Unmet healthcare needs, access to services and experiences with health providers among persons with spinal cord injury in Australia.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: Appropriate and timely lifelong access to healthcare following a spinal cord injury (SCI) is critical, yet unmet healthcare needs in this population are common. Poor experiences with healthcare providers can be a barrier to health-seeking behaviour, and we hypothesised that there would be an association between unmet healthcare needs and care experiences. This study aimed to: (1) describe healthcare provider utilisation in the past year, unmet care needs and satisfaction with healthcare services; (2) explore the association between experiences with healthcare providers and unmet healthcare needs; and (3) explore the association between healthcare provider utilisation and participant characteristics, including unmet healthcare needs. SETTING: Community. METHODS: Analysis of data for 1579 Australians aged ≥ 18, who were ≥ 1-year post-SCI and living in the community. Bayesian penalised regression was used to model six binary outcomes: unmet healthcare needs; the use of general practitioners (GPs), allied health practitioners, rehabilitation specialists; medical specialists; and hospitalisations in the past 12-months. RESULTS: Unmet needs were reported by 17% of participants, with service cost the common deterrent. There was evidence of an effect for provider experiences on unmet healthcare needs, but no evidence that unmet healthcare needs was associated with the use of GPs, allied health practitioners, and rehabilitation or medical specialists. CONCLUSIONS: Unmet healthcare needs were reported in the context of high healthcare use and large proportions of secondary conditions in a cohort with long-term SCI. Improved health access for people with SCI include better primary-secondary care collaboration is needed.

Australian arm of the International Spinal Cord Injury (Aus-InSCI) Community Survey: 3. Drivers of quality of life in people with spinal cord injury.

STUDY DESIGN: Cross-sectional population-based survey for the Australian cohort of the International Spinal Cord Injury (InSCI) Community Survey. OBJECTIVES: To differentiate subgroups of people with spinal cord injury (SCI) who self-report good and poor overall quality of life (QoL) using domains of the International Classification of Functioning (ICF), and to evaluate how these factors contribute to QoL when considered together, while controlling confounders. SETTING: Australian survey data from four state-wide SCI services, one government insurance agency, and three not-for-profit consumer organisations. METHODS: Explanatory factors for QoL were compared between participants reporting poor vs. good QoL. Path models estimated total, direct and mediated contributions from each explanatory factor to QoL ratings after accounting for confounders. RESULTS: Most participants (62%) reported good or very good QoL, 12% reported poor or very poor QoL. When explanatory factors were considered together, the strongest total effects on QoL involved social integration (+0.36 SDs), subjective social position (+0.29), secondary health condition burden (-0.28), activity/participation problem burden (-0.26), day-to-day assistance (-0.26), mental health (+0.18), pain (-0.16), self-efficacy (+0.15), vitality (+0.14) and environmental barriers (-0.11). Effects of social integration, mental health, vitality, self-efficacy, pain and activity/participation problems were partly or wholly direct. CONCLUSION: Opportunities to improve QoL in people with SCI exist at every level of the health system. Virtually all aspects of the ICF framework make a substantive difference to QoL outcomes. Social and psychological factors and ability to complete desired activities have key direct effects and influence effects of secondary health condition burden and environmental barriers.

Australian arm of the International Spinal Cord Injury (Aus-InSCI) community survey: 1. population-based design, methodology and cohort profile.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To describe design and methods of Australian arm of International Spinal Cord Injury (Aus-InSCI) community survey, reporting on participation rates, potential non-response bias and cohort characteristics. SETTING: Survey of community-dwelling people with SCI at least 12 months post-injury, recruited between March 2018 and January 2019, from state-wide SCI services, a government insurance agency and not-for-profit consumer organisations across four Australian states. METHODS: The Aus-InSCI survey combined data for people with SCI from nine custodians, using secure data-linkage processes, to create a population-based, anonymised dataset. The Aus-InSCI questionnaire comprised 193 questions. Eligibility, response status and participation rates were calculated. Descriptive statistics depict participant characteristics. Logistic regression models were developed for probability of participation, and inverse probability weights generated to assess potential non-response bias. RESULTS: 1579 adults with SCI were recruited, a cooperation rate of 29.4%. Participants were predominantly male (73%), with 50% married. Mean age was 57 years (range 19-94) and average time post-injury 17 years (range 1-73). Paraplegia (61%) and incomplete lesions (68%) were most common. Males were more likely than females to have traumatic injuries (p < 0.0001) and complete lesions (p = 0.0002), and younger age-groups were more likely to have traumatic injuries and tetraplegia (p < 0.0001). Potential non-response bias evaluated using selected outcomes was found to be negligible in the Aus-InSCI cohort. CONCLUSIONS: The Aus-InSCI survey made efforts to maximise coverage, avoid recruitment bias and address non-response bias. The distributed, linked and coded (re-identifiable at each custodian level) 'virtual quasi-registry' data model supports systematic cross-sectional and longitudinal research.

Factors Related to Engagement in Employment After Spinal Cord Injury in Australia: A Cross-sectional Study.

OBJECTIVE: To explore the association between sociodemographic, health, functional independence, and environmental variables with engagement in paid work for people with spinal cord injury (SCI). DESIGN: Self-reported, cross-sectional Australian data from a large international SCI survey. SETTING: Community-based. PARTICIPANTS: 1189 working-age people with SCI (18-67 years) or aged >67 years and engaged in paid employment. Respondents were community based and at least 1 year after injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment and work integration variables. Bayesian penalized regression was used to determine associations between 23 predictor variables and engagement in paid work. RESULTS: Most participants (87%) were employed pre-injury, with 39% in paid employment at the time of the survey. Participants who attained a master's/doctoral degree (odds ratio [OR]=3.01; 95% credible interval [CrI], 1.63, 5.44) and those married (OR=1.68; 95% CrI, 1.13, 2.49) were more likely to be engaged in paid work. Women (OR=0.55; 95% CrI, 0.37, 0.81), people receiving a disability pension (OR=0.17; 95% CrI, 0.13, 0.24), and older participants (OR=0.75; 95% CrI, 0.63, 0.90) were less likely to be in paid work. Working participants identified hardships including problems completing their work (60%) and accessing the workplace (32%), as well as unmet needs relating to assistive devices required for completing their work (50%). CONCLUSIONS: Findings from the current study can assist in directing resources to subgroups within the SCI population who need greater assistance or intervention related to employment outcomes, including through vocational rehabilitation services/programs. Unmet needs and workplace issues expressed by employed individuals identify gaps in work integration and satisfaction that could affect employment sustainability that need to be addressed.

Utilising International Statistical Classification of Diseases and Related Health Conditions (ICD)-10 Australian Modification Classifications of "Health Conditions" to Achieve Population Health Surveillance in an Australian Spinal Cord Injury Cohort.

STUDY DESIGN: Retrospective, non-randomised, registry controlled. OBJECTIVE: To develop a conceptual ICD-10 taxonomic framework for population health surveillance across all-phases of spinal cord injury and disorders (SCI/D). SETTING: Public Hospital Admitted Patient Care (APC) collection, South Australian Dept. Health, South Australia, Australia. METHODS: A core ICD-10-Australian Modification (AM) coded dataset was retrieved from the APC hospital patient admission collection (2012-2017). Search filters and key words referenced to the National Library of Medicine thesaurus identified and quantified incident SCI/D cases. Incident SCI/D case data held in the Australian Spinal Cord Injury Registry (ASCIR) of South Australia (2012-2017) tested fidelity. Data linkage to the South Australian Death Registry controlled for cohort attrition. Both unadjusted and case-mix adjusted core data set yields were evaluated. Outcomes were assessed in terms of APC frequency difference (Δ%) versus ASCIR. RESULTS: 3,504 APC cases were extracted, of which 504 (mean, SD age 55 ± 20 yrs; 348 [69%] male, 202 [39%] traumatic; 135 [32%]) cervical; 51 [10.1%] thoracic and (16 [3.2%]) lumbar met criteria. Comparator data were 385 ASCIR new index cases mean, SD age 56 ± 19 yrs, 229 [75%] male, 162 [42%] traumatic. Case-mix adjusted analysis yielded 336 (APC Δ33%) all-cause incident cases (vs. ASCIR -13 Δ%) and 131 incident cases of traumatic aetiologies (vs. ASCIR -19 Δ%). CONCLUSIONS: The ICD-10 core "Health Condition" data-set assembled extends our understanding of SCI/D epidemiology and with further development may create a cost-efficient and sustainable framework that will improve health system performance and equity within and between countries. SPONSORSHIP: The Lifetime Support Authority of South Australia sponsored the study.

Australian arm of the International Spinal Cord Injury (Aus-InSCI) Community Survey: 2. Understanding the lived experience in people with spinal cord injury.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To identify common problems across key domains of functioning, health and wellbeing, as well as evaluate self-reported quality of life (QoL) by people with SCI, examining differences by age, gender, injury characteristics and level of mobility. SETTING: Data from four state-wide SCI clinical services, one government insurance agency and three not-for-profit consumer organisations. METHODS: Participants were 18 years or over with SCI and at least 12 months post-injury, recruited between Mar'18 and Jan'19. The Aus-InSCI questionnaire comprised 193 questions, including socio-demographics, SCI characteristics, body functions and structures, activities and participation, environmental and personal factors, and appraisal of health and well-being. General linear model was used to examine differences in functioning and QoL. RESULTS: Participants (mean age 57 years, range 19-94 years) with tetraplegia and/or complete injuries had more health problems, activity/participation problems and environmental barriers. However, self-rated overall QoL did not differ for injury level or completeness. Participants with more recent injuries exhibited lower independence levels, more mental health problems and poorer satisfaction with self and their living conditions. Major activity/participation problems related to intimate relationships and accessing public transportation. Less than half of the working age population were engaged in paid work. The top two environmental barriers frequently related to accessing public places or homes and unfavourable climatic conditions. CONCLUSIONS: This large, comprehensive community survey draws a detailed picture of the lived experience of people with SCI in Australia, identifying priority needs, gaps in services and barriers to achieving a full and satisfying life.

Mental health screening amongst police officers: factors associated with under-reporting of symptoms.

BACKGROUND: Mental health screening in the workplace aims to identify employees who are becoming symptomatic, in order to provide timely support and evidence-based interventions to those affected. Given the stigma associated with mental illness, accurate disclosure of mental health symptoms cannot be assumed. The present study sought to investigate factors associated with the accurate reporting of mental health symptoms amongst police officers. METHODS: A total of 90 serving police officers completed identical mental health screening surveys, one administered by the employer and the other anonymously by an independent organisation. Responses were then linked to compare differences in the number and severity of mental health symptoms reported on each questionnaire. RESULTS: Comparisons of matched self-report scores indicated that employees under-reported symptoms of mental health disorders when completing screening administered by their employer, with only 76.3% of symptoms declared. Under-reporting occurred regardless of gender and symptom type. Less senior staff (p = 0.05) and those with the most severe post-traumatic stress disorder and common mental disorder symptoms (p = 0.008) were significantly more likely to under-report symptoms. CONCLUSIONS: Employer-administered mental health screening is not able to accurately capture all mental health symptoms amongst first responders. The fact that the severity of symptoms predicted the level of under-reporting means that simple changes to cut-off values cannot correct this problem.

Employment outcomes following spinal cord injury: a population-based cross-sectional study in Australia.

STUDY DESIGN: Self-reported cross-sectional data for the Australian cohort participating in the International Spinal Cord Injury Community survey. OBJECTIVES: To contextualise post-injury employment for people with spinal cord injury (SCI) in Australia, including work participation rates, time to resuming work, underemployment and pre- and post-SCI employment changes. SETTING: Australian survey data from four state-wide SCI services, one government insurance agency and three not-for-profit consumer organisations across New South Wales, Queensland, South Australia and Victoria. METHODS: Data were analysed from 1579 participants with SCI who are at least 1-year post discharge from an inpatient facility. Survey measures included 16-items dedicated to employment. Pre- and post-injury job titles were based on the International Standard Classification of Occupations (ISCO-08) major classification. A mix of chi-squared, t-test and negative binomial regression were used to analyse data. RESULTS: The absolute post-injury employment rate was 49.9%, with one-third of the sample currently working. Pre-injury employment and engagement with vocational rehabilitation resulted in higher employment rates. Individuals who were unable to return immediately following inpatient rehabilitation took mean 28 months (SD, 35.9) to return. Time to employment was significantly lengthier for those without pre-injury jobs, at 59.7 months [SD, 43.8] (p < 0.001). Engagement in less manual roles increased post-injury, accounting for three quarters of post-SCI jobs. Underemployment was identified by 16.6% of those currently working. CONCLUSIONS: While there are current services and programmes in place in Australia that support post-injury employment, findings indicate a need for more comprehensive early intervention focused services targeted towards employers and individuals.

Work and SCI: a pilot randomized controlled study of an online resource for job-seekers with spinal cord dysfunction.

STUDY DESIGN: A prospective, parallel randomized controlled trial (RCT). OBJECTIVES: To test the preliminary effects of an online resource targeted to job-seekers with spinal cord injury or disorder (SCI/D), and to determine the feasibility of proceeding to a full-scale RCT. SETTING: A community cohort in Australia. METHODS: Forty-eight adults (M = 42 years, SD = 10.95, 27 males) were randomized to receive 4-weeks access to the Work and SCI resource (n = 25) or to a wait-list control group (n = 23). The Work and SCI intervention involved six stand-alone learning modules which provided job-searching and career-planning information through text, videos, and interactive activities. Self-report measures were administered at baseline and after 4 weeks: Job Procurement Self-Efficacy Scale (JSES), Life Orientation Test-Revised (LOT-R), and Patient Health Questionnaire-9 (PHQ-9). RESULTS: Online usage data identified high uptake of the Work and SCI resource, although study attrition was problematic. Intention-to-treat analyses failed to reach statistical significance, whereas complete data revealed a significant interaction effect for optimism (LOT-R). CONCLUSION: Further research to develop and enhance Work and SCI is indicated. Remediable strategies to optimize recruitment and statistical power in a future definitive RCT are discussed. SPONSORSHIP: This project was funded by the auDA Foundation (project 16019).

Leisure-Time Physical Activity Participation in Middle-Aged and Older Adults With a Spinal Cord Injury in Australia.

Objectives: Adults with spinal cord injury (SCI) are often sedentary, increasing their risk of cardiometabolic diseases. Leisure-time Physical Activity (LTPA) is physical activity completed during recreation time for enjoyment. We aimed to quantify LTPA in people ≥45 years with SCI and to explore its relationship with participants' characteristics. Methods: This is a secondary analysis on a subset of the Australian International SCI Survey in participants ≥45 years, at least 12 months post-injury. We described levels of LTPA and used multivariable regressions to estimate the associations between participant characteristics and LTPA. Results: Of 1,281 participants (mean age: 62.7 years, mean time since injury: 18.7 years; 74% males) 44% reported no participation in LTPA. The average LTPA participation was 197 (SD 352) minutes per week (median: 50). Females (ß = -62.3, 95% CI [-112.9, -11.7]), and participants with non-traumatic injuries (ß = -105.2, 95% CI [-165.9, -44.6]) performed less LTPA. Time since injury was not associated with moderate-to-heavy LTPA (LR: Probability > F = 0.785). Conclusion: LTPA promotion in the SCI population ≥45 years focusing on females and non-traumatic injuries is warranted.

Complex lived experiences and hidden disability after spinal cord injury: a latent profile analysis of the Australian arm of the International Spinal Cord Injury (Aus-InSCI) Community Survey.

PURPOSE: To identify and examine subgroups of people with spinal cord injury (SCI) with different patterns of lived experience, and examine hidden impairments and disability among functionally independent and ambulant people. MATERIALS AND METHODS: Latent profile analysis of population-based data from the Australian arm of the International Spinal Cord Injury (InSCI) Community survey (n = 1579). RESULTS: Latent subgroups reflected levels of functional independence and extent of problems with health, activity/participation, environmental barriers, and self-efficacy. Quality of life (QoL), psychological profiles, and activity/participation were often as good or better in participants who reported lower (vs. higher) functional independence alongside comparable burden of health problems and environmental barriers. QoL, mental health, and vitality reflected self-efficacy and problem burdens more closely than functional independence. Ambulant participants reported a substantial burden of underlying, potentially hidden impairments, with QoL and mental health similar to wheelchair users. CONCLUSION: Hidden disability among more independent and/or ambulant people with SCI can affect well-being substantially. Early and ongoing access to support, rehabilitation, and SCI specialist services is important irrespective of cause, type, severity of injury, and level of functional independence. Improved access to SCI expertise and equity of care would help to improve early recognition and management of hidden disability. TRIAL REGISTRATION: Not applicable.

Hidden disability can substantially affect the well-being and quality of life of people with spinal cord injury (SCI) who appear to be functioning well and independently.Early and ongoing access to rehabilitation and SCI specialist services is important for people with SCI of any cause, type, severity, and level of functional independence.The potential for and implications of hidden disability are key considerations for the broader community of health practitioners who manage people with SCI, to ensure that appropriate referrals to specialist SCI services occur.Hidden disability is a key consideration in the design and implementation of disability support systems.

Leisure-Time Physical Activity in People With Spinal Cord Injury-Predictors of Exercise Guideline Adherence.

Objectives: This study described leisure-time physical activity (LTPA) for people in Australia with spinal cord injury (SCI) and whether certain sociodemographic and psychosocial variables might be associated with LTPA uptake and guidelines adherence. Methods: The Physical Activity Scale for Individuals with a Physical Disability was used to measure the intensity and volume of LTPA of 1,579 individuals with SCI. Summary statistics were calculated for LTPA guidelines adherence. Analyses included regression modelling. Results: Of the 1,579 participants, 58% performed LTPA and 13% adhered to recommended guidelines for weekly LTPA. There was an association with being an "exerciser" based on the time since injury (OR = 1.02 [95% 1.01-1.03]), a traumatic injury (OR = 1.53 [95% CI 1.13-2.08]) and a higher self-rating of health (OR = 1.10 [95% CI 0.95-1.27]). Where LTPA guidelines were met, adherence was most related to a traumatic injury (OR = 1.75 [95% CI 1.02-3.02]) and being unemployed (OR = 1.53 [95% CI 1.03-2.25]). Conclusion: Of those who performed LTPA with SCI, one in four met population-specific LTPA guidelines. Sociodemographic variables were moderately associated with being an "exerciser" or LTPA "guideline-adherent."

Factors influencing thigh muscle volume change with cycling exercises in acute spinal cord injury - a secondary analysis of a randomized controlled trial.

Objective: To conduct a per-protocol analysis on thigh muscle volume outcomes from the Spinal Cord Injury and Physical Activity (SCIPA) Switch-On Trial.Design: Secondary analysis from an assessor-blind randomized, controlled trial.Setting: Four acute/sub-acute hospitals in Australia and New Zealand.Participants: 24 adults (1 female) within four weeks of motor complete or incomplete spinal cord injury (SCI)Intervention: Functional electrical stimulation-assisted cycling (FESC) or passive cycling (PC) 4x/week for 12 weeks.Outcome Measures: Whole thigh and muscle group volumes calculated from manually segmented MR images.Results: 19/24 participants completed ≥ twelve weeks of the intervention. Five participants experienced hypertrophy (4 FESC; 1 PC) and eight attenuation of atrophy (<20% volume loss) (3 FESC; 5 PC) in thigh muscle volume. Six participants were non-responders, exhibiting atrophy >20% (3 FESC; 3 PC). Mean (SD) change for FESC was -2.3% (25.3%) and PC was -14.0% (12.3%). After controlling for baseline muscle volumes, a strong significant correlation was found between mean weekly exercise frequency and quadriceps and hamstring volumes (r=6.25, P=0.006), regardless of mode. Average watts was highly correlated to quadriceps volumes only (r=5.92, P=0.01), while total number of sessions was strongly correlated with hamstring volumes only (r=5.91, P=0.01).Conclusion: This per-protocol analysis of FESC and PC early after SCI reports a partial response in 42% and a beneficial response in 25% of patients who completed 12 weeks intervention, regardless of mode. Strong correlations show a dose-response according to exercise frequency. Characteristics of non-responders are discussed to inform clinical decision-making.

A pulse survey: assessment and management of bone loss in spinal cord injury.

STUDY DESIGN: An online survey OBJECTIVES: To describe current clinical practices regarding osteoporosis assessment and management in people with Spinal Cord Injury (SCI) and compare them to recommended diagnostic tests and interventions. SETTING: An international collaboration surveying professionals working in SCI Medicine. METHODS: Online cross-sectional survey regarding clinical practice trends in the assessment and treatment of osteoporosis in people with SCI. Assessment of whether discrete professional characteristics influenced practices and if those practices were consistent with recommendations from professional organizations. RESULTS: Eighty-two professionals working in SCI Medicine completed the survey. Respondents were equally likely to test for bone loss during the post-acute phase (between 4- and 18-months post injury) and after low impact fracture (41.46% and 42.68%, respectively) and more likely to test during the chronic phase (51.22%). The majority of respondents (n = 56, 70%) assessed bone density with DXA at the hip, and many (48.78%, n = 40) prescribed simultaneous mobilization, vitamin D and calcium to prevent bone loss in the acute, post-acute and chronic phases. A number of evaluations and interventions were inconsistent with best practice recommendations. CONCLUSIONS: Given that reported practices for detection and treatment of osteoporosis in SCI are inconsistent and not data-driven, there is need for dissemination and adoption of existing clinical practice guidelines.

Can targeted job-information for adults with spinal cord dysfunction be effectively delivered online? A pilot study.

OBJECTIVE: To pilot a novel email-based information package (Work and SCI) for job-seekers with an acquired spinal cord injury (SCI) or spinal cord dysfunction (SCI/D). STUDY DESIGN: Prospective, non-randomized, repeated measures trial. SETTING: Community dwelling cohort in Australia. PARTICIPANTS: Five people with SCI (mean age 46.4 years, SD = 10.2; 4 female) initially reviewed Work and SCI. Twenty-four with SCI/D subsequently enrolled, of whom 16 (mean age 46.4 years, SD = 11.1; 7 female), completed the intervention. INTERVENTION: Intervention participants accessed Work and SCI over a 4-week period. OUTCOME MEASURES: Individual changes in pre-post scores for the My Vocational Situation Scale, Job Procurement Self-Efficacy Scale, Patient Health Questionnaire-9 and Life Orientation Test-Revised were examined. RESULTS: Reliable change in pre-post scores across outcomes were reported by 38% (n = 6) of participants. Favorable comments on the Work and SCI resource were provided in addition to suggestions for improvement. CONCLUSIONS: Preliminary data suggest that Work and SCI may help to establish vocational interests among job-seekers with a SCI/D, however further work is needed to enhance participant compliance. This might include moderator support to promote and maintain participation. A controlled design will also help to identify factors that influence engagement with the Work and SCI resource.

Functional recovery measures for spinal cord injury: an evidence-based review for clinical practice and research.

BACKGROUND/OBJECTIVE: The end goal of clinical care and clinical research involving spinal cord injury (SCI) is to improve the overall ability of persons living with SCI to function on a daily basis. Neurologic recovery does not always translate into functional recovery. Thus, sensitive outcome measures designed to assess functional status relevant to SCI are important to develop. METHOD: Evaluation of currently available SCI functional outcome measures by a multinational work group. RESULTS: The 4 measures that fit the prespecified inclusion criteria were the Modified Barthel Index (MBI), the Functional Independence Measure (FIM), the Quadriplegia Index of Function (QIF), and the Spinal Cord Independence Measure (SCIM). The MBI and the QIF were found to have minimal evidence for validity, whereas the FIM and the SCIM were found to be reliable and valid. The MBI has little clinical utility for use in the SCI population. Likewise, the FIM applies mainly when measuring burden of care, which is not necessarily a reflection of functional recovery. The QIF is useful for measuring functional recovery but only in a subpopulation of people with SCI, and substantial validity data are still required. The SCIM is the only functional recovery outcome measure designed specifically for SCI. CONCLUSIONS: The multinational work group recommends that the latest version of the SCIM (SCIM III) continue to be refined and validated and subsequently implemented worldwide as the primary functional recovery outcome measure for SCI. The QIF may continue to be developed and validated for use as a supplemental tool for the nonambulatory tetraplegic population.

Nature of the Non-traumatic Spinal Cord Injury Literature: A Systematic Review.

Background: Non-traumatic SCI (NTSCI) etiologies represent a markedly heterogeneous cluster of conditions defined within the consensus NTSCI taxonomy. This meta-analysis assembles evidence about the occurrence of NTSCI and its clinical outcomes with respect to 6 research domains. Purpose: To investigate the quality and quantity of clinical NTSCI evidence published in the peer reviewed literature with reference to prognosis, diagnosis, intervention, process of care, methodology, and qualitative approaches. Methods: PubMed and MEDLINE OVID MeSH heading searches were conducted for 5 common-language NTSCI descriptors. Filters were English language and Entrez date (1997-2016). Filters also controlled for case reports, editorials or errata, and invited reviews. NTSCI etiologies incorrectly classified, animal studies, and multidimensional mapping studies were excluded. Full texts were retrieved and ranked for evidence quality according to PRISMA statement guidelines, or PEDro criteria. Data were extracted and simple descriptive statistics applied. Results: The search terms non traumatic and non-traumatic SCI retrieved 282 articles, with 39 duplicates. After exclusion of 117 articles: Level 1V (60); NTSCI incorrectly evaluated (14); publication bias (2); non-English language (1); and animal experiments (1), 126 titles/abstracts were screened and ranked against criteria. Of the 8 papers allocated for full-text review, a subset of 3 articles was ranked level 1A (1) or level 11A (2); mean PEDro score 5.75±0.5. Reasons for full-text exclusions (5) were NTSCI incorrectly classified (1) and statistical limitations (4). Of the 6 domains, prognostics had adequate data yield (86) for evidence synthesis (4.8% ranked level 1A, or 11A). Notable evidence gaps were identified in qualitative (1), methodological (2), and diagnostic (8) domains. Conclusion: Therapeutic approaches require an evidence-based understanding of the distinct contexts in which NTSCI occurs, especially in less resourced settings. Our findings underscore the need for qualitative and quantitative research on the occurrence of NTSCI in all contexts.

Rehabilitation of people with spinal cord damage due to tumor: literature review, international survey and practical recommendations for optimizing their rehabilitation.

BACKGROUND/OBJECTIVES: People with spinal cord dysfunction (SCDys) due to tumor (benign and malignant) pose enormous rehabilitation challenges. Objectives were: conduct literature search regarding epidemiology, clinical features and outcomes for SCDys due to tumor following rehabilitation, the ideal setting for rehabilitation and practical considerations for rehabilitation; and propose framework and practical considerations for managing people with SCDys due to tumor in spinal rehabilitation units (SRUs). DESIGN: Survey of rehabilitation health care professionals, consensus opinion from experts and literature search. SETTING: Workshop at International Spinal Cord Society and American Spinal Injury Association combined annual meeting, May 16, 2015, Montréal, Canada. PARTICIPANTS: Workshop attendees and experts in the rehabilitation of people with SCDys due to tumor. OUTCOMES MEASURES: Reports of services offered to people with SCDys due to tumor, including whether those with benign and malignant tumors are admitted into rehabilitation, any admission criteria used and the rational for declining admission. RESULTS: Most respondents (n = 33, 83%) reported that people with benign tumors were routinely admitted for rehabilitation but only 18 (45%) reported that people with malignant tumors were routinely admitted. A range of criteria and reasons for declining admission were given. Evidence from the literature and the opinion of experts support the admission of people with SCDys due to tumor into specialist SRUs. CONCLUSIONS: A framework and practical considerations for managing people with SCDys due to tumor in SRUs are proposed. Patients with tumor causing SCDys should be given greater access to specialist SRU in order to achieve the best outcomes.

Important Clinical Rehabilitation Principles Unique to People with Non-traumatic Spinal Cord Dysfunction.

Background: Non-traumatic spinal cord dysfunction (SCDys) is caused by a large range of heterogeneous etiologies. Although most aspects of rehabilitation for traumatic spinal cord injury and SCDys are the same, people with SCDys have some unique rehabilitation issues. Purpose: This article presents an overview of important clinical rehabilitation principles unique to SCDys. Methods: Electronic literature search conducted (January 2017) using MEDLINE and Embase (1990-2016) databases for publications regarding SCDys. The focus of the literature search was on identifying publications that present suggestions regarding the clinical rehabilitation of SCDys. Results: The electronic search of MEDLINE and Embase identified no relevant publications, and the publications included were from the authors' libraries. A number of important clinical rehabilitation principles unique to people with SCDys were identified, including classification issues, general rehabilitation issues, etiology-specific issues, and a role for the rehabilitation physician as a diagnostic clinician. The classification issues were regarding the etiology of SCDys and the International Standards for Neurological Classification of Spinal Cord Injury. The general rehabilitation issues were predicting survival, improvement, and rehabilitation outcomes; admission to spinal rehabilitation units, including selection decision issues; participation in rehabilitation; and secondary health conditions. The etiology-specific issues were for SCDys due to spinal cord degeneration, tumors, and infections. Conclusions: Although there are special considerations regarding the rehabilitation of people with SCDys, such as the potential for progression of the underlying condition, functional improvement is typically significant with adequate planning of rehabilitation programs and special attention regarding the clinical condition of patients with SCDys.

A systematic review of the usefulness of pre-employment and pre-duty screening in predicting mental health outcomes amongst emergency workers.

Despite a lack of proven efficacy, pre-employment or pre-duty screening, which alleges to test for vulnerability to PTSD and other mental health disorders, remains common amongst emergency services. This systematic review aimed to determine the usefulness of different factors in predicting mental disorder amongst emergency workers and to inform practice regarding screening procedures. Systematic searches were conducted in MEDLINE, PsycINFO and EMBASE to identify cohort studies linking pre-employment or pre-duty measures in first responders with later mental health outcomes. Possible predictors of poor mental health were grouped into six categories and their overall level of evidence was assessed. Twenty-one prospective cohort studies were identified. Dynamic measures including physiological responses to simulated trauma and maladaptive coping styles (e.g. negative self-appraisal) had stronger evidence as predictors of vulnerability in first responders than more traditional static factors (e.g. pre-existing psychopathology). Personality factors (e.g. trait anger) had moderate evidence for predictive power. Based on the evidence reviewed, however, we are unable to provide emergency services with specific information to enhance their current personnel selection. The results indicate that pre-duty screening protocols that include personality assessments and dynamic measures of physiological and psychological coping strategies may be able to identify some personnel at increased risk of mental health problems. However, further longitudinal research is required in order to provide meaningful guidance to employers on the overall utility of either pre-employment or pre-duty screening. In particular, research examining the sensitivity, specificity and positive predictive values of various screening measures is urgently needed.