Comparison of the prevalence of osteoporosis in people with spinal cord injury according to bone mineral density reference values for the diagnosis of osteoporosis: a retrospective, cross-sectional study.

BACKGROUND: Spinal cord injury (SCI) is a complex cause of rapid low bone mass that easily predisposes the affected individuals to osteoporosis-induced fractures. Several studies have investigated osteoporosis pathophysiology in SCI; however, those associated with its diagnosis in SCI are limited. Additionally, errors in osteoporosis diagnosis and its prevalence vary based on the bone mineral density (BMD) reference values (BMDRV), and no studies have reported BMDRV application for osteoporosis diagnosis in individuals with SCI. Therefore, this study aimed to compare the prevalence of osteoporosis among Korean adults aged ≥ 50 years with SCI according to BMDRV for diagnosing osteoporosis. METHODS: Overall, 855 patients with SCI who underwent BMD tests of the lumbar spine, femoral neck, and total hip at the National Rehabilitation Center (NRC) in Korea between 2010 and 2020 were included in this retrospective cross-sectional study. Osteoporosis was diagnosed in patients with SCI by comparing the differences in prevalence, diagnostic consistency, and risk factors according to the region-based BMDRV of the dual-energy x-ray absorptiometry (DXA) manufacturer and international BMDRV based on the Third National Health and Nutrition Examination Survey (NHANES III) data of females aged 20-29 years. RESULTS: The prevalence of osteoporosis according to the T-score provided by a single reference population of the NHANES III (TNHA) (PONHA) (males: 26.69%; females: 69.35%) was significantly higher in females and males than that according to the T-scores provided by the DXA manufacturer (TDXA) (PODXA) (males: 15.32%; females: 43.15%). The lumbar spine and femoral neck were major osteoporosis diagnosis sites for the PODXA and PONHA, respectively. Risk factors for osteoporosis differed based on the probability of osteoporosis (also known as the OZ ratio) according to the BMD criteria; however, the risk factors were similar according to old age, female sex, low body mass index (BMI), and long SCI period. No significant relationship was noted between the different SCI-related clinical factors (p > 0.05). CONCLUSIONS: The osteoporosis diagnostic site and prevalence in SCI differed according to the regional-based TDXA and international standards of the TNHA. Therefore, further studies on BMDRV are warranted to establish accurate diagnostic criteria for osteoporosis prevention in patients with SCI.

Association between functional outcomes and psychological variables in persons with spinal cord injury.

We aimed to explore the association of functional outcomes with psychological variables, including depression, anxiety, sleep quality, and suicide risk, in persons with spinal cord injuries (SCIs). The secondary aim was to determine specific functions related to the psychological variables. This retrospective study included 259 persons with SCIs who were admitted to the Korean National Rehabilitation Center between 2019 and 2021. The participants were interviewed by a psychiatrist and completed questionnaires, including the Korean Beck Depression Inventory II (K-BDI-II), Korean Beck Anxiety Index, Insomnia Severity Index, and Mini International Neuropsychiatric Interview. To assess functional outcomes, the Spinal Cord Independence Measure III (SCIM III) and Walking Index for Spinal Cord Injury were determined by a physical therapist. The findings revealed a negative correlation of SCIM III subdivisions 1 and 3 with K-BDI-II. Specifically, feeding and mobility in bed and actions to prevent pressure injuries were functional factors associated with all four psychological variables. Our findings can guide clinicians to focus on improving functional independence and activities of daily living during the management of persons with SCI to prevent psychological consequences. Developing devices that aid in improving functional independence is crucial and may improve psychological problems in such individuals.

Risk Factors for Suicidality in Individuals With Spinal Cord Injury: A Focus on Physical and Functional Characteristics.

OBJECTIVE: : To demonstrate the association between the physical and functional characteristics of individuals with spinal cord injury (SCI) and suicidality, an area of research that is less understood than the association with demographic, social, and psychological characteristics. METHODS: : A retrospective cross-sectional study was conducted with 259 patients with SCI admitted for rehabilitation at the National Rehabilitation Center, Seoul, between January 2019 and December 2021. Demographic, SCI-related, physical, and functional data were collected from their medical records. Suicide risk was assessed using the Mini International Neuropsychiatric Interview. RESULTS: : The 259 participants had an average age of 49.1 years, and 75.7% were male. The analysis revealed a statistically significant negative correlation between age and suicidality. No significant differences were found for sex, education, occupation, or SCI-related factors. Lower upper extremity motor score (UEMS) was significantly associated with higher suicide risk. Regarding functional factors, the inability to perform independent rolling, come to sit, wheelchair propelling, and self-driving were associated with increased suicidality. In the multiple linear regression analysis, lower UEMS, limited shoulder joint motion, upper extremity spasticity, and dependent wheelchair propulsion were predictors of higher suicide risk. CONCLUSION: : This study highlights the associations among physical status, functional dependency, and suicide risk in individuals with SCI. These findings emphasize the need to address psychological aspects and physical and functional factors in the management of individuals with SCI who are at a high risk of suicide.

Characteristics Associated with Bone Loss after Spinal Cord Injury: Implications for Hip Region Vulnerability.

BACKGRUOUND: In individuals with spinal cord injury (SCI), bone loss progresses rapidly to the area below the level of injury, leading to an increased risk of fracture. However, there are limited data regarding SCI-relevant characteristics for bone loss and the degree of bone loss in individuals with SCI compared with that in non-SCI community-dwelling adults. METHODS: Data from men with SCI who underwent dual-energy X-ray absorptiometry at the National Rehabilitation Center (2008 to 2020) between 12 and 36 months after injury were collected and analyzed. Community-dwelling men were matched 1:1 for age, height, and weight as the control group, using data from the Korea National Health and Nutrition Examination Survey (KNHANES, 2008 to 2011). RESULTS: A comparison of the SCI and the matched control group revealed significantly lower hip region T-scores in the SCI group, whereas the lumbar spine T-score did not differ between groups. Among the 113 men with SCI, the paraplegia group exhibited significantly higher Z-scores of the hip region than the tetraplegia group. Participants with motor-incomplete SCI showed relatively preserved Z-scores of the hip region compared to those of the lumbar region. Moreover, in participants with SCI, the percentage of skeletal muscle displayed a moderate positive correlation with femoral neck Z-scores. CONCLUSION: Men with SCI exhibited significantly lower bone mineral density of the hip region than community-dwelling men. Paraplegia rather than tetraplegia, and motor incompleteness rather than motor completeness were protective factors in the hip region. Caution for loss of skeletal muscle mass or increased adiposity is also required.

Caregiver burden according to ageing and type of care activity in caregivers of individuals with spinal cord injury.

OBJECTIVE: To describe caregiver burden according to the caregivers' general characteristics, especially with ageing, and type of care activities provided by caregivers of individuals with spinal cord injury. DESIGN: A cross-sectional study was conducted utilizing a structured questionnaire that included general characteristics, health conditions, and caregiver burden. SETTING: A single center study in Seoul, Korea. SUBJECTS: Participants were recruited from 87 individuals with spinal cord injuries and 87 caregivers. METHODS: The Caregiver Burden Inventory was used to assess caregiver burden. RESULTS: Caregiver burden was significantly different by age (p = 0.001), relationship (p = 0.025), sleep hours (p = <0.001), underlying disease (p = 0.018), pain (p = <0.001), and daily activities of individuals with spinal cord injury (p = 0.001). Caregiver's age (B = 0.339, p = 0.049), sleep duration (B = -2.896, p = 0.012) and pain (B = 2.558, p < 0.001) predicted caregiver burden. Toileting assistance was the most challenging and time-consuming for caregivers, while patient transfer was associated with the greatest concerns for body injury. CONCLUSION: Caregiver education should be targeted according to caregiver's age and type of assistance. Social policies need to be developed to distribute devices and care-robots to reduce caregiver burden and thereby assist caregivers.

Sacral interface pressure can be alleviated by repositioning with a small-angle change using an automated bed in patients with spinal cord injury.

AIM OF THE STUDY: This study aimed to compare interface pressure and total contact area of the sacral region in different positions, including small-angle changes, in patients with spinal cord injury (SCI). Furthermore, we analyzed the clinical factors influencing pressure to identify the pressure injury (PI) high-risk group. MATERIALS AND METHODS: An intervention was conducted for patients with paraplegia (n = 30) with SCI. In the first and second trials, interface pressure and total contact area of the sacral region were recorded from large- and small-angled positions using the automatic repositioning bed, which can change the angle of the back, lateral tilt, and knee. RESULTS: Positions with back raised ≥45° showed significantly higher pressure on the sacrum than most other positions. The pressure and contact area differences were statistically insignificant for combinations of small-angled changes <30°. Additionally, the duration of injury (ß = 0.51, p = 0.010) and neurological level of injury (NLI) (ß = -0.47, p = 0.020) were significant independent predictors of average pressure. Similarly, the duration of injury (ß = 0.64, p = 0.001), the Korean version of the spinal cord independence measure-III (ß = -0.52, p = 0.017), and body mass index (BMI; ß = -0.34, p = 0.041) were significant independent predictors of peak pressure. CONCLUSIONS: For repositioning, combinations of small-angle changes <30° effectively reduce pressure on the sacral region in patients with SCI. Lower BMI, longer duration of injury, lower functioning score, and NLI ≥ T7 are predictors of high sacral pressures, which increase the risk for PI. Therefore, patients with these predictors require strict management.

Influence of Sociodemographic Factors, Health Conditions, and Activity on Participation in People With Spinal Cord Injury in South Korea.

OBJECTIVE: To verify the causal relationship between sociodemographic factors, health conditions, and activities that influence the participation of people with spinal cord injury (SCI) using International Spinal Cord Injury (InSCI) Survey data and to investigate the moderation effects of environmental restrictions and health care system concerns. DESIGN: Cross-sectional community survey and structural equation model. SETTING: SCI databases of the Korea National Rehabilitation Center and Korea Spinal Cord Injury Association. PARTICIPANTS: Community-dwelling adults (N=890) with SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The InSCI questionnaire domains included sociodemographic factors, health conditions, activity, participation, environmental restrictions, and health system concerns. Sociodemographic factors included age, education, and income. Health conditions included bowel dysfunction, respiratory problems, and pain, among others. Activity included "daily routine" and "using hands," among others. Participation included "interacting with people" and "intimate relationships," among others. Environmental restrictions included "public places" and "negative attitudes," among others. Health care system concerns included "nursing care" and "experience of being treated," among others. RESULTS: The hypothesis that health conditions would have a significant effect on activity was supported because 51% of the total variance in activity factors was explained by health condition factors. The hypothesis that activity would have a significant effect on participation was also supported because 63.4% of total variance in participation factors was explained by activity factors. The moderation effect tests supported the hypotheses that health conditions, activity, and participation would differ depending on the extent of environmental restrictions as well as the extent of health system concerns. CONCLUSIONS: When formulating policies and recommendations to promote the participation of people with SCI living in the South Korean community, the influence of environmental restrictions and health systems as well as the causal influence of health conditions and activity should be considered.

Characteristics of Pediatric Spinal Cord Injury in South Korea: A Single-Centered Study.

OBJECTIVE: To determine the characteristics of pediatric spinal cord injury (SCI) in South Korea from 1990 to 2019. METHODS: This single-centered retrospective study included pediatric SCIs. Individuals were divided into the following five groups according to onset age: ≤5, 6-12, 13-14, 15-17, and 18-19 years. The severity of complete injury was graded according to the American Spinal Injury Association impairment scale A (AIS A). Incomplete injury was graded according to AIS B, C, and D. Pearson chi-square test was used for statistical analysis. RESULTS: Of the 267 individuals included, 216 (80.9%) had traumatic SCIs (male-to-female ratio of 3.2:1), and 51 (19.1%) had non-traumatic SCIs (male-to-female ratio of 0.7:1). In the traumatic SCI group, 192 (88.9%) individuals were ≥15 years at the time of injury (males, 78.6%). The most common etiologies of traumatic SCIs, ranging from most to least common, were accidents related to motorcycles, falls, cars, and diving. In the non-traumatic SCI group, inflammatory (33.3%) and neoplastic (25.5%) etiologies were found to be the most common ones. CONCLUSION: We found that traumatic SCIs incidence in the pediatric population was high, particularly in male individuals aged 15-19 years. The non-traumatic SCIs mostly cause paraplegia and incomplete injury. Therefore, it can be used as a basic data for the evaluation, treatment and prevention strategy of pediatric patients with SCI.

Factors Affecting Metabolic Syndrome in Individuals With Chronic Spinal Cord Injury.

OBJECTIVE: To assess the validity of different anthropometric measures (waist circumference [WC], body mass index [BMI], and percentage body fat) in diagnosing metabolic syndrome (MetS) among individuals with SCI and provides preliminary data for future studies in setting obesity cutoff values for this population. METHODS: This was a single-center retrospective cohort study. Sample information, anthropometric measures, and MetS variables of 157 individuals with chronic SCI were collected from an electronic medical records database. RESULTS: Increasing age (odds ratio [OR]=1.040, p=0.016) and lower neurological level of injury (OR=1.059, p=0.046) were risk factors for MetS. Male BMI (r=0.380, p<0.001) and male WC (r=0.346, p<0.001) were positively correlated with the number of MetS subfactors. Individuals with non-obese WC, excluding central obesity, were associated with having no MetS subfactors (p=0.005), and individuals with obese WC were associated with one or more subfactors (p=0.005). BMI was associated with MetS diagnosis (area under the curve=0.765, p<0.001), with the calculated cutoff value for BMI being 22.8 kg/m2. CONCLUSION: This study calls for a stricter BMI cutoff for individuals with SCI in diagnosing MetS and warrants a large population-based study to define central obesity according to sex and ethnicity.

Epidemiological changes in traumatic spinal cord injuries for the last 30 years (1990-2019) in South Korea.

STUDY DESIGN: Retrospective descriptive study. OBJECTIVES: To identify the characteristics of and epidemiological trends in traumatic spinal cord injuries (TSCIs) in Korea from 1990 to 2019. SETTING: National Rehabilitation Center affiliated with the Ministry of Health and Welfare in Korea. METHODS: The medical records of 3395 individuals with TSCIs were retrospectively reviewed. Three groups were formed based on onset period (1990-1999, 2000-2009, and 2010-2019) and six groups based on age (≤15, 16-30, 31-45, 46-60, 61-75, and ≥76 years). Pearson's chi-square and analysis of variance tests were used for statistical analysis. RESULTS: From 1990 to 2019, the mean age (standard deviation, [SD]) at the time of injury increased from 32.4 (SD = 12.4) years in the 1990s to 47.1 (SD = 16.2) years in the 2010s (F = 222.317 p = <0.001). Land transport and falls were the most common causes of TSCIs. The number of injuries from land transport gradually decreased, while that from falls increased (24.9% in 1990s to 46.3% in 2010s [χ2 = 134.415 p < 0.001]). In the >60 years group, falls were the most common cause of injury, which resulted in 42.9% TSCIs in the 1990s to 59.1% in the 2010s (χ2 = 10.398, p > 0.05). Tetraplegia (n = 769, 58.6%) was more common than paraplegia; incomplete tetraplegia (entire population: =564, 43%; >60 years group: n = 186, 43%) was the highest in the 2010s. CONCLUSIONS: Falls have been the most common cause of TSCIs after 2010s. Implementing national education and campaigns for preventing falls is important to reduce/prevent TSCIs caused by falls in the aged population.

Epidemiologic changes in nontraumatic spinal cord injury for the last 30 years (1990-2019) in South Korea.

STUDY DESIGN: Retrospective descriptive study. OBJECTIVES: To summarize epidemiologic data on nontraumatic spinal cord injury (NTSCI) for the last 30 years and compare these findings to data from individuals with traumatic spinal cord injury (TSCI). SETTING: National Rehabilitation Center affiliated with the Ministry of Health and Welfare in Korea. METHODS: The medical records of 948 individuals with NTSCIs were retrospectively reviewed. Three groups were created based on onset period (1990-1999, 2000-2009, 2010-2019) and six groups based on age (≤15, 16-30, 31-45, 46-60, 61-75, and ≥76 years). Pearson's chi-square and analysis of variance tests were used for statistical analysis. RESULTS: The male-to-female ratio was 1.30:1 for NTSCI individuals and 3.47:1 for TSCI individuals. The mean age (standard deviation [SD]) at the time of injury increased from 38.7 (SD = 18.1) years in the 1990s to 55.5 (SD = 16.6) years in the 2010s (F = 44.597, p ≤ 0.001). Vertebral column degenerative disorder was the primary cause of injury in 28.9% of the cases, and the most common neurologic level was T12-L2. Paraplegia occurred in 74.6% of cases, and tetraplegia in 25.4% of cases. The proportion of NTSCI individuals increased from 11.2% to 29.3% during the observation period. CONCLUSIONS: The proportion of NTSCI among total spinal cord injuries has increased in Korea over the last 30 years (1990-2019). Compared to individuals with TSCI, those with NTSCI had a higher age at onset, with different male-to-female ratios. Our study is the most comprehensive investigation of NTSCI in Korea, and our findings can inform research directions and medical guidelines.

Test-retest reliability and validity of the Sitting Balance Measure-Korean in individuals with incomplete spinal cord injury.

STUDY DESIGN: Cross-cultural reliability and validity. OBJECTIVES: To develop and validate the Korean version of the Sitting Balance Measure (SBM-K) in Korean persons with incomplete spinal cord injury (ISCI). SETTING: Tertiary care center. METHODS: Twenty-nine persons with ISCI were evaluated using SBM-K, which was validated using the kappa coefficient and intraclass coefficient (ICC). The correlation between SBM-K individual items and total score was analyzed using Spearman's correlation, and the internal consistency of test items was measured using Cronbach's alpha. Additionally, the standard error measurement (SEM) and minimal detectable change (MDC) were measured. For the clinical validity of SBM-K, the correlation of SBM-K with the modified Sitting Balance Scale (mSBS) and the Korean-Spinal Cord Independence Measure-III (KSCIM-III) was determined via Spearman's correlation. Linear regression was performed to determine whether SBM-K could predict KSCIM-III. RESULTS: The weighted kappa score of the SBM-K individual items and ICC of SBM-K total score were 0.76-0.83 (good-very good) and 0.98 (0.95-0.99), respectively. The correlation between the SBM-K total score and individual items was notable (r = 0.78-0.98). Cronbach's alpha, SEM, and MDC of SBM-K were 0.98, 0.59, and 1.64, respectively. The clinical validity of SBM-K correlated with mSBS (r = 0.88) and KSCIM-III (r = 0.65-0.89). SBM-K accounted for 17-72% of the variance in predicting KSCIM-III. CONCLUSIONS: SBM-K showed sufficient test-retest reliability, validity, and marginal measurement errors. SBM-K can serve as an optimal clinical assessment tool for Korean ISCI patients and may provide clinicians with reliable sitting balance assessment in Korean clinical settings.

Should We Delay Urodynamic Study When Patients With Spinal Cord Injury Have Asymptomatic Pyuria?

OBJECTIVE: To assess the incidence of urinary tract infection (UTI) with post-urodynamic study (post-UDS) in patients with spinal cord injury (SCI) and study its relationship with pre-UDS pyuria. METHODS: Patients with SCI who were hospitalized and underwent UDS during a 4-year period were reviewed. Patients with pre-test lower urinary tract symptoms were excluded. Urinalysis and urine culture were performed before and 24 hours after UDS. Prophylactic antibiotics were administered for 5 days starting from the morning of the UDS. UTI was defined as bacteriuria with accompanying symptoms. RESULTS: Of 399 patients reviewed, 209 (52.4%) had pyuria in pre-UDS urinalysis, and 257 (64.4%) had bacteriuria in pre-UDS culture. Post-UDS UTI occurred in 6 (1.5%) individuals who all complained of fever: 5 (2.4%) of the post-UDS UTI cases occurred in patients with pre-UDS pyuria, and 1 (0.5%) in a person without. The differences between groups were not statistically significant (p=0.218). Of 221 patients with bacteriuria (gram-negative isolates) on pre-UDS culture, resistance to ciprofloxacin, cephalosporin, and trimethoprim/sulfamethoxazole (TMP/SMT) was noted in 52.9% (117 cases), 57.0% (126 cases), and 38.9% (86 cases), respectively. CONCLUSION: No difference was found in the prevalence of post-UDS UTI based on the presence of pyuria in pre-UDS urinalysis. UDS may be performed even in SCI cases of pre-UDS pyuria without increasing the prevalence of post-UDS UTI if prophylactic antibiotics are administered. TMP/SMT could be used as a first-line antibiotic for the prevention of post-UDS UTI in Korea.

The effect of treadmill exercise on gait efficiency during overground walking in adults with cerebral palsy.

OBJECTIVE: To investigate the effect of treadmill walking exercise as a treatment method to improve gait efficiency in adults with cerebral palsy (CP) and to determine gait efficiency during overground walking after the treadmill walking exercise. METHODS: Fourteen adults with CP were recruited in the experimental group of treadmill walking exercise. A control group of 7 adults with CP who attended conventional physical therapy were also recruited. The treadmill walking exercise protocol consisted of 3-5 training sessions per week for 1-2 months (total 20 sessions). Gait distance, velocity, VO2, VCO2, O2 rate (mL/kg·min), and O2 cost (mL/kg·m) were assessed at the beginning and at the end of the treadmill walking exercise. The parameters were measured by KB1-C oximeter. RESULTS: After the treadmill walking exercise, gait distance during overground walking up to 6 minutes significantly increased from 151.29±91.79 to 193.93±79.01 m, and gait velocity increased from 28.09±14.29 to 33.49±12.69 m/min (p<0.05). Energy efficiency evaluated by O2 cost during overground walking significantly improved from 0.56±0.36 to 0.41±0.18 mL/kg·m (p<0.05), whereas O2 rate did not improve significantly after the treadmill walking exercise. On the other hand, gait velocity and O2 cost during overground walking were not significantly changed in the control group. CONCLUSION: Treadmill walking exercise improved the gait efficiency by decreased energy expenditure during overground walking in adults with CP. Therefore, treadmill walking exercise can be an important method for gait training in adults with CP who have higher energy expenditure.