Shoulder impairment in persons with a spinal cord injury & associations with activities and participation

Schouderproblemen bij mensen met een dwarslaesie; daar kunnen we de schouders niet over op halen…De meeste mensen met een dwarslaesie kunnen niet meer lopen en zijn afhankelijk van hun armen voor dagelijkse activiteiten, zoals rolstoel rijden en het in en uit de rolstoel komen. Het is daarom niet vreemd dat schouderproblemen bij mensen met een dwarslaesie vaak voorkomen. Dit proefschrift gaat over: 1) hoe vaak schouderproblemen, d.w.z. schouderpijn en beperkingen in de beweeglijkheid van de schouder, voorkomen bij mensen met een dwarslaesie en 2) of er een relatie is tussen het hebben van schouderproblemen en het kunnen uitvoeren van dagelijkse activiteiten en werk.Uit dit onderzoek blijkt dat schouderproblemen al snel na het ontstaan van de dwarslaesie optreden. Het hoort dus niet bij de “late gevolgen” zoals vaak wordt aangenomen. In een studie naar slijtage van de schouder bij mensen met schouderpijn met en zonder dwarslaesie vonden we dat mensen met een dwarslaesie niet vaker, maar wel ernstiger slijtage van het schoudergewricht hebben. Schouderproblemenkomen met name voor bij mensen met een hoge dwarslaesie, die hun armen minder goed kunnen gebruiken. Mensen die tijdens de revalidatie een verminderde beweeglijkheid van de schouder hebben, blijken op lange termijn meer hulp nodig te hebben en minder vaak betaald werk te hebben. Ook voor schouderproblemen bij mensen met een dwarslaesie geldt: voorkomen is beter dan genezen. Training (levenslang) van de schouder- en rugspieren, een optimale rolstoel en hulpmiddelen zijn van groot belang om zolang mogelijk pijnvrij en zelfstandig te kunnen leven.Most people with a spinal cord injury (SCI) are not able to walk and depend on their arms for many activities, like wheelchair propulsion and getting in and out the wheelchair. It is therefore not surprising that many people with a SCI suffer from shoulder problems. In this thesis we studied: 1) the prevalence of shoulder problems, especially shoulder pain and shoulder joint range of motion in persons with as SCI, and 2) the relation between shoulder problems and performance of daily activities and participation in work.This thesis shows that people with an SCI develop shoulder problems shortly after the injury and it is not solely a “late complication” as often assumed. In a study on shoulder arthrosis in people with shoulder pain we found that, although arthrosis is found as often in people with and without an SCI, severity in people with an SCI is more outspoken.Shoulder problems showed to appear mostly in people with a tetraplegia (people with limited arm function). People with a limited motion of their shoulder range are on the long-term more likely to become dependent on help, and less often have a paid job.The old saying “prevention is better than cure” applies here too. People with an SCI should train their upper body, and the provision of optimal devises, such as a wheelchair, should be warranted to facilitate an independent life without shoulder pain

Does cardiometabolic risk profile differ among individuals with traumatic and non-traumatic spinal cord injury (SCI): the evidence from the multicenter SCI cohort in Switzerland (SwiSCI).

STUDY DESIGN Longitudinal study. OBJECTIVE To explore whether individuals with traumatic spinal cord injury (TSCI) and non-traumatic SCI (NTSCI) experience different trajectories in changes of cardiometabolic disease (CMD) factors during initial rehabilitation stay. SETTING Multicenter Swiss Spinal Cord Injury Cohort (SwiSCI) study. METHODS Individuals without history of cardiovascular diseases were included. CMD factors and Framingham risk score (FRS) were compared between TSCI and NTSCI. Linear mixed models' analysis was employed to explore the trajectory in CMD factors changes over rehabilitation period and a multivariate linear regression analysis was used at discharge from inpatient rehabilitation to explore factors associated with CMD risk profile in TSCI and NTSCI. We performed age and sex-stratified analyses. RESULTS We analyzed 530 individuals with SCI (64% with TSCI and 36% NTSCI). The median age was 53 years (IQR:39-64) with 67.9% (n = 363) of the study cohort being male. The median rehabilitation duration was 4.4 months (IQR 2.4-6.4). At admission to rehabilitation, FRS (9.61 vs. 5.89) and prevalence of hypertension (33.16% vs. 13.62%), diabetes (13.68% vs. 4.06%), and obesity (79.05% vs. 66.67%) were higher in NTSCI as compared to TSCI, No difference was observed in cardiometabolic syndrome between the groups (around 40% in both groups). Overall, we observed longitudinal increases in total cholesterol, HDL-C and HDL/total cholesterol ratio, and a decrease in fasting glucose over the rehabilitation period. No differences in longitudinal changes in cardiovascular risk factors were observed between TSCI and NTSCI. CONCLUSIONS There was no deterioration in cardiometabolic risk factors over rehabilitation period, at discharge from initial rehabilitation stay. Both TSCI and NTSCI experienced high burden of cardiometabolic syndrome components with NTSCI experiencing more disadvantageous risk profile. The effectiveness of therapeutic and lifestyle/behavioral strategies to decrease burden of cardiometabolic disease and its components in early phase should be explored in future studies

The burden of cardiovascular risk in individuals with spinal cord injury (SCI) and its association with rehabilitation outcomes - Results from the Swiss SCI Cohort.

OBJECTIVES To determine the cardiovascular risk burden rehabilitation discharge, and explore the association between recovery during rehabilitation and CVD-risk profile. METHODS We included adults without CVD history admitted for rehabilitation. We evaluated rehabilitation outcomes on admission and discharge. CVD-risk was assessed by Framingham risk score (FRS), high-density lipoprotein (HDL), and fasting glucose level. RESULTS We analyzed data from 706 participants (69.55% men) with median age of 53.5 years. The median time-since-injury was 14 days and the admission length was 5.2 months. Majority had paraplegia (53.26%), and motor incomplete injury (53.68%). One-third of the cohort had high cardiovascular risk profile pre-discharge. At discharge, poorer anthropometric measures were associated with higher FRS and lower HDL levels. Individuals with higher forced vital capacity (>2.72 L) and peak expiratory flow (>3.4 L/min) had 0.16 mmol/L and 0.14 mmol/L higher HDL compared to those with lower respiratory function, respectively. Individuals with higher mobility score (>12.5) and functional independence score (>74) had 0.21 mmol/L and 0.18 mmol/L higher HDL compared to those with lower scores. CONCLUSION There is high cardiometabolic syndrome burden and CVD-risk upon rehabilitation discharge. Higher respiratory function, mobility, and overall independence were associated with better CVD profile, although with study design limitations and short follow-up. Future studies should explore whether rehabilitation outcomes could be used to prioritize screening

Early Changes in Androgen Levels in Individuals with Spinal Cord Injury: A Longitudinal SwiSCI Study.

We aimed to explore longitudinal changes in androgen levels in individuals with spinal cord injury (SCI) within initial inpatient rehabilitation stay and identify clinical/injury characteristics associated with hormone levels. Linear regression analysis was applied to explore the association between personal/injury characteristics and androgen hormones (total testosterone, free testosterone, sex hormone-binding globulin (SHBG), dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEA-S)) at admission to rehabilitation. Longitudinal changes in androgen levels were studied using linear mixed models. Analyses were stratified by sex and by injury type. We included 70 men and 16 women with SCI. We observed a non-linear association between age, time since injury, and androgens at baseline. At admission to initial rehabilitation, mature serum SHBG (full-length, protein form which lacks the N-terminal signaling peptide) was higher, while DHEA and DHEA-S were lower among opioid users vs. non-users. Serum levels of total testosterone and DHEA-S increased over rehabilitation period [β 3.96 (95%CI 1.37, 6.56), p = 0.003] and [β 1.77 (95%CI 0.73, 2.81), p = 0.01], respectively. We observed no significant changes in other androgens. Restricting our analysis to men with traumatic injury did not materially change our findings. During first inpatient rehabilitation over a median follow up of 5.6 months, we observed an increase in total testosterone and DHEA-S in men with SCI. Future studies need to explore whether these hormonal changes influence neurological and functional recovery as well as metabolic parameters during initial rehabilitation stay

MRI evaluation of shoulder pathologies in wheelchair users with spinal cord injury and the relation to shoulder pain

OBJECTIVE: To describe the number, specifics and co-occurrence of shoulder pathologies detected by MRI in manual wheelchair users with spinal cord injury and to evaluate the association between shoulder pathologies and presence of shoulder pain.DESIGN: Cross-sectional observation study.SETTING: Community.PARTICIPANTS: Fifty-one wheelchair-dependent persons with spinal cord injury (44 males, 7 females, median age 50 years (IQR 14), median time since injury 24 years (IQR 16)) were allocated to pain or no-pain group based on the Wheelchair User Shoulder Pain Index.INTERVENTIONS: Not applicable.OUTCOME MEASURES: All persons underwent shoulder MRI. Pathologies were scored blinded by two experienced radiologists. Participant characteristics, number and severity of shoulder pathologies were analyzed descriptively. Logistic regression was performed to evaluate the association between MRI findings and shoulder pain.RESULTS: The median number of co-occurring MRI findings per person ranged from 0 to 19 (out of 31 possible findings). The cluster of MRI findings occurring most often together were tendon tears of supraspinatus (present in 84%), subscapularis (69%) and biceps (67%) and osteoarthritis of acromioclavicular joint (80%). When correcting for age and time since injury, the logistic regression showed no statistically significant correlation between the individual pathologies and shoulder pain.CONCLUSION: MRI findings of shoulder pathology are very frequent in persons with and without shoulder pain. Therefore, when diagnosing the cause of shoulder pain and planning interventions, health care professionals should keep this finding in mind and MRI should not be interpreted without careful consideration of clinical history and functional testing.</p

BMJ Open

Introduction Study drop-out and attrition from treating clinics is common among persons with chronic health conditions. However, if attrition is associated with adverse health outcomes, it may bias or mislead inferences for health policy and resource allocation. Methods This retrospective cohort study uses data attained through the Swiss Spinal Cord Injury (SwiSCI) cohort study on persons with spinal cord injury (SCI). Vital status (VS) was ascertained either through clinic medical records (MRs) or through municipalities in a secondary tracing effort. Flexible parametric survival models were used to investigate risk factors for going lost to clinic (LTC) and the association of LTC with subsequent risk of mortality. Results 1924 individuals were included in the tracing study; for 1608 of these cases, contemporary VS was initially checked in the MRs. VS was ascertained for 704 cases of the 1608 cases initially checked in MRs; of the remaining cases (n=904), nearly 90% were identified in municipalities (n=804). LTC was associated with a nearly fourfold higher risk of mortality (HR=3.62; 95% CI 2.18 to 6.02) among persons with traumatic SCI. Extended driving time (ie, less than 30 min compared with 30 min and longer to reach the nearest specialised rehabilitation facility) was associated with an increased risk of mortality (HR=1.51, 95% CI 1.02 to 2.22) for individuals with non-traumatic SCI. Conclusion The differential risk of LTC according to sociodemographic and SCI lesion characteristics underscores the importance of accounting for attrition in cohort studies on chronic disease populations requiring long-term care. In addition, given the associated risk of mortality, LTC is an issue of concern to clinicians and policy makers aiming to optimise the long-term survival of community-dwelling individuals with traumatic SCI. Future studies are necessary to verify whether it is possible to improve survival prospects of individuals LTC through more persistent outreach and targeted care

International Comparison of Vocational Rehabilitation for Persons With Spinal Cord Injury:Systems, Practices, and Barriers

Background: Employment rates among people with spinal cord injury or spinal cord disease (SCI/D) show considerable variation across countries. One factor to explain this variation is differences in vocational rehabilitation (VR) systems. International comparative studies on VR however are nonexistent. Objectives: To describe and compare VR systems and practices and barriers for return to work in the rehabilitation of persons with SCI/D in multiple countries. Methods: A survey including clinical case examples was developed and completed by medical and VR experts from SCI/D rehabilitation centers in seven countries between April and August 2017. Results: Location (rehabilitation center vs community), timing (around admission, toward discharge, or after discharge from clinical rehabilitation), and funding (eg, insurance, rehabilitation center, employer, or community) of VR practices differ. Social security services vary greatly. The age and preinjury occupation of the patient influences the content of VR in some countries. Barriers encountered during VR were similar. No participant mentioned lack of interest in VR among team members as a barrier, but all mentioned lack of education of the team on VR as a barrier. Other frequently mentioned barriers were fatigue of the patient (86%), lack of confidence of the patient in his/her ability to work (86%), a gap in the team's knowledge of business/legal aspects (86%), and inadequate transportation/accessibility (86%). Conclusion: VR systems and practices, but not barriers, differ among centers. The variability in VR systems and social security services should be considered when comparing VR study results

Mapping of Dietary Interventions Beneficial in the Prevention of Secondary Health Conditions in Spinal Cord Injured Population: A Systematic Review.

OBJECTIVES Individuals with spinal cord injury are at risk of secondary health conditions (SHC) that develop as a consequence of autonomic dysfunction, prolonged oxidative stress and inflammation, and physical inactivity coupled with inadequate energy and nutritional intake. SHC can be debilitating and even life-threatening, and its prevention remains one of the major challenges in the continuum of medical care of aging SCI population. An unhealthy diet is a major driver of inflammation, oxidative stress, and unfavourable metabolic status and may be a practical preventive target to tackle increased SHC risk post-injury. AIMS To provide a catalogue of dietary interventions beneficial in prevention of SHC among individuals with SCI by conducting a systematic review of the literature on dietary interventions and dietary supplementation in promoting health and well-being after the injury. In addition, we aimed to provide a summary of observational studies exploring the association between habitual diet (macro- and micronutrients intake and dietary patterns) and health patterns following the injury. METHOD This review was registered at PROSPERO (University of York) with registration number CRD42022373773. Four medical databases (EMBASE.com, MEDLINE [Ovid], Cochrane CENTRAL, and Web of Science Core Collection) and Google Scholar were searched from inception until 11th July 2022. Studies were included if they were clinical trials or observational studies conducted in adult individuals with SCI and provided information of interest. Based on strength of the study design and risk of bias assessment (using the NIH tool), we classified studies from Level 1 (most reliable studies) to Level 4 (least reliable studies). RESULTS Of 12,313 unique citations, 47 articles (based on 43 original studies) comprising 32 interventional (22 RCTs, 3 NRCT, and 7 pre-post studies) and 11 observational studies (2 cohort studies, 2 case-control, 1 post-intervention follow-up study, and 6 cross-sectional studies) were included in the present systematic review. Twenty studies (46.5%) were classified as Level 1 or 2, indicating high/moderate methodological quality. Based on those studies, dietary strategies including high protein diet, intermittent fasting, balanced diet in combination with physical conditioning and electrical stimulation, and dietary supplementation including alpha-lipoic acid, creatine, vitamin D, and cranberry-derived supplements and probiotics were mapped as the most promising in prevention of SHC among individuals with SCI. CONCLUSIONS To develop timely and effective preventive strategies targeting major SHC (e.g., cardiometabolic diseases, urinary tract infections) in SCI, further research is warranted to confirm the effectiveness of dietary strategies/interventions identified through the current systematic review of the literature