Using Reference Values to Identify Profiles of Swallowing Impairment in a Case Series of Individuals With Traumatic Spinal Cord Injury.

PURPOSE: In this article, we illustrate use of a systematic approach to rating videofluoroscopic swallowing studies (VFSS), the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) method. The method is applied to a clinical case series of individuals with a history of traumatic spinal cord injury (tSCI) requiring surgical intervention using a posterior approach. Previous studies suggest that swallowing is highly variable in this population given heterogeneity in mechanisms, location and extent of injury, and in surgical management approaches. METHOD: The case series involved 6 individuals who were at least 1 month postsurgery for management of tSCI. Participants completed a VFSS using a standardized bolus protocol. Each VFSS was blindly rated in duplicate using the ASPEKT method and compared with published reference values. RESULTS: The analysis revealed considerable heterogeneity across this clinical sample. Penetration-aspiration scale scores of 3 or higher were not observed in this cohort. Of note, patterns of impairment did emerge, suggesting there are some commonalities across profiles in this population, including the presence of residue associated with poor pharyngeal constriction, reduced upper esophageal opening diameter, and short upper esophageal sphincter opening duration. CONCLUSIONS: Although the participants in this clinical sample shared a history of tSCI requiring surgical intervention using a posterior approach, there was great heterogeneity in swallowing profile. Using a systematic method to identify atypical swallowing parameters can guide clinical decision making for determining rehabilitative targets and measuring swallowing outcomes.

Advancing research and clinical care in the management of neuropathic pain after spinal cord injury: Key findings from a Canadian summit.

Background: Optimal management of neuropathic pain (NP) is essential to enhancing health-related quality of life for individuals living with spinal cord injury (SCI). A key strategic priority for the Ontario Neurotrauma Foundation (ONF) and Rick Hansen Institute (RHI) is optimizing NP management after SCI. Aims: A National Canadian Summit, sponsored by ONF and RHI, was held to develop a strategic plan to improve NP management after SCI. Methods: In a one-day meeting held in Toronto, Ontario, a multidisciplinary panel of 18 Canadian stakeholders utilized a consensus workshop methodology to (1) describe the current state of the field, (2) create a long-term vision, and (3) identify steps for moving into action. Results: A review of the current state of the field identified strengths including rigourously developed evidence syntheses and practice landscape documentation. Identified gaps included limited evidence on NP hindering recommendation development in evidence syntheses, absence of a national strategy, care silos with limited cross-continuum connections, limited consumer involvement, and limited practice standard implementation. The panel identified key themes for a long-term vision to improve the management of SCI NP in Canada, including establishing an integrated collaborative network; standardized care and outcome evaluation; education; advocacy; and directing resources to innovative solutions. The panel identified the next step as prioritization of areas that will have the greatest impact in a 5-year time frame. Conclusion: A strategic plan outlining a long-term vision to improve management of NP after SCI in Canada was developed and will inform future activities of the sponsors.

Contexte: La gestion optimale de la douleur neuropathique est essentielle à l'amélioration de la qualité de vie liée à la santé des personnes vivant avec une lésion de la moelle épinière. L'une des priorités stratégiques de la Fondation ontarienne de neurotraumatologie et de l'Institut Rick Hansen est l'optimisation de la prise en charge de la douleur neuropathique après une lésion de la moelle épinière.Buts: Un sommet national canadien parrainé par la Fondation ontarienne de neurotraumatologie et l'Institut Rick Hansen a été tenu afin d'élaborer un plan stratégique pour l'amélioration de la gestion de la douleur neuropathique après une lésion de la moelle épinière.Méthodes: Dans le cadre d'une rencontre d'une journée tenue à Toronto, Ontario, un panel multidisciplinaire composé de 18 parties prenantes canadiennes a eu recours à la méthodologie de l'atelier consensuel pour (1) décrire la situation actuelle dans le domaine, (2) définir une vision à long terme et (3) déterminer les étapes à suivre pour passer à l'action.Résultats: Une revue de la situation actuelle dans le domaine a permis d'en répertorier les forces, parmi lesquelles on compte des synthèses de données probantes élaborées avec rigueur et la documentation des pratiques. Les lacunes suivantes ont été répertoriées: des données probantes limitées en ce qui concerne la formulation de recommandations pour empêcher la douleur neuropathique dans les synthèses de données probantes; l'absence de stratégie nationale; un mode de prestation des soins en silos, où les liens entre les continuums sont limités; une participation du consommateur limitée et une mise en œuvre limitée des normes de pratique. Le panel a répertorié les grands thèmes pour élaborer une vision à long terme afin d'améliorer la prise en charge de la douleur neuropathique occasionnée par une lésion de la moelle épinière au Canada, parmi lesquels on compte: l'établissement d'un réseau de collaboration intégré; la normalisation des soins et l'évaluation des résultats; l'éducation; le plaidoyer; et l'attribution de ressources aux solutions novatrices. Le panel a déterminé que la prochaine étape consisterait à prioriser les domaines qui auront le plus de répercussions au cours des cinq prochaines années.Conclusion: Un plan stratégique définissant une vision à long terme pour améliorer la prise en charge de la douleur neuropathique après une lésion de la moelle épinière a été élaboré. Ce plan servira de base aux prochaines activités des promoteurs.

Creation of an Algorithm to Identify Non-traumatic Spinal Cord Dysfunction Patients in Canada Using Administrative Health Data.

Background: The lack of consensus on the best methodology for identifying cases of non-traumatic spinal cord dysfunction (NTSCD) in administrative health data limits the ability to determine the burden of disease and provide evidence-informed services. Objective: The purpose of this study is to develop an algorithm for identifying cases of NTSCD with Canadian health administrative databases using a case-based approach. Method: Data were provided by the Canadian Institute for Health Information that included all acute care hospital and day surgery (Discharge Abstract Database), ambulatory (National Ambulatory Care Reporting System), and inpatient rehabilitation records (National Rehabilitation Reporting System) of patients with neurological impairment (paraplegia, tetraplegia, and cauda equina syndrome) between April 1, 2004 and March 31, 2011. The approach to identify cases of NTSCD involved using a combination of diagnostic codes for neurological impairment and NTSCD etiology. Results: Of the initial cohort of 23,703 patients with neurological impairment, we classified 6,362 as the "most likely NTSCD" group (had a most responsible diagnosis or pre-existing diagnosis of NTSCD and diagnosis of neurological impairment); 2,777 as "probable NTSCD" defined as having a secondary diagnosis of NTSCD, and 11,179 as "possible NTSCD" who had no NTSCD etiology diagnoses but neurological impairment codes. Conclusion: The proposed algorithm identifies an inpatient NTSCD cohort that is limited to patients with significant paralysis. This feasibility study is the first in a series of 3 that has the potential to inform future research initiatives to accurately determine the incidence and prevalence of NTSCD.

Do Performance-Based Wheelchair Propulsion Tests Detect Changes Among Manual Wheelchair Users With Spinal Cord Injury During Inpatient Rehabilitation in Quebec?

OBJECTIVE: To quantify and compare the responsiveness and concurrent validity of 3 performance-based manual wheelchair propulsion tests among manual wheelchair users with subacute spinal cord injury (SCI) undergoing inpatient rehabilitation. DESIGN: Quasi-experimental repeated-measures design. SETTING: Publicly funded comprehensive inpatient SCI rehabilitation program. PARTICIPANTS: Consenting adult manual wheelchair users with a subacute SCI admitted and discharged from inpatient rehabilitation (N=14). INTERVENTION: Participants performed 20-m propulsion at both self-selected natural and maximal speeds, the slalom, and the 6-minute propulsion tests at rehabilitation admission and discharge. MAIN OUTCOME MEASURES: Time required to complete the performance-based wheelchair propulsion tests. Standardized response means (SRMs) were computed for each performance test and Pearson correlation coefficients (r) were calculated to explore the associations between performance tests. RESULTS: The slalom (SRM=1.24), 20-m propulsion at maximum speed (SRM=.99), and 6-minute propulsion tests (SRM=.84) were the most responsive. The slalom and 20-m propulsion at maximum speed were strongly correlated at both admission (r=.93) and discharge (r=.92). CONCLUSIONS: The slalom and 6-minute propulsion tests best document wheelchair propulsion performance change over the course of inpatient rehabilitation. Adding the 20-m propulsion test performed at maximal speed provides a complementary description of performance change.

Secondary health conditions and spinal cord injury: an uphill battle in the journey of care.

PURPOSE: To understand the journey of care in the prevention and management of secondary health conditions (SHCs) following spinal cord injury (SCI). METHOD: This was a case study design with 'Ontario' as the case. The Network Episode Model was used as the conceptual framework. Data sources included in depth interviews with persons with SCI, care providers, and policy and decision makers. Document analysis was also conducted on relevant materials and policies. Key informants were selected by purposeful sampling as well as snowball sampling to provide maximum variation. Data analysis was an iterative process and involved descriptive and interpretive analyses. A coding structure was developed based on the conceptual framework which allowed for free nodes when emerging ideas or themes were identified. RESULTS: Twenty-eight individuals were interviewed (14 persons with SCI and 14 persons representing care providers, community advocacy organization representatives, system service delivery administrators and policy-makers). A major over-arching domain that emerged from the data was the concept of 'fighting'. Eleven themes were identified: at the micro-individual level: (i) social isolation and system abandonment, (ii) funding and equitable care, (iii) bounded freedom and self-management; at the meso care provider level: (iv) gender and caregiving strain, (v) help versus disempowerment, (vi) holistic care-thinking outside the box, (vii) poor communication and coordination of care; and at the macro health system level: (viii) fight for access and availability, (ix) models of care tensions, (x) private versus public tensions and (xi) rigid rules and policies. CONCLUSIONS: Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. If we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level. IMPLICATIONS FOR REHABILITATION: • Secondary health conditions are problematic for individuals with a spinal cord injury (SCI). • This study aimed to understand the journey of care in the prevention and management of secondary health conditions (SHCs) following SCI. • Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. • All stakeholders involved recognized the disparities in access to care and resources that exist within the system. We recommend that if we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.

Application of the Andersen's health care utilization framework to secondary complications of spinal cord injury: a scoping review.

PURPOSE: The purpose of this scoping review was to identify research priority areas related to secondary complications and associated health care use for individuals with spinal cord injury (SCI). DATA SOURCES: Peer-reviewed journals were identified using CINAHL, MEDLINE, PubMed, Embase, Social Sciences Abstracts, Social Works Abstract and PsycInfo search engines. Key references were hand searched. STUDY SELECTION: A total of 289 abstracts were identified from the initial search strategy. We removed studies that did not measure health care and those that did not involve analytical investigation. DATA EXTRACTION: The selected 31 studies were reviewed in detail using a coding template based on the domains and sub-components of the Andersen model (i.e. environmental, population characteristics, health behavior and outcome). RESULTS: Most studies measured predisposing characteristics (e.g., age, gender) and need characteristics (e.g., level of injury). There was a notable absence of environmental characteristics (e.g., health system, neighborhood variables), enabling characteristics and health behaviors (beyond diet and nutrition). CONCLUSIONS: We identified a gap in the SCI literature. Future research should focus on longitudinal study designs with more representation of non-traumatic spinal cord injury, as well as utilizing more advanced statistical analyses (i.e., multivariate level) to adjust for confounding variables.

Evaluation of the cost-effectiveness of electrical stimulation therapy for pressure ulcers in spinal cord injury.

OBJECTIVE: To evaluate the incremental cost-effectiveness of electrical stimulation (ES) plus standard wound care (SWC) as compared with SWC only in a spinal cord injury (SCI) population with grade III/IV pressure ulcers (PUs) from the public payer perspective. DESIGN: A decision analytic model was constructed for a 1-year time horizon to determine the incremental cost-effectiveness of ES plus SWC to SWC in a cohort of participants with SCI and grade III/IV PUs. Model inputs for clinical probabilities were based on published literature. Model inputs, namely clinical probabilities and direct health system and medical resources were based on a randomized controlled trial of ES plus SWC versus SWC. Costs (Can $) included outpatient (clinic, home care, health professional) and inpatient management (surgery, complications). One way and probabilistic sensitivity (1000 Monte Carlo iterations) analyses were conducted. SETTING: The perspective of this analysis is from a Canadian public health system payer. PARTICIPANTS: Model target population was an SCI cohort with grade III/IV PUs. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Incremental cost per PU healed. RESULTS: ES plus SWC were associated with better outcomes and lower costs. There was a 16.4% increase in the PUs healed and a cost savings of $224 at 1 year. ES plus SWC were thus considered a dominant economic comparator. Probabilistic sensitivity analysis resulted in economic dominance for ES plus SWC in 62%, with another 35% having incremental cost-effectiveness ratios of $50,000 or less per PU healed. The largest driver of the economic model was the percentage of PU healed with ES plus SWC. CONCLUSIONS: The addition of ES to SWC improved healing in grade III/IV PU and reduced costs in an SCI population.

Functional electrical stimulation therapy for grasping in traumatic incomplete spinal cord injury: randomized control trial.

The purpose of this single-site randomized control trial was to assess the short-term and long-term efficacy of functional electrical stimulation (FES) therapy over conventional occupational therapy in improving voluntary hand function in incomplete C4-C7 spinal cord injury individuals. All 22 participants recruited in this randomized control trial received treatment for both the left and right upper extremities. Every participant, irrespective of group allocation, received one dose (60 min per day, 5 days per week for the duration of 8 weeks) of conventional occupational therapy for hand function. Of the 22 participants, 12 individuals received an additional dose of conventional occupational therapy, while the remaining 10 participants received a dose of FES hand therapy. The primary outcome measure was Functional Independence Measure (FIM) self-care subscore. The secondary outcome measures were Spinal Cord Independence Measure (SCIM) self-care subscore and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT). The participants who received FES therapy showed significantly greater improvements in hand function at discharge, and were able to maintain their gains at long-term follow-up as assessed using FIM self-care subscore, SCIM self-care subscore, and TRI-HFT. The FES therapy effectively increased independence and thereby improved quality of life of individuals with tetraplegia when compared with conventional occupational therapy.

Functional electrical stimulation therapy of voluntary grasping versus only conventional rehabilitation for patients with subacute incomplete tetraplegia: a randomized clinical trial.

BACKGROUND: Functional electrical stimulation therapy (FET) has a potential to improve voluntary grasping among individuals with tetraplegia secondary to traumatic spinal cord injury (SCI). OBJECTIVE: This single-site, randomized controlled trial examined the efficacy of 40 hours of FET with conventional occupational therapy (COT) compared with COT alone to improve grasping. METHODS: Twenty-four subjects with subacute traumatic incomplete SCI (C4-C7, AIS B-D) consented to participate in 40 hours of therapy over 8 weeks, beyond the conventional rehabilitation program. Subjects were randomized to receive FET + COT (n = 9) or COT (n = 12). The key outcomes were changes in Functional Independence Measure (FIM) self-care subscores, Spinal Cord Independence Measure (SCIM) self-care subscores, and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT) performed at baseline and follow-up. RESULTS: At the end of the treatments, the change in mean FIM self-care subscore for the FET + COT group was 20.1 versus 10 (P = .015) for the COT group. Subjects randomized to FET + COT also had greater improvements in the SCIM and TRI-HFT. No longer term follow-up was feasible. CONCLUSION: FET significantly reduced disability and improved voluntary grasping beyond the effects of considerable conventional upper extremity therapy in individuals with tetraplegia.

Responses of the trunk to multidirectional perturbations during unsupported sitting in normal adults.

Understanding how the human body responds to unexpected force perturbations during quiet sitting is important to the science of motor behavior and the design of neuroprostheses for sitting posture. In this study, the performance characteristics of the neck and trunk in healthy individuals were assessed by measuring the kinematic responses to sudden, unexpected force perturbations applied to the thorax. Perturbations were applied in eight horizontal directions. It was hypothesized that displacement of the trunk, settling time and steady-state error would increase when the perturbation direction was diagonal (i.e., anterior-lateral or posterior-lateral) due to the increased complexity of asymmetrical muscle responses. Perturbation forces were applied manually. The neck and trunk responded in a synchronized manner in which all joints achieved peak displacement simultaneously then returned directly to equilibrium. Displacement in the direction of perturbation and perpendicular to the direction of perturbation were both significantly greater in response to diagonal perturbations (p<.001). The center of mass returned to equilibrium in 3.64±1.42 s after the onset of perturbation. Our results suggest that the trunk sometimes behaves like an underdamped oscillator and is not controlled by simple stiffness when subjected to loads of approximately 200 N. The results of this study are intended to be used to develop a neuroprosthesis for artificial control of trunk stability in individuals with spinal cord injury.

Influence of sport participation on community integration and quality of life: a comparison between sport participants and non-sport participants with spinal cord injury.

BACKGROUND/OBJECTIVE: To determine whether community integration and/or quality of life (QoL) among people living with chronic spinal cord injury (SCI) are superior among sport participants vs non-sport participants. STUDY DESIGN: Cross-sectional study. PARTICIPANTS/METHODS: Persons (n=90) living in the community with SCI (ASIA Impairment Scale A-D), level C5 or below, > 15 years of age, >12 months postinjury, and requiring a wheelchair for >1 hours/day were divided into 2 groups based on their self-reported sport participation at interview: sport participants (n=45) and non-sport participants (n 5). RESULTS: Independent-sample t tests revealed that both Community Integration Questionnaire (CIQ) and Reintegration to Normal Living Index (RNL) total mean scores were higher among sport participants vs nonsport participants (P < 0.05). Significant correlation between CIQ and RNL total scores was found for all participants (Pearson correlation coefficients, P < 0.01). Logistic regression analysis revealed that the unadjusted odds ratio of a high CIQ mean score was 4.75 (95% CI 1.7, 13.5) among current sport participants. Similarly, the unadjusted odds ratio of a high RNL score was 7.00 (95% CI 2.3, 21.0) among current sport participants. Regression-adjusted odds ratios of high CIQ and high RNL scores were 1.36 (95% CI 0.09, 1.45) and 0.15 (95% CI 0.04, 0.55), respectively. The odds ratio for pre-SCI sport participation predicting post-SCI sport participation was 3.06 (95% CI 1.23, 7.65). CONCLUSIONS: CIQ and QoL scores were higher among sport participants compared to non-sport participants. There was an association between mean CIQ and RNL scores for both groups. Sport participants were 4.75 and 7.00 times as likely to have high CIQ and QoL scores. Both groups had a similar likelihood of high CIQ and RNL scores after adjusting for important confounders. Individuals who participated in sports prior to SCI were more likely to participate in sports post-SCI.

Evaluating knowledge of autonomic dysreflexia among individuals with spinal cord injury and their families.

BACKGROUND/OBJECTIVE: Autonomic dysreflexia (AD) is a potentially life-threatening complication of spinal cord injury (SCI) characterized by episodic paroxysmal hypertension and bradycardia in response to a noxious stimulus below the level of injury. Recognition of AD is crucial for individuals with SCI and their family members to facilitate timely and appropriate management. The objectives of this study were to (a) evaluate knowledge of AD among SCI consumers and their family members and (b) identify the preferred format and timing of education regarding AD recognition and management for these stakeholders. METHODS: Cross-sectional descriptive study on a cohort of community-dwelling individuals with chronic SCI (N = 100) and their family members (N = 16) by self-report mail survey. Frequency distributions were used to tabulate survey responses on AD knowledge level and to characterize learning preferences and 2 x 2 chi2 analyses were conducted to determine whether there were factors (ie, impairment) associated with AD knowledge (ie, how to treat AD). RESULTS: Individuals with SCI and their family members have gaps in their knowledge of AD. Traumatic SCI etiology (vs nontrauma) was associated with greater knowledge about treating AD. Although the SCI sample was a high-risk group, 41% had not heard of AD. More concerning was that 22% of individuals with SCI reported symptoms consistent with unrecognized AD. Respondents indicated that AD education would be best delivered during rehabilitation by a healthcare professional. CONCLUSIONS: Further work is needed to promote knowledge about recognizing and managing AD. This may help reduce risk of cardiac and cerebrovascular disease in the SCI population.

Pulse wave velocity for assessment of arterial stiffness among people with spinal cord injury: a pilot study.

BACKGROUND/OBJECTIVE: The most significant complication and leading cause of death for people with spinal cord injury (SCI) is coronary artery disease (CAD). It has been confirmed that aortic pulse wave velocity (PWV) is an emerging CAD predictor among able-bodied individuals. No prior study has described PWV values among people with SCI. The objective of this study was to compare aortic (the common carotid to femoral artery) PWV, arm (the brachial to radial artery) PWV, and leg (the femoral to posterior tibial artery) PWV in people with SCI (SCI group) to able-bodied controls (non-SCI group). METHODS: Participants included 12 men with SCI and 9 non-SCI controls matched for age, sex, height, and weight. Participants with a history of CAD or current metabolic syndrome were excluded. Aortic, arm, and leg PWV was measured using the echo Doppler method. RESULTS: Aortic PWV (mean +/- SD) in the SCI group (1,274 +/- 369 cm/s) was significantly higher (P < 0.05) than in the non-SCI group (948 +/- 110 cm/s). There were no significant between-group differences in mean arm PWV (SCI: 1,152 +/- 193 cm/s, non-SCI: 1,237 +/- 193 cm/s) or mean leg PWV (SCI: 1,096 +/- 173 cm/s, non-SCI: 994 +/- 178 cm/s) values. CONCLUSIONS: Aortic PWV was higher among the SCI group compared with the non-SCI group. The higher mean aortic PWV values among the SCI group compared with the non-SCI group indicated a higher risk of CAD among people with SCI in the absence of metabolic syndrome.