Spinal Cord Injury Center Research Articles

Treatment of urinary tract infection in persons with spinal cord injury: guidelines, evidence, and clinical practice

Objectives: To investigate current clinical practice in the treatment of urinary tract infections (UTIs) in persons with spinal cord injury (SCI) in SCI centers where German is spoken and to compare it with current guidelines and evidence-based standards evaluated by a literature review.Methods: A standardized questionnaire was mailed to 16 SCI rehabilitation centers. The results were compared with a literature reviewResults: Of the 16 centers, 13 responded. Indications for UTI treatment, medications, and treatment duration differed substantially among the individual centers and from the existing guidelines. Antibiotic treatment is regarded as the method of choice. Compared with the existing literature, patients in two center were undertreated, whereas they were overtreated in seven centers.Conclusion: Even in specialized centers, treatment of UTI in patients with SCI is based more on personal experience of the treating physicians than on published evidence. This may at least partly be due to the paucity of evidence-based data. The observed tendency toward overtreatment with antibiotics carries substantial future risks, as this strategy may well lead to the induction of multiresistant bacterial strains. Therefore, developing guidelines would be an important step toward a unification of the different treatment strategies, thus reducing unnecessary antibiotic treatment. Furthermore, evidence-based studies evaluating the success of antibiotic treatment as well as the usefulness of alternative strategies are urgently needed.

Trends in Epidemiology and Management of Type II Odontoid Fractures

A retrospective cohort study of consecutive type II Odontoid fractures presenting to a Level 1 Regional Model Systems Spinal Cord Injury Center between June 1985 and July 2006. To assess trends in management of type II Odontoid fractures presenting to a Level 1 Model Systems Regional Spinal Cord Injury Center over a 20-year period. Type II Odontoid fracture management is controversial, and a majority of studies have had relatively small cohorts. There is no consensus regarding definitive treatment, particularly in older patients. Medical records of 263 consecutive type II Odontoid fractures from June 1985 to July 2006 were retrospectively reviewed. Patients were excluded if they had neurologic deficits, nonacute fracture, or ambiguous fracture classification. A cohort of 192 neurologically intact, acute type II odontoid fractures were identified. Admission records were reviewed for age, date of injury, date of admission, date of discharge, mechanism of injury, associated injuries, medical comorbidities, and radiologic findings. There was a statistically significant increase in the rate of presentation of type II odontoid fractures with time. The average age and medical comorbidities of the patient did not change over time. The probability of operative management markedly increased over time, corresponding to a statistically significant increase in length of hospital stay for patients undergoing surgery. The discharge disposition correlated significantly to both age of the patient and associated injuries. The number and frequency of type II odontoid fractures compared with other spine injuries seems to be increasing over the last 2 decades, which may be correlated with the increasing number of elderly persons in the population, given that referral patterns have been unchanged at our institution. Prospective outcomes data are needed to better elucidate optimal treatment algorithms from both, an outcomes and cost-efficacy perspective.

Poor Nutrition Is a Relative Contraindication to Negative Pressure Wound Therapy for Pressure Ulcers

To assess the efficacy of negative-pressure wound therapy (NPWT) for healing of pressure ulcers (PrUs) in individuals with spinal-cord injury (SCI). Multicenter, 28-day observational study. Ten Veterans Affairs Medical Center SCI centers. Eighty-six SCI inpatients with Stage III/IV pelvic PrUs. Standard wound care with NPWT versus standard wound care alone (NoNPWT). Change in wound surface area (WSA) using the Verg Videometer Measurement Documentation software. The proportion of patients demonstrating a decrease in WSA (healing subgroup) was not significantly different between the NPWT (n = 33) and NoNPWT (n = 53) groups (67% vs 70%, respectively). In the healing subgroup, there was no significant difference between the NPWT versus NoNPWT groups in WSA decrease (-43 ± 22% vs -50% ± 26%, not statistically significant). Similarly, in the nonhealing subgroup, there was no significant difference between NPWT and NoNPWT groups (31% ± 26% vs 32% ± 34%). In the NPWT group, the nonhealing subgroup (11/33) had significantly lower serum albumin levels than the healing subgroup (22/33) (2.9 ± 0.4 vs 3.3 ± 0.5 mg/dL, P < .05). In the NoNPWT group, there was no significant difference in serum albumin levels between the healing versus nonhealing subgroups (3.2 ± 0.3 vs 3.2 ± 0.3 mg/dL). In SCI patients with Stage III/IV pelvic PrUs, NPWT did not significantly influence the rate of healing. Additionally, in malnourished individuals (albumin <3.0 mg/dL), NPWT was not efficacious. Healing outcomes in the NPWT group were significantly influenced by albumin levels, whereas no such disparity was noted between the healing and nonhealing PrUs for the NoNPWT group. Nutritional status appears to be important in the effectiveness of NPWT.

Length of stay and medical stability for spinal cord-injured patients on admission to an inpatient rehabilitation hospital: a comparison between a model SCI trauma center and non-SCI trauma center

Retrospective database review. To compare lengths of stay (LOS), pressure ulcers and readmissions to the acute care hospital of patients admitted to the inpatient rehabilitation facility (IRF) from a model spinal cord injury (SCI) trauma center or from a non-SCI acute hospital. Only sparse data exist comparing the status of patients admitted to IRF from a model SCI trauma center or from a non-SCI acute hospital. Acute care, IRF and total LOS were compared between patients transferred to IRF from the SCI center (n=78) and from non-SCI centers (n=131). The percentages of pressure ulcers on admission to IRF and transfer back to acute care were also compared. Patients admitted to IRF from the SCI trauma center (SCI TC) had significantly shorter (P=0.01) acute care LOS and total LOS compared with patients admitted from non-SCI TCs. By neurological category, acute-care LOS was less for all groups admitted from the SCI center, but statistically significant only for tetraplegia. There was no significant difference in the incidence of readmissions to acute care from IRF. More patients from non-SCI centers (34%) than SCI centers (12%) had pressure ulcers (P<0.001). Acute care in organized SCI TCs before transfer to IRF can significantly lower acute-care LOS or total LOS and incidence of pressure ulcers compared with non-SCI TCs. Patients admitted to IRF from SCI TCs are no more likely to be sent back to an acute hospital than those from non-SCI TCs.

Implementing the Central Line Bundle To Reduce Peripherally Inserted Central Catheter (PICC) Bloodstream Infections

PURPOSE: Central venous access devices are vital tools in caring for the many patients. Unfortunately, catheter-related bloodstream infection (CLABSI) is the most frequently occurring nosocomial infection. In 2006 Institute of Health Improvement (IHI) published a bundle of interventions to assist hospitals in reducing the rate of CLBSI. We report the impact of implementing such bundle in the rate of CLABSI in our Spinal Cord Injury Center (SCI).

Assessing patterns of participation and enjoyment in children with spinal cord injury

To determine patterns of participation and levels of enjoyment in young people with spinal cord injuries (SCI) and to assess how informal and formal participation varies across child, injury-related, household, and community variables. One hundred and ninety-four participants (106 males, 88 females; mean age 13y 2mo, SD 3y 8mo, range 6-18y) with SCI and their primary caregivers completed a demographics questionnaire and a standardized measure of participation (the Children's Assessment of Participation and Enjoyment, [CAPE]) at three pediatric SCI centers in a single hospital system in the United States. Their mean age at injury was 7 years 2 months (SD 5y 8mo, range 0-17y); 71% had paraplegia, and 58% had complete injuries. Young people participated more often in informal activities (t((174))=29.84, p<0.001) and reported higher enjoyment with these (t((174))=2.01, p=0.046). However, when engaging in formal activities, they participated with a more diverse group (t((174))=-16.26, p<0.001) and further from home (t((174))=-16.08, p<0.001). Aspects of informal participation were related to the child's age, sex, and injury level, and formal participation to the child's age and caregiver education. Caregiver education was more critical to formal participation among young people with tetraplegia than among those with paraplegia (F((4,151))=2.67, p=0.034). Points of intervention include providing more participation opportunities for young people with tetraplegia and giving caregivers the resources necessary to enhance their children's formal participation.

Girls with spinal cord injury: Social and job-related participation and psychosocial outcomes.

To examine social and job-related participation among girls with spinal cord injury (SCI) and relationships between participation, depression, and quality of life. This sample included 97 girls (aged 7-17 years) who had sustained SCI at least 1 year prior to interview, and who were receiving care at three pediatric SCI centers within a single hospital system. Participants completed the Children's Assessment of Participation and Enjoyment, Children's Depression Inventory, and Pediatric Quality of Life Inventory. Caregivers completed a demographics form. Girls participated more often in social activities than in job-related activities and participated in social activities with a more diverse group and further from home. A broader context of social participation was related to lower depression, which in turn was related to higher quality of life. Higher frequency of job-related participation was related to lower depression, which in turn was related to higher quality of life. Social and job-related participation are related to psychosocial outcomes among girls with SCI. Participation in social and job-related activities should be a focus of rehabilitation for girls, because the skills gained from this involvement may help build resilience against future obstacles to socialization and employment.

Clinical presentation of spondylodiscitis as a long-term complication in incomplete paraplegia: a report of three cases

Case report. Complications in spinal cord injury (SCI) are a challenging problem for the patients and often difficult to manage. Three cases of spondylodiscitis, localized at the lumbosacral junction in long-term paraplegic patients are presented. Spinal Cord Injury Center, Orthopaedic University Hospital Heidelberg, Heidelberg, Germany. In all three cases, neurological deterioration (ASIA A) was caused by a secondary compression of the spinal cord at the lumbosacral spine. Increase of spasticity and pain, atonic bladder and sphincter function accompanied by vegetative symptoms were present in all patients. Microbiological analysis of the sacral area showed coagulase negative staphylococcus in two cases, whereas in one case no microorganism was found. The diagnosis was made by MRI of the whole spine and surgical treatment was required. At follow-up (6 months), patients showed no AIS (ASIA Impairment Scale) changes. If neurological deterioration occurs, spondylodiscitis should be ruled out in paraplegic individuals. The therapeutic goal is to achieve emergent decompression of the spinal cord and to administrate adequate antibiotic therapy to avoid a neurologically complete situation.

The relationship between bladder management and health-related quality of life in patients with spinal cord injury in the UK

Cross-sectional study. (1) To assess the relationship between bladder management methods and the health-related quality of life (HRQL) in patients with spinal cord injury (SCI). (2) To identify any correlation between the two questionnaires used to assess the quality of life (one validated for SCI and one validated for bladder symptoms). Spinal Cord Injury Centre, Royal National Orthopaedic Hospital, Middlesex, UK. This study is based on two questionnaires with results collected from 142 people with SCI. The two questionnaires were based on information from the Short-Form 36-Item Health Survey (SF-36) and the King's Health Questionnaire and included demographic characteristics, bladder management methods and the frequency of incontinence. There is a moderate correlation between the results of the SF-36 and the King's Health Questionnaire. Only 21% SCI patients report normal voiding without any other form of bladder management. The type of bladder management may influence the HRQL in patients with SCI. Clean intermittent catheterization by attendant, indwelling transurethral catheterization and indwelling suprapubic catheterization are the three groups with the worst mental status. In addition, the frequency of incontinence is a strong influence on HRQL. The results of this study may provide a general baseline HRQL for patients with SCI. Our findings show the relationships between bladder management methods and quality of life in patients with SCI. In addition, the impact of incontinence on quality of life was also confirmed.

Congenital absence of the internal carotid artery in a patient with spinal cord injury: case report

Case report. To describe a rare case of congenital absence of the internal carotid artery (ICA) in the setting of acute spinal cord injury and review the existing literature. Regional Spinal Cord Injury Center of the Delaware Valley, Philadelphia, PA, USA. We report on a 47-year-old male who presented as a T2 ASIA A spinal cord injury with a T2-T3 fracture dislocation injury after a 25-feet fall from a tree. Magnetic resonance angiography imaging of the neck carried out as per routine spinal trauma protocol suggested an acute traumatic injury to the carotid artery. Therefore, computed tomographic angiography imaging of the neck was performed, which revealed absence of the left ICA and a diminutive left carotid canal at the skull base, suggesting congenital absence. Follow-up magnetic resonance imaging of the brain to evaluate for acute infarct showed no diffusion restriction contributing to the evidence that this was a congenital anomaly and not traumatic occlusion of the artery. Congenital absence or hypoplasia of the ICA is a rare anomaly. It should be considered in the differential in patients who have absent or diminished carotid arteries on radiologic imaging in the setting of trauma.

Predictors and Outcomes of Antibiotic Adequacy for Bloodstream Infections in Veterans With Spinal Cord Injury

Evans CT, Burns SP, Chin A, Weaver FM, Hershow RC. Predictors and outcomes of antibiotic adequacy for bloodstream infections in veterans with spinal cord injury. Objective To identify predictors and outcomes associated with receiving inadequate empirical antimicrobial treatment for bloodstream infections (BSIs) in persons with spinal cord injury (SCI). Design Retrospective cohort study from October 1, 1997, through September 30, 2004. Setting A Department of Veterans Affairs SCI center that serves approximately 700 patients a year. Participants Hospitalized patients with SCI (N=123) who had 1 or more BSIs during the study period. Interventions Not applicable. Main Outcome Measures Adequacy of antimicrobial treatment (inadequate treatment was defined as the absence of antimicrobial agents for a particular organism within 2 days after the collection of blood cultures and/or the microorganism's resistance to the antimicrobial administered), hospital length of stay (LOS) post-BSI infection, and in-hospital and 30-day mortality. Cluster-adjusted multivariable models were assessed. Results Over one third (88; 37.4%) of the 235 episodes of BSI identified received inadequate empirical antibiotic treatment. Having a polymicrobial BSI was associated with inadequate treatment (odds ratio [OR]=3.28; 95% confidence interval [CI]=1.62–6.65; P=.001). Factors protective against inadequate therapy included having a comorbid pressure ulcer (OR=0.37; 95% CI=0.21–0.68; P=.001) or a BSI that was not primary (OR=0.30; 95% CI=0.15–0.58; P<.0001). Mortality did not differ between the inadequate and adequate treatment groups (11.4% vs 10.9%; P=.92). Similarly LOS postinfection was not affected by treatment status (inadequate treatment median=22d vs adequate treatment median=27d; P=.98). Conclusions Over one third of patients received inadequate empirical treatment, which was associated with having a polymicrobial BSI. However, inadequate treatment was not associated with increased mortality or LOS postinfection.

Percutaneous enterogastric tube dislodgement in tetraplegics

Case reports describing abdominal complications following percutaneous enteral gastric (PEG) tube placement in three tetraplegics. The aim was to increase provider awareness of PEG tube dislodgement as a complication in tetraplegics. Spinal cord injury center, Veteran's Administration hospital. The charts of three spinal cord injured veterans with tetraplegia were reviewed for clinical presentation and radiographic findings supporting the diagnosis of acute abdominal complications following PEG tube dislodgement. PEG tube dislodgement in tetraplegics can present with occult findings and lead to disastrous outcomes if the diagnosis is delayed. PEG tube dislodgement should be considered in tetraplegics who develop even subtle abdominal complaints, especially if the injury is complete. Further assessment with computed tomography (CT) scans or fistulograms should be considered to help with decision making.

Yes, we can manually remove faeces

Last week I was speaking at a one-day conference, at which the new national guidelines for the management of neurogenic bowel dysfunction after spinal cord injury were launched by the Spinal Cord Injuries Centres of the UK and Ireland (2009), which will be the subject of a future paper in BJNN. Delegates had the privilege of listening to the patients' perspective of bowel care from those who had suffered spinal injuries at various levels. One of the consistent comments and a situation commonly faced by patients is nurses refusing to perform manual removal of faeces because this was either seen to be ‘degrading’ or not permitted.

Artificial disc versus spinal fusion in the treatment of cervical spine degenerations in tetraplegics: a comparison of clinical results

Comparative prospective study. To determine functionality of the cervical spine when using ProDisc C in comparison with the conventional method of treatment (decompression and fusion) in paraplegics. Spinal Cord Injury Centre in Germany. Two homogeneous groups were studied. The patients were treated with ventral decompression and either had a fusion with an iliac bone graft and plate (group 1) or had received a disc replacement (group 2). Pre- and postoperatively, the subjective scores of SF 36 and Neck Disability Score were determined. Also, objective data of the Spinal Cord Independence Measure (SCIM) III and mobility of the cervical spine, using the neutral-0-method, were evaluated. Prosthesis implementation and union or fusion were monitored by X-rays. Complications and alterations of the neurology were recorded according to the American Spinal Injury Association Score. Neurological remissions of the radicular syndrome that caused the operation were observed. In one case, the dislocation of the prosthesis necessitated an alternative treatment. Mobility of the cervical spine after 6 months was higher in group 2. Both groups showed signs of improvement in the Neck Disability Score and in SF 36. None of the two groups had changes in their SCIM score. One case in group 2 showed ventral blocking; all cases of group 1 fused successfully. Usage of prostheses results in improved total mobility of the cervical spine in comparison with the outcomes of a fusion. This study also confirmed these results in tetraplegics.

Provider Perspectives on Soldiers With New Spinal Cord Injuries Returning From Iraq and Afghanistan

Weaver FM, Burns SP, Evans CT, Rapacki LM, Goldstein B, Hammond MC. Provider perspectives on soldiers with new spinal cord injuries returning from Iraq and Afghanistan. Objective The military conflicts in Iraq and Afghanistan have resulted in many soldiers returning with serious combat injuries, including spinal cord injuries (SCIs). The purpose of this study was to query providers regarding any unique problems or needs in a cohort of these soldiers treated in Veterans Health Administration (VHA) SCI Centers. Design Semistructured questionnaire. Setting Seventeen VHA SCI Centers. Participants Thirty-eight providers, including physicians, nurses, therapists, social workers, and psychologists who volunteered to return completed questionnaires. Interventions Not applicable. Main Outcome Measures Identification of medical and psychosocial issues, rehabilitation delays, therapy and vocational needs, social support, and discharge planning. Results Providers identified several injuries and conditions beyond SCI that were experienced by these soldiers including fractures, pressure ulcers, traumatic brain injuries, posttraumatic stress disorder, and resistant infections. Rehabilitation was often delayed because these problems needed to be addressed first. Soldiers' family and friends provide considerable support. Vocational needs include use of technology, especially computers; education; and participation in sports. Although most return to the community after discharge, many soldiers are still active duty, and some return to military base housing. Conclusions Combat soldiers returning with SCI often have additional medical and psychosocial problems that require appropriate and timely intervention. They have strong support from family and friends and are motivated to integrate back into the community after discharge.

Characteristics of Recurrent Pressure Ulcers in Veterans With Spinal Cord Injury

Background/Objective: To describe characteristics of recurrent pressure ulcers (PrUs) in veterans with spinal cord injury (SCI).Design: Descriptive, cohort study.Settings and Participants: Twenty-four veterans with SCI from 6 SCI centers in the Department of Veterans Affairs.Methods: Data from a prospective study evaluating PrUs were analyzed for 24 veterans with 29 recurrent PrUs during 9 months. Additional retrospective medical record data were analyzed for 15 veterans who received inpatient treatment.Results: Participants were male, 50% non-Hispanic white, with paraplegia (63%), complete SCI (83%), a mean age of 56 years, and mean time since SCI of 21 years. Most PrUs recurred (63%, n = 15 patients) in the same location as the most recent ulcer and at the ischial tuberosities (63%). Mean time to recurrence was 16.6 weeks. PrUs were stage III (28%, n = 8) or IV (45%, n = 13) with undermining (48%), necrotic slough (50%), and minimal exudate. One third were (n = 9) larger than 16 cm2. Mean Bates-Jensen Wound Assessment Tool Score was 33.63. Inpatient medical record data (n = 15) showed 73% with documentation indicating infection treated with antibiotics (53%, n = 8 patients), osteomyelitis (47%, n = 7), and/or cellulitis (1 3%, n = 2) noted. Plastic surgery consultation was obtained for 67% with surgery as an option for 73% (1 without consultation). Scheduled repositioning was documented for 21%.Conclusions: Most PrUs were severe, located at the same anatomic site, and recurred within 4 months, suggesting that the recurrent ulcers were more likely incomplete healing of the initial PrUs. This sample of veterans with SCI provides early data on recurrent PrU characteristics.

SCIRehab Project Series: The Psychology Taxonomy

Context: The integration of psychologists as members of the rehabilitation team has occurred in conjunction with the evolution and adoption of interdisciplinary teams as the standard of care in spinal cord injury (SCI) rehabilitation. Although the value of psychological services during rehabilitation is endorsed widely, specific interventions and their association with patient outcomes have not been examined adequately.Objective: To address this shortcoming, psychologists from 6 SCI centers collaborated to develop a psychology intervention taxonomy and documentation framework.Methods: Utilizing an interactive process, the lead psychologists from 6 centers compiled an inclusive list of patient characteristics assessed and interventions delivered in routine psychological practice at the participating rehabilitation facilities. These were systematically grouped, defined, and compared.Results: The resulting taxonomy became the basis of a documentation framework utilized by psychologists for the study. The psychology taxonomy includes 4 major clinical categories (assessment, psychotherapeutic interventions, psychoeducational interventions, and consultation) with 5 to 10 specific activities in each category.Conclusions: Examination of psychological interventions and their potential association with positive outcomes for persons who sustain SCI requires the development of a taxonomy. Results of these efforts illustrate similarities and differences in psychological practice among SCI centers and offer the opportunity to blend research and clinical practice in an innovative approach to evidence-based practice improvement. The established taxonomy provides a basic framework for future studies on the effect of psychological interventions.

Employment and vocational rehabilitation services use among veterans with spinal cord injury

AlthoughthereisaconsiderablebodyofliteraturedocumentingpoorreturntoworkratesamongpersonswithSCIinthe general population, little attention has been given to understanding patterns of return to work and use of vocational rehabilitation services among veterans with SCI. The purposes of the present study were to investigate the extent to which veterans are able to obtaincompetitiveemploymentafteraspinalcordinjuryandtoexploreveterans'useofexistingvocationalrehabilitationservices. This study surveyed 30 veterans receiving healthcare at the VA North Texas Healthcare System Spinal Cord Injury Center. Thirty percent of our sample had a history of employment after SCI, a rate that is comparable to figures reported in prior studies of employment rates among non-veterans with SCI. Most veterans were unaware of vocational services either within or outside of the VA, and awareness of services was significantly lower for persons with tetraplegia compared to veterans with paraplegia. Of those who were aware of vocational services, only a minority used them. The findings of this study emphasize the need to educate veterans, especially those with more severe injuries, about vocational rehabilitation services as a possible means of improving employment outcomes in this special population.

SCIitelsafe Prefect Series: The Supplemental Cursing Taxonomy

Context: Spinal cord injury (SCI) rehabilitation nurses document the occurrence of educational and care management efforts in traditional nursing documentation methods but not the intensity (or dose) of such interactions. This article describes a process to capture these nursing interventions.Methods: Nurses at 6 US inpatient SCI centers used 2 in-person meetings and weekly telephone calls over 9 months to develop a taxonomy of nursing patient education efforts and care management.Results: This was subsequently incorporated into a point-of-care documentation system and used to capture details of nursing care for 1,500 SCI rehabilitation patients enrolled in the SCIRehab study. The taxonomy consists of 10 education and 3 care management categories. The point-of-care system includes time spent on each category along with an indication of whether the patient and/or family received the education/care management. In addition, a subjective measure of patient participation in nursing activities is included.Conclusions: Creation of a SCI rehabilitation nursing taxonomy is feasible, and its use has had an impact on nursing practice. It also has implications for future clinical documentation, because greater accuracy and details of patient education and care management will be a permanent practice in the participating systems at the conclusion of the study.

SCIRehab Project Series: The Speech Language Pathology Taxonomy

Introduction: Outcomes research for speech language pathology (SLP) interventions for acute traumatic spinal cord injury (SCI) rehabilitation in the US is difficult because of the lack of a treatment classification system (taxonomy).Objective: To describe a taxonomy developed by speech language pathologists (SLPs) to examine the effects of SLP interventions on SCI rehabilitation outcomes.Methods: The SCIRehab study uses practice-based evidence, a rigorous observational methodology that examines treatment processes without specifying or requiring specific therapeutic interventions. Speech language pathology lead clinicians and researchers at 6 US SCI centers developed a detailed SLP taxonomy documentation process that is comprehensive of SLP interventions for patients with SCI.Results: The SLP taxonomy consists of 7 intervention categories that address deficits (speech production for patients with artificial airway, motor speech and voice, swallowing, cognitive-communication, and communication) and the associated exercises and tasks that patients perform. Time is recorded for each category, and supplementary information focuses on cueing needs and family involvement that helps to describe and guide intervention selection. The SCIRehab project is enrolling 1,500 patients with acute traumatic SCI at 6 inpatient rehabilitation facilities.Conclusions: Speech language pathology taxonomy information is being captured for the SCIRehab patients who are referred for SLP services; this may be the first attempt to document the many details of the SLP rehabilitation process for patients with SCI in the US.