Assessments and interventions on body functions, structures and activity to prepare adults with acute spinal cord injury or disease for participation: a scoping review.

Introduction: In the acute phase after a spinal cord injury or disease (SCI/D), various therapeutic assessments and interventions are applied with the goal of restoring structures, preventing complications and preparing the patient as best as possible for further activity and finally participation. The goal was to identify and evaluate the available evidence on assessments and interventions for body functions and structures to prepare adults with acute spinal cord SCI/D for activity and participation during the first 14 days. Methods: A scoping review was conducted. The search was performed on June 19, 2023 using the databases PubMed, PEDro, Cochrane library and Embase. These were screened for studies including patients with acute SCI/D and physiotherapeutic or occupational therapy assessments and interventions. Only studies in English or German published between 2012 and 2023 were included. Results: Twelve publications met the inclusion criteria, namely three systematic reviews, two randomized controlled trials, two observational studies and five clinical practice guidelines. Assessments as the Spinal Cord Independence Measure, as well as exercises such as daily passive mobilization of body structures against contractures were used in the entire population, while others were only applied in subgroups of SCI/D such as the Graded Redefined Assessment of Strength, Sensation and Prehension or functional electrical stimulation with and without additional movements. The methodological quality of the studies found varied greatly from good to very poor. Discussion: Heterogeneity in research design and study population as well as lack of high-quality studies do not cover the standard of clinical management in the acute phase and further comprehensive research is needed.

Evidence-based recommendations for the rehabilitation and management of the ageing population with spinal cord injury: a systematic review of clinical practice guidelines.

INTRODUCTION: The intersection of ageing and spinal cord injury (SCI) is of global concern. Two scenarios have been described: 1) "SCI with ageing," an increase in the average age of SCI onset, and 2) "ageing with SCI," an increase in post-injury life expectancy. These scenarios entail complex health care and rehabilitation needs due to the accumulation of comorbidities, ageing-related and SCI-induced physiological changes, and post-SCI secondary health conditions. We systematically reviewed Clinical Practice Guidelines (CPGs) with the objective of identifying the extent to which SCI CPGs include recommendations for the rehabilitation and management of people who are "ageing with SCI" or who have acquired an "SCI with ageing". We termed these as "ageing-related recommendations". We also aimed to describe them and identify gaps. EVIDENCE ACQUISITION: We searched PubMed (NCBI), CINAHL Complete (EBSCOhost) and Embase (Elsevier) for relevant CPGs between 28 December 2022 and 5 January 2023. Included CPGs were evidence-based and had at least one ageing-related recommendation for SCI rehabilitation and management. We used the two core sets of the International Classification of Functioning, Disability and Health (ICF) to identify gaps. EVIDENCE SYNTHESIS: Only 16 (30%) of the 52 identified CPGs included ageing-related recommendations. Most were recent US or European publications and lacked specific chapters on ageing. These CPGs included 40 ageing-related recommendations, mostly "strong" but based on "low" to "very low" quality of evidence. The overall quality of the development process was low and did not consider the values and preferences of stakeholders and patients. Common topics included cardiovascular, bone, metabolic, bowel, bladder, and skin health. The recommendations could be linked to 30 ICF categories which represented only 18% of the ICF categories included in the comprehensive versions of two ICF Core Sets. Key gaps were found in mobility, interpersonal interactions, and relationships, neuromusculoskeletal and movement-related, mental, sensory and pain functions. CONCLUSIONS: There is a notable lack of high-quality ageing-related recommendations for SCI management and rehabilitation. Future research should prioritize the generation of high-quality evidence to develop age-sensitive CPGs. Future SCI CPGs need to address the complex challenges at the interface of ageing and SCI, considering patient and stakeholder preferences.

Reciprocal association between pain and quality of life after newly acquired spinal cord injury.

PURPOSE: Pain is highly prevalent in spinal cord injury (SCI) and a key determinant of quality of life (QoL). This is the first study to examine reciprocal associations between pain and QoL in patients undergoing their first inpatient rehabilitation after SCI. METHODS: Longitudinal data, with three measurement time points (1 month and 3 months after SCI onset, and at discharge from inpatient rehabilitation) from the Inception Cohort of the Swiss Spinal Cord Injury Cohort Study. Participants were 381 individuals aged ≥ 16 years with a newly diagnosed traumatic or non-traumatic SCI. 75.1% were male and the average age was 53.2 years. Random intercept cross-lagged panel models were conducted to examine the reciprocal association between pain intensity and QoL, as measured with the International SCI QoL Basic Data Set three individual items (satisfaction with life, physical health, and psychological health) and total score (mean of the three individual items). RESULTS: Both item and total QoL scores increased over time. 1 month: 5.3 (SD = 2.7), 3 months: 5.9 (SD = 2.3), discharge: 6.6 (SD = 2.0). Participants reported relatively low levels of pain intensity that remained stable over the course of inpatient rehabilitation. 1 month: 2.7 (SD = 2.3), 3 months: 2.6 (SD = 2.4), discharge: 2.7 (SD = 2.5). There were no significant cross-lagged associations between QoL and pain intensity across time. CONCLUSION: Results indicate that pain intensity does not predict changes in QoL during first rehabilitation, and vice versa. Associations between pain intensity and QoL reported by previous studies may be attributable to individual characteristics and timely events that simultaneously influence pain and QoL.

Revisiting functioning recovery in persons with spinal cord injury undergoing first rehabilitation: Trajectory and network analysis of a Swiss cohort study.

Information about an individual's functioning and its longitudinal development is key to informing clinical rehabilitation. However, the description and understanding of the detailed longitudinal course of functioning, i.e., functioning trajectories, is rare in the current SCI literature. The aim of this study was to re-estimate previously identified functioning trajectories of individuals with spinal cord injury (SCI) undergoing initial rehabilitation in Switzerland using trajectory analysis, and to identify highly influential functioning domains that could become trajectory-specific targets for clinical interventions using network analysis. The study was based on data from the Swiss SCI Cohort Study and included individuals with SCI (N = 1099) who completed their rehabilitation in one of four collaborating centers between May 2013 and March 2022. For the trajectory analysis, functioning was operationalized using the total sum score of the Spinal Cord Independence Measure version III (SICM III), which was assessed at up to four time points (T1-T4) during rehabilitation. For the network analysis, individual SCIM III items were used to operationalize relevant functioning problems at T1 (admission) and T4 (discharge). The re-estimation of trajectory analysis confirmed the previously identified mean functioning trajectory classes of stable high functioning (N = 239; 21.75%), early (N = 33; 3.00%), moderate (N = 753; 68.52%), and slow (N = 74; 6.73%) functioning improvement. The network analysis revealed highly connected functioning problems at T1 for the moderate functioning improvement class, including "Feeding", "Dressing upper body", and "Dressing lower body", "Mobility in bed", and "Use of toilet". These functioning domains might indicate potential trajectory-specific targets for clinical interventions. This study has increased our knowledge about functioning trajectories of individuals with SCI undergoing initial rehabilitation in Switzerland and its findings may inform discussions about the application and use of functioning trajectories in clinical practice. Due to the exploratory nature of this study, further research is needed to confirm the findings presented.

Risk factors of major complications after flap surgery in the treatment of stage III and IV pressure injury in people with spinal cord injury/disorder: a retrospective cohort study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To identify risk factors associated with major complications after flap surgery in people with spinal cord injury or disorder (SCI/D) and stage III and IV pressure injury (PI). SETTING: Swiss hospital specialized in the treatment of people with SCI/D using the Basel Decubitus Approach. METHODS: We examined 60 risk factors for major postoperative complications in PIs over sacrum/coccyx, ischium or trochanter between 01/2016 and 12/2021. We performed descriptive analysis and computed global p-values using likelihood ratio tests adjusted for clustering of PIs in individuals. RESULTS: We included 220 PI treatment procedure from 149 individuals. The study population consisted of 163 (74%) men, 133 (60%) traumatic SCI, 136 (58%) stage IV PI, 198 (90%) individuals with paraplegia, 93 (42%) with osteomyelitis, and 85 (39%) with recurrent PI. Major complications 42 (19%) occurred more often in individuals with stage IV PI (p < 0.01), individuals without osteomyelitis (p < 0.03), and individuals with pathological blood concentrations of cystatin c (p < 0.028), calcium (p < 0.048), and vitamin B12 (p < 0.0049) as well as normal blood concentrations of HbA1c (p < 0.033). Immobilization (p < 0.0089) and hospital stay (p < 0.0001) of individuals with major complications was longer. CONCLUSION: In the Basel Decubitus Approach, stage IV PI, absence of osteomyelitis, reduced vitamin B12 and calcium, elevated cystatin c, and normal HbA1c should be addressed to reduce major complications.

Research Priorities of the Pediatric Spinal Cord Injury Population: An International Insight for Rehabilitation Care.

BACKGROUND: Although feedback from people with adult-onset spinal cord injury (SCI) has been considered for new rehabilitation programs, little is known about the priorities of the pediatric-onset SCI population. This study describes and compares health and life (H&L) domain research priorities of youth with pediatric-onset SCI and their parents/caregivers. METHODS: A cross-sectional survey, designed by the Pan-European Paediatric Spinal Cord Injury (PEPSCI) Collaboration, was performed at six European countries. Dyad data from 202 participants, youth with pediatric-onset SCI (n = 101) and their parents/caregivers (n = 101), were analyzed with the PEPSCI H&L domain surveys. RESULTS: The cohort was composed of 8 to 12-year-olds (30.7%), 13 to 17-year-olds (38.6%), and 18 to 25-year-olds (30.7%). The top three H&L domain research priorities reported by parents/caregivers of 8 to 12-year-olds were "walking/ability to move" (91%), "bladder" function (90%), and "general health/feel" (89%), compared with "physical function" (93%), "general health/feel" (90%), and "walking/ability to move" (89%) rated by parents/caregivers of 13 to 25-year-olds. "Bowel" function (85%), "leg/foot movement" (84%), and "bladder" function (84%) were reported as priorities by 13 to 25-year-olds, whereas "physical function" (84%), "experience at school" (83%), and "general mood" were highlighted by 8 to 12-year-olds. The top 10 priorities preferred by 13 to 25-year-olds when compared with the top 10 priorities reported by their parents/caregivers, included problems related to "bowel" and "pain." CONCLUSIONS: Health domain research priorities were highlighted by 13 to 25-year-olds, compared with their parents/caregivers who equally identified H&L domains. This survey will aid health care and clinical research organizations to engage stakeholders to implement a comprehensive research strategy for the pediatric SCI population.

Use of professional home care in persons with spinal cord injury in Switzerland: a cross-sectional study.

BACKGROUND: Persons with spinal cord injury (SCI) living in the community often require care. The boundaries between professional home care and informal care are blurred, and it is unclear who the typical user of home care is. The objective of this study was to describe the characteristics of persons with SCI using professional home care in Switzerland, determine the frequency of home care visits, and investigate the association of sociodemographic factors, SCI-specific characteristics, secondary health conditions, and functional independence with the use of home care. METHODS: We used cross-sectional data from the 2017 community survey of the Swiss Spinal Cord Injury Cohort Study (SwiSCI). Out of 3,959 eligible individuals 1294 completed the questionnaire and were included in the analysis (response rate 33%). Using descriptive statistics, differences between home care users and non-users as well as the frequency of home care visits were investigated. The association between sociodemographic factors, SCI-specific characteristics, secondary health conditions, functional independence and the use of home care was analyzed using multivariable logistic regression. Multiple imputation was used to account for missing data. RESULTS: Of 1,294 participants, 280 (22%) used professional home care. The median weekly professional home care duration was 6 h (Q1 = 2, Q3 = 12). More home care was used in persons with lower functional independence (Odds ratio (OR) 0.30 per 10 unit decrease in the Spinal Cord Independence Measure, 95%-Confidence interval (CI) 0.24-0.37), fewer secondary health conditions (OR 0.96 per unit Spinal Cord Injury Secondary Conditions Scale, 95%-CI 0.94-0.99), tetraplegia (OR 2.77, 95%-CI 1.92-4.00), women (OR 2.42, 95%-CI 1.70-3.43), higher age (OR 1.22 per 10 years increase, 95%-CI 1.06-1.39), living alone (OR 2.48, 95%-CI 1.53-4.03), and those receiving support from an informal caregiver (OR 1.88, 95%-CI 1.27-2.77). CONCLUSIONS: This is the first study to examine the use of professional home care from the perspective of persons with SCI in Switzerland. Lower functional independence strongly predicts increased home care use. The findings showed that professional home care complements informal care and is more likely to be used by individuals with SCI who live alone, have tetraplegia, and are female.

Quality of life from the patient perspective at the end of the first rehabilitation after the onset of spinal cord injury/disorder - A qualitative interview-based study.

CONTEXT: At present, there is a lack of information concerning patients' perspectives on their quality of life (QoL) after a recently acquired spinal cord injury/disorder (SCI/D). OBJECTIVE: To explore patients' perspectives on their QoL during their first inpatient rehabilitation after the onset of SCI/D. METHODS: Qualitative study. Semi-structured face-to-face interviews were conducted with 20 participants aged 18 years or older at least three months after the onset of SCI/D and two weeks before they were discharged from their first rehabilitation. Audio-recorded interviews were transcribed and analyzed according to the thematic content analysis. Interviewees rated their QoL with the SCI QoL data set. RESULTS: The interviewees judged their satisfaction with life as a whole, their physical and mental health, as relatively high with values between six and eight (with 10 meaning complete satisfaction). They highlighted social aspects, health topics, and the experience of autonomy as relevant to their concept of QoL. The aspects that positively influenced QoL included the level of well-being in the current social and institutional environment, the increased level of energy, strength, and autonomy in daily life, and an improved mental state derived from general positive personal attitudes. In contrast, the social restrictions during the COVID-19 pandemic, physical issues including pain, a lack of progress associated with psychological dissatisfaction, and limitations in personal independence decreased patients' QoL. CONCLUSION: Since the interviewees described different aspects from the areas of social, health and autonomy as important for their QoL, exploring and addressing these areas should be used to achieve an individualized first rehabilitation.

Risk constellation of hospital acquired pressure injuries in patients with a spinal cord injury/ disorder - focus on time since spinal cord injury/ disorder and patients' age.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: The aim of this study was to evaluate how time since spinal cord injury/disorder (SCI/D) and patients' age influence risk constellation for hospital acquired pressure injuries (HAPI) in patients with a SCI/D. SETTING: Acute care and rehabilitation clinic specialized in SCI/D. METHODS: We collected patients' characteristics and 85 risk factors for HAPI development in adults with SCI/D with at least one HAPI during their inpatient stay between August 2018 and December 2019. We analyzed patients' characteristics and HAPI risk factors using descriptive statistics according to time since SCI/D ( < 1 year, 1-15 years, > 15 years) and patients' age (18-35 years, 35-65 years, > 65 years). RESULTS: We identified 182 HAPI in 96 patients. Comparing patients with SCI/D < 1 year with the other groups, autonomic dysreflexia (p < 0.001), abnormal body temperature (p = 0.001), hypertensive episode (p = 0.005), and pneumonia (p < 0.001) occurred more frequently; mean hemoglobin (p < 0.001), albumin (p = 0.002) and vitamin D levels (p = 0.013) were significantly lower, and patients with time since SCI/D < 1 year scored fewer points (10-12) on the Braden Scale (p < 0.001). Comparing groups per patients' age, only the SCIPUS score was higher in patients > 65 years compared to the other two groups (p = 0.002). CONCLUSIONS: Different risk factor constellation seem to be underlying HAPI development with more differences in patients time since SCI/D than patients' age. Awareness of these differences in risk factor constellation depending on time since SCI/D in these patients might lead to different HAPI prevention strategies. SPONSORSHIP: The study team didn't receive any additional sponsorship.

Metabolic profile of complete spinal cord injury in pons and cerebellum: A 3T 1H MRS study.

The aim of this exploratory study was the assessment of the metabolic profiles of persons with complete spinal cord injury (SCI) in three region-of-interests (pons, cerebellar vermis, and cerebellar hemisphere), with magnetic resonance spectroscopy, and their correlations to clinical scores. Group differences and association between metabolic and clinical scores were examined. Fifteen people with chronic SCI (cSCI), five people with subacute SCI (sSCI) and fourteen healthy controls were included. Group comparison between cSCI and HC showed lower total N-acetyl-aspartate (tNAA) in the pons (p = 0.04) and higher glutathione (GSH) in the cerebellar vermis (p = 0.02). Choline levels in the cerebellar hemisphere were different between cSCI and HC (p = 0.02) and sSCI and HC (p = 0.02). A correlation was reported for choline containing compounds (tCho) to clinical scores in the pons (rho = - 0.55, p = 0.01). tNAA to total creatine (tNAA/tCr ratio) correlated to clinical scores in the cerebellar vermis (rho = 0.61, p = 0.004) and GSH correlated to the independence score in the cerebellar hemisphere (rho = 0.56, p = 0.01). The correlation of tNAA, tCr, tCho and GSH to clinical scores might be indicators on how well the CNS copes with the post-traumatic remodeling and might be further examined as outcome markers.

The effect of the general practitioner as the first point of contact for care on the satisfaction with health care services in persons living with chronic spinal cord injury: A cross-sectional study.

OBJECTIVE: The primary objective of this study was to investigate the effect of having a general practitioner (GP) as a first point of contact for care on the satisfaction with care services in persons with spinal cord injury (SCI), and how this effect is related to socio-demographic and health-related factors. METHODS: This is a cross-sectional survey conducted within the framework of the Swiss Spinal Cord Injury Cohort Study Community Survey 2017. Outcome measures comprised three aspects of care (treatment with respect, understandability of explanations, and involvement in decision-making) and satisfaction with GP care and SCI centres. Information was grouped by first contact of care (GP or SCI specialist) and compared using the Mann-Whitney U test and logistic regression analysis. RESULTS: Out of 3,959 invitees, 1,294 participants (33%) completed the survey. No significant association was found between the three aspects of care and the first contact of care. Persons who first contacted a GP and lived within a 10-minute travel distance to the GP practice were significantly less likely to be satisfied with their GP care (-5.7 percentage points, CI 95% = -10.7, -0.7), as compared to those living farther away. Persons who first contacted a GP rather than an SCI specialist were more likely to be satisfied with their GP care if married (7.1 percentage points, CI 95% = 1.4, 12.7), employed (6.6 percentage points, CI 95% = 0.9, 12.3), had a high social status (11.0 percentage points, CI 95% = 2.0, 20.1), or had tetraplegia (10.8 percentage points, CI 95% = 3.6, 18.1). For the same group, satisfaction with SCI centres was significantly higher in persons with good (10.1 percentage points, CI 95% = 0.1, 20.1) or very good health (8.2 percentage points, CI 95% = 1.0, 15.4), as compared to those with poor health. CONCLUSION: The majority of participants were satisfied with the services offered by their first contact point for care, with variations due to factors endogenous to the participants. Socio-demographic and health-related factors should be integrated into health care planning strategies and improvement initiatives to ensure equitable access and better quality of health care services.

Effect of a computerized decision support system on the treatment approach of stage III or IV pressure injury in patients with spinal cord injury: a feasibility study.

BACKGROUND: Stage III and IV pressure injuries (PIs) in patients with spinal cord injury (SCI) require complex interdisciplinary and interprofessional treatment approaches that are difficult to implement. Practical aspects, such as information exchange and coordination, remain challenging. We investigated whether a computerized decision support system (CDSS) could increase treatment adherence and improve clinical outcomes and interprofessional collaboration. METHOD: In this feasibility study, a core team developed the initial treatment process and adapted it based on several discussions with clinical experts and information technologists. The CDSS followed the Basel Decubitus Approach and was used in a clinic specializing in SCI. Thirty patients with SCI admitted for stage III/IV PI between July 2016 and May 2017 were randomly allocated to standard or CDSS-supported care. Between-group differences in treatment adherence, complication rates, length of stay, and costs were analyzed using descriptive statistics. The use of the CDSS and potential barriers and facilitators were evaluated through interprofessional focus groups, transcribed verbatim, and thematically analyzed (30 participants). RESULTS: No differences in SCI characteristics, comorbidities, or PI characteristics (localization: ischium [number (n) = 19 PI, 63%], sacrum [n = 10 PI, 33%], recurrent PI [n = 21, 70%]) were found between the two groups. Furthermore, no statistically significant differences were observed in treatment adherence, frequency of major (20% vs. 13% between CDSS and control group) and minor (33% vs 27%) complications, and length of stay (98 [±28] vs 81 [±23] days). Healthcare professionals found the CDSS to be helpful for visualizing the treatment process. However, the high workload and difficulties in the information technology processes, such as missing reminders, slow computer performance and data processing, and poor accessibility, hindered the effective implementation of the CDSS. CONCLUSION: The implementation of the CDSS to support the treatment of stage III/IV PI in patients with SCI was feasible and included definitions of milestones, interventions, and outcomes. However, to assess the impact of the CDSS, a longer observation period is required. Further, the technical difficulties must be addressed, and solid integration of the CDSS into the clinical information system is necessary. TRIAL REGISTRATION: This quality improvement project received a declaration of no objection from the Ethics Committee of Northwest and Central Switzerland (EKNZ UBE-16/003), and ethical approval was received for the focus groups (EKNZ Req-2017-00860).

Prevalence of an insufficient vitamin D status at the onset of a spinal cord injury - a cross-sectional study.

STUDY DESIGN: A cross-sectional study. OBJECTIVE: This study aimed to investigate the vitamin D status after acute spinal cord injury (SCI) onset. SETTING: Specialized SCI rehabilitation center in Switzerland. METHODS: Patients admitted to the center after an acute SCI onset were included. The prevalence of a deficient (25(OH)D ≤ 50 nmol/l), insufficient (50 < 25(OH)D ≤ 75 nmol/l) and sufficient (25(OH)D > 75 nmol/l) vitamin D status were determined after admission. Vitamin D status was compared between different patient groups based on demographic and SCI characteristics. The occurrence of bed rest, falls and pressure injuries were also assessed. RESULTS: In total, 87 patients (median (interquartile range); 53 (39-67) years, 25 females, 66 traumatic SCI, 54 paraplegia) were included. Assessed a median of 15 (9-22) days after SCI onset, median vitamin D status was 41 (26-57) (range 8-155) nmol/l. The majority of patients had a deficient (67%, 95% confidence interval (95% CI) 0.56-0.76) or insufficient (25%, 95% CI 0.17-0.36) vitamin D status. A moderate negative correlation was found between vitamin D status and body mass index (p = 0.003). A moderate positive correlation was found between vitamin D and calcium status (p = 0.01). CONCLUSION: A deficient or insufficient vitamin D status directly after SCI onset is highly prevalent. Vitamin D status should be carefully observed during acute SCI rehabilitation. We recommend that all patients with recent SCI onset should receive vitamin D supplementation with a dosage depending on their actual vitamin D status.

Patients' experiences with goal setting during initial rehabilitation after newly acquired spinal cord injury: A pilot qualitative interview study.

OBJECTIVE: To explore patients' experiences with goal setting during initial rehabilitation after newly acquired spinal cord injury/disorder (SCI/D). DESIGN: Qualitative design with semi-structured interviews and purposively sampled participants. Interviews were transcribed verbatim. Transcripts were analyzed for qualitative content analysis using the Mayring method. SETTING: Specialized acute care and rehabilitation center for SCI/D-patients. PARTICIPANTS: Patients in initial rehabilitation after a newly acquired SCI/D. INTERVENTIONS: n.a. OUTCOME MEASURES: n.a. RESULTS: Ten participants were interviewed in the post-acute phase after a newly acquired SCI/D. Participants described individual patient characteristics as well as organizational elements influencing their experience with goal setting. Organizational elements comprised structural elements (e.g. ward rounds, rehabilitation meetings, etc.) and interaction with and among the interprofessional teams. Perspectives from various health care professionals (HCPs) were perceived as increasing adequate goal setting and motivation. Furthermore, the participants described their own involvement and motivation as crucial for goal achievement. The main point of the critique was the standardization of the goal setting process. Interviewees would have preferred individualized goal setting embedded in a clearly foreseeable rehabilitation plan. CONCLUSION: Organization and collaboration with and among the HCPs should be geared towards identifying specific patient needs during the course of rehabilitation and deriving individually tailored goals from them. Communication plays an important role in the individual goal setting.

Treatment approaches of stage III and IV pressure injury in people with spinal cord injury: A scoping review.

CONTEXT: The treatment of pressure injury (PI) stage III and IV in people with spinal cord injury or spinal cord disorder (SCI/D) requires a multidisciplinary and surgical involvement. OBJECTIVES: This scoping review aims to identify published relevant surgical multidisciplinary treatment approaches, describe the elements and evaluate the effectiveness of the approaches. METHODS: We searched PubMed and Medline databases for studies about treatment approaches for people aged ≥18 years with chronic SCI/D and PI stage III or IV over ischium, trochanter or sacrum published between January 1990 and December 2021 in English or German language. Two independent reviewers screened the articles. One reviewer extracted information on study author(s), year of publication, study title, study design, country of origin, sample size as well as data on elements and effectiveness of the approaches. RESULTS: 10 different approaches were described in two retrospective cohort studies, three case series, five discussion papers, one review and one guideline. All approaches included debridement, flap surgery, pressure relief and immobilization as well as infection control. Some approaches described elements such as risk screening (7/10), osteomyelitis treatment (8/10), nutritional therapy (8/10), physiotherapy, occupational therapy and psychology (6/10), spasticity control (7/10), and prevention and education (6/10). Only one study reported on the effectiveness of the approaches. CONCLUSION: There are key elements for surgical multidisciplinary treatment approaches. However, due to differences in the content of some of these elements and missing elements in some approaches, comparability is difficult and the effectiveness of the complex approaches remains uncertain.

Mean kurtosis-Curve (MK-Curve) correction improves the test-retest reproducibility of diffusion kurtosis imaging at 3 T.

Diffusion kurtosis imaging (DKI) is applied to gain insights into the microstructural organization of brain tissues. However, the reproducibility of DKI outside brain white matter, particularly in combination with advanced estimation to remedy its noise sensitivity, remains poorly characterized. Therefore, in this study, we investigated the variability and reliability of DKI metrics while correcting implausible values with a fit method called mean kurtosis (MK)-Curve. A total of 10 volunteers (four women; age: 41.4 ± 9.6 years) were included and underwent two MRI examinations of the brain. The images were acquired on a clinical 3-T scanner and included a T1-weighted image and a diffusion sequence with multiple diffusion weightings suitable for DKI. Region of interest analysis of common kurtosis and tensor metrics derived with the MK-Curve DKI fit was performed, including intraclass correlation (ICC) and Bland-Altman (BA) plot statistics. A p value of less than 0.05 was considered statistically significant. The analyses showed good to excellent agreement of both kurtosis tensor- and diffusion tensor-derived MK-Curve-corrected metrics (ICC values: 0.77-0.98 and 0.87-0.98, respectively), with the exception of two DKI-derived metrics (axial kurtosis in the cortex: ICC = 0.68, and radial kurtosis in deep gray matter: ICC = 0.544). Non-MK-Curve-corrected kurtosis tensor-derived metrics ranged from 0.01 to 0.52 and diffusion tensor-derived metrics from 0.06 to 0.66, indicating poor to moderate reliability. No structural bias was observed in the BA plots for any of the diffusion metrics. In conclusion, MK-Curve-corrected DKI metrics of the human brain can be reliably acquired in white and gray matter at 3 T and DKI metrics have good to excellent agreement in a test-retest setting.

Glutathione in the Pons Is Associated With Clinical Status Improvements in Subacute Spinal Cord Injury.

OBJECTIVES: In spinal cord injury (SCI), the primary mechanical injury is followed by secondary sequelae that develop over the subsequent months and manifests in biochemical, functional, and microstructural alterations, at the site of direct injury but also in the spinal cord tissue above and below the actual lesion site. Noninvasive magnetic resonance spectroscopy (MRS) can be used to assess biochemical modulation occurring in the secondary injury phase, in addition to and supporting conventional MRI, and might help predict and improve patient outcome. In this article, we aimed to examine the metabolic levels in the pons of subacute SCI by means of in vivo proton MRS at 3 T and explore the association to clinical scores. MATERIALS AND METHODS: In this prospective study, between November 2015 and February 2018, single-voxel short-echo MRS data were acquired in healthy controls and in SCI subjects in the pons once during rehabilitation. Besides the single-point MRS examination, in addition, in participants with SCI, the clinical status (ie, motor, light touch, and pinprick scores) was assessed twice: (1) around the MRS session (approximately 10 weeks postinjury) and (2) before discharge (at approximately 9 months postinjury). The group differences were assessed with Kruskal-Wallis test, the post hoc comparison was assessed with Wilcoxon rank sum test, and the clinical correlations were conducted with Spearman rank correlation test. Bayes factor calculations completed the statistical part providing relevant evidence values. RESULTS: Twenty healthy controls (median age, 50 years; interquartile range, 41-55 years; 18 men) and 18 subjects with traumatic SCI (median age, 50 years; interquartile range, 32-58 years; 16 men) are included. Group comparison showed an increase of total N -acetylaspartate and combined glutamate and glutamine levels in complete SCI and a reduction of total creatine in incomplete paraplegic SCI. The proton MRS-based glutathione levels at baseline correlate to the motor score improvement during rehabilitation in incomplete subacute SCI. CONCLUSIONS: This exploratory study showed an association of the metabolite concentration of glutathione in the pons assessed at approximately 10 weeks after injury with the improvements of the motor score during the rehabilitation. Pontine glutathione levels in subjects with traumatic subacute incomplete SCI acquired remote from the injury site correlate to clinical score and might therefore be beneficial in the rehabilitation assessments.

Functional connectivity and amplitude of low-frequency fluctuations changes in people with complete subacute and chronic spinal cord injury.

After spinal cord injury (SCI), reorganization processes and changes in brain connectivity occur. Besides the sensorimotor cortex, the subcortical areas are strongly involved in motion and executive control. This exploratory study focusses on the cerebellum and vermis. Resting-state functional magnetic resonance imaging (fMRI) was performed. Between-group differences were computed using analysis of covariance and post-hoc tests for the seed-based connectivity measure with vermis and cerebellum as regions of interest. Twenty participants with complete SCI (five subacute SCI, 15 with chronic SCI) and 14 healthy controls (HC) were included. Functional connectivity (FC) was lower in all subjects with SCI compared with HC in vermis IX, right superior frontal gyrus (pFDR = 0.008) and right lateral occipital cortex (pFDR = 0.036). In addition, functional connectivity was lower in participants with chronic SCI compared with subacute SCI in bilateral cerebellar crus I, left precentral- and middle frontal gyrus (pFDR = 0.001). Furthermore, higher amplitude of low-frequency fluctuations (ALFF) was found in the left thalamus in individuals with subacute SCI (pFDR = 0.002). Reduced FC in SCI indicates adaptation with associated deficit in sensory and motor function. The increased ALFF in subacute SCI might reflect reorganization processes in the subacute phase.

Predicting non-response in patient-reported outcome measures: results from the Swiss quality assurance programme in cardiac inpatient rehabilitation.

BACKGROUND: Quality assurance programmes measure and compare certain health outcomes to ensure high-quality care in the health-care sector. The outcome of health-related quality of life is typically measured by patient-reported outcome measures (PROMs). However, certain patient groups are less likely to respond to PROMs than others. This non-response bias can potentially distort results in quality assurance programmes. OBJECTIVE: Our study aims to identify relevant predictors of non-response during assessment using the PROM MacNew Heart Disease questionnaire in cardiac rehabilitation. METHODS: This is a cross-sectional study based on data from the Swiss external quality assurance programme. All patients aged 18 years or older who underwent inpatient cardiac rehabilitation in 16 Swiss rehabilitation clinics between 2016 and 2019 were included. Patients' socio-demographic and basic medical data were analysed descriptively by comparing two groups: non-responders and responders. We used a random intercept logistic regression model to estimate the associations of patient characteristics and clinic differences with non-response. RESULTS: Of 24 572 patients, there were 33.3% non-responders and 66.7% responders. The mean age was 70 years, and 31.0% were women. The regression model showed that being female was associated with non-response [odds ratio (OR) 1.22; 95% confidence interval (CI) 1.14-1.30], as well as having no supplementary health insurance (OR 1.49; 95% CI 1.39-1.59). Each additional year of age increased the chance of non-response by an OR of 1.02 (95% CI 1.02-1.02). Not being a first language speaker of German, French or Italian increased the chance of non-response by an OR of 6.94 (95% CI 6.03-7.99). Patients admitted directly from acute care had a higher chance of non-response (OR 1.23; 95% CI 1.10-1.38), as well as patients being discharged back into acute care after rehabilitation (OR 3.89; 95% CI 3.00-5.04). Each point on the cumulative illness rating scale total score increased the chance of non-response by an OR of 1.05 (95% CI 1.04-1.05). Certain diagnoses also influenced the chance of non-response. Even after adjustment for known confounders, response rates differed substantially between the 16 clinics. CONCLUSION: We have found significant non-response bias among certain patient groups, as well as across different treatment facilities. Measures to improve response rates among patients with known barriers to participation, as well as among different treatment facilities, need to be considered, particularly when PROMs are being used for comparison of providers in quality assurance programmes or outcome evaluation.

Effect of an interprofessional small-group communication skills training incorporating critical incident approaches in an acute care and rehabilitation clinic specialized for spinal cord injury and disorder.

Aim: To investigate the impact of site-specific inter-professional small-group communication skills training (CST) that incorporates critical incident approaches to learning on patient satisfaction with communication. Setting: Rehabilitation clinic specialized for spinal cord injury/disorder (SCI/D). Methods: Retrospective observational cohort study design using patient and health-professional self-report data. Data for patient satisfaction with communication were collected in 2014 (existing records) and each year from 2015 to 2021 (post-program; volunteers) using the MECON survey. Results: Fifteen basic (n = 161 participants), 16 refresher (n = 84), and five short (n = 17) CST seminars were conducted. Overall, 262 employees (105 physicians, 63 nurses, 36 physio- and occupational therapists, and 58 others) participated; 92 participants (response rate 37.6%) responded to feedback surveys. They rated the seminars positive concerning the alternation between theory, discussion, and practical exercise in 91.3%, and rated the length of the training ideal in 80.2%. Post-program patient satisfaction overall increased from 83.1% (confidence interval (CI) 2.6%) to 90% (CI 0.8%; R2 = 0.776; p= 0.004). It was higher in specific communication-related topics: "receiving information" (81.1%, CI 3.1-90.2%, CI 1.0%; p = 0.003), "being able to bring in concerns" (83%, CI 1.0-90.8%; R2 = 0.707; p = 0.009) and "being treated with respect" (89.4%, CI 2.6-94.4%, CI 0.8%; R2 = 0.708; p = 0.004). Practice implications: Inter-professional CST is feasible and well accepted by professionals from various professional groups. During seven years of continuous training, independent patient ratings of satisfaction with professional communication have improved significantly. Participants attest to the training's high credibility and usefulness in everyday life.