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BackgroundLung cancer surgery is associated with a high incidence of postoperative pulmonary complications (PPCs). We evaluated whether enhanced recovery after surgery plus pulmonary rehabilitation was superior over enhanced recovery after surgery alone in reducing the incidence of postoperative PPCs and length of hospital stay.MethodsIn this pragmatic multicentre, randomised controlled, parallel-group clinical trial, eligible patients scheduled for video-assisted lung cancer surgery were randomly assigned (1:1) to either a newly developed programme that integrated preoperative and postoperative pulmonary rehabilitation components into a generic thoracic enhanced recovery after surgery pathway, or routine thoracic enhanced recovery after surgery. Primary outcome was the overall occurrence of PPCs within 2 weeks after surgery. Secondary outcomes were the occurrence of specific complications, time to removal of chest drain, and length of hospital stay (LOS).ResultsOf 428 patients scheduled for lung cancer surgery, 374 were randomised with 187 allocated to the experimental programme and 187 to control. Incidence of PPCs at 14 Days was 18.7% (35/187) in the experimental group and 33.2% (62/187) in the control group (intention-to-treat, unadjusted HR 0.524, 95% CI 0.347 to 0.792, p=0.002). Particularly, significant risk reduction was observed regarding pleural effusion, pneumonia and atelectasis. Time to removal of chest drain and LOS were not significantly reduced in the experimental group.ConclusionsAdding pulmonary rehabilitation to enhanced recovery after surgery appears to be effective in reducing the incidence of PPCs, but not LOS. Standard integration of pulmonary rehabilitation into thoracic enhanced recovery after surgery is a promising approach to PPC prophylaxis.Trial registration numberChiCTR1900024646.

Systematic review.We aimed to provide a comprehensive overview of the English and Chinese literature reporting epidemiological data on spinal cord injury (SCI) in China.3 English and 3 Chinese language electronic databases were searched from the earliest record to 15 March 2020. Sociodemographic characteristics, incidence rates, etiology and lesion characteristics, in-hospital mortality, and secondary health conditions and complications were extracted from included reports.A total of 51 studies were included, 32 in the Chinese language. Forty-seven studies were based on hospital records. Mean age of incident cases ranged from 34 to 55 years and male-to-female ratios ranged from 0.35:1 to 15.3:1. SCI incidence varied from 14.6 to 60.6 per million. Thirty-five studies reported only on traumatic SCI with traffic accidents, high falls, low falls and being hit by objects being the most common causes. Specific causes for non-traumatic SCI were poorly reported. Proportions with tetraplegia and complete injury ranged from 37.4% to 82.0% and 14.1% to 73.9%, respectively. Reported in-hospital mortality attributed to SCI varied from 1.1% to 18.4%. Leading cause of in-hospital mortality for acute SCI was respiratory problems; respiratory problems, urinary tract infections and pressure sores were the most common complications.Epidemiological data on SCI in China are only available for a limited number of provinces and mostly outdated. Updated data on incidence with accurate geographical information and etiology across all Chinese provinces are needed for targeted implementation of preventive strategies. Research on community outcomes needs to be developed in China.

Poor mental health challenges outcomes and treatment of people living with HIV/AIDS (PLWHA) and may be related to illness perceptions. To investigate if depression and anxiety were associated with illness perceptions, we drew a random sample of 729 PLWHA from 13 administrative units in Liangshan Prefecture, Sichuan, China. Among the PLWHA surveyed, 222 and 175 had probable anxiety or depression. In mixed-effects logistic regression, negative illness perceptions were associated with increased odds of anxiety/depression. In linear mixed-effects quantile regression, the relationship of more negative illness perceptions with more severe and frequent symptoms of anxiety/depression grew stronger in the upper quantiles of the GAD-7 and PHQ-9 distributions, well beyond scale cut-offs for probable clinical relevance. We hypothesize that negative illness perceptions of HIV/AIDS and severity of depression and anxiety symptoms may mutually reinforce each other. Illness perceptions are a promising intervention target for improving the mental health of PLWHA.

Objective: To evaluate if bilateral or unilateral upper limb robot-assisted rehabilitation training using a new three-dimensional end-effector robot that targets shoulder and elbow flexion and abduction is superior to conventional therapy with regard to upper extremity motor function recovery and neuromuscular improvement in stroke patients. Design: Randomized, controlled, parallel, assessor-blinded, three-arm clinical trial. Setting: Southeast University Zhongda Hospital Nanjing, Jiangsu, China. Methods: Seventy patients with hemiplegic stroke were randomly assigned to conventional training (Control, n = 23) or unilateral (URT, n = 23), or bilateral robotic training (BRT, n = 24). The conventional group received routine rehabilitation, 60 min/day, 6 days/week, for 3 weeks. For URT and BRT upper limb robot-assisted rehabilitation training was added. This was 60 min/day, 6 days/week, for 3 weeks. The primary outcome was upper limb motor function assessed with Fugl-Meyer–Upper Extremity Scale (FMA–UE). Secondary outcomes were activities of daily living (ADL) assessed with the Modified Barthel Index (MBI), Motor Evoked Potential (MEP) to assess corticospinal tract connectivity, Root Mean Square (RMS) value, and integrate Electromyography (iEMG) value recorded by surface electromyography to evaluate muscle contraction function. Results: The primary outcome indicator FMA–UE (least square mean (LSMEAN): 31.40, 95% confidence interval (95% CI): 27.74–35.07) and the secondary outcome indicator MBI (LSMEAN: 69.95, 95% CI: 66.69–73.21) were significantly improved in BRT as opposed to control (FMA–UE, LSMEAN: 24.79, 95% CI: 22.23–27.35; MBI, LSMEAN: 62.75, 95% CI: 59.42–66.09); and unilateral (FMA–UE, LSMEAN: 25.97, 95% CI: 23.57–28.36; MBI, LSMEAN: 64.34, 95% CI: 61.01–67.68). BRT also showed greater improvement in the anterior deltoid bundle with regard to muscle contraction function indicated by RMS (LSMEAN: 257.79, 95% CI: 211.45–304.12) and iEMG (LSMEAN: 202.01, 95% CI: 167.09–236.94), as compared to the controls (RMS, LSMEAN: 170.77, 95% CI: 148.97–192.58; iEMG, LSMEAN: 132.09, 95% CI: 114.51–149.68), and URT (RMS, LSMEAN: 179.05, 95% CI: 156.03–202.07; iEMG, LSMEAN: 130.38, 95% CI: 107.50–153.26). There was no statistically significant difference between URT and conventional training for any outcome. There was no significant difference in MEP extraction rate after treatment between groups (p = 0.54 for URT, p = 0.08 for BRT). Conclusions: A 60 min daily training for upper extremities using a three-dimensional end-effector targeting elbow and shoulder adding conventional rehabilitation appears to promote upper limb function and ADL in stroke patients only if delivered bilaterally. URT does not seem to result in better outcomes than conventional rehabilitation. Electrophysiological results suggest that training using a bilateral upper limb robot increases the recruitment of motor neurons rather than improving the conduction function of the corticospinal tract.

Evidence on associations of residential greenness with dyslipidemia is limited, particularly regarding dose-response relations and mediation.To investigate associations between greenness and dyslipidemia, non-linear dose-response relationships and mediators.This cross-sectional study draws on the 2018 Fujian Behavior and Disease Surveillance (FBDS) cohort that used multi-stage stratified random sampling from the general population of Fujian Province, China. Participants with one or more abnormities in total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), or low-density lipoprotein cholesterol (LDL-C) were classified as having dyslipidemia. Residential greenness was operationalized as 3-year average of the normalized difference vegetation index (NDVIData from 43,183 participants were analyzed. Increases in NDVIIncreased residential exposure to greenness was associated with decreased risk of dyslipidemia. A non-linear dose-response relationship between greenness and dyslipidemia suggests that specific thresholds of greenness need to be reached in order to achieve effects. BMI, PM

To investigate the experience of environmental barriers by people with spinal cord injury (SCI) across 22 countries. Specific aims were to describe and compare the prevalence of environmental barriers experienced across countries, and to analyze determinants of environmental barriers at individual and country level.Cross-sectional community survey.Individuals (N=12,591) living with SCI in the community.Not applicable.Nottwil Environmental Factors Inventory-Short Form.Most barriers were experienced in relation to accessibility, climate, transportation, finances, and state services. More severe barriers were experienced in settings with lower gross domestic product (GDP), which especially refers to medical supplies (gamma=-0.38; P.001) and finances (gamma=-0.37; P.001) in this study. However, in a multivariable negative binomial regression using within-between estimation of the number of barriers experienced on the selected predictors, the effect of GDP was reversed when it was adjusted for covariates. On the individual level, the number of experienced barriers decreased with better mental health and greater self-care ability. People with low income, with paraplegia, complete lesions, and more health problems reported more barriers. On the country level, fewer barriers were reported in countries with higher average age, better mental health, and greater self-care ability, as well as in those with a higher percentage of traumatic SCI, paraplegia, and complete lesions. More barriers were reported in countries with a higher percentage of married individuals, lower average household income, higher average time since injury, higher mean vitality scores, and greater income inequality.Study participants reported a significant number of environmental barriers, many of which are modifiable. Complementary interventions are recommended. Within and between country effects of covariates sometimes pointed in different directions, suggesting that countries with a different composition of SCI population also differed in environmental contexts.

Objectives: To describe the employment situation of individuals with spinal cord injury (SCI) in 22 countries participating in the International Spinal Cord Injury community survey, to compare observed and predicted employment rates, to estimate gaps in employment rates among people with SCI compared with the general population, and to study differences in employment between men and women.Design: Cross-sectional survey.Setting: Community.Participants: People of employable age (N=9875; 18-64 y) with traumatic or non-traumatic SCI (including cauda equina syndrome) who were at least 18 years of age at the time of the survey, living in the community, and able to respond to one of the available language versions of the questionnaire.Interventions: Not applicableMain Outcome Measures: The observed employment rate was defined as performing paid work for at least 1 hour a week, and predicted employment rate was adjusted for sample composition from mixed logistic regression analysis.Results: A total of 9875 participants were included (165-1174 per country). Considerable differences in sample composition were found. The observed worldwide employment rate was 38%. A wide variation was found across countries, ranging from 10.3% to 61.4%. Some countries showed substantially higher or lower employment rates than predicted based on the composition of their sample. Gaps between the observed employment rates among participants with SCI and the general population ranged from 14.8% to 54.8%. On average, employment rates were slightly higher among men compared with women, but with large variation across countries. Employment gaps, however, were smaller among women for most countries.Conclusions: This first worldwide survey among people with SCI shows an average employment rate of 38%. Differences between observed and predicted employment rates across countries point at country-specific factors that warrant further investigation. Gaps with employment rates in the general population were considerable and call for actions for more inclusive labor market policies in most of the countries investigated.

Acute ST-elevation myocardial infarction (STEMI) is associated with a high incidence of complications as well as a considerable hospitalization rate and economic burden. Preliminary evidence suggests that remote ischemic conditioning (RIC) is a promising non-invasive intervention that may effectively and safely reduce myocardial infarct size, subsequent cardiac events and complications, and mortality. However, RIC’s cardio-protective effect remains under debate, especially for single timepoint RIC programs. Adequately powered large-scale randomized controlled trials investigating clinical outcomes are thus needed to clarify the role of full disease cycle RIC programs. The intelligent “Internet Plus”-based full disease cycle remote ischemic conditioning (i-RIC) trial is a pragmatic, multicenter, randomized controlled, parallel group, clinical trial. The term, intelligent “Internet Plus”-based full disease cycle, refers to smart devices aided automatic and real-time monitoring of remote ischemic pre-, per- or post-conditioning intervention for patients with STEMI undergoing percutaneous coronary intervention (PCI). Based on this perspective, 4700 STEMI patients from five hospitals in China will be randomized to a control and an intervention group. The control group will receive PCI and usual care, including pharmacotherapy, before and after PCI. The intervention group will receive pre-, per-, and post-operative RIC combined with long-term i-RIC over a one-month period in addition. A smartphone application, an automated cuff inflation/deflation device and “Internet Plus”-based administration will be used in the long-term phase. The primary outcome is the combined cardiac death or hospitalization for heart failure rate. Secondary outcomes include clinical and functional outcomes: major adverse cardiac and cerebrovascular events rate, all-cause mortality, myocardial reinfarction rate, readmission rate for heart failure and ischemic stroke rate, unplanned revascularization rate, plasma concentration of myocardial infarction-related key biomarkers, infarct size, cardiac function, cardiopulmonary endurance, health-related quality of life, total hospital length of stay, total medical cost, and compliance with treatment regime. The i-RIC trial is designed to test the hypothesis that clinical and functional outcomes can be improved with the i-RIC program in STEMI patients undergoing PCI. The concept of RIC is expected to be enhanced with this intelligent “Internet Plus”-based program focusing on the full disease cycle. If the i-RIC program results in superior improvement in primary and secondary outcomes, it will offer an innovative treatment option for STEMI patients and form the basis of future recommendations. Chinese Clinical Trial Registry ( http://www.chictr.org.cn ): ChiCTR2000031550, 04 April 2020.

Objectives: Evidence on social inequalities in mental health of persons with physical impairments is limited. We therefore investigate associations of individual-level socioeconomic status (SES) and the country-level socioeconomic development (SED) with mental health in persons with spinal cord injury (SCI).Methods: We analyzed data from 12,588 participants of the International SCI Community Survey from 22 countries. To investigate individual-level inequalities, SES indicators (education, income, financial hardship, subjective status) were regressed on the SF-36 mental health index (MHI-5), stratified by countries. Country-level inequalities were analyzed with empirical Bayes estimates of random intercepts derived from linear mixed-models adjusting for individual-level SES.Results: Financial hardship and subjective status consistently predicted individual-level mental health inequalities. Country-level SED was inconsistently related to mental health when adjusting for individual-level SES. It however appeared that higher SED was associated with better mental health within higher-resourced countries.Conclusion: Reducing impoverishment and marginalization may present valuable strategies to reduce mental health inequalities in SCI populations. Investigations of country-level determinants of mental health in persons with SCI should consider influences beyond country-level SED, such as cultural factors.

Objective: To examine the effectiveness of a set of rules for referral and therapy input in a three-tiered physiotherapy program on activities of daily living (ADL), motor function, and quality of life of stroke survivors. Design: Randomized controlled study. Setting: Rehabilitation departments of 11 teaching hospitals. Subjects: A total of 285 participants with stroke. Outcome measures: Primary outcome was ADL independence measured with the Modified Barthel Index (MBI) at weeks 3, 6, 9, 13, and 17. Secondary outcomes were motor function and quality of life measured with Fugel-Meyer Assessment (FMA) and Stroke-Specific Quality-of-Life (SSQOL) scale. Intervention: Two complementary sets of rules governing rehabilitation delivery were introduced: a set of criteria that determined when someone ought to move from tier 1 onto tier 2, and from tier 2 onto tier 3, and a second set of rules that determined the amount and type of physiotherapy input given in each tier. Control group participants received conventional rehabilitation without any specified guidelines. Results: With a difference of 3.97 (95% confidence interval (CI): 1.59–6.36), MBI increased stronger in the study group than in controls between baseline and week 3 ( P = 0.001). This difference could be sustained until study end-point. No significant differences were found for FMA. Differences in increase of SSQOL were higher in the intervention than control at week 9 ( P Conclusion: Introduction of a set of rules for referral and therapy input at different stages of rehabilitation partially improved patients’ ADL and quality of life, but did not improve motor function.

Cross-sectional study. To compare physical function, post-traumatic stress disorder (PTSD) and quality of life (QOL) between individuals with spinal cord injury (SCI) caused by the Wenchuan earthquake and individuals with SCI caused by nondisaster trauma and to explore the relationship between physical function, PTSD and QOL. Community, Sichuan, China. Two hundred individuals with SCI (39 caused by the Wenchuan earthquake, 161 with other traumatic etiology) were surveyed. Physical function was assessed with the Spinal Cord Independence Measure-SR, PTSD with the PTSD Checklist-C, and QOL with the World Health Organization QOL-BREF. Independent sample t-tests and rank-sum tests were used to compare the two groups. Structural equation modeling (SEM) was used to analyze the relationship between physical function, PTSD and QOL. QOL of the study participants was at a moderate to low level, physical function was at a medium level. The prevalence of PTSD in the group injured due to the Wenchuan earthquake was 64.1% as opposed to 10.0% in individuals with other traumatic etiology. In the SEM, earthquake-related etiology was strongly related to increased PTSD symptoms which negatively affected QOL. Earthquake-related etiology was however also associated with slightly increased physical function which was associated with better QOL and less PTSD symptoms Prevalence of PTSD in earthquake survivors with SCI was largely increased as compared with people with SCI of other traumatic etiology. In spite of this, the groups did not differ in QOL because of better physical function of earthquake survivors. Effective intervention for PTSD is still needed in earthquake survivors with SCI. Continuous rehabilitative measures to improve physical function and QOL in both groups are also recommended.

ObjectivesTo investigate superiority of a telerehabilitation programme for COVID-19 (TERECO) over no rehabilitation with regard to exercise capacity, lower limb muscle strength (LMS), pulmonary function, health-related quality of life (HRQOL) and dyspnoea.DesignParallel-group randomised controlled trial with 1:1 block randomisation.SettingThree major hospitals from Jiangsu and Hubei provinces, China.Participants120 formerly hospitalised COVID-19 survivors with remaining dyspnoea complaints were randomised with 61 allocated to control and 59 to TERECO.InterventionUnsupervised home-based 6-week exercise programme comprising breathing control and thoracic expansion, aerobic exercise and LMS exercise, delivered via smartphone, and remotely monitored with heart rate telemetry.OutcomesPrimary outcome was 6 min walking distance (6MWD) in metres. Secondary outcomes were squat time in seconds; pulmonary function assessed by spirometry; HRQOL measured with Short Form Health Survey-12 (SF-12) and mMRC-dyspnoea. Outcomes were assessed at 6 weeks (post-treatment) and 28 weeks (follow-up).ResultsAdjusted between-group difference in change in 6MWD was 65.45 m (95% CI 43.8 to 87.1; pConclusionsThis trial demonstrated superiority of TERECO over no rehabilitation for 6MWD, LMS, and physical HRQOL.Trial registration numberChiCTR2000031834.

Objective (1) to describe environmental barriers and participation restrictions experienced by people with spinal cord injury (SCI) from China, (2) to examine associations between lesion characteristics and participation restrictions, considering a mediating role of environmental barriers, (3) to identify those environmental barriers that have the largest influence on participation. Design Cross-sectional study. This study is part of the International Spinal Cord Injury Survey (InSCI). Setting Community, Jiangsu and Sichuan Province, China. Participants 1355 persons with SCI. Interventions Not applicable. Outcome measures Participation restrictions were measured with items from the Model Disability Survey, Environmental Barriers were measured with the Nottwil Environmental Factors Inventory-Short Form. Results Participants experienced a median of five (IQR 1-9) environmental barriers and five (IQR 0-9) participation restrictions. Environmental barriers were mainly reported in relation to climate, insufficient resources and accessibility, and participation restrictions mainly occurred in using public transportation, taking care of others, and getting to places. In an adjusted zero-inflated Poisson model, people with more severe injuries reported a greater number of environmental barriers (complete injury: IRR = 1.31, 95%CI = [1.24,1.38]) and participation restrictions (tetraplegia: IRR = 1.15, 95%CI = [1.10,1.21]; complete injury: IRR = 1.25, 95%CI = [1.18,1.31]). Moreover, environmental barriers (IRR = 1.07, 95%CI = [1.06,1.08]) were a significant predictor of participation restrictions and partially mediated the association of lesion completeness with participation restrictions. Barriers related to accessibility of public places (IRR = 1.47, 95%CI = [1.33,1.62]), accessing homes (IRR = 1.32, 95%CI = [1.21,1.44]), long distance transportation (IRR = 1.11, 95%CI = [1.04,1.20]), communication devices (IRR = 1.07, 95%CI = [1.01,1.15]) and state services (IRR = 1.10, 95%CI = [1.02,1.19]) had the greatest negative impact on participation. Conclusion Social participation of people with SCI is seriously restricted in China. Removing environmental barriers will be an important element of programs to address this problem.

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.

This review aim to provide an overview of recommendations and quality of existing clinical practice guidelines (CPGs) for the management of traumatic brain injury (TBI) from the rehabilitation perspective. Comprehensive literature search, including health databases, CPG clearinghouse/developer websites, and grey literature using Internet search engines up to September 2017. All TBI CPGs published in the last decade were selected if their scope included management of TBI, systematic methods for evidence search, clear defined recommendations, and supporting evidence for rehabilitation interventions. Three authors independently critically appraised the quality of included CPGs using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) Instrument. Four of 13 potential CPGs met the inclusion criteria. Despite variation in scope, target population, size, and guideline development processes, all four CPGs assessed were good quality (AGREE score of 5-7/7). Key rehabilitation recommendations included education, physical rehabilitation, integrated computer-based management, repetitive task-specific practice in daily living activities, safe equipment usage, cognitive/behavioral feedback, compensatory memory/visual strategies, swallowing/communication, and psychological input for TBI survivors. In conclusion, although rehabilitation is an integral component in TBI management, many published CPGs do not include rehabilitation. These CPGs, however, recommend comprehensive, flexible coordinated multidisciplinary care and appropriate follow-up, education, and support for patients with TBI (and carers).

Objective: To evaluate published traumatic brain injury (TBI) clinical practice guidelines (CPGs) and assess rehabilitation intervention recommendations for applicability in disaster settings. Methods: Recommendations for rehabilitation interventions were synthesized from currently published TBI CPGs, developed by the Department of Labor and Employment (DLE); Scottish Intercollegiate Guidelines Network (SIGN); Department of Veterans Affairs/Department of Defence (DVA/DOD); and American Occupational Therapy Association (AOTA). Three authors independently extracted, compared, and categorized evidence-based rehabilitation intervention recommendations from these CPGs for applicability in disaster settings. Results: The key recommendations from a rehabilitation perspective for TBI survivors in disaster settings included patient/carer education, general physical therapy, practice in daily living activities and safe equipment use, direct cognitive/behavioral feedback, basic compensatory memory/visual strategies, basic swallowing/communication, and psychological input. More advanced interventions are generally not applicable following disasters due to limited access to services, trained staff/resources, equipment, funding, and operational issues. Conclusions: Many recommendations for TBI care are challenging to implement in disaster settings due to complexities related to the environment, resources, service provision, workforce, and other reasons. Further research is needed to identify and address barriers for implementation.

Background Social relationships are powerful determinants of health and inequalities in social relationships across socioeconomic status (SES) groups may contribute to social inequalities in health. This study investigates inequalities in social relationships in an international sample of persons with spinal cord injury and explores whether social gradients in relationships are moderated by the countries’ socioeconomic development (SED). Methods Data from 12,330 participants of the International SCI Community Survey (InSCI) performed in 22 countries were used. We regressed social relationships (belongingness, relationship satisfaction, social interactions) on individual SES (education, income, employment, financial hardship, subjective status) and countries’ SED (Human Development Index) using multi-level models (main effects). To test potential moderation of the SED, interaction terms between individual SES and countries’ SED were entered into multi-level models. Results Paid work, absence of financial hardship and higher subjective status were related to higher belongingness (OR, 95% CI: 1.50, 1.34–1.67; 1.76, 1.53–2.03; 1.16, 1.12–1.19, respectively), higher relationship satisfaction (OR, 95% CI: 1.28, 1.15–1.42; 1.97, 1.72–2.27; 1.20, 1.17–1.24, respectively) and fewer problems with social interactions (Coeff, 95% CI: 0.96, 0.82–1.10; 1.93, 1.74–2.12; 0.26, 0.22–0.29, respectively), whereas associations with education and income were less consistent. Main effects for countries’ SED showed that persons from lower SED countries reported somewhat higher relationship satisfaction (OR, 95% CI: 0.97, 0.94–0.99) and less problems with social interactions (Coeff, 95% CI: -0.04, -0.09- -0.003). Results from moderation analysis revealed that having paid work was more important for relationships in lower SED countries, while education and subjective status were more important for relationships in higher SED countries (interaction terms p<0.05). Conclusion Social relationships in persons with spinal cord injury are patterned according to individual SES and the countries’ SED and larger socioeconomic structures partly moderate associations between individual SES and social relationships.

STUDY DESIGN: Cohort study with two measurement occasions.OBJECTIVES: To investigate change in environmental barriers experienced by people living with spinal cord injury (SCI) over a 5-year period.SETTING: Community, Switzerland.METHODS: Data were from the Swiss spinal cord injury (SwiSCI) survey. Main outcome measure was the Nottwil Environmental Factors Inventory-Short Form. Random-effects Poisson regression featuring between-within estimation was used to examine predictors of the number of environmental barriers and of its change over time.RESULTS: One thousand five hundred and forty-nine persons participated in Survey 2012 and 1530 participated in Survey 2017; 761 participated in both surveys. In both surveys most participants reported at least three barriers. Leading issues were unfavorable climate, inaccessibility of buildings and public spaces, and lack of or insufficiently adapted means of transportation. Reporting of barriers related to climate, finances, and state services declined over time. Between subjects, having more health problems, lesser physical independence, poorer mental health, and a lower household income were related to a higher number of barriers experienced. Within subjects, improvements in income, physical independence, and mental health over time were related to a reduction in barriers.CONCLUSIONS: Inaccessibility of buildings and places and problems with transportation remained major barriers over a 5-year period and should be priorities of Swiss disability policy. People with reduced mental and physical health, and those with lower income are vulnerable groups deserving specific attention. Policies targeting income and life-long rehabilitation targeting health promotion and maintenance may be suitable means to reduce the experience of environmental barriers.

Spasticity commonly emerges during the process of recovery after spinal cord injury (SCI) and critically exacerbates motor dysfunction. Given insufficient effects of individual therapies, we combined repetitive transcranial magnetic stimulation (rTMS) with treadmill training (Tr) in rats with SCI to investigate potential synergistic effects on alleviating spasticity and motor dysfunction. Animals were randomized into four groups: SCI only, rTMS, Tr, and rTMS plus Tr. At the study endpoint eight weeks after the start of interventions, the rTMS plus Tr group exhibited the largest decrease in maximal H-reflex amplitude/maximal M-wave amplitude ratio (effect size (ES): -0.082, 95% confidence interval (CI): -0.118 to -0.046, p 0.001) as well as the greatest improvement in motor function measured with the Basso, Beattie, and Bresnahan locomotor scale (ES: 1.811, 95% CI: 1.018 to 2.603, p 0.001; significantly different from all other groups at p 0.01) and grid-walking test (ES: -5.1, 95% CI: -7.784 to -2.416, p 0.001, significantly different from rTMS alone at p 0.01). Pathological analyses demonstrated that the combined treatment facilitated the growth of serotonergic axons around the lesion site, and the upregulation of 5-hydroxytryptamine, potassium-chloride cotransporter-2, and glutamic acid decarboxylases 67 in the lumbar spinal cord distal to the injury site. All effects of combined treatment of rTMS and treadmill training were enhanced compared to treadmill training or rTMS alone. Treadmill training and rTMS intervention appear to have synergistic effects on hyperreflexia and locomotion likely related to a restored balance between facilitatory and inhibitory inputs to motoneurons.

Persons experiencing disabilities often face difficulties to establish and maintain intimate partnerships and the decision whether to live alone or with others is often not their own to make. This study investigates whether individual and country-level characteristics predict the partnership status and the living situation of persons with spinal cord injury (SCI) from 22 countries. We used data from 12,591 participants of the International SCI Community Survey (InSCI) and regressed partnership status and living situation on individual (sociodemographic and injury characteristics) and country-level characteristics (Human Development Index, HDI) using multilevel models. Females, younger persons, those with lower income, without paid work, more severe injuries, and longer time since injury were more often single. Males, older persons, those with higher income, paid work, less severe injuries, and those from countries with higher HDI more often lived alone. This study provides initial evidence for the claim that the partnership status and the living situation of people with SCI are influenced by sociodemographic and socioeconomic factors and are not merely a matter of choice, in particular for those with severe injuries.

Background Older persons are particularly vulnerable to the impact of earthquakes and are more likely to suffer from depression. Objectives We aimed to estimate the prevalence of depression, to compare the prevalence between disaster-affected and non-disaster affected areas, and to explore additional risk factors for depression 6 months after the Lushan earthquake. Design A cross-sectional study was conducted. Setting A magnitude 7.0 earthquake occurred in Lushan County, Ya'an Prefecture, Sichuan Province, on April 20, 2013. In total, 196 people were killed, and 11,470 were injured over 5 days. Participants A multistage cluster sampling strategy was used. A total of 1,509 older persons (aged 60 or older) participated. Methods The Geriatric Depression Scale-15, the University of California Los Angeles Loneliness scale, the Activities of Daily Living Scale, the Social Support Rating Scale, and the Family Apgar Index scale were used to evaluate symptoms of depression, loneliness, dependence with respect to activities of daily living, perceived social support, and family function, respectively. A generalized linear regression model and multiple logistic regression analysis were employed to identify risk factors for depression. Results Using a cutoff score of 8, the prevalence of depression was 29.16% in the hardest-hit disaster area, 29.06% in the hard-hit disaster area, 31.61% in the moderately-hit disaster area, 17.94% in the remote non-disaster area, and 12.28% in the neighboring non-disaster area. The prevalence was significantly higher in the disaster areas than in the non-disaster areas. Risk factors for depression included an educational level of elementary school or lower, a greater number of chronic illnesses, feelings of loneliness, limitations in activities of daily living, family dysfunction, and low levels of social support. Conclusion Depression was highly prevalent in elderly survivors and was significantly more prevalent in disaster areas than in non-disaster areas. Psychological interventions and care should focus on older survivors.

Cohort study with two measurement occasions.To investigate change in environmental barriers experienced by people living with spinal cord injury (SCI) over a 5-year period.Community, Switzerland.Data were from the Swiss spinal cord injury (SwiSCI) survey. Main outcome measure was the Nottwil Environmental Factors Inventory-Short Form. Random-effects Poisson regression featuring between-within estimation was used to examine predictors of the number of environmental barriers and of its change over time.One thousand five hundred and forty-nine persons participated in Survey 2012 and 1530 participated in Survey 2017; 761 participated in both surveys. In both surveys most participants reported at least three barriers. Leading issues were unfavorable climate, inaccessibility of buildings and public spaces, and lack of or insufficiently adapted means of transportation. Reporting of barriers related to climate, finances, and state services declined over time. Between subjects, having more health problems, lesser physical independence, poorer mental health, and a lower household income were related to a higher number of barriers experienced. Within subjects, improvements in income, physical independence, and mental health over time were related to a reduction in barriers.Inaccessibility of buildings and places and problems with transportation remained major barriers over a 5-year period and should be priorities of Swiss disability policy. People with reduced mental and physical health, and those with lower income are vulnerable groups deserving specific attention. Policies targeting income and life-long rehabilitation targeting health promotion and maintenance may be suitable means to reduce the experience of environmental barriers.

Background Several studies indicate that older age is a risk factor for probable post-traumatic stress disorder (PTSD). However, evidence on the prevalence and risk factors for elderly disaster survivors is limited. Methods Multi-stage stratified sampling was applied in this cross-sectional study. The Revised Version of the Impact of Event Scale (IES-R) was used to evaluate symptoms of PTSD. Chi-squared test was used for univariable analysis of prevalence of probable PTSD by possible determinants. Multivariable logistic regression analysis was utilized to further explore risk factors for PTSD. Results 427 elderly survivors age 60 or older participated. The prevalence of probable PTSD was 40.5, 36.3, and 21.5% according to a cut off score of the IES-R of 33, 35, and 2 points on average across items, respectively. In multivariable logistic regression, elderly survivors with a higher number of diagnosed chronic illnesses were more likely to be screened positive for PTSD and those with a greater number of family members living in the same home were less likely to be classified as having probable PTSD for all cut off scores. Elderly survivors with improved economic status and those with primary school or lower education were more often estimated to have probable PTSD with a cut off score of 35 and 2 points on average. Conclusions Elderly survivors in a high impact area following a major earthquake are at high risk for developing PTSD. Those who live alone and report pre-existing chronic illness are particularly vulnerable.

Purpose: Earthquake survivors whose physical injuries result in disability may be at increased risk for prolonged and severe post-traumatic stress disorder. We estimated the prevalence of post-traumatic stress disorder, functional limitations, and environmental barriers in 289 survivors with disabilities induced by the 2008 Wenchuan earthquake eight years after the disaster. We also investigated the relationship of post-traumatic stress disorder symptom severity with function, considering a mediating role of environmental barriers.Methods: Post-traumatic stress disorder was measured with post-traumatic stress disorder checklist-civilian version. Physical and mental functioning was assessed with Medical Outcomes Short Form-36 and perceived environmental barriers were evaluated with Nottwil Environmental Factors Inventory-Short Form. Path analysis was employed to examine the relationship of exposures, post-traumatic stress disorder symptom severity, environmental barriers, and physical and mental function.Results: Prevalence of probable post-traumatic stress disorder was 18.68% (95% CI: 14.19-23.18%). Earthquake survivors with lower physical and mental functioning perceived more environmental barriers, and those who perceived more barriers demonstrated more severe post-traumatic stress disorder symptoms, confirming a mediating role of environmental barriers.Conclusions: Long-term community-based health services for earthquake survivors with disabilities should combine both mental and physical rehabilitation and focus on creating disability-inclusive environments.Implications for rehabilitationEarthquake survivors whose physical injuries result in permanent disability may experience two different types of psychological trauma. The first originates from the initial psychological impact of the disaster and their injuries and the second arises from the added difficulty of coping with environmental barriers given the limitations imposed by their impairments.Even years after the disaster, prevalence of post-traumatic stress disorder is likely high in earthquake survivors with acquired musculoskeletal or neurological impairments and needs to be considered in the rehabilitation process.Physical and mental functioning, as well as environmental barriers, are important intervention targets to reduce post-traumatic stress disorder symptoms.Long-term community-based health services for earthquake survivors with disabilities are needed that combine both mental health and physical rehabilitation components with advocating for disability-inclusive environments.

Objective To provide prevalence estimates for problems in functioning of community-dwelling persons with spinal cord injury (SCI) and to examine associations between various areas of functioning with the purpose of supporting countries in identifying targets for interventions. Design Cross-sectional survey. Setting Community, 22 countries including all World Health Organization regions. Participants Persons (N=12,591) with traumatic or nontraumatic SCI aged 18 years or older. Interventions Not applicable. Main Outcome Measures We estimated the prevalence of problems in 53 areas of functioning from the Brief International Classification of Functioning, Disability and Health (ICF) core set for SCI, long-term context, or ICF rehabilitation set covering 4 domains: impairments in body functions, impairments in mental functions, independence in performing activities, and restrictions in participation. Associations between areas of functioning were identified and visualized using conditional independence graphs. Results Participants had a median age of 52 years, 73% were male, and 63% had paraplegia. Feeling tired, bowel dysfunction, sexual functions, spasticity, pain, carrying out daily routine, doing housework, getting up off the floor from lying on the back, pushing open a heavy door, and standing unsupported had the highest prevalence of problems (>70%). Clustering of associations within the 4 functioning domains was found, with the highest numbers of associations within impairments in mental functions. For the whole International Spinal Cord Injury sample, areas with the highest numbers of associations were circulatory problems, transferring bed-wheelchair, and toileting, while for the World Health Organization European and Western Pacific regions, these were dressing upper body, transferring bed-wheelchair, handling stress, feeling downhearted and depressed, and feeling happy. Conclusions In each domain of functioning, high prevalence of problems and high connectivity of areas of functioning were identified. The understanding of problems and the identification of potential targets for intervention can inform decision makers at all levels of the health system aiming to improve the situation of people living with SCI.

A public health disaster occurs when the adverse health effects of an event such as a natural hazard or threat exceed the coping capacity of the affected human population. The coping capacity of the affected population is hereby dependent on available resources including financial and human resources, health infrastructure, as well as knowledge, planning and organizational capabilities, and social capital. Disasters therefore disproportionally affect lesser resourced regions and countries of the world and pose specific challenges to their health systems as well as to the international humanitarian community in terms of dealing with mortality and injuries, communicable and noncommunicable disease, mental health effects, and long-term disability. Challenges for health care delivery in disaster situations in lesser resourced settings include deficiencies in the construction of resilient health care facilities, the lack of disaster response plans, shortage of specialized medical personnel, shortcomings regarding training in disaster response, and scarcity of resources such as medicines and portable medical devices and supplies. Other challenges include the absence of appropriate algorithms for the distribution of scarce resources; lack of coordination of medical teams and other volunteers; limited awareness of particular health issues such as mental health problems or disability and rehabilitation; and lack of plans for evacuation, sheltering, and continuation of treatment of those with preexisting health conditions. Many challenges lesser resourced settings face with regard to health care delivery after disasters such as the organization of mortality management, triage and treatment of the injured, or the delivery of rehabilitative and mental health care cannot be reduced to the lack of baseline resources in terms of health infrastructure, technology, and personnel but are related to the absence of proper planning for future disaster scenarios including implementation strategies and simulation exercises. This not only encompasses the formal drafting of disaster preparedness and response plans, contingency planning of hospitals, and the provision of disaster-related training to health personnel but also in particular the identification and involvement of the potentially and traditionally affected communities and especially vulnerable groups in all the process of disaster risk reduction.

Objective To examine environmental barriers, func-tioning, and quality of life in Wenchuan earthquake survivors with spinal cord injury. Design Cross-sectional study. Subjects Thirty-two adult Wenchuan earthquake survivors with spinal cord injury. Methods Data were collected on environmental factors with the Nottwil Environmental Factors Inventory Short Form (NEFI-SF), physical and mental functioning with the 36-item Short-Form Health Survey (SF-36), and quality of life with the World Health Organization Quality of Life-BREF (WHOQOL-BREF). Descriptive analysis of environmental barriers and comparisons of SF-36 and WHOQOL-BREF domain scores with normative data were performed. Variations in outcomes across demographic and lesion characteristics were examined using Mann-Whitney U test. Associations of NEFI-SF with SF-36 and WHOQOL-BREF domain scores were explored using Spearman's correlation. Results Wenchuan earthquake survivors with spinal cord injury were affected by a large number of environmental barriers. Their functioning and quality of life were considerably reduced in comparison with respective reference populations. Neither environmental barriers nor functioning or quality of life varied systematically by demographic and lesion characteristics. Increased numbers of perceived environmental barriers were strongly associated with decreased scores across SF-36 and WHOQOL-BREF sub-domains. Conclusion Wenchuan earthquake survivors with SCI faced a considerable number of environmental barriers and showed decreased functioning and quality of life. Environmental barriers were strongly related to functioning and quality of life.

Objective Previous epidemiological studies of adole-scent idiopathic scoliosis in mainland China have had diverse results. The aim of this cross-sectional study was to determine the epidemiology of adolescent idiopathic scoliosis based on a representative sample city, Wuxi, in eastern China. Methods Primary and secondary school students aged 10-16 years were enrolled in the study. Physical examination and Adam's forward bending test, combined with scoliometer measurements were performed at school-based screening. Students with an angle of trunk inclination of 5° or more were referred for whole-spine X-ray. The threshold for confirmed diagnosis was a Cobb angle of 10° or more. Results A total of 79,122 students were screened. The overall prevalence of adolescent idiopathic scoliosis in Wuxi City was estimated as 2.4%. Girls had a higher prevalence in each age subgroup compared with boys. Higher prevalence was found in individuals with lower body mass index. Mild and moderate curves were the most common types in our study. Conclusion The prevalence of adolescent idiopathic scoliosis in this region was slightly higher. Medical resources should be considered for children with lower body mass index and high risk of scoliotic progression. Measurement with a scoliometer would be suitable for mild-to-moderate scoliotic deformities, while alternative methods should be developed for those with severe deformities or higher body mass index.

The cyberspace plays an important role in improving the quality, equity, and efficiency of health services. Studying people's adoption of online health services, such as online health consultation services (OHCS) can benefit both industry and policy in the health service sector. This paper investigates influencing factors and paths of people's intention of adopting OHCS by employing the extended valence framework, with our new contribution of integrating subjective norm and offline habit into the model. Five hundred forty-three university students participated in the survey. Structural equation models and Sobel-Goodman tests were applied to test the models. The results show that subjective norm (β = 0.077, p = 0.041), trust in providers (β = 0.194, p = 0.002) and perceived benefit (β = 0.463, p < 0.001) positively affect the intention to adopt OHCS, while offline habit (β = −0.111, p = 0.026) has a negative effect. However, the association of perceived risk (β = −0.062, p = 0.315) and adoption is not supported. Moreover, trust in providers plays a mediating role between subjective norm and the intention of adopting, while perceived benefit mediates the relationship between trust in providers and the intention of adopting. This study highlights the importance of trust, subjective norm, perceived benefit, and persisting habits in promoting the adoption of OHCS.

Cross-sectional study.To compare physical function, post-traumatic stress disorder (PTSD) and quality of life (QOL) between individuals with spinal cord injury (SCI) caused by the Wenchuan earthquake and individuals with SCI caused by nondisaster trauma and to explore the relationship between physical function, PTSD and QOL.Community, Sichuan, China.Two hundred individuals with SCI (39 caused by the Wenchuan earthquake, 161 with other traumatic etiology) were surveyed. Physical function was assessed with the Spinal Cord Independence Measure-SR, PTSD with the PTSD Checklist-C, and QOL with the World Health Organization QOL-BREF. Independent sample t-tests and rank-sum tests were used to compare the two groups. Structural equation modeling (SEM) was used to analyze the relationship between physical function, PTSD and QOL.QOL of the study participants was at a moderate to low level, physical function was at a medium level. The prevalence of PTSD in the group injured due to the Wenchuan earthquake was 64.1% as opposed to 10.0% in individuals with other traumatic etiology. In the SEM, earthquake-related etiology was strongly related to increased PTSD symptoms which negatively affected QOL. Earthquake-related etiology was however also associated with slightly increased physical function which was associated with better QOL and less PTSD symptoms CONCLUSIONS: Prevalence of PTSD in earthquake survivors with SCI was largely increased as compared with people with SCI of other traumatic etiology. In spite of this, the groups did not differ in QOL because of better physical function of earthquake survivors. Effective intervention for PTSD is still needed in earthquake survivors with SCI. Continuous rehabilitative measures to improve physical function and QOL in both groups are also recommended.

In order to determine the validity of the International Classification of Functioning, Disability, and Health brief Core Set for Obstructive Pulmonary Disease (ICF-OPD) for the assessment of functioning and environmental factors in Chinese chronic OPD (COPD) patients, we conducted a cross-sectional study with a convenience sample of 100 COPD patients. Data were collected using common questionnaires for COPD patients (Modified British Medical Research Council Questionnaire, COPD Assessment Test, St George’s Respiratory Questionnaire (SGRQ)), the Brief ICF Core Set for OPD, and the comprehensive ICF checklist. All except one category of the Brief ICF-OPD Core Set were confirmed in our evaluation of its content validity, but there is a high prevalence of problems in 8 categories that were not considered in the Brief ICF-OPD Core Set. The functioning-related components of the Brief ICF-OPD Core Set largely performed similarly to SGRQ in terms of differentiating between patients with different disease severity. Moreover, high correlations between the Brief ICF-OPD Core Set overall score and component scores with the respective SGRQ scales and moderate correlations between ICF-OPD Core Set overall score and component scores and lung function parameters. This study largely confirmed content, known group, and convergent validity of the ICF-OPD.

Nursing students from vocational college programs contribute to over 60% of the nursing student population in China. However, there remains a lack of systematic, quantitative studies examining the prevalence of mental health problems in this population. The purpose of this study was to explore the prevalence of depression, anxiety and stress symptoms and associated factors in vocational college nursing students in Sichuan, China. A total of 554 nursing students from vocational colleges participated in this cross-sectional study. Outcomes were measured with the Depression, Anxiety and Stress Scale 21 (DASS 21). Logistic regressions analysis was performed to examine correlates of mental health problems. The prevalence rates of depression, anxiety and stress symptoms among vocational college nursing students in China were 28.7% (95%

Objective To estimate the prevalence of disability and anxiety in Covid-19 survivors at discharge from hospital and analyze relative risk by exposures. Design Multi-center retrospective cohort study. Setting Twenty-eight hospitals located in eight provinces of China. Methods A total of 432 survivors with laboratory-confirmed SARS CoV-2 infection participated in this study. At discharge, we assessed instrumental activities of daily living (IADL) with Lawton’s IADL scale, dependence in activities of daily living (ADL) with the Barthel Index, and anxiety with Zung’s self-reported anxiety scale. Exposures included comorbidity, smoking, setting (Hubei vs. others), disease severity, symptoms, and length of hospital stay. Other risk factors considered were age, gender, and ethnicity (Han vs. Tibetan). Results Prevalence of at least one IADL problem was 36.81% (95% CI: 32.39–41.46). ADL dependence was present in 16.44% (95% CI: 13.23–20.23) and 28.70% (95% CI: 24.63–33.15) were screened positive for clinical anxiety. Adjusted risk ratio (RR) of IADL limitations (RR 2.48, 95% CI: 1.80–3.40), ADL dependence (RR 2.07, 95% CI 1.15–3.76), and probable clinical anxiety (RR 2.53, 95% CI 1.69–3.79) were consistently elevated in survivors with severe Covid-19. Age was an additional independent risk factor for IADL limitations and ADL dependence; and setting (Hubei) for IADL limitations and anxiety. Tibetan ethnicity was a protective factor for anxiety but a risk factor for IADL limitations. Conclusion A significant proportion of Covid-19 survivors had disability and anxiety at discharge from hospital. Health systems need to be prepared for an additional burden resulting from rehabilitation needs of Covid-19 survivors.