Academy of Spinal Cord Injury Professionals 2020 Educational Conference: ASCIP One Vision Online September 12, 13, 21, and 22, 2020 Poster Presentations P1–P30

doi:10.1080/10790268.2020.1794753

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P1 Classifying first instance of clinically diagnosed upper extremity pain and pathology in individuals with traumatic spinal cord injury

Beth A Cloud-Biebl ¹, Ashley Lahti ¹, Ellen Larkin ¹, Cassandra J Lindstrom ¹, Kathleen Michaels ¹, Megan Piotrowski ¹, Rachel M Svendson ¹, LaDeanna Swanson ¹, Samuel J Weigel ¹

Abstract

Background: Upper extremity (UE) pain/pathology is commonly reported in individuals with spinal cord injury (SCI); however, surveys account for much of the data and thus don’t necessarily reflect frequency of diagnosis.

Objective: The purpose of this study is to determine the first instance of clinically diagnosed UE pain/pathology in individuals with traumatic SCI in Olmsted County, MN.

Design: A retrospective chart review was completed using a medical record linkage system (the Rochester Epidemiology Project (REP) for Olmsted County, MN and surrounding areas) and associated medical records dating 1976–2016.

Methods: Potential subjects were identified with SCI diagnosis codes occurring during the study period, 1976–2016. Traumatic SCI was confirmed by searching the REP and medical records. Time following confirmed SCI and within the study period was reviewed in the REP to identify clinical diagnoses suggesting UE pain/pathology not directly related to the traumatic event leading to SCI. The medical record was reviewed to confirm a diagnosis of UE pain/pathology. Primary outcomes include: (1) proportion of individuals with traumatic SCI who had a confirmed UE pain/pathology diagnosis during the study period and (2) median pain-free time following SCI determined by Kaplan Meier survival analysis.

Results observed: Eighty-two individuals were confirmed to have traumatic SCI (median age: 34 years [range 18–84], 77% male). SCI was classified by neurological level of injury (39% with paraplegia, 61% with tetraplegia) and ASIA impairment scale grade (32% A, 16% B, 17% C, 30% D, and 5% unable to determine). Median follow-up time available after SCI was 10.7 years (range: 1 week to 38.8 years). Fifty percent of the cohort had clinical diagnoses of UE pain/pathology during the available follow-up period. Median pain-free time was 7.7 years (95% CI:4.5–13.7).

Conclusions: Results of this study demonstrate the importance of healthcare providers screening for UE pain/pathology in patients with traumatic SCI. It additionally provides context for when patients are likely to start experiencing difficulty, which can guide both prevention and timely diagnosis.

Support: This study was made possible using the resources of the Rochester Epidemiology Project, which is supported by the National Institute on Aging of the National Institutes of Health (NIH) under Award Number R01AG034676. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Keywords: Upper extremity, Pain, Pathology, Spinal cord injury, Epidemiology

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P2 Who accesses remote web-based training: implications for clinical care

Rachel Hibbs ¹, Kaitlin Digiovine ², Lynn Worobey ², Michael Boninger ²

Abstract

Background: With the abundant amount of information available on the Internet, many individuals turn to it for health information and education. This as well as increased access to the Internet via mobile devices may lend web-based trainings as a method with which to reach individuals who otherwise have limited access to quality spinal cord injury (SCI) education due to rural locations, limited access to transportation.

Objective: Web-based training offers a unique opportunity to reach individuals with SCI who might otherwise not have access to evidence-based education. For some, transportation and location in relation to clinicians well-versed in SCI care may significantly limit quality of care and education for these individuals. We will present data regarding who accessed web-based transfer training, including personal demographics, transfer ability, levels of shoulder pain, online learning readiness, and self-efficacy to inform clinicians and researchers of the audiences that might benefit most from online-learning and remote education.

Design: Randomized control trial.

Methods: Baseline measures collected include demographics, Online Learning Readiness Scale (OLRS), Moorong Self-Efficacy Scale (MSES), Wheelchair User Shoulder Pain Index (WUSPI), and Transfer Assessment Instrument (TAI). Participants were randomized to either an immediate or wait-list control group (6 month delay) to complete self-paced transfer training modules hosted through Coursesites.

Results Observed: 121 individuals accessed the web-based transfer training. Participation was higher among, a manual wheelchair users (86%), white non-hispanics (79%) and those with at least some college education (91%). Participation was evenly spread based on sex and income. There was a wide spread based on age (24–73) and years since injury (1–57). Manual wheelchair users had higher baseline TAI scores (62% vs 43%, P < 0.001), were younger (60 vs 51, P = 0.002), and transferred more frequently per day (14 vs 10, P=0.046) than did power wheelchair users. The mean baseline self-efficacy as scored on MSES was low (28.9%) as compared to other studies (82–88%) of similar subjects. Online learning readiness ranged from 22 to 100%.

Conclusions: Clinically, those we might consider who would be most receptive to a remove web-based intervention include both manual and power wheelchair users, both male and female clients, individuals with higher than high school education. Of note, even low self-efficacy and online learning preparedness did not deter individuals from accessing the training.

Support: NIDILRR grant 90SI5014, 90DP0078.

Keywords: Web-based training, transfers

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P3 Lower thoracic spinal cord stimulation improves bowel management in tetraplegics

Anthony F DiMarco ^1,⁵, Robert T Geertman ³, Kutaiba Tabbaa ⁴, Gregory A Nemunaitis ¹, Krzysztof E Kowalski ^2,⁵

Abstract

Background: Bowel dysfunction following spinal cord injury (SCI) has a significant impact on independence, dignity, and may cause serious life-threatening consequences. Some of the challenges relate to their dependence on caregiver support, need for medications, and the extensive time requirements associated with bowel management (BM). Spinal Cord Stimulation (SCS) has been shown to restore an effective cough and may also improve bowel function, as well.

Objective: To establish whether usage of SCS to restore cough may improve BM in individuals with SCI.

Design: Clinical trial assessing the clinical outcomes and side effects associated with the cough system.

Methods: In five tetraplegics, SCS was applied at home, 2–3 times/day, on a chronic basis and also as needed for secretion management. Stimulus parameters were self-determined (20–30 V, 50 Hz, 0.2 ms) to deliver the optimal regimen during daily bowel routine. Airway pressure generation (P) was measured at total lung capacity in conjunction with participant maximal spontaneous expiratory effort, as an index of expiratory muscle strength. Questionnaires related to BM, were collected.

Results observed: Mean P during spontaneous efforts was 30 ± 8cmH₂O. Following a period of reconditioning (24 weeks) SCS resulted in P of 109 ± 25 cmH2O and 124 ± 22 cmH₂O, at 20 and 30 V, respectively. The time required for BM routines was reduced from 118 ± 34 min to 18 ± 2 min (P<0.05). Digital anorectal stimulation and/or manual evacuation methods for BM were completely eliminated in 4 and 2 patients, respectively. The number of medications required for BM was also reduced. No patients experienced fecal incontinence as result of SCS. The improvement in BM time was inversely related to the improvement in airway pressure generation via SCS, over time.

Conclusions: Our results suggest that SCS to restore cough may be a useful method to improve BM and life quality for both SCI patients and their caregivers. The improvement in BM time is related to the development of large intra-abdominal pressures.

Support: NIH-NINDS (5U01NS 83696), NCATS and CTSA (UL1TR002548) Non-Financial Disclosure Statement: Dr. Anthony DiMarco owns patent rights for technology utilized in this research study.

Keywords: Cough, Respiratory muscles, Spinal cord stimulation, Bowel routine

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P4 Force sensitive resistors provide novel assessment of trainer assistance during dynamic multi-modal rehabilitation with epidural stimulation for individuals with spinal cord injury

Margaux B Linde ¹, Andrew R Thoreson ¹, Peter J Grahn ^1,², Dimitry Sayenko ³, Cesar Lopez ¹, Megan L Gill ¹, Daniel D Veith ¹, Kalli J Fautsch ¹, Rena Hale ¹, Jonathan S Calvert ², Lisa A Beck, Kristin D Zhao ¹

Abstract

Background: Epidural stimulation (ES) and transcutaneous stimulation (TS) below the level of spinal cord injury (SCI) has shown restoration of functions in humans with chronic paralysis. Previous use of multi-modal rehabilitation (MMR), defined as task-specific training with ES or TS, significantly enhanced performance of standing and stepping tasks in participants with motor complete paraplegia. Functional improvements over the course of MMR can be characterized using metrics of trainer assistance. However, variations in trainer assistance are difficult to quantify during dynamic trainer assisted rehabilitation activities. Previously, force sensitive resistors (FSRs) have been used to quantify static activities during TS.

Objective: We intend to classify trainer assistance during dynamic MMR, utilizing FSRs during body weight supported (BWS) stepping activities at selected time points over 12 months.

Design: A feasibility study to assess the validity of incorporating FSRs to quantify dynamic assistance during MMR of persons with SCI.

Methods: Over 12 months, two male participants with traumatic SCI, AIS-A, performed ES-enabled stepping activities with trainer assistance and BWS provided as-needed as part of an IRB-approved study. Recordings from electrogoniometers (Noraxon, US) positioned over the knee joints to detect knee angles were synchronized to skin surface electromyographic (EMG) recordings from bilateral lower extremity muscles. Additionally, FSRs were positioned bilaterally at the tibial tuberosity of the participant and on the trainers’ hands (hip placement) to detect the duration of assistance provided. Devices were calibrated and synchronized to video via a common data acquisition system (ADInstruments, Australia).

Results observed: FSR measures demonstrated independence during stepping tasks showing decreased duration of force measured in Newtons (N) applied at the knee and hip locations by the trainer during the use of ES. Both participants improved independence with lower BWS and reduced duration of trainer forces over the course of MMR.

Conclusions: The establishment of objective assistance measures during rehabilitation plays a critical role in quantifying recovery during investigations of novel interventions, such as MMR. FSRs positioned at locations where trainer assistance is commonly applied during training detected changes during stepping tasks over time.

Support: The Grainger Foundation, Regenerative Medicine Minnesota, The Jack Jablonski Bel13ve in Miracles Foundation, Minnesota Office of Higher Education, Craig H. Neilsen Foundation, Mayo Clinic: Graduate School of Biomedical Sciences, Center for Regenerative Medicine, Rehabilitation Research Center, Transform the Practice.

Keywords: Spinal cord injury, Epidural stimulation, Force sensitive resistors

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P5 Effectiveness of using pre-packaged portion-controlled meals for weight loss in people with spinal cord injury

Christa M Ochoa ¹, Erina Nowshin Sarker ¹, Katherine Froehlich-Grobe ¹, Seema Sikka ¹, Rita Hamilton ¹

Abstract

Background: While the prevalence of obesity continues to increase among the general population, weight maintenance through physical activity and healthy eating can be especially challenging for people with spinal cord injury (SCI). Specifically, eating a balanced diet can demand a degree of mobility and accessibility that may be difficult for some to achieve. This study investigates the effectiveness of using pre-packaged portion-controlled meals (PCM) to aid weight-loss over a 13-week period for people living with SCI.

Objective: Identify the effectiveness of PCM for weight loss and change in self-efficacy among people with SCI.

Design: Single-group pretest/posttest design was used to conduct study activities over a 13-week period.

Methods: 25 participants were enrolled to receive 13 weeks of PCMs (2 entrees and 2–3 protein shakes daily) delivered to their home to facilitate meeting a personalized daily calorie goal based on measured resting metabolic rate (RMR) and they visited our facility once a month to have their weight and blood pressure (BP) measured. Study outcomes included body weight, self-reported self-efficacy for healthy eating, and self-reported dietary intake using the Automated Self-Administered 24-Hour Dietary Recall.

Results observed: Participant retention was 72% (18/25) over the 13 weeks. At follow-up, the vast majority (83.3%) reported being satisfied or very satisfied with the PCMs and 100% rated them as helpful. Participants lost 9.54 pounds on average, with a mean decrease of 4.2% of starting body weight by 13 weeks (P < 0.01). Although not significant (P = 0.06), participants reported eating an average of 242 fewer calories per day at the end of the 13-week program (1,341 daily calories at baseline vs. 1,115 by 13 weeks). Participant ratings of total and nutrition-related self-efficacy did not increase significantly but were higher on average at follow-up, with a mean increase of 2.1 points (P = 0.48) and 0.18 points for the nutrition subscale (P = 0.87).

Conclusions: These results suggest that PCM may be effective in promoting weight-loss among people with spinal cord injury and may encourage healthy eating habits even after the meals are discontinued. Further research with larger samples would aid in understanding how this weight-loss approach fares in comparison to other possible interventions.

Support: National Institute for Disability, Independent Living, and Rehabilitation Research (NIDILRR), grant #90IFRE0022.

Keywords: Obesity, Spinal cord injury, Portion-controlled meals, Weight loss

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P6 Effectiveness of using pre-packaged portion-controlled meals for weight loss in people with spinal cord injury

Christa M Ochoa ¹, Erina Nowshin Sarker ¹, Katherine Froehlich-Grobe ¹, Seema Sikka ¹, Rita Hamilton ¹

Abstract

Background: While the prevalence of obesity continues to increase among the general population, weight maintenance through physical activity and healthy eating can be especially challenging for people with spinal cord injury (SCI). Specifically, eating a balanced diet can demand a degree of mobility and accessibility that may be difficult for some to achieve. Therefore, we are investigating the effectiveness of using PCMs to aid weight-loss over a 13-week period for people living with SCI.

Objective: Identify the effectiveness of pre-packaged portion-controlled meals (PCM) for weight loss and change in self-efficacy among people with SCI.

Design: Single-group pretest/posttest design was used to conduct study activities over a 13-week period.

Methods: 25 participants were enrolled to receive 13 weeks of PCMs (2 entrees and 2–3 protein shakes daily) delivered to their home to facilitate their meeting a personalized daily calorie goal based on measured resting metabolic rate (RMR) and they visited our facility once a month to have their weight and blood pressure (BP) measured. Study outcomes included body weight, self-reported self-efficacy for healthy eating, and self-reported dietary intake using the Automated Self-Administered 24-Hour Dietary Recall.

Results Observed: Participant retention was 72% (18/25) over the 13 weeks. At follow-up, the vast majority (83.3%) reported being satisfied or very satisfied with the PCMs and 100% rated them as helpful. Participants lost 9.54 pounds on average, with a mean decrease of 4.2% of starting body weight by 13 weeks (P < 0.01). Although not significant (P = 0.06), participants reported eating an average of 242 fewer calories per day at the end of the 13-week program (1,341 reported daily calories at baseline vs. 1,115 by 13 weeks). Participant ratings of total and nutrition-related self-efficacy did not increase significantly but were higher on average at follow-up, with a mean total increase of 2.1 points (P = 0.48) and 0.18 points for the nutrition subscale (P = 0.87).

Conclusions: These results suggest that PCM may be effective in promoting weight-loss among people with spinal cord injury and may encourage healthy eating habits even after the meals are discontinued. Further research with larger samples would aid in understanding how this weight-loss approach fares in comparison to other possible interventions.

Support: National Institute for Disability, Independent Living, and Rehabilitation Research (NIDILRR), grant #90IFRE0022

Keywords: Obesity, Spinal cord injury, Portion-controlled meals, Weight loss

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P7 A review of prescription opioid use for pain in individuals with spinal cord injury

Jo Ann Shoup ¹, Jennifer Coker ², Jeffrey Berliner ^2,³

Abstract

Background: There is a high prevalence of chronic pain after spinal cord injury (SCI), with estimates of 60–80 percent. With limited clinical evidence of efficacy for SCI, up to 70 percent of individuals with SCI are prescribed opioids for pain relief at some point post-acute injury.

Objective: To perform a literature review of prescription opioid use for chronic pain in the spinal cord injury (SCI) population.

Design: A literature review was conducted to locate relevant literature on SCI and prescription opioids.

Methods: PubMed database was used for the following search terms: “spinal cord injury and opioids”; “spinal cord injury and opioid use for pain”. For inclusion, articles were required to be published in the last 10 years, in English, involve human subjects for research, and include prescription opioids. Editorials and commentaries were included. Using PubMed’s “best match” search function, the first five best matches from each of the first 100 search results of each search term was abstracted. Identification of other significant literature was obtained through review of each selected article’s references. Duplicates were removed. Articles were coded for article type, year of publication, journal, article aims, content area, patient population, prescription opioid risks and benefits, and relevance to SCI pain.

Results observed: Fifteen eligible articles were included. Eleven were published in SCI-specific journals and 13 were published in the past 5 years. Five were intervention studies. Most articles highlighted the risks associated with prescription opioids as a treatment for SCI pain; however, there were several articles that referenced benefits after first line treatment failed. Risks of chronic opioid usage includes worse rehabilitation outcomes due to sedation from opioids and increased risk of bone fractures from accidental falls during transfers or other daily activities. Minimal evidence exists that relatively short-term use of Tramadol, an opioid pain reliever, is beneficial to reducing neuropathic pain. Oxycodone has very limited supportive evidence for SCI pain in two small studies and has known high addiction potential. Discharge on opioids increases the risk of long-term use, especially polypharmacy use.

Conclusions: The current lack of evidence-based pain management alternatives for individuals with SCI creates a gap in SCI clinical care. Future research can help address this gap by assessing alternative methods of pain treatment through rigorous evaluation.

Support: N/A.

Keywords: Spinal cord injury, Prescription opioids, Polypharmacy, Literature review, Evidence base

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P8 All were looking for freedom: A Photovoice study of community participation after spinal cord injury in India

Susan D Newman ¹, Suparna Qanungo ¹, Raman Singh ²

Abstract

Background: The World Health Organization’s (WHO) International Perspectives on Spinal Cord Injury state, “once a person with spinal cord injury (SCI) has had their immediate health needs met, social and environmental barriers are the main obstacles to successful functioning and inclusion in society”. Among low- and middle-income countries (LMIC), India presents with a unique need for research on the relationship of environmental factors and community participation, and the experience of disability for individuals with SCI.

Objective: To (1) investigate the experiences and perceptions of individuals with SCI in Delhi, India regarding barriers and facilitators affecting their community participation, and (2) use this information to guide advocacy efforts to improve accessibility and inclusion for wheelchair users.

Design: Qualitative description using Photovoice, a visual qualitative research methodology, and a community-engaged research approach. Photovoice allows people to document and discuss their life conditions as they see them.

Methods: Recruitment of a convenience sample was facilitated by our partner in Delhi, India. After training in Photovoice, 10 participants with SCI took photographs that represented their experiences in the community, followed by semi-structured interviews for photo reflection and discussion. Interview data were translated, transcribed, and analyzed using directed content analysis. The International Classification of Function, Disability and Health (ICF) guided our coding of activities, participation, and environmental factors identified in the participants’ photographs and interviews. A group discussion facilitated sharing of experiences and planning for advocacy and action to address challenges identified.

Results observed: Participants identified numerous barriers in the physical environment, primarily in public spaces, including poor road and sidewalk conditions, missing or inadequate ramps, and inaccessible banks and ATM machines. Negative attitudes of others towards disability were also identified as a barrier. Barriers inhibited personal mobility and interfered with participation in major life areas, such as economic life and recreation and leisure activities. Support from others helped to mediate the effect of environmental barriers. Physical assistance from others facilitated participants’ mobility and navigation of inaccessible environments. Participants described the importance of advocacy efforts to increase public awareness and improve community participation for individuals with SCI.

Conclusions: Photovoice is an effective way to engage diverse individuals with SCI in low resource settings in research addressing community participation and to promote advocacy.

Support: MUSC Center for Global Health, Pilot Project Program

Keywords: India, Photovoice, Community participation, Environmental factors

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P9 Capsaicin 8% patch for spinal cord injury neuropathic pain

Michelle Trbovich ¹, Madeline Dicks ², Ana Henriques ², Bryce Kirkman ², Colby Beal ²

Abstract

Background: Neuropathic pain (NP) after spinal cord injury (SCI) has a prevalence of 40–50% and is often refractory to available therapies which provide pain reduction of 20–30%, at best. NP can exacerbate physical disability and decrease quality of life (QOL). Patients have reported willingness to trade potential recovery of strength, bowel, bladder, or sexual function for pain relief. One proposed mechanism causing NP is up-regulation of transient receptor potential vanilloid 1 (TRPV 1) proteins in uninjured C fibers and dorsal root ganglia causing increased neuronal excitability. Recent studies have found up-regulation of TRPV 1 receptors after central nerve injury from SCI.

Objective: Capsaicin is a highly selective agonist of TRPV 1 proteins. Capsaicin 8% patch (C8P) is FDA approved for NP in human immunodeficiency virus autonomic neuropathy and post herpetic neuralgia. A single topical application for 1 h causes reversible TRPV 1 defunctionalization. Pain relief after application can last 8–12 weeks and has reduced oral opioid use in these populations. In persons with SCI, the efficacy of capsaicin has not been extensively studied. C8P is a promising topical therapy for NP after SCI and carries with it less systemic side effects than traditional therapies. We hypothesize that C8P will improve pain scores, quality of life and function in persons with SCI.

Design: Randomized single-blinded crossover study

Methods: Persons with SCI and NP refractory to at least two agents were randomized to receive the active C8P or the control capsaicin 0.025% patch. Primary and secondary outcome measures were utilized to evaluate pain control, QOL and overall function. Primary outcome measures: Visual Analog Scale Secondary outcomes measures: Multidimensional Pain Inventory, World Health Organization Quality of Life, Spinal Cord Independence Measure

Results observed: Four persons have completed the protocol to date. Statistical power is low; however, findings to date are as follows. Primary outcome measures demonstrated no significant change in pain over time. Secondary outcome measures demonstrated improvements with pain severity, social and outdoor activity participation, physical and psychological health, and social relationships.

Conclusions: Although primary outcome measures were not clinically significant, secondary outcome data is promising. These findings are consistent with previous non-SCI studies. Data collection is ongoing and future enrollment will provide more robust data.

Support: Foundation for PMR, Milbank SCI Rehabilitation award

Keywords: Spinal cord injury, Capsaicin, Neuropathic Pain, Quality of life, Psychological Health

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P10 Prevalence of non-traumatic spinal cord injury and classification according to etiology at a veterans’ hospital

Tommy Yu ^1,², John Cunneen ¹, Morgan Pyne ^1,², Steven Peretiatko ²

Abstract

Background: There is a scarcity of literature on the epidemiology of non-traumatic spinal cord injury (NTSCI) in the United States, even though evidence has illustrated differences in rehabilitation outcomes and comorbid issues among spinal cord injuries based on etiology.

Objective: To investigate the prevalence of non-traumatic SCI in comparison to that of traumatic SCI (TSCI) at a Spinal Cord Injury (SCI) Center within the Veterans’ Administration (VA) healthcare system.

Design: This is a retrospective chart review of patients who were included in the SCI registry at a VA SCI Center between October 1st, 2009 and September 30th, 2017.

Methods: The SCI registry was accessed to determine eligible subjects. 2687 total charts were reviewed, with 1831 meeting inclusion criteria. The prevalence of NTSCI v. TSCI was obtained, analyzed, and compared. Patient demographics including age of SCI onset, gender, employment, marital status, race, and neurological level of injury per International Standard for Neurological Classification of Spinal Cord Injury (ISNCSCI) were correlated with the etiology of injury. Simple ratio of the prevalence of NTSCI v. TSCI was the primary outcome. The frequency of each NTSCI based on the International Spinal Cord Injury Data Sets for Non-Traumatic Spinal Cord Injury was analyzed.

Results observed: 1831 charts met inclusion criteria. When motor neuron disorders (MND) and multiple sclerosis (MS) were included in the NTSCI group, TSCI outnumbered NTSCI (1067 vs. 764). When these diagnoses were excluded, the NTSCI total was 251 (19% of total). Excluding MND and MS, the most common NTSCI etiologies were: vertebral column degenerative disorders (n = 103, 41.0%), neoplastic (n = 48, 19.1%), and infection (n = 32, 12.7%). The mean age for disease onset was 50.1 for NTSCI v. 37.9 for TSCI. The most common level of injury was C5 for both groups. For NTSCI, incomplete tetraplegia was the most common injury pattern (n = 105, 44.7%), followed by incomplete paraplegia (n = 98, 41.7%), complete paraplegia (n = 23, 9.8%), and complete tetraplegia (n = 9, 3.8%). NTSCI had a lower frequency of complete injuries than TSCI (13.6% v. 43.7%). The ratio of paraplegia v. tetraplegia was approximately 1:1 in both groups. Males outnumbered females in both NTSCI and TSCI (95.2% vs. 95.8%).

Conclusions: Overall, the results of this study are grossly consistent with previously reported etiologic data on NTSCI in the general population. Certain demographics, such as male predominance, reflect the patient population served at the VA. A large portion of the NTSCI Veterans who receive care at our institution are diagnosed with MS or MND.

Support: This was an unfunded study without financial support.

Keywords: Spinal cord injury, Tetraplegia, Paraplegia, Epidemiology, Paralysis

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P11 Prevalence of non-traumatic spinal cord injury and classification according to etiology at a veterans’ hospital

Tommy Yu ^1,², John Cunneen ¹, Morgan Pyne ^1,², Steven Peretiatko ²

Abstract

Background: There is a scarcity of literature on the epidemiology of non-traumatic spinal cord injury (NTSCI) in the United States, even though evidence has illustrated differences in rehabilitation outcomes and comorbid issues among spinal cord injuries based on etiology.

Objective: To investigate the prevalence of non-traumatic SCI in comparison to that of traumatic SCI (TSCI) at a Spinal Cord Injury (SCI) Center within the Veterans’ Administration (VA) healthcare system.

Design: This is a retrospective chart review of patients who were included in the SCI registry at a VA SCI Center between October 1st, 2009 and September 30th, 2017.

Methods: The SCI registry was accessed to determine eligible subjects. 2687 total charts were reviewed, with 1831 meeting inclusion criteria. The prevalence of NTSCI v. TSCI was obtained, analyzed, and compared. Patient demographics including age of SCI onset, gender, employment, marital status, race, and neurological level of injury per International Standard for Neurological Classification of Spinal Cord Injury (ISNCSCI) were correlated with the etiology of injury. Simple ratio of the prevalence of NTSCI v. TSCI was the primary outcome. The frequency of each NTSCI based on the International Spinal Cord Injury Data Sets for Non-Traumatic Spinal Cord Injury was analyzed.

Results observed: 1831 charts met inclusion criteria. When motor neuron disorders (MND) and multiple sclerosis (MS) were included in the NTSCI group, TSCI outnumbered NTSCI (1067 v. 764). When these diagnoses were excluded, the NTSCI total was 251 (19% of total). Excluding MND and MS, the most common NTSCI etiologies were: vertebral column degenerative disorders (n = 103, 41.0%), neoplastic (n = 48, 19.1%), and infection (n = 32, 12.7%). The mean age for disease onset was 50.1 for NTSCI v. 37.9 for TSCI. The most common level of injury was C5 for both groups. For NTSCI, incomplete tetraplegia was the most common injury pattern (n = 105, 44.7%), followed by incomplete paraplegia (n = 98, 41.7%), complete paraplegia (n = 23, 9.8%), and complete tetraplegia (n = 9, 3.8%). NTSCI had a lower frequency of complete injuries than TSCI (13.6% vs. 43.7%). The ratio of paraplegia v. tetraplegia was approximately 1:1 in both groups. Males outnumbered females in both NTSCI and TSCI (95.2% vs. 95.8%).

Conclusions: Overall, the results of this study are grossly consistent with previously reported etiologic data on NTSCI in the general population. Certain demographics, such as male predominance, reflect the patient population served at the VA. A large portion of the NTSCI Veterans who receive care at our institution are diagnosed with MS or MND.

Support: This was an unfunded study without financial support.

Keywords: Spinal cord injury, Tetraplegia, Paraplegia, Epidemiology, Paralysis

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P12 Prevalence of skin cancer in patients with spinal cord injury

Tommy Yu ^1,², Stephen L Luther ²

Abstract

Background: Skin cancer is the most common type of cancer in the United States, however, there is no known data among people with spinal cord injury. Literature search found one guideline which recommended skin cancer screening for high risk individuals such as those with a family history of skin cancer, abnormal moles, or a history of significant sun exposure/severe sunburns. The frequency of screening is to be determined by dermatologists. This is the first study to investigate the rates of skin cancer among this unique population. With this knowledge, we emphasize the importance of annual skin examination and patient education about the skin cancer risk and self-detection recommendations.

Objective: To investigate an prevalence of skin cancer and the cancer types among veterans with spinal cord injury. Secondarily, to evaluate the relationship of skin cancer to the level, and severity of the spinal cord injury (SCI).

Design: Retrospective chart review.

Methods: Subjects with SCI who presented for annual examination between May 2013 and May 2015 were included. Exclusion criteria included diagnosis of amyotrophic lateral sclerosis or multiple sclerosis. The primary outcome was the rate of subjects with skin cancer and their subtypes.

Results Observed: Of the 1265 patients included in this study, 934 individuals who fit the inclusion criteria were evaluated for skin cancer occurrence. A total of 109 patients, 11.6%, were diagnosed with skin cancer. Forty-six subjects had basal cell carcinoma, 20 had squamous cell carcinoma, 7 had melanoma, and 36 had a combination of various types of carcinomas. We then analyzed the association between severity of SCI and skin cancer diagnosis. No significant variation in occurrence of skin cancer between each group of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) class was noted.

Conclusions: We reviewed the statistics in our SCI population and found that basal cell carcinoma is the most common skin cancer, followed by squamous cell carcinoma. Non-melanoma vs melanoma ratio is about 9.5:1. With this local data, we emphasize the importance of annual skin examination, application of sunscreen and UV protective garments, patient education about the characteristics of suspicious skin changes, so skin cancer can be detected at earlier stages.

Support: Source of funding: none.

Keywords: Tetraplegia, Paraplegia, Melanoma, Basal cell carcinoma, Squamous cell carcinoma, Skin cancer

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

13 Evaluating the perceived competency of a physical therapist with a new disability

John Ficucello ¹, Steven W Litchman ¹, John Whalen ¹, Marc Campo ²

Abstract

Background: The Americans with Disabilities Act is intended to prevent discrimination against qualified individuals on the basis of disability. Little is known about the perceived competency of physical therapists with disabilities.

Objective: To examine the perceptions of physical therapists about the competency of a hypothetical physical therapist with a new disability requiring a manual wheelchair and performing his/her duties either unassisted, or with the assistance of a physical therapy aide/technical assistant.

Design: Cross-sectional survey.

Methods: A link to an online survey was e-mailed to directors of physical therapy departments, practices and academic programs. Statements addressing the perceived competency of a hypothetical physical therapist with a disability were presented in Likert-type format.

Results observed: Most respondents (65%) agreed that it would be a reasonable accommodation to hire a physical therapist aide/technical assistant. Slightly more respondents (51.3%) agreed that the hypothetical physical therapist would be better suited for a managerial position, rather than a clinical one. Although the use of a physical therapy aide/technical assistant improved perceived competency, the majority did not feel the hypothetical physical therapist would be competent providing direct patient care in all inpatient settings, school/preschool, and home health. Certain examination categories, including balance, functional mobility, and motor control, were perceived to be competently performed only with a physical therapy aide/technical assistant. Most respondents thought it would be appropriate for a physical therapy aide/technical assistant to assist with therapeutic exercise and modalities but not appropriate to assist with manual therapy and wound care.

Conclusions: The lack of agreement among the physical therapists surveyed emphasizes the need for future studies in this area to better understand potential biases in employment of physical therapists with disabilities and remedies to address them.

Support: No sources of funding

Keywords: Physical therapist, Employment, Disability, Perceived competency, Accommodations

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P14 Contrast baths for neuropathic pain due to spinal nerve root compression by myeloma: A case report

Elaine H Hatch ¹, Christopher Gorrell ², Benjamin A Abramoff ³

Abstract

Background: A 54-year-old man with multiple myeloma presented with progressive lower extremity weakness and pain. He was found to have extensive myelomatous involvement of his lumbar spine with multilevel moderate-severe neuroforaminal stenosis due to collapsed osseous structures and foraminal neoplasms. The patient’s pain limited his participation in physical therapy despite a pain medication regimen that included methadone, gabapentin, duloxetine, hydromorphone, and lidocaine cream.

Objective: To describe a case of the use of contrast baths for cancer-related neuropathic pain.

Design: Case study.

Methods: At the discretion of the patient’s physical therapist, contrast baths for this patient were initiated. Feet were submerged to ankle depth in shallow water basins, alternating 2 min in warm (104°F) water and 1 min in cold (49°F) water for a total of three cycles.

Results Observed: The patient reported immediate and significant relief from a pain level of 8/10–3/10 in the submerged areas of his feet for approximately 10 h. Repeated contrast baths allowed the patient to participate in 3 h of therapy daily and to sleep comfortably.

Conclusions: Although common in individuals with cancer as well as nerve root compression, neuropathic pain can be difficult to prevent and manage due to the complex interweaving pain mechanisms involved in its pathophysiology. Contrast baths have been used for many decades to relieve pain, but are rarely used in the rehabilitation setting. The mechanism of contrast bath therapy is unknown and has been theorized to be due to alternating peripheral vasoconstriction and vasodilation which ultimately leads to reduction of edema and improved circulation. Contrast baths are a simple and cost-effective therapy that can be performed independently. As demonstrated in this case, they can potentially provide marked improvement in neuropathic pain and, in the acute rehabilitation setting, may enable patients to better participate in intensive physical therapy. Long-term studies are needed to measure continued pain relief and safety.

Support: No disclosures.

Keywords: Contrast baths, Neuropathic pain, Rehabilitation, Pain management, Cancer pain

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P15 Large rectus sheath hematoma in a patient with complete tetraplegia on anticoagulation: A case report

Malcolm K Moses-Hampton ^1,², Gizelda T B Casella ¹

Abstract

Background: Rectus Sheath Hematoma (RSH) is an uncommon clinical event associated with trauma, surgical complications and anticoagulation. It arises from the erosion of the deep epigastric artery with bleeding into the rectus abdominis muscle sheath. The common presenting sign is severe abdominal pain concerning for acute abdomen and it is diagnosed by abdominal ultrasound or CT. In cases of active extravasation, the recommended management is embolization or surgical ligation of the deep inferior epigastric artery.

Objective: To bring awareness of this uncommon and dangerous complication of anticoagulation that can be difficult to diagnose in a patient with tetraplegia.

Design: Case report.

Methods: 65-year-old male with tetraplegia (C6 AIS B) since 1980 receiving apixaban for atrial flutter, who presented for management of nephrolithiasis. Patient underwent ureteral stent placement and anticoagulation shifted to Enoxaparin 1 mg/Kg twice a day peri-procedurally. After surgery patient had acute hypoxic respiratory failure secondary to acute on chronic diastolic heart failure due to volume overload, and stabilized after diuretics. In subsequent day, he became hypotensive (60/40 mmHg) with drop of hemoglobin (12.9–7.8 mg/dl in 15-hours), no pain, autonomic dysreflexia (AD), or apparent blood loss and with an unchanged abdominal exam. He underwent computed tomography (CT) of abdomen and pelvis without contrast.

Results observed: CT demonstrated a large left RSH (8.8 × 11 × 24 cm). He required fluid, blood, and vasopressor resuscitation. Repeat CT with angiography showed active bleed of the left inferior epigastric artery. He underwent coil embolization with resolution of the bleed. Due to quadriplegia, he did not experience abdominal pain, AD (likely masked by hypovolemic shock) and initial physical exam only showed a large flaccid abdomen. Later, the hematoma could be palpated at the left lower abdomen. RSH precipitating factors were anticoagulation with Enoxaparin and this patient’s longstanding atrophy of the abdominal wall, placing his vasculature at increased risk of injury caused by frequent injections of enoxaparin.

Conclusions: This is the first reported case of RSH in a patient with quadriplegia undergoing anticoagulation. Initial presentation was a significant drop in blood pressure, no pain, AD, or palpable mass in the abdominal wall. Healthcare providers must be aware of this life-threatening condition despite its rarity, especially when anticoagulation is present in a patient with abnormal abdominal wall innervation and sensation.

Support: None.

Keywords: Rectus sheath hematoma, Anticoagulation, Complication, Spinal cord injury, Tetraplegia

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P16 The challenges of surgical versus conservative management of cervical myelopathy in a competitive wheelchair athlete: A case report

Daniela Iliescu ¹, Jonathan Napolitano ²

Abstract

Background: Cervical myelopathy is most often managed through surgical decompression with or without fusion. Surgery is thought to prevent clinical worsening and improve function. However, cervical myelopathy may not always improve with decompression since usually its presence signals a cascade that has already begun. Some cases of transient myelopathy may improve with conservative management alone. There is minimal research looking at nonoperative treatment versus surgical treatment.

Objective: To mitigate the challenge of surgical intervention for prevention of functional loss in cervical myelopathy versus focusing on functional recovery with conservative management.

Design: Case report.

Methods: 18 yo male competitive wheelchair track and marathon athlete due to congenital lipomeningocele with acute left shoulder weakness.

Results observed: Patient presented with a two-week history of acute onset of severe left shoulder weakness without trauma, upon return to offseason track training. Weakness was noticed 1 d after a workout of repetitive tricep “dips”. On exam, the only pertinent positives were atrophy of the left posterior shoulder musculature and weakness in shoulder abduction, flexion, and external rotation. Shoulder MRI and US showed no evidence of rotator cuff tear or nerve entrapment. MRI C-spine revealed known severe central canal spinal stenosis, with a faint focal increased T2 hyperintense signal at the C4 level. EMG confirmed evidence of decreased activation of left C3–C5 innervated muscles, concerning for central myelopathy. Initial management included oral steroids, positional restrictions, and home exercise program. Two separate surgeons recommended deferring surgery given progressive improvement in shoulder function. Consideration was also given to the functional limitation of cervical fusion of the flexion necessary for bowel and bladder care and extension needed for positioning in his track chair. He then started an intensive PT program to focus on scapular and shoulder muscle strengthening with modalities. A year after the initial presentation, his exam showed marked improvement in shoulder strength and control. He had a successful fall training and racing season completing 2 marathons.

Conclusions: This case exemplifies the difficulties providers and patients encounter when deciding between surgical intervention and conservative management. Surgical decompression and fixation could have significantly affected the patient’s quality of life. Patience in decision making with close observation of symptoms is imperative in determining the best individual treatment course tailored to athletes and their injuries.

Support: None.

Keywords: Spinal cord injury, Cervical myelopathy, Athlete, Adaptive sports

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P17 Gastrointestinal malrotation and opioid-induced ileus in a veteran with acute non-traumatic spinal cord injury: A case report

Dallin Lindahl ¹, Michael Albert Ibrahim ¹, Steven Brose ^1,²

Abstract

Background: Complications with neurogenic bowel dysfunction is the second most common cause of rehospitalization in persons with SCI and has a significant impact on quality of life. This is a case report demonstrating how a previously undiagnosed bowel malrotation contributed to an ileus in a new SCI patient, leading to a delay in surgical intervention.

Objective: N/A.

Design: A 68-year-old man complained of increasing urinary and bowel incontinence, difficulty with walking, and frequent falls, as well as dramatically increased neck pain. MRI findings showed increased T2 signal in the cervical spine consistent with myelopathy, and he was admitted to the SCI center at a VAMC for C3–C5 anterior cervical discectomy and fusion. Neurologic examination showed the patient to have C3 ASIA D SCI. Before undergoing surgery, the patient’s hospital course was complicated by uncontrolled pain and severe constipation. One day following increased opioid prescription, the patient developed significant abdominal distention with projectile vomiting that was unresponsive to subsequently decreasing opioids and medical management. Abdominal x-ray showed marked gastric distention and a nasogastric tube was placed with over 1L of output. CT of abdomen showed a distended stomach, possibly representing gastric outlet obstruction (GOO). Upper GI series showed barium enter the duodenum without evidence of GOO. However, the duodenum did not cross midline and proximal small bowel loops remained on the right side of the abdomen, consistent with malrotation.

Methods: N/A.

Results observed: Patient was initially made NPO and diet was advanced after the results of the upper GI series. The patient was managed with upper motor neuron neurogenic bowel strategies and oral opioid prescription was reduced. The ileus resolved and spinal surgery was performed one week from the originally scheduled date. The patient responded well to surgery and subsequent inpatient rehabilitation, was weaned off opioids entirely before discharge, and bowel function returned to markedly above his pre-surgical level with volitional control and no need for bowel medications.

Conclusions: The patient’s previously undiagnosed bowel malrotation exacerbated the patient’s bowel issues caused by his SCI and acute opioid pain management, creating an atypical neurogenic bowel picture and a delay in the patient’s needed surgical intervention. Opioid use in known to exacerbate constipation, especially in SCI patients, which can result is a more complicated hospital course and worse functional outcomes.

Support: None.

Keywords: Neurogenic bowel, Malrotation, Ileus

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P18 Interdisciplinary rehabilitation of incomplete tetraplegia related to Os odontoideum in a teenager with chromosome 5 abnormality

Lauren Massey ¹, Margaret Jones ¹

Abstract

Background: Chromosome 5 abnormality, also known as Cri-du-Chat Syndrome, is characterized by a “cat-like cry”, intellectual disability, developmental delay and craniofacial abnormalities and is caused by deletion of the short arm of chromosome 5p. There is little published report of associated vertebral abnormalities with this specific chromosomal abnormality. Os odontoideum is a rare finding of the second cervical vertebra where a circumferentially corticated ossicle is separated from the body of C2, distinct from a fracture. The etiology of this finding is somewhat controversial, with both traumatic versus congenital origins considered. The clinical presentation of this finding is variable, where some present with pain or neurologic symptoms while others find out about the anomaly incidentally.

Objective: The authors present a case of the interdisciplinary rehabilitation care for a teenager with incomplete tetraplegia related to os odontoideum and associated retro-odontoid cyst, craniocervical stenosis and myelomalacia in the setting of chromosome 5 abnormality. This teen was able to participate in school and be independent in dressing and toileting. Her mother noted months of progressive left sided weakness and she was ultimately found to have os odontoideum, retro-odontoid cyst likely related to chronic local instability, craniocervical stenosis and myelomalacia. In the context of progressive weakness, decision was made for decompression and fusion at the occipitocervical junction for stability. Post-operatively, she demonstrated issues with incomplete tetraplegia and functional deficits below her baseline. Due to lack of pediatric inpatient services, she was brought to an adult inpatient rehabilitation facility with focus on interdisciplinary rehabilitation to work through her significant impairments

Design: Case report.

Methods: Review of medical record, observation through clinical care

Results observed: Through interdisciplinary rehabilitation, accounting for her intellectual disability and incomplete tetraplegia, this patient was able to discharge home with assistance from family. She became continent of bowel and bladder, mod I for short distances with MWC for mobility and was able to participate in transfers and dressing.

Conclusions: Interdisciplinary rehabilitation strategies in an adult hospital can be refined to work with young adults with intellectual disability and tetraplegia who require inpatient rehabilitation. Dynamic rehabilitation team processes can help promote function in such patients and allow for successful return to the living in the community with family and returning to school

Support: None.

Keywords: Cri-du-chat syndrome, Os odontoideum, Craniocervical stenosis, Incomplete tetraplegia, Spinal cord disorder, Intellectual disability

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P19 Challenges in managing combined rectal prolapse and lower motor neuron bowel dysfunction after spinal cord injury: A case study

Derek Day ¹, Christine Krull ^1,²

Abstract

Background: Neurogenic bowel dysfunction after spinal cord injury (SCI) and associated constipation, fecal incontinence, and anorectal conditions significantly impact quality of life. A lower motor neuron (LMN) pattern increases risk of fecal incontinence and rectal prolapse. There is a paucity of information in medical literature to guide the management of neurogenic bowel complicated by rectal prolapse.

Objective: To describe a unique case of LMN bowel syndrome after SCI complicated by rectal prolapse and discuss management strategies.

Design: Case study.

Methods: Authors participated in patient care, reviewed the medical record, discussed management strategies with experts in the field, and reviewed literature relevant to LMN dysfunction and rectal prolapse in SCI.

Results observed: A 33-year-old male was admitted to an acute inpatient rehabilitation hospital two weeks after sustaining a complete SCI (T11 AIS A) from a fall. Rectal exam showed an atonic, areflexic external anal sphincter without voluntary contraction or sensation. A LMN bowel program with manual disimpaction after mini enema, oral senna, and fiber failed to control frequent incontinence episodes despite extensive efforts to optimize dosing and timing. Disimpaction often yielded minimal results, but activities which increased abdominal pressure led to incontinence. Eight weeks after SCI, an intermittent rectal prolapse was discovered. Literature review and discussion with experts yielded a consensus that evidence-based management of prolapse in SCI was limited, but colostomy would likely be best for long-term quality of life. After extensive counseling, the patient deferred surgical management until conservative options were exhausted, including a planned outpatient trial of a transanal irrigation device with balloon catheter. At discharge incontinence episodes persisted, albeit less frequently.

Conclusions: Rectal prolapse is an important potential complication of LMN bowel dysfunction which can significantly impair bowel management. Rectal prolapse often occurs intermittently, making diagnosis challenging. A collaborative interdisciplinary approach is key to identify anorectal problems and troubleshoot management challenges. Oral medication titration should target stool consistency that is formed enough to prevent accidents, yet soft enough to avoid exacerbation of prolapse or constipation. Potential bowel program strategies to avoid exacerbating prolapse include employing a side-lying bowel program position, avoiding straining, and avoiding bathroom equipment with cut outs. Further escalation of bowel management, including trans-anal irrigation systems and colostomy, may be necessary to obtain an acceptable quality of life.

Support: None.

Keywords: Spinal cord injury, Neurogenic bowel, Rectal prolapse

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P20 Pseudomeningocele causing bradycardia in a patient with incomplete tetraplegia

Mariam N Mian ¹

Abstract

Background: The incidence of durotomies with an anterior surgical approach is reported between 0% and 8%, being more common in anterior cervical corpectomies than anterior cervical disc fusion. With known ossification of the posterior longitudinal ligament (OPLL), the incidence increases to 6.7%–31.8%.

Objective: We present a case of a pseudomeningocele after an anterior and posterior approach of cervical decompression in a patient with OPLL, resulting in symptomatic bradycardia.

Design: Case report

Methods: A patient in their sixties presented with progressive gait imbalance and bilateral hand weakness. Imaging revealed OPLL at C3–C5 and underwent an anterior C3–C4 corpectomy/fusion and posterior C2–5 decompression/ fusion. Post-operatively, he was classified as sensory incomplete tetraplegia. His hospital course was complicated by persistent respiratory failure requiring prolonged ventilation, and bradycardic syncopal episodes. On exam, he had a persistent soft anterior neck mass. Imaging revealed progression of the fluid collection in size. The fluid was aspirated and confirmed as CSF. Syncopal episodes resolved with aspiration and returned with fluid reaccumulating. Thus, it was suspected the symptomatic bradycardia was due to the pseudomeningocele compressing the carotid sinus. A lumbar drain was placed for decompression, unsuccessfully. He underwent a re-exploration and redo of the anterior cervical fusion, and a muscle graft to the 2 mm dural defect.

Results observed: This case presents a medically complex patient with several post-operative complications, uniquely a pseudomeningocele triggering syncopal bradycardic episodes. In our literature review, this has not been documented before. The closest case is by Frenkel et al, where a C5 surgical fixation screw irritated the vagus nerve with movement, resulting in bradycardic and asystole episodes. Managing CSF leaks can be challenging. Primary closure runs the risk of creating new, smaller dural defects. Larger defects will likely require more than bed rest. Another option is to leave the pseudomeningocele alone. In our case, the pseudomeningocele affected the health of the patient with bradycardic syncopal episodes and conservative repair measures failed. A lumbar drain was unsuccessful, and ultimately required a surgical re-exploration and a muscle graft.

Conclusions: This case highlights the complicated nature in managing dural tears. Risk factors include an anterior cervical corpectomy and decompression, and an underlying diagnosis of OPLL. Untreated dural tears can develop into pseudomeningoceles, which can contribute to life-threatening outcomes.

Support: N/A.

Keywords: Dural tears, Ossification of the Posterior Ligament, Bradycardia

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P21 A comparison of case reports in interdisciplinary inpatient rehabilitation for metastatic spinal cord compression: Does the end justify the means?

Naomi Greenberg ¹, Marni Nutkowitz ¹, Tariq Rajnarine ¹

Abstract

Background: Metastatic spinal cord compression occurs between 5–10 in every 200 patients with terminal cancer in the last 2 years of their lives. This compression often results in irreversible neurological damage, resulting in paraplegia or tetraplegia. Metastatic spinal cord compression represents over 25% of non-traumatic admissions to inpatient spinal cord injury units. In the past these patients were equated with hospice care, but with advances in medicine and patients living longer, rehabilitation is now often recommended. Inpatient rehabilitation has been shown to improve human dignity and purpose, which is often diminished in this patient population. Inpatient rehabilitation has also been linked to improvements in fatigue, function, mood, pain, quality of life and decreased caregiver burden.

Objective: To examine our current practice and consider the optimal way to treat the physical, medical and emotional challenges for patients with metastatic spinal cord compression in an inpatient rehabilitation setting.

Design: Comparison of 2 case studies from patients who underwent an inpatient rehabilitation course of case at MossRehab on the spinal cord injury unit

Methods: An interdisciplinary treatment plan of care was completed for 2 patients on the spinal cord injury unit at MossRehab at an acute inpatient rehabilitation level of care

Results observed: Patient participation in therapy, ability to make functional changes, reaction to medical intervention and discharge planning had significant differences between the two patients. Care in an acute inpatient rehabilitation setting can be effective for patients diagnosed with metastatic spinal cord compression but needs to be designed to match a patient's needs.

Conclusions: The interdisciplinary approach to patient care found in acute inpatient rehabilitation can benefit patients with metastatic spinal cord compression. It is crucial that the team works with the patient and caregivers to establish an individual plan of care and realistic goals tailored to meet the patient's specific needs to allow for an optimal outcome.

Support: Please see reference list below.

Keywords: Metastatic spinal cord compression, Inpatient rehabilitation, Interdisciplinary approach to cancer care

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P22 Necrotic transverse myelitis following self-immolation in a teenager

Kaila T Yeste ¹, Christine A Cleveland ¹

Abstract

Background: A 16-year-old male with a history of autism spectrum disorder who presented to the Emergency Department with second and third-degree burns of 66% total body surface area from self-inflicted injury in a suicide attempt. He continued to require close monitoring via sitter for suicidal ideation, which was one of the factors that delayed his transfer to rehabilitation. He entered rehab one year after his initial presentation.

Objective: Recognizing necrotic transverse myelitis in a critically-ill patient and understanding the prognosis. Appreciating the interdisciplinary approach to the care of teenagers with spinal cord injury and concurrent mental illness.

Design: Case report.

Methods: Chart analysis.

Results observed: The patient underwent imaging for bilateral lower extremity clonus discovered one month after initial admission. MRI of the brain and spine showed cord malacia from C6-T1. He underwent IVIG for the possibility of an autoimmune response to his burn injury causing his spinal cord findings; however, his symptoms did not improve. In fact, he remained paraplegic with bowel and bladder dysfunction. His ASIA exam revealed C4 ASIA D injury. The patient demonstrated difficulty coping with his diagnosis and remained withdrawn from participating in rehab goals including skin integrity, self-catheterization, bowel training, and contracture prevention.

Conclusions: The initial care of this patient was appropriately focused on life-saving interventions due to his extensive burn surface area and inhalation injury; therefore, the timing of transverse myelitis is not clear. However, it is hypothesized that there is a relationship between burn injury leading to systemic immune response and transverse myelitis. Special care was taken to educate the patient and family on prognosis, but the patient struggled to accept his acquired spinal cord injury. In the end, his family felt unable to care for him at home and he continues to await long-term placement over one year later.

Support: None.

Keywords: Transverse myelitis, Self-immolation, Mental illness

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P23 A case of pulmonary vein thrombosis in a patient with chronic spinal cord injury

Gregory Dimas ^1,², Tommy Yu ^1,²

Abstract

Background: Patient is a 63 year-old male patient with a history of chronic incomplete tetraplegia secondary to motor vehicle crash in 2007, chronic respiratory insufficiency requiring tracheostomy, who resides in a long-term care facility. He presented with an acute onset of tachypnea (respiratory rate 36–40) and mild tachycardia. His respirations were shallow, even though his oximetry was normal on room air. A CT angiogram of thorax was ordered to evaluate for suspected pulmonary embolism (PE). The result showed no PE, but revealed an acute right inferior pulmonary vein thrombus (PVT); extensive emphysematous changes, and retained pulmonary tracheal and right mainstem bronchus secretions.

Objective: To describe the rare occurrence of idiopathic pulmonary vein thrombosis in a patient with chronic spinal cord injury.

Design: Case study.

Methods: Case description.

Results observed: Pulmonologist was consulted and started treatment-dose enoxaparin (dose adjusted for weight at 40 mg q12 hours) for three months for the right inferior PVT. He underwent bronchoscopy a few days later, which revealed thick secretions in right mainstem bronchus, bronchus intermedius, and right lower lobe. His symptoms eventually resolved and no respiratory complications upon completion of 3-month enoxaparin.

Conclusions: While the incidence of PVT is unclear, it is known to be associated with lung transplantation, lobectomy, or malignancy. Idiopathic PVT is extremely rare and has only been reported in case reports. Pulmonary vein thromboses are commonly asymptomatic, but nonspecific symptoms including cough, hemoptysis, and dyspnea have been reported. In this case, the patient has a history of chronic respiratory insufficiency and emphysema, which make the diagnosis even more challenging. He received anticoagulation treatment without potential complications such as pulmonary infarction, pulmonary edema or right ventricular failure.

Support: None.

Keywords: Spinal cord injury, Tetraplegia, Pulmonary vein thrombosis

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P24 Atypical initial presentation of Chiari I malformation and holocord syrinx: A case report

Evan Berlin ¹, Margaret Jones ¹, Lauren Massey ¹

Abstract

Background: We describe a 53-year-old woman with no known significant past medical history who presented to her primary care provider with complains of persistent headaches that she attributed to “whiplash” after a motor vehicle collision months earlier. Upon further review, the patient stated she had worsening headaches when she sneezed, coughed, laughed or cried, and concurrent radiating pain down both legs in these instances as well. Over this time period, she also developed ataxia and a pronounced right sided ankle weakness, which prompted her to seek medical evaluation. MRI of brain and spine revealed Chiari I malformation as well as holocord syrinx. With initial treatment, the patient underwent multiple epidural blood patches, however she developed worsening post-tussive headaches along with worsening foot drop and development of mild dysarthria as well. Due to her constellation of symptoms and worsening function, she proceeded with surgery and underwent craniocervical decompression and duraplasty. Her post-operative course was complicated by new onset distal left lower extremity weakness approximately two days after surgery, with ongoing evidence of a positive Lhermitte’s sign, and exacerbation of her neuropathic pain with any maneuvers that caused increased pressure or Valsalva. The patient was admitted to inpatient rehabilitation with incomplete tetraplegia, with strength worse in her lower extremities as compared to her upper extremities, requiring ankle foot orthotics (AFOs).

Objective: To highlight the case of a patient with Chiari I malformation and holocord syrinx with initial clinical symptoms presenting in adulthood.

Design: Poster.

Methods: Chart review.

Results observed: Distal lower extremity weakness persisted, and she required bilateral AFOs at time of discharge. Positively, she did have slight return of previously lost strength through her R ankle and foot. The patient’s post-tussive headaches and pain improved mildly during her stay using multimodal pain symptom strategies. Her dysarthria improved significantly, and she was discharged from speech therapy prior to her discharge date from rehabilitation.

Conclusions: Lower extremity weakness persisted, and she was discharged with bilateral AFOs. Positively, she did have slight return of previously lost strength through her R ankle and foot. The patient’s post-tussive headaches and pain improved during her stay using multimodal pain approach. Her dysarthria improved significantly, and she was discharged from speech therapy prior to her discharge from rehab.

Support: None.

Keywords: Chiari I malformation, Holocord syrinx, Foot drop

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P25 Ethical discussion of rehabilitation in a patient with traumatic spinal cord injury with new-onset acute blindness

Austin M Henke ¹, Daun Chung ²

Abstract

Background: Vision contributes 70% sensory input navigating environments. Vision loss is a rare known complication of lumbar surgeries increasing in incidence to 1 in 500 surgeries. Spinal decompression surgeries accompany traumatic spinal cord injuries. The American Spinal Injury Association ASIA Impairment Scale correlates outcome studies with prognosticating independence. Based on these studies, injuries at C7 with AIS A can be modified independent with most/all tasks of daily living without comorbid vision impairment.

Objective: Discuss the practicality and ethical decisions in rehabilitation of spinal cord injury with acquired legal blindness.

Design: Using an illustrative single case via historical data and literature review.

Methods: A 52-year-old male with a traumatic spinal cord injury resulting in tetraplegia due to a motor vehicle accident. Imaging revealed injuries significant for severe disc herniation of C5–C6 with spinal stenosis, cord edema and an L1 vertebral body fracture with a compressed chance fracture. He underwent both cervical, then lumbar surgeries on the following day. He remained intubated between surgeries due to evidence of respiratory failure. He arose from surgery with bilateral complete vision loss. He was admitted to comprehensive rehabilitation as a traumatic SCI C4 AIS A with acquired bilateral blindness, most notably with antigravity strength in bilateral wrist extensions and sensation to lower thoracic level.

Results observed: Further evaluation, by an ophthalmologist, determined bilateral posterior optic nerve infarctions with partial vision- the ability to see shadows in left lower lateral quadrant. There was discussion on the futility of rehabilitation without a vision component as the vision rehabilitation center was unable to accommodate a spinal cord injury. He was discharged to neuro-transitional center with a power wheelchair, requiring moderate assistance with transfers and self-care. His final AIS was C7 AIS A with ZPP motor T1 and Sensory T11 with no change in vision.

Conclusions: The potential of this individual to functionally improve, given his preserved motor function, but limited by acquired blindness. In this case, there is an ethical decision versus moral obligation on the utility of rehabilitation in a patient with limited disposition and resources. A case such as this indicates there is a potential for vision rehabilitation within a comprehensive acute rehabilitation hospital.

Support: None.

Keywords: Spinal cord injury, Lumbar surgery’ Vision rehabilitation, Functional outcomes, Posterior ischemic optic neuropathy, Acquired vision loss, Rehabilitation

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

26 Heterotopic ossification in spinal cord ischemia

Mariam N Mian ¹

Abstract

Background: Neurogenic heterotopic ossification (HO) is a well-documented phenomenon in traumatic neurological injuries. About 20% of cases of TBI and SCI develop HO. In non-traumatic neurological injuries, such as stroke, HO has been reported with an incidence of 0.5–1.2% and 6.4% in non-traumatic myelopathies. We present a case of an uncommon cause of non-traumatic spinal cord injury, spontaneous spinal cord ischemia, and the development of HO (6,7).

Objective: To describe a case of heterotopic ossification in a patient with incomplete paraplegia due to spinal cord ischemia.

Design/method: Case report

Results observed: A 30-year-old male is admitted to acute inpatient rehabilitation after developing sudden onset shoulder pain and new weakness in his legs progressing to paraplegia within 24 h. He underwent an extensive work up for his new paraplegia, including treatment with IVIG and plasmapheresis with no response, and an exhaustive infectious work up with negative results. He was discussed in the hospital’s radiology conference and ultimately diagnosed with a spontaneous spinal cord infarction resulting in sensory incomplete paraplegia. During his rehabilitation course, he developed sudden left leg swelling. His workup was negative for a deep venous thrombosis, and fracture. His lab work was notable for elevated creatine kinase, and C – reactive protein, prompting a bone scan. The three-phase bone scan was positive for uptake in the left medial side of his hip, consistent with neurogenic heterotopic ossification.

Conclusions: Risk factors for developing HO include trauma, male sex, age 20–30s and severity of injury, with more severe injuries resulting in higher incidences of HO. There is conflicting evidence whether male sex and age 20–30s are associated as risk factors or as data bias as most traumatic injuries involve males in their 20–30s. Other associated risk factors include UTI, spasticity, and pressure ulcers (5,8). While our patient had many of the above risk factors, there is a lower incidence of HO development in non-traumatic injuries, but with the same consequences. Thus, it is prudent for the clinician to be aware of HO development in non-traumatic myelopathies.

Support: None.

Keywords: Heterotopic ossification, Spontaneous spinal cord ischemia, Nontraumatic spinal cord injury

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P27 Acute pancreatitis and cholecystitis following a diagnostic esophagogastroduodenoscopy with duodenal biopsy in a patient with tetraplegia: A case report

Vicki L Anderson ¹, Anem Bano ¹, Shirley Mathew ¹, Gizelda TB Casella ¹

Abstract

Background: Pancreatitis may occur as a complication of endoscopic retrograde cholangiopancreatography and esophagogastroduodenoscopy (EGD), especially when duodenal polypectomy is performed. Symptoms and signs of pancreatitis include nausea, vomiting, severe abdominal pain radiating to the back, abdominal distension, fever and may cause septic shock.

Objective: Bring awareness to atypical presentation of a potentially life-threatening post-EGD complication in spinal cord injury (SCI) patients.

Design/method: Case report.

Findings: 61-year-old man with longstanding tetraplegia (C4 ASIA A), neurogenic bowel/bladder, chronic kidney disease stage 4, hypertension, diabetes mellitus Type-2, atrial fibrillation (lifelong anticoagulation) presented for a colonoscopy/EGD due to anemia (hemoglobin below 7 mg/dl). He had an uneventful colonoscopy and EGD with biopsy/polypectomy in the descending duodenum near the Ampulla of Vater. Next day, he developed oliguria, severe abdominal distension, but no pain, nor change in vital signs initially.

Results observed: Abdominal X-ray demonstrated ileus, CBC and BMP were mildly abnormal, but amylase and lipase were 1233 and 3664 U/L, respectively. Patient was transferred to the ICU for aggressive fluid resuscitation. CT of abdomen/pelvis showed intra-abdominal fluid with peripancreatic stranding and pericholecystic fluid consistent with pancreatitis/cholecystitis. Ten days later, had severe anemia (hemoglobin 6.5 mg/dL) and second EGD demonstrated a clot at the biopsy site, which was injected with epinephrine to prevent further bleeding. His prolonged ICU course was complicated by pulmonary edema, acute renal failure, bowel obstruction, elevated liver enzymes, ileus, requiring nasogastric suctioning and total parenteral nutrition for several weeks.

Conclusions: The Ampulla of Vater is surrounded by the sphincter of Oddi, which controls the flow of bile and pancreatic secretions into the duodenum and prevents reflux into the ducts. Swelling at the ampulla after polypectomy may have obstructed the flow of pancreatic enzymes causing pancreatitis. This case highlights the unique presentation of acute pancreatitis in a patient with complete tetraplegia following a relatively routine procedure. Abdominal pain was absent and the first signal was oliguria and progressive/significant abdominal distension. The initial work up aimed to rule out bowel perforation but elevated amylase, lipase led to the diagnosis confirmed by CT scan. Due to atypical presentation in patients with tetraplegia, who have abnormal visceral sensation, clinical recognition of acute pancreatitis requires higher degree of clinical suspicion, especially when biopsy is performed near the Ampulla of Vater.

Support: None.

Keywords: Spinal cord injury, Tetraplegia, Pancreatitis, EGD, Duodenal biopsy

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P28 Case of a determined person with tetraplegia with a vision to live well after injury

Vidya Jayawardena ^1,^2,³

Abstract

Background: Spinal cord injury is a devastating condition that alters one’s life in all aspects. With support from a team of rehabilitation specialists, life course can be altered to the betterment of the individual. This is a success story of an elderly male who went on to continue playing the trombone and write books after injury, as he was doing before.

Objective: In many instances after initial injury, patients are given a grim prognosis by various providers without much knowledge of long term outcomes after injury. This can have a lasting effect on the patient. When SCI specialists discuss the possibilities and the capacity to regain function after initial incomplete injury, their outlook can be changed dramatically. This is a case report of such an individual whose motor and sensory function improved slowly. His psychological wellbeing also improved with functional gains. Currently he continues to enjoy his new life as a person with SCI, doing what he has always done, playing the trombone in prestigious Aardvark Jazz orchestra and writing books.

Design: Case report of a 79 year old professor emeritus of a prestigious university, who had a fall during morning exercise routine. His MRI of the cervical spine performed on the day of injury revealed multilevel degenerative changes throughout the cervical spine consistent with diffuse idiopathic skeletal hyperostosis (DISH) as well as severe spinal canal stenosis at levels C3-C4 with a T2 hyperintensity within the spinal cord at the C3-C4 region, which was thought to be either related to myelomalacia, although injury from the acute trauma could not be excluded. His initial documented American Spinal Injury Association (ASIA) examination in outside hospital was noted to be classified as a C3 AIS C.

Methods: After undergoing C3–C6 posterior decompression with lateral mass screws and fusion, he had multiple post-surgical complications including CSF leak and pseudo meningocele formation at the surgical site needing re-intervention by neurosurgical team.

Results observed: He had a prolonged hospital course for rehabilitation, during which time he was determined to get better as much as possible, so that his family only needed to do minimal care for him. During his hospitalization it was encouraging to the team to note that his strength and sensation improved to C5 ASIA D. His pulmonary function improved. With intense therapy, his ability to tolerate standing and then his ability to ambulate with assistive device was achieved. During the course of his rehabilitation he started playing his trombone although his initial effort was affected by poor pulmonary function. His satisfaction with life scale improved and he was proud of his progress.

Conclusions: This is an example of “Living Well after SCI”. Although soon after his initial injury he was dependent in all of his care, he became mostly independent due to his incompleteness of injury. As spinal cord injury rehabilitation specialists we have the opportunity to observe our patients throughout their acute rehabilitation as well as post rehabilitation. He went on to write books, some of them on dealing with spinal cord injury, others on his interests in health care in general. He also started traveling to other countries on wheelchair accessible cruises. Reading his books has given the team an insight on patients’ perspective of catastrophic events, and motivated them to be more empathic towards their struggles.

Support: None.

Keywords: Spinal cord injury, Tetraplegia, American Spinal Injury Association

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P29 Paraplegia post pelvic ring fracture: Case report

Zainab Al Lawati ¹, Riley Smith ¹

Abstract

Background: A complete paraplegic spinal cord injury (SCI) results in a total loss of sensory and motor functions as well as loss of sphincter tone. Suspecting SCI after poly-trauma might be delayed due to multiple predominating musculoskeletal injures and the urgency to treat them to prevent fatal complications.

Objective: This is a case study of a poly-traumatic patient who developed complete lower extremity weakness and numbness after motor vehicle accident. After stabilizing his open fracture of pubic ring and symphysis pubis, left tibia fracture and multiple carpal bone fractures; it was noted that the patient does not move his bilateral lower extremities, no sensation below umbilical line and no anal tone. CT scan and MRI of his spine showed severe traumatic spinal cord injury at T8-T9 secondary to disk herniation at T8-T9 with myelo-malacia and tethered cord at T8.

Design: Physiatry was involved in his care and addressed urgent issues with regards to SCI. Neurosurgery was collaborating with PM&R and the patient underwent bilateral pedicle screw fixation at T7, T8 as well as unilateral pedicle fixation at right T9 in addition to bilateral pedicle fixation at T10.

Methods: His post-op recovery was unremarkable and he stayed in the in-patient rehabilitation unit to address his poly-trauma rehabilitation needs as well as SCI rehabilitation issues. He was transferred to sub-acute rehabilitation.

Results observed: Patient is currently managing post SCI related rehabilitation issues in sub-acute rehabilitation facility. His bowel/ bladder concerns were addressed, spasticity managed with Baclofen and neuropathic pain management is optimized.

Conclusions: This report illustrates the significance of early Physiatry involvement in poly-trauma patients to explore potential additional injuries and ensure adequate and appropriate management in a timely manner.

Support: Funding for project (if any): none.

Keywords: Spinal cord injury, Computed topography, Magnetic resonance imaging

J Spinal Cord Med. 2020 Sep 16;43(5):749–771.

P30 Gastrointestinal malrotation and opioid-induced ileus in a veteran with acute non-traumatic spinal cord injury: A case report

Dallin Lindahl ¹, Michael Albert Ibrahim ¹, Steven Brose ^1,²

Abstract

Background: Complications with neurogenic bowel dysfunction is the second most common cause of rehospitalization in persons with SCI and has a significant impact on quality of life. This is a case report demonstrating how a previously undiagnosed bowel malrotation contributed to an ileus in a new SCI patient, leading to a delay in surgical intervention.

Objective: N/A.

Design: A 68-year-old man complained of increasing urinary and bowel incontinence, difficulty with walking, and frequent falls, as well as dramatically increased neck pain. MRI findings showed increased T2 signal in the cervical spine consistent with myelopathy, and he was admitted to the SCI center at a VAMC for C3–C5 anterior cervical discectomy and fusion. Neurologic examination showed the patient to have C3 ASIA D SCI. Before undergoing surgery, the patient’s hospital course was complicated by uncontrolled pain and severe constipation. One day following increased opioid prescription, the patient developed significant abdominal distention with projectile vomiting that was unresponsive to subsequently decreasing opioids and medical management. Abdominal x-ray showed marked gastric distention and a nasogastric tube was placed with over 1L of output. CT of abdomen showed a distended stomach, possibly representing gastric outlet obstruction (GOO). Upper GI series showed barium enter the duodenum without evidence of GOO. However, the duodenum did not cross midline and proximal small bowel loops remained on the right side of the abdomen, consistent with malrotation.

Methods: N/A.

Results observed: Patient was initially made NPO and diet was advanced after the results of the upper GI series. The patient was managed with upper motor neuron neurogenic bowel strategies and oral opioid prescription was reduced. The ileus resolved and spinal surgery was performed one week from the originally scheduled date. The patient responded well to surgery and subsequent inpatient rehabilitation, was weaned off opioids entirely before discharge, and bowel function returned to markedly above his pre-surgical level with volitional control and no need for bowel medications.

Conclusions: The patient’s previously undiagnosed bowel malrotation exacerbated the patient’s bowel issues caused by his SCI and acute opioid pain management, creating an atypical neurogenic bowel picture and a delay in the patient’s needed surgical intervention. Opioid use in known to exacerbate constipation, especially in SCI patients, which can result is a more complicated hospital course and worse functional outcomes.

Support: None.

Keywords: Neurogenic bowel, Malrotation, Ileus

PERMALINK

Academy of Spinal Cord Injury Professionals 2020 Educational Conference: ASCIP One Vision Online September 12, 13, 21, and 22, 2020 Poster Presentations P1–P30

P1 Classifying first instance of clinically diagnosed upper extremity pain and pathology in individuals with traumatic spinal cord injury

Beth A Cloud-Biebl

Ashley Lahti

Ellen Larkin

Cassandra J Lindstrom

Kathleen Michaels

Megan Piotrowski

Rachel M Svendson

LaDeanna Swanson

Samuel J Weigel

Abstract

P2 Who accesses remote web-based training: implications for clinical care

Rachel Hibbs

Kaitlin Digiovine

Lynn Worobey

Michael Boninger

Abstract

P3 Lower thoracic spinal cord stimulation improves bowel management in tetraplegics

Anthony F DiMarco

Robert T Geertman

Kutaiba Tabbaa

Gregory A Nemunaitis

Krzysztof E Kowalski

Abstract

P4 Force sensitive resistors provide novel assessment of trainer assistance during dynamic multi-modal rehabilitation with epidural stimulation for individuals with spinal cord injury

Margaux B Linde

Andrew R Thoreson

Peter J Grahn

Dimitry Sayenko

Cesar Lopez

Megan L Gill

Daniel D Veith

Kalli J Fautsch

Rena Hale

Jonathan S Calvert

Lisa A Beck

Kristin D Zhao

Abstract

P5 Effectiveness of using pre-packaged portion-controlled meals for weight loss in people with spinal cord injury

Christa M Ochoa

Erina Nowshin Sarker

Katherine Froehlich-Grobe

Seema Sikka

Rita Hamilton

Abstract

P6 Effectiveness of using pre-packaged portion-controlled meals for weight loss in people with spinal cord injury

Christa M Ochoa

Erina Nowshin Sarker

Katherine Froehlich-Grobe

Seema Sikka

Rita Hamilton

Abstract

P7 A review of prescription opioid use for pain in individuals with spinal cord injury

Jo Ann Shoup

Jennifer Coker

Jeffrey Berliner

Abstract

P8 All were looking for freedom: A Photovoice study of community participation after spinal cord injury in India

Susan D Newman

Suparna Qanungo

Raman Singh

Abstract

P9 Capsaicin 8% patch for spinal cord injury neuropathic pain

Michelle Trbovich

Madeline Dicks

Ana Henriques

Bryce Kirkman

Colby Beal

Abstract

P10 Prevalence of non-traumatic spinal cord injury and classification according to etiology at a veterans’ hospital

Tommy Yu

John Cunneen

Morgan Pyne

Steven Peretiatko

Abstract

P11 Prevalence of non-traumatic spinal cord injury and classification according to etiology at a veterans’ hospital

Tommy Yu

John Cunneen