentation, Clinical Course, and Clinical Outcomes: A Rapid Systematic Review.

Persons living with spinal cord injury (SCI) are potentially at risk for severe COVID-19 disease given that they often have decreased lung capacity and may lack the ability to effectively evacuate their lungs. Known risk factors for negative outcomes after COVID-19, such as obesity, diabetes, and cardiovascular disease, disproportionally affect people with SCI and raise concerns for the mortality risk among persons with SCI. A rapid systematic review of English, Spanish, Portuguese, and Chinese literature on COVID-19 and SCI was performed using the keywords "spinal cord injury" and "COVID-19." We included studies that provided information on clinical presentation, characteristics, course, and outcomes of COVID-19 disease in SCI. We excluded studies on patients who did not have an SCI before severe acute respiratory syndrome coronavirus-2 infection or did not report clinical information. We included 10 studies in total: nine studies with a total of 171 patients and a survey study of 783 healthcare professionals. Fever (74%), cough (52%), and dyspnea (33%) were the most frequently reported symptoms, and 63% showed abnormalities on X-ray imaging. In the included case series and reports (N = 31), only 1 patient required mechanical ventilation, but 3 patients died (10%). The mortality rate in a large registry study (N = 140) was 19%. Clinical presentation of COVID-19 in SCI patients was similar to the general population, and though adverse events and intensive care unit admission were low, the mortality rate was high (10-19%). No prognostic factors for severe disease or mortality could be identified. Registration (PROSPERO): CRD42020196565.

A Community Perspective on Bowel Management and Quality of Life after Spinal Cord Injury: The Influence of Autonomic Dysreflexia.

Autonomic dysfunction is common in individuals with spinal cord injury (SCI) and leads to numerous abnormalities, including profound cardiovascular and bowel dysfunction. In those with high-level lesions, bowel management is a common trigger for autonomic dysreflexia (AD; hypertension provoked by sensory stimuli below the injury level). Improving bowel care is integral for enhancing quality of life (QoL). We aimed to describe the relationships between bowel care, AD, and QoL in individuals with SCI. We performed an online community survey of individuals with SCI. Those with injury at or above T7 were considered at risk for AD. Responses were received from 287 individuals with SCI (injury levels C1-sacral and average duration of injury 17.1 ± 12.9 [standard deviation] years). Survey completion rate was 73% (n = 210). Bowel management was a problem for 78%: it interfered with personal relationships (60%) and prevented staying (62%) and working (41%) away from home. The normal bowel care duration was >60 min in 24% and most used digital rectal stimulation (59%); 33% reported bowel incontinence at least monthly. Of those at risk for AD (n = 163), 74% had AD symptoms during bowel care; 32% described palpitations. AD interfered with activities of daily living in 51%. Longer durations of bowel care (p < 0.001) and more severe AD (p = 0.04) were associated with lower QoL. Bowel management is a key concern for individuals with SCI and is commonly associated with symptoms of AD. Further studies should explore ways to manage bowel dysfunction, increase self-efficacy, and ameliorate the impact of AD to improve QoL.

Phenol reduces hypertonia and enhances strength: a longitudinal case study.

Phenyl alcohol blocks are used to relieve spasticity. Such nerve conduction blocks result from phenol-induced axonotmesis and could potentially affect muscle properties related to the ability to generate, maximize, and reduce force. This study assessed the 12-week longitudinal effect of phenol on position (stiffness) and velocity (damping) components of hypertonia, in addition to strength (peak torque and times to generate and reduce torque) in an individual with chronic elbow flexor spasticity following stroke. Phenol motor point injections of flexor muscles paradoxically increased the magnitude of flexion torque and decreased the times required to generate and reduce flexion and extension joint torques, in addition to reducing elbow extension stiffness and damping. Large reductions in the velocity-related component of hypertonia (damping changes > 90%) occurred immediately following injection, which is a finding that supports the velocity-dependent definition of spasticity. Although the changes in damping were large and transient, changes in stiffness and strength variables were small, slower to occur, and maintained. This suggests secondary changes following nerve block, possibly facilitated by regular elbow use subsequent to spasticity reduction.

Relationship between clinical assessments of function and measurements from an upper-limb robotic rehabilitation device in cervical spinal cord injury.

Upper limb robotic rehabilitation devices can collect quantitative data about the user's movements. Identifying relationships between robotic sensor data and manual clinical assessment scores would enable more precise tracking of the time course of recovery after injury and reduce the need for time-consuming manual assessments by skilled personnel. This study used measurements from robotic rehabilitation sessions to predict clinical scores in a traumatic cervical spinal cord injury (SCI) population. A retrospective analysis was conducted on data collected from subjects using the Armeo Spring (Hocoma, AG) in three rehabilitation centers. Fourteen predictive variables were explored, relating to range-of-motion, movement smoothness, and grip ability. Regression models using up to four predictors were developed to describe the following clinical scores: the GRASSP (consisting of four sub-scores), the ARAT, and the SCIM. The resulting adjusted R(2) value was highest for the GRASSP "Quantitative Prehension" component (0.78), and lowest for the GRASSP "Sensibility" component (0.54). In contrast to comparable studies in stroke survivors, movement smoothness was least beneficial for predicting clinical scores in SCI. Prediction of upper-limb clinical scores in SCI is feasible using measurements from a robotic rehabilitation device, without the need for dedicated assessment procedures.

Effect of a robotic rehabilitation device on upper limb function in a sub-acute cervical spinal cord injury population.

Robotic rehabilitation devices have been suggested as a tool to increase the amount of rehabilitation delivered after a neurological injury. Clinical robotic rehabilitation studies of the upper extremity have generally focused on stroke survivors. We present the results of a multi-center pilot study where an upper-limb robotic rehabilitation device (Armeo Spring®, Hocoma AG) was incorporated into the rehabilitation program of 12 subjects with sub-acute cervical spinal cord injury (motor level C4-C6, AIS A-D). Outcomes were measured using two tests of upper extremity function: ARAT and GRASSP. The change in scores for the arm receiving the Armeo training were not statistically significant when compared to the arm not receiving the Armeo training at discharge from therapy and over follow up assessments (8.7 +/- 2.9 compared to 7.4 +/- 2.5 for ARAT at discharge, p = 0.98, and 13.0 +/- 3.2 compared to 13.3 +/- 3.3 for GRASSP at discharge, p = 0.69). Nevertheless, subjects with some minimal (partial) hand function at baseline had a significantly larger increase in GRASSP scores than subjects with no minimal hand function preserved at baseline (19.3 +/- 2.4 compared to 6.6 +/- 4.7, p = 0.02). This suggests that the initial functional capabilities of patients can influence the benefits measured after robotic rehabilitation training and heterogeneous subject populations should be avoided in early phase studies.