Rehabilitation of Persons with Spinal Cord Injury in Bangladesh.

There is a knowledge gap about the rehabilitation system for the persons with spinal cord injury (SCI). A rehabilitation scenario is necessary to conduct a national community survey in conjunction with the International Spinal Cord Injury Community Survey (InSCI) in order to gather data on the lived experiences of people with SCI, to map out the health and rehabilitation system of Bangladesh, it's demographic characteristics, accessible resources and rehabilitation challenges. Information for this narrative report was acquired through a structured questionnaire, which was supplemented by an online search of agencies, government websites, rehabilitation-related organizations and published papers during the period of March 2020 to April 2021. Bangladesh is a developing country with a vast population and a developing health care system. Representative government and non-government rehabilitative care settings a total of sixteen survey replies (n=16) were obtained. During the year 2019, a total of 1035 people with SCI were seen. The majority of patients with SCI were hospitalized by a non-government facility (38.65%), whereas the two main public general hospitals consulted roughly 30.0% of people with SCI. The rehabilitation team leader in the majority of the facilities (93.75%) was a physiatrist, but just a few had a full complement of rehabilitation professionals and only 12.5% of settings provide community care. Indoor rehabilitation facilities, equipment and a competent rehabilitation staff are not available at many of the tertiary care facilities including National Trauma Institute (NITOR), where most of the SCI report first after the trauma. A consistent and nationwide data source is unavailable and the majority of the available SCI research publications are hospital-based demographic studies in Bangladesh. SCI was commonly due to work-related trauma in young male manual laborers due to fall from height or road traffic accidents. The country faces multiple challenges in rehabilitation of people with SCI regarding triage, a referral system development, infrastructure and shortage of expert human resources in addition, currently there is no three-tier rehabilitation care continuum available. Keeping pace with the transition to a developed country by 2041, the Bangladesh health sector also has to be oriented to face the focused challenge of caring for people with SCI. As recommended by WHO Rehabilitation 2030 initiatives, establishment of an SCI dedicated national institute and escalation of number of related specialists such as trauma and orthopedic surgery, spinal neurosurgery and physical rehabilitation medicine, skilled professionals such as rehabilitation nurses, therapists, case managers and social workers to work in a team required for specialized care of SCI.

Use of antibiotics and the prevalence of antibiotic-associated diarrhoea in patients with spinal cord injuries: an international, multi-centre study.

BACKGROUND: Little is known about the use of antibiotics and the extent of antibiotic-associated diarrhoea (AAD) in patients with spinal cord injuries (SCIs). AIMS: To record the use of antibiotics, establish the prevalence of AAD and Clostridium difficile infection (CDI), and assess if there was any seasonal variation in antibiotic use and incidence of AAD in patients with SCIs. METHODS: A retrospective study was conducted in six European SCI centres between October 2014 and June 2015. AAD was defined as two or more watery stools (Bristol Stool Scale type 5, 6 or 7) over 24 h. FINDINGS: In total, 1267 adults (median age 54 years, 30.7% female) with SCIs (52.7% tetraplegia, 59% complete SCI) were included in this study. Among the 215 (17%) patients on antibiotics, the top three indications for antibiotics were urinary tract infections (UTIs), infected pressure ulcers and other skin infections. Thirty-two of these 215 (14.9%) patients developed AAD and two patients out of the total study population (2/1267; 0.16%) developed CDI. AAD was more common in summer than in spring, autumn or winter (30.3% vs 3.8%, 7.4% and 16.9%, respectively; P<0.01). AAD was associated with age ≥65 years, tetraplegia, higher body mass index, hypoalbuminaemia, polypharmacy, multiple antibiotic use and high-risk antibiotic use. Summer and winter seasons and male sex were identified as independent predictors for the development of AAD. CONCLUSION: This survey found that AAD is common in patients with SCIs, and UTI is the most common cause of infection. Summer and winter seasons and male sex are unique predictors for AAD. Both AAD and UTIs are potentially preventable; therefore, further work should focus on preventing the over-use of antibiotics, and developing strategies to improve hospital infection control measures.

Reajustement des charges des appareils de traction cervicale au cours de l'arthrose cervicale a Kinshasa

Objectif : Reajuster les charges des appareils de traction cervicale par la mesure des ecarts entre les charges affichees et celles accrochees; en vue d'une correction eventuelle par rapport au poids du patient.Methodes : C'est une etude de cas portant sur 6 materiels de traction cervicale appartenant aux 4 centres de reeducation et aux Cliniques Universitaires de Kinshasa; de janvier 2005 a decembre 2010 dans la ville de Kinshasa. Le reajustement des charges de ces appareils de traction a permis de verifier a l'aide d'un dynamometre intercale entre la sangle de traction et l'autre bout de la corde; la concordance ou non des charges accrochees au bout libre de l'appareil et celles affichees au dynamometre lors de la traction. Nous avons calcule la variation de la charge de la tete sur la colonne cervicale en fonction du degre de la lordose et du niveau de la vertebre. Etant donne que la tete pese en moyenne 8;1% du poids corporel; la charge a accrocher devait etre superieure au poids de la tete pour exercer une reelle traction sur la colonne cervicale.Resultats : Le reajustement des charges des appareils de traction cervicale dans ces cinq services a montre des ecarts importants entre les charges accrochees et celles affichees au dynamometre; compris entre 1;5 et 10 kg. Il a ete aussi mis en evidence l'importance de la lordose cervicale et celle du niveau de la vertebre dans l'augmentation de la charge sur la colonne; les variations de charges obeissant a une progression arithmetique.Conclusion : Nos resultats peuvent donc permettre; dans un contexte des pays a faibles revenus; d'aider les praticiens a proceder au reajustement des appareils de traction avant la prise en charge

Contributing to the growth of Physical and Rehabilitation Medicine (PRM): call for a Cochrane Field in PRM.

The European Society of Physical and Rehabilitation Medicine (ESPRM), together with the European Journal of PRM and the PRM Section and Board of the European Union of Medical Specialists (UEMS), started an action to establish a relationship with Cochrane (formerly the Cochrane Collaboration). Cochrane is a global, independent network of researchers, professionals, patients, carers and people interested in health, with contributors from more than 130 countries. Its aim is to produce credible, accessible health information that is free from any conflicts of interest. Cochrane produces the Cochrane Library, an evidence-based resource that includes today more than 6300 Cochrane systematic reviews. Cochrane is made up of many different review groups and other entities (such as Centres and Branches), distributed around the world, that are mainly focused on specific healthcare problems (diseases, or organs). Inside Cochrane also Fields have been created, that focus on a dimension of health care other than a specific healthcare problem. A Cochrane Field represents a bridge between Cochrane and the stakeholders of the related healthcare area. The medical specialty of PRM is covering a broad medical domain: it deals with function, activities and participation in a large number of health conditions, mostly but not exclusively musculoskeletal, neurological and cardiorespiratory. Consequently, the currently more than 200 existing Cochrane Reviews are scattered among different groups. A PRM Field could greatly serve to the need of the specialty, spreading the actual Cochrane knowledge, focusing needs today not covered by Cochrane Reviews, facing the intrinsic methodological problems of the specialty. This paper introduces a call for the development of a PRM Cochrane Field, briefly reviewing what Cochrane is and how it is organized, defining the value and identifying a pathway toward the development of a PRM Cochrane Field, and finally shortly reviewing the Cochrane reviews of PRM interest.

Current research funding methods dumb down health care and rehabilitation for disabled people and aging population: a call for a change.

Health care systems in Western societies are faced with two major challenges: aging populations and the growing burden of chronic conditions. This translates into more persons with disabilities and the need for more Physical and Rehabilitation Medicine (PRM) services. We raise the point of how these emerging needs are faced by the actual research funding. We briefly present the results of an analysis we made about research funding by the Italian National Health Service as an interesting case study, since it relates to Italy (the financer) and the United States, where National Institutes of Health (NIH) reviewers were identified according to their classification of research topics. The topics of potentially greatest interest for aging Western societies, like chronicity, disability and rehabilitation, were among those least often funded and considered in the traditional method of financing research projects. These results could be based on those PRM peculiarities that make the specialty different from all other classical biomedical specialties, namely the bio-psycho-social approach and its specific research methodologies. Moreover, PRM researchers are spread among the different topics as usually classified, and it is probable that PRM projects are judged by non-PRM reviewers. There are at least two possible ways in which research can be better placed to meet the emerging needs of Western societies (chronicity, disability and consequently also rehabilitation). One is to create specific keywords on these topics so as to improve the match between researchers and reviewers; the second is to allocate specific funds to research in these areas. In fact, the not coherence between emerging needs and research priorities have already been periodically addressed in the past with specific "political" and/or "social" initiatives, when researchers were forced to respond to new emergencies: some historical examples include cancer or HIV and viral diseases or the recent Ebola outbreak.

Permanent mechanical deformation of an intrathecal baclofen pump secondary to scuba diving: a case report.

STUDY DESIGN: Case report. OBJECTIVES: To describe the case of a spinal cord injury patient that went scuba diving resulting in a mechanical deformation of his intrathecal baclofen pump. SETTING: University Hospitals Leuven, Belgium. METHODS: Case report. RESULTS: Diving below 10 meters of depth can result in irreversible mechanical damage of the drug reservoir of an intrathecal baclofen pump. CONCLUSION: Patients with an intrathecal baclofen pump should be warned for the risks associated with scuba diving and should not dive more than 10 meters below sea level.

Muscle rupture after minimal trauma of the spastic muscle: three case reports of patients with spinal cord injury.

STUDY DESIGN: Retrospective study of three cases. OBJECTIVES: To report three cases of muscle rupture caused by minimal trauma in spinal cord injury (SCI) patients with severe spasticity and a literature review of the underlying mechanisms. SETTING: Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Belgium METHODS: Retrospective study of three cases of muscle ruptures in SCI patients with severe spasticity. All muscle lesions were diagnosed by ultrasound. Literature review (Pubmed) was performed to identify extrinsic and intrinsic risk factors. RESULTS: According to the literature and our clinical findings, several structural and mechanical alterations of the spastic muscle in combination with specific stretching during therapy or a transfer can cause a muscle rupture after minimal trauma. CONCLUSION: To the authors' knowledge, this is the first report of muscle rupture due to spasticity in SCI patients. Altered mechanical properties of the spastic muscle in combination with extreme stretching may cause partial or complete ruptur. Although this is a rare complication of spasticity, medical staff and therapists should be aware of the risk factors in order to prevent and quickly identify muscle lesions.

Etiology of spinal cord injuries in Sub-Saharan Africa.

STUDY DESIGN: Review. OBJECTIVES: The aim is to highlight the epidemiology of spinal cord injuries (SCIs) in Sub-Saharan Africa in order to improve prevention strategies. SETTING: University Hospitals Leuven, Belgium. METHODS: Pubmed was searched over August and September 2010. A combination of the following MeSH-terms was used: 'Africa South of the Sahara', 'Spinal Cord Diseases', 'Paraplegia' and 'Spinal Cord Injuries'. Limits were set on articles published as from 1990. The World Health Organization database was also consulted. RESULTS: We obtained 243 hits of which 13 articles were relevant to the case. These papers covered seven countries: Ethiopia, Ghana, Nigeria, Senegal, Sierra Leone, South Africa and Zimbabwe. In traumatic SCIs, motor vehicle accidents are the most frequent cause of injury followed by falling from a height and thirdly violence, being the most important cause of SCI in South Africa. In the Plateau State of Nigeria, collapsing tunnels in illegal mining are the most prevalent cause. For the non-traumatic SCIs, tuberculosis appeared to be the most important cause, followed by malignant illnesses. Human immunodeficiency virus (HIV) serology tests were only available in the article concerning Ethiopia. Relatively more men were involved in traumatic SCIs and the average age was higher in the non-traumatic than in the traumatic group. CONCLUSION: Although literature on the subject is scarce, prevention should focus on road-safety, tuberculosis and HIV. Standardized registration of SCI is needed for prevention and further research. The use of the current International SCI core data set should be encouraged worldwide as a uniform classification method.

Neuroanatomy and neurophysiology related to sexual dysfunction in male neurogenic patients with lesions to the spinal cord or peripheral nerves.

STUDY DESIGN: Review article. OBJECTIVES: The neuroanatomy and physiology of psychogenic erection, cholinergic versus adrenergic innervation of emission and the predictability of outcome of vibration and electroejaculation require a review and synthesis. SETTING: University Hospital Belgium. METHODS: We reviewed the literature with PubMed 1973-2008. RESULTS: Erection, emission and ejaculation are separate phenomena and have different innervations. It is important to realize, which are the afferents and efferents and where the motor neuron of the end organ is located. When interpreting a specific lesion it is important to understand if postsynaptic fibres are intact or not. Afferents of erection, emission and ejaculation are the pudendal nerve and descending pathways from the brain. Erection is cholinergic and NO-mediated. Emission starts cholinergically (as a secretion) and ends sympathetically (as a contraction). Ejaculation is mainly adrenergic and somatic. For vibratory-evoked ejaculation, the reflex arch must be complete; for electroejaculation, the postsynaptic neurons (paravertebral ganglia) must be intact. CONCLUSION: Afferents of erection, emission and ejaculation are the pudendal nerve and descending pathways from the brain. Erection is cholinergic and NO-mediated. Emission starts cholinergically (as a secretion) and ends sympathetically (as a contraction). Ejaculation is mainly adrenergic and somatic. In neurogenic disease, a good knowledge of neuroanatomy and physiology makes understanding of sexual dysfunction possible and predictable. The minimal requirement for the success of penile vibration is a preserved reflex arch and the minimal requirement for the success of electroejaculation is the existence of intact post-ganglionic fibres.

Prediction of driving after stroke: a prospective study.

BACKGROUND: The process of determining whether patients with stroke should drive again often involves off-road evaluations and road tests that usually take about 2 to 3 h to complete. OBJECTIVES: This prospective study sought to identify the combination of tests that best predicts fitness to drive after stroke. The main aim was to develop a short and predictive predriving assessment battery. METHODS: Sixty-eight consecutive stroke patients were studied who performed a mandatory predriving assessment at the Belgian Road Safety Institute, Brussels, within 18 months. Performance in a predriving assessment included medical examination (when needed), visual and neuropsychological evaluations, and an on-road test. Based on these assessments, a physician, psychologist, and the driving safety expert who administered the tests decided if a subject was either "fit to drive,""temporarily unfit to drive," or "unfit to drive." RESULTS: Logistic regression analysis revealed a combination of visual neglect, figure of Rey, and on-road tests as the model that best predicted (R(2) = 0.73) fitness to drive after stroke. Using a discriminant function that included the 3 tests of the logistic model, the fitness to drive judgments of 59 (86.8%) subjects were correctly predicted. The sensitivity and specificity of the predictions were 79.4% and 94.1%, respectively. CONCLUSION: Fitness to drive after stroke can be predicted from performance on a few road-related tests with a high degree of accuracy. However, some individuals require extended assessments and further tests.

Effect of simulator training on driving after stroke: a randomized controlled trial.

BACKGROUND: Neurologically impaired persons seem to benefit from driving-training programs, but there is no convincing evidence to support this notion. The authors therefore investigated the effect of simulator-based training on driving after stroke. METHODS: Eighty-three first-ever subacute stroke patients entered a 5-week 15-hour training program in which they were randomly allocated to either an experimental (simulator-based training) or control (driving-related cognitive tasks) group. Performance in off-road evaluations and an on-road test were used to assess the driving ability of subjects pre- and post-training. Outcome of an official predriving assessment administered 6 to 9 months poststroke was also considered. RESULTS: Both groups significantly improved in a visual and many neuropsychological evaluations and in the on-road test after training. There were no significant differences between both groups in improvements from pre- to post-training except in the "road sign recognition test" in which the experimental subjects improved more. Significant improvements in the three-class decision ("fit to drive," "temporarily unfit to drive," and "unfit to drive") were found in favor of the experimental group post-training. Academic qualification and overall disability together determined subjects that benefited most from the simulator-based driving training. Significantly more experimental subjects (73%) than control subjects (42%) passed the follow-up official predriving assessment and were legally allowed to resume driving. CONCLUSIONS: Simulator-based driving training improved driving ability, especially for well educated and less disabled stroke patients. However, the findings of the study may have been modified as a result of the large number of dropouts and the possibility of some neurologic recovery unrelated to training.

A special case on the use of ultrasonography for evaluation of the spinal canal and its contents in adults.

In this article we present a 70-year-old man with a history of severe trauma in the upper thoracic spine. This patient presented at our emergency department with a leaking wound in the lower neck after removal of osteosynthetic material. He had undergone a laminectomy of the third thoracic vertebra in the past. As an incidental finding, while examining the region of the lower neck by transcutaneous ultrasonography, we diagnosed a post-traumatic syrinx of the spinal medulla at this level.

The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk after stroke.

OBJECTIVE: To examine the clinimetric characteristics of the Trunk Impairment Scale (TIS). This newly developed scale evaluates motor impairment of the trunk after stroke. The TIS scores, on a range from 0 to 23, static and dynamic sitting balance as well as trunk co-ordination. It also aims to score the quality of trunk movement and to be a guide for treatment. DESIGN: Two physiotherapists observed each patient simultaneously, but scored independently. Each patient was re-examined by one of the therapists. SUBJECTS: Twenty-eight patients in a rehabilitation setting. RESULTS: Kappa and weighted kappa values for item per item reliability ranged for all but two, from 0.62 to 1. All percentages of agreement exceeded 81%. Intraclass correlations (ICC) for the summed scores of the different subscales were between 0.85 and 0.99. Test-retest and interobserver reliability for the TIS total score (ICC) was 0.96 and 0.99, respectively. The 95% limits of agreement for the test-retest and interexaminer measurement error were -2.90, 3.68 and -1.84, 1.84, respectively. Cronbach alpha coefficients for internal consistency ranged from 0.65 to 0.89. Content validity was defined. Spearman rank correlations with the Barthel Index (r = 0.86) and the Trunk Control Test (r = 0.83) was used to examine construct and concurrent validity, respectively. CONCLUSIONS: Analysis of different clinimetric parameters support the use of the TIS in both clinical use and future stroke research. Guidelines for treatment and level of quality of trunk activity can be derived from the assessment.

Coordination deficits on the ipsilesional side after unilateral stroke: the effect of practice on nonisodirectional ipsilateral coordination.

Previous studies have identified motor deficits on the ipsilesional side of patients recovering from a cerebro-vascular accident (CVA), including deficits in interlimb coordination. In the present study, unilateral stroke patients and a control group of healthy age-matched controls performed nonisodirectional coordination of the ipsilateral limbs across two days of practice with feedback. Findings revealed that control subjects were already quite successful at initiation of practice but further improved the coordination pattern across both days. The group of CVA patients also showed some improvement but problems with coordination of the ipsilateral limb segments persisted across practice. Variability in both timing and amplitude of both limb segments did improve with practice in both groups but these measures remained significantly higher in the CVA patients. Even though isodirectional and nonisodirectional coordination of the ipsilateral limb segments are normally considered to be part of the intrinsic motor repertoire, the present study suggests that nonisodirectional ipsilesional limb coordination poses considerable difficulties for CVA patients that are not easily overcome with feedback-assisted practice.

Group physiotherapy improves time use by patients with stroke in rehabilitation.

Does feedback about the time use of patients with stroke influence the organisation of services in rehabilitation? An observation was made of the time use by 22 patients with stroke in a specialised rehabilitation unit, feedback was given to the staff, and another observation on 16 patients was made one year later. As a result of the first observation, the physiotherapy staff were urged to organise group sessions for patients with similar levels of disability, allowing practice with a higher patient to staff ratio. During the second observation, patients spent significantly more time on therapy (8%) and with their peers (25%). These results indicate that feedback about patients' time use can substantially influence management and consequently patients' behaviour in rehabilitation.

Coordination of upper and lower limb segments: deficits on the ipsilesional side after unilateral stroke.

Coordination of the ipsilateral limbs was studied in unilateral stroke patients and a control group of healthy age-matched controls. Cyclical single-limb movements of the forearm and lower leg as well as their coordination, with the segments moving either in the same (isodirectional) or in different directions (nonisodirectional), were investigated under normal vision and blindfolded conditions. Findings revealed that stroke patients experienced difficulties with coordination of the limb segments on the ipsilesional side and this effect was more pronounced during nonisodirectional than during isodirectional coordination. In addition, cycle durations were larger and movement amplitudes shorter in stroke patients as compared to controls. Overall, the present findings clearly demonstrated motor control deficits in stroke patients on the so-called "unaffected side." The availability of normal vision did not alleviate these deficits. Therefore, the more general implication of the present findings appears to be that interlimb coordination is a complex function, requiring the integrity of both hemispheres. Comparison of the left- and right-hemispheric stroke groups revealed that patients with a left-hemisphere lesion tended to be more variable in performing the more difficult nonisodirectional pattern than patients with a right-hemisphere lesion. This possibly hints at a more pronounced involvement of the left hemisphere in the organization of ipsilateral coordination. The spatiotemporal features of movement (cycle duration, amplitude), however, did not differ between both stroke groups.

Predicting motor recovery of the upper limb after stroke rehabilitation: value of a clinical examination.

BACKGROUND AND PURPOSE: Only a few studies have been conducted to predict motor recovery of the arm after stroke. The aims of this study were to identify which clinical variables, assessed at different points in time, were predictive of motor recovery, and to construct useful regression equations. METHOD: One hundred consecutive stroke patients who had an obvious motor deficit of the upper limb were evaluated on entry to the study (two to five weeks post-stroke) and at two, six and 12 months after stroke. The Brunnström-Fugl-Meyer test was used as the outcome measure. Predictors included demographic data, overall disability, clinical neurological features, neuropsychological factors and secondary shoulder complications. RESULTS: In multiple regression analyses, motor performance was invariably retained as the predictive factor with the highest R-square. Other significant predictive variables were overall disability, muscle tone, proprioception and hemi-inattention. Between 53% and 89% of the total amount of variance was accounted for in all selected models. The accuracy of prediction from clinical measurement in the acute phase diminished as the time span of measurement of outcome increased. Similarly, assessment of the variables at two and six months, rather than in the acute stage, resulted in a considerable improvement in the percentage variance explained at 12 months. The highest accuracy was obtained when predictions were made step-by-step in time. CONCLUSIONS: It is possible to predict motor recovery of the upper limb accurately through the use of a few clinical measures. Predictive equations are proposed, the use of which are practicable in both clinical practice and research.

Successful treatment of idiopathic anejaculation with electroejaculation after microsurgical vas aspiration.

This case report describes a couple suffering from infertility secondary to psychogenic anejaculation, which was refractory to all conservative treatment modalities. A first trial of microsurgical vas aspiration in combination with in-vitro fertilization (IVF) resulted in a pregnancy. After 2 years, three more trials of microsurgical vas aspiration in combination with either IVF or subzonal insemination (SUZI) resulted in embryo transfer without pregnancy. Finally, after 3 years, spermatozoa obtained by rectal probe stimulation under general anaesthesia were cryopreserved. A second intracytoplasmic sperm injection (ICSI) procedure using these cryopreserved spermatozoa also resulted in a second pregnancy. Although sperm concentration was in the normal range, in all samples obtained by either rectal probe electrostimulation or microsurgical vas aspiration, motility was <30% in all but two samples.

Pregnancy after electroejaculation in combination with intracytoplasmic sperm injection in a patient with idiopathic anejaculation.

OBJECTIVE: To assess the possibility of achieving a pregnancy in the wife of a patient suffering from idiopathic anejaculation who failed to respond to therapeutical modalities such as psychotherapy, sex therapy, and vibrostimulation. DESIGN: Case report. SETTING: The IVF program at the Leuven University Fertility Centre. PATIENT(S): A patient suffering from idiopathic anejaculation. INTERVENTION(S): Intracytoplasmic sperm injection (ICSI) in combination with electroejaculation. MEAN OUTCOME MEASURE(S): Fertility rate, cleavage rate, clinical pregnancy. RESULT(S): Two IVF procedures were performed of which the second resulted in an ongoing pregnancy and the delivery of a healthy boy. CONCLUSION(S): Electroejaculation may offer fertility chances in a patient suffering from idiopathic anejaculation resistant to conventional treatment modalities. When sperm quality shows very low motility, ICSI should be offered to improve pregnancy chances.