National Spinal Injuries Centre Research Articles

Lactobacillus casei Shirota probiotic drinks reduce antibiotic associated diarrhoea in patients with spinal cord injuries who regularly consume proton pump inhibitors: a subgroup analysis of the ECLISP multicentre RCT

Study designThis was a sub-group analysis of a multicentre, randomised, placebo-controlled, double-blind trial (ECLISP trial)ObjectivesTo assess the efficacy of a probiotic containing at least 6.5 × 109 live Lactobacillus casei Shirota (LcS) in preventing antibiotic associated diarrhoea (AAD) in patients with spinal cord injury (SCI) who consumed proton pump inhibitor (PPI) regularly. LcS or placebo was given once daily for the duration of an antibiotic course and continued for 7 days thereafter. The trial was registered with ISRCTN:13119162.SettingThree SCI centres (National Spinal Injuries Centre, Midland Centre for Spinal Injuries and Princess Royal Spinal Cord Injuries Centre) in the United KingdomMethodsBetween November 2014, and November 2019, 95 eligible consenting SCI patients (median age: 57; IQ range: 43-69) were randomly allocated to receive LcS (n = 50) or placebo (n = 45). The primary outcome is the occurrence of AAD up to 30 days after finishing LcS/placebo.ResultsThe LcS group had a significantly lower incidence of AAD at 30 days after finishing the antibiotic course (28.0 v 53.3%, RR: 95% CI: 0.53, 0.31–0.89; z = 2.5, p = 0.01). Multivariate logistic regression analysis identified that LcS can reduce the risk of AAD at 30 days (OR: 0.36, 95% CI 0.13, 0.99, p < 0.05). No intervention-related adverse events were reported during the study.ConclusionsLcS has the potential to prevent AAD in what could be considered a defined vulnerable group of SCI patients on regular PPI. A confirmatory, randomised, placebo-controlled study is needed to confirm this apparent therapeutic success to translate it into appropriate clinical outcomes.SponsorshipYakult Honsha Co., Ltd.

Psychological Screening, Standards and Spinal Cord Injury: Introducing Change in NHS England Commissioned Services.

Psychologist resourcing across the United Kingdom (UK) spinal cord injury centres (SCICs) varies considerably, which has detrimentally impacted standardising service provision for people with spinal cord injuries/disorders (PwSCI/D) compared with other nations. This paper presents the outcome of a project involving the Spinal Cord Injury Psychology Advisory Group (SCIPAG) and NHS England Clinical Reference Group/SCI transformation groups to agree upon screening and standards and shares data from the National Spinal Injuries Centre (NSIC) and the Yorkshire and Midlands Regional SCICs. Inpatients completed the GAD-7, the PHQ-9, and the short form of the Appraisals of DisAbility: Primary and Secondary Scale (ADAPSSsf), assessing adjustment. A total of 646 participants were included, with 43% scoring above the clinical threshold on at least one of the measures on admission. A subset of 272 participants also completed discharge measures and 42% remained above the threshold on discharge, demonstrating sustained psychological need. This paper provides support for services to move to a screen-and-assessment model supplemented by referral options for those with changing needs or who present with difficulties outside the remit of screening. The findings also support the efficacy of universal screening across the system and consideration of screening and standards for psychological care by the wider psychology community.

The influence of psychological need on rehabilitation outcomes for people with spinal cord injury.

Single-centre, retrospective study of peoplewith a spinal cord injury or disorder(PwSCI/D) and identified psychological need. To examine the effect of psychological need on rehabilitation outcomes. National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, United Kingdom. Self-reported data from the Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) were used to examine identified psychological need (characterised by referral for psychological treatment, or scoring above clinical threshold in admission psychometric measures) on SCI rehabilitation outcome domains. Participants were grouped according to whether they were referred, not referred, scored above or below clinical threshold. 234 participants were included (Mean age at injury (years) = 53, 70% Male, 29% tetraplegia, 38% paraplegia, 33% ASIA D). There was a significant improvement in outcome scores from admission to discharge across all domains irrespective of participant group, however individuals with identified psychological need scored lower across all rehabilitation domains than those without. While individuals with psychological need demonstrated longer rehabilitation stays, more frequent and longer discharge delays, they also showed comparatively greater rehabilitation improvements. Psychological screening measures were more effective at detecting psychological need than individuals identified via referral, and participants scoring above clinical threshold had poorest overall rehabilitation outcomes. Individuals with psychological need have greater rehabilitation need and may require longer rehabilitation and benefit from additional discharge planning. Early, proactive psychometric screening can better facilitate improvements for delivering rehabilitation. Future research should consider specific contributing factors to psychological need, such as pre-existing mental health conditions or socio-demographic influences.

Building and Sustaining Inpatient-Clinician Collaboration in Spinal Cord Injury Rehabilitation: A Case Example Using the Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) and Goal Planning Programme.

Goal planning is core for the delivery of the biopsychosocial model of rehabilitation and is commonly practiced in spinal cord injury (SCI) and other physical health settings. Despite a strong theoretical basis from several branches of psychology, evidence regarding specific practice, interventions and impact has yet to be established, with no universal standards in this area. Study One outlines the standards used at the National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital since the inception of the SMS-NAC and goal planning programme in 1989. The results outline the impact of a quality improvement project undertaken since 2016 and track the interventions used to improve inpatient care. Study Two reports on an international survey of rehabilitation measure usage and goal planning practice with inpatient adult and children and young people (CYP) with SCI. Respondents replied that inpatient presence at goal planning meetings only took place in 75% (adult) and 76% (CYP) of services, with more services indicating 4 or more members of the multidisciplinary team being present (85% and 90%, respectively). This paper demonstrates the gains that can be made when a structured quality improvement methodology is used and highlights the need for standards regarding goal planning in SCI rehabilitation to be developed.

Suprapubic catheterisation: a study of 1000 elective procedures.

To investigate the risks and long-term outcomes of suprapubic catheter (SPC) insertion in a population predominantly with spinal cord injury. We used the theatre database at the National Spinal Injuries Centre in Stoke Mandeville Hospital to identify 1000 consecutive SPC insertions from 1998 to 2015. We retrospectively analysed all records for these patients. Follow-up ranged from 4 weeks to 16.45 years (median 3.3 years). Either cystoscopy-guided suprapubic puncture (Lawrence Add-a-Cath trochar) or a direct incision onto a urethral sound (Lowsley retractor) followed by cystoscopy was used for 98% of insertions. Complications graded as Clavien-Dindo IIIb or higher occurred in 0.6% of patients. Return to theatre was necessary in 0.4%, including three laparotomies due to bleeding or misplacement of the catheter, but no bowel injuries occurred. One death occurred within 30 days due to pulmonary embolism. There were no significant differences in outcomes between insertion methods. Tolerance of long-term suprapubic catheterisation was high, despite 59% of cases experiencing mostly minor complications. Tract losses during routine community change and variability in antibiotic prescribing highlighted areas for educational development which could improve patient outcomes. This study supports the view that the risk of major complications from SPC insertion is lower than previously reported. Minor complications related to the catheter are common in the long term but are generally well tolerated.

The value of the whole picture: rehabilitation outcome measurement using patient self-report and clinician-based assessments after spinal cord injury.

This is a retrospective longitudinal study. To explore the relative impact and contribution of using both the Spinal Cord Independence Measure III (SCIM) and Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) to assess rehabilitation outcome following an acute spinal cord injury (SCI). The study was performed at National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK. A patient self-report SMS-NAC and clinician-rated SCIM were administered on admission and discharge from the NSIC as part of standardised care. This paper presents a retrospective analysis of the rehabilitation outcomes of 195 people with spinal cord injury (PwSCI) following their first admission. In both measures, PwSCI improved from admission to discharge. Individuals with higher SCI obtained lower scores in both measures, at both admission and discharge. The SMS-NAC demonstrated the greatest increase in knowledge and skill for PwSCI who had higher and more complete injuries. On the SCIM, PwSCI who had lower and less complete injuries demonstrated the greatest increase in outcome. Overall, both measures demonstrated responsiveness to change during SCI rehabilitation and enable clinicians to systematically determine areas to focus rehabilitation effort. The relative strengths and contribution to delivering person-centred care for each are identified. The SMS-NAC enables clinicians to record, for people with higher injuries, their subjective self-report of skill and knowledge gains from rehabilitation that may be missed with other measures. Consequently, using both is encouraged in appreciation of the value of recording verbal (instructional) independence as well as functional (physical) independence.

Peripheral nerve decompression in the upper limb in spinal cord injury: experiences at the National Spinal Injuries Centre, UK.

Retrospective cohort study of consecutive upper limb peripheral nerve decompressions in SCI patients. All procedures were performed at a single National Spinal Injuries Centre between 2015 and 2019. Entrapment neuropathies in the upper limb are underdiagnosed and undertreated in patients with spinal cord injury (SCI). This cohort study represents the first published outcomes of upper limb peripheral nerve decompression in patients with SCI. National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire, UK. Data collected from electronic medical records included patient demographics, procedures performed, length of inpatient stay, nerve conduction studies, and patient satisfaction. Patients were also contacted by telephone to complete a questionnaire that included patient satisfaction, the NHS 'Friends & Family Test' and validated patient-reported outcome measures (PROMs). Thirty-four decompression procedures (24 carpal tunnel, 10 cubital tunnel) were performed in 24 patients (14 with paraplegia, 10 tetraplegia). 71% of patients had pre-operative nerve conduction studies: 71% of these were graded as severe. Mean length of stay was 14 nights. 91% of patients were satisfied with their procedure at clinic follow-up. Mean Boston Carpal Tunnel Questionnaire (BCTQ) symptom scores were reduced from 3.7 to 1.3 pre- vs. post-operatively (p < 0.001). Patient Reported Ulnar Nerve Evaluation (PRUNE) scores reduced from 49.4 to 23.0 (p = 0.01). In our experience, SCI patients tend to present with severe upper limb nerve entrapment syndromes. Operative management is well tolerated with low risk of complications and can result in marked improvements in symptoms and function.

Vaginal delivery is safely achieved in pregnancies complicated by spinal cord injury: a retrospective 25-year observational study of pregnancy outcomes in a national spinal injuries centre

BackgroundWomen with spinal cord injuries (SCI) represent a high risk population during pregnancy with comparatively few studies in the literature regarding their management and pregnancy outcomes, due to the relative rarity of the condition. Our objective was to assess pregnancy outcomes in women with spinal cord injury.MethodsWe performed a retrospective observational study of pregnancy outcomes by reviewing maternity records of all pregnant women with SCI attending the National Spinal Injury Centre at Buckinghamshire NHS Trust between 1991 and 2016. The outcome measures were Maternal demographic data, antenatal complications, method of anaesthetic, intrapartum data (gestation at delivery, onset of labour, mode of delivery, indication for obstetric intervention) and neonatal outcomes (low birth weight, stillbirth, neonatal death).ResultsFifty women with a total of 68 pregnancies were identified. Five patients sustained SCI during pregnancy and the remaining 63 pregnancies were conceived at least 1 year after SCI, of which 45 pregnancies had a SCI at T10 or above (73%) and 23 pregnancies at T11 or below (27%). The most common antenatal complications in SCI patients were worsening of spasms (38%) and urinary tract infection (24%). Preterm delivery occurred in 18% of women. Vaginal delivery was achieved in 77% of pregnancies, including 14% instrumental delivery rate and 23% Caesarean delivery rate.ConclusionsOur findings support the current evidence that pregnancy outcomes are generally successful and that vaginal delivery can be safely achieved in the majority of women, independent of the level of SCI.

A history of Stoke Mandeville Hospital and the National Spinal Injuries Centre.

Stoke Mandeville Hospital and the National Spinal Injuries Centre (NSIC) are renowned worldwide for the successful treatment of spinal injuries and as the birthplace of the Paralympic movement. The emergence of the spinal centre was a direct result of the setting up of the Emergency Medical Services in the Second World War to treat injured soldiers. This paper documents the history of the hospital as a whole and the influence of the NSIC in particular on the overall facilities leading up to and after the building of the modern NSIC in 1983.

Advantages and challenges of using mobile ethnography in a hospital case study: WhatsApp as a method to identify perceptions and practices

The focus of this article is to provide the reader with reflexivity and a framework for using mobile ethnography. Based on a case study with an ethnographic approach (including mobile ethnography using WhatsApp), we identified perceptions and practices for improved workflows and procedures related to nurses’ introduction and implementation of self-catheterization at the National Spinal Injuries Centre in Great Britain. We offer detailed procedures, advantages, and challenges in using mobile ethnography. The ethnographic approach consisted of four phases, including initial workshops, go-along observations, interviews, and a mobile ethnographic approach using WhatsApp as a mobile diary for six nurses. Within the case study, three major themes were revealed by the ethnographic approach, with the conclusion that nurses have positive attitudes towards self-catheterization, but these nurses are becoming less influential and the practices around this technique are consequently disappearing. The main result is that use of WhatsApp as a self-tracking tool can extend the methodological toolbox, but reflexivity and preliminary work are required to make the practice beneficial.

Poor specificity of National Early Warning Score (NEWS) in spinal cord injuries (SCI) population: a retrospective cohort study

Retrospective chart audit. The National Early Warning Score (NEWS) is based on seven physiological parameters which can be altered in some individuals with spinal cord injuries (SCI). The aim was to start the development of adapted NEWS suitable for SCI population. The objective was to determine the SBP NEWS specificity based on neurological level of injury (NLI) and completeness of injury. Tertiary centre in the UK. Adult patients admitted for the first time to the National Spinal Injuries Centre between 1 January 2015 and 31 December 2016 were included if they were >6 months post injury. Data were extracted retrospectively including the last ten consecutive BP and heart rate readings before discharge. Data were analysed based on different AIS grades, completeness of injury and NLI. One hundred and ninety one patients were admitted in 2015 and 2016 and 142 patients were included in the primary analysis. The mean SBP ranged between 92 and 151 mmHg. Patients with the NLI of T6 and above (≥T6) motor complete lesions had a significantly lower SBP than motor incomplete lesions. The specificity of the SBP NEWS was 35.3% in ≥T6 motor complete individuals versus 80.3% in ≥T6 motor incomplete individuals. The baseline BP is significantly lower in the ≥T6 motor complete SCI individuals (>6 months post injury) resulting in a very low specificity of 35.3% to SBP NEWS, which could lead to mismatch between clinical deterioration and NEWS resulting in lack of timely clinical response.

367. Vaginal delivery is safely achieved in pregnancies complicated by spinal cord injury: A retrospective 25-year observational study of pregnancy outcomes in a national spinal injuries centre

Objective To assess pregnancy outcomes in women with spinal cord injury. Design A retrospective observational study. Setting: National Spinal Injury Centre at Buckinghamshire NHS Trust. Population Fifty women with a total of 68 pregnancies were identified. Five patients sustained SCI during pregnancy and the remaining 63 pregnancies were conceived at least one year after SCI, of which 45 pregnancies had a SCI at T10 or above (73%) and 23 pregnancies at T11 or below (27%). Methods Retrospective review of the maternity records of all pregnant women with SCI attending Buckinghamshire NHS Trust between 1991 and 2016. Main Outcome Measures Maternal demographic data, antenatal complications, method of anaesthetic, intrapartum data (gestation at delivery, onset of labour, mode of delivery, indication for obstetric intervention), neonatal outcomes (low birth weight, stillbirth, neonatal death). Results The most common antenatal complications in SCI patients were worsening of spasms (38%) and urinary tract infection (24%). Preterm delivery occurred in 18% of women. Vaginal delivery was achieved in 77% of pregnancies, including 14% instrumental delivery rate and 23% Caesarean delivery rate. Conclusions This is the largest reported study of pregnancy outcomes in SCI patients since 1972. Our findings support the current evidence that pregnancy outcomes are generally successful and that vaginal delivery can be safely achieved in the majority of women, independent of the level of SCI.

Rapid incremental closed traction reduction of cervical facet fracture dislocation: the Stoke Mandeville experience.

Retrospective case series study. To determine the success rate and neurological outcomes of rapid incremental closed traction reduction (RICTR) of cervical dislocations with spinal cord compression in the National Spinal Injuries Centre (NSIC), between June 2006 and December 2011. Tertiary spinal injuries centre, Stoke Mandeville Hospital, UK. A list of cervical trauma patients who were admitted to NSIC between January 2006 and December 2011 was retrieved from the hospital's electronic records, consultant and admission logbooks. Patients, admitted within 7 days of cervical facet dislocation and spinal cord injury (SCI), were included. Retrospective data collection and analysis was done using a data collection form and an Excel spreadsheet. Seventeen patients have met the eligibility criteria of the study. One patient was excluded because he only had nerve root symptoms. The procedure was successful in 44% of the cases. Eighty-six percent of patients in the successful RICTR group improved in their discharge motor index score (MIS), whereas 43% improved in their post-reduction MIS. Overall, 81% of the cohort had improvements in their discharge MIS. Our RICTR success rate was low compared to the reported average success rate in the literature, likely due to delays in admission. Neurological outcomes were favourable in the majority of patients at discharge. In our opinion, early admission and RICTR attempts could have improved the results and therefore we would recommend that RICTR procedures are done for suitable patients in the Emergency Departments of Major Trauma Centres (MTC).

Use of antibiotic and prevalence of antibiotic-associated diarrhoea in-patients with spinal cord injuries: a UK national spinal injury centre experience.

This was a retrospective audit, with the aims being to (1) record the use of antibiotics; (2) establish the prevalence of antibiotic-associated diarrhoea (AAD) and Clostridium difficile-associated diarrhoea (CDAD); and (3) assess if there was any seasonal variation in antibiotic use and incidence of AAD. The study was performed at a single spinal cord injury (SCI) centre in the UK. Data were collected using a standardised questionnaire during October 2014 to June 2015. We define AAD as two or more watery stools of type 5, 6 or 7 (Bristol stool scale) over 24 h. Three-hundred-and-nineteen adults (mean age: 55.9 years, 29.2% female) with SCI (58.2% tetraplegia; 43.7% complete SCI) were included. Of 70 (21.9%) patients on antibiotics, the top three indications for antibiotics were urinary-tract infections, infected pressure ulcers and other skin infections. Seventeen of 78 (21.8%) developed AAD and three of 319 (0.94%) developed CDAD. AAD was more common in the summer season than in spring, autumn and winter (47.1%, 10.0%, 10.0%, 23.8%, P=0.025). AAD was associated with older adults greater than 65 years (70.6% vs 23.8%, P=0.007). Polypharmacy and the summer season were identified as independent predictors for AAD. This survey found that AAD is common in SCI patients and may be a risk factor for a poorer outcome and increased hospital costs. A multicentre study is underway to establish the incidence and risk factors for AAD.

Effects of Transcranial Direct Current Stimulation (tDCS) on Chronic Pain in Spinal Cord Injured Patients

Introduction: Pain following spinal cord injury (SCI) is notoriously difficult to manage and often refractory to treatment. Novel approaches, such as non-invasive brain stimulation, targeting central mechanisms associated with chronic pain, have shown early promise as a safe treatment in various patient groups, including spinal cord injury. To date the number of small clinical trials using non-invasive brain stimulation to treat chronic pain in SCI has produced mixed results. We report here the findings of a UK based trial examining the effects of anodal transcranial direct current stimulation (TdCs) administration on pain in spinal injury patients. Methods: Sixteen spinal injury patients from the National Spinal Injury Centre, Stoke Mandeville Hospital, Aylesbury, UK participated in a single centre, double blind randomized control trial. Patients were randomly allocated to either the active (n=8) or sham (n=8) treatment groups. tDCS was administered by electrodes with anode placement over the dominant M1 and the cathode electrode over the contralateral supraorbit scalp area. Subjects received either active (2 mA anodal current) or sham tDCS for 20 min daily treatment for 5 consecutive days with the dose based on previously reported chronic pain studies in spinal cord injury patients. A mixed ANOVA was used to evaluate both tDCS treatment and time effects on validated assessment measures for pain and depression up to 2 weeks following treatment intervention. Results: No adverse effects of the treatment were observed in this study, nor were there any significant differences between groups in rating perception of stimulation. While treatment appeared to have reduced group pain scores on a visual analogue scale [VAS], there were no statistically significant differences between active and sham treatment groups when re-examined in the 2 week follow up. Conclusion: There were some reductions in self-assessed VAS pain score in our small group of SCI patients during treatment in both the sham and active tDCS and at two weeks’ post treatment. However, our study appears to indicate only a placebo-like effect of tDCS on chronic pain in SCI, and not one attributed to the active, anodal stimulation over motor cortex. We also did not observe any significant effects over time or treatment for an assessment of neuropathic pain. We observed some trends of non-significant reduction in some of selfassessed pain scores measures, however, these are inconclusive. Studies of clinical efficacy of pain treatment by tDCS in spinal cord injury should therefore be conducted on a larger scale, and with a longer follow up period to address the limited evidence available.

Use of antibiotic and incidence of antibiotic associated diarrhoea in patients with spinal cord injuries: a UK National Spinal Injury Centre experience

Use of antibiotic and incidence of antibiotic associated diarrhoea in patients with spinal cord injuries: a UK National Spinal Injury Centre experience

Professor Paul Kennedy

DPhil student Jasmine Hearn interviewed Clinical Psychologist Professor Paul Kennedy of the National Spinal Injuries Centre and the University of Oxford. Paul shared his experiences working in the field of chronic illness, the impact of psychology at the National Spinal Injures Centre, and his advice for others seeking careers in clinical psychology and research.

A re-audit to evaluate the use of nutrition screening tool in the National Spinal Injuries Centre (NSIC) at Stoke Mandeville Hospital

A re-audit to evaluate the use of nutrition screening tool in the National Spinal Injuries Centre (NSIC) at Stoke Mandeville Hospital

Return-to-work intentions during spinal cord injury rehabilitation: an audit of employment outcomes.

Single-centre, retrospective cohort study. To analyse the return-to-work intentions during spinal cord injury (SCI) rehabilitation. Tertiary care, spinal cord injury rehabilitation unit, National Spinal Injuries Centre, Stoke Mandeville Hospital, Ayelsbury, UK. Employment outcomes were obtained from the Needs Assessment Checklist (NAC), for all patients admitted to the unit between February 2008 and October 2014. NAC1 is completed within 4 weeks post-mobilisation and NAC2 upon the patient moving to the pre-discharge ward. Data from 362 participants were analysed for return-to-work intentions, by gender, age and injury severity. Seventy-six percent of the sample population was employed at the time of their injury. At NAC1, 22.4% of individuals had made plans to return to work, whereas 44.2% had not; at NAC2, 34.3% had made plans to return to work and 31.2% had not. This difference was found to be statistically significant. There were significant differences in return-to-work intentions by injury severity at NAC1 but not NAC2, and by age group at NAC2 but not NAC1. Less than half of those employed at the time of their injury had made plans to return to work before their discharge from the unit. The low proportion of individuals with SCI returning to work--just one in three--is concerning in view of the lost health and psychosocial benefits, and requires greater prominence during rehabilitation. Future research into effective employment interventions to improve employment outcomes in this population is required.

Incidence of pulmonary embolism after the first 3 months of spinal cord injury.

Pulmonary embolism (PE) is a significant cause of morbidity and mortality in patients with spinal cord injury (SCI). Prophylactic anticoagulation is associated with a reduction in mortality rates, but there is limited evidence regarding the incidence rate of PE following cessation of anticoagulation after the first 3 months of injury. Single-centre retrospective study. To estimate the incidence rate of PE after 90 days of SCI. The National Spinal Injuries Centre at Stoke Mandeville Hospital, Aylesbury, UK. The study includes 640 new-onset SCI patients. All computer tomography pulmonary angiograms (CTPAs) or ventilation-perfusion lung scans between 2008 and 2013 were identified. Medical notes and scans were reviewed and clinical outcomes and radiological findings were recorded. A total of 91 patients with a new-onset SCI had a CTPA or a perfusion lung scan. PE was detected in a total of 8 patients. The incidence of PE was 1.25%; 95% confidence interval (0.39-2.11) over a 6-year period. The duration of injury at the time of PE was 7 months. The incidence rate of PE post 3 months of SCI remains significant, though much lower than immediately post injury.