Chronic Spinal Cord Injury Population Research Articles

Exoskeletal-Assisted Walking During Acute Inpatient Rehabilitation Enhances Recovery for Persons with Spinal Cord Injury-A Pilot Randomized Controlled Trial.

Spinal cord injury (SCI) negatively impacts individuals' functional independence, and motor and sensory function. Intense walking training has been shown to facilitate recovery for individuals with chronic SCI. Powered robotic exoskeletons provide therapists with a tool that allows them to conduct walking training with less therapist effort as compared to conventional walking training. Exoskeletal-assisted walking (EAW) has been studied in the chronic SCI population with preliminary reports showing benefits in mobility, health, and quality-of-life outcomes. However, few reports have studied EAW's benefits in the acute (<90 days post) SCI population at a time when neural plasticity is most dynamic and modifiable. The purpose of the study was to conduct a pilot randomized controlled trial (RCT) to understand the effects of incorporated EAW in acute inpatient rehabilitation (AIR) for individuals with SCI on functional, motor, and sensory recovery. The study outcomes included the Spinal Cord Independence Measure (SCIM) III and International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor and sensory scores that were assessed by unblinded assessors. We also recorded EAW session data, including adverse events, walking and up time, step counts, Borg Rating of Perceived Exertion (RPE), and compliance with scheduled EAW training. From August 2019 to July 2022, 16 participants completed the AIR with incorporated EAW, and 12 completed the standard AIR, all with SCI and preserved leg function within 90 days post-injury. During each session, the AIR with incorporated EAW group averaged 34.3 (±9.4) min of up time, 25.4 (±7.7) min of walk time, and 536 (±157) steps. Analysis via two-by-two mixed-effects models showed significant increases in the SCIM total score and ISNCSCI total motor and sensory scores over time for the AIR with incorporated EAW group [SCIM total score: F(1, 26) = 5.59, p = 0.03; total motor score: F(1, 26) = 8.06, p < 0.01; total sensory score: F(1, 19.2) = 5.08, p = 0.04], outperforming the standard AIR group. The AIR with incorporated EAW group showed 13, 14, and 22 points higher changes in the SCIM total score, total motor score, and total sensory score (respectively) by discharge compared with the standard AIR group. Incorporating EAW into AIR may facilitate functional, motor, and sensory recovery for individuals with SCI during AIR better than standard AIR. However, the study had a limited sample size. Further studies are needed to clarify the effects of EAW in AIR.

A Systematic Review of the Accuracy of Estimated and Measured Resting Metabolic Rate in Chronic Spinal Cord Injury.

The objective of this systematic review was to examine resting metabolic rate (RMR) measured through indirect calorimetry in adults with chronic spinal cord injury (SCI) and to evaluate the predication equations used for the estimation of RMR in this population. The authors additionally aimed to review the impact of sex and level of injury on RMR. A MEDLINE/PubMed, Google Scholar, Scopus, and Web of Science search was performed for studies published from the database inception to January 2018, identifying 326 articles. On the basis of the inclusion criteria, 22 studies remained for review. All articles that were identified were full-text, English language articles examining adults with chronic SCI who were fasted for a minimum of 8 hr before undergoing RMR through indirect calorimetry for at least 20 min. The measured RMR ranged from 1,256.0 to 1,854.0kcal/day, whereas the estimated RMR ranged from 1,276.8 to 1,808.0kcal/day in the chronic SCI population. Seven studies overestimated RMR from 4% to 15%, whereas two studies underestimated RMR from 2% to 17% using prediction equations established for the able-bodied population. Two studies produced SCI-specific equations to estimate RMR. With regard to sex and level of injury, RMR does not differ between individuals with tetraplegia and paraplegia, whereas sex-based differences remain inconclusive, given limited results. These data provide evidence for the use of indirect calorimetry to assess RMR and the need to validate SCI-specific prediction equations in the estimation of RMR.

GH deficiency in patients with spinal cord injury: efficacy/safety of GH replacement, a pilot study.

ObjectiveGrowth hormone (GH) was shown to stimulate proliferation, migration and survival of neural cells in animal models. GH deficiency (GHD) was reported following traumatic brain lesions; however, there are not available data in spinal cord injury (SCI) patients. The aim of the study was to evaluate (1) the frequency of GHD in chronic SCI population; (2) the efficacy/safety of GH replacement in patients with SCI and suboptimal GH secretion.Design and methodsNineteen consecutive patients with chronic thoracic complete SCI (AIS-A) were studied. Patients with low GH secretion were randomized in a double-blind, placebo-controlled study to receive either subcutaneous placebo injections or GH combined with physical therapy, for 6 months. Baseline cranial MRI, AIS motor and sensory scale, quality of life (spinal cord impact measurement) and modified Ashworth spasticity scale, quantitative sensory testing and neurophysiological exploration were assessed at baseline, 1, 3 and 6 months following treatment.ResultsThirteen had GH deficiency. Seven received GH, five placebo and one dropped out. Both groups were similar according to clinical and demographical data at baseline, except for greater GH deficiency in the GH treatment group. At 6th month, patients treated with GH showed a significant improvement in SCIM-III score and in electrical perception threshold up to the 5th level below SCI, on both sides compared to baseline.ConclusionsGHD seems to be frequent in traumatic SCI and GH replacement is safe without side effects. GH combined with physical therapy can improve quality of life of SCI patients and, strikingly, the sensory perception below lesion level.

Vitamin D, diet, and lifestyle in a chronic SCI population.

Study DesignCross-sectional study.ObjectivesDetermine dietary, lifestyle, and clinical factors associated with plasma 25-hydroxyvitamin D [25(OH)D] levels in persons with chronic spinal cord injury (SCI).SettingVeterans Affairs Medical Center in Boston, MA.Methods174 participants completed food frequency and health questionnaires, provided a blood sample, and underwent dual x-ray absorptiometry (DXA) to assess %-total body fat. Linear regression models were used to assess cross-sectional associations of personal, lifestyle, and nutritional factors with plasma 25(OH)D.ResultsIndependent factors positively associated with higher plasma 25(OH)D included vitamin D intake, age, hours of planned exercise, female sex, white race, wine consumption, and if a never or former smoker. The most important predictor of 25(OH)D was supplement intake. The majority of subjects (98.9% for vitamin D and 74.1% for calcium) did not meet the recommended daily allowance for adults from their diet alone. Level and completeness of SCI, injury duration, mobility, %-total body fat, time outside, and comorbid diseases were not associated with plasma 25(OH)D.ConclusionsPlasma 25(OH)D level in chronic SCI is not associated with clinical factors specific to SCI such as injury level and completeness, injury duration, and mobility mode, but related to supplement intake and other lifestyle factors.

Soft tissue sarcoma affecting the right shoulder of a man with paraplegia from a remote traumatic spinal cord injury: a case report

IntroductionPeople with spinal cord injury (SCI) are getting older due to a combination of increased life expectancy and older age at the time of injury. This trend makes it more likely for these patients to have other chronic health conditions including cancer. Inevitably relatively rare cancers such as soft tissue sarcomas (STS), which are more common with advancing age, will occur in some SCI patients. The present case represents the first report of a limb STS in a patient with chronic paraplegia from a traumatic SCI.Case presentationWe report a case of a 50-year-old right handed male with a T6 chronic, complete SCI (American Spinal Injury Association Impairment Scale A) who presented with a large mass involving his right shoulder musculature that was determined to be a high grade spindle cell sarcoma. The patient was followed closely by Physiatry over an approximately 6-month time course including prior to his tumor diagnosis, during the pre-radiation and pre-surgical planning phase, and then post-operatively for his acute inpatient rehabilitation. He was successfully discharged home to live alone in his accessible apartment complex.DiscussionThis case is the first ever reported case of a person living with a traumatic SCI who subsequently developed a limb STS. In addition to its novelty, this case illustrates how health conditions such as rare cancers are presenting more often as the chronic SCI population is getting older, which creates both unique diagnostic and management challenges for cancer rehabilitation specialists.

Commentary on Comparison of Coronary Artery Calcification Scores, National Cholesterol Education Program Guidelines for Coronary Heart Disease Risk Assessment, Treatment Paradigms in Individuals with Chronic Traumatic Spinal Injury

This commentary considers the implications of the findings related to the effect of a study related to coronary heart disease (CHD) risk assessment in individuals with a chronic spinal cord injury (SCI). The findings from the study suggest that there is poor agreement in CHD risk assessment between the previously used guidelines, the National Cholesterol Education Program (NCEP) Guidelines, and coronary artery calcium scores (CACS). Since this publication, a new atherosclerotic cardiovascular disease (ASCVD) risk estimator has been developed. This has not been used in any study with SCI participants. The study also showed that 18 (47.4%) of the participants had some element of CAC, indicating the presence of CHD. Many previous articles have discussed CHD risk factors and mortality in the SCI population. Despite this, there have been very few interventions to decrease the CHD risk in the chronic SCI population.

Venous Thromboembolism: A Comparison of Chronic Spinal Cord Injury and General Surgery Patients in a Metropolitan Veterans Affairs Hospital.

Venous thromboembolic events result in significant morbidity, mortality, and costly therapeutic interventions. As medical resource allocation strategies are becoming more pervasive, appropriate risk stratification and prophylactic regimens are essential. Previous studies have shown a decreased incidence of perioperative venous thromboembolism in the chronic spinal cord injury population. The question remains of whether chronic spinal cord injury is protective against venous thromboembolism. A retrospective review of all cases involving chronic spinal cord injury patients who underwent plastic and reconstructive surgery operations (n = 424) and general surgery patients (n = 777) with a primary outcome of deep venous thrombosis or pulmonary embolism within 90 days of surgery was performed. The incidence of postoperative deep venous thrombosis in the control and spinal cord injury groups was 1.7 percent and 0.2 percent, respectively (p = 0.027). However, such significance was not observed with regard to postoperative pulmonary embolism incidence (p = 0.070). Collectively, the incidence of postoperative venous thromboembolism-specifically, deep venous thrombosis or pulmonary embolism-was significantly greater in the general surgery population (p = 0.014). A nearly 10-fold increased risk of venous thromboembolism was seen among the control group (1.9 percent versus 0.2 percent) despite administration of optimal prophylaxis. This study demonstrates a profoundly low incidence of venous thromboembolism among chronic spinal cord injury patients compared with general surgery patients. Future efforts to elucidate how chronic spinal cord injury confers a protective mechanism may potentially influence the evolution of venous thromboembolism prevention guidelines, and spark the development of alternative prophylactic agents or customized application of prevention efforts.

Serum 25(OH)D, PTH and correlates of suboptimal 25(OH)D levels in persons with chronic spinal cord injury

Study DesignCross-sectional cohort study.ObjectivesTo describe: 1) the prevalence of suboptimal 25-hydroxy vitamin D status (Serum 25(OH)D <75nmol/L) and identify correlates of vitamin D deficiency; and, 2) the prevalence of secondary hyperparathyroidism (Serum intact PTH ≥ 7.0 pmol/L) and identify the relationships between serum parathyroid hormone (PTH) and 25(OH)D in adult men and women with chronic spinal cord injury (SCI).SettingOutpatient services, including an osteoporosis clinic at a tertiary spinal cord rehabilitation hospital in Ontario.MethodsSerum levels of 25(OH)D and intact PTH were acquired at enrolment. Clinical correlates of suboptimal vitamin D status were collected via interview and chart abstraction, and identified by univariate logistic regression analysis. Pearson correlations were run to assess the relationships between serum PTH and 25(OH)D. Significance was p<0.05.ResultsThirty-nine percent of the cohort, comprised of 62 adult men and women with chronic SCI, had suboptimal serum 25(OH)D levels. Factors associated with suboptimal vitamin D levels included having vitamin D assessed in the winter months (OR=7.38, p=0.001), lack of a calcium supplement (OR=7.19, p=0.003), lack of a vitamin D supplement (OR=7.41, p=0.019), younger age (OR=0.932, p=0.010), paraplegia (OR=4.22, p=0.016), and lack of bisphosphonate (OR=3.85, p=0.015). Significant associations were observed between serum PTH and 25(OH)D (r=−0.304, p=0.032) and between PTH and C-telopeptide of type I collagen (CTX-I) (r=0.308, p=0.025).ConclusionsDisruption of the vitamin D-PTH axis may contribute to the bone loss seen in the chronic SCI population. The threshold for optimal serum 25(OH)D levels in the chronic SCI population may be higher than in the non-SCI population. Serum 25(OH)D level are likely important risk factors contributing to declining bone mass and increased fracture risk post-SCI.

Determining the optimal method for proteinuria detection in chronic spinal cord injury

A retrospective analysis. The objective of this study is to determine whether dipstick protein analysis (DSP) or random urine protein:creatinine ratios (UPC) are accurate in predicting clinical proteinuria in the chronic spinal cord injury (SCI) population. A retrospective analysis was performed in 219 veterans with SCI, comparing DSP and 24-h urine protein excretion. Sensitivity, specificity, predictive values (PV) and receiver-operator characteristic (ROC) curves of DSP in predicting clinical proteinuria were calculated with and without correction for specific gravity (SG). A prospective study was also performed in 62 SCI patients, comparing the UPC and 24-h urines. Sensitivity, specificity, PV and ROC curves of UPC in predicting clinical proteinuria were calculated. Any level of positive DSP had high specificity, but low sensitivity, for detecting the presence of clinical proteinuria. ROC curves of DSP for identifying clinical proteinuria yielded area under the curve of 0.749 (95% confidence interval 0.699-0.794), and adjustment for SG did not significantly improve accuracy. A UPC of <0.3 was sensitive with a high negative PV for ruling out clinical proteinuria, whereas a ratio >0.8 was specific with a high positive PV. A UPC between 0.3-0.8 had an intermediate sensitivity and specificity. Urine collections of 24-h are still needed in the chronic SCI population for accurate detection of clinically significant proteinuria. DSP may not reliably detect low-grade clinical proteinuria, whereas a UPC below 0.3 may be used to rule out clinical range proteinuria.

The effects of exercise training on physical capacity, strength, body composition and functional performance among adults with spinal cord injury: a systematic review

Systematic review. To conduct a systematic review of evidence surrounding the effects of exercise on physical fitness in people with spinal cord injury (SCI). Canada. The review was limited to English-language studies (published prior to March 2010) of people with SCI that evaluated the effects of an exercise intervention on at least one of the four main components of physical fitness (physical capacity, muscular strength, body composition and functional performance). Studies reported at least one of the following outcomes: oxygen uptake/consumption, power output, peak work capacity, muscle strength, body composition, exercise performance or functional performance. A total of 166 studies were identified. After screening, 82 studies (69 chronic SCI; 13 acute SCI) were included in the review. The quality of evidence derived from each study was evaluated using established procedures. Most studies were of low quality; however, the evidence was consistent that exercise is effective in improving aspects of fitness. There is strong evidence that exercise, performed 2-3 times per week at moderate-to-vigorous intensity, increases physical capacity and muscular strength in the chronic SCI population; the evidence is not strong with respect to the effects of exercise on body composition or functional performance. There were insufficient high-quality studies in the acute SCI population to draw any conclusions. In the chronic SCI population, there is good evidence that exercise is effective in improving both physical capacity and muscular strength, but insufficient quality evidence to draw meaningful conclusions on its effect on body composition or functional capacity.

Kidney Disease as a Predictor of Mortality in Chronic Spinal Cord Injury

The purpose of this study is to assess the predictive value of proteinuria and creatinine clearance (CrCl) in relation to mortality in patients with spinal cord injury. Computerized medical records covering 6 to 11 years were reviewed in 2004 to determine all-cause mortality. Long-term survival was assessed by means of Kaplan-Meier analysis. Multiple and stepwise Cox proportional hazards models were used to identify risk factors for mortality. The dependent variable was duration of survival in months. Potential predictors included proteinuria, CrCl, age, duration and type of injury, type of bladder management, ethnicity, diabetes mellitus, hypertension, coronary artery disease, hematocrit, serum albumin level, and serum cholesterol level. With the Cox model, proteinuria with protein of 500 mg/d or greater (hazard ratio [HR], 2.98), CrCl less than 60 mL/min (<1.00 mL/s; HR, 3.89), or both (HR, 7.86) were associated independently with increased mortality. When added individually to the base Cox model, bladder catheter use (HR, 1.70) and age (HR, 1.05) also were independently predictive of time to death. Patients with preserved CrCl (>or=60 mL/min) and no proteinuria (protein < 500 mg/d) had a significantly greater duration of survival compared with patients with proteinuria (protein >or= 500 mg/d), decreased CrCl (<60 mL/min), or both (median survival, 120, 86, 87, and 47 months, respectively; P < 0.0001). There was no significant difference in survival in patients with proteinuria (protein >or= 500 mg/d) and preserved CrCl (>or=60 mL/min) compared with those with no proteinuria (protein < 500 mg/d) and decreased CrCl (<60 mL/min; P = 0.90). However, those with both proteinuria and decreased CrCl had significantly worse survival compared with those with only 1 condition (P < 0.01). Kidney disease was associated with an increase in both cardiovascular and noncardiovascular mortality. The presence of either proteinuria with protein of 500 mg/d or greater or CrCl less than 60 mL/min is associated independently with increased mortality in the chronic spinal cord injury population. The presence of both conditions further increases this risk.

Bacteremia In The Chronic Spinal Cord Injury Population: Risk Factors For Mortality

Background: Individuals with spinal cord injury (SCI) have a lifelong increased risk of systemic infection, which may be associated with episodes of life-threatening bacteremia. Information concerning specific organisms causing bacteremia, the sites of primary infection, and clinical predictors for mortality are necessary to provide optimal treatment.Methods: A retrospective review of positive blood cultures collected over a 3 2-month period in chronic SCI patients treated at the Veterans Affairs Medical Center SCI Unit.Results: One hundred and twenty-three episodes of bacteremia occurred in 63 patients during 83 hospitalizations; 30 patients had multiple episodes of bacteremia. There were 1 ,644 admissions during this period, yielding an incidence of bacteremia of 7 .5% (5.8% after excluding positive cultures that were believed to be caused by contaminants). The patients (31 with paraplegia and 32 with quadriplegia) had a mean age of 59 ± 2 years, and a mean duration of injury of 23 ± 2 years. Bladder management technique consisted of indwelling bladder catheter (n = 53), ileal conduit (n = 6), intermittent catheterization (n = 2), and spontaneous voiding (n = 2). Episodes of bacteremia were nosocomial in 89 out of 123 episodes. Multiple debilitating factors were present, including pressure ulcers in 3 6 out of 63 patients, chronic ventilator dependency in 5 out of 63 patients, recent surgical procedures in 17 out of 63 patients, unde rlying malignancy in 5 out of 63 patients, and evidence of malnutrition in 2 9 out of 63 patients (serum albumin concentration < 2.5 g/dl). Early mortality rate (death within 30 days of bacteremia) occurred in 8 out of 63 patients (13 %) and late mortality (> 1 month following a bacteremic episode) occurred in 1 0 additional participants, such that total mortality was 1 8 out of 63 (2 9%). The sources of bacteremia were urinary tract infection (n = 3 9), presumed contaminant (n = 28), decubitus ulcers (n = 21 ), intravascular catheter (n = 1 9), pneumonia (n = 5), and other (n = 11 ). Gram-negative rods accounted for 2 6 out of 3 9 episodes of bacteremia from a urinary source. Methicillin-resistant Staphylococcus au reus, methicillin-sensitiveS au reus, and coagulase-negative staphylococci were the predominant organi sms when intravascular catheters or pressure ulce rs were the source of bacteremia.Conclusion: In this population, bacteremia predominantly was caused by hospital-associated organisms, and occurred mainly in malnourished patients who required hospitalization for major unde rlying debilitating conditions, particularly pressure ulcers. Chronic indwelling bladder cathet e rs and chronic vascular catheter usage also were highly prevalent in patients with bacteremic episodes. Hypoalbuminemia was the strongest independent predictor for mortality.

Thyroid hormone changes in chronic spinal cord injury.

Spinal cord injury (SCI) impacts metabolic function and deranges various hormonal axes. Previous studies characterizing thyroid hormones in SCI reported depressed triiodothyronine (T3) and thyroxin (T4), primarily in acute tetraplegics. These studies cited an 11-13 percent incidence of low T3 syndrome (LT3S) in SCI patients, with an increased incidence in tetraplegics (20-36 percent). The purpose of this study was to evaluate thyroid function and determine the incidence and clinical relevance of LT3S in the chronic SCI population. Thyroid function tests were performed on 30 chronic SCI patients (14 tetraplegics and 16 paraplegics) and 30 age- and gender-matched controls. Mean T3 and T4 levels were significantly depressed in SCI patients relative to controls, while T3 resin uptake (T3RU) values were significantly elevated. LT3S only occurred in the SCI population with an incidence of 23.3 percent. SCI patients with LT3S did not differ significantly from those without in the level or completeness of injury, age or the interval since injury. They did, however, have co-existent pathology: decubiti, urinary tract infections, etc. When SCI patients with normal T3 were compared with controls, they still had depressed mean T3 levels. We conclude that LT3S occurs frequently in the chronic SCI population and suggest that depressed serum T3 levels may predispose SCI patients to sick euthyroidism in the face of minor pathologic insult.