POSTER AWARD WINNER EDUCATION: SCI-U: AN INNOVATIVE APPROACH TO ONLINE PATIENT EDUCATION IN SPINAL CORD INJURY

John Shepherd; Karla Badger-Brown; Brian Lingley; Joanne Smith; Saagar Walia; Matthew Legassic; Dalton Wolfe

doi:10.1179/1079026812Z.00000000092

J Spinal Cord Med. 2012 Sep;35(5):419–478.

PARTNERS IN SUCCESS: EXPLORING RESEARCH-STAKEHOLDER PARTNERSHIPS AS A CRITICAL MECHANISM FOR KNOWLEDGE TRANSLATION AND EVIDENCE-BASED PRACTICE

Peter Athanasopoulos ¹, Amy Latimer-Cheung ², Heather Gainforth ³, Sonya Corkum ⁴, Kelly Arbour-Nicitopoulos ⁵, Kathleen Martin Ginis ⁶

Abstract

Background/Objective

There are increased expectations for researchers to translate their scientific findings into practical tools and to disseminate these tools broadly. In turn, practitioners and service organizations are under pressure to integrate evidence into their practice. The purpose of this workshop is to present research-stakeholder partnerships as a mechanism for successful knowledge translation and for effectively facilitating evidence-based practice. Specifically, we will highlight the critical elements for successful partnership and the research and organizational outcomes of a successful partnership.

Methods/Overview

SCI Action Canada was established in 2008 with a mandate of advancing physical activity knowledge and participation among Canadians living with spinal cord injury. SCI Action Canada is a consortium of nine researchers from across Canada and the United Kingdom and twenty community organizations. Fostering strong partnerships between the research community and service organizations has resulted in multiple successful knowledge translation initiatives and adoption of evidence-based practice. To exemplify these successes and mechanisms for collaboration, this workshop will focus specifically on strong the partnership between SCI Action Canada and the Canadian Paraplegic Association (CPA) of Ontario, a consumer driven service agency.

Results

Creating a successful partnership requires time and trust between organizations. Together, our team including the Director of SCI Action Canada, Partnership Manager from CPA Ontario, a Knowledge Mobilization Expert and a Researcher will describe the process of creating partnerships and fostering trust between organizations. The knowledge translation research that has resulted from this partnership, including an evaluation of a knowledge dissemination initiative and a study of organizational networks, will be highlighted along with some of lessons learned. The important contributions of this research to the field of knowledge translation and its influence on practice within CPA Ontario will be discussed.

Conclusions

Partnerships are an invaluable resource for knowledge translation and evidence-based practice. In successful partnerships both researchers and service organizations have much to gain.

Acknowledgements

Research supported by a Community-University Research Alliance grant from SSHRC. Research team members supported by a Mentor-Trainee Award from the Ontario Neurotrauma Foundation (KMG and AEL), the Canada Research Chair (CIHR) program (AEL) and a CIHR Canada Graduate Scholarship (HLG).

J Spinal Cord Med. 2012 Sep;35(5):419–478.

ENHANCING EDUCATION DELIVERY: AN EVALUATION OF THE CLIENT EDUCATION SESSIONS AND PRINT MATERIALS IN A SPINAL CORD INJURY PROGRAM

Karen Anzai ¹, Amber Backwell ², Corrie Funk ³, Kim van Wyk ⁴, Walt Lawrence ⁵, Brad Jacobsen ⁶, Andrea Townson ⁷

Abstract

Background/Objective

Education is a vital component of Spinal Cord Injury (SCI) rehabilitation. It is essential that persons with SCI are equipped with the knowledge, skills and confidence needed to maintain their health. The rehabilitation education program at the GF Strong Rehabilitation Centre aims to prepare SCI clients for their return to the community, while operating in an evidence-based, client-centred manner. While the education program involves an array of activities, this evaluation looks specifically at the weekly inpatient education sessions and print material distribution. The education sessions are one hour sessions that occur twice weekly and are provided by various members of the rehabilitation team. There are 18 sessions in total, and session topics include, but are not limited to: pain management, bowel and bladder management, nutrition, housing, healthy relationships, and sexual health. Objectives: To evaluate the SCI inpatient education sessions and supporting print material as part of an ongoing Quality Improvement project at GF Strong. We evaluated the effectiveness of these sessions in improving the knowledge and skills of SCI patients in regards to SCI-related care. We wanted to know if this translates into improved confidence, self-efficacy, and ultimately self-management surrounding their care once back out into the community. Further, we sought to find out what could be done to enhance education delivery at GF Strong to meet these goals.

Methods/Overview

Three focus groups and 12 telephone interviews were conducted to evaluate the inpatient education sessions and print material.

Results

The first two focus groups consisted of inpatients nearing the end of their rehabilitation stay at GF Strong. The third focus group consisted of former GF Strong clients who had been back out in the community for at least 3 months to one year, and who were residing in the Greater Vancouver area. The telephone interviews were also with outpatients, but with those who resided outside of the Greater Vancouver area, including those in rural and remote areas. Themes were abstracted from notes and recordings made during the focus groups and telephone interviews. Members of the evaluation team identified reoccurring and prominent points discussed.

Conclusions

In an effort to improve the quality of the inpatient education sessions at GF Strong, the results of this evaluation are being incorporated into future sessions and print material updates.

Acknowledgements

none.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

THE EFFECTS OF CYCLOSPORIN-A ON FUNCTIONAL OUTCOME AND AXONAL REGROWTH FOLLOWING SPINAL CORD INJURY IN ADULT RATS

H Delaviz ¹, A Mirzaei ², A Roozbehi ³, M Taghi Joghataie ⁴, M Mehdizadeh ⁵

Abstract

Background/Objective

It has been shown that the immunophilin ligands have special advantage in spinal cord repair.

Methods/Overview

In this study the effects of cyclosporin-A (CsA) on functional recovery and histological outcome were evaluated following spinal cord injury in rats. After spinal cord hemisection in thirty six adult female Sprague-Dawley rats (200–250 g), treatment groups received CsA (2.5 mg/kg i.p.) at 15min and 24h after lesion (CsA 15min group and CsA 24h group) daily, for 8 weeks. Control and sham groups received normal saline and in sham operated animals the spinal cord was exposed in the same manner as treatment groups, but was not hemisected. Hindlimb motor function was assessed in 1, 3, 5 and 7 weeks after lesion, using locomotive rating scale developed by Basso, Bresnahan and Beattie (BBB). Motor neurons were counted within the lamina IX of ventral horn and lesion size was measured in 5 mm of spinal lumbar segment with the epicenter of the lesion site.

Results

The mean number of motor neurons and the mean BBB scale in 3, 5 and 7 weeks in CsA 15min groups significantly increased compared to the control group. Although, the lesion area reduced in rats with CsA treatment compared to the control group, no significant difference was observed. Thus, the CsA can improve locomotor function and histological outcome in the partial spinal cord injury.

Acknowledgements

This research study was financially supported by a grant from Tehran University of Medical Sciences (Tehran-Iran, No; 364).

J Spinal Cord Med. 2012 Sep;35(5):419–478.

PROGRAM EVALUATION STRATEGIES FOR CLINICIANS: CASE-EXAMPLES OF INTERVENTIONS AIMED AT IMPROVING WELL-BEING

Sander Hitzig ¹, Charlene Alton ², Patricia Bain ³, Sylvia Haycock ⁴, Nicole Leong ⁵, Aliza Panjwani ⁶

Abstract

Background/Objective

People who cope poorly after spinal cord injury (SCI) are at risk of long-term difficulties, and there is a need for interventions that address the psychological and environmental factors early post-SCI in order to improve outcomes in quality of life (QoL) and community participation. Given the need to be efficient with available resources in the current health care system, undertaking program evaluation may help to strengthen the value of a program by effectively illustrating its impact on an evidence-based practice. Program evaluation is the systematic gathering, analysis and reporting of data about a program to assist in decision-making, which can serve to demonstrate whether clients are being helped by the program, and if they are satisfied with the services provided. Thus, the objectives of this workshop are to provide clinicians with case examples of program evaluation activities done at a SCI tertiary hospital, which will serve to illustrate strategies for developing their own evaluation frameworks relevant to their clinical practice.

Methods/Overview

An inter-professional panel from occupational therapy, research, social work, and therapeutic recreation will provide an overview of two clinical initiatives that implemented a program evaluation framework. This includes: 1) the Spinal Cord Rehabilitation Program (SCRP) Cottage Program, a 4-day/3 night trip to an accessible campground in Ontario where patients with SCI engage in a variety of outdoor activities (i.e., handcycling, canoeing, sailing, etc.); and 2) The Community Reintegration Out-Patient (CROP) service, a psycho-education group aimed at improving emotional, physical and social well-being.

Results

The evaluation frameworks presented will characterize the steps undertaken for their design, and summarize the findings obtained. As well, these case examples will provide strategies for outcome tool selection, suggestions for involving researchers with the process, and will highlight research ethics board considerations. Finally, a brief discussion will be held by a research and clinician panel on the benefits and challenges of conducting program evaluation.

Conclusions

Developing and implementing a program evaluation framework can provide evidence on the efficacy of a clinical program, provide feedback to staff on the status of their practice, and thus improve patient care.

Acknowledgements

Funding Source: Toronto Rehabilitation Institute – UHN, which receives funding under the Provincial Rehabilitation Research Program from the Ministry of Health and Long-Term Care in Ontario. The views expressed do not necessarily reflect those of the Ministry. Granting Agency: Ontario Neurotrauma Foundation/Rick Hansen Institute; Grant# 2010-RHI-MTNI-836.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

DEVELOPMENT OF SCI REHABILITATION IN NEPAL

Carol Scovil ¹, Sylvia Haycock ², Edith Ng ³, Angie Andreoli ⁴, Nora Cullen ⁵

Abstract

Background/Objective

Rehabilitation for Spinal Cord Injury (SCI) in Nepal began in 1997 when Green Pastures Hospital and Rehabilitation Centre transitioned from leprosy to more general rehabilitation. In 2002 the Spinal Injury Rehabilitation Centre in Kathmandu was founded, providing a second SCI centre to serve a country of 30 million people. Primary care in SCI rehabilitation is provided by Nepali clinicians. Expatriate professionals have been involved in the initial implementation, as well as ongoing capacity building. Over the past 15 years, SCI rehabilitation has significantly improved, despite limited infrastructure and resources. NepalAbility (NA) is a Canadian non-profit organization that supports rehabilitation within Nepal by enhancing education amongst staff, patients and families across the continuum of care. Since 2006, NA has sent 9 interprofessional teams to Nepal, each providing education and service to local clinicians. This ongoing commitment has allowed relationships to develop with local staff and medical centres, and for teams to respond to the changes in SCI rehabilitation over time.

Methods/Overview

Initially, NA teams provided education on core principles of SCI, including management, complication prevention, and rehabilitation techniques. In response to feedback from Nepali clinicians and their increased knowledge base, recent teams have focused on hands-on assessment and treatment skills. Promoting collaboration and networking across interprofessional groups has been of paramount importance. Team building and recognition of clinicians’ skills and strengths have assisted with knowledge sharing and translation. Further, leveraging existing systems and processes has played a key role in the continued implementation and sustainability of best practices in rehabilitation in Nepal.

Results

Changes such as the use of intermittent instead of indwelling catheters demonstrate the adoption of SCI best practices in Nepal. Occupational Therapy is now recognized as essential to care, both in the acute and rehabilitation phases, and is becoming a more developed and understood profession in Nepal. This year NA has committed funding support for a dedicated neurorehab physiotherapist in an acute care centre to further enhance care during the acute phase after SCI, as well as following stroke and brain injury.

Conclusions

Despite the relatively short history of SCI treatment in Nepal, clinicians and hospitals continue to improve collaborative care to help promote best practices for rehabilitation after SCI.

Acknowledgements

none.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

ESTABLISHING BEST PRACTICES IN PATIENT AND FAMILY EDUCATION

Sandra Mills ¹, Charlie Warriner ², Nicole Leong ³

Abstract

Background/Objective

With shorter lengths of stay, it is vital that patients learn the skills to live safely and healthy in the community. Best practices in adult education and patient education will be demonstrated and discussed that help better prepare patients and families for transition to the community. Research shows patients benefit from an education program designed and delivered according to adult learning principles. Is education uptake influenced by peer co-facilitated,problem based learning using adult education practices?

Methods/Overview

A literature review was conducted to assess education needs of people in a sub-acute SCI rehab program as well as best practices in SCI education. Themes relevant to adult education and SCI were identified. The TRI – Spinal Cord Rehab Patient and Family Education Program includes adult and dialogue education principles and evidence-based information on each topic. The SCRP Education program reflects best practice in adult learning. The program is offered for 30 minutes twice per week over a six week cycle. Key learning points relevant to newly injured patients are reviewed. Problem-based learning scenarios during the session help identify the meaning, relevance and strategies to patient's life. Peer co-facilitators review the learning scenarios and share life experiences.

Results

Patients and family members are demonstrating learning through their ability to solve problems both during the education session and in therapy. In six education cycles 86% of patients agreed or strongly agreed they plan on using the information provided during the session. Peer led problem based learning is facilitating patient's understanding of relevance and meaningfulness to daily life.

Conclusions

Adult learning and education principles are key requirements in optimizing patient and family education programs in SCI rehabilitation. Engaging patients in their care and education promotes uptake and receptivity to information. Workshop participants will engage in an education session followed by dialogue and discussion on the strengths and challenges of offering a comprehensive patient and family education program in SCI rehab.

Acknowledgements

none.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

EVIDENCE BASED, COMMUNITY VETTED: THREE CASE STUDIES OF KNOWLEDGE TRANSLATION TO THE SCI COMMUNITY

Kathleen Martin Ginis ¹, Spero Ginis ²

Abstract

Background/Objective

SCI Action Canada is an alliance of 30 community-based organizations and university-based researchers working together to increase physical activity participation among people living with SCI. The alliance is underpinned by a commitment to the rigorous development and testing of physical activity-enhancing resources and interventions, and the translation of those innovations into products and services for implementation within the SCI community. This poster presents three case studies documenting SCI Action Canada knowledge translation activities whereby research evidence was community-vetted, and ultimately developed into products and services for the SCI community.

Methods/Overview

Three knowledge translation case studies will be presented: (1) Dissemination of The Physical Activity Guidelines for Adults with SCI; (2) Marketing of the Get in Motion SCI physical activity counseling service, and (3) Translation of Active Homes research procedural materials into consumer resources for home-based strength-training. The case studies will (a) highlight the evidence base that led to each knowledge translation activity, (b) describe how this evidence was vetted through the SCI community during the knowledge translation process, 3) and describe how the evidence was translated into services and resources that inform, teach and enable people living with SCI to initiate and maintain a physically active lifestyle.

Results

Based on web-site hits, downloads, the number of requests for information, mailouts, and other indices of community reach, SCI Action Canada has reached a substantial proportion of the Canadian SCI community through its knowledge translation activities. This success is due, in part, to the engagement of the SCI community throughout the knowledge translation process.

Conclusions

When the goal is to utilize research to improve the health and well-being of members of a community, community members should be involved in the knowledge translation process. The SCI Action Canada cases highlight the value of vetting evidence based-findings through the real world experience of end-users.

Acknowledgements

Granting Agency: Social Sciences and Humanities Research Council Funding Source: Rick Hansen Institute Ontario Neurotrauma Foundation Canadian Paralympic Committee.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

POSTER AWARD WINNER – PATIENT CARE

SOCIAL NETWORKS AND SECONDARY HEALTH CONDITIONS: THE CRITICAL SECONDARY TEAM FOR INDIVIDUALS WITH A SPINAL CORD INJURY

Sara Guilcher ¹, Louise Lemieux-Charles ², Tiziana Casciaro ³, Catharine Craven ⁴, Mary Ann McColl ⁵, Susan Jaglal ⁶

Abstract

Background/Objective

To describe the structure of informal networks for individuals with spinal cord injury (SCI) living in the community, to understand the quality of relationships of informal networks, and to understand the role of informal networks in the prevention and management of secondary health conditions (SHCs).

Methods/Overview

We used a mixed method exploratory descriptive approach. In-depth semi structured interviews were conducted with community-dwelling individuals with a SCI living in Ontario. The recruitment strategy included purposeful snowball sampling for maximum variation experiences. The Arizona Social Support Interview Survey was used to measure social networks. Participants were asked the following open-ended questions: (1) What have been your experiences with your health care in the community? (2) What have been your experiences with care related to prevention and/or management of SHCs? (3) What has been the role of your informal social networks (friends/family) related to SHCs?

Results

Fourteen key informant interviews were conducted (6 men, 8 women). The majority of individuals (n = 13) reported significant challenges with SHCs in the past year. The overall median for available informal networks was 11.0 persons (range 3–19). Networks were larger for social support (median = 6.5), and physical assistance (median = 4.0), followed by positive feedback (median = 3.5), advice (median = 3.0), material assistance (median = 2.5) and intimate relations (median = 2.5). The informal network engaged in the following roles: (1) advice/validating concerns; (2) knowledge brokers; (3) advocacy; (4) preventing SHCs; (5) assisting with finances; and (6) managing SHCs. Participants described their informal networks as a “secondary team”, that is, a critical and essential force in dealing directly and indirectly with SHCs.

Conclusions

While networks are smaller for persons with SCI compared to the general population, these ties seems to be strong, which is essential when the roles involve a level of trust, certainty, tacit knowledge, and flexibility. These informal networks serve as essential key players in filling the gaps that exist within the formal health care system.

Acknowledgements

Granting Agency/Funding Source: Women's College Research Institute, Toronto Rehabilitation Institute – UHN, the Ontario Neurotrauma Foundation, the Health Services and Policy Research Network, Canadian University Research Alliance and the Canadian Institutes of Health Research.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

“THE FINGER” – AN AID FOR DIGITAL RECTAL STIMULATION

Dianna Mah-Jones ¹

Abstract

Background/Objective

Individuals with a spinal cord injury above the conus medullaris have a hyperreflexic bowel. There is increased colonic wall and anal tone and the external anal sphincter remains tight thereby retaining stool. A key intervention is digital rectal stimulation (DRS) in which a gloved, lubricated finger is inserted into the rectum then slowly rotated to stimulate increased reflex muscular activity and to relax the external anal sphincter. Thirty-five to 50% of individuals with neurogenic bowel dysfunction utilize DRS.

Methods/Overview

A client with a C3 AIS C spinal cord injury identified independence in bowel management as a pre-discharge goal. The client had good dexterity in his right hand and adequate upper body control to be able to clean himself after toileting when sitting on a padded raised toilet seat. However, he did not have enough reach to perform DRS. The commercially available Royal Grip Digital Bowel Stimulator was much longer than he needed plus was relatively expensive. Thus, a custom approach was utilized: a prosthetic finger was made using Rolyan thermoplastic beads. The softened beads were molded around the third digit of his right hand, extending 2″ beyond his digit and gently curved at the distal end.

Results

To perform the digital stimulation, the client followed the usual procedures of gloving and lubricating The Finger. The stretchiness of the latex glove accommodated the length of the prosthetic without difficulty. He was easily able to insert The Finger into the anal canal and perform the necessary motions as often as he needed and in a timely manner. He could check himself to know when he had completed his bowel evacuation. The client reported he was able to finish his bowel routine in 20 minutes as compared to 60 minutes with nursing staff.

Conclusions

Independence in bowel routine provides dignity, privacy and efficiency for an intimate function. A prosthetic finger made from thermoplastic beads may be an effective assistive device for individuals needing only 2″ to 3″ of extra reach to perform DRS. The thermoplastic is non-porous, lightweight and easily formed. Fitted snuggly to the digit, it requires no strapping. Its compact size makes it discreet for travel. The cost for materials is less than $2.00. As a prosthetic device, there is minimal sensory feedback and individuals who have absent sensation over the perineum may have difficulty situating the aid. Further trials of The Finger with persons with upper motor neuron bowel syndrome is planned.

Acknowledgements

non-funded.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

ACESSIBILITY TO REHABILITATION OF ADULT PATIENTS WITH DUAL DIAGNOSIS OF SPINAL CORD INJURY AND MENTAL HEALTH DISORDER

Mirela Anton ¹, Sera Nicosia ²

Abstract

Background/Objective

Spinal cord injuries present devastating life changes.When individuals also have mental health comorbidities there are unique challenges in cooping and learning new skills required for patients with diagnosis of a new spinal cord injury. A chart review was done to better understand the population referred to Spinal Cord Injury Rehabilitation program at the Regional Rehabilitation Center ( RRC). A subset of the population included those with diagnosis of Spinal Cord Injury/Illness combined with Mental Health Disorder (MHD). This review was done in an effort to identify and provide appropriate services for these patients.

Methods/Overview

Acute and rehabilitation data was prospectively retrieved and collected from the RRC Referral Database and the Rick Hansen SCI registry (RHSCIR) database for all the patients with dual diagnosis SCI/Mental Health admitted to Hamilton General Hospital and referred from the community to the SCI inpatient Rehabilitation Unit from September 2010–Septemeber 2011. Data elements captured included age, sex, SCI diagnosis, SCI etiology, SCI level, mental health diagnosis, admission date to acute, admission date to rehabilitation, and reason for not being admitted to rehabilitation. Study sample: The chart review revealed about 100 patients during the six months interval. A total of 21 patients with Dual Diagnosis of SCI/Mental Health were identified. There were 9 males and 12 females. The ages ranged from 21 to 88 years. The average age was 49 years. The subsequent six months review is pending.

Results

Six of the 21 patients (28%) were not admitted to the SCI impatient Rehabilitation unit. Out of 28% patients that were not admitted to the inpatient rehabilitation, 14% still received rehabilitation on outpatient basis. The most common reasons for not being admitted were the following: 1) patient did not require inpatient stay and were referred to outpatient rehabilitation program; 2) patient was referred directly to Toronto SCI rehabilitation program; 3) patient were not ready medically; 4) patients were repatriated to acute community hospital.

Conclusions

The results of this review so far suggests that the majority (72%) of the patients identified with Dual Diagnosis of SCI and Mental Health disorder between September 2010 and April 2011 were admitted to the SCI impatient Rehabilitation Program. The outcome of this review will facilitate in the planning of services, treatment approaches and clarify resources required for this patient population.

Acknowledgements

None.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

ACCESS TO CARE (ACT) FOR TRAUMATIC SPINAL CORD INJURY: A SURVEY OF CANADIAN ACUTE AND REHABILITATION CENTRES

Vanessa K Noonan ¹, Andrea Townson ², Richard Fox ³, R John Hurlbert ⁴, A Gary Linassi ⁵, Karen Ethans ⁶, Deborah Tsui ⁷, Anthony S Burns ⁸, Catharine Craven ⁹, Dalton Wolfe ¹⁰, Catherine Truchon ¹¹, Dany Gagnon ¹², Julie Charron ¹³, Michael G Fehlings ¹⁴, Lesley Soril ¹⁵, Argelio Santos ¹⁶, Marcel F Dvorak ¹⁷

Abstract

Background/Objective

The ideal system of care for persons with traumatic spinal cord injury (tSCI) has not been defined. The Trauma Association of Canada developed standards for trauma patients and the Commission on Accreditation of Rehabilitation Facilities has guidelines for SCI, but currently no standards are used consistently across Canada. The objective of this study was to describe acute and rehabilitation care delivery for tSCI in Canada.

Methods/Overview

A standardized survey was sent to 25 acute and rehabilitation centres participating in the Access to Care and Timing (ACT) study. The survey included questions about: 1) number of admissions/discharges in a 12-month period; 2) care delivery (e.g. structure of in-patient units); and 3) the relationship among acute and rehabilitation facilities (e.g. admission criteria). The survey was completed using data from the Rick Hansen Spinal Cord Injury Registry in each centre or other hospital databases, clinical protocols and expert opinion. Data was analyzed using descriptive statistics.

Results

Surveys were completed by 24 of 25 centres (96% completion rate). The sample included 12 acute centres, 9 rehabilitation centres and 3 acute/rehabilitation centres, covering 7 provinces. Centres providing acute and rehabilitation care in one hospital were described separately, resulting in the analysis of data from 15 acute and 12 rehabilitation centres. The number of admissions for tSCI per acute and rehabilitation centre ranged between 19 and 104 (median 39) and 15 to 96 (median 33), respectively in a 12-month period. Grouping patients with tSCI on spine-specific units, regardless of level of injury, occurs in 7 of 15 acute centres and 9 of 12 rehabilitation centres. In 11 of 15 acute centres a physiatrist is consulted prior to admission to an in-patient rehabilitation centre. Differences were noted in the admission criteria to in-patient rehabilitation (e.g. required age of patient on admission, sitting tolerance, ventilation status) among centres.

Conclusions

A patient's journey following a tSCI involves multiple phases and is influenced by clinical and administrative processes and decisions. Results from the ACT survey identified similarities and differences in the provision of care across Canada. Further work is needed to minimize regional disparities. Evidence generated from the ACT project will be used to develop SCI standards that will be implemented by Accreditation Canada in the near future.

Acknowledgements

Granting Agency/Funding Source: Health Canada.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

AUTONOMIC DYSREFLEXIA, SEIZURES, RHABDOMYOLYSIS AND ACUTE RENAL FAILURE IN A SPINAL CORD INJURED PATIENT WITH AN INTRATHECAL BACLOFEN PUMP: A CASE REPORT

Karen Chu ¹, Yolanda Kiersnowski ², Michael Boyd ³, Steven Wong ⁴, Andrea Townson ⁵

Abstract

Background/Objective

To describe the presentation, diagnosis and management of a case of autonomic dysreflexia, seizures, rhabdomyolysis and acute renal failure in a patient with intermittent intrathecal baclofen withdrawal symptoms.

Methods/Overview

A 41 year old male with a C7 ASIA impairment scale C spinal cord injury had been on intrathecal baclofen treatment for severe spasticity since 1997. In 2011, he developed increasing abdominal spasms, autonomic dysreflexia (systolic blood pressure >200 mm Hg, heart rate 140 bpm) and seizures. The presumed diagnosis was intrathecal baclofen withdrawal. Despite oral baclofen, diazepam, lorazepam and hydromorphone and an increase in intrathecal baclofen, his intermittent severe abdominal spasms and autonomic instability progressed over several weeks. His legs remained flaccid throughout the episodes. Interrogation of the pump was unremarkable. X-rays and CT scan showed the tip of the catheter in good position with CT contrast seen at the tip of the catheter. Spinal MRI showed no change in a previously identified cystic myelomalacia. CSF aspiration through the side-port of the pump was easily performed and the fluid was negative for infection. An indium scan through his pump showed no progression of radioactivity beyond the L3-4 level where the catheter tubing entered his spinal canal. The working diagnosis was an intermittent kink and possible leak at that level resulting in inconsistent delivery of intrathecal baclofen. Before the surgery to replace his catheter and pump could occur, he presented with a decreased level of consciousness, rhabdomyolysis and acute renal failure (CK 37,260 U/L + creatinine 290 umol/L). He had independently increased his oral medications up to 120 mg of diazepam and 12 mg of lorazepam daily.

Results

He was started on hemodialysis for acute renal failure. A temporary external pump and catheter were placed to provide alternate delivery of intrathecal baclofen. He had marked relief of his spasms and autonomic instability with placement of the external “bypass” system. Once he was medically stable, his catheter and pump were replaced resulting in full control of his symptoms since that time.

Conclusions

This case highlights complications following intrathecal baclofen withdrawal. Indium scans are a helpful investigative tool when routine studies such as x-rays and CT scans do not reveal a definitive diagnosis. External bypass systems can be used diagnostically and therapeutically in patients experiencing withdrawal symptoms.

Acknowledgements

No funding source.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

KNOWLEDGE MOBILIZATION IN SPINAL CORD INJURY: BUILDING A NATIONAL COMMUNITY OF PRACTICE

Heather Flett ¹, Jane Hsieh ², Dalton Wolfe ³, Jennifer Hunter ⁴, Richard Riopelle ⁵

Abstract

Background/Objective

A community of practice provides opportunities for collaborative networking, building capacity, knowledge sharing, developing expertise, and problem solving (Serrat, 2008). In Canada, the Spinal Cord Injury Knowledge Mobilization Network (SCI KMN) has built a community of practice connecting six major SCI rehabilitation sites. This community of practice is the foundation upon which this network enables the implementation of best practices in SCI rehabilitation.

Methods/Overview

The process of building this community of practice was based on the shared goal of implementing best practices in pressure ulcer, pain, and bladder management. First, by adapting an implementation science framework (Fixen, 2005) to suit the needs of a healthcare setting, the SCI KMN systematically assembled an infrastructure that values collaboration and consultation across funders, researchers, leaders, clinicians and consumers. Efficient methods of sharing and implementing knowledge, and problem solving were created by having 1) formal stakeholder analysis with deliberate engagement efforts; 2) collaborative decision-making methods involving an online Delphi; 3) project-specific objectives and organizational structure; 4) access to a web-based collaboration platform that hosts online discussions, document sharing and archiving to ensure fidelity for sustainable and ongoing work; 5) web and tele-conferences, and regular face-to-face meetings; and 6) planned evaluations of intervention, implementation and community of practice building activities.

Results

These SCI KMN activities can be used as examples of strategies for building effective communities of practice.

Conclusions

SCI KMN members have benefited from collaboration between stakeholders across the country. Furthermore, since each of the sites have different organizational structures, cultures, practices, and healthcare funding, this community of practice has created a unique opportunity to acquire broader perspectives on both organizational and system barriers to best practice implementation and, more importantly, to identify innovative strategies to address potential healthcare gaps.

Acknowledgements

Ontario Neurotrauma Foundation, Alberta Paraplegic Foundation, Rick Hansen Institute 2010-RHI-ONF-BPI-832; 2010-RHI-ONF-BPI-865; 2010-RHI-ONF-BPI-834; 2010-RHI-ONF-BPI-833; 2010-RHI-ONF-BPI-866.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

IMMEDIATE EFFECTS OF LUNG VOLUME RECRUITMENT TECHNIQUE USING A MANUAL RESUSCITATION BAG IN INDIVIDUALS WITH TETRAPLEGIA

Rudy Niebuhr ¹, Tanya Kozera ²

Abstract

Background/Objective

Manual lung volume recruitment (LVR) techniques (also known as breath stacking) using a modified manual resuscitation bag have been shown to enhance lung volumes and to improve peak expiratory flow in patients with neuromuscular disease. In LVR, serial breath stacking is performed using a modified manual resuscitation bag until maximal lung insufflation is attained. Individuals with tetraplegia also have reduced lung volumes and correspondingly lower expiratory flow rates (cough efficiency). This has implications on secretion clearance and other respiratory complications in this population. No studies have been published that document the changes to lung volumes or expiratory flow rates in spinal cord injury (SCI) even though LVR techniques are becoming routine treatment interventions for both acute and chronic SCI. Since LVR is administered in clinical or home settings with limited access to spirometry, peak expiratory (cough) flow (PCF) meters are one device that may be used to ascertain the value of the enhanced LVR breath. No studies have evaluated the use of a PCF device as a means of assessing the LVR assisted breath. The purpose of this study was twofold; 1) to determine the difference in forced vital capacity (FVC) and peak expiratory flow (PEF) between an unassisted breath and a breath assisted with LVR in patients with tetraplegia and 2) to determine the correlation between spirometry measured peak expiratory flow and a peak expiratory flow cough meter in a LVR assisted breath.

Methods/Overview

Sixteen subjects (with sub-acute and chronic tetraplegia) underwent repeated measures spirometry testing for unassisted and LVR assisted breaths. Spirometry tests were performed in accordance with American Thoracic Society standards. LVR assisted breaths were also measured using a PCF device.

Results

Significant differences between the unassisted breath and the LVR assisted breath were found in all spirometry values; FVC was increased by 0.65 L (p < 0.01) and PEF increased by 0.55 L/s (p < 0.01). In the LVR assisted breath the correlation between PEF and PCF was 0.72 (p < 0.01).

Conclusions

LVR is an effective means to increase lung volumes in individuals with tetraplegia. Peak cough flow device values correspond with spirometry values in the LVR assisted breath and may be useful to detect the change in expiratory flow in clinical or home settings.

Acknowledgements

Manitoba SCI Research Committee.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

PROMOTING SELF-CARE INDEPENDENCE FOR A CLIENT WITH CENTRAL CORD SYNDROME

Dianna Mah-Jones ¹

Abstract

Background/Objective

Central cord syndrome (CCS) is an incomplete spinal cord injury characterized by more motor impairment in the upper extremities than the lower extremities. Understandably, clients with CCS have very low Motor Functional Independence Measure scores when admitted to a rehabilitation program. This case study will share the iterative process for enabling participation in self-care tasks by a 63 year old client with C4 AIS D spinal cord injury and significant limitations in arm function.

Methods/Overview

The initial emphasis of his rehabilitation program was to create a foundation for function by strengthening his lower body and trying to manage the restricted range, significant weakness and increased tone in the arms. Guided by the client's goals, he was first enabled to operate his cell phone. Next, he was transitioned from sip and puff driving of a power chair to manual driving; special positioning was required to facilitate arm placement and to provide gravity assist. Once the client had sufficient balance and mobility, alternative techniques for lower extremity dressing, including socks and shoelaces, and toileting were determined. Brushing teeth and combing hair without the use of hands were achieved through a unique grooming station. Feeding was a particular challenge as the client was unable to bend his elbows and he did not have funding for a commercial powered feeder. With collaborative input, a feeding tower was designed utilizing pulleys and a lever to harness his trunk and shoulder movement.

Results

At discharge, the client was able to dress his lower extremities, toilet himself, brush his teeth, comb his hair and, with set-up of food on the plate, feed himself using alternate strategies and adaptive equipment. As he had very little movement in his shoulder and elbows he was dependent in upper body dressing and bathing.

Conclusions

For the Central Cord client who lacks arm function, the possibility of participating in basic self-care tasks may appear quite limited. However, with perseverance and creative problem solving, solutions can be found to make ‘‘doing’’ possible.

Acknowledgements

none.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

OPTIMIZING PATIENT FLOW IN INPATIENT SPINAL CORD REHABILITATION

Heather Flett ¹, Jennifer Yee ², Kristina Guy ³, Joanne Zee ⁴, Anthony Burns ⁵

Abstract

Background/Objective

To optimize patient flow in spinal cord rehabilitation (SCR) by implementing strategies to reduce length of stay (LOS) and determining barriers to discharge.

Methods/Overview

National comparator data (Canadian Institute for Health Information) were used to determine a program LOS target and establish LOS targets for specific spinal cord injury (SCI) Rehabilitation Patient Groups (RPG) based on diagnostic categories (trauma/non-trauma), admission motor Functional Independence Measure (FIM) score, and age. To understand the barriers to discharge, six categories of reasons for extending LOS were defined: (1) Continued need for inpatient SCR; (2) Community services not available; (3) Housing not available; (4) Equipment not obtained; (5) Service interruption due to change in health status; (6) Logistics. When target LOS was exceeded, specific reasons for extending LOS were recorded using these categories. A patient census tool tracked extensions to target LOS and the associated reasons for extension. Outcome metrics included: LOS, FIM change, FIM efficiency, and reasons for extending LOS.

Results

463 individuals were admitted for inpatient rehabilitation from March 1, 2010 to December 31, 2011. Overall program mean LOS was 68.8 days, an 18% reduction compared to the 2009/10 fiscal year. While LOS decreased, absolute FIM change and FIM efficiency increased by 20% and 39% respectively. For all four traumatic SCI RPGs, mean LOS was below target however mean LOS exceeded targets for four out of five non-traumatic RPGs. Reasons for extending LOS were recorded from April 1–December 31, 2011. Of the 139 individuals admitted during this timeframe, 50 individuals (36%) had a LOS above target with a total of 94 reasons for extending LOS. The most frequent reasons for extending LOS were: equipment not obtained (31%), continued need for inpatient SCR (27%), service interruption (17%), and discharge housing not available (16%). Individuals with non-traumatic SCI were more likely to have LOS extended particularly due to continued need for inpatient SCR.

Conclusions

The use of benchmarking to establish objective LOS targets and assist decision making has lead to improved patient flow and efficiency: reduced program LOS, improved FIM change, and increased FIM efficiency. The systematic collection of data on discharge barriers has provided insight into individual patient needs and underlying system issues which will inform future program efficiency initiatives.

Acknowledgements

none.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

KNEE DXA MEASUREMENT FOR THE ASSESSMENT OF SUB-LESIONAL OSTEOPOROSIS AFTER SPINAL CORD INJURY: A KNOWLEDGE TRANSLATION (KT) INITIATIVE

Catharine Craven ¹, Isabelle Coté ², Dalton Wolfe ³, Mélanie Boulet ⁴, Lora Giangregorio ⁵

Abstract

Background/Objective

Fragility fractures of the knee region secondary to sub-lesional osteoporosis post SCI result in significant morbidity. Dual energy x-ray absorptiometry (DXA) measures of bone mineral density (BMD) are the current gold standard for detection of osteoporosis, fracture risk assessment, and evaluation of treatment effectiveness. DXA is routinely used to measure knee region BMD among patients with SCI in Ontario. This study aimed to implement routine knee DXA testing in Quebec.

Methods/Overview

DXA technologists and treating physiatrists in Quebec were trained using an existing training manual and one to one education sessions by the lead investigator and a DXA technologist from Toronto. Knee DXA scans of 34 healthy men and women at Lyndhurst Centre (LC) and 15 at Centre Hospitalier de l'Université Laval (CHUL) were performed using a Hologic densitometer (Waltham, MA), modified spine software, and a polycarbonate knee positioning device. Using a common scanning analysis protocol, scans of the distal femur (DF) and proximal tibia (PT) were acquired twice with re-positioning between scans. Root mean squared standard deviation and coefficient of variation (RMSSD, RMSCV) were calculated to compare precision of DXA measures at the two sites, and the least significant change at the 95% confidence interval (LSC 95%) is reported.

Results

The mean BMD of DF was 0.967gr/cm² and 1.004gr/cm² for LC and CHUL, respectively. The mean BMD of PT was 0.818gr/cm² and 0.918gr/cm² for LC and CHUL, respectively. RMSCV % was less than 3% at both sites with slightly higher CV at CHUL. At both centres, the precision was poorer for the proximal tibia than the distal femur. The RMSSD values were 30% and 40% greater at CHUL than at LC for the PT and DF, respectively. The LSC CI 95% values for DF at LC and CHUL were 0.043 and 0.74, respectively. The LSC CI 95% values for PT were 0.118 and 0.171 at LC and CHUL, respectively.

Conclusions

It was feasible to translate a specialized knee BMD protocol from a specialized SCI rehabilitation setting to a general DXA laboratory service. Although the precision achieved is comparable to previous reports, precision error could be improved by providing ongoing support and feedback, and eliminating language barriers thereby enhancing communication. Further knowledge translation efforts are needed to ensure uptake of SCI-specific management paradigms once knee region DXA testing is routine.

Acknowledgements

ONF Grants # 2008-ONF-REPAR-601 & 2011-ONF-REPAR2-885.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

FACILITATING BEST PRACTICE IN THE TREATMENT OF SPINAL CORD INJURIES: APPLYING A CONTINUUM OF LEARNING MECHANISMS IN AN OCCUPATIONAL THERAPY INPATIENT REHABILITATION SETTING

Elizabeth Kloczko ¹, Lisa Sheikovitz ², Tracie Herman ³

Abstract

Background/Objective

Competence is defined as “successfully performing a behavior or task measured according to a specific criterion” (Hinojosa, Bowen, Case-Smith, Epstein, Moyers & Schwope, 2000). Clinical competencies have been shown to improve patient safety, patient centered care, staff empowerment and evidence based practice (Singh, Feld-Glazman, Van Lew, Herman, Capasso & Dicembri, 2010). Our objective is to demonstrate a model of clinical competence used on an inpatient acute care rehabilitation unit to ensure quality care for the complex and unique spinal cord injury (SCI) population.

Methods/Overview

Rusk is an acute rehabilitation center with a team that specializes in SCI. The Occupational Therapy Department has a clinical ladder that provides various levels of mentoring and instruction. Our continuum of learning begins with a series of educational modules for students and new therapists. Examples include pressure mapping, transfer skills, barrier free design, assistive technology, shoulder, modalities, seating and mobility. These supporting modules build a foundation for an interactive SCI Module. Staff level therapists participate in competencies in the areas listed above which provide more comprehensive and hands-on learning. In addition, they receive on-going co-treatments and mentoring which support best practice interventions. We will discuss the importance of these clinical competencies, the complexity of SCI patients, outline our SCI learning module, and our follow-up mentoring and co-treatment process. We will share our results of administered pre and post module assessments to analyze the amount of knowledge therapists acquired during the Spinal Cord Module.

Results

The pre/post assessment asks therapists about their clinical background and confidence in assessment and treatment of SCI. They grade themselves on a 10 point scale with 1 being the least and 10 being the most confident/knowledgeable. The questionnaire includes qualitative questions on how the module contributes to learning and which parts are found to be most helpful.

Conclusions

Clinical competencies and modules are a vital part to therapists’ growth and development which enhances the quality of patient care. Our model of learning competencies/student modules are examples of how to teach clinical skills efficiently and effectively in an acute inpatient rehab unit. The questionnaire that we administer along with the competencies/modules assures that we meet the needs of the learner and that we stay consistent with current practice.

Acknowledgements

n/a.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

DYSPHAGIA REHABILITATION FOLLOWING SCI: A DESCRIPTIVE CASE STUDY

Anellina Ventre ¹

Abstract

Background/Objective

Management of swallowing difficulty (Dysphagia) and increased risk of aspiration following cervical spine injury is complex and has a significant impact on quality of life, especially with aging. The purpose of a dysphagia assessment is to determine change in swallowing physiology and factors that elevate the risk of aspiration during oral intake while ensuring that swallow function is efficient enough to maintain hydration and nutritional needs. Management of any identified risks of aspiration or swallow inefficiencies can be addressed with the use of compensatory strategies, modified texture foods and liquids, and by employing rehabilitation techniques to alter the function of the musculature. Dysphagia is well studied in other populations. The SCI dysphagia literature focuses on intra-operative techniques, including hardware, to reduce risks of developing swallowing difficulties post-operatively. This poster will demonstrate that evidenced-based treatment methodologies from other populations can be applied to the SCI population.

Methods/Overview

Review of the dysphagia literature from other patient populations and propose techniques that are applicable to the SCI population. Descriptive case review of rehabilitation of complex dysphagia following SCI, using validated dysphagia management techniques.

Results

Successful rehabilitation of swallow function in a 61 year old patient with complex dysphagia following anterior cervical repair for a C4-6 fracture secondary to a fall. This case study demonstrates a clinical pathway and best practice for management of dysphagia and aspiration risk following SCI.

Conclusions

Evidence-based dysphagia rehabilitation carried out by a Speech and Language Pathologist plays a key role in achieving functional outcomes with people with complex dysphagia following SCI. Demonstrates the need for outcome measures that capture change in swallow function and health management knowledge (minimizing risks of aspiration) in people with quadriplegia.

Acknowledgements

Toronto Rehabilitation Institute – UHN, Education-Continuing Professional Development, Speech and Language Pathology project 2011–2012.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

A BALANCED SCORECARD USED TO DETERMINE SUCCESS IN AN SCI RESOURCE CENTRE

Sandra Mills ¹, Sheila Casemore ², Jennifer Yee ³

Abstract

Background/Objective

Spinal cord injury (SCI) often occurs suddenly. The person with the injury or diagnosis and their family has to adapt quickly and seek information on living with an SCI. Spinal Cord Connections (SCC) is a groundbreaking partnership between Toronto Rehabilitation Institute – UHN Spinal Cord Rehab Program (SCRP) and Canadian Paraplegic Association Ontario. SCC is both a resource centre and a website for patient, client and family education learning opportunities. SCC Leadership sought an effective tool to monitor objectives and user outcomes. Balanced scorecards are not currently used in the overall project management of a combined resource centre and website development.

Methods/Overview

A balanced scorecard was created for SCC to connect the various components of strategic planning, resource allocation and overall management of the resource centre and website. The scorecard measures success and the strategic objectives SCC is working to accomplish. Through the scorecard process the SCC Leadership was clearly able to define the vision and go-forward strategy to enable success.

Results

Since its inception in April 2011, quarterly tracking has provided SCC Leadership with a tool to identify strengths and areas requiring development and resources. Challenges and opportunities are explored each quarter as the team reviews metrics and tolerance limits for each indicator. Financial indicators help us link spending to programs and objectives in a timely and disciplined manner. Customer Perspective indicators allow us to track utilization targets, information dissemination and access and reach. Internal Business Perspective indicators examine marketing and outreach initiatives. Learning and Growth indicators track knowledge transfer and continual growth.

Conclusions

A balanced scorecard provides an approach to project management and strategic planning in a partnership environment. A practical and well disciplined approach to SCC program design, development, implementation and evaluation has resulted in the execution of a comprehensive suite of patient, client and family education tools. The physical resource centre was established as a Leading Practice by Accreditation Canada in 2011. The website will launch with a comprehensive strategy and identified metrics in place to meet client need.

Acknowledgements

none.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

A BENCHMARKING APPRAISAL ON THE TIMING OF SURGICAL DECOMPRESSION FOR TRAUMATIC CERVICAL SPINAL CORD INJURY

Julio Furlan ¹, Kayee Tsung ², Michael Fehlings ³

Abstract

Background/Objective

This study examines the process benchmarking of management of patients with acute traumatic cervical spinal cord injury (SCI) in order to determine the potential barriers and ideal timelines for each step to early surgical decompression.

Methods/Overview

We collected data from charts and the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS) forms regarding the time and reasons for delay of each step in the management of patients with SCI. The reasons for delays in the management steps will be classified into: (a) healthcare-related (“extrinsic”) factors and (b) patient-related (“intrinsic”) factors. The cases were grouped into patients who underwent early surgical decompression of spinal cord (up to 24 hours since SCI) and individuals who underwent later surgery ()24 hours after injury).

Results

While both groups showed comparable time periods related to intrinsic factors, patients who underwent early surgical treatment had a significantly shorter time period associated with extrinsic factors when compared with patients who underwent later surgical decompression of spinal cord (19.16 hours versus 71.28 hours, respectively). Both patient groups were comparable regarding prehospital time (137 min versus 185.5 min), time in a second general hospital prior to transfer to spine center (369.5 min versus 730.8 min) and time in the trauma emergency department (221.7 min versus 226.4 min). Patients who underwent early surgical decompression of spinal cord had significantly shorter waiting time (577.6 min versus 1982.1 min), shorter waiting time for assessment by spine surgeon (73.5 min versus 274.4 min) and shorter waiting time for surgical decision (241.7 versus 832.3 min) than those patients who underwent later surgical treatment.

Conclusions

Our benchmarking analysis suggests that health-related factors are key determinants of the timing from SCI to spinal cord decompression. Time in the general hospital and time of waiting for surgical decision were the most important causes of delays for surgical decompression of spinal cord. Moreover, this benchmarking analysis indicates that early surgical decompression of spinal cord is possible in the vast majority of the cases of acute traumatic cervical SCI.

Acknowledgements

This study was supported by a Spinal Cord Injury Solutions Network Rapid Response Award from the Rick Hansen Foundation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

DEALING WITH SECONDARY HEALTH CONDITIONS AND SPINAL CORD INJURY: AN UPHILL BATTLE IN THE JOURNEY OF CARE

Sara Guilcher ¹, Catharine Craven ², Louise Lemieux-Charles ³, Mary Ann McColl ⁴, Susan Jaglal ⁵

Abstract

Background/Objective

To understand the journey of care in the prevention and management of secondary health conditions (SHCs) following spinal cord injury (SCI).

Methods/Overview

This was a case study design with “Ontario” as the case. The network episode model was used as the conceptual framework. Data sources included in depth interviews with persons with SCI, care providers, and policy and decision makers. Document analysis was also conducted on relevant materials and policies. Key informants were selected by purposeful sampling as well as snowball sampling to provide maximum variation. Data analysis was an iterative process and involved descriptive and interpretive analyses. A coding structure was developed based on the conceptual framework which allowed for free nodes when emerging ideas or themes were identified.

Results

Twenty-eight individuals were interviewed (14 persons with SCI and 14 persons representing care providers, community advocacy organization representatives, system service delivery administrators and policy makers). A major over-arching domain that emerged from the data was the concept of “fighting”. Eleven themes were identified: at the micro-individual level- (1) Social isolation and system abandonment, (2) Funding and equitable care, (3) Bounded freedom and self-management; at the meso care provider level- (4) gender and caregiving strain, (5) help versus disempowerment, (6) holistic care- thinking outside the box, (7) poor communication and coordination of care; and at the macro health system level- (8) fight for access and availability, (9) models of care tensions, (10) private versus public tensions and (11) rigid rules and policies.

Conclusions

Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. If we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.

Acknowledgements

Granting Agency/Funding Source: Women's College Research Institute, Toronto Rehabilitation Institute – UHN, the Ontario Neurotrauma Foundation, the Health Services and Policy Research Network, Canadian University Research Alliance and the Canadian Institutes of Health Research.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

IMPLEMENTING THE SCIPUS RISK ASSESSMENT SCALE

Carol Scovil ¹, Heather Flett ², Lan Nguyen ³, Diane Leber ⁴, Jacquie Brown ⁵, Anthony Burns ⁶

Abstract

Background/Objective

Secondary health complications such as Pressure Ulcers (PU) after Spinal Cord Injury (SCI) affect rehabilitation outcomes, and remain a risk for individuals living with SCI. We are participating in a 6-centre collaboration focusing on SCI Best Practices Implementation (BPI) to reduce secondary health complications. The first BPI focuses on PU prevention as 70% of pressure ulcers are preventable. Experts from the National Implementation Research Network (NIRN), University of North Carolina at Chapel Hill, are providing support to increase BPI effectiveness.

Methods/Overview

A consensus-based approach was used to prioritize best practice recommendations for PU prevention and management. One practice identified was to conduct a comprehensive PU risk assessment (RA), using a validated RA tool. An existing RA measure, the Braden Scale, is widely used but is not specific to SCI. In contrast, the SCI PU scale (SCIPUS) is SCI specific, but has less-established psychometric properties.

Results

Using the principles of implementation science, and support from NIRN, feedback was gathered from front-line staff, and a chart audit done to evaluate current Braden completion rates. The completion rate for the Braden was 29%, and staff perceived it as not specific to SCI population and of questionable utility. Audit results were used to engage and educate stakeholders (leadership and staff) and justify implementing the SCIPUS to replace the Braden. Implementing the SCIPUS required a change in institutional policy, including its ratification as an accepted RA measure, as well as approval of the form itself. In collaboration with other BPI sites, risk factor definitions were clarified and the SCIPUS reformatted. Content was preserved. The changes facilitated ease of completion and accommodated the time required for completion of admission bloodwork. A month of general education in PU prevention and management (to get buy-in and increase overall staff competency) was followed by required, practical SCIPUS training sessions for all nursing staff. SCIPUS ‘champions’ were identified and trained on each unit, and provided ongoing coaching and support for each unit. Feedback and assessment will be facilitated through ongoing chart audits. A concurrent research project is also assessing the psychometric properties of the SCIPUS.

Conclusions

The BPI project provides a framework to effectively implement best practices for PU reduction, and lays the groundwork for future BPI in other areas.

Acknowledgements

Ontario Neurotrauma Foundation Grant Number: 2010-RHI-ONF-BPI-832.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

DEVELOPING A WEBSITE TO CONVEY HEALTH RELATED INFORMATION FOR PEOPLE WITH SPINAL CORD INJURIES

Sandra Mills ¹, Jairus Pryor ², Sheila Casemore ³, Gillian Lynn-Davis ⁴

Abstract

Background/Objective

The internet is becoming a more critical resource for health related information. People with spinal cord injury (SCI) use the internet to search for reliable information. The Spinal Cord Connections (SCC) website is a partnership between UHN – TRI Spinal Cord Rehab Program (SCRP) and Canadian Paraplegic Association (CPA) Ontario, designed to provide trustworthy, useful information on SCI. In order for websites to meet the Accessibility for Ontarians with Disabilities Act (AODA), websites must comply with the Web Content Accessibility Guidelines (WCAG 2.0). The SCC website was rebuilt, moving from a software that had no ability to be inspected or modified to a more open and customizable environment in order to meet AODA standards, and to improve real-world usability of the site.

Methods/Overview

The SCC site moved to a new content management system, based on open-source software. A new presentation layer was implemented, utilizing ‘responsive design’ for mobile devices and coded with web standards in mind. User-centred design principles were used to reorganize the website information architecture. Usability testing of the new site was performed throughout the change process.

Results

100% of respondents found the site to be easy to use, well-designed, and informative in the usability testing. Information was easier to find, and easier to read. All participants in the testing strongly recommended the site to anyone living with an SCI. The site was tested and found compatible with a much wider range of devices and assistive technologies.

Conclusions

Through the use of open-source technologies and responsive design, many of the accessibility and maintenance issues have been eliminated. Our user-centric overhaul of the site's information architecture has made navigation simpler, and information easier to find. Usability testing confirms these conclusions, and the new SCC is a solid foundation to build and maintain a community site focused on the needs of people with spinal cord injuries.

Acknowledgements

none.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

NEW NATIONAL ACCREDITATION STANDARDS FOR SPINAL CORD INJURY SERVICES

Stephanie Carpenter ¹

Abstract

Background/Objective

Accreditation Canada has developed two sets of standards for spinal cord injury services: Acute Spinal Cord Injury Services and Spinal Cord Injury Rehabilitation Services. These standards were developed to address key quality and safety issues in the delivery of spinal cord injury services through a partnership with the Rick Hansen Institute (RHI).

Methods/Overview

The spinal cord injury services standards were developed under the guidance of an advisory committee composed of experts in the field. The poster addresses the background and motivation for developing standards for acute and rehabilitation spinal cord injury, the development process, and the elements of these standards that meet the quality and safety needs of organizations providing care to patients with spinal cord injury through accreditation. Issues core to the standards include continuity of services, early and thorough assessment, client and family support and education, and effective transitioning through the continuum of care.

Results

The standards have been evaluated through a national consultation and pilot tested in four Canadian organizations.

Conclusions

Accreditation Canada's acute and rehabilitation spinal cord injury standards not only address the safety needs of patients receiving care, but provide a tool for organizations to continuously improve their services through national standards of excellence.

Acknowledgements

Funding Source: Accreditation Canada and The Rick Hansen Institute.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

POSTER AWARD WINNER – RESEARCH

FUNCTIONAL RELEVANCE OF HAND MUSCLE SYNERGY DISRUPTIONS AFTER SPINAL CORD INJURY

José Zariffa ¹, John D Steeves ², Dinesh K Pai ³

Abstract

Background/Objective

In order to guide and improve rehabilitation interventions for grip function after spinal cord injury (SCI), it is important to have a detailed understanding of the motor control strategies that the central nervous system uses to control the hand. We examined whether changes in the motor control of the hand after SCI are manifested in the form of changes to muscle synergies. We further sought to determine if there exists a correlation between functional ability and the extent of muscle synergy disruption.

Methods/Overview

Surface electromyography (EMG) data was recorded from eight hand muscles in ten able-bodied subjects and six subjects with SCI as they performed various functional tasks using grip types relevant to activities of daily living. Muscle synergies were extracted using non-negative matrix factorization. Functional performance in each task was quantified using a 5-point clinical scale.

Results

The synergies most commonly observed in able-bodied subjects were co-activation of extensor digitorum communis and extensor indicis proprius, and of flexor digitorum superficialis and flexor carpi ulnaris. The proportion of subjects in which particular synergies occurred was significantly different for subjects with SCI compared to able-bodied subjects (p < 0.001). Deviations from the average able-bodied synergies in subject with SCI were found to be poorly correlated (r = −0.04) with functional ability.

Conclusions

Our results suggest that the disruptions and re-organizations of neural circuitry after SCI are reflected by the extracted muscle synergies, but the question of how muscle synergies can guide rehabilitation interventions remains open.

Acknowledgements

This work was supported by the Sensorimotor Computation Major Thematic grant from the Peter Wall Institute for Advanced Studies. Additional support was provided by: the Canada Research Chairs Program, the Human Frontier Science Program, NSERC, and CFI.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

THE SCI GET FIT TOOLKIT: EXAMINING THE EVALUATION AND DISSEMINATION PROCESS

Kelly Arbour-Nicitopoulos ¹, Kathleen Martin Ginis ², Amy E Latimer-Cheung ³

Abstract

Background/Objective

On March 2010, SCI Action Canada released the physical activity guidelines (PAG) for adults with SCI. This work lead to a systematic consultation process in June 2011 with leading experts in the field of SCI, physical activity, and sport to develop evidence-informed recommendations for a physical activity resource called the SCI Get Fit Toolkit. This study examines the knowledge translational research involved in evaluating and disseminating the toolkit.

Methods/Overview

A two-step evaluation process was used. Face-to-face interviews were conducted with active SCI consumers to assess the presentation clarity of the toolkit's content. An 18-item questionnaire was completed by expert panel members from the systematic consultation to evaluate the consistency between the final version of the toolkit and the evidence-informed recommendations.

Results

Six consumers with SCI completed the interviews, while seven experts completed the questionnaire. Consumers suggested that the toolkit include additional examples of activities for power chair users and strategies for overcoming barriers, and greater detail on the recommended intensity of activity, how to perform activities and locate equipment. Overall, consumers found the toolkit to be appropriate and the content to be useful for encouraging persons with SCI to meet the PAG. Responses from the expert panel were favorable (M = 6.2 on a 7-point Likert scale), indicating that the toolkit was consistent with the panel's recommendations. One suggestion from the panel was to include more images of persons with tetraplegia. Over a 3-month time period, a variety of strategies were used to disseminate the toolkit including: (i) distribution of 3,000 paper copies through the Canadian Paraplegic Association's (CPA) Outspoken! magazine, (ii) distribution of 200 paper copies during a toolkit launch event and during a Rick Hansen Institute's showcase event, (iii) an Outspoken! magazine publication, (iv) one local newspaper article, and (v) one academic and one non-academic presentation.

Conclusions

The SCI Get Fit Toolkit appears to be an appropriate, evidence-based physical activity resource to complement the PAG for adults with SCI. A variety of short-term dissemination activities have resulted in a wide reach of the toolkit to the target audience. Future dissemination activities include distribution of toolkits to other CPA partners and rehabilitation centres, and creating an online toolkit section to be hosted on the SCI Action Canada website.

Acknowledgements

Rick Hansen Institute, Ontario Neurotrauma Foundation, Canadian Paralympic Committee.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

A RANDOMIZED CONTROLLED TRIAL OF FUNCTIONAL ELECTRICAL STIMULATION THERAPY FOR WALKING VERSUS A CONVENTIONAL EXERCISE PROGRAM IN PATIENTS WITH CHRONIC INCOMPLETE SPINAL CORD INJURY: EFFECTS ON BODY COMPOSITION

Lora Giangregorio ¹, Catharine Craven ², Naaz Kapadia ³, Keiva Richards ⁴, Milos R Popovic ⁵

Abstract

Background/Objective

Functional Electrical Stimulation (FES) used in conjunction with Body Weight Support Treadmill Training (BWSTT) has a potential to improve gait and may potentially improve body composition in individuals with chronic incomplete traumatic spinal cord injury (SCI). The purpose of the current report was to evaluate the effects of FES-assisted BWSTT on indices of body composition, when compared to a conventional exercise program in individuals with spinal cord injury (SCI).

Methods/Overview

A single blind parallel group randomized controlled trial (www.clinicaltrials.gov – NCT0020196819) was conducted at an SCI rehabilitation centre. Individuals with chronic (≥18 months) motor incomplete SCI were recruited and randomized using sealed envelopes to FES–assisted BWSTT or a conventional exercise program (aerobic training and resistance training); each were performed thrice-weekly for 4 months. Outcomes were assessed at baseline, discharge (4 months) and 12 months by assessors blinded to group allocation. Whole body and leg lean mass and whole body fat mass were measured with dual-energy x-ray absorptiometry. Lower leg muscle cross-sectional area (CSA) and fat CSA were measured with peripheral quantitative computed tomography. Between-group differences were analyzed in intention to treat analyses using a repeated measures general linear model.

Results

34 individuals entered the study (17 FES and 17 exercise): 77% were male, mean (SD) age was 55.3 (15.1) and mean (SD) duration of injury was 9.5 (10.3). 27 individuals remained at 12-month follow-up. There were no significant differences between groups at baseline for any of the body composition variables. There were no significant between-group differences or changes over time for any body composition variable in intention-to-treat analysis. There were 13 reported side effects or adverse events deemed to be related to study participation (7 FES, 5 exercise activities); most were minor and resolved with modifications to the exercise protocol. One episode of fainting resulted in an emergency room visit and withdrawal from the study.

Conclusions

FES-assisted walking did not result in a change in whole body or lower extremity muscle or fat mass in individuals with chronic, motor incomplete SCI when compared to a traditional exercise program, and there were no significant within group changes over time in either group. Care should be taken in the design of exercise interventions in individuals with SCI to minimize the occurrence of adverse events.

Acknowledgements

Granting Agency/Funding Source: Ontario Neurotrauma Foundation Grant Number: 2004-SCI-SC-04 and 2008-SCI-SC(2)-594.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

SELF-REPORTED PHYSICAL ACTIVITY OF INDIVIDUALS WITH SCI AT ADMISSION AND DISCHARGE FROM INPATIENT REHABILITATION

Dominik Zbogar ¹, Andrei Krassioukov ², William Miller ³, Molly Verrier ⁴

Abstract

Background/Objective

Little is known about the amount of physical activity experienced by individuals with spinal cord injury (SCI) during inpatient rehabilitation. Physical activity early after a SCI is thought to be important for its benefits in optimizing recovery as well as its ability to reduce secondary complications. This preliminary investigation determined the amount and intensity of physical activity undertaken during inpatient SCI rehabilitation.

Methods/Overview

Participants in this observational study were consecutive admissions to two Canadian inpatient SCI rehabilitation centres. Participants were assessed with the Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI). The PARA-SCI categorizes the intensity of activities as nothing, mild, moderate, or heavy and documents time spent on activities. The PARA-SCI was administered on two days near admission and again, near discharge for each patient and averaged to obtain activity for a typical weekday. A 2x4 mixed model ANOVA was conducted to explore the relationship between minutes of physical activity and physical activity intensity at admission and discharge from inpatient SCI rehabilitation.

Results

The 22 subjects in this investigation were 48 ± 15 years old. Average time from injury to rehabilitation admission was 24 ± 13 days. Nineteen individuals were traumatic and 3 non-traumatic;16 had incomplete injuries, 6 were complete. There was no statistically significant interaction or time effect. The main effect for intensity yielded significance [F(3, 84) = 71.7, p= 0.0005]. Post-hoc analysis indicated that the mean score for time spent in activities classified as nothing was significantly higher than all other intensities. Mild physical activity also significantly differed from heavy intensity. Time in moderate and heavy intensity did not differ significantly from each other.

Conclusions

That there was no significant change in activity levels from admission to discharge is notable. We anticipated increasing levels of physical activity with time in inpatient rehabilitation as functional recovery occurred. Of relevance, it appears the minimum threshold for physical activity for individuals with chronic SCI is exceeded in this group, as moderate (M = 94.68) and heavy activity (M = 35.69) account for above 20 minutes of time. What remains to be elucidated is whether these activities are truly aerobic in nature. Review of heart rate data collected during the day will be analyzed to answer this question.

Acknowledgements

Granting Agency/Funding Source: Michael Smith Foundation For Health Research Grant Number: CI-SSH-00379.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

DOING WHAT THE GUIDELINES SAY: INCREASING AWARENESS, KNOWLEDGE, AND ADHERENCE TO THE PHYSICAL ACTIVITY GUIDELINES FOR ADULTS WITH SPINAL CORD INJURY THROUGH THE GET IN MOTION TELEPHONE-BASED COUNSELING SERVICE

Jennifer R Tomasone ¹, Kelly A Arbour-Nicitopoulos ², Amy E Latimer-Cheung ³, Kathleen, A Martin Ginis ⁴

Abstract

Background/Objective

In June 2008, SCI Action Canada launched Get in Motion (GIM), the first national physical activity (PA) telephone counseling service for Canadians with spinal cord injury (SCI). In September 2011, following the release of the PA Guidelines for Adults with SCI (Martin Ginis et al., 2011), the GIM service was restructured to help clients meet the Guidelines. The primary objective of this pilot study was to examine GIM clients’ (1) awareness and knowledge of the Guidelines, and (2) aerobic and strength-training behaviour at time of enrolment. Preliminary secondary analyses were also conducted to examine change in awareness, knowledge, and behaviour after 2 months of GIM counseling.

Methods/Overview

Upon enrolment, GIM clients reported their current aerobic and strength-training PA, and their awareness and knowledge of the Guidelines. Clients were then mailed a copy of the Guidelines prior to their first counseling session. During the sessions, the counselor focused telephone discussions around strategies to increase PA levels to meet the Guidelines. At 2-months, clients again reported their awareness and knowledge of the Guidelines and their current PA behaviour.

Results

Since restructuring GIM, 17 adults have enrolled (Mage = 51.2 ± 14.0 years, Myears post injury = 21.0 ± 18.0, 53% female, 47% paraplegia). At enrolment, 23.5% of clients met the aerobic (at least 20 min of moderate to vigorous intensity aerobic activity at least twice per week) and 23.5% of clients met the strength-training Guidelines (3 sets of 8–10 repetitions of each exercise for each major muscle group at least twice per week). One client was aware of the Guidelines, while none of the clients were able to recall them specifically. Of the 5 clients who have completed 2 months of counseling thus far, 100% met the aerobic Guideline, while 20% met the strength-training Guideline. All clients reported being aware of and were able to recite both Guidelines at 2 months.

Conclusions

At enrolment, very few GIM clients were aware of the Guidelines, and none could recite them. Within the first 2 months of using the GIM service, clients became aware of the Guidelines, and those who were previously not meeting the aerobic Guidelines began meeting them. Preliminary results also suggest that it may be easier for clients to meet the aerobic, rather than strength-training Guidelines. These data provide preliminary support of the benefits of GIM for increasing awareness and knowledge of, and for starting to meet, the PA Guidelines.

Acknowledgements

Granting Agency: Ontario Neurotrauma Foundation Grant Number: 2011-ONFSCISO-113 Granting Agency: Rick Hansen Institute Grant Number: 2010-04 Granting Agency: Social Sciences and Humanities Research Council Grant Number: 883-2007-1006).

J Spinal Cord Med. 2012 Sep;35(5):419–478.

PRELIMINARY DATA ON RELATIONSHIPS BETWEEN CENTRAL PULSE WAVE VELOCITY AND CAROTID ARTERY INTIMA-MEDIA THICKNESS IN INDIVIDUALS WITH CHRONIC SPINAL CORD INJURY

Julia Totosy de Zepetnek ¹, Tessa Luijben ², Maureen MacDonald ³

Abstract

Background/Objective

Assessing vascular characteristics such as wall stiffness and vessel wall anatomy might increase the predictive accuracy of cardiovascular risk stratification. However, literature exploring relationships between different measures of vascular properties is limited and inconsistent. It remains unclear whether “early stage” vascular change, such central pulse wave velocity (cPWV), is directly related to “later stage” vascular change, such as carotid intima-media thickness (cIMT). Understanding these relationships may provide insight into the atherosclerotic process, particularly in populations at greater risk of cardiovascular disease such as spinal cord injury (SCI). The present study explored associations between cPWV and cIMT in individuals with chronic SCI.

Methods/Overview

Eleven men with SCI who had lesions from C3-T8, AIS A-C, and 11.9 ± 9.6 YPI participated; age: 42.3 ± 10.7 years, %body fat: 28.5 ± 5.6%, waist circumference: 96.7 ± 18.5 cm, and VO2peak: 15.9 ± 7.6 mL/kg/min. cPWV from carotid to femoral was measured using infra-red sensors, while cIMT was measured using ultrasound.

Results

No associations were found between cPWV and cIMT (r = 0.06; p = 0.85).

Conclusions

Previous studies have reported positive correlations between cPWV and cIMT in large samples of older and diabetic populations, but no associations in younger adults. Rationale could be that older or diabetic patients have experienced longer exposure to cardiovascular risk factors and probably more advanced atherosclerosis; therefore “early” and “late” structural assessments of the arterial system reflect similar adverse changes. The lack of association found in the present study suggests that in this chronic SCI population, increased cPWV represents one aspect of vascular change that is not reflected in the measurement of cIMT. The cPWV values in the present study were similar to an aging or diseased population, whereas the cIMT values were similar to healthy age matched able-bodied individuals. It is possible that central artery stiffness (cPWV) is elevated in this sample due to paralysis, while local carotid artery structure (cIMT) is unaltered in the present study's younger and relatively active population. Future studies should take into consideration expanded indicators of vascular structure and function including femoral IMT and distensibility, endothelial function, dyslipidemia, blood pressure, frequency of autonomic dysreflexic episodes, and injury characteristics in a larger sample.

Acknowledgements

Funding Source: Ontario Neurotrauma Foundation Grant Number: 2011-ONF-RHI-MT-888; Granting Agency: Natural Sciences and Engineering Research Council Grant Number: 2009-2013-238819-2008.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

ASSOCIATIONS BETWEEN ARTERIAL STIFFNESS AND TRADITIONAL AND SCI SPECIFIC CARDIOVASCULAR DISEASE RISK FACTORS

Masae Miyatani ¹, Cameron Moore ², Kei Masani ³, Paul Oh ⁴, Catharine Craven ⁵

Abstract

Background/Objective

Elevated arterial stiffness (≥1200cm/sec) assessed via measurement of aortic pulse wave velocity (aPWV: cm/sec) is an independent predictor of coronary artery disease (CAD) related morbidity and mortality in the general population. We have reported elevated aPWV values among individuals with chronic SCI. To date, the relative contributions of traditional CAD and SCI specific risk factors to elevated aPWV among individuals with chronic SCI is unknown. Objective: To describe an ongoing cohort study, which aims to determine if risk factors (traditional, SCI-specific, or combination) predict aPWV values among individuals with chronic SCI.

Methods/Overview

A cohort of 100 men and women age 18–80 years, with chronic SCI (C1-T12; AIS A-D, >2 years post injury) without CAD is planned. aPWV is assessed using two Doppler flowmeters between the common carotid and femoral arteries (cm/s). Demographic data and traditional risk factors (i.e, age, blood pressure, HbA1c, blood glucose lipid profile, smoking history, family history CAD, % body fat and Vo2peak) and SCI specific risk factors (NLI, AIS, injury duration, age at injury, and SCIM scores) are recorded.

Results

Cohort characteristics to date include (n = 58); C3-T12, AIS A-D, Age at injury: 32.9 ± 15.3 yrs, Injury duration: 14.7 ± 10.9 yrs, Age: 47.6 ± 12.2 yrs, Height: 174.3 ± 8.9cm, and Weight: 82.1 ± 18.0 kg. aPWV values were not obtained for two participants. Mean aPWV values (n = 56) was 1063 ± 365 cm/sec (n = 56), 15 (26.9%) had elevated PWV values. Recruitment is ongoing.

Conclusions

Multiple linear regression models will be used to investigate the relationships between risk factors (determinants) and aPWV (outcome) while adjusting for important confounders and effect modifiers. Study results will enhance the understanding of the relationships between risk factors and aPWV among people with chronic SCI and contribute to establishment of diagnostic protocols.

Acknowledgements

Granting Agency/Funding Ontario Neurotrauma Foundation Grant Number: 2008-SCI-PDF-692; Craig H. Neilsen Foundation Grant Number: 191150.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

FUNCTIONAL ELECTRICAL STIMULATION THERAPY FOR WALKING VERSUS CONVENTIONAL EXERCISE PROGRAM FOR PATIENTS WITH CHRONIC INCOMPLETE SPINAL CORD INJURY: A RANDOMIZED CONTROLLED TRIAL

Naaz Kapadia ¹, Kei Masani ², Catharine Craven ³, Lora Giangregorio ⁴, Sander Hitzig ⁵, Keiva Richards ⁶, Milos R Popovic ⁷

Abstract

Background/Objective

Multi-channel surface Functional Electrical Stimulation (FES) used in conjunction with Body Weight Support Treadmill Training (BWSTT) has a potential to improve gait and balance in individuals with chronic incomplete traumatic spinal cord injury (SCI). The objective of this study was to investigate short- and long-term benefits of thrice weekly FES-assisted BWSTT versus conventional exercise program on improvements in gait and balance in chronic traumatic incomplete SCI individuals.

Methods/Overview

A single blind parallel group randomized controlled trial (www.clinicaltrials.gov – NCT0020196819) was conducted wherein individuals with chronic (18 months) motor incomplete SCI (C2-T11, AIS C or D) were recruited from an outpatient SCI rehabilitation hospital and randomized using sealed envelopes to FES-assisted BWSTT or conventional exercise program, each was performed thrice-weekly for 4 months. Outcomes were assessed at baseline, 4, 6 and 12 months by blind assessors. The gait and balance outcome measures collected were 2, 4 and 6 min walk distance, time required to complete 10m Walk Test (10mWT), time required to complete the Timed Up and Go (TUG), kinematic data during ambulation collected using the Vicon system, Walking Mobility Scale, Locomotor sub scale of FIM and assistive device score. As a functional measure SCIM was also collected. All assessments were performed at baseline, 4, 6 and 12 months except the kinematic data using Vicon system which was collected at baseline, 4 and 6 months only.

Results

34 individuals entered the study (17 FES and 17 exercise): 77% were male, mean (SD) age was 55.3 (15.1) and mean (SD) duration of injury was 9.5 (10.3). 27 individuals remained at 12-month follow-up. The results of our study showed that, at discharge from therapy, irrespective of group allocation all participants improved their walking distance, as measured by 6 min walk test (p = 0.002), and balance as measured by TUG (p = 0.003). No statistically significant gains were achieved in walking speed, at any time points. In most cases the participants were able to retain the gains in walking distance and balance at both short and long term follow up. No significant differences between the two groups emerged, on any of the outcome measures, at any of the time points.

Conclusions

Irrespective of type of training as long as chronic incomplete SCI individuals are involved in some kind of physical training program targeting lower extremity training they improve their walking and balance even years post SCI.

Acknowledgements

Granting Agency/Funding Source: Ontario Neurotrauma Foundation Grant Number: 2004-SCI-SC-04 and 2008-SCI-SC-(2)-594.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

RESPONSIVENESS AND SENSITIVITY OF A CLINICAL IMPAIRMENT MEASURE SPECIFIC FOR TRAUMATIC TETRAPLEGIA: AN INTERNATIONAL MULTI-CENTRE ASSESSMENT OF THE GRASSP VERSION 1.0

Sukhvinder Kalsi-Ryan ¹, Inge-Marie Velstra ², Dorcas Beaton ³, Marc Bolliger ⁴, Armin Curt ⁵, Milos Popovic ⁶, J Rietman ⁷, Molly Verrier ⁸, Michael Fehlings ⁹

Abstract

Background/Objective

GRASSP was developed to capture subtle changes in neurological impairment of the upper extremity after cervical spinal cord injury (SCI) during the acute, sub-acute, and chronic phases. Psychometric properties of reliability and validity are well established. Responsiveness testing is required to understand application of the GRASSP in clinical trials and interventional studies. Scientific Aims: 1) To develop responsiveness, and establish the sensitivity of GRASSP. 2) To establish how the measure can be applied in clinical trials and interventional studies.

Methods/Overview

A prospective longitudinal study including individuals with acute tetraplegia is currently being conducted as a multi-centre/multi-national study. Serial testing consists of GRASSP, International Standards for Neurological Classification for Spinal Cord Injury (ISNCSCI), Spinal Cord Independence Measure (SCIM), Capabilities of Upper Extremity Questionnaire (CUE), Questionnaires and Life Satisfaction Survey (LISAT-11) administered 0 to 10 days, 1, 3, 6, and 12 months post injury. Analysis: A comparison of the standardized changes from baseline to each time point for GRASSP and ISNCSCI using the Freidman and Wilcoxin signed rank test will be conducted to determine amount of change captured by all measures.

Results

To date 113 patients have been enrolled (35-Can, 78-Eur), 80 (20-Can, 60-Eur) with 6 month follow up and 55 with (Can-10, Eur-48) with 12 month follow up. Enrollment in Europe is closed and in Canada will close in July 2012. Results: Sub-analysis of small datasets show increased sensitivity of GRASSP in measuring the upper limb when compared to ISNCSCI across the recovery of one year.

Conclusions

GRASSP Version 1.0 is a sensitive upper limb impairment measure which will be useful in clinical and research settings to assess the sensory, motor and functional changes occurring after injury. The subtleties that the measure characterizes are valuable in elucidating the underlying approaches to improve concomitant hand function and define efficacy of new interventions.

Acknowledgements

Ontario Neurotrauma Foundation, Rick Hansen Institute, Physiotherapy Foundation of Canada, Canadian GRASSP Longitudinal Study Group, European Longitudinal Study Group, European Multicenter Study in SCI (EMSCI) and the Institute for Research in Paraplegia (IFP).

J Spinal Cord Med. 2012 Sep;35(5):419–478.

HAND-RIM KINETICS WHILE ASCENDING CURBS OF VARIOUS HEIGHTS IN MANUAL WHEELCHAIR USERS WITH SPINAL CORD INJURY

Dany Gagnon ¹, Jessica Hassan ², Mathieu Lalumière ³, Guillaume Desroches ⁴, Raphaël Zory ⁵, Didier Pradon ⁶

Abstract

Background/Objective

Manual wheelchair users (MWUs) with spinal cord injury (SCI) are generally trained to ascend and descend curbs during functional rehabilitation. Although ascending curbs may be highly demanding for the upper limbs (U/Ls), and may contribute to musculoskeletal impairments at the U/Ls in this population, no comprehensive biomechanical study has investigated this manual wheelchair skill. The effects of curb heights on upper limb efforts also remain unknown in MWUs with SCI. This study compared hand-rim kinetics of the non-dominant upper limb, when ascending curbs of three different heights, among manual wheelchair users with SCI.

Methods/Overview

Fifteen individuals with SCI who use a manual wheelchair as their primary means of mobility participated in this study. During a laboratory assessment, participants ascended curbs of various heights (4, 8 and 12cm) on three occasions, respectively, from a starting line set 3m before the curb. Each participant's wheelchair was equipped with instrumented wheels to record forces applied to the non-dominant hand-rim whereas the movements of the wheelchair and non-dominant upper limb were recorded with a 3D motion analysis system. The curb ascent task was divided into three adjustment phases: front wheels elevation and rear wheels ascent and post-ascent. The peak net total (Ftot) and tangential (Ftang) forces, rate of rise of Ftot and mechanical efficiency were computed as outcomes and compared across phases and curb heights using ANOVAs.

Results

All participants ascended the 4 and 8cm curbs whereas only 12 participants ascended the 12cm curb. Similar wheelchair velocity was observed across curb heights before initiating the ascent although it tended to be faster for the 12cm high curb. The highest Ftot and Ftang were reached during the rear wheels ascent phase. The duration of the rear wheels ascent phase, as well as the Ftot during this phase, progressively increased with the height of the curb. The Ftang and the rate of rise of the Ftot were higher when ascending the 8 and 12cm curbs compared to when ascending the 4cm curb. Similar mechanical efficiency was computed across curb heights during this period.

Conclusions

When ascending a curb, MWUs with SCI exposed their U/L to the greatest efforts during the rear wheels ascent phase which further progressed with increased curb height. Whenever possible, MWUs with SCI should solicit assistance when climbing curbs higher than 8 cm to preserve U/L integrity and to advocate for wheelchair accessible environments.

Acknowledgements

Dany Gagnon holds a Junior 1 Research Career Award from the Fonds de la recherche en santé du Québec (FRSQ). Simon Décary received a Summer Research Award in Health Sciences from the Faculty of Medicine, University of Montreal. The project was financed in part by the FRSQ. The equipment and material needed for the work completed at the Pathokinesiology Laboratory was financed in part by the Canada Foundation for Innovation (CFI).

J Spinal Cord Med. 2012 Sep;35(5):419–478.

IMPLEMENTATION MODEL FOR AN ON-LINE QUALITY OF LIFE OUTCOMES TOOL-KIT

Dahlia Kairy ¹, Sander Hitzig ², Luc Noreau ³

Abstract

Background/Objective

The Participation and Quality of Life (PAR-QoL) tool-kit (www.parqol.com) is an on-line resource designed to support clinicians and researchers working in the field of spinal cord injury (SCI) on the outcome tool selection process related to quality of life (QoL). A challenge is to promote and sustain usage of the site by key stakeholders, and to develop an evaluation process for continuously assessing its impact on knowledge and practice.

Methods/Overview

The development, implementation and evaluation strategy for the tool-kit follows the knowledge to action framework, which represents proposed steps to go from knowledge creation to sustained change in practice for groups that may vary in size and setting. Initial efforts were geared at tailoring the knowledge to our target population (clinicians, researchers). Implementation of the tool-kit involves an iterative process to monitor its sustained use, to identify barriers to use, and to evaluate impact on clinical practice.

Results

The content of the site was developed by experts in the field of SCI and QoL measurement, who synthesized the evidence on QoL outcome measures used to assess the impact of secondary health conditions post-SCI. Several strategies are being implemented for promoting the tool-kit. To sustain interest in the website, a number of interactive features have been implemented, including a blog feature, and news and event module. These features highlight events (e.g., conferences), new developments (e.g., articles), and other resources that appeal to a wide audience (including consumers with SCI). The tool-kit continues to be promoted at relevant stakeholder venues, including academic conferences, and by distributing flyers promoting the site to be posted at targeted stakeholder settings (e.g., rehab hospitals). To identify barriers to use, a usability assessment will be conducted to obtain feedback on the design and content of the site from key stakeholders, as well as relevance and use in practice using a mixed-methods approach. Monthly traffic reports provide a means for monitoring use of the website. Reports from the first two months following the launch of the website detailed that the site received 10,121 visitors from across the world.

Conclusions

Multiple knowledge translation strategies are key for ensuring successful uptake of the tool-kit by the SCI professional community. Outcomes of these activities will inform future directions of the site, and will ensure the knowledge generated is applicable for intended users.

Acknowledgements

Granting Agency: Ontario Neurotrauma Foundation; Quebec Rehabilitation Research Network (REPAR). Grant Numbers: Grant #: 2011-ONF-REPAR2-880; Grant #: 2011-ONF-REPAR2-885: Grant #: 2010-KM-SCI-QOL-825; Grant #: 2008-ONF-REPAR-601.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

DEPRESSION MANAGEMENT ON AN IN-PATIENT SPINAL CORD INJURY UNIT

Shannon Janzen ¹, Swati Mehta ², Amanda McIntyre ³, Katherine Salter ⁴, Robert Teasell ⁵

Abstract

Background/Objective

Depression Following Spinal Cord Injury: A Clinical Practice Guideline discusses the various factors (e.g., biological, psychological and social) that add to the complexity of diagnosing depression among individuals with SCI. The PVA guidelines recommend screening, assessment, and where appropriate, that a treatment plan consisting of appropriate pharmacological and non-pharmacological treatment and necessary referrals be created. The objective of this study is to assess if the diagnosis and treatment of depression among SCI patients on an inpatient rehabilitation unit adheres to the clinical practice guidelines.

Methods/Overview

Consecutive admissions to an SCI rehabilitation program from July 2009 to March 2011 were audited. Data extraction included information pertaining to the use of a depression screen or assessment and the corresponding score or diagnosis, any anti-depressant medications used, and notes pertaining to the presence of depressive symptoms or behaviors. Patient data such as age, admission/discharge dates and FIM scores were extracted from the National Rehabilitation Reporting System.

Results

100 patients were identified for inclusion. Depression screening was completed by the psychologist for 6 patients. Depression screening tools used included: The Geriatric Depression Scale (n = 2), Beck Depression Inventory (n = 2), PHQ = 9 (n = 1) and the Center for Epidemiological Studies Depression Scale (n = 1). Fifty-seven patients were also interviewed by a psychologist, however it is unclear if the purpose of the interview was to diagnose depression. Overall, anti-depressants were administered to 45 patients. Of those individuals whose depression treatment began during rehabilitation, none had been screened for depression and only 6 had documentation of being seen for assessment by a psychologist. No formal documentation of treatment plans was identified for individuals receiving anti-depressant therapy.

Conclusions

Adoption of clinical guidelines promotes an efficient means to ensure accurate diagnosis and appropriate treatment of depression following SCI. The present study has identified a treatment gap between recommended and actual practice that should be addressed in order to improve patient care.

Acknowledgements

Ministry of Health and Long-Term Care Alternative Funding Plan.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

RESPIRATORY FUNCTION INCREASES WITH APPLICATION OF FES AMONG PEOPLE WITH SCI, AND WITH IMPROVED SITTING POSTURE IN ABLE-BODIED PEOPLE

Meredith Kuipers ¹, Matija Milosevic ², Kristiina McConville ³, Milos Popovic ⁴, Molly Verrier ⁵

Abstract

Background/Objective

Pathological breathing in SCI is dependent on the level and completeness of injury, a result of multi-system motor dysfunction including incoordination of respiratory muscles and postural instability. Post-SCI muscle paralysis leads to poor expiratory lung capacity and reduced tidal volume during upright sitting by compromising diaphragmatic function (Lin 2006). Functional electrical stimulation (FES) has been shown to improve sitting posture and lung capacity during a forced expiratory manoeuvre (Triolo 2009). However, quiet breathing respiratory function (RFQ) remains to be investigated with application of FES among people with SCI. Objectives: 1. To investigate the effects of posture on RFQ during quiet sitting in able-bodied subjects (ABs). 2. To test the feasibility of trunk muscle FES to improve RFQ in SCI using two different muscle groups controlling anterior-posterior (AP-FES) and medial-lateral (ML-FES) displacements.

Methods/Overview

ABs (n = 10) were asked to maintain quiet sitting balance in upright (SitUP) and slouch (SitSL) postures. Subjects with SCI (n = 3) were asked to maintain quiet sitting balance while sitting: unsupported (SitUN); assisted by AP-FES; and by ML-FES. RFQ measures (tidal volume, VT (l); respiratory rate, RR (min-1); and minute ventilation, VE (l/min)) were obtained for both groups using a portable metabolic testing system (MetaMax®3X, Cortex).

Results

Among ABs, SitUP was associated with greater respiratory volumes, but not greater breathing frequency. During SitUP, VT increased by 14% compared to SitSL (p < 0.01); RR did not change significantly between SitUP and SitSL (p = 0.18). Similarly, VE was 6% greater during SitUP compared to SitSL (p < 0.05). In three SCI case studies, the overall trend was toward a greater VE with the application of AP-FES and ML-FES, compared to SitUN. The increase in VE of more than 10% in two of three SCI cases was due to a combination of bidirectional changes in both VT and RR.

Conclusions

The overall increase in VE in ABs during upright sitting may be due to optimal respiratory mechanics: as posture may optimize mechanical function of the diaphragm to achieve peak quiet breathing VT, the RR remains stable between upright and slouch postures. Among SCI cases, there was a trend toward improved RFQ indicated by an increase in VE with application of FES. These results will facilitate an understanding of the link between postural control and RFQ in people with SCI, and to develop subject-specific FES protocols to test this relationship.

Acknowledgements

Granting Agency: Ontario Graduate Scholarship program (MJK) Granting Agency: Toronto Rehabilitation Institute – UHN Student Scholarship (MJK) Granting Agency: Alexander Graham Bell Scholarship from Natural Sciences and Engineering Research Council (MJK) Granting Agency: NSERC CREATE Academic Rehabilitation Engineering Training Program (MM) Granting Agency: Canadian Institutes of Health Research Grant Number: 129179 (MRP, MCV).

J Spinal Cord Med. 2012 Sep;35(5):419–478.

PERFORMANCE OF ABLE-BODIED SUBJECTS DURING KNEE EXTENSION AGAINST GRAVITY: BENCHMARK DATA FOR FUNCTIONAL ELECTRICAL STIMULATION CONTROL SYSTEMS

Cheryl Lynch ¹, Dimitry Sayenko ², Milos Popovic ³

Abstract

Background/Objective

Functional electrical stimulation (FES) uses electricity to generate contractions in paralyzed muscles. Many FES applications for individuals with SCI require a closed-loop control system that works without user intervention. Knee extension against gravity is a commonly used test bed for designing closed-loop FES control systems. There are currently no realistic performance criteria available for this test bed. The purpose of this study was to generate the required benchmarks by recording voluntary knee extension against gravity in able-bodied individuals.

Methods/Overview

We affixed adhesive motion tracking dots to the seated subject's right side at bony landmarks corresponding to the hip, knee, and ankle. A custom LabView application logged data from the motion tracking system and provided auditory cues. We told the subject to swing his or her knee to reflect the rising and falling pitch of a sinusoidally varying auditory cue. The subject executed a series of 60 s trials at 20, 40, 60, and 80 cycles per minute (cpm). Next, the subject executed five maximum velocity knee extension trials. We processed the motion tracking data to yield the knee angle as a function of time for each trial. We identified the lag of the rising and falling phases of each sinusoidal trial with respect to the reference trajectory, and determined the 10%–90% rise time, 2% settling time, percent overshoot, and steady-state error for each maximum velocity knee extension trial.

Results

The sinusoidal tracking trials showed a modest lag during the rising phase (mean: 0.37 s at 20 cpm, 0.09 s at 40 cpm, 0.16 at 60 cpm, 0.06 s at 80 cpm) and minimal lag during the falling phase (mean: −0.11 s at 20 cpm, −0.07 at 40 cpm, 0.07 s at 60 cpm, 0.03 s at 80 cpm). The maximum velocity knee extension trials showed a quick rise time, modest overshoot, slow settling time, and large steady-state error (mean: 0.20 s, 9.14%, 1.24 s, 13.9 deg).

Conclusions

The performance of the able-bodied subjects was substantially different from the ideal response that is currently used as the benchmark for evaluating closed-loop FES control systems. These results indicate that the current perfect performance benchmark is inappropriate and likely uses an excessive amount of muscle energy to attempt to achieve unrealistic results. The benchmark data that we present in this abstract can be used by the FES control community to more realistically assess the performance of their control algorithms during knee extension against gravity.

Acknowledgements

Funding Source: Natural Sciences and Engineering Research Council of Canada (Grant #249669).

J Spinal Cord Med. 2012 Sep;35(5):419–478.

FES-ASSISTED WALKING VERSUS CONVENTIONAL EXERCISE TO AUGMENT GAIT IN CHRONIC SCI: IMPACT ON QUALITY OF LIFE & COMMUNITY INTEGRATION

Sander Hitzig ¹, Aliza Panjwani ², Naaz Desai ³

Abstract

Background/Objective

To evaluate the quality of life (QoL) and community participation benefits of four months of functional electrical stimulation (FES)-assisted walking versus conventional exercise among subjects with chronic incomplete spinal cord injury (SCI).

Methods/Overview

A parallel group randomized controlled trial (www.clinicaltrials.gov – NCT0020196819) was conducted. Thirty four adult subjects with chronic (≥18 months) motor incomplete SCI (C1-T10 AIS C or D) were randomized to FES-assisted walking (n = 17) or aerobic and resistance training (n = 17) thrice-weekly for 4 months. QoL and community participation were assessed using the Spinal Cord Independence Measure (SCIM), Satisfaction with Life Scale (SWLS), Lawton Instrumental Activities of Daily Living Scale, Craig Handicap and Assessment Reporting Technique (CHART), and the Reintegration to Normal Living (RNL) Index. In addition, subjects completed open-ended questions regarding their perceptions of the intervention(s). Outcomes were assessed at baseline, 4, 6, and 12 months by assessors blinded to group allocation with the SCIM assessed at baseline and at 12 months only. Data was obtained for 27 subjects at the 12-month follow-up. Data were analyzed per protocol using repeated measures ANOVA (FES versus Non-FES) with each case having four within-subject measurements (baseline, 4, 6, and 12 months) except the SCIM, which was analyzed with two within-subject measurements (baseline and 12 months). Open-ended responses were analyzed by a qualitative content analysis approach.

Results

No baseline differences were detected between groups on the QoL or community participation outcome measures. From baseline to 12 months, the FES group had a significant increase in the mean SCIM mobility sub-score compared to the non-FES exercise group (p = 0.0003). Although no significant differences emerged between groups in QoL or community participation, the open-ended responses provided by subjects in both intervention arms indicated positive gains in well-being from trial participation. Noted benefits reported by subjects across groups included gains in self-confidence and mood.

Conclusions

The perspectives of subjects reflect positive gains in well-being at 4, 6 and 12 months regardless of intervention type. For the FES group, these improvements may be reflective of the gains in mobility. Self-efficacy and affect/mood domains should be prospectively evaluated in future FES intervention trials.

Acknowledgements

Sponsorship: Ontario Neurotrauma Foundation; Rick Hansen Institute; Funding provided by the Toronto Rehabilitation Institute – UHN, which receives funding under the Provincial Rehabilitation Research Program from the Ministry of Health and Long-Term Care in Ontario. The views expressed do not necessarily reflect those of the Ministry.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

IS THE EMERGENCY DEPARTMENT AN APPROPRIATE SUBSTITUTE FOR PRIMARY CARE FOR PERSONS WITH TRAUMATIC SPINAL CORD INJURY?

Sara Guilcher ¹, Catharine Craven ², Andrew Calzavara ³, Mary Ann McColl ⁴, Susan Jaglal ⁵

Abstract

Background/Objective

To describe the patterns (e.g., number of visits by year post injury) and characteristics of ED visits (e.g., acuity level, timing of visits, reasons for visits) made by persons with TSCI over a 6 year period following injury.

Methods/Overview

Using a retrospective cohort with administrative data, rates of ED utilization and reasons for ED visits were calculated between the fiscal years 2003–2009 for persons with TSCI. Reasons for visits were categorized by acuity level: potentially preventable visits were defined as visits related to ambulatory sensitive conditions; low acuity and high acuity visits were defined by the Canadian Triage and Acuity Scale.

Results

The total number of ED visits for the six year period is 4403 (n = 1217). Of these visits, 752 (17%) were classified as potentially preventable, 1443 (33%) as low acuity and 2208 (50%) as high acuity. The majority of patients, regardless of acuity level, did not see a family/general practitioner on the day of the ED visit. The majority of ED visits occurred during the weekday (Mon-Fri 07:00-16:59). ED use was highest in the first year following injury but remained high over the subsequent years. For potentially preventable visits, the majority of visits were related to urinary tract infections (n = 385 visits, 51.2%), followed by pneumonia (n = 91, 12.1%).

Conclusions

Given the high prevalence of secondary health conditions, and the high rates of ED use for low acuity and potentially preventable conditions, these results suggest that the ED is being used as an inappropriate substitute for primary care for individuals with TSCI 50% of the time.

Acknowledgements

Granting Agency/Funding Sources: The Women's College Research Institute, Toronto Rehabilitation Institute – UHN, the Ontario Neurotrauma Foundation, the Health Services and Policy Research Network, Canadian University Research Alliance and the Canadian Institutes of Health Research.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

DESCRIBING THE FEASIBILITY, AND PLANNING FOR THE SCALABILITY OF CENTRAL RECRUITMENT FOR PATIENTS WITH SUBACUTE SCI IN TERTIARY ACADEMIC REHABILITATION CENTRES

Molly Verrier ¹, Joey Carson ², Louise Brisbois ³, Catharine Craven ⁴

Abstract

Background/Objective

Participant recruitment is a common barrier to clinical research, including studies involving individuals with subacute spinal cord injuries (SCI). We are piloting a centralized recruitment process for three studies at Toronto Rehabilitation Institute - UHN. Our goal is to reduce patient burden and maximize research participation by exploring the feasibility and scalability of this model in a tertiary, academic rehabilitation centre for patients with sub-acute SCI.

Methods/Overview

Upon admission, patients are screened for research suitability by their primary nurse, and asked for permission to be approached and screened by a research representative. The representative acts as the primary link between the patient and the research department. If permission is granted, the representative screens the patient's health record to assess his or her eligibility for ongoing studies, followed by a meeting with the patient to discuss the studies and obtain informed consent. A related audit of ongoing research projects requiring subjects with subacute and chronic SCI at the centre was conducted.

Results

From July 2011 to February 2012, 83% (134/162) of new patients were deemed ‘suitable’ for research. Nurses obtained permission from 74% (99/134) of suitable patients for research contact and health record screening. There were 79 patients eligible for participation in one study; 81% (64/79) of whom consented. There were 59 patients eligible for participation in two or more studies; 46% (27/59) of whom consented to multiple studies. The average time taken from admission to consent was 16 days.

Conclusions

The central recruitment model appears to be increasing research participation, while involving fewer instances of patient interaction with multiple research coordinators. Ideally we would like to reduce the window of time between rehab admission and participant consent further particularly given the number of studies with subacute inclusion criteria and the increasing pressures to shorten inpatient rehabilitation length of stay. Our next steps are to evaluate scalability by expanding our processes and ethics approvals for recrutiment of outpatients with chronic injury followed by inclusion of the forty additional ongoing studies at our centre in these processes over the next calendar year.

Acknowledgements

Ontario Neurotrauma Foundation, Rick Hansen Institute.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

RECONSTRUCTION OF UNCONSTRAINED UPPER LIMB MOVEMENT FROM ELECTROCORTICOGRAPHIC SIGNALS

Omid Talakoub ¹, Cesar Marquez-Chin ², Robert Chen ³, Milos R Popovic ⁴, Willy Wong ⁵

Abstract

Background/Objective

Many stroke survivors or individuals with incomplete spinal cord injury have chronic motor and sensory impairments. Although many individuals can recover some function during initial rehabilitation, a large number of patients are unable to use their upper extremities in their daily living activities even after months of clinical therapy. One way to make these individuals independent is to provide them with movement assistive devices that help them to regain some lost functions. The purpose of this study is to explore the possibility of identifying upper limb movement kinematics using standard 4 contact subdural electrodes placed over the primary motor cortex.

Methods/Overview

Our earlier study shows that amplitude of ECoG recording resembles arm velocity in reaching tasks. Thus, we hypothesize that the amplitude ECoG recordings from primary motor cortex is proportional to arm speed. As such, we employ a MLR model to quantify relationship between neural activity and kinematic data. Two important physiological characteristics of the motor system are also taken into consideration. The first is the delay between the cortical activity and the corresponding motor output. The lag represents a transmission delay between cortical motoneuron spike response and emergence of EMG. The second physiological characteristic relates to ERD/ERS (power changes) in the beta and gamma frequency bands. We desire the predicted output to be “gated” by the activity in the beta and gamma bands. Specifically, high activity in beta band coupled with low energy in gamma band is an indicator of the cessation of movement and vice versa.

Results

To evaluate the accuracy of the model, we estimated the arm velocity of a single trial by using the remaining trials as a training set. Training and test data were then permuted. The average Pearson correlation between the estimated velocity and actual limb velocity was 84%. The results show good agreement with experimental data. We note that much of the prediction error occurs after the arm has reached the target, when the subjects hold their hand in the final position at the end of the trial. The residual neural activity after movement termination can thus be attributed possibly to the working of the hand against gravity.

Conclusions

We introduce a novel technique to reproduce three-dimensional movements of an arm in motion using the activity of the primary motor cortex recorded from only four subdural contacts.

Acknowledgements

NSERC, University of Toronto.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

EXPLORING RELATIONSHIPS BETWEEN KNEE REGION BONE MINERAL DENSITY AND PREVALENT FRACTURES AMONG INDIVIDUALS WITH SCI: A NESTED CASE-CONTROL STUDY

Deena Lala ¹, Catharine Craven ², Lehana Thabane ³, Lora Giangregorio ⁴

Abstract

Background/Objective

Individuals with spinal cord injury (SCI) often develop sublesional osteoporosis predisposing them to an increased fracture risk particularly at the distal femur and proximal tibia. The objective of this study was to explore whether areal bone mineral density (aBMD) of the distal femur or proximal tibia can discriminate between individuals with and without fragility fracture among patients with SCI.

Methods/Overview

A nested case-control study was performed using data from a larger two-year prospective cohort study (CIHR grant #86521). Individuals with traumatic SCI and duration of injury (DOI) ≥ two years were included. Subjects were questioned about the cause, location, and time of any lower extremity fragility fractures that occurred post SCI. aBMD of the distal femur and proximal tibia were measured using dual-energy x-ray absorptiometry (DXA). Univariate analysis was used to determine significant correlates (age; gender; motor complete injury; DOI; and bisphosponate use) of fractures. Logistic regression was used to explore the relationship between the presence of fragility fractures and aBMD. Results are reported as odds ratios (OR) per standard deviation (SD) decrease in aBMD, 95% confidence intervals (CI) and associated p-values.

Results

Of the 68 subjects (48 males 19 females), there were 18 cases with fragility fracture and 49 controls without fracture. Forty five distal femur BMDs and 61 proximal tibia BMDs were below the fracture threshold (0.78g/cm2), while 19 distal femur BMDs and 37 proximal tibia BMDs were below the fracture breakpoint (0.49g/cm2) for individuals with SCI. Individuals with fragility fractures had significantly lower aBMD of the distal femur (p = <0.0001) and proximal tibia (p = <0.0001) than those without fractures. A decrease in aBMD of the distal femur was associated with fractures (OR = 0.20; 0.06–0.49, p = 0.003), as was a decrease in aBMD of the proximal tibia (OR = 0.16; 0.05–0.42; p = 0.001). Distal femur aBMD (OR = 0.21, 0.05–055, p = 0.006) and proximal tibia aBMD (OR = 0.17; 0.04–0.50; p = 0.004) remained significant correlates of prior fragility fracture after adjusting for motor complete injury.

Conclusions

BMD of the distal femur and proximal tibia are associated with prevalent fractures. These findings may support the current practice of using aBMD to identify individuals with SCI at high risk of fracture if confirmed in larger prospective studies.

Acknowledgements

Grant Agency: Ontario Neurotrauma Foundation Grant Number: 2009-SCI-MA-684 Grant Agency: Canadian Institute of Health Research Grant Number: 86521 Grant Agency: Spinal Cord Injury Solutions Network (RHI) Grant Number: 2010.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

REVIEW OF KNOWLEDGE TRANSLATION AND IMPLEMENTATION STRATEGIES IN SPINAL CORD INJURY

Vanessa K Noonan ¹, Dalton Wolfe ², Karine Boily ³, Nancy P Thorogood ⁴, So Eyun Park ⁵, Jane Hsieh ⁶, Janice J Eng ⁷

Abstract

Background/Objective

Challenges in translating research evidence into the clinical setting are well known. To facilitate translation of evidence into spinal cord injury (SCI) clinical practice there is a need to determine which factors are critical to ensure successful implementation and evaluate if knowledge translation (KT) initiatives have impacted outcomes. The objective of this study was to conduct a systematic review of the literature to evaluate the KT strategies used throughout the SCI continuum of care (pre-hospital through to community) and determine the effect on patient and clinical outcomes.

Methods/Overview

Four electronic databases MEDLINE/Pubmed, CINAHL, EMBASE and PsycINFO were searched for English studies published from January 1980 to July 2011. Studies were included if there was a SCI KT initiative that described the process of implementation. Two reviewers independently screened the abstracts and the full articles and rated the study quality. Data abstracted included: 1) details of the KT initiative, 2) the implementation strategy (methods and evaluation), 3) impact of the KT initiative on patient or clinical outcomes (methods and evaluation), and 4) barriers and facilitators encountered with implementation.

Results

A total of 2902 publications were identified in the initial search, 94 full articles were reivewed and 19 studies met the inclusion criteria. Strategies used for implementing research evidence included disseminating clinical practice guidelines, incorporating standardized assessments into routine clinical practice and educating clinical staff. Frequently cited barriers included lack of knowledge, time, and cost, while facilitators included management support, engagement of stakeholders and the presence of a team member to act as a liaison among the various clinical groups involved. Implementation strategies for KT initiatives were evaluated in 6 of the 19 studies. Impact of the implementation on patient or clinical outcomes was only reported in 13 of the 19 studies.

Conclusions

Results from this systematic review provide an overview of the status of KT research in SCI. The relative success of the KT strategies and associated barriers and facilitators identified in this review may also inform ongoing KT initiatives in SCI and other health conditions.

Acknowledgements

Granting Agency: Health Canada.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

RESEARCH USE AND NEEDS: A GLANCE AT ORGANIZATIONS AIMED AT IMPROVING THE HEALTH OF CANADIANS LIVING WITH A DISABILITY

Shane N Sweet ¹, Amy Latimer-Cheung ², Chris Bourne ³, Kathleen Martin Ginis ⁴

Abstract

Background/Objective

Knowledge translation has gained importance in recent years, inspired by the inefficiencies of the current diffusion of research and the low research use in health organizations (Landry et al., 2003). To date, no studies have identified the use of research in organizations that promote healthy living for adults with a disability, including persons with a spinal cord injury. Therefore, the purpose of the current study was to examine the research use and needs of organizations promoting healthy living in this population.

Methods/Overview

Sixty individuals working within these organizations responded to our survey. The participants had a mean age of 44 years, and the majority were female (71%), had a bachelor's (52%) or a postgraduate degree (36%) and were senior managers (27%) or program coordinators (27%) with an average of seven years of experience. Responses to questions pertaining to the individuals’ research use and preference for the type of research information and the method of receiving/reading such information were collected.

Results

Fifty three percent of individuals often or always used research to guide their decisions when developing their last program. Individuals reported that demographic data (89%) and program evaluation data (90%) were the most useful type of research information, while research evidence from individual studies (45%), systematic reviews/meta-analyses (55%) or professional journals (53%) were not as favored. The preferred methods of receiving/reading research were from conferences/workshops (77%), short summaries of research (74%), websites (69%), email (67%) and newsletters (58%). Exploratory analyses revealed that research use and some of the preferences differed by education status. Postgraduates were more likely than non-postgraduates to use research (73% vs 40%, X22 = 6.17, p < .05) and to prefer receiving/reading research from individual studies (64% vs 34%, X2 = 4.88, p < .05) and systematic reviews/meta-analyses (82% vs 40%, X22 = 10.07, p < .05).

Conclusions

Better methods are needed to increase the uptake of research in these organizations, especially for individuals who do not hold a postgraduate degree. Since individuals reported a preference for short summaries and websites as a method of receiving/reading research evidence, one proposed method is to develop an online research portal that allows individuals to access short summaries of key research evidence.

Acknowledgements

Granting Agency: Canadian Institutes of Health Research; Institute Community Support Program.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

THE INFLUENCE OF AGE ON RECOVERY OF WALKING ABILITY IN PERSONS WITH MOTOR COMPLETE, SENSORY INCOMPLETE SPINAL CORD INJURY (ASIA IMPAIRMENT SCORE B)

Christina V Oleson ¹, John F Ditunno ²

Abstract

Background/Objective

To determine the effect of age on recovery of walking in persons with motor complete, sensory incomplete spinal cord injury (ASIA Impairment Score B).

Methods/Overview

Records of 72-hour admission ASIA impairment scores and one year ASIA Impairment Scores were reviewed for patients with motor complete sensory incomplete SCI that presented to our institution between 2005 and 2011. Of 46 eligible subjects between ages 16 and 70, 39 had complete records for evaluation. Recovery of ambulation was classified in one of two ways: 1) wheelchair ambulation or 2) walking community distances of 200 feet with or without a short limb brace but without an assistive device. Persons whose function fell between the above two categories were not studied. Percentages of ambulatory function by age category were performed. Due to small sample sizes, significant differences between groups were calculated using the Fisher's exact test.

Results

The final sample of 39 subjects was comprised of 32 between ages 16 and 49 and 7 ages 50 and older. The 7 eliminated from study pool as described above had included 6 subjects in the older age category, all of whom had expired by the one year follow up. Of those ages 50 and older, no subjects regained ability to walk in the community, compared with nearly 44% of those younger than age 50 (p = 0.036).

Conclusions

In addition to using pinprick in LE dermatomes L2-S1 to predict ambulatory recovery in patients with ASIA Impairment Score B SCI, age may be an independent factor on ability to recover ambulatory function. Larger sample sizes will need to be examined before findings can be applied to other settings.

Acknowledgements

NIDRR H133N060011.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

METABOLIC SYNDROME (METS) RISK FACTORS ARE NOT SUFFICIENT TO DETECT ELEVATED ARTERIAL STIFFNESS AMONG PEOPLE WITH CHRONIC SPINAL CORD INJURY (SCI)

Cameron Moore ¹, Masae Miyatani ², Paul Oh ³, Catharine Craven ⁴

Abstract

Background/Objective

Metabolic Syndrome (MetS) has been identified as a significant and independent risk factor for increased arterial stiffness in the able bodied population. To date, the association between arterial stiffness and MetS profiles in people with chronic SCI is unknown.

Methods/Overview

Forty-two consenting men and women with chronic SCI (C3-T12; AIS A-D; time post injury: 14.9 ± 11.1 yrs; age: 49.8 ± 12.3 yrs; height: 173.0 ± 10.3 cm; and weight: 82.0 ± 18.9 kg) participated. MetS was defined in accordance with the NHLBI/AHA guidelines as having any three of the following five risk factors: 1) elevated waist circumference: ≥102 cm in males, ≥88 cm in females; 2) elevated triglycerides: ≥1.70 mmol/L or drug treatment for elevated triglycerides; 3) reduced HDL-C.

Results

Thirteen participants (31.0%) had aPWV values ≥1200 cm/sec indicating vascular end-organ damage. Eleven participants (26.2%) were diagnosed with MetS. Of those with aPWV values ≥1200 cm/sec, only seven (46%) were positive for MetS. Five participants diagnosed with MetS did not have increased arterial stiffness.

Conclusions

Traditional MetS risk factors underestimate the prevalence of elevated arterial stiffness and possible subclinical vascular end-organ damage in people with chronic SCI. aPWV is better than MetS for detecting vascular end-organ damage in people with SCI so that treatment may be initiated prior to onset of adverse cardiac events (heart attack or stroke). Further exploration and validation of these assumptions is required. SCI specific risk factors such as age at injury, duration of injury, NLI, and AIS should be included in future risk assessment models.

Acknowledgements

Granting Agency/Funding Source: Ontario Neurotrauma Foundation Grant Number: 2008-SCI-PDF-692.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

INCREASING SPORT PARTICIPATION IN PERSONS WITH SPINAL CORD INJURY: FACILITATORS, BARRIERS, AND RESOURCES

Jessie Stapleton ¹, Kelly Arbour-Nicitopoulos ², Kathleen Martin Ginis ³

Abstract

Background/Objective

Emerging evidence indicates that sport participation has significant health, fitness, and social benefits for people with spinal cord injury (SCI) (Gioia et al., 2006; Martin Ginis et al., 2010; Muraki et al., 2000; Tasiemski et al., 2005). Despite these benefits, less than 5% of people with SCI participate in sports (Martin Ginis et al., 2010). The SCI Get Fit Toolkit was recently launched to promote exercise and sport participation in people with SCI. This evidence-based resource includes a variety of tools and information specifically tailored to the SCI population, such as the physical activity (PA) guidelines for adults with SCI (Martin Ginis et al., 2011), activity examples, benefits of PA, PA planning, and safety information. The current study is a part of a larger study that aims to qualitatively evaluate the SCI Get Fit Toolkit. To identify reasons individuals with SCI do or do not participate in sport. A secondary purpose was to evaluate the effectiveness of the Toolkit for promoting sport participation.

Methods/Overview

Semi-structured interviews were conducted via telephone or focus group with 8 individuals with SCI. Participants included inpatients, outpatients, and community-dwelling consumers with SCI. Thematic analyses of the transcribed data from five of the 16 discussion points were used to identify patterns in responses (Braun & Clarke, 2006).

Results

The patterns were dichotomized into sport facilitators and barriers. Sport facilitators encompassed two consistent, distinct themes: social opportunities (e.g., peer groups/meeting people) and personal fulfillment (e.g., for interest or enjoyment). Sport barriers encompassed three distinct themes: age, accessibility, and financial issues. Participants felt that the Toolkit provided appropriate informational resources to promote sport, but could be improved in terms of the presentation (clarity) of the information and addition of activities that can be done at little cost to the individual.

Conclusions

Increasing sport participation may be advocated through rehabilitation settings and community-based PA settings where social opportunities are largely available. Dissemination of the SCI Get Fit Toolkit may provide consumers with the necessary information and resources for initiating sport participation.

Acknowledgements

Granting Agency/Funding Source: Rick Hansen Institute, Ontario Neurotrauma Foundation, and Canadian Paralympic Committee.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

A COST-UTILITY ANALYSIS COMPARING EARLY VERSUS LATER SURGICAL DECOMPRESSION OF SPINAL CORD IN THE MANAGEMENT OF TRAUMATIC CERVICAL SPINAL CORD INJURY

Julio Furlan ¹, Michael Fehlings ²

Abstract

Background/Objective

This cost-utility analysis (CUA) compares early (up to 24 hours since injury) versus later surgical decompression of spinal cord (more than 24 hours after injury) in order to determine which approach is more cost effective in the management of patients with acute traumatic cervical spinal cord injury (SCI).

Methods/Overview

Cases were grouped into patients with complete motor SCI (Group I) and individuals with incomplete SCI (Group II). A CUA was performed for each group of patients using data for the first year after SCI. The perspective of a public health care insurer was adopted. Utilities were estimated based on data of the SF-26 from the Surgical Trial in Acute Spinal Cord Injury Study.

Results

When considering the later surgical decompression as the baseline strategy, the incremental cost-effectiveness ratio (ICER) was CDN$ 8,523,852 per quality-adjusted life year (QALY) for patients in Group I and CDN$ 275,390 per QALY in Group II. The probabilistic analysis indicated that there is no clearly dominant strategy. Using the Monte-Carlo simulation, early surgery would be more cost effective in 23.32% of the times in Group I, but it would be more costly and less effective than later surgical decompression in 26.21% of the times in Group I. Early surgical decompression strategy would be dominant in 30.46% of the times in Group II, but it would be dominated in 16.73% of the times in Group II at a willingness-to-pay of CDN$ 50,000.

Conclusions

The results of our economic analysis suggests that, although no strategy is clearly superior to the other, early surgical decompression of spinal cord can be more cost effective than delayed surgery in approximately one quarter of the patients with complete SCI and one third of the individuals with incomplete SCI.

Acknowledgements

This study was supported by a Cervical Spine Research Society grant and a Spinal Cord Injury Solutions Network Rapid Response Award from the Rick Hansen Foundation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

A SYSTEMATIC REVIEW OF THE USE OF STANDARD, HYDROPHILIC AND GEL-LUBRICATED CATHETERS IN PATIENTS WITH SPINAL CORD INJURY (SCI)

Kung Cheung ¹, Swati Mehta ², Amanda McIntyre ³, Shannon Janzen ⁴, Robert W Teasell ⁵, Dalton L Wolfe ⁶

Abstract

Background/Objective

Urinary tract infection (UTI) and bladder-related complications are reported to be the most frequent complications in individuals with spinal cord injury (SCI). As a result, hydrophilic and gel-lubricated catheters have been introduced in attempt to reduce these complications. The purpose of this systematic review is to study the effectiveness of hydrophilic and gel-lubricated catheters in reducing UTI compared to standard uncoated catheters post SCI.

Methods/Overview

A key term literature search was conducted in the following electronic databases: Medline, CINAHL, EMBASE, and PsycInfo. Studies published before March 2012 were evaluated and included based on the following criteria: 1) at least three study participants; 2) at least 50% of participants had an SCI; and 3) study subjects participated in a comparison study between standard uncoated polyvinyl chloride (PVC) catheters and coated catheters including hydrophilic catheters and/or gel-lubricated catheters. Level of evidence was determined using the Sackett scale.

Results

Six studies met the inclusion criteria (5 level 1; 1 level 2). Pooled sample size of all included studies was 509. Sample sizes of each study ranged from 16 to 224 with a mean of 85. There are conflicting results for hydrophilic catheters in establishing its effectiveness in directly reducing UTI. Three of the six studies reported no significant differences in mean number or frequency of UTI between the hydrophilic and standard catheters. However, it is reported that the hydrophilic catheters significantly delay the onset of first UTI incidence and reduces the number of antibiotics-treated UTI. Hydrophilic catheters were also associated with a significant decrease in number of microhematuria (p < 0.03) and both the gel-lubricated and hydrophilic catheters reported a decrease in the number of bacteruria (p < 0.03). In terms of urethral trauma, gel-lubricated catheters resulted in a reduced urethral cell count than the standard PVC catheters (p < 0.05). Overall, there are higher patients’ satisfactions in using gel-lubricated and hydrophilic catheters compared to the standard catheters.

Conclusions

Hydrophilic and gel-lubricated catheters represent an effective alternative to standard catheters in reducing urethal micro-trauma and bacteriuria, resulting in improved patient's satisfactions. However, more studies are needed to determine the effectiveness of hydrophilic catheters in directly reducing UTI incidence for patients with SCI.

Acknowledgements

This project was supported by the Rick Hansen Institute and Ontario Neurotrauma Foundation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

ONLINE PHYSICAL ACTIVITY FOR PEOPLE WITH SCI

Dalton Wolfe ¹, Kelly Ravenek ², Bonnie Chapman ³, Chris Fraser ⁴, Matthew Legassic ⁵, Saagar Walia ⁶

Abstract

Background/Objective

Physical activity (PA) is important for everyone, but especially for those with SCI due to their relative inactivity post-injury and also the many barriers to PA participation including inaccessible facilities, transportation and other environmental and personal barriers. Objective: To determine the feasibility of offering online, real-time seated aerobics classes through the use of video conferencing technology to persons with SCI in their own homes.

Methods/Overview

Nineteen individuals with SCI (below C4) were recruited for participation across 4 groups in an online, real-time seated aerobics program. The program consisted of 9 weeks of 2 live classes per week with a final week (week 10) of two archived classes. Each 45–60 minute class included a warm-up, aerobics, stretching and cool-down period with an experienced seated aerobics instructor. The primary outcome measure consisted of a post-program customized satisfaction/feasibility survey (i.e., general satisfaction, quality of instruction, rating of video-conferencing and monitoring technologies used, etc.). Secondary outcomes included measures of the sense of group cohesion, PA participation (short form of PARA-SCI), social cognitive predictors of exercise (self-efficacy & perceived behavioural control), quality of life (SF-36V, PQoL), comparison of live vs archived classes as well as on-going adverse event monitoring.

Results

Preliminary results (n = 9) demonstrated a high degree of satisfaction with all aspects of the exercise programming and to a lesser degree with the utility of the video-conferencing and monitoring technologies with the majority of participants indicating “extremely satisfied”. A few individuals indicated either “slightly satisfied” or “slightly dissatisfied” with the technologies and this was most likely to occur with individuals who had issues with maintaining Internet access or had lower bandwidths. No serious adverse events related to the exercise sessions were reported and there is also a preference for the live classes over the archived classes, although both were rated highly.

Conclusions

Offering real-time seated aerobics classes to persons with SCI in their homes is feasible and may be a viable method of providing PA-related services to persons with SCI, who otherwise may not receive this support. Participants have been enthusiastic in their enjoyment of the classes, however, further data collection and analysis (n = 10) is needed to lend further support to this preliminary conclusion.

Acknowledgements

Granting Agency/Funding Source: SCI Solutions Network (Rick Hansen Institute) Grant Number: SCISN Ref# 2011-06S.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

QUALITY OF LIFE AND DEPRESSION POST-SPINAL CORD INJURY: AN EVALUATION OF OUTCOME MEASURES

Aliza Panjwani ¹, Luc Noreau ², Sander Hitzig ³

Abstract

Background/Objective

Emotional well-being following spinal cord injury (SCI) can be a challenge as evidenced by the high rates of depression in this population. Although depression has been shown to negatively impact subjective well-being, there are several measurement issues associated with the assessment of quality of life (QoL). Hence, the objective was to help clarify issues of QoL measurement by conducting a systematic literature review on depression and QoL post-SCI. Doing so will inform SCI clinicians on 1) the theoretical underpinnings of the QoL outcome measures used; 2) which QoL tools have been validated for the SCI population; and 3) the sensitivity of QoL tools for assessing the impact of depression.

Methods/Overview

A systematic review of literature was conducted via electronic databases, such as Medline, PsychInfo, and CINAHL using relevant subject headings (N = 327). The following inclusion criteria were used: 1) English language; 2) 50% of the sample had a SCI; and 3) standardized measure of depression was used (e.g., Beck Depression Inventory; BDI). The exclusion criteria were if the studies did not specifically examine QoL in relation to depression. The outcome measures in the remaining articles (N = 20) were identified and categorized using Dijker's (2003) model of QoL.

Results

Out of the 20 articles, 85% used measures that were validated for evaluating depression post-SCI, with the Center for Epidemiological Studies Depression Scale and Older Adult Health and Mood Questionnaire being the two most common. The only QoL measures used in all the studies were those that assessed subjective well-being (‘insider’ viewpoint) of Dijker's (2003) model, while none assessed QoL from an objective (“outsider’/'societal’) perspective. The Satisfaction with Life Scale (SWLS) and Life Satisfaction Index A and Z (LSI-A; LSI-Z) were the most frequently used measures, and only the SWLS has been validated for use with the SCI population. All of the studies found a significant association between depression and QoL post-SCI, except for one study using a non-standardized measure of QoL.

Conclusions

Subjective well-being is sensitive to the impact of depression, but there is a need for more studies to use measures of QoL that are validated for use in the SCI population. As well, it is important to note the dearth of data on this topic from an objective viewpoint, which takes into account the societal perspective of what consitutes good QoL.

Acknowledgements

Granting Agency: Ontario Neurotrauma Foundation/Réseau Provincial de Recherche en Adaptation-Readaptation. Grant Numbers: 2010 - KM - SCI-QOL - 825; Grant #: 2008 - ONF - REPAR - 601 (SCI-IMPACT); Grant #: 2007 - ONF - REPAR - 518 (COM-QOL).

J Spinal Cord Med. 2012 Sep;35(5):419–478.

DIRECT COSTS OF ADULT TRAUMATIC SPINAL CORD INJURY IN ONTARIO

Sarah Munce ¹, Sara JT Guilcher ², Chantal Couris ³, Kinwah Fung ⁴, Catharine Craven ⁵, Susan Jaglal ⁶

Abstract

Background/Objective

To determine the total direct costs of publicly funded health care utilization for the three fiscal years 2003/04 to 2005/06 (April 1, 2003 to March 31, 2004 to April 1, 2005 to March 31, 2006), from time of initial hospitalization to one year post initial acute discharge among individuals with traumatic spinal cord injury (SCI).

Methods/Overview

Health system costs were calculated for 559 individuals with traumatic SCI (C1-T12 AIS A-D) for acute inpatient, emergency department (ED), inpatient rehabilitation (i.e., short-stay inpatient rehabilitation), complex continuing care (CCC) (i.e., long-stay inpatient rehabilitation), home care services, and physician visits in the year after index hospitalization. All care costs were calculated from the government payer's perspective, the Ontario Ministry of Health and Long-Term Care (MOHLTC).

Results

Total direct costs of health care utilization in this traumatic SCI population (including the acute care costs of the index event and inpatient readmission in the following year after the index discharge) were substantial: $102,900/person in 2003/04, $100,476 in 2004/05, and $123,674 in 2005/06 Canadian Dollars (2005 CDN $). The largest cost driver to the health care system was inpatient rehabilitation care. From 2003/04 to 2005/06, the average per person cost of rehabilitation was approximately three times the average per person costs of inpatient acute care. The linear regression results highlight the incremental individual-level costs associated with age, concurrent TBI, and both inpatient rehabilitation and complex continuing care hospitalizations.

Conclusions

The high costs and long length of stay (mean 90 days) in inpatient rehabilitation are important system cost drivers, emphasizing the need to evaluate treatment efficacy and subsequent health outcomes among patients with traumatic SCI admitted for inpatient rehabilitation.

Acknowledgements

Granting Agency/Funding Source: Ontario Neurotrauma Foundation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

FEASIBILITY OF USING CLINICAL MEASURES TO EVALUATE TRUNK CONTROL IN NON TRAUMATIC SPINAL CORD INJURY

Molly Verrier ¹, Sylvie Nadeau ², Heather Flett ³, Sharon Gabison ⁴, Ajodele Zapparoli ⁵, Audrey Roy ⁶

Abstract

Background/Objective

Measuring the effects of trunk control on function for persons with spinal cord injury is challenging. The objective of this analysis was to determine the feasibility of quantifying postural control restoration and characterize the impacts of sensory-motor trunk impairments on sitting and standing mobility in patients with Non Traumatic Spinal Cord Injury (NTSCI).

Methods/Overview

Data have been analyzed for subjects (n = 7) with (NTSCI) who were part of a larger study. Subjects ranged in age from 20 to 74 (43.3 ±19.0) years old with level of lesion ranging from C2 and L4. Subjects were assessed at admission to a rehab unit and within 3 weeks of discharge of the rehab unit with tests used to determine clinical status, functional mobility, maximal strength, physical activity and outcome and contextual variables. To clinically assess trunk control the Multidirectional Reach Test (MRT) and the T-Shirt Test (TST) was used.

Results

Subjects showed improvement in strength and functional mobility measures but researchers encountered difficulties in implementing the MRT and TST as subjects had significant difficulties in completing the tasks and data were inconsistent both between subjects and when comparing their admission and discharge assessments for these tests.

Conclusions

As expected strength and mobility improve throughout the rehab admission; however, evaluating the effect of a change in trunk control on function in the rehab phase may require the development of more highly refined tests for trunk control that are better customized for subjects’ individual impairments/abilities.

Acknowledgements

Craig H. Neilson Foundation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

COMPARISON OF THE SPINE ADVERSE EVENTS SEVERITY INSTRUMENT WITH ICD-10 CODES FOR DETECTION OF ADVERSE EVENTS IN PATIENTS WITH TRAUMATIC SCI

John Street ¹, Antoinette Cheung ², Vanessa Noonan ³, Nancy Thorogood ⁴, Jason Chen ⁵, Charles Fisher ⁶, Marcel Dvorak ⁷

Abstract

Background/Objective

Adverse events are common during acute care in patients with traumatic spinal cord injury (tSCI). Administrative data is often used to report adverse events; however, this data may not reflect patient complexity and outcome. The Spine Adverse Events Severity (SAVES) instrument is a prospective data collection method that has previously been validated for adverse event recording in the spine. The objective of this study was to compare the SAVES instrument with the use of ICD-10 codes for measuring adverse events in patients with tSCI.

Methods/Overview

Patients discharged between 2006 and 2010 were identified from our prospective registry. Two cohorts were created based on the method used to record adverse events; one used ICD-10 codes and the other used SAVES data. The ICD-10 codes were appropriately mapped to the SAVES instrument. There were 212 patients in the ICD-10 Cohort and 173 patients in the SAVES Cohort. Analyses were adjusted to account for the different sample sizes and the two cohorts were comparable based on age, gender and motor score.

Results

The number of adverse events recorded per person was doubled using SAVES. SAVES reported a significantly greater number of 15 adverse events, including incidence of neuropathic pain (x2.3; p < 0.05). There were eight adverse events identified more frequently by SAVES that significantly impacted length of stay (p < 0.05). Risk factors for adverse events were better characterized using the SAVES method, and the strength of association between risk factors and adverse events was also stronger using this method.

Conclusions

Implementation of the SAVES instrument for patients with tSCI captured more individuals experiencing adverse events and more adverse events per person compared to ICD-10 codes. This study demonstrates the utility of prospectively collecting adverse event data using validated tools.

Acknowledgements

Granting Agency/Funding Source: Rick Hansen Institute and Health Canada.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

EFFECT OF MOTOR CORTEX RTMS ON NEUROPATHIC PAIN AFTER SPINAL CORD INJURY

Jetté Fanny ¹, Meziane Hadj ², Côté Isabelle ³, Catherine Mercier ⁴

Abstract

Background/Objective

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive method that induces changes in cortical excitability. Studies have shown that rTMS applied over the motor cortex (M1) can alleviate neuropathic pain from diverse origins. The aim of the study was to evaluate the analgesics effects of a single rTMS session applied over the lower limb vs. upper limb motor region (compared to sham stimulation) for SCI population. The secondary aim was to document the neurophysiological changes underlying the analgesic effect of rTMS.

Methods/Overview

We recruited 16 SCI participants with chronic neuropathic pain (mean age, 50 ± 9y). Half had complete motor loss. A quasi-experimental cross-over design was used, each participant being exposed to two active (hand/foot M1 area) and one sham rTMS conditions, separated by at least 2 weeks, in a randomized counterbalanced order. The rTMS intervention duration was 20 minutes (40 5-seconds trains at 10Hz). The outcomes measures were pain intensity, amplitude of motor evoked potentials and center of gravity (CoG) shift of the FDI cortical representation. Moreover, the impact of different clinical characteristics (type and location of lesion, duration, etc.) has been explored.

Results

A decrease in pain was observed in the first 48h post-intervention for both active conditions. There was no difference between the three conditions after that 48h period. For both active conditions, patients with incomplete lesion had a better analgesic effect than patients with complete lesion. TMS motor map measurements revealed an increase in corticospinal excitability after stimulation of hand area, but not for the other two conditions. Only small nonsignificant CoG shifts in mediolateral axis were observed in response to rTMS, but interestingly they tended to be in opposite directions between the 2 actives conditions.

Conclusions

Active rTMS applied over the motor cortex decreased neuropathic pain regardless of the motor region stimulated (hand/foot area) and of the changes in cortical excitability, suggesting that the analgesic effect is not associated with local changes at the level of the motor cortex itself. Pain reduction then probably rely on distant effects such as top-down activation of brainstem periaqueductal grey matter driving descending inhibition or triggering of mechanisms resulting in the secretion of endogenous opioids. Future researches are needed to better understand the role of those mechanisms in the analgesic effect of rTMS on neuropathic pain.

Acknowledgements

Fanny Jetté had a scholarship from Université Laval.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

TRUNK MUSCLE STRENGTH, LOWER EXTREMITY MOTOR SCORE AND REACHING ABILITIES, DURING STANDING, OF INDIVIDUALS WITH INCOMPLETE SPINAL CORD INJURY: PRELIMINARY DATA

Cyril Duclos ¹, Dany Gagnon ², Audrey Roy ³, Philippe Ménard ⁴, Catherine Dansereau ⁵, Molly Verrier ⁶, Sylvie Nadeau ⁷

Abstract

Background/Objective

Trunk control is important in the performance of everyday activities. In persons with incomplete spinal cord injury (ISCI), who are able to walk, the ability to execute trunk movements in standing is recognized as being clinically important, but has rarely been studied. In addition, the association of this ability with the level of sensorimotor impairments is unknown. The present study aimed to evaluate trunk displacements during multidirectional reaching tasks in standing, and to relate these displacements to trunk muscle strength and the ASIA Lower Extremity Motor Score (LEMS).

Methods/Overview

Nine persons (44.6 yrs old (SD 18.9)) with ISCI (ASIA D, Time since injury: 84 days (SD 48)) were evaluated at the end of intensive rehabilitation. Maximal isometric muscle strength was measured in the sitting position, in right and left lateral flexion, anterior flexion and extension of the trunk, using a hand-held dynamometer affixed to a rigid frame. Participants were asked to reach in 6 directions (front, back, left, right, 45° to the left, and 45° to the right) with their preferred arm. The displacement of their 1st thoracic vertebrae was measured with a laser meter between quiet standing and maximal reach position. Maximal strength and trunk displacements were normalized to body mass and trunk length respectively. The level of association between variables was examined with Pearson correlation coefficients.

Results

Normalized trunk displacement was the longest in the forward directions (front: 0.54 (SD 0.16), 45° left: 0.46 (0.09), 45° right: 0.42 (0.09), in % of trunk length), then sideways (left: 0.40 (0.07), right: 0.40 (0.10)) and last backward (0.27 (0.10). Trunk extensors were the strongest muscle group (p0.001), about twice as strong as the other groups. The right and left lateral flexion strength showed a strong correlation (r = 0.85) while correlations between other muscle groups were below 0.7. LEMS and maximal strength of the trunk extensors were strongly and moderately correlated to forward reaching (r = 0.81 and 0.62, respectively). The correlations with reaching distances in the other directions were below 0.5.

Conclusions

These preliminary data revealed that forward trunk displacement is specifically associated with the trunk extensor and lower limb muscle strength, while reaching in other directions is likely affected by other factors, such as balance, trunk mobility or sensory capacities. Further analysis of the data is warranted to appreciate the importance of these other factors.

Acknowledgements

Funding source: Craig H. Neilsen Foundation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

ORTHOSTATIC HYPOTENSION AT DISCHARGE FROM INPATIENT SPINAL CORD INJURY REHABILITATION

Chelsea Pelletier ¹, Graham Jones ², Audrey Hicks ³

Abstract

Background/Objective

Physical activity guidelines for adults with chronic spinal cord injury (SCI) have recently been released. Before physical activity guidelines can be developed for adults with acute SCI, it is critical to assess safety and describe baseline cardiovascular status in this population. Orthostatic hypotension (OH) provides a measure of autonomic regulation and is particularly prevalent in the acute phase of SCI. As a means to identify an optimal screening protocol for exercise, the purpose of this study was to assess OH in a group of participants at discharge from inpatient SCI rehabilitation.

Methods/Overview

Nineteen participants (35.6 ± 12.3 years old, 11 males) were recruited and assessed for OH during the last two weeks of inpatient SCI rehabilitation (91.6 ± 40.3 days post injury). Participants were classified according to level of injury: tetraplegia (TP: n = 8, C3-C7, AIS A-D), high paraplegia (HP: n = 4, T4, AIS A-C), and low paraplegia (LP: n = 7, T6-L5, AIS A-D). Participants completed a passive “sit-up” test, involving 15 min of supine rest followed by 15 min in an upright position. Blood pressure and heart rate responses were monitored using a Finometer and 3-lead electrocardiogram.

Results

None of the participants experienced symptomatic or asymptomatic OH and all three groups showed a significant increase in systolic and diastolic arterial pressure (SAP, DAP) in response to the change in position. Supine and seated SAP was significantly lower in TP (94.37 ± 16.13 mmHg supine, 116.64 ± 13.35 mmHg seated) compared to LP (124.31 ± 33.94 mmHg supine, 154.61 ± 26.26 mmHg seated). Similarly, DAP was also significantly lower in TP (48.07 ± 14.08 mmHg supine, 71.37 mmHg seated) compared with LP (66.49 mmHg supine, 93.93 mmHg seated). There were no significant differences in supine or seated SAP or DAP between HP and LP. Although the change in SAP or DAP from supine to sitting was not significantly different between groups, there was a trend for a greater change in blood pressure in those with LP compared with TP (effect size = 0.52 for SAP; 0.43 for DAP).

Conclusions

At discharge from inpatient rehabilitation, patients with spinal cord injury appear to have sufficient autonomic control to raise blood pressure in response to a passive postural change, regardless of level of injury. Further work should examine other measures of autonomic function and cardiovascular regulation during exercise and recovery.

Acknowledgements

Granting Agency: Rick Hansen Institute Grant Number: 2010-80 Granting Agency: Ontario Neurotrauma Foundation Grant Number: 2009-RHI-MTNI-801.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

STRATEGIES DEVELOPED BY PARENTS IN WHEELCHAIRS AT TWO STAGES OF CHILD DEVELOPMENT, 0 TO 5 AND 6 TO 12 YEARS OLD

Cynthia Bergeron ¹, Claude Vincent ², Normand Boucher ³

Abstract

Background/Objective

Despite the growing number of individuals with motor disabilities who decide to become parents, their parenting role has received little attention in society, research or rehabilitation. The aim of this study was to document the various dimensions of the experience of parents in wheelchairs with children aged 0 to 5 and 6 to 12. More specifically, for each parenting dimension at these two stages of child development, the objectives were to: 1) identify the environmental and personal obstacles encountered, 2) document the personal strategies developed, and 3) document the types of formal and informal support used. A conceptual model was then developed.

Methods/Overview

Interviewed were conducted with six fathers and six mothers in wheelchairs, majority of participant have a spinal cord injury, followed by a thematic analysis of the content using procedures that met rigorous qualitative research criteria.

Results

In performing their parenting role in the four dimensions with children aged 0 to 5 and the three dimensions with children aged 6 to 12, the parents encountered two types of obstacles, developed seven types of personal strategies and used four types of informal and formal support.

Conclusions

The diversity of personal strategies is evidence of the parents’ desire to develop alternative ways to overcome obstacles. For the group aged 0 to 5 years old, the personal strategies aimed to “develop ways of doing things”, “carry out some physical modifications” within the house, “use technical aids” and “planning activities in advance” were crucial to allow parents to take care of the children by themselves. For those aged 6 to 12 years old, the strategies aimed to “guide the child”, “to develop his/her social skills” and “carry out some advocacy” were more important than with the other group. During the first year, the care provided to the child and the mobility in the community were the main reasons to seek support with children aged 0 to 5. With children aged 6 to 12, the main reason for seeking support was accessibility limitations. From these findings, some recommendations are suggested at clinical as well as at political and social level. And finally, the initial conceptual model was improved in the light of these findings.

Acknowledgements

Cynthia Bergeron, the first author, hold a scholarship from the Canadian Institutes of Health Research.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

BRAIN-CONTROLLED FUNCTIONAL ELECTRICAL STIMULATION FOR RETRAINING OF GRASP FUNCTION

Steven McGie ¹, Milos Popovic ²

Abstract

Background/Objective

Functional electrical stimulation (FES) describes the application of electrical stimuli to a muscle or motor nerve, with the purpose of inducing functional muscle contractions. This technique has long been proposed as a way of restoring motor function in individuals with neurologically-based motor disabilities, such as those caused by stroke or spinal cord injury (SCI). Brain-machine interface (BMI) is another technique that is being developed to assist individuals with neurological disabilities. A BMI records brain activity through one of several different modalities, then extracts or derives from these recordings a control signal, which can be applied to any number of assistive devices. To date, only one study has investigated how a BMI-controlled FES system might be used as a tool for rehabilitation, rather than as a permanent prosthetic, despite there being neurophysiological reasons why BMI-controlled FES may be able to provide greater benefit than regular FES. We have therefore developed a non-invasive BMI-controlled FES system, with the intention of applying it as an intervention for individuals with high-level incomplete SCI.

Methods/Overview

The system uses electroencephalography (EEG) to obtain neural activity from the area of primary motor cortex implicated in hand control. Changes in a specified bandpower within this signal are detected through a custom program, and used to provide a control signal to an electrical stimulator. Upon receiving this command, the stimulator changes from “resting” mode to “flexion” mode, generating a grasp. Since the stimulation introduces a significant artefact into the EEG signal, the next command, which switches from “flexion” to “extension” mode, is generated by a push-button. The final switch, from “extension” back to “resting”, is automatically timed. Participants in the proposed study will receive 40 hour-long sessions of using BMI-controlled FES to perform functional movements. A variety of measures will be used to examine changes in the participants’ grasping function and neurophysiological condition over the course of the intervention.

Results

The BMI-controlled FES system has been successfully developed and tested. Recruitment for the study has been opened, though no suitable participants have been enrolled at the time of writing.

Conclusions

The feasibility of developing a BMI-controlled FES system has been proven. The underlying physiological theory suggests that testing with individuals with SCI will show significant functional improvements.

Acknowledgements

Toronto Rehabilitation Institute – UHN Ontario Student Opportunity Trust Funds.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

EXPRESSION AND FUNCTIONAL ROLE OF BK CHANNELS IN CHRONICALLY INJURED SPINAL CORD WHITE MATTER

Hui Ye ¹, Josef Wan Buttigieg ¹, MS Yudi ¹, Jian Wang ¹, Michael Fehlings ¹

Abstract

Background/Objective

Spinal cord injury (SCI) causes neuronal death, demyelination of surviving axons, and altered ion channel functioning, resulting in impaired axonal conduction. The large-conductance, voltage and Ca2+-activated K+ (BK or Maxi K+) channels contribute to the repolarization phase of action potentials. Therefore, they may play a significant role in regulating axonal conduction in SCI.

Methods/Overview

In this paper, using combined electrophysiological and molecular approaches, we tested the hypothesis that the deficit in axonal conduction in chronic SCI is partially due to the activation of axonal BK channels.

Results

BK channels were found to be expressed in spinal cord white matter axons. These channels are not sensitive to BK channel blocker iberiotoxin in uninjured cords, likely reflecting their juxtaparanodal localization. After chronic injury, BK channels were exposed due to axonal demyelination at the injured site and their activation was found to depend on calcium influx, likely through N-type voltage-dependent calcium channels. Activation of BK channels introduced a reduction in the size of the compound action potentials (CAPs) and in axonal response to high frequency stimulation (HFS). Administration of BK channel blocker iberiotoxin significantly enhanced axonal conduction in the injured cords.

Conclusions

Thus, pharmacological targeting of axonal BK channels may provide a therapeutic strategy for the treatment of chronic SCI, by restoring conduction to the remaining functional axons.

Acknowledgements

Canadian Institutes of Health Research Heart and Stroke Foundation of Canada.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

EXTENT OF SOCIAL PARTICIPATION AND DIFFICULTIES ENCOUNTERED BY PEOPLE WITH SCI

Luc Noreau ¹, John Cobb ², Lydia Cartar ³, Jean Leblond ⁴, Vanessa Noonan ⁵

Abstract

Background/Objective

Following SCI, the fundamental goal of rehabilitation is the return to full social participation (daily activities and social roles). Studies describe participation after SCI, but little is known about how many people participate as much as they actually want, and no studies report how many individuals would like to participate but encounter significant difficulties when attempting to do so. The objective of this project is to determine the extent of social participation and the difficulties that limit full participation following SCI.

Methods/Overview

This project is part of the SCI Community Survey, which aimed at identifying major outcomes about community living. Participants (n = 902) across Canada with traumatic SCI (mean age = 49 ± 13, time since injury = 18 ± 13 yrs.) completed a survey (online or via telephone) covering major dimensions of community living. To describe participation in 26 daily activities (at home and in their community), participants answered four sub-questions: the extent of participation (as much or less than wanted, or not performed); the assistance required (equipment, environment, person, etc.); the difficulty encountered (none to extreme); and the reason for the restriction of participation (disability, environment, discrimination, etc.).

Results

Despite that participation was reported to be ‘as much as I want’ by a significant proportion of participants (58% + 19) across the 26 items, there are important restrictions of participation in activities such as holiday/travelling, leisure activities, paid work, home activities, maintaining health where the proportion is under 40%. Moreover, 53% of participants would like to participate more in at least 6 of the 26 activities, and only a few people (7%) wouldn't want to participate more. While a high majority of people identify their disabilities as a source of their participation difficulties (usually > 80%), environmental barriers is reported in more than 50% of participants for activities or social roles outside home, including emotional constraints causing difficulties when the activity requires interpersonal relationships.

Conclusions

This study is the first to describe participation in 26 regular, daily activities following SCI in the context of: type of activity, extent of participation, difficulties encountered, and the convergence of these factors. This information has the potential to identify the type of support services needed to enhance social participation of people with SCI in specific life domain.

Acknowledgements

Rick Hansen Institute, grant number: 2010-03 Ontario Neurotrauma Foundation, grant number: 2010-RHI-SURVEY-812.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

SCI-IMPACT: THREE YEARS OF COLLABORATION TO FACILITATE KNOWLEDGE TRANSFER

Catharine Craven ¹, Frédérique Courtois ², Desireé Maltais ³, Mélanie Boulet ⁴, Anthony Burns ⁵, Isabelle Coté ⁶, David Ditor ⁷, Laura Giangregorio ⁸, Sander L Hitzig ⁹, Pamela Houghton ¹⁰, Eldon Loh ¹¹, Nicole Mittmann ¹², Luc Noreau ¹³, Daphney St-Germain ¹⁴, Dalton Wolfe ¹⁵

Abstract

Background/Objective

The SCI-IMPACT team is the product of an Ontario Neurotrauma Foundation -Réseau Provincial de Recherche en Adaption-Réadaption (ONF-REPAR) funding initiative to promote inter-provincial collaboration on spinal cord injury (SCI) research. This partnership was formed to align knowledge and expertise related to secondary health complications (SHC) and their impact on quality of life following SCI across Ontario and Quebec.

Methods/Overview

This three-year initiative required collaboration among 28 researchers from 10 institutions. Members formed five subgroups to address issues related to psychological and financial impacts of pressure ulcers, neurogenic bowel, sexual and autonomic dysfunction, and fragility fractures. As well, one subgroup focused on evaluating the quality of life impact of all the aforementioned SHCs.

Results

The team format provided opportunities for knowledge exchange related to expertise and methodologies. With regard to mentorship, the project facilitated capacity building with the inclusion of 6 graduate students in the subgroups and opportunities for junior researchers to assume leadership roles. Most notably, a new leadership opportunity emerged for the management of the overall team in Quebec. Pooling of resources resulted in successfully obtaining five grants totaling over $1.1Million, publication of 4 articles and 2 abstracts, 5 podium presentations, and 5 manuscripts in preparation. Challenges included institutional differences in the ethics process, communication and translation obstacles, cultural differences in the recruitment process, and imbalances in scientific and clinical expertise across provinces.

Conclusions

SCI-IMPACT was a significant success with regards to facilitating sustainable partnerships, knowledge exchange opportunities, and building capacity for continued research growth. Infrastructure supports were key to resolving cultural, institutional and communication barriers, facilitating team growth and resolving financial reporting dilemmas. Funding to bring the group together has resulted in a broad inter-professional network of stakeholders keen to pursue collaborations based on a common focus and a strong desire to accelerate early wins. The team has secured funding for three more years and has extended the project aims to include two additional subgroups: Pain and SHC prevention. The team members view this ground work as a stepping stone for further collaborations and building a firm infrastructure to facilitate a future team grant application.

Acknowledgements

Granting Agency/Funding Source: Ontario Neurotrauma Foundation Grants # 2008-ONF-REPAR-601 & 2011-ONF-REPAR2-885.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

A PHENOMENOLOGICAL ANALYSIS OF NEUROGENIC BOWEL DYSFUNCTION FOLLOWING SPINAL CORD INJURY

Andréanne Guindon ¹, Sander Hitzig ², Maureen Connolly ³, Jude Delparte ⁴, Daphney St-Germain ⁵, Anthony Burns ⁶

Abstract

Background/Objective

Neurogenic bowel dysfunction is a major challenge to living with a spinal cord injury (SCI). Although this secondary health complication has been rated as having a high impact by people with SCI, no study has directly investigated what it is like to live with a bowel routine from the consumer perspective.

Methods/Overview

Nineteen individuals from the Toronto Rehabilitation Institute – UHN Spinal Cord Rehabilitation Program (Toronto, ON) and Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale (Québec, QC) participated in single face-to-face, phenomenological interviews in English and French respectively. Phenomenology examines lived experiences of humans from their own perspective. To attain a diverse sample, recruitment was stratified for participants’ language (French, English), injury duration (≥10years).

Results

Examples of themes identified from the indigenous typologies analysis include involuntaries inside and outside the home, impact on social activities, nature of stool (constipation and diarrhea), time required, discomfort and pain, lack of dietary flexibility, scheduling and travel, required routine and lack of spontaneity and freedom, impact on intimacy, disrupted sleep, autonomy and lack of autonomy, lack of continuity with support services, and architectural accessibility.

Conclusions

Neurogenic bowel dysfunction impacts several life domains of people with SCI; which limits their ability to fully participate in the community and maintain well-being. Moreover, it appears that social and community participation revolves around the bowel routine, necessitating the need for a great deal of resources and planning. These issues provide targets for intervention and should be assessed as outcomes.

Acknowledgements

Granting Agency: Ontario Neurotrauma Foundation Grant Number: 2009-SCI-NEURBOW-802.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

THE INFLUENCE OF OPIOID USE ON NEUROPSYCHOLOGICAL PERFORMANCE IN A POPULATION WITH SPINAL CORD INJURY

Nasreen Latheef ¹, Andrea Furlan ², Cheryl Bradbury ³, Robin Green ⁴

Abstract

Background/Objective

Pain is a significant problem after spinal cord injury and has a major influence on quality of life and the ability to participate in rehabilitation. Opioids are the most potent analgesics available and have been used for chronic non-cancer pain, including neuropathic pain. Opioids cause adverse events – which may impair attention, processing speed, memory and judgment. Research question: To determine the influence of opioid use on neuropsychological measures in a population with spinal cord injury.

Methods/Overview

Patients with spinal cord injury without brain injury confirmed by MRI and DTI scans were recruited. The following data was extracted from the hospital charts: pain localization, intensity, description, the type of pain medications (acetaminophen, NSAIDs, opioids), use of other medications with potential for psychomotor and cognitive side effects such as anti-emetics, benzodiazepines, antidepressants and anticonvulsants. The scores in the following domains of the neuropsychological tests were extracted: attention, speed of information processing, verbal memory, visual memory, and executive function. We will also describe the population in terms of depression, anxiety and neurobehavioural ratings. Some of the neuropsychological tests that will be assessed are CVLT-2, WMS-3, STROOP, SDMT, WTAR, and BDI.

Results

We have currently recruited and extracted data for 16 participants, of which 9 participants are opioid users, and 7 who are non-opioid users (control group). The most common opioid used was oxycodone (n = 7), followed by morphine sulphate (n = 1) and hydromorphone (n = 1). The range of daily morphine equivalents was from 15mg to 96.7mg, and the average was 47.1mg. The association between opioid daily dose and the score in specific domains of the neuropsychological tests will be done by bivariate correlation (Pearson correlation).

Conclusions

We expect to finish the data analysis by August 2012. The results of this study will be new in the field and will serve as a foundation for future research around cognitive measures and opioid usage. It will also help assess cognitive measures that are required during psychomotor performances such as driving.

Acknowledgements

No external funding.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

LACK OF GENERALIZABILITY OF THE RANDOMIZED CLINICAL TRIAL DATA ON INITIAL MANAGEMENT OF ACUTE TRAUMATIC CERVICAL SPINAL CORD INJURY TO ELDERLY PATIENTS IN CLINICAL PRACTICE

Julio Furlan ¹, Milos Popovic ², Catharine Craven ³

Abstract

Background/Objective

This systematic review examines the age distribution of patients included in previous randomized clinical trials (RCT) on initial management of acute traumatic spinal cord injury (SCI).

Methods/Overview

The literature search for this systematic review was conducted using MEDLINE, EMBASE and Cochrane databases. All RCTs focused on initial management of patients with acute traumatic SCI published from 1980 to 2011 were included. The age distribution in those captured studies was compared with the population in Canada, Ontario and Toronto based on data from the National Trauma Registry, Ontario Trauma Registry and Toronto Western Hospital Spinal Cord Database. Age distribution was collapsed into elderly individuals (65 years of age or older) and younger individuals (age <65 years).

Results

This systematic review captured nine RCTs on treatment of patients with acute traumatic SCI that reported the subject's age distribution. These were the First, Second and Third NASCIS trials, Maryland GM-1 trial, Japanese trial, Nimodipine trial, Gacycline trial, Sygen GM-1 trial and Cethrin trial. The frequency of elderly SCI individuals in RCTs varied from zero to 8.8%, which were significantly different from the proportion of elderly SCI individuals in the population data (23.4% to 34%). Of note, three studies limited the inclusion of subjects based on their age at time of SCI.

Conclusions

The results of this systematic review are indicative of an ageistic selection of patients for randomized clinical trials in the initial management of traumatic SCI. Given this, the generalizability of the data from these RCTs on management of acute traumatic SCI is limited. Investigators of future RCTs should consider the age distribution of potential subjects in the study inclusion and exclusion criteria.

Acknowledgements

None.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

TREATING BLADDER DYSFUNCTION ACCORDING TO CLINICAL PRACTICE GUIDELINES POST SCI

Shannon Janzen ¹, Amanda McIntyre ², Swati Mehta ³, Eldon Loh ⁴, Robert Teasell ⁵

Abstract

Background/Objective

Bladder dysfunction is a common complication following spinal cord injury (SCI). Recommendations for bladder management in adults with spinal cord injury require differentiation between upper (UMN) and lower motor neuron (LMN) injuries. A chart audit was completed to compare actual practice regarding the treatment of bladder dysfunction post SCI to clinical practice guidelines.

Methods/Overview

Medical charts of 100 SCI patients admitted and discharged from a rehabilitation unit between July 2009 and March 2011 were reviewed. Two independent reviewers determined: 1) whether bladder dysfunction was documented; 2) whether there was differentiation between UMN and LMN bladder dysfunction; 3) the treatment received (e.g., medications, testing, bladder emptying strategies). Where the differentiation was not documented in the medical records, an SCI rehab specialist determined whether the bladder dysfunction was UMN or LMN. The association of pharmacological treatments with UMN vs LMN bladder dysfunction were compared using the Fishers exact test.

Results

68% of the patients had some form of bladder dysfunction. It was documented that 33 of those patients had neurogenic bladder; however, no further differentiation between UMN and LMN bladder dysfunction was made in the medical records. The four most frequently administered bladder medications were: Bethanechol, Tolterodine, Tamsulosin and Oxybutynin. There was no statistical difference found in the administration of bladder medications based on the UMN neurogenic bladder group (n = 48) compared to the LMN neurogenic bladder group (n = 20).

Conclusions

It is important that the type of bladder dysfunction be assessed and documented to guide appropriate treatment when treating bladder dysfunction in SCI patients. Our current chart reviews demonstrate a gap between actual and best practices. Barriers to implementation of CPG need to be identified in order to improve bladder management.

Acknowledgements

Ministry of Health and Long-Term Care Alternative Funding Plan.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

SPATIALLY DISTRIBUTED SEQUENTIAL STIMULATION IMPROVES FATIGUE RESISTANCE IN PLANTAR FLEXORS OF ABLE-BODIED INDIVIDUALS

Dimitry G Sayenko ¹, Robert Nguyen ², Milos R Popovic ³, Kei Masani ⁴

Abstract

Background/Objective

Developing means to counter muscle fatigue during electrical stimulation has received much interest. One of the countermeasures is aimed at achieving an asynchronous behavior by delivering electrical stimulation through multiple electrode locations on a single muscle, producing a fused contraction with relatively low stimulation rates, and delaying the onset of fatigue. The purpose of the present study was to investigate in details the fatigue-reducing ability of interleaved sequential stimulation in the able-bodied population. In particular, we aimed to investigate the fatigability and contractile properties of the intact plantar flexor muscles during a fatiguing exercise produced using spatially distributed sequential stimulation (SDSS) and a single active electrode stimulation (SES). We hypothesized that the reduced muscle fatigue during SDSS may be achieved in non-paralyzed muscles as evidenced by the muscle physiological properties.

Methods/Overview

A bout of fatiguing stimulation consisted of 180 trains was applied to the triceps surae through surface electrodes for 15 able-bodied subjects. To indicate muscle force decay during the fatiguing stimulation, we calculated (1) torque amplitude, (2) fatigue index, and (3) torque-time integral. To describe the muscle contraction progression and relaxation during the fatiguing stimulation, we analyzed (4) torque rise time, (5) the rate of torque development, (6) the half-relaxation time, as well as (7) the rate of the relaxation. In addition, we characterized (8) the degree of contractile fusion during the ascending phase of the torque peaks by analysing the percentage of the accumulated power of the spectrum within 8-12 Hz compared to outside of the frequency limit.

Results

We demonstrated the minimum changes in the muscle force decay, as well as in the rates of muscle contraction progression and relaxation during the fatiguing stimulation using the novel method – SDSS, as opposed to a more conventional approach - SES.

Conclusions

The present work verifies and extends previously reported our findings on the effectiveness of using SDSS in plantar flexor muscles to reduce muscle fatigue. Using corresponding protocols for the fatiguing stimulation, the present study demonstrated the fatigue-reducing ability of SDSS in able-bodied population by higher fatigue indices, as well as by less change in the muscle contractile properties as compared with single active electrode setup.

Acknowledgements

Granting Agency/Funding Source: Canadian Institute of Health Research Grant Number: MOP111225.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

EFFECTS OF VARYING THE DISTANCE BETWEEN SEATS DURING SITTING PIVOT TRANSFERS ON MUSCULAR DEMAND AT THE SHOULDERS IN INDIVIDUALS WHO SUSTAINED A SPINAL CORD INJURY

Guillaume Desroches ¹, Dany Gagnon ², Sylvie Nadeau ³, Milos Popovic ⁴

Abstract

Background/Objective

The performance of SPT is amongst the most strenuous functional activity realized by individuals with a spinal cord injury (SCI) that exposed the shoulder joints (SJ) to great loads. In order to minimize loads at the SJ and the risk of secondary impairments, individuals with a SCI will usually minimize the distance separating the initial from the target seat before performing a SPT. However, depending on the wheelchair characteristics and physical environment, it is not always possible to minimize this distance. Thus, the purpose of this study was to determine the effect of increasing the distance between seats on the loads at the SJ using electromyographic muscular utilization ratios (MUR).

Methods/Overview

Twenty-four individuals who sustained a SCI participated in the current study. During a laboratory assessment, participants performed two SPTs between an initial and a target seat separated by 2 cm (near condition) and two additional SPTs after the distance between seats was increased to 12 cm (far condition). During all SPTs, the right upper limb assumed a leading role. Electromyographic (EMG) activity of the anterior deltoid (ANT), the clavicular (CLAV) and sternal (STERN) fibres of the pectorialis major was recorded at the leading and trailing SJs. MUR were computed for each muscle by dividing EMG activity by a maximum value obtained during isometric maximum voluntary contractions. Then, peak MUR for each of the muscles was computed for the four phases of SPT and compared using paired student t tests (p < 0.05).

Results

At the leading SJ, a significant increase in MUR was found between near and far conditions for ANT during the pre-lift phase (61% vs. 74%), for STERN during the pre-lift and upper-limb loading phases (38% vs. 42%; 55% vs. 59%) and for CLAV during the lift-pivot phase (49% vs. 56%). For the trailing SJ, significant increases in MUR were found for ANT during the lift-pivot phase (110% vs. 120%) and for CLAV during the lift-pivot and post-lift phases (49% vs. 59%; 17% vs. 20%).

Conclusions

This study confirmed that minimizing the distance between initial and target seats is an effective compensatory strategy to minimize muscular demand at the SJ and possibly optimize performance during SPTs. The highest muscular demand found when the seats were farther one from another may lead to secondary SJ impairments and reduce functional mobility in individuals with SCI. Therapists should encourage individuals with SCI to be as close as possible from the target seat when performing SPT.

Acknowledgements

Guillaume Desroches holds a Postdoctoral fellowship from the Canadian Institutes of Health Research in collaboration with the March of Dimes of Canada. Dany Gagnon holds a Junior 1 Research Career Award from the Fonds de la recherche en santé du Québec (FRSQ).The project was financed in part by the FRSQ. The Pathokinesiology Laboratory was supported in part by the Canada Foundation for Innovation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

A MODEL FOR BRIDGING THE TRANSLATIONAL VALLEY OF DEATH IN SPINAL CORD INJURY RESEARCH

William M Barrable ¹, Nancy P Thorogood ², Vanessa K Noonan ³, Phalgun B Joshi ⁴, Ken Stephenson ⁵, Brian K Kwon ⁶, Marcel F Dvorak ⁷

Abstract

Background/Objective

To improve health care outcomes with cost-effective treatments and prevention initiatives, basic health research must be translated into clinical application and implementation, a process commonly referred to as translational research. Few basic research discoveries achieve their fullest potential, it is estimated that only 14% of health-related scientific discoveries enter into medical practice and that it takes an average of 17 years for research evidence to extend into clinical practice. The transition from bench-to-bedside research is so fraught with obstacles that it is often referred to as the “valley of death”.

Methods/Overview

The Rick Hansen Institute (RHI) has developed a unique Praxis Model for translational research in the field of spinal cord injury (SCI). Praxis can be defined as the process by which a theory, lesson, or skill is enacted, practiced, embodied or realized. At RHI this means bringing knowledge into action and represents the process by which translational research is practiced to bridge the “valley of death” in the research and commercialization of SCI discoveries; to improve healthcare outcomes for people with SCI and decrease the financial impact on the healthcare system. The research continuum begins with discovery science which feeds into the knowledge cycle, continues with the acceptance and uptake into the treatment of spinal cord injuries, and results in the ultimate outcome of improved health. The core activity within the Praxis Model is a knowledge cycle that consists of a four-phased strategy: 1) Environmental scan, 2) Knowledge generation and synthesis, 3) Knowledge validation, and 4) Implementation.

Results

The RHI has participated and supported over 60 studies since 2007 and has engaged researchers from nine countries, 46 academic institutions and various accreditation and professional associations. Currently, the model is being independently evaluated to determine its strengths and limitations. Examples of RHI initiatives using the Praxis Model and results of the evaluation will be presented.

Conclusions

The RHI has developed an innovative solution to move knowledge into action. The Praxis Model strives to lead collaboration across the global SCI community by providing resources, infrastructure and knowledge. Lessons learned in developing the Praxis Model may assist other organizations dealing with similar translational research challenges.

Acknowledgements

Health Canada.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

EVALUATION OF THE DISCOVERING THE POWER IN ME CBT-BASED PILOT STUDY IN TORONTO

Kathryn Boschen ¹

Abstract

Background/Objective

Discovering the Power in Me (DPM) is a 3-day intensive cognitive-behavioural-based 12-unit small-group workshop developed in the US to help people with disabilities improve their self-esteem and quality of life. It follows the agentic perspective of social cognitive theory that people contribute to their own living circumstances, they are not simply passive products of them. The goal of the program is to develop and enhance personal goal-setting, self-reflecting, self-evaluating, and self-worth. It encourages participants to motivate themselves to succeed by changing their habits, attitudes, beliefs, and expectations where needed.

Methods/Overview

The DPM is a 12-unit program developed by the Pacific Institute in Seattle, WA. A formal external program evaluation was requested of the author. This took place with 7 individuals with spinal cord injury (SCI) or acquired brain injury (ABI) who were recruited by the Canadian Paraplegic Association for the purpose of examining the suitability of this clinical intervention for these two client groups. Using a mixed-methods study design (quantitative and qualitative), data were gathered on the following dimensions: Self-esteem (Rosenberg Self-Esteem Scale, RSE), Life Satisfaction Scale (LISAT-11, Fugl-Meyer), and two in-house instruments, a 12-item Likert-scale Pre-Post Seminar Survey measuring self-confidence, and a qualitative ‘‘Further Feedback’’ form for individual reactions to the DPM program in areas related to insights gained through the program, who the program would appeal and be beneficial to, overall program satisfaction, and several other items. Five of the seven questions were open-ended and two used a 4-point rating scale. The quantitative instruments were administered three times: at program commencement, completion, and 3 months post-completion, in a repeated-measures design.

Results

The Toronto DPM pilot was well-received by the participants, who felt it was a worthwhile program to have participated in which they would recommend to a like-minded friend. The quantitative data showed mixed results with either slight improvement or in several cases no changes.

Conclusions

Given the small number of individuals in this initial study caution should be used in drawing conclusions from the evaluation results. This is particularly true for the participants with ABI. Given that DPM is a cognitively-based intervention those with cognitive impairment are less better able to participate and less likely to benefit from the program than those with SCI.

Acknowledgements

Funding Sources: Community Grant through a partnership between the Ontario Neurotrauma Foundation and the Krembil Foundation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

ECONOMICS OF TRAUMATIC SPINAL CORD INJURY IN CANADA

Carly Rivers ¹, Vanessa Noonan ², Logan H Trenaman ³, Phalgun Joshi ⁴, Marcel Dvorak ⁵, Hans H Krueger ⁶

Abstract

Background/Objective

To determine the economic burden of traumatic spinal cord injury (tSCI) in Canada, and evaluate potential costs avoided by reducing the incidence of secondary complications, particularly pressure ulcers (PUs) and urinary tract infections (UTIs).

Methods/Overview

Health economics analysis. An estimated 1,400 Canadians survive a tSCI/year and suffer a high rate of preventable secondary complications. This study uses information from academic/grey literature on the incidence, prevalence, resource use, survival and quality of life of individuals with tSCI to estimate the lifetime economic burden of a tSCI and potential costs avoided if the incidence of secondary complications (e.g. PUs/UTIs) can be reduced. Direct and indirect costs are calculated in estimating the lifetime economic burden of a tSCI while the focus is on direct costs avoided by reducing the incidence of secondary complications.

Results

Total lifetime economic burden of a tSCI occurring at age 35 is $1.47-$3.03 million dollars; 50% of this is direct costs. The total annual economic burden of tSCI in Canada is estimated at $2.67 billion. If a modest 20% reduction of PU or UTI incidence was achieved in the Canadian tSCI population, $71.08 and $12.21 million in direct care costs, respectively, could be avoided annually in Canada.

Conclusions

tSCI is a huge economic burden to healthcare systems. Advances in prevention of secondary complications can greatly reduce both burden on tSCI patients substantially reduce economic burden. These advances are relevant to other patient groups, leading to even further patient and economic benefit.

Acknowledgements

Granting Agency/Funding Source: Rick Hansen Institute and Health Canada.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

Poster AWARD WINNER – STUDENT

COMPARISON OF MULTIDIRECTIONAL SEATED POSTURAL STABILITY BETWEEN INDIVIDUALS WITH SPINAL CORD INJURY AND HEALTHY INDIVIDUALS

Cindy Gauthier ¹, Dany Gagnon ², Murielle Grangeon ³, Géraldine Jacquemin ⁴, Sylvie Nadeau ⁵, Kei Masani ⁶, Milos Popovic ⁷

Abstract

Background/Objective

Seated stability is affected in many individuals with spinal cord injury (SCI) since the strength and sensorimotor synergies of the muscles governing seated stability are impaired. As a consequence, individuals with SCI are exposed to an increased risk of instability, even of fall, when maintaining a sitting posture or performing functional activities. Since seated stability has not been studied extensively in this population, this study aimed to compare multidirectional seated stability between individuals with SCI and healthy individuals, and to evaluate the effects of abdominal and lower back muscle paralysis on multidirectional seated stability.

Methods/Overview

Fifteen individuals with complete and incomplete SCI and 15 gender-, height- and weight-matched healthy individuals participated in a laboratory assessment. Participants were instructed to lean as far as possible, at a self-selected speed, in eight directions, set apart by 45° intervals, on two occasions while seated on an instrumented chair with their feet placed on force plates and their hands resting on their thighs. Eight direction-specific stability indices (DSI), expressing the percentage of the centre of pressure (COP) displacement over the theoretical position the COP could have reached to attain the boundary of the base of support (BOS) in the indicated trajectory, were calculated. A global stability index (GSI), representing the area defined by the contour of the maximum COP excursion reached in all directions, normalized against the area of the BOS, was calculated. A two-way ANOVA was conducted to verify if significant differences existed between groups and directions.

Results

All DSI and the GSI, except in the anterior (p = 0.052) and posterior (p = 0.041) directions, were lower (p < 0.025) in individuals with SCI than in healthy individuals. Individuals with SCI who had partial or full control of their abdominal and lower trunk muscles(SCILow) obtained DSI and GSI that were similar (p = 0.051−0.692) to those of healthy individuals. Individuals with SCI who had paralysis of the abdominal and lower trunk muscles(SCIHigh) reached lower DSI and GSI than did healthy individuals (p ≤ 0.005) and individuals with SCILow (p = 0.002−0.020).

Conclusions

Multidirectional seated stability is reduced in individuals with SCIHigh in comparison to healthy individuals. The DSI and the GSI may become useful measures of multidirectional seated stability for rehabilitation professionals to characterize change over time, or the impact of various treatments.

Acknowledgements

Dany Gagnon holds a Junior 1 Research Career Award from the Fonds de la recherche en santé du Québec (FRSQ). Cindy Gauthier received a Summer Research Grant from the Quebec Rehabilitation Research Network. The project was financed in part by the FRSQ. The Pathokinesiology Laboratory was supported in part by the Canada Foundation for Innovation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

THERAPEUTIC BENEFITS OF A SPINAL CORD INJURY PSYCHO-EDUCATION GROUP: A QUALITATIVE PERSPECTIVE

Nicole Digout ¹, Alana Zinman ², Patricia Bain ³, Sylvia Haycock ⁴, Debbie Hébert ⁵, Sander Hitzig ⁶

Abstract

Background/Objective

The process of community reintegration post-spinal cord injury (SCI) requires new learning, problem solving and adaptation to lifestyle changes. However, there is limited literature on the benefits of therapeutic education initiatives for SCI that serve to facilitate the coping process. Hence, the objective is to provide a qualitative description of the therapeutic benefits gained from participating in a psycho-education group aimed at improving well-being post-SCI.

Methods/Overview

The Community Reintegration Out-Patient (CROP) service is a closed psycho-education group, co-facilitated by 2 inter-professional team members, where clients with SCI: 1) discussed topics relevant to emotional, physical and social well-being; 2) learned about the role of “self’ in the recovery process by sharing experiences within a group setting; and 3) developed a roadmap for improving coping, well-being and overall self management skills while reintegrating back into the community. Eight persons with SCI completed semi-structured interviews on their perceptions of the CROP service. Interviews were analyzed using fundamental qualitative methodology in order to provide a comprehensive summary of the event. The technique of “code-recode’ was conducted by two analysts to verify content validity of the identified themes.

Results

The following main themes emerged: 1) finding self; 2) knowledge acquisition; 3) skill implementation; and 4) group processes. The therapeutic benefits gained with regard to ‘finding self’ included improved self-esteem, self-confidence, and being able to understand their limitations associated with SCI. Participants commented that they gained significant ‘knowledge’ related to their SCI and obtained self-management strategies, which was derived from the educational materials and from ‘interactions with the group’. As well, participation in the CROP provided them with opportunities to ‘implement the skills’ gained in the community setting. Overall, the group was highly satisfied with the CROP service except they felt more time was needed for each session.

Conclusions

The identified themes suggest that the CROP service met its therapeutic goals for improving well-being across several domains of functioning post-SCI. Overall, the described benefits of CROP Service provides a model that can be adapted by rehabilitation professionals at different settings to help persons with SCI better manage emotional, environmental, and social stressors that challenge community participation.

Acknowledgements

Funding Source: Toronto Rehabilitation Institute - UHN, which receives funding under the Provincial Rehabilitation Research Program from the Ministry of Health and Long-Term Care in Ontario. The views expressed do not necessarily reflect those of the Ministry; Ontario Neurotrauma Foundation/Rick Hansen Institute – Grant# 2010-RHI-MTNI-836.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

THE AVERAGE COST OF PRESSURE ULCER MANAGEMENT IN A COMMUNITY DWELLING SPINAL CORD INJURY POPULATION

Brian C Chan ¹, Natasha Nanwa ², Nicole Mittmann ³, Dianne Bryant ⁴, Peter C Coyte ⁵, Pamela E Houghton ⁶

Abstract

Background/Objective

In the community dwelling spinal cord injured (SCI) population, pressure ulcers (PU) are a commonly observed. Prevalence rates of PU in SCI have been observed upwards of 28%. Although several studies have investigated the economic impact of PU in the general population, there is little information on the health economic impact of PU in the SCI population. The primary objective of this study is to determine resource use and costs of a community dwelling SCI individual experiencing a PU from a societal perspective in 2010 Canadian dollars.

Methods/Overview

From a community dwelling SCI cohort from Ontario, Canada, a non comparative cost analysis was conducted. Medical resource use such as inpatient hospitalization, physician visits, nursing and allied health practitioner visits as well as non-medical resource use such as paid and unpaid time lost was collected over the study period. Multiplying resource use with associated unit costs determined from publicly available sources, total and average costs were calculated. Results were stratified by variables such as age, severity level, location of SCI and duration of PU. Sensitivity analyses on the number of hours of unpaid time lost, inpatient hospitalization and wait time in the emergency department were also carried out.

Results

Among the 12 study participants, total average monthly cost per community dwelling SCI individual with a PU was $4,745. Individuals with a cervical level injury had higher average costs compared to thoracic injury. Higher costs were also observed in individuals over the age of 65 years compared to below 65 and for individuals with no history of PU compared to individuals with past PU. Individuals currently experiencing a PU that is less than a year in duration, greater than 10cm2 and in stage III also had a higher cost compared to PUs that were more than a year duration, less than 10cm2 and in stage II or IV respectively. Hospital admission costs represented the greatest percentage of the total cost (62%). Results were most sensitive to variations in hospitalization costs.

Conclusions

The results of this analysis present the sizable costs incurred by community dwelling SCI individuals with a PU.

Acknowledgements

Grant Agency: Ontario Neurotrauma Foundation Grant Number: #2009-RHI-MTNI-804.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

QUASI-STATIC POSTURAL STEADINESS IN STANDING IS INFLUENCED BY VISUAL INPUTS IN INDIVIDUALS WITH SPINAL CORD INJURY

Jean-François Lemay ¹, Dany Gagnon ², Cyril Duclos ³

Abstract

Background/Objective

Maintaining balance is challenging for many individuals with spinal cord injury (SCI) who have regained the ability to walk. In these individuals, given their residual impairments, the contribution of visual inputs during standing may be higher than in healthy individuals. This study aimed to compare changes in quasi-static balance when standing with eyes open and closed among individuals with SCI and healthy controls, and, for individuals with SCI, to verify the association between these changes and clinically assessed balance performance.

Methods/Overview

Fifteen individuals with an incomplete SCI, walking independently with or without assistive devices, and 14 healthy controls participated in the study. During a laboratory assessment, participants were asked to stand on forceplates with feet in a standardized position during two 45-second trials with their eyes open (EO) and closed (EC) respectively. Reaction forces were recorded at a sampling frequency of 600 Hz. The resultant centre of pressure (COP) time series was low-passed filtered (5 Hz) and down-sampled (600 Hz) before analysis. COP measurements included: the mean values of the Root Mean Square distance (RMS), the mean COP velocity (MV), and the COP sway-area (SA). Romberg ratios (EC performance/EO performance) for all COP measures were computed. Individuals with SCI were also assessed with the Mini-BESTest. An ANOVA was used to compare groups and conditions, and t-tests (adjusted p value = 0.025) were used to confirm these differences. Romberg ratios were compared between groups using t-tests (p = 0.05). Spearman correlation coefficients quantified the association between the Romberg ratios and the Mini-BESTest for the SCI group.

Results

All data confirmed reduced balance in individuals with SCI when compared to healthy participants in both EO and EC conditions. COP data, except for healthy participant SA and MV, showed the EO condition to be the most stable. Romberg ratios of MV and SA were higher in individuals with SCI confirming a higher reliance on visual inputs in standing. Only RMS (r = 0.745) and SA (r = 0.785) ratios were significantly associated to the Mini-BESTest score.

Conclusions

Standing balance is reduced in individuals with SCI when compared to healthy individuals. Removing visual inputs further reduced steadiness, especially among individuals with SCI. In this population, reliance on visual inputs is elevated and associated with performance on a clinical balance assessment test.

Acknowledgements

Jean-François Lemay received a Doctoral Training Award from the Fonds de recherche du Québec – Santé (FRQS). Dany Gagnon and Sylvie Nadeau hold a Junior 1 and Senior Research Career Award from the FRQS, respectively. The project was financed in part by the Craig H. Neilsen Foundation. The Pathokinesiology Laboratory was supported in part by the Canada Foundation for Innovation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

EFFECTS OF SURFACE RESISTANCE ON HAND-RIM KINETICS DURING THE PERFORMANCE OF WHEELIES AMONG MANUAL WHEELCHAIR USERS WITH SPINAL CORD INJURY

Mathieu Lalumiere Boucher ¹, Dany Gagnon ², Jessica Hassan ³, Guillaume Durocher ⁴, François Routhier ⁵, Laurent Bouyer ⁶

Abstract

Background/Objective

Achieving the ability to balance a manual wheelchair on the two rear wheels (wheelie) is an important goal for individuals with spinal cord injury (SCI) during intensive functional rehabilitation. To facilitate the learning of this complex wheelchair skill, practicing wheelies on various surfaces has been suggested in clinical practice. Surprisingly, the performance of wheelies has not been studied extensively using a comprehensive biomechanical approach, and the effects of varying surface resistances on upper limb efforts and postural stability (balance), during wheelies, remain unclear. The objective of this biomechanical study was to compare the effects of four distinct surface resistances (friction) on hand-rim kinetics of the non-dominant upper limb during the performance of wheelies among manual wheelchair users with spinal cord injury.

Methods/Overview

Sixteen individuals, who sustained a SCI (Level of SCI: T2-T12, ASIA: A, B, C), use a manual wheelchair as their primary means of mobility and have the ability to perform wheelies, participated in this study. During a laboratory assessment, participants were asked to randomly perform wheelies on four surfaces representing various friction coefficients: natural (NAT), regular 5cm thick foam (LOW), memory foam (MOD), and rear wheels blocked (HIGH). Four trials were conducted for each of the four surfaces. Each participant's wheelchair was equipped with instrumented wheels to record hand-rim kinetics whereas the movements of the wheelchair, non-dominant upper limbs, trunk, and head were recorded with a 3D motion analysis system. The wheelie was divided into preparation, take-off, balance, and landing phases. The mean and peak net total and tangential forces were computed and compared using repeated measures ANOVAs.

Results

The net mean and peak total and tangential forces were greater during the take-off phase in comparison to the other phases of the wheelie. During the take-off phase, the greatest net mean and peak total and tangential forces, as well as the longest take-off phase duration, were reached with HIGH in comparison to the other surface resistances.

Conclusions

The performance of wheelies on low or moderate density foam led to forces similar to those computed when doing wheelies on natural surface (NAT). Though the use of low or moderate density foam may have limited effects on upper limb loading during wheelies, they may still represent a valuable alternative to favour as quasi-static postural steadiness may be optimized.

Acknowledgements

Mathieu Lalumiere Boucher received a Summer Research Award in Health Sciences from the Faculty of Medicine, University of Montreal. Dany Gagnon holds a Junior 1 Research Career Award from the Fonds de la recherche en santé du Québec (FRSQ). The project was financed in part by the FRSQ. The Pathokinesiology Laboratory was supported in part by the Canada Foundation for Innovation.

J Spinal Cord Med. 2012 Sep;35(5):419–478.

INVESTIGATING LIFE SATISFACTION OF COMMUNITY-DWELLING INDIVIDUALS WITH TRAUMATIC SPINAL CORD INJURY: A PILOT STUDY UTILIZING THE RICK HANSEN SPINAL CORD INJURY REGISTRY

Deborah Tsui ¹, Michael Finlay ², Laura Cremasco ³, Sascha Boulet ³, Brian Drew ³

Abstract

Background/Objective

An estimated 44,000 individuals are living with traumatic spinal cord injury (SCI) in Canada. Studies investigating the quality-of-life (QoL) of people with SCI have found lower QoL when compared to the general population. However, differences in QoL were not found between people with tetraplegia versus paraplegia. QoL of individuals with SCI have been shown to relate to perception of health, participation, community integration, social relationships, social support, and living circumstances. In this population, decreased QoL have shown correlation with presence of comorbidities, restricted social participation, and increased pain, spasticity, and bowel and bladder dysfunction. The Rick Hansen SCI Registry (RHSCIR) is a Canadian database that collects and stores information about healthcare and health outcomes of people with traumatic SCI. This pilot study aimed to use the RHSCIR in Hamilton, Ontario to: 1) determine whether QoL is different between those with tetraplegia versus paraplegia, and 2) to investigate the association between QoL and participant characteristics in people with SCI who live in the community.

Methods/Overview

RHSCIR is a multicentre prospective study of adult patients with traumatic SCI who are admitted to Canadian tertiary hospitals with specialized spine care. Eligible patients admitted to Hamilton Health Sciences from September 2006 to April 2010 were recruited. Consenting participants who were discharged to the community and could be contacted were interviewed by phone. RHSCIR's Community Follow-Up Questionnaire was administered to collect information regarding sociodemographics, SCI characteristics, and QoL (using the Life Satisfaction-11 (LISAT-11) Questionnaire). Data analyses used the Mann-Whitney U test and Spearman's rho correlation.

Results

In this pilot study, 26 participants completed the community follow-up interview. QoL, as measured by LISAT-11 average scores, did not differ significantly between those with tetraplegia (4.1 ± 1.2) and paraplegia (4.1 ± 1.0) (p = 0.608). LISAT-11 average scores correlated significantly with completeness of injury (r = 0.509, p = 0.008), employment status (r = 0.463, p = 0.017) and financial assistance status (r = 0.450, p = 0.021).

Conclusions

For people with traumatic SCI who live in the community, QoL may be influenced more by social and financial factors than by level of spinal injury. Healthcare professionals should consider these factors when working with individuals whose rehabilitation goals include return to community living.

Acknowledgements

Funding Sources: Health Canada, Government of Ontario, Rick Hansen Foundation, Rick Hansen Institute.

SCIENTIFIC PLANNING COMMITTEE

Chair - Catharine Craven, BA, MSc, MD, FRCPC

Assistant Professor, Department of Medicine, University of Toronto; Clinician Scientist, Toronto Rehabilitation Institute – University Health Network

Chair - Milos Popovic, PhD, PEng

Chair, Spinal Cord Injury Research, Rehabilitation Engineering Laboratory, Toronto Rehabilitation Institute – University Health Network; Professor, Institute of Biomaterials and Biomedical Engineering, University of Toronto

Chair - Molly Verrier, Dip P&OT, MHSc

Associate Professor Emeritus, Department of Physical Therapy, Physiology, Rehabilitation Science, Institute of Medical Science, Faculty of Medicine, University of Toronto; Senior Scientist, Toronto Rehabilitation Institute – University Health Network, Lead SCI Mobility Laboratory

Heather Flett, BA, BSc PT, MSc

Advanced Practice Leader, Spinal Cord Rehab, Toronto Rehabilitation Institute – University Health Network; Lecturer, Department of Physical Therapy, University of Toronto

Sukhvinder Kalsi-Ryan, BSc PT, MSc, PhD

Postdoctoral Fellow, Toronto Western Research Institute and Toronto Rehabilitation Institute – University Health Network

Nancy Lawson

Consumer Representative

Luc Noreau, PhD

Director, Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec City; Full Professor, Department of Rehabilitation, Faculty of Medicine, Université Laval

Christine Short, MD, FRCPC

Co-director, Rehabilitation and Supportive Care QEII Health Sciences Centre; Division Head, Physical Medicine and Rehabilitation; Co-appointment, Division of Neurosurgery, Capital District Health Authority; Associate Professor, Department of Medicine, Dalhousie University

John Steeves, PhD

Peter Wall Institute Distinguished Scholar in Residence; Professor, Departments of Cellular and Physiological Sciences, Rehabilitation Sciences, Surgery (Neurosurgery) and Zoology at the University of British Columbia and Vancouver Coastal Health Research Institute (part of Vancouver Coastal Health)

Keith Tansey, MD, PhD

Director, Spinal Cord Injury Research and Restorative Neurology, Shepherd Center; Departments of Neurology and Physiology, Emory University School of Medicine; Spinal Cord Injury Clinic, Atlanta Veterans Administration Medical Center

Sophie Twyne, RN

Acute Spinal Cord Program, Sunnybrook Health Sciences Centre

Gale Whiteneck, PhD, FACRM

Research Director, Craig Hospital Research Program

Jaynie Yang, BSc PT, PhD

Professor, Department of Physical Therapy, Centre for Neuroscience, University of Alberta

PLANNING COMMITTEE

Bill Adair

Chief Executive Officer, Canadian Paraplegic Association Ontario

Zina Bezruk

Administrative Assistant, Toronto Rehabilitation Institute - University Health Network

Tory Bowman

SCI Education Coordinator, Canadian Paraplegic Association Ontario

Catharine Craven, BA, MSc, MD, FRCPC

Assistant Professor, Department of Medicine, University of Toronto; Clinician Scientist, Toronto Rehabilitation Institute – University Health Network

Lynn Francis

Executive Assistant, Canadian Paraplegic Association Ontario

Tara Jeji, MD, MBA

Program Director, SCI, Ontario Neurotrauma Foundation

Colleen McGillivray, MD

Physiatrist, Toronto Rehabilitation Institute – University Health Network

Sandra Mills, MEd, BRLS (TRS)

Patient and Family Educator, Toronto Rehab – University Health Network

Milos R. Popovic, PhD, PEng

Chair, Spinal Cord Injury Research, Rehabilitation Engineering Laboratory, Toronto Rehabilitation Institute – University Health Network; Professor, Institute of Biomaterials and Biomedical Engineering, University of Toronto

Robyn Verdun, MD

Family Physician, Toronto Rehabilitation Institute – University Health Network

Molly Verrier, Dip P&OT, MHSc

Associate Professor Emeritus, Department of Physical Therapy, Physiology, Rehabilitation Science, Institute of Medical Science, Faculty of Medicine, University of Toronto; Senior Scientist, Toronto Rehabilitation Institute – University Health Network, Lead SCI Mobility Laboratory

Nancy Xia

SCI Information Assistant, Canadian Paraplegic Association Ontario

Conference Services

Jill Fredericks

Manager, Conference & Educational Technology Services

Jason Almeida

Sponsorship & Business Development Officer, Conference Services

Kim Hussey

Event and Marketing Coordinator, Conference Services

Nancy La

Conference Coordinator, Conference Services

PERMALINK

POSTER AWARD WINNER EDUCATION

John Shepherd

Karla Badger-Brown

Brian Lingley

Joanne Smith

Saagar Walia

Matthew Legassic

Dalton Wolfe

Series information

Abstract

Background/Objective

Methods/Overview

Results

Conclusions

Acknowledgements

PARTNERS IN SUCCESS: EXPLORING RESEARCH-STAKEHOLDER PARTNERSHIPS AS A CRITICAL MECHANISM FOR KNOWLEDGE TRANSLATION AND EVIDENCE-BASED PRACTICE

Peter Athanasopoulos

Amy Latimer-Cheung

Heather Gainforth

Sonya Corkum

Kelly Arbour-Nicitopoulos

Kathleen Martin Ginis

Series information

Abstract

Background/Objective

Methods/Overview

Results

Conclusions

Acknowledgements

ENHANCING EDUCATION DELIVERY: AN EVALUATION OF THE CLIENT EDUCATION SESSIONS AND PRINT MATERIALS IN A SPINAL CORD INJURY PROGRAM

Karen Anzai

Amber Backwell

Corrie Funk

Kim van Wyk

Walt Lawrence

Brad Jacobsen

Andrea Townson

Series information

Abstract

Background/Objective

Methods/Overview

Results

Conclusions

Acknowledgements

THE EFFECTS OF CYCLOSPORIN-A ON FUNCTIONAL OUTCOME AND AXONAL REGROWTH FOLLOWING SPINAL CORD INJURY IN ADULT RATS

H Delaviz

A Mirzaei

A Roozbehi

M Taghi Joghataie

M Mehdizadeh

Series information

Abstract

Background/Objective

Methods/Overview

Results

Acknowledgements

PROGRAM EVALUATION STRATEGIES FOR CLINICIANS: CASE-EXAMPLES OF INTERVENTIONS AIMED AT IMPROVING WELL-BEING

Sander Hitzig

Charlene Alton

Patricia Bain

Sylvia Haycock

Nicole Leong

Aliza Panjwani

Series information

Abstract

Background/Objective

Methods/Overview

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Acknowledgements

DEVELOPMENT OF SCI REHABILITATION IN NEPAL

Carol Scovil

Sylvia Haycock

Edith Ng

Angie Andreoli

Nora Cullen

Series information

Abstract

Background/Objective