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

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

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

Needs and Research Priorities for Young People with Spinal Cord Lesion or Spina Bifida and Their Caregivers: A National Survey in Switzerland within the PEPSCI Collaboration.

The aim of this study was to describe the needs and research priorities of Swiss children/adolescents and young adults (from here, "young people") with spinal cord injury/disorder (SCI/D) or spina bifida (SB) and their parents in the health and life domains as part of the international Pan-European Pediatric Spinal Cord Injury (PEPSCI) collaboration. Surveys included queries about the satisfaction, importance, research priorities, quality of life (QoL), and characteristics of the young people. Fifty-three surveys with corresponding parent-proxy reports were collected between April and November 2019. The self-report QoL sum scores from young people with SCI/D and SB were 77% and 73%, respectively. Parent-proxy report QoL sum scores were lower, with 70% scores for parents of young people with SCI/D and 64% scores for parents of young people with SB. "Having fun", "relation to family members", and "physical functioning" were found to be highly important for all young people. "Physical functioning", "prevention of pressure injuries", "general health", and "bowel management" received the highest scores for research priority in at least one of the subgroups. As parents tend to underestimate the QoL of their children and young people prioritized research topics differently, both young peoples' and caregivers' perspectives should be included in the selection of research topics

Functional connectivity and amplitude of low-frequency fluctuations changes in people with complete subacute and chronic spinal cord injury.

After spinal cord injury (SCI), reorganization processes and changes in brain connectivity occur. Besides the sensorimotor cortex, the subcortical areas are strongly involved in motion and executive control. This exploratory study focusses on the cerebellum and vermis. Resting-state functional magnetic resonance imaging (fMRI) was performed. Between-group differences were computed using analysis of covariance and post-hoc tests for the seed-based connectivity measure with vermis and cerebellum as regions of interest. Twenty participants with complete SCI (five subacute SCI, 15 with chronic SCI) and 14 healthy controls (HC) were included. Functional connectivity (FC) was lower in all subjects with SCI compared with HC in vermis IX, right superior frontal gyrus (pFDR = 0.008) and right lateral occipital cortex (pFDR = 0.036). In addition, functional connectivity was lower in participants with chronic SCI compared with subacute SCI in bilateral cerebellar crus I, left precentral- and middle frontal gyrus (pFDR = 0.001). Furthermore, higher amplitude of low-frequency fluctuations (ALFF) was found in the left thalamus in individuals with subacute SCI (pFDR = 0.002). Reduced FC in SCI indicates adaptation with associated deficit in sensory and motor function. The increased ALFF in subacute SCI might reflect reorganization processes in the subacute phase

Functional connectivity and amplitude of low-frequency fluctuations changes in people with complete subacute and chronic spinal cord injury

After spinal cord injury (SCI), reorganization processes and changes in brain connectivity occur. Besides the sensorimotor cortex, the subcortical areas are strongly involved in motion and executive control. This exploratory study focusses on the cerebellum and vermis. Resting-state functional magnetic resonance imaging (fMRI) was performed. Between-group differences were computed using analysis of covariance and post-hoc tests for the seed-based connectivity measure with vermis and cerebellum as regions of interest. Twenty participants with complete SCI (five subacute SCI, 15 with chronic SCI) and 14 healthy controls (HC) were included. Functional connectivity (FC) was lower in all subjects with SCI compared with HC in vermis IX, right superior frontal gyrus (p$_{FDR}$ = 0.008) and right lateral occipital cortex (p$_{FDR}$ = 0.036). In addition, functional connectivity was lower in participants with chronic SCI compared with subacute SCI in bilateral cerebellar crus I, left precentral- and middle frontal gyrus (p$_{FDR}$ = 0.001). Furthermore, higher amplitude of low-frequency fluctuations (ALFF) was found in the left thalamus in individuals with subacute SCI (p$_{FDR}$ = 0.002). Reduced FC in SCI indicates adaptation with associated deficit in sensory and motor function. The increased ALFF in subacute SCI might reflect reorganization processes in the subacute phase