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Study design: Controlled pragmatic intervention with follow-up. Objectives: To describe cardiometabolic risk outcomes after a pragmatic intervention implemented into standard spinal cord injury (SCI) rehabilitation. Setting: Inpatient SCI rehabilitation in East-Denmark. Participants: Inpatients, >18 years, having sustained a SCI within the last 12 months at admission to rehabilitation, regardless of etiology, neurological level or completeness of the lesion or mobility status. Methods: Patient education on health promotion was guided by evidence and included feedback on peak oxygen uptake (VO2peak) (primary outcome measure), body mass index (BMI), Dual energy X-ray absorptiometry and metabolic profile (secondary outcome measures). Paired t-tests, non-parametric tests and Analysis of Variance (ANOVA) were used for analyzes. VO2peak and BMI were compared to historical data. Results: VO2peak increased significantly from admission to discharge but did not exceed historical data despite a minimal clinical important difference. BMI decreased significantly during rehabilitation (p< 0.001) followed by a significant increase after discharge (p= 0.006). There was a trend that people with American Spinal Injury Association Impairment Scale (AIS) D SCI increased lean mass to nearly normal values. Criteria for pre-diabetes or diabetes were present in 28.5% and dyslipidemia in 45% of the participants 44.2 days after time of injury. Conclusions: Despite improvements during rehabilitation, outcome measures were worse than recommended, and most outcome measures worsened at follow up, even in people with an AIS D SCI. Meaningful support regarding exercise and diet when tackling altered life circumstances is needed after discharge.

Study design: Expert opinion, feedback, revisions, and final consensus. Objectives: To update the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS version 2.0) and incorporate suggestions from the SCI pain clinical and research community with respect to overall utility. Setting: International. Methods: The ISCIPBDS working group evaluated these suggestions and made modifications. The revised ISCIPBDS (Version 3.0) was then reviewed by members of the International SCI Data Sets Committee, the American Spinal Injury Association (ASIA) Board, the International Spinal Cord Society (ISCoS) Executive and Scientific Committees, individual reviewers and societies, and posted on the ASIA and ISCoS websites for 1 month to elicit comments before final approval by ASIA and ISCoS. Results: The ISCIPBDS (Version 3.0) was updated to make the dataset more flexible and useful: 1. The assessment can be based on the patient’s perception of several of his/her “worst” pain(s) or based on the International SCI Pain (ISCIP) Classification-defined or other pain types, depending on the specific research questions or clinical needs. 2. Pain interference should usually be rated for overall pain but may also be used for specific pain problems if needed. 3. An optional pain drawing was added to complement the check box documentation of pain location. 4. Data categories consistent with the Extended Pain Dataset list of current treatments were added. 5. Several new training cases were added.

Study design: A register based cohort study. Objectives: To investigate labour market participation following spinal cord injury (SCI) and to describe the impact of personal and SCI characteristics. Setting: Norway. Methods: Persons registered with SCI in the Norwegian SCI registry 2011–2017, and matched reference individuals without SCI from the general population (named controls) were followed for up to six years after injury using national registry data on employment, education, income, and social security benefits. Main measures of labour market participation were: (1) Receiving any amount of pay for work, and (2) Receiving sickness and disability benefits. Results: Among the 451 persons with SCI (aged 16–66 years and working before injury), the estimated percentages receiving pay for work and sickness and disability benefits in the sixth years after injury were 63% (95% CI 57–69) and 67% (95% CI 61–72). Conclusion: SCI substantially decreased labour market participation up to six years after injury compared to matched controls. Even if a relatively large proportion of persons with SCI remained in some degree of work activity, more than half did so in combination with receiving benefits.

Study design: Expert opinion, feedback, revisions and final consensus. Objectives: To update the International Spinal Cord Injury (SCI) Core Data Set while still retaining recommended standardization of data reporting. Setting: International. Methods: Comments on the data elements received from the SCI community were discussed in the International Core Data Set working group. The suggestions from this group were iteratively reviewed. The final version was circulated for final approval. Results: The International SCI Core Data Set (Version 3.0) consists of 21 variables. The variable ‘Gender’ has been changed to ‘Sex assigned at birth’; for the variable ‘Spinal Cord Injury Etiology’, the item, ‘Sports or exercise during leisure time’, has been clarified as ‘including during leisure time’; for the variables ‘Vertebral injury’ and ‘Associated injuries’, the item ‘Unknown’ is reworded into: ‘Not applicable (non-traumatic case)’ and ‘Unknown’; the variable ‘Spinal surgery’ has been expanded to include surgeries for individuals with non-traumatic SCI; for the variables related to the International Standards for Neurological Classification of SCI only the neurological level of injury (NLI) and the American Spinal Injury Association (ASIA) Impairment Scale (AIS) are to be reported, and a separate variable is included indicating if the NLI or the AIS or both are impacted by a non-SCI condition. Conclusion: The International SCI Core Data Set (Version 3.0) should be collected and reported for all studies of SCI to facilitate uniform descriptions of SCI populations and facilitate comparison of results collected worldwide.

Study design: Consensus based on the literature. Objective: Create an International Spinal Cord Injury (SCI) Socio-Demographic Basic Data Set (Version 1.0). Setting: International. Methods: The development included an iterative process where the authors reviewed existing variables containing socio-demographic variables and created a first dataset draft, which was followed by several revisions through email communications. In addition, the work was conducted in parallel with a similar endeavour within the National Institute of Neurological Disorders and Stroke SCI Common Data Elements project in the United States. Subsequently, harmonization between the two projects was sought. Following this, a review process was initiated, including The International SCI Data Sets Committee, the American Spinal Injury Association (ASIA) Board, and the International Spinal Cord Society (ISCoS) Scientific and Executive Committees, and then by publishing on the respective websites for membership feedback. The draft was sent to about 40 national and international organizations and several interested individuals for feedback. All review comments were discussed in the working group and responded to before the final draft was developed, and finally approved by ASIA Board and the ISCoS Scientific and Executive committees. Results: The final International SCI Socio-Demographic Basic Data Set includes the following variables: Date of data collection, Marital status, Household member count, Years of formal education, and Primary occupation. Conclusion: The International SCI Socio-Demographic Basic Data Set will facilitate uniform data collection and reporting of socio-demographic information at the time of injury as well as at post-injury follow-ups to facilitate the evaluation and comparisons across studies.

ObjectiveTo investigate the baseline knowledge of autonomic functions and specifically the International Standards to document remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) among medical students and to present the effective methods in learning of the ISAFSCIDesignInterventional training sessionSettingA tertiary hospital.Participants37 medical studentsInterventionsBefore training, a self-rating questionnaire including 24 concepts extracted from the ISAFSCI was administrated to the students. Then students were divided into two groups. One group (N = 19) had a one-hour ISAFSCI booklet self-study (BSS), while the other group (N = 18) received a one-hour lecture-based learning (LBL) about the ISAFSCI. After BSS/LBL, all students were examined by a 15-question written test on the knowledge of ISAFSCI.Main Outcome MeasuresBaseline knowledge self-rating questionnaire before training and comparison of post-training performance on the written test between the BSS and LBL groupsResultsBefore training, students were familiar with only 8 out of the 24 concepts within the questionnaire (demonstrating baseline knowledge rate beyond 50%). Significant difference in post-training performance (P<0.05) between BBS and LBL groups was noted for 5 of 15 items tested, including hypohydrosis, broncho-pulmonary system, lower urinary tract function, bowel function and female sexual function. All questions except the one regarding hypohydrosis were answered with greater than 80% accuracy by LBL group.ConclusionUse of ISAFSCI booklet alone for self-study by medical students is not sufficient to obtain bassline knowledge of autonomic discussions after SCI. It is recommended that formal lecture or presentation should be used to improve the effectiveness of learning the ISAFSCI for medical students.

ObjectiveTo investigate the incidence of cardiac arrhythmias at six months following traumatic spinal cord injury (SCI) and to compare the prevalence of arrhythmias between participants with cervical and thoracic SCI.DesignA prospective observational study using continuous twenty-four-hour Holter monitoring.SettingInpatient rehabilitation unit of a university research hospital and patient home setting.ParticipantsFifty-five participants with acute traumatic SCI were prospectively included. For each participant, the SCI was characterized according to the International Standards for Neurological Classification of SCI by the neurological level and severity according to the American Spinal Injury Association Impairment Scale.Outcome measuresComparisons between demographic characteristics and arrhythmogenic occurrences as early as possible after SCI (4 ± 2 days) followed by 1, 2, 3, 4 weeks and 6 month time points of Holter monitoring.ResultsBradycardia (heart rate [HR] <50 bpm) was present in 29% and 33% of the participants with cervical (C1–C8) and thoracic (T1–T12) SCI six months after SCI, respectively. The differences in episodes of bradycardia between the two groups were not significant (P < 0.54). The mean maximum HR increased significantly from 4 weeks to 6 months post-SCI (P < 0.001), however mean minimum and maximum HR were not significantly different between the groups at the six-month time point. There were no differences in many arrhythmias between recording periods or between groups at six months.ConclusionsAt the six-month timepoint following traumatic SCI, there were no significant differences in occurrences of arrhythmias between participants with cervical and thoracic SCI compared to the findings observed in the first month following SCI.

Study design: Observational study Objective: To describe body mass index (BMI) during rehabilitation in people with a newly sustained spinal cord injury (SCI). Setting: Inpatient SCI rehabilitation in Denmark. Participants: Inpatients, >18 years, having sustained a SCI within the last 12 months at admission to primary rehabilitation, inclusive of various SCI etiology, neurological level, completeness of the lesion or mobility status. Methods: Measures of BMI were obtained at admission and discharge as part of standard care. At one SCI center measures of BMI were sampled at follow up 9.5 months after discharge as well. BMI was described by mean and standard deviation (SD). Paired t-test was used to test difference in BMI between admission and discharge. Repeated measures Analysis of Variance (ANOVA) was used for analyzing BMI deriving from three time points. Results: Overall BMI was stable with no change (25.4 kg/m2at admission and 25.6 kg/m2at discharge) during rehabilitation at the two national centers. In participants with an American Spinal Injury Association (ASIA) Impairment Scale (AIS) D classification, BMI was higher during rehabilitation compared to the other groups and increased significantly (p= 0.008) from discharge to follow up. Conclusions: Overall BMI was stable but higher than recommended in people with SCI undergoing rehabilitation at the two national centers in Denmark. Participants with an AIS D SCI were obese according to SCI adjusted BMI and the World Health Organization (WHO) recommendations during rehabilitation and at follow up.

Study design: Committee consensus process including additional structured feedback from spinal cord injury (SCI) experts attending a focus group workshop. Objectives: To define a taxonomy for standardized documentation of non-SCI-related conditions in the International Standards for Neurological Classification of SCI (ISNCSCI). Setting: Americal Spinal Injury Association (ASIA) International Standards Committee with 16 international ISNCSCI experts. Methods: With the new taxonomy, not-normal sensory or motor scores should be tagged with an asterisk (“*”), if they are impacted by a non-SCI condition such as burns, casts, joint contractures, peripheral nerve injuries, amputations, pain, or generalized weakness. The non-SCI condition and instructions on how to handle the “*”-tagged scores during classification should be detailed in the comments box. While sum scores are always calculated based on examined scores, classification variables such as the neurological level of injury (NLI) or the ASIA Impairment Scale (AIS) grades are tagged with an “*”, when they have been determined on the basis of clinical assumptions. Results: With the extended “*”-tag concept, sensory and motor examination results impacted by non-SCI conditions above, at, or below the NLI can be consistently documented, scored, and classified. Feedback from workshop participants confirms agreement on its clinical relevance, logic and soundness, easiness of understanding, communicability, and applicability in daily work. Conclusions: After multiple internal revisions, a taxonomy for structured documentation of conditions superimposed on the impairments caused by the SCI together with guidelines for consistent scoring and classification was released with the 2019 ISNCSCI revision. This taxonomy is intended to increase the accuracy of ISNCSCI classifications.

Study design: A nationwide population-based register study. Objectives: To investigate the socioeconomic consequences of traumatic (tSCI) and non-traumatic (ntSCI) spinal cord injuries (SCI) in relation to health care costs, risk of job loss, and divorce. Setting: Denmark. Methods: All survivors admitted for specialized SCI rehabilitation from 2008 to 2018 were included (n= 1751), together with their relatives (n= 3084). Control groups for the SCI group (n= 8139) and their relatives (n= 15,921) were identified. Data on socioeconomics up to 2 years before and up to 4 years after the injury year were included. Results: Survivors of tSCI and ntSCI had significantly increased health care costs 2 years before injury compared to their controls, and increased health care cost was maintained 4 years after the injury (all pvalues &lt; 0.0001). The SCI group had significantly increased risk of job loss (OR = 9.26; 95% CI: 7.70–11.15) and higher risk of divorce (OR = 1.44; 95% CI: 1.08–1.87) the 3 following years after injury compared to controls, but risk of divorce was only significant for the ntSCI group (OR = 1.58; 95% CI: 1.09–2.29). No significant differences on health care cost and job loss between the group of relatives of SCI survivors and their controls were found, except for the relatives (n= 1604) of SCI survivors &lt;18 years old, where a higher risk of job loss was found (OR = 1.43, 95% CI 0.97–2.1). Conclusion: These results emphasize that socioeconomic consequences for survivors of both tSCI and ntSCI are pervasive and long-lasting.

Study design: Cross-sectional study. Objectives: To describe the socio-demographics, injury characteristics, prevalence of shoulder and neck symptoms, weekly participation in leisure time physical activity (LTPA) and quality of life (QoL) of individuals with spinal cord injury in Denmark (SCI). Setting: Nation-wide community survey, Denmark. Methods: Individuals with SCI for >2 years were included from three SCI rehabilitation departments. Questionnaire data regarding socio-demographic details, SCI injury characteristics, medical history, shoulder and neck symptoms, LTPA and QoL were collected. Results: Of 2454 potential participants, 1517 (62%) responded to the survey (mean age = 56.2, SD 16.1, 37% female, 42% tetraplegia, 23% complete SCI, mean time since injury = 16.9, SD 13.5). 75% used some form of assistive mobility device. Responders and non-responders showed no sex or injury type/severity differences. Shoulder and neck symptoms within the past 3 months were reported by 63 and 67% respectively, with 51% reporting shoulder symptoms within the past week. Among those with symptoms, 61% had experienced shoulder symptoms and 56% neck symptoms, for more than 30 days during the previous 3 months. Symptoms often prevented participants from performing their usual activities (due to shoulder symptoms 46%, neck symptoms 41%). Conclusions: A high prevalence of self-reported shoulder and neck symptoms was found, which may limit physical function and social activities. We succeeded in generating the Danish Spinal Cord Injury Shoulder (DanSCIS) dataset, which comprised a substantial proportion of Danish adults with SCI. Future studies using data from this cohort will investigate patterns and associations between shoulder/neck symptoms, use of assistive mobility devices, LTPA and QoL.

Study design: Explorative qualitative study based on an interpretative phenomenological approach. Objectives: This study explored the possibility of transferring knowledge and skills from a spinal cord injury (SCI) unit to the home environment; the individual and structural factors that potentially influenced this transfer; and its compatibility with a meaningful everyday life. Setting: Hospital-based rehabilitation unit and community in Denmark. Methods: Fourteen individuals with SCI were selected with maximum variation according to age, sex, marital status, and level of injury. In-depth, semi-structured interviews were conducted in the participants’ homes, 2–10 months after discharge from an SCI unit. Data analysis involved taking an interpretative phenomenological approach combined with a template analysis and applying the transfer of training theory to the discussion. Results: Transitioning from the SCI unit to the home environment involved a multidimensional change of context in which most of the participants’ previous life roles had changed. This overarching theme had a decisive influence on: balancing loss and acceptance, facing external structural barriers, and the strength of social relationships when the knowledge and skills acquired at the unit were applied in a meaningful everyday life. Conclusions: Transition from the SCI unit to the home environment is influenced by a multidimensional change of context that may restrict the use of acquired skills post-discharge, provide distant prospects for tertiary health promotion, and aggravate the experience of loss in people with SCI. Maintaining relationships is a strong mediator for transferring skills and re-establishing a meaningful everyday life.

Study design: Test-retest study. Objective: To describe the test-retest reliability of an individualized approach for peak oxygen uptake (VO2peak) testing in a clinical context, accommodating inpatients with heterogeneous levels of physical functioning. Setting: Inpatient rehabilitation. Method: Test-retest on two types of devices (recumbent stepper and arm-crank ergometer) with two predefined protocols of varying load increments on each device. No participants performed all four test modalities. VO2peak, respiratory exchange ratio (RER), peak workload, and the reason for termination were reported. Of 23 participants included, 21 completed the test-retest procedure. Participants were inpatients, =18 years, who sustained a spinal cord injury (SCI) within the last 12 months at the time of admission. The median age was 52 years and 74% were male. Median time since injury at the time of the first test (T1) was 5.5 months. Seventeen were classified as American Spinal Injury Association Impairment Scale D. Intraclass correlation coefficients (ICC) and Bland–Altman plots for VO2peak was calculated to determine intra- and intertester reliability of VO2peak. Results: Mean VO2peak obtained at T1 was 1.91?L/min (95%CI: 1.31–2.51); 1.26?L/min and 2.69?L/min for the recumbent stepper protocols; 0.61?L/min and 1.39?L/min for the arm-crank ergometer protocols. ICC for intra- and intertester reliability was 0.997 (95%CI: 0.986–0.999) and 0.994 (95%CI: 0.978–0.998) respectively. Bland–Altman plots showed a mean difference of -0.005 (SD 0,12) for overall test-retest. Conclusion: Test-retest reliability was high. Mean VO2peak at discharge from rehabilitation was higher than previously reported and individualized test modalities seemed to yield more optimal results in a heterogenous and representative sample during rehabilitation.

Study design: Cross-sectional study. Objectives: The purpose was to reveal late health consequences and life issues after a traumatic spinal cord injury (tSCI) in North Macedonia (NM). Setting: Community dwelling adults with tSCI in NM. Methods: Persons that sustained tSCI in 1999–2005 were selected, physical examined and a questionnaire was administered. Descriptive statistics were conducted. Results: From 203 eligible persons, 40 agreed to participate. Mean (range) age at time of injury was 36 (27–75) years and time since injury ranged 9–20 years. Around seventy percent reported current health problems, of which pain and spasm (>60%) were most prevalent, followed by urinary tract infections and pressure injuries. About 30% had never been to a medical specialist and ≈70% had only once been to physiotherapy after discharge from the primary inpatient period. Only one participant had a fully adjusted home for a person with a disability. Those with most severe tSCI (American Spinal Injury Association Impairment Scale (AIS) A, B, and C) seldom left their homes. About 50% were retired and/or unemployed, 50% were working. Conclusion: This is the first study describing community-dwelling persons with a tSCI in NM. Our study revealed that persons with tSCI reported health issues mostly related to pain, spasms, urinary tract infections and pressure injuries. They lacked follow-ups, experienced physical barriers and poor inclusion in the society, and lacked financial support. Therefore, they were often socially isolated and fully dependent on their families. NM is in need of structured rehabilitation programs and better adaption for persons with reduced mobility.

Study design: Systematic review.Objectives:Sleep disturbances are a common complaint among individuals with spinal cord injury (SCI) and were not usually present before the SCI. Their sleep disturbances, including disrupted sleep, spasms, and problems with initiating and sustaining sleep through the night, affect SCI individuals’ overall quality of life due to excessive tiredness and low energy levels during the day. Despite the high prevalence of sleep complaints in this population, current knowledge about sleep in the SCI population has not been systematically assessed.Setting: Capital Region of Denmark.Methods:We systematically reviewed literature identified from the PubMed and EMBASE databases following PRISMA guidelines.Thirty-seven articles met our inclusion criteria, as only controlled studies were included. This could be a comparison of (1) SCI individuals and able-bodied controls, (2) cervical with thoracolumbar SCI individuals, or (3) cervical, thoracolumbar SCI individuals and able-bodied controls.Results:Individuals with SCI have a higher prevalence of sleep-disordered breathing and periodic leg movements during sleep (PLMS), lower heart rate, but no nocturnal lowering of blood pressure. 24-hour energy expenditure and sleeping metabolic rate were significantly lower, and bowel movements were altered. Endocrine alterations were found in investigations of melatonin, cortisol and antidiuretic hormone. Questionnaires revealed a high prevalence of subjectively poorer sleep quality in individuals with SCI compared with able-bodied controls.Conclusions:There are significant differences between groups with SCI and able-bodied controls. SCI objectively and subjectively markedly affects an individual’s sleep.

Study design: Retrospective chart study. Objectives: The aim was to examine continuation of treatment of individuals with spinal cord injury including myelomeningocele and neurogenic detrusor overactivity, treated with repeated intra-detrusor Botulinum toxin A injections, and to investigate factors associated with discontinuation of treatment. Setting: Rigshospitalet, Denmark Methods: This study included 128 individuals with spinal cord injury and neurogenic detrusor overactivity, who were offered repeated Botulinum toxin A injections between 2001 and 2018. Continuation rates of the treatment were estimated using Kaplan Meier analysis. A Cox proportional hazard analysis was used to investigate factors predictive of discontinuation. Results: A total of 1156 treatments were performed. The median number of treatments was six (IQR 9, range 1−51), and median follow-up was 10.6 years (IQR 8.5, range 0−16.9). All urodynamic parameters changed significantly after the first treatment (p&lt; 0.001). The continuation group had significantly higher mean maximum bladder capacity after the first injections compared with the discontinuation group, with a mean difference between the groups of 84.5 mL (95% CI 4.7–164.2) (p= 0.038). The probability of continuing treatments after 5 years was 59% (95% CI 50.0–67.8) and 50% (95% CI 40.1–59.3) after 10 years. Individuals aged 31–50 years were more likely to continue treatment compared with those aged >50 years (95% CI 0.21‒0.79) (p= 0.008). No other factors predicted discontinuation. Conclusions: This long-term follow-up study showed that 50% of people with spinal cord injury starting intra-detrusor Botulinum toxin A for neurogenic detrusor overactivity are still receiving injections after 10 years.

Study design: Cross sectional survey of 1055 persons with spinal cord injury (SCI) in Denmark, the Netherlands, Norway and Switzerland. Objectives: (1) To analyse the employment levels of people of working age with SCI, including possible gender differences. (2) To study the relevance of occupational class before SCI and its impact on employment and occupational class after SCI. Setting: Members of national SCI consumer associations. Methods: Employment status and social mobility after SCI was regressed on occupational class before SCI, using multinomial and binary logistic regression analysis of employment, while controlling for other explanatory variables to employment after SCI and demographic characteristics. Results: Employment levels after injury were similar for men and women in each of the four nations, but Dutch women had significantly lower scores on predicted employment than Dutch men. Employment and social mobility trajectories were heavily in favour of middle-class occupations. Gender differences in employment status at the time of study primarily occurred among those in working-class occupations before SCI, with men less likely than women of being non-employed. Working-class men were significantly more likely than working-class women to retain a working-class occupation at the time of study, and although non-significant, to attain a middle-class occupation after SCI. Conclusion: There was little variation in employment by gender within and across countries but significant differences between working-class and middle-class occupations before and after injury. The results suggest that targeted employment measures should be particularly invested in the rehabilitation of women in working-class occupations.

Study design: Prospective cohort study Objectives: To describe epidemiological data and complications after acute traumatic spinal cord injury (tSCI) in Former Yugoslav Republic of Macedonia (FYROM). Setting: University Clinic for Traumatology, Orthopedics, Anesthesia and Intensive Care Unit and Emergency Center (TOARILUC), Mother Teresa, Skopje, FYROM. Method: During the inclusion period March 2015 to September 2016, 38 tSCI patients were included. MRI, CT scan, and clinical examinations including International Standards for Neurological Classification of SCIwere performed at admission. The information included: demographic data, transport type, date of admission and discharge, past illnesses, addiction habits, cause and type of injury, injury level, associated injuries, injury-related complications, and mortality. Results: Mean age was 43 years (median 41, range 17–83). Seventeen patients had a complete and 15 an incomplete SCI, six were unknown. Most frequent causes for tSCI were traffic accidents (42%) and falls (40%), 24% of the accidents were contracted at work. Sixteen patients were ventilator dependent at some point during the acute period. Common complications were pressure ulcers, gastrointestinal-related, and infections. Hospital length of stay (LOS) ranged from 1 to 73 days. The in-hospital mortality rate was 32%. Conclusion: The annual incidence of tSCI in FYROM was in 2015–16 13 persons/million inhabitants per year. The epidemiological profile of tSCI in FYROM implies that preventive measures should be taken to reduce incidence of accidents in traffic and at work places. The high mortality rate and complications underline further actions to improve the acute care of tSCI in FYROM.

Study design: A feasibility study, supplemented by a noncontrolled pretest/posttest. Objectives: To examine if a nationwide volunteer peer-mentoring program for in-patients with acute/subacute spinal cord injury is feasible and achievable. Setting: The Spinal Cord Injury Center of Western Denmark and Clinic for Spinal Cord Injuries, Rigshospitalet, Denmark. Methods: Volunteer mentor groups were formed similarly in two highly specialized SCI centers covering Denmark. Hospital staff was responsible for referral to the mentoring project and for the interdisciplinary evaluation of patient eligibility. At each of the two centers, a person living with the consequences of SCI coordinated the intervention in collaboration with healthcare personnel. Designated project personnel introduced eligible participants to the project. Staff at the SCI centers arranged to fit in the supplementary mentoring with ongoing treatment. A self-report questionnaire was completed prior to and after peer intervention. Outcome: patient reports regarding mentoring sessions, change in quality of life (QoL), depression items from the Short Form Health Survey (SF-36), pain frequency and intensity (11-point Numerical Rating Scale). Results: A nationwide mentor corps was established. Fifty-two eligible in-patients completed the study. Significant improvement in QoL was found after mentoring. Frequency and intensity of pain did not change, although five out of nine depression items improved significantly. A majority (94%) of the participants recommended others to meet with a peer mentor. Conclusions: Establishing a nationwide volunteer mentor system at a highly specialized neuro-rehabilitation units for SCI in-patients is both feasible and acceptable.

ObjectiveTo investigate the use of functional outcome measurements after spinal cord injury (SCI) in current clinical practice and to explore the knowledge about the Spinal Cord Independence Measure (SCIM) among SCI physicians in China, and to find facilitators for a broader utilization of SCIM.DesignA survey-based study.SettingSCI workshops at Peking University.Participants125 Chinese SCI physicians attending annual workshops in two consecutive years.InterventionsNot applicable.Outcome measuresA questionnaire was administered. The following items were included: whether functional outcome measurement for SCI individuals was performed and with which assessment tool(s); what items should be included in the assessment; whether they knew about the SCIM, its latest version, the Chinese translation, and if so from what source; the possible reasons why SCIM was not implemented in clinical practice; and whether training before using the SCIM was needed, and the training method preferred.ResultsAmong these physicians, 84.8% performed functional outcome measurement for individuals with SCI, but only 29.6% of attendees were aware of the SCIM and 20.8% had used it. Lack of training was the major reason why SCIM was not used in clinical practice. Furthermore, 74.4% of the physicians felt they needed formal training before using the SCIM.ConclusionThe use of SCIM is limited in clinical practice in China, which is mainly attributed to lack of knowledge and training. Formal training on the use of the SCIM is essential for its dissemination and will improve functional SCI outcome measurement in China.

Observational cross-sectional study. Due to weakened pelvic floor muscles, the risk of pelvic organ prolapse (POP) may increase after a spinal cord injury (SCI); hence, the aim of this study was to investigate the occurrence of POP after SCI and to evaluate the need for urogynecological consultations offered to women with SCI. Clinic for Spinal Cord Injuries, Rigshospitalet, Denmark. Women with SCI who visited our SCI-clinic during January 2013−January 2018 were offered a specialized urogynecological consultation. Any symptoms of POP, urinary/fecal incontinence, or bladder/bowel emptying problems were registered, and POP was classified according to the POP quantification system during a pelvic examination. Differences in baseline characteristics between women with POP stage 0−1 and POP stage ≥2 were investigated. A total of 98 women were included in the study. Fourteen women (14%) reported POP symptoms and 21 women (21%) had anatomical POP stage ≥2. The group with POP stage ≥2 had a significantly higher age, higher parity, more with vaginal delivery, and more postmenopausal women, but the groups did not differ on median time after injury, neurological level, and completeness of injury. A total of 71% experienced urinary incontinence, 27% experienced fecal incontinence, 63% experienced bladder emptying problems, and 70% experienced bowel emptying problems. Consequently, 65% received treatment. Women with SCI are not in increased risk of developing anatomical POP. Nonetheless, the high occurrence of other urogynecological issues and the high treatment-rate supports the need for specialized urogynecological consultations offered to women with SCI.

Cross-sectional study. There is a knowledge gap on urinary incontinence in women with spinal cord injury. Hence, the aim of this study was to determine the prevalence and conditions associated with urinary incontinence in this population. Clinic for Spinal Cord Injuries, Rigshospitalet, Denmark. Women with a spinal cord injury between September 1999 and August 2016, who attended a consultation in our clinic during August 2010–August 2016, were included. Data were obtained from an electronic medical record database, in which standardized questionnaires were filled out by the treating physician during the consultation. Data regarding the injury, bladder function, mobility, spousal/cohabitation status, and quality of life were obtained from the most recently filled-out questionnaires. Of the 609 included women, 299 (49%) experienced urinary incontinence: 27% daily, 13% weekly, and 9% monthly. The odds of urinary incontinence increased if the woman used a wheelchair permanently (odds ratio (OR) 2.16, 95% confidence interval (CI) 1.24–3.77), needed aids to walk (OR 1.73, 95% CI 1.08–2.76), and if the woman’s spousal/cohabitation status was unmarried/not living with a partner (OR 1.60, 95% CI 1.11–2.32). Conversely, the odds of urinary incontinence decreased if the woman used an indwelling catheter (OR 0.35, 95% CI 0.18–0.67) compared with normal bladder-emptying method. Finally, incontinence was associated with decreased quality of life on the general, physical, and emotional domain. Urinary incontinence is a prevalent problem in women with spinal cord injury, affecting half of the population, and it is associated with impaired mobility, unmarried/non-cohabiting status, and reduced quality of life.

Prospective quasi-experimental study, pre- and post-design. Assess safety, feasibility, training characteristics and changes in gait function for persons with spinal cord injury (SCI) using the robotic exoskeletons from Ekso Bionics. Nine European rehabilitation centres. 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). 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). Exoskeleton training was generally safe and feasible in a heterogeneous sample of persons with SCI. Results indicate potential benefits on gait function and balance.

The aim of this study is to develop a treatment diary for patients receiving spasticity treatment including botulinum toxin injection and physiotherapy and/or occupational therapy. The diary focuses on problems triggered by skeletal muscle overactivity; agreed goals for treatment and the patient’s self-evaluation of achievement on the Goal Attainment Scale; which skeletal muscles were injected; physiotherapists’ and occupational therapists’ evaluation of the patients’ achievement of objectives on the Goal Attainment Scale; and proposals for optimization of treatment and changing goals. The evaluation included a satisfaction questionnaire and the WHO-QoL BREF and WHO-5 well-being score. Overall, 10 patients were enrolled in the pilot study. The patients were generally satisfied with the diary, found that it involved them more in their treatment and made it easier to set personal goals, and found it worth the time spent using it. However, no clear advantage in relation to their quality of life (WHO-QoL BREF and WHO-5 well-being score) was reported.

Objective: To evaluate the effect of colostomy on bowel function and quality of life (QoL) in individuals with spinal cord injury (SCI).Design: Cross-sectional descriptive study.Setting: Department for Spinal Cord Injuries and Departments of Gastroenterology and Radiology, Rigshospitalet.Participants: Eighteen individuals with SCI and a colostomy performed post injury, 12 males, 6 females, 8 with tetraplegia and 10 with paraplegia. Median age at time of study was 49.9 years, years since lesion was 3–56 years, and time since colostomy was performed 0.5 to 20 years.Interventions: Questionnaires and measurement of gastrointestinal transit time (GITT).Outcome measures: Retrospective data collection from patient records, a questionnaire on bowel management pre and post colostomy, quality of life (QoL) by SF-36, and GITT.Results: Seventy-two percent significantly reduced their use of time on bowel emptying after the colostomy. All but one reported being content with the colostomy. Thirty-nine percent reported one or more problems related to the colostomy. Seventy-five percent had a GITT within normal range for able-bodied populations. When disregarding the physical component, QoL was not significantly lower in the total study group compared to a Danish norm group, but significantly lower when compared the subgroup of persons with tetraplegia.Conclusion: A colostomy reduces the time necessary for bowel management. The majority of individuals with SCI and a colostomy did not perceive bowel management as being a problem. The results indicate that colostomy is a favourable option for individuals with SCI, who spend long hours on bowel management and for whom non-invasive procedures did not improve the situation enough.

AbstractBackground/Objective:The end goal of clinical care and clinical research involving spinal cord injury (SCI) is to improve the overall ability of persons living with SCI to function on a daily basis. Neurologic recovery does not always translate into functional recovery. Thus, sensitive outcome measures designed to assess functional status relevant to SCI are important to develop.Method:Evaluation of currently available SCI functional outcome measures by a multinational work group.Results:The 4 measures that fit the prespecified inclusion criteria were the Modified Barthel Index (MBI), the Functional Independence Measure (FIM), the Quadriplegia Index of Function (QIF), and the Spinal Cord Independence Measure (SCIM). The MBI and the QIF were found to have minimal evidence for validity, whereas the FIM and the SCIM were found to be reliable and valid. The MBI has little clinical utility for use in the SCI population. Likewise, the FIM applies mainly when measuring burden of care, which is not necessarily a reflection of functional recovery. The QIF is useful for measuring functional recovery but only in a subpopulation of people with SCI, and substantial validity data are still required. The SCIM is the only functional recovery outcome measure designed specifically for SCI.Conclusions:The multinational work group recommends that the latest version of the SCIM (SCIM III) continue to be refined and validated and subsequently implemented worldwide as the primary functional recovery outcome measure for SCI. The QIF may continue to be developed and validated for use as a supplemental tool for the nonambulatory tetraplegic population.

We examined the effects of ejaculation by penile vibratory stimulation on bladder capacity in men with spinal cord lesions.

The tibialis anterior muscle of nine paraplegic men was chronically stimulated (2–6 h per day; at 10 Hz, 5 s on, 5 s off) under isometric loading conditions for 5 days per week for 4 weeks. After 4 weeks of training, muscle fatigue resistance in an electrically evoked test had increased by an average of 75% (P< .01, n= 9), but there were no changes in the relative composition of the three myosin heavy chain (MHC) isoforms. Five of the subjects continued training for an additional 5 weeks (2 h per day, 3 days per week). Although there was a tendency for twitch time to peak torque to increase after this additional period, no change occurred in relative MHC isoform content. However, in situ hybridization analysis revealed that even after 2 weeks of stimulation, there was evidence of upregulation of the mRNA for the MHC‐I isoform and downregulation of the MHC‐IIX isoform, a development that continued in weeks 4 and 9. This study provides evidence, at the level of gene transcription, that a fast‐to‐slow change in MHC isoform composition may be possible in human muscle when its usage is significantly increased. © 2002 Wiley Periodicals, Inc. Muscle Nerve 25: 000–000, 2002

Urinary tract infection is the most frequently reported secondary impairment in individuals with spinal cord lesion. The most prevalent risk indicator is an indwelling catheter. Hydrophilic catheters for clean intermittent catheterization may induce lower rates of bacteriuria and long-term urethral complications. Due to chronic bacterial infection within biofilms, an antibacterial treatment based on a urinary culture of bacteria in the urine and its antimicrobial susceptibility may fail to eradicate catheter-associated urinary tract infection. No commercially available drugs are sufficiently active against the bacteria in a mature biofilm. Biomaterials may be modified to decrease the formation of a biofilm. Silver alloy catheters are effective in preventing urinary tract infection when indwelling urinary catheterization is necessary. The risk of systemic argyria in long-term use needs to be evaluated. Suprapubic cystostomy drainage in patients with neurogenic bladder is preferred to an indwelling urethral catheter. In cases of recurring urinary tract infection in patients with a permanent urinary catheter, it may be beneficial to change the catheter every 1 or 2 weeks. There is some evidence that cranberry products may prevent urinary tract infection. In the future, bacterial interference and vaccination may be a possibility for prevention of urinary tract infection.