Incidence and Risk Factors of Pneumonia in Individuals With Acute Spinal Cord Injury: A Multi-national, Multi-center, Prospective Cohort Study.

OBJECTIVE: To describe the occurrence of pneumonia in individuals with acute spinal cord injury (SCI) and identify its key predictors. DESIGN: Multi-centric, longitudinal cohort study. SETTING: 10 specialized SCI rehabilitation units in Europe and Australia. PARTICIPANTS: Eligible were 902 men and women with acute SCI, aged 18 years or older, with cervical or thoracic lesions and not dependent on 24-hour mechanical ventilation; 503 participated in the study (N=503). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We assessed demographics and lesion related parameters at study entry, and any pneumonia events throughout inpatient rehabilitation. Respiratory function, decubitus, and urinary tract infections were assessed at 1, 3, and 6 months post injury as well as at discharge from inpatient rehabilitation. Time to event (pneumonia) analyses were done using the Kaplan-Meier method, and potential predictors for pneumonia were analyzed with multivariable survival models. RESULTS: Five hundred three patients with SCI were included, with 70 experiencing at least 1 pneumonia event. 11 participants experienced 2 or more events during inpatient rehabilitation. Most events occurred very early after injury, with a median of 6 days. Pneumonia risk was associated with tetraplegia (hazard ratio [HR]=1.78; 95% confidence interval [CI] 1.00-3.17) and traumatic etiology (HR=3.75; 95% CI 1.30-10.8) American Spinal Injury Impairment Scale (AIS) A (HR=5.30; 95% CI 2.28-12.31), B (HR=4.38; 95% CI 1.77-10.83), or C (HR=4.09; 95% CI 1.71-9.81) lesions. For every 10 cmH2O increase in inspiratory muscle strength, pneumonia risk was reduced by 13% (HR=0.87; 95% CI 0.78-0.97). CONCLUSION: Pneumonia is a major complication after SCI with the highest incidence very early after injury. Individuals with traumatic or AIS A, B, or C tetraplegia are at highest risk for pneumonia.

Respiratory muscle training in individuals with spinal cord injury: effect of training intensity and -volume on improvements in respiratory muscle strength.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To investigate the effect of training intensity and -volume on improvements in respiratory muscle strength in individuals with spinal cord injury (SCI). SETTING: SCI rehabilitation center in Switzerland. METHODS: Inpatients with SCI, lesion level C4-T12, who had at least 10 individualized inspiratory muscle training sessions with respiratory function measurements before and after the training period. Multiple regression analysis with natural logarithmic (ln) transformation of the outcome values was used to examine the effect of training intensity and -volume, lesion level and completeness, and baseline respiratory muscle strength on improvements in respiratory muscle strength. RESULTS: Overall, 67 individuals were analyzed. Variation in PImax was explained by PImax at baseline and training intensity. This adjusted effect size suggested a 7% (95% CI 2.8 to 11.6%) increase in PImax per 10 units of increase in training intensity. Controlling for the variation in baseline PEmax, the effect of training intensity on PEmax was conditional on AIS (p < 0.021). While individuals with motor complete lesions showed a 6.8% (95% CI 2.1 to 11.7%) increase in PEmax per 10 units of increase in training intensity, the corresponding adjusted effect size in those with motor incomplete lesions was 0.1% (95% CI -4.3 to 4.5%). The full models explained 57 and 60% of the variance of lnPImax and lnPEmax, respectively. CONCLUSION: The intensity of inspiratory muscle training was more relevant than training volume for the improvement of respiratory muscle strength in individuals with SCI. Thus, training intensity should be chosen as high as possible.

Development and validation of models to predict respiratory function in persons with long-term spinal cord injury.

STUDY DESIGN: Multicenter, cross-sectional study. OBJECTIVES: To validate previously developed respiratory function prediction models for persons with long-term spinal cord injury (SCI) and if necessary develop and validate new models. SETTING: Ten SCI rehabilitation centers. METHODS: Five respiratory function parameters were measured in adults with chronic, traumatic, motor complete SCI (C4-T12). First, the models published in 2012 were validated using Bland-Altman plots. Then, new models were calculated using 80% of the dataset by multiple regression analysis with the candidate predictors gender, age, height, weight, time post injury (TPI), lesion level, and smoking. In a third step, the new models were validated using the other 20% of the dataset by Bland-Altman plots. RESULTS: In total 613 participants were included. For persons with long-term SCI, the 2012 models were poorly predictive, especially for respiratory muscle strength (R2 = 0.4). Significant predictors for all respiratory function parameters in the new models (R2 = 0.7-0.8) were lesion level, gender and weight. Small effects on single outcome parameters were observed for TPI and age whereas smoking had no effect. For the new models the mean differences between measured and predicted values for respiratory muscle strength were 4.0 ± 36.0 cm H2O and for lung function parameters -0.5 ± 1.2 L (FVC), -0.3 ± 0.9 L (FEV1) and -0.5 ± 2.0 L/s (PEF). CONCLUSION: We did not find better models for lung function in long-term SCI but those for respiratory muscle strength showed better accuracy. SPONSORSHIP: The content of this publication was developed under grant from Wings for Life, grant number WFL-CH-017/14.

Needs assessment in community-dwelling older adults toward digital interventions to promote physical activity: Cross-sectional survey study.

Background: Tackling physical inactivity represents a key global public health challenge. Strategies to increase physical activity (PA) are therefore warranted. Despite the rising availability of digital interventions (DIs), which offer tremendous potential for PA promotion, there has been inadequate attention to the special needs of older adults. Objective: The aim was to investigate community-dwelling older adults' needs, requirements, and preferences toward DIs to promote PA. Methods: The target population of this cross-sectional study was community-dwelling older adults (≥60 years old) within German-speaking Switzerland. Potential respondents were informed about the study and sent a link to a self-developed and self-administered online survey by our cooperating institutions. Results: Overall, 922 respondents who completed the online survey were included in the final analysis. The mean age of the sample was 72 years (SD 6.4, range 60-98). The preferred delivery mode of DIs to promote PA was a website (428/922, 46.4%) and 80.3% (740/922) preferred video-based structures. Most respondents expressed the need for personal access, personal goals, personal messages, and a personal contact in case of problems or questions (585/817, 71.6%; 546/811, 67.3%; 536/822, 65.2%; 536/822, 65.2%). Memory training, psychological wellbeing, and nutrition were mainly rated as relevant additional content of DIs to promote PA (690/849, 81.2%; 661/845, 78.2%, 619/849, 72.9%). Conclusion: Community-dwelling older adults may be willing to use DIs to promote PA in the long term, but this study identified particular needs and requirements in terms of design, technological realization, delivery mode, support, and individualization/personalization among the sample. Our results can inform future developments of DIs to promote PA specifically tailored to older adults. However, caution is warranted in interpreting the findings due to the sample's high PA and education levels.

Respiratory function and respiratory complications in spinal cord injury: protocol for a prospective, multicentre cohort study in high-income countries.

INTRODUCTION: Pneumonia is one of the leading complications and causes of death after a spinal cord injury (SCI). After a cervical or thoracic lesion, impairment of the respiratory muscles decreases respiratory function, which increases the risk of respiratory complications. Pneumonia substantially reduces patient's quality of life, may prolong inpatient rehabilitation time, increase healthcare costs or at worse, lead to early death. Respiratory function and coughing can be improved through various interventions after SCI, but the available evidence as to which aspect of respiratory care should be optimised is inconclusive. Furthermore, ability of respiratory function parameters to predict pneumonia risk is insufficiently established. This paper details the protocol for a large-scale, multicentre research project that aims to evaluate the ability of parameters of respiratory function to predict and understand variation in inpatient risk of pneumonia in SCI. METHODS AND ANALYSIS: RESCOM, a prospective cohort study, began recruitment in October 2016 across 10 SCI rehabilitation centres from Australia, Austria, Germany, the Netherlands and Switzerland. Inpatients with acute SCI, with complete or incomplete cervical or thoracic lesions, 18 years or older and not/no more dependent on 24-hour mechanical ventilation within the first 3 months after injury are eligible for inclusion. The target sample size is 500 participants. The primary outcome is an occurrence of pneumonia; secondary outcomes include pneumonia-related mortality and quality of life. We will use the longitudinal data for prognostic models on inpatient pneumonia risk factors. ETHICS AND DISSEMINATION: The study has been reviewed and approved by all local ethics committees of all participating centres. Study results will be disseminated to the scientific community through peer-reviewed journals and conference presentations, to the SCI community, other stakeholders and via social media, newsletters and engagement activities. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov NCT02891096.

Evaluation of a clinical implementation of a respiratory muscle training group during spinal cord injury rehabilitation.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the clinical implementation of a respiratory muscle training group during rehabilitation of individuals with spinal cord injury. SETTING: Spinal cord injury rehabilitation center. METHODS: Individuals with complete or incomplete lesions during inpatient rehabilitation, level C4-T12.Ten or more training sessions of either an inspiratory or a combined in- and expiratory muscle training were performed in a group setting with respiratory function measurements before and after the training period. RESULTS: Analysis of 79 persons. Inspiratory muscle training was performed for 7 weeks with a median of 3.1 training sessions per week. Median training intensity was at 33% of baseline PImax and 58 repetitions were performed per training session. Respiratory mucle strength parameters improved by 18-68% of baseline values and lung function parameters by 11-31% after inspiratory muscle training.The combined respiratory muscle training was performed for 13 weeks with a median of 2.8 sessions per week and 88 repetitions per training session. Median inspiratory training resistance was at 39% of baseline PImax and median expiratory training resistance was at 27% of baseline PEmax. Respiratory muscle strength parameters improved by 14-51% of baseline values and lung function parameters improved by 15-34% after the combined in- and expiratory muscle training. CONCLUSION: Respiratory resistance training improved respiratory function of individuals with acute spinal cord injury. Even if the combined respiratory muscle training was performed with more repetitions per training and nearly twice as long, relative improvements of respiratory function parameters were comparable with isolated inspiratory muscle training.

Maximum Inspiratory Pressure is a Discriminator of Pneumonia in Individuals With Spinal-Cord Injury.

BACKGROUND: Respiratory complications remain a major cause of mortality among individuals with spinal-cord injury (SCI). The present study investigated whether respiratory function is a discriminator of pneumonia in individuals with SCI and is aimed to determine the best predictive parameter. METHODS: This was a retrospective cohort study. Individuals with traumatic SCI, level C3 to T12, complete and incomplete lesions, were included. Data on respiratory function were extracted from medical records. The receiver operating characteristic curve was calculated for each parameter (forced vital capacity, FEV1, peak expiratory flow, and maximum inspiratory and expiratory pressure [PImax and PEmax]) to determine the discriminator with the largest area under the curve between individuals with and without pneumonia. RESULTS: Data of 307 subjects were analyzed. PImax was identified as the best discriminator between individuals with and without pneumonia, both in motor complete (area under the curve 0.86, 95% CI 0.78-0.93, P < .001) and incomplete individuals (area under the curve 1.0, 95% CI 1.00-1.00, P < .001). In individuals with motor complete lesions, the threshold value for PImax was 115% of the lesion-specific reference value (sensitivity 74.4%, specificity 83.4%). In motor incomplete individuals, the PImax threshold value was 93.5 cm H2O (sensitivity 100%, specificity 100%). CONCLUSIONS: PImax is the best discriminator between spinal cord-injured individuals with versus those without pneumonia. Individuals with a PImax below threshold values are at risk of pneumonia.

Laboratory evaluation of four different devices for secretion mobilization: Acapella choice, green and blue versus water bottle.

BACKGROUND: Secretion removal is a key issue in patients with respiratory diseases, and is known to be most effective at vibration frequencies of ∼ 13 Hz and with the greatest amplitudes possible. The Acapella devices and the water bottle are used for secretion removal in daily clinical practice but without detailed knowledge on optimal settings. The aim of this study was to evaluate the 3 different Acapella devices and the water bottle at various settings and flows to determine the optimal devices and settings for effective secretion removal. METHODS: Three different Acapella devices were tested at flows of 6, 12, 20, 30, 40, and 50 L/min, and at all 5 settings. The water bottle was filled with 5, 10, or 15 cm of water, and tested at flows of 3, 6, 10, 12, and 20 L/min. For all devices and combinations of settings, we measured the frequency and amplitude of the vibrations, as well as the required pressure to generate vibrations. RESULTS: Setting 4 was the best for all 3 Acapella devices, and the filling height of the water bottle should be 5 cm. At these settings, all devices elicited vibration frequencies between 12 and 15 Hz, which is theoretically optimal for secretion mobilization. The resistance pressures of the devices to elicit these vibrations were between 5 and 11 cm H2O. However, the Acapella devices elicit higher vibration amplitudes (5-8 cm H2O) than the water bottle (1.8 cm H2O) CONCLUSIONS:: Setting 4 was optimal for all 3 Acapella devices. The Acapella devices may be more efficient for secretion mobilization than the water bottle, because they elicit greater amplitude of vibrations.