[Design and evaluation of preventive seats for pressure ulcers associated with spinal injuries]. / Diseno y evaluación de asientos preventivos de úlceras por presión para lesionados medulares.

INTRODUCTION: Pressure ulcers are a dominant health problem for people who, for various reasons, must spend most of their time in a seated position. The spinal cord injury patients are the most affected for this situation. One strategy to prevent pressure ulcers is throughthe use of special seats. In the Instituto Nacional de Rehabilitación, contoured special seats have been developed according to anatomical measure of spinal cord injured patients. OBJECTIVE: To find one or more combinations of test materials that reduced pressure below 60 mmHg, in the ischial area, in order to help to prevent pressure ulcers. MATERIAL AND METHODS: The special seats were fabricated using thermoplastic materials and polyurethane foams, following prosthetic fitting technique; and were tests in healthy volunteers. RESULTS: The results were compared with a vinyl seat, because most of wheelchairs have it. All different test combinations were superior to vinyl seat, specially the two polyurethane foam- polypropylene combinations. A group of nine patients with spinal cord injury were recruited to test the designed seats, for a three month period. DISCUSSION: The results showed that pressure values are lower in the special seats than in the vinyl seats. No complications or pressure ulcers were found during follow up.

Validation of inertial measurement units for the assessment of trunk control in subjects with spinal cord injury.

BACKGROUND: Trunk control (TC) constitutes one of the main objectives in the rehabilitation of people with a spinal cord injury (SCI), but there are few clinically validated tests to assess it. Accelerometers have been proposed as sensitive and suitable procedures to assess TC. OBJECTIVE: To evaluate test-retest reliability, construct and criterion validity of accelerometer parameters to assess TC in people with SCI. METHODS: A cross-sectional study of simultaneous application of Clinical Trunk Control Test (CTCT) and accelerometer evaluation was conducted. Accelerometers were placed on the trunks of 27 people with SCI and 15 people without SCI. Reliability was assessed by three repeated measures in random order of selected static and dynamic TC tasks. Acceleration on three axes was analyzed using five metrics. Criterion validity was assessed by analyzing correlation of acceleration to CTCT scores. Construct validity was assessed by analyzing capacity of inertial measurement units (IMU) to differentiate individual's characteristics, ASIA Impairment scale, gait capacity, level of TC, and neurological level of injury. RESULTS: Reliable IMU data were obtained in people with SCI and without SCI, of all accelerometer axes, metrics, and tested items of the CTCT. Reliability of acceleration decreases with the increasing demand for TC tasks. Ten acceleration parameters showed construct and criterion validity. CONCLUSION: Accelerometer parameters are reliable, valid, and sensitive to evaluate TC in people with SCI. SIGNIFICANCE: A set of IMU parameters were validated as reliable and valid measures to evaluate TC, which could be useful for the assessment of progression of people with SCI and clinical interventions.

Nerve transfer rehabilitation in tetraplegia: Comprehensive assessment and treatment program to improve upper extremity function before and after nerve transfer surgery, a case report.

CONTEXT: A 28-year-old male, sustained a traumatic Spinal Cord Injury (SCI) in January 2015, and was classified as AIS A, neurological level of injury (NLI) C4. As an inpatient at the SCI rehabilitation unit, he underwent multidisciplinary assessment involving SCI specialists, peripheral nerve surgeons, psychologists, occupational and physical therapists. Team consensus determined he was a candidate for nerve transfer surgery to improve upper extremity function. The patient undertook a pre-surgical neurorehabilitation program of 3 months duration. Surgery was performed bilaterally at 11 and 13 months after SCI (right and left arm respectively). FINDINGS: Upon completion of surgical procedures, the patient underwent an intensive post-surgical rehabilitation program based on established goals, with follow-up every 3 months, up to 24 months after the surgery. Notable improvements were wheelchair propulsion, the ability to relieve pressure, grasp, pinch, and release an object. Standardized measures for SCI individuals (SCIM-III, CUE-Q, LiSAT-9 and UEMS) showed significant improvements. CLINICAL RELEVANCE: Nerve transfers in tetraplegia are an underused technique. The benefits of surgery along with an intensive neurorehabilitation program, can improve independence and function in daily living activities for a properly selected group of individuals.

Prognostic validity of a clinical trunk control test for independence and walking in individuals with spinal cord injury.

Objective: The objective of the present work was to determine the prognostic validity of the trunk control test for walking and independence in individuals with SCI.Design: A cohort, prospective study was carried out in all individuals with sub-acute SCI.Setting: All inpatients at the Mexico City based National Rehabilitation Institute (INR).Participants: Ninety individuals with a clinical diagnosis of sub-acute SCI, American Spinal Injury Association Impairment Scale (AIS) A-D, and that have not participated in a rehabilitation program were included. Thirty-five individuals had good initial trunk control and the remaining 55 had poor trunk control. All individuals participated in a standard rehabilitation program subsequently.Interventions: N/AOutcome Measures: The trunk control test was performed at baseline. At 1, 3, 6, 9 and 12 months after the first evaluation, walking and independence were assessed.Results: Survival Analysis revealed that 62.5% and 100% individuals with good trunk control at baseline assessment were respectively walking and independent in ADL at 12 months and 14% and 48% individuals with poor trunk control were walking and independent in ADL. Cox regression analysis revealed that individuals with good trunk control were 4.6 times more likely to walk independently at 12 months and 2.9 times more likely to be independent in activities of daily living.Conclusion: The present study revealed that the trunk control test is useful for providing a prognosis of independence and walking at 1 year in individuals with SCI, independently of the neurologic level and the severity of the injury.

Walking speed is not the best outcome to evaluate the effect of robotic assisted gait training in people with motor incomplete Spinal Cord Injury: A Systematic Review with meta-analysis.

CONTEXT: While there are previous systematic reviews on the effectiveness of the use of robotic-assisted gait training (RAGT) in people with spinal cord injuries (SCI), as this is a dynamic field, new studies have been produced that are now incorporated on this systematic review (SR) with meta-analysis, updating the available evidence on this area. OBJECTIVE: To synthesise the available evidence on the use of RAGT, to improve gait, strength and functioning. METHODS: SR and meta-analysis following the Cochrane Handbook for Systematic Reviews of Interventions were implemented. Cochrane Injuries Group Specialized Register, PubMed, MEDLINE, EMBASE, CINAHL, ISIWeb of Science (SCIEXPANDED) databases were reviewed for the period 1990 to December 2016. Three researchers independently identified and categorized trials; 293 studies were identified, 273 eliminated; remaining 15 randomized clinical trials (RCT) and five SR. Six studies had available data for meta-analysis (222 participants). RESULTS: The pooled mean demonstrated a beneficial effect of RAGT for WISCI, FIM-L and LEMS (3.01, 2.74 and 1.95 respectively), and no effect for speed. CONCLUSIONS: The results show a positive effect in the use of RAGT. However, this should be taken carefully due to heterogeneity of the studies, small samples and identified limitations of some of the included trials. These results highlight the relevance of implementing a well-designed multicenter RCT powered enough to evaluate different RAGT approaches.

Valoración de un programa para la provisión de sillas de ruedas adecuadas para pacientes con lesión medular tomando como indicadores la calidad de vida y la prevención de úlceras por presión / Evaluation of a program for the provision of appropriate wheelchairs for patients with spinal cord injury using quality of life and pressure ulcer prevention as indicators

Introducción. La lesión medular afecta la calidad de vida y el estado de salud de la persona que la padece. Por su parte, el uso de una silla de ruedas adecuada a las necesidades y características particulares de cada individuo puede aumentar los cuidados en la salud, prevenir complicaciones como las úlceras por presión e incrementar la calidad de vida. Objetivo: Valorar la percepción de la calidad de vida y dar seguimiento a la formación de úlceras por presión como indicadores del impacto que tiene un programa basado en las "Pautas de suministro de sillas de ruedas manuales en entornos de menores recursos" de la OMS. Material y Métodos. A un grupo piloto de lesionados medulares se les otorgó una silla de ruedas adecuada; se les aplicaron los cuestionarios CHART-SF y WHOQOL-BREF para medir su calidad de vida y se les hizo seguimiento del desarrollo de úlceras por presión durante 12 meses. Resultados. Los principales hallazgos fueron una mejor percepción de la movilidad en el CHART-SF, mientras que en el WHOQOL -BREF el grupo no percibió ningún cambio, ni positivo ni negativo, en su calidad de vida. Los pacientes no desarrollaron úlceras por presión durante el estudio. Conclusiones. Los cuestionarios aplicados no son suficientemente sensibles para medir la calidad de vida en pacientes con lesión medular.

Introduction. Spinal cord injury affects the quality of life and health status of the person who suffers it. On the other hand, the use of a wheelchair adapted to the particular needs and characteristics of each individual can increase health care, prevent complications such as pressure ulcers and increase quality of life. Objective: To assess the perception of quality of life and to monitor the development of pressure ulcers as indicators of the impact of a program based on the WHO "Guidelines for the provision of manual wheelchairs in low-income settings". Material and Methods. A pilot group of spinal cord injured persons were provided with a suitable wheelchair; they were administered the CHART-SF and WHOQOL-BREF questionnaires to measure their quality of life and were followed up for the development of pressure ulcers for 12 months. Results. The main findings were a better perception of mobility in the CHART-SF, while in the WHOQOL-BREF the group did not perceive any change, either positive or negative, in their quality of life. Patients did not develop pressure ulcers during the study. Conclusions. The questionnaires applied are not sufficiently sensitive to measure quality of life in patients with spinal cord injury.

A prospective, longitudinal, descriptive study of the effect of a customized wheelchair cushion on clinical variables, satisfaction, and functionality among patients with spinal cord injury.

The Instituto Nacional de Rehabilitación (Rehabilitation National Institute) (INR) developed a prototype wheelchair cushion (INR cushion) designed to adjust to the anthropometry of the user's ischiogluteal area and prevent pressure ulcer formation while maintaining or promoting functionality. A prospective, longitudinal, descriptive study was conducted from February 2010 to February 2011 to evaluate the effect of using the INR cushion on clinical variables, functionality, and user satisfaction. Sixteen patients were recruited (9 male, 7 female, average age 31.8 [range 22-47] years, average body mass index 25 [range 22-34], average time in a wheelchair 10.1 [range 3-26] years) who met the study protocol inclusion criteria of being pressure ulcer-free for at least 6 months and capable of propulsion and transfer without assistance, chronic spinal cord injury (>2 years), and without chronic-degenerative diseases or cognitive problems. Each participant received the cushion for a 2-month evaluation. Eight clinical variables were assessed: trunk control, posture, spasticity, transfer capacity, comfort, skin reaction, propulsion capacity, and pressure release capacity. The clinical assessment was performed using validated scales and instruments: Modified Ashworth Scale (MAS), Functional Independence Measure™ (FIM), Norton Scale, and assessment of skin reaction. Interface pressures were measured using force sensing array, and participants completed a structured interview to assess user expectation, perceived functionality, perceived quality, and likelihood of recommending the device. Two patients withdrew due to appointment conflicts; of the remaining 14, significant differences between the user's experience with other products and the INR were found with regard to pressure redistribution (P = 0.012); all participants but 1 graded the INR as good in all interview categories. No participants developed a pressure ulcer during the study. The customized cushion was especially functional among patients with incomplete thoracic and cervical injuries, high FIM scores, and moderate levels of activities of daily living. Taller patients (P = 0.01) and patients with higher degrees of spasticity (P = 0.007) were less satisfied with functionality. The results of this study contributed to the redesign process of the cushion. These findings may be useful to establish predictors, both subjective and clinical, for patient utilization of wheelchair cushion use.