Effective bowel management in spinal cord injury during inpatient rehabilitation: data from the Dutch spinal cord injury database.

STUDY DESIGN: Retrospective Observational Study. OBJECTIVES: To describe bowel management in individuals with a recently acquired spinal cord injury (SCI) both at admittance and discharge from first inpatient rehabilitation, and to determine factors that contribute to effective bowel management (EBM) at discharge. SETTING: Specialized rehabilitation centers in the Netherlands. METHODS: Data from the Dutch Spinal Cord Injury Database (DSCID) collected between 2015 and 2019 was used. EBM was defined by the variables of stool frequency and fecal incontinence. After univariate analysis, a multivariate regression analysis was conducted. RESULTS: Of 1,210 participants, 818 (68%) did not have EBM at admittance. At discharge, 308 (38%) did still not have EBM (in total 33% of all participants). The odds of having EBM at discharge was 2.82 times higher for participants with ASIA Impairment Scale (AIS) D compared to those with AIS-A (95% CI: 1.38-5.78). Participants with non-traumatic SCI had higher odds of having EBM than those with traumatic SCI (OR: 0.59, 95% CI 0.38-0.91). Use of suppositories, small enema, medication influencing bowel function, and oral laxatives at admittance did not influence EBM significantly at discharge. CONCLUSIONS: Bowel management improves during first inpatient rehabilitation. However, realizing EBM after a recently acquired SCI is a challenge. This endorses the importance of bowel management during inpatient rehabilitation, especially for people with AIS-A and non-traumatic etiology.

Faecal Microbiota in Patients with Neurogenic Bowel Dysfunction and Spinal Cord Injury or Multiple Sclerosis-A Systematic Review.

BACKGROUND: Neurogenic bowel dysfunction (NBD) frequently occurs in patients with spinal cord injury (SCI) and multiple sclerosis (MS) with comparable symptoms and is often difficult to treat. It has been suggested the gut microbiota might influence the course of NBD. We systematically reviewed the literature on the composition of the gut microbiota in SCI and MS, and the possible role of neurogenic bowel function, diet and antibiotic use. METHODS: A systematic search was conducted in PubMed and Embase, which retrieved studies on the gut microbiota in SCI and MS. The Newcastle-Ottawa Quality Assessment Scale (NOS) was used to assess methodological quality. RESULTS: We retrieved fourteen papers (four on SCI, ten on MS), describing the results of a total of 479 patients. The number of patients per study varied from 13 to 89 with an average of 34. Thirteen papers were observational studies and one study was an intervention study. The studies were case control studies in which the gut microbiota composition was determined by 16S rRNA gene sequencing. The methodological quality of the studies was mostly rated to be moderate. Results of two studies suggested that alpha diversity in chronic SCI patients is lower compared to healthy controls (HC), whereas results from five studies suggest that the alpha diversity of MS patients is similar compared to healthy subjects. The taxonomic changes in MS and SCI studies are diverse. Most studies did not account for possible confounding by diet, antibiotic use and bowel function. CONCLUSION: Based on these 14 papers, we cannot draw strong conclusions on the composition of the gut microbiota in SCI and MS patients. Putatively, alpha diversity in chronic SCI patients may be lower compared to healthy controls, while in MS patients, alpha diversity may be similar or lower compared to healthy controls. Future studies should provide a more detailed description of clinical characteristics of participants and of diet, antibiotic use and bowel function in order to make valid inferences on changes in gut microbiota and the possible role of diet, antibiotic use and bowel function in those changes.

Functional independence of persons with long-standing motor complete spinal cord injury in the Netherlands.

Context/Objective: Since life expectancy of persons with spinal cord injury (SCI) has improved, it is relevant to know whether this group is able to maintain functional abilities many years after onset of SCI. Objectives of this study were (1) to examine associations between time since injury (TSI) and functional independence in persons with long-standing SCI and (2) to explore associations between functional independence and level of injury, comorbidities, mental health, waist circumference and secondary health conditions (SHCs).Design: TSI-stratified cross-sectional study. Strata were 10-19, 20-29 and 30+ years.Setting: Community.Participants: 226 persons with long-standing SCI. Inclusion criteria: motor complete SCI; age at injury 18-35 years; TSI ≥ 10 years; current age 28-65 years; wheelchair dependency.Interventions: Not applicable.Outcome measures: The Spinal Cord Independence Measure III (SCIM) was administered by a trained research assistant. Level of injury, comorbidities, mental health, waist circumference and SHCs were assessed by a rehabilitation physician.Results: Mean TSI was 23.6 (SD 9.1) years. No significant differences in SCIM scores were found between TSI strata. SCIM scores were lower for persons with tetraplegia, autonomic dysreflexia, hypotension, more than four SHCs and a high waist circumference. In linear regression analyses, TSI nor age was associated with the SCIM total score. Only level of injury (ß = -0.7; P < .001) and waist circumference (ß = -0.1; P = .042) were independent determinants (explained variance 55%).Conclusion: We found no association between TSI and functional independence in persons with long-standing motor complete SCI. This study confirms the possible effect of overweight on functional independence.

Cardiorespiratory fitness and physical strain during prosthetic rehabilitation after lower limb amputation.

BACKGROUND: Sufficient cardiorespiratory fitness has been regarded a prerequisite for prosthetic walking. In order to improve cardiorespiratory fitness, adequate strain ought to be placed on the system during training. OBJECTIVES: To determine cardiorespiratory fitness at the start and end of inpatient rehabilitation after lower limb amputation and determine the physical strain experienced during conventional prosthetic rehabilitation. STUDY DESIGN: Multicenter prospective cohort study. METHODS: Cardiorespiratory fitness was assessed using a peak one-legged cycle exercise test. Physical strain was assessed during a minimum of three full rehabilitation days using heart rate recordings. Physical strain was expressed in the time per day that heart rate exceeded 40% of heart rate reserve. RESULTS: At the start of rehabilitation, peak aerobic capacity was on average 16.9 (SD, 6.5) mL/kg/min (n = 33). Overall, peak aerobic capacity did not improve over the course of rehabilitation (n = 23, p = 0.464). Fifty percent of the patients experienced a physical strain level that satisfies minimum criteria for maintaining cardiorespiratory fitness (>40% heart rate reserve for 30 min/day). CONCLUSION: Cardiorespiratory fitness was low and did not increase during conventional prosthetic rehabilitation. On average, the physical strain during rehabilitation was insufficient to elicit potential improvements in aerobic capacity. Results stress the need for dedicated physical training modules at the individual level. CLINICAL RELEVANCE: This study shows that clinicians ought to be aware of the relatively low cardiorespiratory fitness of people who have undergone lower limb amputation and that improvements during rehabilitation are not always obtained. Results stress the need for physical training modules in which intensity is imposed at the individual level.

Exoskeleton gait training after spinal cord injury: An exploratory study on secondary health conditions.

OBJECTIVE: To explore changes in pain, spasticity, range of motion, activities of daily living, bowel and lower urinary tract function and quality of life of individuals with spinal cord injury following robotic exoskeleton gait training. DESIGN: Prospective, observational, open-label multicentre study. METHODS: Three training sessions per week for 8 weeks using an Ekso™ GT robotic exoskeleton (EKSO Bionics). Included were individuals with recent (<1 year) or chronic (>1 year) injury, paraplegia and tetraplegia, complete and incomplete injury, men and women. RESULTS: Fifty-two participants completed the training protocol. Pain was reported by 52% of participants during the week prior to training and 17% during training, but no change occurred longitudinally. Spasticity decreased after a training session compared with before the training session (p <0.001), but not longitudinally. Chronically injured participants increased Spinal Cord Independence Measure (SCIM III) from 73 to 74 (p = 0.008) and improved life satisfaction (p = 0.036) over 8 weeks of training. Recently injured participants increased SCIM III from 62 to 70 (p < 0.001), but no significant change occurred in life satisfaction. Range of motion, bowel and lower urinary function did not change over time. CONCLUSION: Training seemed not to provoke new pain. Spasticity decreased after a single training session. SCIM III and quality of life increased longitudinally for subsets of participants.

Progress of the Dutch Spinal Cord Injury Database: Completeness of Database and Profile of Patients Admitted for Inpatient Rehabilitation in 2015.

Background: In the Dutch International Spinal Cord Injury (SCI) Data Sets project, we translated all International SCI Data Sets available in 2012 and created a Dutch SCI Database (NDD). Objective: To describe the number of included patients and completeness of the NDD, and to use the NDD to provide a profile of people with traumatic SCI (T-SCI) and non-traumatic SCI (NT-SCI) in the Netherlands. Methods: The NDD includes patients admitted for their first inpatient rehabilitation after onset of SCI to 1 of the 8 rehabilitation centers with a specialty in SCI rehabilitation in the Netherlands. Data of patients admitted in 2015 were analyzed. Results: Data for 424 patients were available at admission; for 310 of these patients (73.1%), discharge data were available. No significant differences were found between patients with and without data at discharge. Data were nearly complete (>90%) for lower urinary tract, bowel, pain, and skin. Data on sexual function has the lowest completion rate. Complete neurological and functional data were available for 41.7% and 38%, respectively. Most patients were male (63.4%), had NT-SCI (65.5%), and had incomplete SCI (58.4% D). Patients with T-SCI differed from patients with NT-SCI on most characteristics, and they stayed considerably longer in the rehabilitation center (112 days vs 65 days, p < .001). Place of discharge was not different between both groups. Conclusion: With the NDD, we collect important data on the majority of Dutch SCI patients, although much work needs to be done to improve the completeness of the data collection.

Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso Bionics.

STUDY DESIGN: Prospective quasi-experimental study, pre- and post-design. OBJECTIVES: Assess safety, feasibility, training characteristics and changes in gait function for persons with spinal cord injury (SCI) using the robotic exoskeletons from Ekso Bionics. SETTING: Nine European rehabilitation centres. METHODS: Robotic exoskeleton gait training, three times weekly over 8 weeks. Time upright, time walking and steps in the device (training characteristics) were recorded longitudinally. Gait and neurological function were measured by 10 Metre Walk Test (10 MWT), Timed Up and Go (TUG), Berg Balance Scale (BBS), Walking Index for Spinal Cord Injury (WISCI) II and Lower Extremity Motor Score (LEMS). RESULTS: Fifty-two participants completed the training protocol. Median age: 35.8 years (IQR 27.5-52.5), men/women: N = 36/16, neurological level of injury: C1-L2 and severity: AIS A-D (American Spinal Injury Association Impairment Scale). Time since injury (TSI) < 1 year, N = 25; > 1 year, N = 27. No serious adverse events occurred. Three participants dropped out following ankle swelling (overuse injury). Four participants sustained a Category II pressure ulcer at contact points with the device but completed the study and skin normalized. Training characteristics increased significantly for all subgroups. The number of participants with TSI < 1 year and gait function increased from 20 to 56% (P = 0.004) and 10MWT, TUG, BBS and LEMS results improved (P < 0.05). The number of participants with TSI > 1 year and gait function, increased from 41 to 44% and TUG and BBS results improved (P < 0.05). CONCLUSIONS: Exoskeleton training was generally safe and feasible in a heterogeneous sample of persons with SCI. Results indicate potential benefits on gait function and balance.

Bladder-emptying methods, neurogenic lower urinary tract dysfunction and impact on quality of life in people with long-term spinal cord injury.

OBJECTIVES: To describe bladder-emptying methods used by people with long-term spinal cord injury (SCI) and to determine usage differences in relation to time since injury, sex, lesion level and completeness of lesion. Furthermore, to evaluate the relationship between bladder-emptying methods and the impact of neurogenic lower urinary tract dysfunction (NLUTD) on quality of life (QoL). DESIGN: Cross-sectional multicenter study. SETTING: Dutch community. PARTICIPANTS: Persons dependent on wheelchairs (N = 282) with traumatic or non-traumatic SCI for ≥10 years and age at injury of 18-35 years. INTERVENTIONS: Not applicable. OUTCOME MEASURES: The International Lower Urinary Tract Function Basic SCI Data Set and the Short-Form Qualiveen (SF-Qualiveen). RESULTS: Median time since injury was 22.0 years (IQR: 16.8-30.3). Clean intermittent catheterization (CIC) was most commonly used (42.6%). Longer time since injury was associated with fewer continent urinary diversions and more transurethral catheter use. Transurethral catheter use and continent urinary diversions were more prevalent among women. Participants with tetraplegia were more likely to use reflex voiding or a suprapubic catheter, and participants with paraplegia were more likely to use CIC. Transurethral catheter users reported the highest impact of NLUTD on quality of life (SF-Qualiveen score: 1.9; SD = 0.8). Participants with a continent urinary diversion reported the lowest impact (SF-Qualiveen score: 0.9; SD = 0.6). Higher age and indwelling catheter use versus CIC were associated with a higher impact of NLUTD on QoL. CONCLUSIONS: CIC is the most common bladder-emptying method in Dutch people with long-term SCI. Clinicians should be aware of the impact of NLUTD on QoL, especially for those using an indwelling catheter.

Low-intensity wheelchair training in inactive people with long-term spinal cord injury: A randomized controlled trial on fitness, wheelchair skill performance and physical activity levels.

OBJECTIVE: To investigate the effects of low-intensity wheelchair training on wheelchair-specific fitness, wheelchair skill performance and physical activity levels in inactive people with long-term spinal cord injury. DESIGN: Randomized controlled trial. PARTICIPANTS: Inactive manual wheelchair users with spinal cord injury for at least 10 years (n = 29), allocated to exercise (n = 14) or no exercise. METHODS: The 16-week training consisted of wheelchair treadmill-propulsion at 30-40% heart rate reserve or equi-valent in terms of rate of perceived exertion, twice a week, for 30 min per session. Wheelchair-specific fitness was determined as the highest 5-s power output over 15-m overground wheelchair sprinting (P5-15m), isometric push-force, submaximal fitness and peak aerobic work capacity. Skill was determined as performance time, ability and strain scores over a wheelchair circuit. Activity was determined using a questionnaire and an odometer. RESULTS: Significant training effects appeared only in P5-15m (exercise vs control: mean +2.0 W vs -0.7 W, p = 0.017, ru=0.65). CONCLUSION: The low-intensity wheelchair training appeared insufficient for substantial effects in the sample of inactive people with long-term spinal cord injury, presumably in part owing to a too-low exercise frequency. Effective yet feasible and sustainable training, as well as other physical activity programmes remain to be developed for inactive people with long-term spinal cord injury.

Trajectories in the course of body mass index after spinal cord injury.

OBJECTIVE: To identify different trajectories of the course of body mass index (BMI) after spinal cord injury (SCI) and to study whether other cardiovascular risk factors (blood pressure, lipid profile) follow the same trajectories. DESIGN: Multicenter prospective cohort study with measurements at the start of active rehabilitation, after 3 months, at discharge, and 1 and 5 years after discharge. SETTING: Rehabilitation centers. PARTICIPANTS: Persons with a recent SCI (N=204). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: BMI trajectories. RESULTS: Three BMI trajectories were identified: (1) a favorable stable BMI during and after rehabilitation (± 22-23 kg/m(2)) (54%); (2) a higher but stable BMI during inpatient rehabilitation (± 24 kg/m(2)) and an increase after discharge (up to 29 kg/m(2)) (38%); and (3) an increase in BMI during inpatient rehabilitation (from ± 23 up to 28 kg/m(2)) and leveling off after discharge (8%). Profile analyses showed that an unfavorable change in BMI was not accompanied by clear unfavorable changes in blood pressure or lipid levels. CONCLUSIONS: BMI in people with SCI follows distinct trajectories. Monitoring body mass, food intake, and daily physical activity during and especially after inpatient SCI rehabilitation is important to prevent obesity and related cardiovascular risk factors.

Wheelchair exercise capacity in spinal cord injury up to five years after discharge from inpatient rehabilitation.

OBJECTIVE: To elucidate the course and determinants of wheelchair exercise capacity in spinal cord injury up to 5 years after discharge from inpatient rehabilitation, and to describe loss to follow-up. DESIGN: Prospective cohort study, with measurements at the start and discharge from inpatient rehabilitation, 1 and 5 years after discharge. SUBJECTS: A total of 225 wheelchair-dependent persons with spinal cord injury. METHODS: Random coefficient analysis of the course and determinants of peak aerobic power output (POpeak) and peak oxygen uptake (VO2peak). RESULTS: A total of 162 participants attended 1 or more peak exercise tests and were analysed. Significant changes were found for both VO2peak and POpeak between start and 5 years after discharge, and discharge and 5 years after discharge. No significant changes were found for VO2peak and POpeak between 1 year and 5 years after discharge. Age, gender, level and completeness of lesion were determinants for level of VO2peak and age, gender, and level of lesion for level of POpeak. No significant determinants were found for the course of wheelchair exercise capacity. The 63 participants who were not analysed were older, and showed more persons with a tetraplegia. CONCLUSION: Wheelchair exercise capacity of persons with spinal cord injury stabilizes at between 1 and 5 years after discharge. The participants appear to be a positive selection of the total study group.

Relation between aerobic capacity and walking ability in older adults with a lower-limb amputation.

OBJECTIVES: To determine the relative aerobic load, walking speed, and walking economy of older adults with a lower-limb prosthesis, and to predict the effect of an increased aerobic capacity on their walking ability. DESIGN: Cross-sectional. SETTING: Human motion laboratory at a rehabilitation center. PARTICIPANTS: Convenience sample of older adults (n=36) who underwent lower-limb amputation because of vascular deficiency or trauma and able-bodied controls (n=21). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Peak aerobic capacity and oxygen consumption while walking were determined. The relative aerobic load and walking economy were assessed as a function of walking speed, and a data-based model was constructed to predict the effect of an increased aerobic capacity on walking ability. RESULTS: People with a vascular amputation walked at a substantially higher (45.2%) relative aerobic load than people with an amputation because of trauma. The preferred walking speed in both groups of amputees was slower than that of able-bodied controls and below their most economical walking speed. We predicted that a 10% increase in peak aerobic capacity could potentially result in a reduction in the relative aerobic load of 9.1%, an increase in walking speed of 17.3% and 13.9%, and an improvement in the walking economy of 6.8% and 2.9%, for people after a vascular or traumatic amputation, respectively. CONCLUSIONS: Current findings corroborate the notion that, especially in people with a vascular amputation, the peak aerobic capacity is an important determinant for walking ability. The data provide quantitative predictions on the effect of aerobic training; however, future research is needed to experimentally confirm these predictions.

Peak oxygen consumption in older adults with a lower limb amputation.

OBJECTIVE: To investigate whether the aerobic capacity of older adults who underwent a lower limb amputation is associated with the presence, cause (traumatic or vascular), and level of amputation (transtibial or transfemoral). DESIGN: Cross-sectional descriptive. SETTING: Human motion laboratory at a rehabilitation center. PARTICIPANTS: Older subjects (n=36) who underwent lower limb amputation and age-matched, able-bodied controls (n=21). All subjects were able to walk for a minimum of 4 minutes. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Peak oxygen consumption (Vo(2)(peak)) was measured using open-circuit respirometry while performing a discontinuous, graded, 1-legged, peak cycle exercise test. RESULTS: After correcting for age, body mass index, and sex, the multiple linear regression analysis revealed that subjects who underwent amputation had a 13.1% lower aerobic capacity compared with able-bodied controls (P=.021). Differentiation among etiologies revealed that subjects with a vascular amputation had a lower Vo(2)(peak) of 29.1% compared with able-bodied controls (P<.001), whereas traumatic amputees did not differ from able-bodied controls (P=.127). After correcting for etiology, no association between level of amputation and Vo(2)(peak) was found (P=.534). CONCLUSIONS: Older adults who underwent an amputation because of vascular deficiency had a lower aerobic capacity compared with able-bodied controls and people with a traumatic amputation. The level of amputation was not associated with Vo(2)(peak).

Return to work five years after spinal cord injury inpatient rehabilitation: is it related to wheelchair capacity at discharge?

OBJECTIVE: To describe the proportion of people with spinal cord injury who returned to work 5 years after discharge from inpatient rehabilitation, and to investigate whether return to work is related to wheelchair capacity at discharge from inpatient rehabilitation. DESIGN: Multi-centre prospective cohort study. SUBJECTS: A total of 103 participants with acute spinal cord injury at 8 Dutch rehabilitation centres, specialized in the rehabilitation of spinal cord injury. All participants were in paid employment before injury. METHODS: Main outcome measure was return to work for at least 1 h per week. The independent variables of wheelchair capacity were peak oxygen uptake (VO2peak), peak aerobic power output (POpeak), and wheelchair skill scores (ability, performance time, and physical strain). Possible confounders were age, gender, lesion level and lesion completeness, and educational level. RESULTS: The proportion of participants who returned to work was 44.7%. After correction for the confounders, POpeak (p=0.028), ability score (p=0.022), performance time (p=0.019) and physical strain score (p=0.038) were significantly associated with return to work. VO2peak was not significantly associated with return to work. CONCLUSION: More than 40% of the participants were able to return to paid work within 5 years after discharge from inpatient rehabilitation. Return to work was related to wheelchair capacity at discharge. It is recommended to train wheelchair capacity during rehabilitation in the context of return to work, since the association with return to work is another benefit of the training of wheelchair capacity in addition to the improvement of mobility and functional independency.