Spinal Cord Injury Clinicians Research Articles

Are Clinical Prediction Rules Used in Spinal Cord Injury Care? A Survey of Practice.

Accurate outcome prediction is desirable post spinal cord injury (SCI), reducing uncertainty for patients and supporting personalized treatments. Numerous attempts have been made to create clinical prediction rules that identify patients who are likely to recover function. It is unknown to what extent these rules are routinely used in clinical practice. To better understand knowledge of, and attitudes toward, clinical prediction rules amongst SCI clinicians in the United Kingdom. An online survey was distributed via mailing lists of clinical special interest groups and relevant National Health Service Trusts. Respondents answered questions about their knowledge of existing clinical prediction rules and their general attitudes to using them. They also provided information about their level of experience with SCI patients. One hundred SCI clinicians completed the survey. The majority (71%) were unaware of clinical prediction rules for SCI; only 8% reported using them in clinical practice. Less experienced clinicians were less likely to be aware. Lack of familiarity with prediction rules was reported as being a barrier to their use. The importance of clinical expertise when making prognostic decisions was emphasized. All respondents reported interest in using clinical prediction rules in the future. The results show widespread lack of awareness of clinical prediction rules amongst SCI clinicians in the United Kingdom. However, clinicians were positive about the potential for clinical prediction rules to support decision-making. More focus should be directed toward refining current rules and improving dissemination within the SCI community.

Applying a Bookmarking Approach to Setting Clinically Relevant Interpretive Standards for the Spinal Cord Injury–Functional Index/Capacity Basic Mobility and Self-Care Item Bank Scores

ObjectivesTo develop clinically relevant interpretive standards for the Spinal Cord Injury–Functional Index/Capacity (SCI-FI/C) Basic Mobility and Self-Care item bank scores. DesignModified “bookmarking” standard-setting methodology, including 2 stakeholder consensus meetings with individuals with spinal cord injury (SCI) and SCI clinicians, respectively, and a final, combined (consumers and clinicians) “convergence” meeting. SettingTwo SCI Model System centers in the United States. ParticipantsFourteen adults who work with individuals with traumatic SCI and 14 clinicians who work with individuals with SCI. Main Outcome MeasuresPlacement of bookmarks between vignettes based on SCI-FI Basic Mobility and Self-Care T scores. Bookmarks were placed between vignettes representing “No Problems,” “Mild Problems,” “Moderate Problems,” and “Severe Problems” for each item bank. ResultsEach consensus group resulted in a single set of scoring cut points for the SCI-FI/C Basic Mobility and Self-Care item banks. The cut points were similar but not identical between the consumer and clinician groups, necessitating a final convergence meeting. For SCI-FI/C Basic Mobility, the convergence group agreed on cut scores of 61.25 (no problems/mild problems), 51.25 (mild problems/moderate problems), and 41.25 (moderate problems/severe problems). For SCI-FI/C Self-Care, the convergence group agreed on cut scores of 56.25 (no/mild), 51.25 (mild/moderate), and 38.75 (moderate/severe). ConclusionsThe results of this study provide straightforward interpretive guidelines for SCI researchers and clinicians using the SCI-FI/C Basic Mobility and Self-Care instruments. These results are appropriate for the full bank, computer adaptive test, and short-form versions of the SCI-FI/C Basic Mobility and Self-Care item banks.

Correlation of neurological level and sweating level of injury in persons with spinal cord injury

Objective: Thermoregulatory dysfunction after spinal cord injury (SCI) impairs quality of life and predisposes persons to life-threatening sequela of heat-related illness (HRI) in conditions of high ambient temperature. SCI clinicians currently have no objective way to predict which persons are at greatest risk of HRI. Evaporative cooling via sweating is the body’s most efficient mechanism of heat dissipation. The relationship between the neurological level of injury (NLOI) and the degree of sudomotor dysfunction is not well defined. This study examines the relationship between the NLOI and sweating level of injury (SwLOI). This information can assist SCI clinicians in identifying individuals with SCI who have most impaired sudomotor function and thus highest risk of HRI. Design: Observational. Setting: Human physiology laboratory. Participants: 10 persons with tetraplegia (TP), 14 with paraplegia (PP) and 10 able-bodied (AB). Intervention: Passive heat stress (1°C rise in core temperature) with sweat responses (SR) quantified with the starch iodine test. Outcome measures: The most caudal dermatomal level in which sweating was visualized was recorded as the SwLOI, which was compared to the NLOI. Minimum, maximum and median differences between NLOI and SwLOI were calculated. Results: Persons with tetraplegia demonstrated no SR. Persons with paraplegia demonstrated SR at a median of 1 level below NLOI. Able-bodied controls demonstrated sweating on all skin surface areas. Conclusions: Persons with motor complete tetraplegia lack evaporative cooling capacity through SR during passive heat stress predisposing them to HRI. Meanwhile, persons with paraplegia sweat on average 1 dermatomal level below their NLOI.

Spinal Cord Injury Veterans' Disability Benefits, Outcomes, and Health Care Utilization Patterns: Protocol for a Qualitative Study.

BackgroundAn estimated 42,000 people currently living with chronic spinal cord injury (SCI) are veterans. SCI was a common combat-related injury in the World Wars and Vietnam era and now affects more than 11% of military personnel injured in Operation Iraqi Freedom and Operation Enduring Freedom. The Veterans Benefits Administration primarily offers financial compensation for disabilities sustained or re-aggravated during military service, called service-connected disability compensation. With the overwhelming cost of living with an SCI, this monthly financial compensation can provide service-connected veterans and their families with access to additional supportive resources (eg, assistive devices and personal aide) and maintain their quality of life (QOL). Little is known about personal, health, functional, and QOL outcomes associated with service-connected and nonservice-connected status for veterans living with an SCI.ObjectiveThe aim of this study is to compare the ways in which Veterans Affairs’ (VA) service-connected and nonservice-connected status may be associated with health and functional outcomes, choice of health care provider, and overall QOL for veterans living with an SCI and their caregivers.MethodsThis cross-sectional qualitative study will gather data using retrospective chart reviews, semistructured interviews, and focus groups. After obtaining institutional review board (IRB) approval, purposeful sampling techniques will be used to recruit and enroll the following key stakeholders: veterans living with an SCI, family caregivers, and SCI health care providers. Concurrent data collection will take place at 2 sites: Veterans Administration New Jersey Healthcare System and Northern New Jersey Spinal Cord Injury System.ResultsThis study was funded in July 2015. IRB approval was obtained by November 2016 at both sites. Enrollment and data collection for phase 1 to phase 4 are complete. A total of 69 veterans, 18 caregivers, and 19 SCI clinicians enrolled in the study. Data analyses for these phases are underway. In phase 5, the follow-up focus group activities are scheduled. The final results are expected by the end of 2019.ConclusionsThe factors that contribute to veterans living with SCI seeking and not seeking VA disability compensation benefits are not well understood in rehabilitation research. Triangulation of these data sources will allow us to compare, contrast, and integrate the results, which can be used to develop clinical guidelines, caregiver training, and patient education programs.International Registered Report Identifier (IRRID)DERR1-10.2196/14039

The Austrian Spinal Cord Injury Study: a registry for patients living with a traumatic spinal cord injury

Study designEstablishing the structure of a prospective spinal cord injury (SCI) patient registry.ObjectivesTo develop a registry for patients with traumatic spinal cord injury (tSCI) in Austria as a base for addressing research questions, improving patient outcomes, and establishing a platform for future clinical trials.SettingsCoordinating institution: Paracelsus Medical University Salzburg, Austria; participating partners are located in nine states in Austria.MethodsThe Austrian Spinal Cord Injury Study (ASCIS) collects longitudinal data on simple forms within a 7-stage follow-up examination timeline.ResultsThe implementation of the ASCIS in 2012 created the first nationwide SCI patient registry in Austria. ASCIS is currently implemented in 17 trauma hospitals in 9 Austrian states, and over 150 individuals with acute tSCI have been registered to date. As in Austria, the structure of the health-care system does not involve a specialized SCI center covering the primary health care and the rehabilitation care, major challenges have to be overcome to involve all participating primary centers and rehabilitation centers, which perform tSCI patient care, for ASCIS. Through implementing ASCIS, a network of SCI clinicians and researchers, which is now beginning to support translational research and to initiate clinical trials for patients with tSCI, has formed.ConclusionsASCIS is uniquely positioned in Austria to capture detailed information from the early acute to the chronic phases of tSCI, to provide this information also to bigger and translational settings, and to connect researchers and clinicians to facilitate clinical research on tSCI.

Methodology for the development and calibration of the SCI-QOL item banks

ObjectiveTo develop a comprehensive, psychometrically sound, and conceptually grounded patient reported outcomes (PRO) measurement system for individuals with spinal cord injury (SCI).MethodsIndividual interviews (n = 44) and focus groups (n = 65 individuals with SCI and n = 42 SCI clinicians) were used to select key domains for inclusion and to develop PRO items. Verbatim items from other cutting-edge measurement systems (i.e. PROMIS, Neuro-QOL) were included to facilitate linkage and cross-population comparison. Items were field tested in a large sample of individuals with traumatic SCI (n = 877). Dimensionality was assessed with confirmatory factor analysis. Local item dependence and differential item functioning were assessed, and items were calibrated using the item response theory (IRT) graded response model. Finally, computer adaptive tests (CATs) and short forms were administered in a new sample (n = 245) to assess test-retest reliability and stability.Participants and ProceduresA calibration sample of 877 individuals with traumatic SCI across five SCI Model Systems sites and one Department of Veterans Affairs medical center completed SCI-QOL items in interview format.ResultsWe developed 14 unidimensional calibrated item banks and 3 calibrated scales across physical, emotional, and social health domains. When combined with the five Spinal Cord Injury – Functional Index physical function banks, the final SCI-QOL system consists of 22 IRT-calibrated item banks/scales. Item banks may be administered as CATs or short forms. Scales may be administered in a fixed-length format only.ConclusionsThe SCI-QOL measurement system provides SCI researchers and clinicians with a comprehensive, relevant and psychometrically robust system for measurement of physical-medical, physical-functional, emotional, and social outcomes. All SCI-QOL instruments are freely available on Assessment CenterSM.

Preventive Health Care Among Community-Dwelling Persons with Spinal Cord Injury

To describe preventive health examinations/tests and behaviors of persons with traumatic spinal cord injury (SCI). Survey. SCI clinic and telephone contact. A total of 59 persons ≥18 years of age with traumatic SCI. None. Preventive health examinations/tests and reason for not receiving an examination or test. Preventive health tests/examinations received within the past year: flu vaccination (40.7%); eye examination (50.8%); dental check-up (64.4%); physical examination (61.0%); vitamin D level (56.0%); cholesterol level (25.4%); and blood glucose level (39.0%). For men, 20.0% had a prostate examination and 20.0% had a colonoscopy. For women, 25.0% had a pelvic examination and 62.5% had a mammogram in the past 2 years. The most endorsed reasons for not getting an examination/test was "It was my choice" followed by "No one told me to have [examination/test]." The number of years injured had an inverse relationship with having vitamin D level checked (r = -334) and had a positive association with having serum cholesterol level checked (r = .474). Preventive health tests and examinations in the SCI population are being obtained at about the same rate as in the U.S. population with some exceptions (ie, cholesterol level check, colonoscopy, and pelvic examination); however, the rates are far from the goals of Healthy People 2020. Primary care and SCI clinicians should be proactive in educating their patients about the importance of preventive health, especially those who have been injured for a long time.

The 6-min Push Test Is Reliable and Predicts Low Fitness in Spinal Cord Injury

The objective of this study is to assess 6-min push test (6MPT) reliability, determine whether the 6MPT is sensitive to fitness differences, and assess if 6MPT distance predicts fitness level in persons with spinal cord injury (SCI) or disease. Forty individuals with SCI who could self-propel a manual wheelchair completed an incremental arm crank peak oxygen consumption assessment and two 6MPTs across 3 d (37% tetraplegia (TP), 63% paraplegia (PP), 85% men, 70% white, 63% Hispanic, mean age = 34 ± 10 yr, mean duration of injury = 13 ± 10 yr, and mean body mass index = 24 ± 5 kg.m). Intraclass correlation and Bland-Altman plots assessed 6MPT distance (m) reliability. Mann-Whitney U test compared 6MPT distance (m) of high and low fitness groups for TP and PP. The fitness status prediction was developed using N = 30 and validated in N = 10 (validation group (VG)). A nonstatistical prediction approach, below or above a threshold distance (TP = 445 m and PP = 604 m), was validated statistically by binomial logistic regression. Accuracy, sensitivity, and specificity were computed to evaluate the threshold approach. Intraclass correlation coefficients exceeded 0.90 for the whole sample and the TP/PP subsets. High fitness persons propelled farther than low fitness persons for both TP/PP (both P < 0.05). Binomial logistic regression (P < 0.008) predicted the same fitness levels in the VG as the threshold approach. In the VG, overall accuracy was 70%. Eighty-six percent of low fitness persons were correctly identified (sensitivity), and 33% of high fitness persons were correctly identified (specificity). The 6MPT may be a useful tool for SCI clinicians and researchers. 6MPT distance demonstrates excellent reliability and is sensitive to differences in fitness level. 6MPT distances less than a threshold distance may be an effective approach to identify low fitness in person with SCI.

Spinal Cord Injury-Functional Index: Item Banks to Measure Physical Functioning in Individuals With Spinal Cord Injury

Tulsky DS, Jette AM, Kisala PA, Kalpakjian C, Dijkers MP, Whiteneck G, Ni P, Kirshblum S, Charlifue S, Heinemann AW, Forchheimer M, Slavin MD, Houlihan B, Tate DG, Dyson-Hudson T, Fyffe D, Williams S, Zanca J. Spinal Cord Injury-Functional Index: item banks to measure physical functioning in individuals with spinal cord injury. ObjectivesTo develop a comprehensive set of patient-reported items to assess multiple aspects of physical functioning relevant to the lives of people with spinal cord injury (SCI), and to evaluate the underlying structure of physical functioning. DesignCross-sectional. SettingInpatient and community. ParticipantsItem pools of physical functioning were developed, refined, and field tested in a large sample of individuals (N=855) with traumatic SCI stratified by diagnosis, severity, and time since injury. InterventionsNone. Main Outcome MeasureSpinal Cord Injury-Functional Index (SCI-FI) measurement system. ResultsConfirmatory factor analysis (CFA) indicated that a 5-factor model, including basic mobility, ambulation, wheelchair mobility, self-care, and fine motor function, had the best model fit and was most closely aligned conceptually with feedback received from individuals with SCI and SCI clinicians. When just the items making up basic mobility were tested in CFA, the fit statistics indicated strong support for a unidimensional model. Similar results were demonstrated for each of the other 4 factors, indicating unidimensional models. ConclusionsThough unidimensional or 2-factor (mobility and upper extremity) models of physical functioning make up outcomes measures in the general population, the underlying structure of physical function in SCI is more complex. A 5-factor solution allows for comprehensive assessment of key domain areas of physical functioning. These results informed the structure and development of the SCI-FI measurement system of physical functioning.

Comparing Quantification of Pain Severity by Verbal Rating and Numeric Rating Scales

Background: Researchers have reported widely varying correlations among the 3 main instruments used to quantify pain severity, Visual Analog Scale (VAS), Verbal Rating Scale (VRS), and Numeric Rating Scale (NRS), both at the level of groups and at the level of individuals.Objective: To assess the comparability of reports of pain severity using a VRS and a NRS in a spinal cord injury (SCI) sample.Methods: Data were taken from a longitudinal observational study. Patients were 168 individuals with new traumatic SCI admitted for inpatient rehabilitation who completed the VRS and NRS multiple times, each time for multiple pains as appropriate.Results: For 1,114 ratings of pain, VRS and corresponding NRS ratings were correlated weakly (Spearman correlation, rho = 0.38). For 36 individuals with at least 10 completions of paired VRS and NRS, rho ranged from -0.55 to 0.76. Variation in NRS rating for each VRS adjective was reduced by about 25% when between-patient variation was eliminated. Mean NRS ratings by VRS adjective, for patients who had used each of at least 2 adjectives at least 5 times each, showed large differences in mean NRS scores between individuals using the same VRS adjective.Conclusion: There are considerable differences between individuals in how NRS and VRS are used; there also seem to be individuals whose understanding of the meaning of the VRS adjectives is completely different from what was assumed by the creators of this VRS. Both VRS and NRS data must be used with extreme caution by SCI clinicians and researchers.

Clinical correlates of frequency analyses of cardiovascular control after spinal cord injury

Spinal cord injury (SCI) has profound effects on cardiovascular autonomic function due to injury to descending autonomic pathways, and cardiovascular diseases are the leading causes of morbidity and mortality after SCI. Evaluation of cardiovascular autonomic dysfunction after SCI and appraisal of simple noninvasive autonomic assessments that are clinically meaningful would be useful to SCI clinicians and researchers. We aimed to assess supine and upright cardiovascular autonomic function from frequency analyses of heart rate and blood pressure variability (HRV and BPV) after SCI. We studied 26 subjects with chronic cervical or thoracic SCI and 17 able-bodied controls. We continuously recorded R-R interval (RRI, by ECG) and beat-to-beat blood pressure (by Finometer) in supine and seated positions. Cardiovascular control was assessed from spectral analysis of RRI and blood pressure time series. Cardiac baroreflex control was assessed from cross-spectral analyses of low-frequency spectra. Supine and upright low-frequency HRV and BPV were reduced in cervical SCI subjects, as were total BPV and HRV. Supine high-frequency HRV was reduced in thoracic SCI subjects. Cardiac baroreflex delay was increased in cervical SCI subjects. Supine frequency domain indexes were correlated with sympathetic skin responses, orthostatic cardiovascular responses, and plasma catecholamine levels. SCI results in reduced sympathetic drive to the heart and vasculature and increased baroreflex delay in cervical SCI subjects and reduced cardiac vagal tone in thoracic SCI subjects. Frequency analyses of autonomic function are related to clinical measures of autonomic control after SCI and provide useful noninvasive clinical tools with which to assess autonomic completeness of injury following SCI.

Spinal Cord Injury: Promise, Progress, and Priorities

Spinal Cord Injury: Promise, Progress, and Priorities from the National Academies' Institute of Medicine proposes a comprehensive research program to enhance neurologic and functional outcomes for people with spinal cord injury (SCI). With funding from the New York State Spinal Cord Injury Board, the Institute of Medicine impanelled a 13-member committee of SCI researchers and advocates that also solicited recommendations from other well-known SCI researchers. The book posits potential for clinical breakthroughs based on recent animal SCI research and outlines a proposal for greater study of basic SCI neurobiology and of neuroplasticity treatment options, coordinated translational trials, and strengthened infrastructure for SCI research. The book most successfully targets persons with SCI, advocates for SCI research, and policy makers. For SCI researchers and SCI clinicians, much of the material is basic review, although the overview may be useful for those new to the field. The chapter on design of clinical trials argues for a traditional “big science” approach with several Centers of Excellence and a National SCI Research Network to be established to facilitate large-scale, multicenter trials. An alternate viewpoint, that exploratory research is often most rapidly and most cost-effectively accomplished on a small scale by many individual basic science researchers and clinician-investigators, is not represented. Many potential therapeutic interventions are addressed, such as preventing secondary neurologic injury, controlling inflammation, promoting axon regrowth, using gene therapy, bridging gaps with transplantation, and restoring impulse conduction. Concerns are raised about the premature clinical use of these new therapies before safety has been fully evaluated (eg, oligodendrocyte-ensheathing glia transplants into the spinal cord of patients with paraplegia). Some areas of SCI research with therapeutic potential are minimally discussed (eg, treatment of incomplete spinal cord injury, neurotransmitters and neurotrophins and their respective receptor changes, plateau potentials, ion-channel alterations, robotics, and brain-computer interfaces). Figures are sparse. The final chapter on state-funded SCI research programs nicely summarizes this less well-known information.