Topics in Spinal Cord Injury Rehabilitation最新文献

Background: Emerging neuromodulation approaches, including epidural electrical stimulation (EES), offer hope for restoration of function following chronic spinal cord injury (SCI). However, integrating neuromodulation therapies into clinical procedures is challenging due to the unique needs of the SCI population.

Objectives: The purpose of this study was to understand the experiences of participants during a first-in-human trial of perilesional EES aimed at restoring sensorimotor function.

Methods: We report participants' experiences by describing their clinical care, experiences during experimental neuromodulation sessions, and perspectives on the utility of a perilesional EES system. Three participants with chronic thoracic SCI participated in semistructured interviews after completing a 14-day inpatient experimental protocol, which included stimulation mapping, lower extremity motor control experiments, and treadmill stepping. Interview data were analyzed using an applied thematic analysis approach. Nine key themes addressed 4 major topic areas: clinical experiences, experiences during laboratory experiments, experiences as a research participant, and perceived value of perilesional EES.

Results: All participants noted the potential for EES to enhance functional recovery, though their postoperative experiences related to clinical care, postoperative pain, and disruptions to routine care differed. Insights gained from qualitative analyses highlighted challenges and opportunities for improving postsurgical care and refining application of EES technology. Further, these results inform recommendations for neuromodulation trials in the SCI community to help mitigate postoperative complications and improve study participant experiences.

Conclusion: Key recommendations include being proactive regarding potential postsurgical complications, educating clinical staff regarding common SCI comorbidities, and customizing experimental protocols to align with the priorities and clinical needs of each participant.

Background: Spinal cord injury (SCI) heightens the susceptibility to neurogenic obesity, which is driven by alterations in energy metabolism and suboptimal dietary habits after injury. Those with SCI may adjust their grocery shopping and eating behaviors, notably influencing overall health outcomes.

Objectives: To assess differences in grocery shopping and eating behaviors between persons with and without (controls) SCI.

Methods: In an online, cross-sectional study, adults with (n = 207) and without (n = 52) SCI completed a one-time survey that assessed grocery shopping behavior (shopping frequency and who completed the shopping) and eating behaviors, including the frequency of consuming alcoholic beverages, fast food, and preferences for fried food. Regression analyses were employed for group comparisons, controlling for relevant measures.

Results: Compared to the controls, a smaller proportion of persons with SCI grocery shopped independently in person (P = .002), and a greater proportion relied on others to fulfill grocery needs (P = .008). Individuals with SCI demonstrated a reduced monthly frequency of overall (P = .019) and independent in-person grocery shopping than controls (P = .014). In contrast, the monthly frequency of grocery shopping through delivery and from their caregivers was similar (P > .05). Fried food and fast-food intake were comparable (P > .05), whereas alcoholic beverage consumption was lower in individuals with SCI than controls (P = .006).

Conclusion: People with SCI reported obtaining groceries less often than controls, and a greater proportion relied on others, rather than themselves, to fulfill grocery needs. These findings highlight the influence of SCI on biobehavioral activities affecting neurogenic obesity, suggesting potential targets for interventions to enhance health outcomes post-SCI.

Background: Investigators have evaluated pharmacological and behavioral/physical interventions for chronic pain following spinal cord injury (SCI). A decade-old systematic review found that evidence was insufficient to conclude that nonpharmacological interventions (behavioral/physical) are effective in reducing chronic pain.

Objectives: To summarize and evaluate recent peer-reviewed literature on the efficacy of nonpharmacological interventions for chronic pain.

Methods: Authors searched for articles published from 2013 to August 2023 in MEDLINE, Cochrane Library, Scopus, CINAHL, and PsycINFO. Inclusion criteria were being 18 years or older, having traumatic SCI diagnosis, and having chronic pain symptoms. Interventions included nonpharmacological interventions-behavioral, complementary, and alternative medicine-and a control group. The primary outcome was pain symptom reduction. Coauthors applied these criteria and reconciled disagreements via unanimous consensus. Coauthors independently extracted data and then reviewed and revised extracted data to assure consistency and completeness. Two reviewers independently assigned a quality score using Hawker's guidelines and assigned a bias score using Cochrane risk-of-bias (RoB2) and Risk Of Bias In Non-randomized Studies (ROBINS-I) tools; they reconciled disagreements.

Results: Database searches produced 2961 results; 26 proceeded to data extraction, of which 15 used behavioral/physical interventions and 11 used stimulation interventions.

Discussion: Knowledge of behavioral/physical intervention methods and an evidence base with other populations are sufficient to recommend cognitive behavioral therapy and variants, particularly for neuropathic pain. In contrast, stimulation treatments are not sufficiently standardized, require equipment and expertise that is not widely disseminated, and have generated limited evidence that is not adequate to support clinical adoption with a high level of confidence. The studies highlight the importance of tailoring interventions to individuals' needs and preferences.

Objectives: To evaluate the effects of functional electrical stimulation (FES) cycling on muscle spasticity in individuals with spinal cord injury (SCI) and provide recommendations for optimal FES cycling parameters to treat muscle spasticity.

Method: In this systematic review, database searches of CINAHL, MEDLINE (Ovid), PEDro, PubMed, and Scopus were conducted to identify relevant studies published up to June 2023. Studies were screened for eligibility. Those that included an FES cycling intervention, an outcome measure of spasticity, and were available in full-text English were included. Two independent reviewers extracted the data and appraised the literature via the Crowe Critical Appraisal Tool (CCAT).

Results: Of the 1782 studies identified, 16 satisfied the criteria for this review. Two-hundred and three participants were included, aged 7 to 80 years old. Ten studies identified a reduction in spasticity following FES cycling via objective or subjective outcome measures. Methodological quality was variable, with CCAT scores ranging from 19/40 (48%) to 35/40 (88%). National Health and Medical Research Council hierarchy levels ranged from II to IV.

Conclusion: Evidence for the effectiveness of FES cycling to reduce muscle spasticity remains inconclusive. Long-term effects on spasticity were evident in moderate- to high-quality studies where FES cycling was conducted for 60 minutes, three times per week for 16 weeks. Additional research with larger sample sizes is warranted to confirm these findings. Further clarification of the optimal parameters of FES frequency, amplitude, and pulse width to reduce spasticity is required.

Background: Chronic pain management with opioids after spinal cord injury (SCI) has been shown to be ineffective, leading to overuse in length and dosage.

Objectives: To assess how the length of opioid use affects associated complications and healthcare usage and costs over 12 months following injury.

Methods: Adults with SCI from MarketScan Database (2000-2021) were followed up 12 months pre- and post-injury. Opioid use (OU) was screened from injury. Individuals were then classified accordingly: no use (No OU), 3 months use (OU 3m), 3 to 6 months use (OU 3-6m), and 6 to 12 months use (OU 6-12m). Related complications, healthcare utilization, and payment outcomes were compared using multivariable generalized linear regressions.

Results: Cohort was composed of 9630 individuals (median age 54; 59% males). Prolonged-use group (OU 6-12m) had a different profile compared to the No OU group: younger, higher rates of males, bone fracture, thoracic injuries, and Medicaid insurance (median age 49 vs. 58; males 62% vs. 56%, fracture 58% vs. 50%, thoracic 29% vs. 21%, Medicaid 32% vs. 24%; all Ps < .0001). A year after SCI, opioid-related complications were constipation, respiratory depression, hypotension, urinary retention, and nausea/vomiting, with an associated cost 2.4 times higher in OU 6-12m compared to No OU ($6958 vs. $2842). Opioid users (>3 months) had more ER visits and higher hospitalization rates compared to No OU. Combined payments (ER, hospitalizations, PT/OT/SLT, outpatient services, and medication refills) were higher for OU 6-12 ($33,014) and OU 3-6m ($22,351) compared to No OU ($13,896; P < .0001).

Conclusion: Considering risk profiles may predict prolonged opioid use and could help clinicians design care management plans to reduce complications and the associated healthcare utilization and payments.

Background: Patients with spinal cord injury (SCI) are at increased risk of renal insufficiency, so their renal function must regularly be monitored. Glomerular filtration rate (GFR) assessment is challenging as it requires measuring clearance of exogenous markers, which is impractical in most clinical settings. Thus, equations have been formulated to estimate GFR that utilize serum creatinine (Cr) or cystatin C (CysC).

Objectives: Given loss of muscle mass after SCI, we hypothesized equations using CysC would be more accurate than those using Cr after SCI.

Methods: Fifty-eight persons (51 male/7 female; age 22-87 years) with SCI level C2-L1/AIS A-D were enrolled. Serum CysC and Cr, 24-hour urine creatinine (24hrUCr) and 24-hour urine urea (24hrUurea) were collected. Average of the 24hrUCr clearance and 24hrUurea clearance was calculated (AvgCl_CrUr). Six GFR estimating equations were compared to AvgCl_CrUr. For each equation, mean bias (AvgCl_CrUr - eGFR) was calculated followed by the Pearson correlation calculation between AvgCl_CrUr and eGFR. In addition, the percentage of estimated values within 15%, 30%, and 50% of AvgCl_CrUr values are reported for each estimating equation.

Results: 2012 CKD-EPI CysC equation (bias 9.32 mg/dL, 95% CI, -1.23 to -17.41) was the most accurate predictor of GFR. This model accurately predicted GFR of 81%, 57%, and 33% within ±50%, ±30%, and ±15% of the AvgCl_CrUr, respectively. Conclusion: In persons with SCI, the CKD-EPI 2012 CysC equation, which uses cystatin C rather than creatinine, is the most accurate of the six equations tested in estimating GFR in persons with SCI.

Background: Spinal cord injuries (SCI) often result in cardiovascular issues, increasing the risk of stroke and cognitive deficits.

Objectives: This study assessed cerebrovascular reactivity (CVR) using functional magnetic resonance imaging (fMRI) during a hypercapnic challenge in SCI participants compared to noninjured controls.

Methods: Fourteen participants were analyzed (n = 8 with SCI [unless otherwise noted], median age = 44 years; n = 6 controls, median age = 33 years). CVR was calculated through fMRI signal changes.

Results: The results showed a longer CVR component (tau) in the grey matter of SCI participants (n = 7) compared to controls (median difference = 3.0 s; p < .05). Time since injury (TSI) correlated negatively with steady-state CVR in the grey matter and brainstem of SCI participants (R_S = -0.81, p = .014; R_S = -0.84, p = .009, respectively). Lower steady-state CVR in the brainstem of the SCI group (n = 7) correlated with lower diastolic blood pressure (R_S = 0.76, p = .046). Higher frequency of hypotensive episodes (n = 7) was linked to lower CVR outcomes in the grey matter (R_S = -0.86, p = .014) and brainstem (R_S = -0.89, p = .007).

Conclusion: Preliminary findings suggest a difference in the dynamic CVR component, tau, between the SCI and noninjured control groups, potentially explaining the higher cerebrovascular health burden in SCI individuals. Exploratory associations indicate that longer TSI, lower diastolic blood pressure, and more hypotensive episodes may lead to poorer CVR outcomes. However, further research is necessary to establish causality and support these observations.

Background: The proportion of patients with American Spinal Injury Association Impairment Scale (AIS) grade D traumatic spinal cord injuries (tSCI) is increasing. Although initial motor deficits can be relatively mild, some individuals fail to recover functional independence.

Objectives: This study aims to identify factors associated with failure to reach complete functional independence after AIS grade D tSCI.

Methods: An observational prospective cohort study was conducted at a level 1 trauma center specialized in SCI care. A prospective cohort of 121 individuals with an AIS-D tSCI was considered. The baseline characteristics, length of acute stay, need for inpatient rehabilitation, and 12-month functional status were assessed. Univariate and classification and regression tree (CART) analyses were performed to identify factors associated with reaching complete versus incomplete functional independence (defined as perfect total SCIM III score at 12-month follow-up).

Results: There were 69.3%, 83.3%, and 61.4% individuals reaching complete independence in self-care, respiration/sphincter management, and mobility, respectively. A total of 64 individuals (52%) reached complete functional independence in all three domains. In the CART analysis, we found that patients are more likely to achieve complete functional independence when they have a baseline motor score ≥83 (65% individuals) and if they present fewer medical comorbidities (70% individuals if Charlson Comorbidity Index [CCI] ≤4).

Conclusion: About half of individuals with AIS grade D tSCI can expect complete long-term functional independence. It is important to recognize early during acute care individuals with baseline motor score <83 or a high burden of comorbidities (CCI ≥5) to optimize their rehabilitation plan.

Background: Musculoskeletal complications are one of the most common reasons for a patient with a spinal cord injury (SCI) to be rehospitalized. Bone loss due to immobilization and changes in metabolic processes because of the SCI lead to an increased risk of fractures.

Objective: To evaluate the prevalence and demographic characteristics of people living with an SCI who had a secondary fracture.

Methods: We used population health administrative data from Ontario, Canada, in individuals with either traumatic (TSCI) or nontraumatic SCI (NTSCI). Records of duplicate cases, missing unique patient identifier numbers, individuals not eligible for provincial health insurance, and age <18 years were excluded. Only records of fractures treated in the emergency department or acute care hospital were included. Descriptive statistics were used to summarize data, using counts and percentages that described the numbers and proportions of fractures by type disaggregated by sex, age groups, and type of SCI.

Results: A total of 14,168 unique records were identified with 4486 as TSCI and 9682 as NTSCI between April 1, 2004 and March 31, 2020 and were followed up to March 31, 2021. Overall, 11% of the cohort had a subsequent fracture with no difference between TSCI and NTSCI. Hip fractures accounted for 21% of the fractures, wrists accounted for 12%, spine 11%, and tibia 11%. The average time to the first subsequent fracture after the SCI was 3.97 (SD 3.4) years.

Conclusion: Monitoring and management of fracture risk needs attention in the first 2 years, with a focus on NTSCI.

Background: Individuals with spinal cord injury (SCI) at and above T6 experience impaired descending cortical control of the autonomic nervous system, which predisposes them to blood pressure (BP) disorders including persistent hypotension.

Objectives: The primary aim of this investigation was to determine the effects of midodrine, 10 mg, administered daily over a 30-day period in the home environment, compared to placebo, on laboratory assessments of BP, cerebral blood flow velocity (CBFv), and cognitive performance in hypotensive individuals with chronic SCI.

Methods: This prospective, randomized, placebo-controlled, double-blind, crossover trial was conducted in 15 individuals with tetraplegia. In the first 30-day period, five participants were randomized to midodrine and 10 were randomized to placebo; participants were then crossed over to the second 30-day period following a 14-day washout. Laboratory assessments of BP, CBFv, and cognitive performance were measured before and after each of the two study arms.

Results: Systolic BP (SBP) was significantly increased following midodrine administration compared to placebo (116 ± 23 mm Hg vs 94 ± 16 mm Hg; p = .002). In addition, diastolic CBFv was increased after midodrine administration compared to placebo (31.0 ± 11.2 vs 25.6 ± 9.1 cm/s; p = .04). However, there were no significant drug by time interaction effects for systolic or mean CBFv (p > .172) and cognitive performance (p = .689).

Conclusion: The results suggest significant increases in SBP and diastolic CBFv without appreciable effects on cognition after 30 days of midodrine administration. Further investigation is needed to identify effective antihypotensive treatment options that not only normalize BP but also improve CBFv and cognition.