Complications Associated with Preventive Management to Reduce the Risk of COVID-19 Spread After Surgery for Spinal Cord Injury.

BACKGROUND: Preventive management to reduce the risk of coronavirus disease-2019 (COVID-19) spread led to delays in active rehabilitation, which may have negatively impacted the outcomes of patients with traumatic spinal cord injury (SCI). Therefore, the aim of this study was to clarify the influence of preventive management on the rate of perioperative complications after surgical treatment for SCI. METHODS: This single-center retrospective study examined the cases of 175 patients who had SCI surgery between 2017 and 2021. We could not continue early rehabilitation interventions starting on April 30, 2020, because of our preventive management to reduce the risk of COVID-19 spread. Using a propensity score-matched model, we adjusted for age, sex, American Spinal Injury Association impairment scale score at admission, and risk factors for perioperative complications described in previous studies. Perioperative complication rates were compared between the COVID-19 pandemic and prepandemic groups. RESULTS: Of the 175 patients, 48 (the pandemic group) received preventive management. The preliminary analysis revealed significant differences between the unmatched pandemic and prepandemic groups with respect to age (75.0 versus 71.2 years, respectively; p = 0.024) and intraoperative estimated blood loss (152 versus 227 mL; p = 0.013). The pandemic group showed significant delays in visiting the rehabilitation room compared with the prepandemic group (10 versus 4 days from hospital admission; p < 0.001). There were significant differences between the pandemic and prepandemic groups with respect to the rates of pneumonia (31% versus 16%; p = 0.022), cardiopulmonary dysfunction (38% versus 18%; p = 0.007), and delirium (33% versus 13%; p = 0.003). With a propensity score-matched analysis (C-statistic = 0.90), 30 patients in the pandemic group and 60 patients in the prepandemic group were automatically selected. There were significant differences between the matched pandemic and prepandemic groups with respect to the rates of cardiopulmonary dysfunction (47% versus 23%; p = 0.024) and deep venous thrombosis (60% versus 35%; p = 0.028). CONCLUSIONS: Even with early surgical intervention, late mobilization and delays in active rehabilitation during the COVID-19 pandemic increased perioperative complications after SCI surgery. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

An interval of clinically silent gastrointestinal bleed in dysautonomic spinal cord injury: a case report.

BACKGROUND: Gastrointestinal bleed (GIB) has high incidence in traumatic spinal cord injured (tSCI) patients and can frequently be life-threatening, especially early post-injury. Several risk factors often compound bleeding risk, some are unique to this patient population. Normally, clinical suspicion for GIB arises from symptoms like coffee-ground emesis, hematemesis, melena or even hematochezia. A hemoglobin drop may be a late sign. Due to tSCI, however, patients often experience neurogenic bowels and dysautonomia, which may delay symptom presentation and complicate timely diagnosis of GIB. We report a case of an almost clinically silent GI bleed in the context of acute cervical tSCI. CASE PRESENTATION: A 21-year-old female presented with cervical cord transection at C-7 in the setting of motor vehicle rollover, for which surgical decompression was performed. During the acute injury phase, she also received a 10-day course of dexamethasone for symptomatic COVID-19 pneumonia. Two weeks after injury, she underwent percutaneous endoscopic gastrostomy (PEG) placement which demonstrated normal gastric and duodenal anatomy. One week later, a large spike (10x) in blood urea nitrogen: creatinine (BUN: Cr) ratio raised concern for GIB, but hemoglobin remained stable, and stool color remained unchanged. The following day, a gastroenterology consult was requested under increased suspicion of GIB from a sudden 3.5 g/dL hemoglobin drop. The patient received blood transfusion and pantoprazole. An upper endoscopy was performed, revealing three small duodenal ulcers. Melanotic stool ensued afterwards. CONCLUSIONS: Due to dysautonomia, clinical presentation of GIB can be significantly delayed in the tSCI patient population, leaving them vulnerable to succumb to illness. This case illustrates the possibility of an interval in which the patient was bleeding, with the sole indicator being an elevated BUN. Our case calls for closer monitoring of and vigilance for tSCI patients, and possibly employment of different strategies to reduce the incidence and enhance early detection of GIB in tSCI patients to subsequently decrease the morbidity and mortality associated with it.

Going Remote: A Revised Study Protocol for a Pilot Randomized Controlled Trial for Biofeedback Treatment of Anxiety Associated With Chronic Spinal Cord Injury.

Background: The incidence of anxiety in adults with spinal cord injury/disorder (SCI/D) exceeds that of the general population. Heart rate variability (HRV) biofeedback training is a potential treatment associated with a reduction in stress and anxiety, however HRV training has not been explored in the SCI/D population. Objectives: To describe a modified protocol piloting HRV training to reduce anxiety associated with SCI/D and detail the COVID-19-related modifications. Methods: To test the feasibility of the biofeedback treatment, 30 adults with SCI/D will complete this pilot randomized controlled trial. Enrollment started in January 2020, halted in March 2020 due to the COVID-19 pandemic, and resumed in March 2021 with a modified protocol. Protocol modifications are documented using the Framework for Reporting Adaptations and Modifications (FRAME). Participants are allocated to the treatment or control arm and undergo eight sessions of physiological monitoring at home using a commercially available HRV sensor and mobile application, which also delivers biofeedback training for those in the treatment arm. Surveys are administered following each session to capture self-reported stress, anxiety, and mood. The study is approved by the HCA-HealthONE institutional review board and is registered with clinicaltrials.gov (NCT# 03975075). Conclusion: COVID-19 has changed the research landscape, forcing scientists to rethink their study designs to address patient and staff safety in this new context. Our modified protocol accomplished this by moving the treatment setting and delivery out of the clinic and into the home. In doing so, we address patient and staff safety, increase external validity, and reduce participant burden.

IncobotulinumtoxinA versus onabotulinumtoxinA intradetrusor injections in patients with neurogenic detrusor overactivity incontinence: a double-blind, randomized, non-inferiority trial.

BACKGROUND: A randomized, double-blind, non-inferiority clinical study was performed on the efficacy and tolerability of IncobotulinumtoxinA (Incobot/A) vs. OnabotulinumtoxinA (OnabotA) intradetrusor injections in patients with refractory neurogenic detrusor overactivity incontinence performing intermittent catheterization. METHODS: Sixty-four patients with spinal cord injury (SCI) or multiple sclerosis were randomized to receive 30 intradetrusor injections of Incobot/A or OnabotA 200 U; 28 patients in incobotulinumtoxinA group and 29 in onabotulinumtoxinA group completed the study. Primary outcome measure was the non-inferior variation from baseline in daily urinary incontinence episodes (week 12), with a non-inferiority margin of one episode/day. Secondary outcomes measures were changes in Incontinence- Quality of Life questionnaire, Visual Analog Scale Score (bother of symptoms on Quality of Life), urodynamic parameters, occurrence of adverse effects and related costs (week 12). RESULTS: At week 12, mean value of difference in urinary incontinence episodes/day between the two groups was -0.2 (95% two-sided CI: -1; 0.7); the difference in incontinence episodes/day between the two groups was -0.4 with a higher limit of one-sided 95% CI of 0.2 episodes/day which was much lower than the non-inferiority margin of one episode/day. Total score and subscores of Incontinence- Quality of Life questionnaire, Visual Analog Scale scores and urodynamics did not show differences between the two groups. Adverse effects were similar for both treatments, with urinary tract infection being the most frequent, localised effect. Minor costs were observed following Incobot/A. CONCLUSIONS: In patients with refractory neurogenic incontinence due to SCI or multiple sclerosis, incobotulinumtoxinA was not inferior to onabotulinumtoxinA in improving clinical and urodynamic findings in the short-term follow-up, with comparable adverse effects but minor costs.

Spasticity following brain and spinal cord injury: assessment and treatment.

PURPOSE OF REVIEW: Spasticity is a common sequela of brain and spinal cord injury and contributes to disability, reduces quality of life, and increases economic burden. Spasticity is still incompletely recognized and undertreated. We will provide an overview of recent published data on the definition, assessment, and prediction, therapeutic advances, with a focus on promising new approaches, and telemedicine applications for spasticity. RECENT FINDINGS: Two new definitions of spasticity have been recently proposed, but operational criteria should be developed, and test-retest and inter-rater reliability should be explored. Cannabinoids proved to be effective in spasticity in multiple sclerosis, but evidence in other types of spasticity is lacking. Botulinum neurotoxin injection is the first-line therapy for focal spasticity, and recent literature focused on optimizing its efficacy. Several pharmacological, interventional, and nonpharmacological therapeutic approaches for spasticity have been explored but low-quality evidence impedes solid conclusions on their efficacy. The recent COVID-19 pandemic yielded guidelines/recommendations for the use of telemedicine in spasticity. SUMMARY: Despite the frequency of spasticity, robust diagnostic criteria and reliable assessment scales are required. High-quality studies are needed to support the efficacy of current treatments for spasticity. Future studies should explore telemedicine tools for spasticity assessment and treatment.

Early insights of the COVID-19 pandemic in the Veterans' Affairs spinal cord injury and disorders population.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: The primary outcome of the study was to identify patient characteristics associated with a positive COVID-19 test. The secondary outcome was to identify patient characteristics associated with mortality from COVID-19. SETTING: Veterans Health Administration (VHA) National Spinal Cord Injury and Disorders (SCI) Registry, created by the National Spinal Cord Injury and Disorders SCI Program Office in March 2020. METHODS: Data was analyzed in the form of descriptive statistics and then subsequent regression analysis was performed. RESULTS: A total of 4,562 persons with SCI were tested for COVID-19 between March and July 2020, and 290 were positive. The study found that African Americans had increased odds of testing positive for COVID-19 (OR 1.53 (1.18-2.00), p < 0.01). Increased age correlated with increased odds of mortality after testing positive for COVID-19 (1.046 (1.003-1.090)). Non-smokers had lower odds of mortality following positive COVID-19 test (0.15 (0.04-0.52)). No association was found between neurologic level of injury (NLI) and positive COVID-19 test or increased mortality. Increased Body Mass Index (BMI) did correlate with positive COVID-19 test but not increased mortality. The case fatality rate for persons with SCI and a positive test for COVID-19 was 12%. CONCLUSIONS: It is important to define the risk factors for patients with SCI to elucidate and mitigate individual and population risks. These risk factors also can play a role in determining the allocation of critical healthcare resources.

Living with spinal cord injury during COVID-19: a qualitative study of impacts of the pandemic in Nepal.

STUDY DESIGN: A qualitative study using focus group discussion. OBJECTIVE: To explore the impacts of COVID-19 on multiple aspects of the lives of individuals living with spinal cord injury (SCI) in Nepal. SETTING: Community settings in Nepal. METHODS: A qualitative phenomenological study was conducted using two virtual focus group discussions. Fourteen individuals with SCI residing in different parts of Nepal participated. A thematic analysis approach was used to analyze and interpret the participants' responses. RESULTS: The four key themes for the impacts of COVID-19 on individuals with SCI were: (1) physical health with subthemes of (a) difficulty due to the presence of COVID-19 symptoms and (b) deterioration in secondary conditions; (2) mental health with subthemes of (c) constant fear of COVID-19 and (d) psychological distress; (3) social life with subthemes of (e) social stigma and (f) social isolation, and (4) economic problems with subthemes of (g) financial burden and (i) inadequate resources. CONCLUSIONS: The pandemic has tremendously impacted the physical, mental, social, and economic aspects of the lives of individuals with SCI. These, in turn, could impede the functioning and well-being of this population. The utilization of telehealth to provide education, psychosocial support, social awareness programs, and the provision of essential medical supplies appear necessary to maintain and improve the well-being of individuals with SCI during this pandemic. Future studies using an in-depth interview approach and psychosocial interventions are recommended.

Physical activity levels and shoulder pain in wheelchair users during COVID-19 restrictions.

BACKGROUND: Manual wheelchair users are at high risk of developing shoulder pain. However, it is not known if restrictions to limit the spread of the COVID-19 virus affected physical activity, wheelchair use and shoulder pain. OBJECTIVE: The aim of the study is to determine whether COVID-19 related restrictions caused changes in physical activity levels and the presence of shoulder pain in persons who use a wheelchair. METHODS: Manual wheelchair users completed a survey about the presence and severity of shoulder pain in a cross-sectional study design. Participants completed the Leisure Time Physical Activity Questionnaire and were asked about daily wheelchair activity before and during lockdown. A logistic regression examined the relationship between increase in shoulder pain severity and change in activity levels. RESULTS: Sixty respondents were included for analysis. There was no significant change in physical activity during lockdown. There was a significant reduction in number of hours of daily wheelchair use and number of chair transfers during lockdown. Of the respondents, 67% reported having shoulder pain and 22% reported their shoulder pain becoming more severe during lockdown. No significant relationship was observed between the change in activity levels and increasing severity of shoulder pain. CONCLUSION: Restrictions to reduce the spread of the COVID-19 virus resulted in no changes in physical activity levels in a sample of adult manual wheelchair users; however, there was a reduced time using a wheelchair each day and fewer chair transfers. The changes in wheelchair activities were not related to the worsening of shoulder pain.

Impact of the COVID-19 Pandemic on Psychosocial Health of Persons With Spinal Cord Injury: Investigation of Experiences and Needed Resources.

Background: Emerging evidence suggests that the COVID-19 pandemic has been accompanied by increased rates of depression and social isolation. However, we do not yet understand how the COVID-19 pandemic has affected the psychosocial health of people with spinal cord injury (PwSCI), a population that is already at risk of experiencing mental health conditions. Objectives: The aims of the study were to (1) examine the impact of the pandemic on the psychosocial health of PwSCI and (2) investigate the experiences of PwSCI and resources they reported needing during the peak of the pandemic. Methods: A cross-sectional survey with closed- and open-ended questions was administered to 51 PwSCI. Participants were included if they had an SCI, were 18 years or older, lived in St. Louis, Missouri, and surrounding areas, and understood English. Results: Canonical correlation showed a significant association between financial security, food insecurity, and personal assistance service use and adverse psychosocial health outcomes (p < .001). Participants reported interest in resources related to COVID-19 precautions for wheelchair users as well as home exercise programming and financial assistance with utilities. Finally, qualitative analysis revealed four major themes: (1) mental health during the pandemic, (2) financial concerns and reduced access to personal assistance services, (3) feelings of social isolation prior to the pandemic, and (4) local and national authorities' handling of the pandemic. Conclusion: PwSCI are impacted by the COVID-19 pandemic and reported a variety of resource needs. These findings may inform service providers, support systems, and organizations to better support PwSCI during times of crisis.

Post-COVID Complications after Pressure Ulcer Surgery in Patients with Spinal Cord Injury Associate with Creatine Kinase Upregulation in Adipose Tissue.

The risk of complications following surgical procedures is significantly increased in patients with SARS-CoV-2 infection. However, the mechanisms underlying these correlations are not fully known. Spinal cord injury (SCI) patients who underwent reconstructive surgery for pressure ulcers (PUs) before and during the COVID-19 pandemic were included in this study. The patient's postoperative progression was registered, and the subcutaneous white adipose tissue (s-WAT) surrounding the ulcers was analyzed by proteomic and immunohistochemical assays to identify the molecular/cellular signatures of impaired recovery. Patients with SCI and a COVID-19-positive diagnosis showed worse recovery and severe postoperative complications, requiring reintervention. Several proteins were upregulated in the adipose tissue of these patients. Among them, CKMT2 and CKM stood out, and CKM increased for up to 60 days after the COVID-19 diagnosis. Moreover, CKMT2 and CKM were largely found in MGCs within the s-WAT of COVID patients. Some of these proteins presented post-translational modifications and were targeted by autoantibodies in the serum of COVID patients. Overall, our results indicate that CKMT2, CKM, and the presence of MGCs in the adipose tissue surrounding PUs in post-COVID patients could be predictive biomarkers of postsurgical complications. These results suggest that the inflammatory response in adipose tissue may underlie the defective repair seen after surgery.

Access limitations and level of psychological distress during the COVID-19 pandemic in a geographically-limited sample of individuals with spinal cord injury.

OBJECTIVES: Assess changes in access and psychological status during the COVID-19 pandemic in people with spinal cord injury (SCI). STUDY DESIGN: Cohort telephone survey study. SETTING: South Florida SCI Model System (SF-SCIMS). PARTICIPANTS: A convenience sample of 51 individuals with traumatic SCI who had previously completed SCIMS Form II follow-up interviews. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Questionnaire administration included assessments of resilience, depressive symptoms, satisfaction with life, anxiety, pain, alcohol and substance use, COVID-19 diagnoses and symptoms, and impact of early COVID-19 community restrictions on various aspects of life. RESULTS: Of the individuals interviewed, 78% reported limited access to their regular activities, 40% to healthcare information and services, 38% to personal protective equipment (PPE), 37% to food/groceries, and 34% to medication refills. Sixteen percent of the participants had at least moderate levels of depression, and 10% had at least moderate levels of anxiety. Statistically significant increases in depressive symptoms (Patient Health Questionnaire 9; P = 0.004) and significant decreases in resilience (SCI-Quality of Life Resilience subscore; P = 0.010) were found when comparing scores on measures of psychological function at the time of the study to scores collected during the previous SCIMS Form II interview (within 2 years pre-COVID-19). CONCLUSION(S): Limitations to basic needs and face-to-face communication can exacerbate challenges in access for persons with disabilities. Our results show increased levels of psychological distress related to decreased access to goods and services in individuals with SCI due to the COVID-19 pandemic. The results of this study can help the SCI community to target strategies for enhanced access, outreach, shared information, and social support in preparation for future community health or weather emergencies.

Resilience and mental health in individuals with spinal cord injury during the COVID-19 pandemic.

STUDY DESIGN: Cross-sectional, observational study. OBJECTIVES: To understand how resilience, access to personal care attendants (PCAs) and medical supplies, and concerns about medical rationing, finances, and social isolation are related to overall and mental health in individuals with spinal cord injury (SCI) in the context of the COVID-19 pandemic. SETTING: Community dwelling adults (N = 187) with SCI. METHODS: Data were collected online between May 1, 2020 and August 31, 2020. Outcomes were overall and mental health, depression and anxiety symptoms, and quality of life (QoL). Predictors were resilience, access to PCAs and medical supplies, and concerns about medical rationing, finances, and social isolation. RESULTS: Incomplete injury, concern about medical rationing, medical supply disruption, and social isolation predicted a greater perceived impact of the pandemic on overall heath. Younger age, decreased resilience, and concern about medical rationing and social isolation predicted greater perceived impact of the pandemic on mental health. Decreased resilience and concern about medical rationing and finances predicted increased anxiety symptoms. Incomplete injury, believing that medical rationing was occurring, decreased resilience, and concern about finances and social isolation predicted increased depressive symptoms. Decreased resilience and concern about finances, medical rationing, and social isolation predicted lower QoL. CONCLUSIONS: The negative effects of the pandemic on the overall and mental health of individuals with SCI may be ameliorated by resilience. In future crises, it may be beneficial to screen individuals for resilience so that those with decreased resilience are offered the appropriate resources to enhance resilience and improve overall wellbeing.

Physical activity and sedentary behavior in people with spinal cord injury: Mitigation strategies during COVID-19 on behalf of ACSM-EIM and HL-PIVOT.

People with spinal cord injury (SCI) face unique challenges during the COVID-19 pandemic, including greater risk of poor COVID-19-related outcomes, increased social isolation, and restricted access to important services. Furthermore, COVID-19 related restrictions have decreased already low levels of physical activity (PA) in this population. Therefore, the purpose of this commentary is to: 1) address the impact of COVID-19 on PA and sedentary behavior (SB) in people with SCI; 2) provide potential SB reduction strategies to guide future research; and 3) provide recommendations to increase PA and reduce SB on behalf of the American College of Sports Medicine Exercise is Medicine (ACSM-EIM) and Healthy Living for Pandemic Event Protection (HL-PIVOT) using a social-ecological model targeting the individual-, social environment-, physical environment-, and policy-level determinants of behavior in people with SCI.

Isolated and anxious: A qualitative exploration of the impact of the COVID-19 pandemic on individuals living with spinal cord injury in the UK.

OBJECTIVE: People living with spinal cord injury (SCI) are often immunocompromised, and at increased risk of respiratory infection. Given the restrictions in response to the COVID-19 pandemic, those with SCI may be at increased risk of health deterioration, though how this is experienced is poorly understood. This study explored the experiences of people living with SCI during the COVID-19 pandemic. DESIGN: Participants completed an online survey consisting of demographic questions, and open-ended qualitative questions pertaining to their experiences during the pandemic. Thematic analysis was utilized for the analytical approach. SETTING: Community-based sample in the UK. PARTICIPANTS: Participants were recruited via social media outlets of UK-based SCI-specific support charities, and snowball sampling (N = 42, F = 34, M = 8). RESULTS: Key themes included: (1) lost access to health services and support, capturing concerns surrounding barriers to healthcare and rehabilitation, which intensified secondary consequences of SCI such as spasm and pain; (2) health anxiety, which was perpetuated by perceived heightened vulnerabilities to respiratory complications; (3) social isolation, with significantly reduced social contact, even with care providers, compounding health experiences. CONCLUSION: People living with SCI during the COVID-19 pandemic experienced a variety of personal physical, psychological, and social challenges, each of which could disrupt daily functioning and quality of life. Increased utilization of telehealth is recommended to support continued engagement in rehabilitation, and foster connection and community amongst others with SCI and health professionals.

Clinical features and prognosis of COVID-19/SARS-CoV-2 infections in persons with spinal cord injury: a review of current literature.

STUDY DESIGN: Focused literature review. OBJECTIVES: Objective of the study was to perform a literature search and summarise the clinical features and prognosis of persons with spinal cord injury (SCI) infected with COVID-19 from the published articles. SETTING: India. METHODS: PubMed, CENTRAL and MEDLINE were systematically searched using specific keywords. The study assessed 2747 scientific studies involving COVID-19 and SCI for possible inclusion in a meta-analysis of SCI and SARS-COV-2. Studies involving persons with SCI who were tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the nasopharyngeal or throat swab polymerase chain reaction were included. RESULTS: Out of 2747 articles, 11 articles (206 participants), including six case reports, were included in this review. Fever was the most frequently observed symptom of COVID-19 infection in the SCI population. C-reactive protein (CRP) and lymphocytopenia were common abnormal laboratory parameters. The most common radiological finding in COVID-19 infection was ground glass opacities in lung fields. Prophylactic/therapeutic anticoagulation was given in a significant number of SCI persons infected with COVID-19. Persons with SCI who were diagnosed early showed good outcomes. CONCLUSIONS: Based on the few studies published on COVID-19 and SCI populations since 2019, this study determined fever, elevated CRP, lymphocytopenia and ground glass opacities, which indicated inflammation, compromised immune response, and lung edema, as the main clinical features of COVID-19 infection in SCI population. Though COVID-19 infection reported an increased number of deaths in few studies, a significant number of SCI populations with positive RT-PCR were treated successfully and discharged at home.

The impact of COVID-19 on community integration, quality of life, depression and anxiety in people with chronic spinal cord injury.

CONTEXT/OBJECTIVE: Compare community integration, quality of life, anxiety and depression of people with chronic spinal cord injury (SCI) living in the community before the outbreak of coronavirus SARS-CoV-2 disease (COVID-19) and during it. DESIGN: Prospective observational cohort study. SETTING: In-person follow-up visits (before COVID-19 outbreak) to a rehabilitation hospital in Spain and on-line during COVID-19. PARTICIPANTS: Community dwelling adults (≥ 18 years) with chronic SCI. OUTCOME MEASURES: Hospital Anxiety and Depression Scale (HADS), Community Integration Questionnaire (CIQ) and World Health Organization Quality of Life (WHOQOL-BREF) were compared using the Wilcoxon ranked test or paired t-test when appropriate. RESULTS: One hundred and seventy five people with SCI assessed on-line between June 2020 and November 2020 were compared to their own assessments before COVID-19. Participants reported significantly decreased Social Integration during COVID-19 compared to pre-pandemic scores (P = 0.037), with a small effect size (d = -0.15). Depression (measured using HADS) was significantly higher than before COVID-19 (P < 0.001) with a moderate effect size (d = -0.29). No significant differences were found in any of the 4 WHOQOL-BREF dimensions (Physical, Psychological, Social and Environmental).Nevertheless, when all participants were stratified in two groups according to their age at on-line assessment, the younger group (19-54 years, N = 85) scored lower during COVID-19 than before, in WHOQOL-BREF Physical (P = 0.004), (d = -0.30) and Psychological dimensions (P = 0.007) (d = -0.29). The older group (55-88 years, N = 0) reported no significant differences in any dimension. CONCLUSIONS: COVID-19 impacted HADS' depression and CIQ's social integration. Participants younger than 55 years were impacted in WHOQOL-BREF's physical and psychological dimensions, meanwhile participants older than 55, were not.

COVID-19 Presentation in an Acute Motor Incomplete Spinal Cord Injury in Inpatient Rehabilitation.

ABSTRACT: Spinal cord injuries lead to impairment of the central regulation of respiratory muscle activity. This impairs the cough response, which can increase the risk of complications if infected with coronavirus disease 2019. This case describes a 32-yr-old man with an acute traumatic motor incomplete spinal cord injury, C4 American Spinal cord Injury Association Impairment Scale D D, in an inpatient rehabilitation facility who presented with only a fever. Initial infectious workup was negative, and he continued to have elevated temperatures with no other symptoms. He was then tested for coronavirus disease 2019 and found to be positive. This is the first documented case that identifies this potentially lethal disease in an acute motor incomplete spinal cord injury in an inpatient rehabilitation setting. We further discuss how physiatrists need to be aware of milder presentation of coronavirus disease 2019 in patients with spinal cord injuries. Inability to recognize this disease can lead to delayed diagnosis and asymptomatic spread in an inpatient rehabilitation setting.

COVID-19 and Acute Cervical Spinal Cord Injury-Case Report of 2 Patients: Do We Need to Rethink Our Standard Treatment Strategy?

STUDY DESIGN: This was a case series. OBJECTIVE: The authors sought to examine the high-risk population of COVID-positive patients with acute cervical spinal cord injury (SCI) in a large level 1 trauma and tertiary referral center. SUMMARY OF BACKGROUND DATA: There are limited studies regarding the surgical management of patients with acute SCI in the setting of the recent coronavirus pandemic. METHODS: The authors describe the cases of 2 patients who died from COVID-related complications after acute cervical SCI. RESULTS: Patients with SCI are at increased risk of pulmonary complications. COVID-19 infection represents a double hit in this patient population, increasing potential morbidity and mortality in the perioperative time frame. Careful consideration must be made regarding the timing of potential surgical intervention in the treatment of acute SCI. CONCLUSIONS: Nationwide database of COVID-positive patients with acute spinal cord injury should be collected and analyzed to better understand how to manage acute SCI in the COVID-19 era. The authors recommend preoperative discussion in patients with acute cervical SCI with COVID-19, specifically emphasizing the increased risk of respiratory complications and mortality.

Respiratory function and respiratory complications in spinal cord injury: protocol for a prospective, multicentre cohort study in high-income countries.

INTRODUCTION: Pneumonia is one of the leading complications and causes of death after a spinal cord injury (SCI). After a cervical or thoracic lesion, impairment of the respiratory muscles decreases respiratory function, which increases the risk of respiratory complications. Pneumonia substantially reduces patient's quality of life, may prolong inpatient rehabilitation time, increase healthcare costs or at worse, lead to early death. Respiratory function and coughing can be improved through various interventions after SCI, but the available evidence as to which aspect of respiratory care should be optimised is inconclusive. Furthermore, ability of respiratory function parameters to predict pneumonia risk is insufficiently established. This paper details the protocol for a large-scale, multicentre research project that aims to evaluate the ability of parameters of respiratory function to predict and understand variation in inpatient risk of pneumonia in SCI. METHODS AND ANALYSIS: RESCOM, a prospective cohort study, began recruitment in October 2016 across 10 SCI rehabilitation centres from Australia, Austria, Germany, the Netherlands and Switzerland. Inpatients with acute SCI, with complete or incomplete cervical or thoracic lesions, 18 years or older and not/no more dependent on 24-hour mechanical ventilation within the first 3 months after injury are eligible for inclusion. The target sample size is 500 participants. The primary outcome is an occurrence of pneumonia; secondary outcomes include pneumonia-related mortality and quality of life. We will use the longitudinal data for prognostic models on inpatient pneumonia risk factors. ETHICS AND DISSEMINATION: The study has been reviewed and approved by all local ethics committees of all participating centres. Study results will be disseminated to the scientific community through peer-reviewed journals and conference presentations, to the SCI community, other stakeholders and via social media, newsletters and engagement activities. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov NCT02891096.