Introduction
Physical deconditioning resulting from lower-limb paralysis after spinal cord injury (SCI) causes changes in micro- and macro-vascular structure and function which, when combined with prolonged sitting pressure and loss of muscle mass covering bony structures, contributes to subcutaneous tissue ischemia and the development of pressure ulcers. Reactivating the paralyzed muscles by inducing electrically stimulated (ES) muscle contractions (partly) reverses many of these complications. Currently no study has examined the effects of long-term, daily home-based low intensity ES. The purpose, therefore, was to examine the effects of 12 weeks daily gluteal and hamstring ES using a wearable clothing garment on gluteal skin and femoral conduit artery vascular function, limb volume and sitting pressure in people with SCI.

Methods
Nine (8♂) persons with chronic (1-24y) SCI received a 12-wk self-administered daily gluteal and hamstring ES (50Hz) program at home using a wearable clothing garment (Axiobionics, [1]) and a portable stimulator (Neuropro, Berkelbike). ES amplitude (80-105mA) was individually set to elicit a strong visible tetanic contraction without discomfort or limb movement. The protocol ran for 6 hrs (30-min ES, 15-min rest) with a 1:4 duty cycle (1s ES, 3s rest; [2]). Participants were instructed to use the garment as much as possible, during day and/or night, >6 hrs/d. Changes in common femoral artery (CFA) diameter and blood blow were determined with ultrasound and Doppler velocity assessments (T3000, Terason), skin vascular function using Laser Doppler flowmetry (Periflux system 5000, Perimed AB), thigh muscle volume estimated using leg circumferences and skin folds, and interface sitting pressure measured using a pressure-mapping device (mFlex).

Results
All participants adhered to the minimum ES requirements, with the garment being worn for ±7 hr/d, resulting in 9 30-min FES cycles. Eight participants chose to wear the garment during the night and one used it both day and night. Resting CFA diameter increased from 0.73±0.20 to 0.79±0.22cm (+8.3%, p <0.001), baseline CFA blood flow from 0.28±0.12 to 0.40±0.15 L/min (+43%, p<0.002). Gluteal skin blood flow (SBF) in response to local heating did not sign. change, but a time*intervention interaction for cutaneous vascular conductance indicated the change in SBF during local heating from baseline to max. levels had increased. Peak pressure under the sitting bones decreased (p=0.003) by 32±23mmHg and pressure gradient (indicating shear stress) decreased from 23±7 to 16±6 mmHg. Thigh volume increased (+19%, p=0.01) from 4.7 to 5.6L.

Discussion
Twelve weeks of daily gluteal and hamstring ES increased structure and function ofthe femoral artery supplying the active skeletal muscle, most likely through repeated increases in hyperaemic shear stress. Peak sitting pressure, pressure gradient and limb volume improved, probably due to an increased gluteal muscle mass, and cutaneous microvascular function at the gluteals somewhat improved. Participant feedback indicated the ES clothing device is feasible for prolonged daily ES. Future work should focus on the potential impact of low-intensity ES in the prevention of co-morbidities related to deconditioning of muscle and vasculature.

References
[1] Barton, T.J.: Am J Phys Med Rehabil. 2018 Oct;97(10):721-726.
[2] Smit, C.A.: J Rehabil Res Dev. 2013;50(7):1035-46.

Introduction: We report the final results of the « PRevention des EScarres par un DIspositif Embarqué » (PRESDIE) study. Up to 85% of persons with a spinal cord injury (PwSCI) develop at least one pressure ulcer in their lifetime and 7 to 8% may die because of this secondary condition. Data from the literature also demonstrated that the incidence and prevalence of pressure ulcers are still high and not reducing. Therefore, prevention remains a challenge. The main aim of this study was to assess the concordance between the continuous recording of sitting pressures measured by the embedded device TexiCare, a 100% sensor-matrices knitted textile, and subject-dependent pressure parameters in everyday activities.

Methods: The PRESDIE study included 90 subjects using a manual wheelchair, from 3 SCI-specialized French departments, that respected the "a priori" calculated number. The follow-up duration was of 28 days, with a comprehensive overview of the daily habits of PwSCI. Clinical and electronic data were analyzed during this period. We carried out a weekly in-site control, including an inspection of the pelvic skin status, the collection of data recorded by the TexiCare central unit and, in parallel, those recorded by the participants in their personal diaries concerning "remarkable events" that might have changed sitting pressures in their everyday activities.

Results: 83% of the PwSCi presented a motor-complete SCI. One pressure ulcer (grade 1) event occurred during the study. The durations of discharge after transfers of various “types” (toilets, shower, car or bed), estimated by TexiCare pressure data, appeared consistent with the nature of the corresponding activities through the annotations in the subjects' diaries. We found a correlation between mobility features collected by the device and the motor score according to the ISNCSCI: both the minimum ellipse (containing 95% of the day's pressure centres) and the distance covered by this pressure centre during the same period were positively correlated to the motor score (Spearman and Kendall test; p<0.05).

Discussion: PRESDIE was the first study that confirmed on a significant cohort and an adapted follow-up period the concordance between continuous pressure recording and clinical data. Such clinical data involved subjects SCI-specific information but also data describing everyday activities. For the moment, the TexiCare device was intended to serve as a measurement tool to enable PMR professionals to optimally choose and adjust equipments (cushion, wheelchair) for each PwSCI. The embedded device TexiCare could provide dynamic essential data to PwSCI and, consequently, the PRESDIE team is now considering a larger-scale trial to validate feedback information from continuous recordings of pelvic pressures in our targeted population.

Introduction: Four out of every five people with spinal cord damage (SCD) report pain is an ongoing problem. As such, clinicians sometimes resort to the use of opioids for the treatment of pain after SCD as is done for other types of intractable pain. However like in other causes of non-cancer chronic pain, the evidence for opioid effectiveness in the treatment of pain after SCD is sparse. Persons with SCD are prescribed opioids for longer durations and at higher doses than persons without SCD who are also prescribed opioids all the while the United States (US) in 2019 remains in the midst of an opioid overdose epidemic which has been exacerbated by the prescription of opioids for pain over the past two decades and there are signs of emerging opioid epidemics in other countries such as Canada and Australia. Drug overdose is now even the leading cause of unintentional death in the US. Compounding the problem, persons with SCD are at an increased risk for overdose death as compared to their matched controls due to conditions related to their SCD. Given the risks associated with the prescription of opioids to persons with SCD and the lack of convincing evidence for their effectiveness, a survey of physicians working with these patients was developed to look at their prescription of opioids. The aim of this survey was to characterize how physicians throughout the world working with patients who have SCD approach the prescribing of opioids for pain, and to compare the results to representative clinical practice guideline recommendations. Methods: A survey targeted to spinal cord injury (SCI) physicians was posted online and circulated among international societies within the field of SCI medicine from August-November 2018. Results: One hundred and twenty three physicians responded to the survey. Of these,107 (92%) managed pain for persons with SCD. Most (82%) felt that opioid prescription was appropriate for uncontrolled acute pain, but fewer (67%) felt it was appropriate for chronic pain. Of those who felt opioids had a role in the treatment of neuropathic pain, 46% did not think there should be a specific upper limit of opioid dose. The majority (85%) would continue prescribing high doses (250 morphine milligram equivalent (MME) doses/day) if that dose were effective. Tramadol was the most common opioid prescribed first line. Conclusion: Most physicians who responded to this survey prescribe opioids for intractable pain after SCD. A significant proportion of respondents believed that there should not be a specific upper limit of opioid dose prescribed if the drug is tolerated; this does not align with current recommendations. Most physicians do not feel influenced in their prescribing habits by regulatory bodies. If physicians decide to taper an opioid that is being tolerated well, it is most commonly related to a fear of the patient developing an opioid use disorder. The authors propose an algorithm that may help align practice patterns with current recommended practice guidelines.

INTRODUCTION:
Despite an enormous amount of research, the prognosis for recovery of lower limb motor function in patients with chronic motor completeSpinal Cord Injury (SCI) remains dismal. Activity-based locomotor training, the only practice used to enhance recovery at present, does not yield significant outcomes. Animal studies have shown significant motor recovery with the combination of spinal Epidural Electric Stimulation (sEES) to activity-based training. Two small case series in the western population have also been published recently showing positive results.
CLINICAL STUDY:
We conducted a pilot clinical study in ten chronic motor-complete spinal cord injured patients. The study was approved by the Institute Ethics Committee. All the subjects provided a written as well as video informed consent. They were randomized into two groups of five patients each. Each group underwentstandardized activity-based training. One group was implanted with a sEES in addition.
The primary outcome measure included duration of standing weight bearing with minimal assistance, control of full weight bearing and assessment of ability to coordinate stepping on a tread-mill. The secondary outcome measures include an improvement in the AIS of at least one grade or 6 points in ASIA motor score, any voluntary movement by additional muscle groups not included in ISNCSCI,Walking Index of Spinal Cord Injury ,assessment of functional independence using SCIM, psychological evaluation by Beck Depression Inventory, electromyography, nerve conduction velocity, somatosensory evoked potential, motor-evoked Potential and evaluation of bladder function by Urodynamic studies.
The sEES group participants were implanted with a surgical stimulator (RESTORE ADVANCED,MEDTRONICS). Multiple combinations of amplitude and frequency were tested to obtain information on what combination caused rhythmic muscle activation simulating walking, standing, and stepping.Training sessions lasting three hours a day were given with sEES turned on. Trials were also conducted to look if the motor achievements were sustained when the stimulator was turned off.
RESULTS:
Preliminary resultsat 14 weeks of activity based training revealed that participantsin the sEES group were able to have control of full weight bearing, stand with minimal assistance for 5 to 15 minutes continuously and walk over ground with assistive devices after activity based training with sEES turned on. These abilities continue to improve. However, the participants could not perform the same activities and there is no voluntary motor activity with the stimulator turned off. There were no serious adverse effects during the study.The participants are under long term follow up and recovery of voluntary motor activity of lower limbs with sEES turned off is being assessed. The six months follow up results of all participants will be presented.
CONCLUSIONS:
Early results showed that motor recovery with regard to standing and walking improved in participants with activity based training combined with sEESas compared to activity based training alone. These results suggest that sEES has the potential for recovery of motor functions after SCI.

Introduction
Informal caregiving is a fundamental part of the health systems. The support of family caregivers is particularly precious in the case of complex chronic conditions, such as spinal cord injury (SCI). Caregivers adjust differently to their role. Studies in different fields have shown that coping strategies are significant predictors of adjustment in caregivers. The aim of this study is therefore to identify the coping strategies used by caregivers of persons with SCI in Switzerland. Knowing the strategies that help them adjust to caregiving may be used to develop interventions targeted at those caregivers who have more difficulties in dealing with their role.

Methods
This is a qualitative study. Face-to-face semi-structured interviews with caregivers (N=22) were conducted and analyzed following the principles of thematic analysis.

Results
The analysis highlighted that caregivers of individuals with SCI use four different strategies to adjust to their role and ensure a life balance in the long term. Our participants are at different stages in their lives and in their career of caregivers, and they use these coping strategies to face the practical as well the existential challenges that arise over time. Caregivers might use more than one coping strategy at a time. The first coping strategy is accepting the situation. The acceptance of the situation seems to help caregivers give up an activity or make changes in their life (plans) to facilitate or make caregiving possible without having regrets. The second coping strategy consists in reframing the experience of caregiving as a “normal” activity or situation, or by showing its positive aspects. To deal with the evolving and upcoming challenges of caregiving, many caregivers adopted a third strategy: setting limits to the caregiver role. This was done, for instance by delegating tasks to professionals, finding time for themselves or making room for other roles. The fourth coping strategy consists in seeking support, mostly from healthcare professionals to treat physical and psychological concerns. The analysis also gives an insight into the skills that caregivers need to implement these coping strategies (e.g., self-examination, communication skills). Lastly, in addition to the coping strategies, several contextual factors that support caregivers in their role (i.e., relational aspects, moral and practical support, personal characteristics) were identified.

Conclusions
The coping strategies identified by the analysis fit a recently typology on caregivers’ adjustment. The caregivers develop cognitive coping strategies in order to make sense of the situation and establish a “new normal”, emotion focussed strategies to accept the situation as well as problem-focused strategies to deal with their tasks and role. Considering that problem-focused and cognitive strategies were shown to be associated with reduced psychological distress and positive outcomes, enhanced self-efficacy and control over life, we encourage the development of educational and support programs dedicated to caregivers that foster these styles of coping. Besides, interventions should also promote social support, as it was shown to be a major facilitator in caregiving.

Introduction:
A successful return to work is crucial to ensure community integration and quality of life in persons with spinal cord injury (SCI). As part of this integration process, it is important to address a person’s work-related functioning as part of the rehabilitation of the individual.
The Work Rehabilitation Questionnaire (WORQ) is a generic questionnaire based on the International Classification of Functioning, Disability and Health (ICF) that aims to assess work-related functioning from the patient’s perspective. WORQ was designed specifically for use in vocational rehabilitation and to assess work disability over time. WORQ has been translated and cross-culturally validated in several languages and a brief version (WORQ-Brief) was also developed for the purpose of feasibility. WORQ was found to be reliable, valid, and feasible when tested in people with musculoskeletal health conditions, but there is no evidence so far in neurological conditions such as SCI. Therefore, the objective of the study is to investigate the psychometric property of WORQ-Brief in people with SCI who are in a vocational rehabilitation setting.

Methods:
We conducted a cross-sectional study in a rehabilitation facility specialized for persons with SCI in Switzerland. The study consisted of quantitative and qualitative parts. We administered WORQ-Brief (20 items) at discharge from first rehabilitation, in persons with SCI who received vocational rehabilitation or vocational counselling services. Internal consistency (reliability) was calculated using Cronbach’s alpha. To test the usability of WORQ, we conducted interviews with patients and clinicians.

Results:
A total of 68 individuals with SCI completed WORQ-Brief between 2016 and 2018. Of these, n= 47 (69.1%) had paraplegia (n=22 complete, n=25 incomplete) and 21 (30.9%) had tetraplegia (n=3 complete, n=18 incomplete). Cronbach’s Alpha was high (0.90). The average WORQ sum score ranged from 0.2 to 6.62 (min = 0, max = 10) and correlated significantly (Spearman = 0.55) with the time required for “daily activities”. WORQ questions were perceived to be easy to understand and answer. Participants also reported that completing WORQ helped think about problems focusing on work-related functioning and the available resources. However, aspects relevant to persons with SCI are missing such as “the ability to maintain a sitting position for a defined amount of time”.

Conclusion:
WORQ proves to be a valid, reliable, and feasible ICF-based instrument to assess work-related functioning in persons with SCI. Modifications may need to be done to improve the applicability of WORQ on people with SCI. We need to conduct future research on a SCI-specific version of WORQ while retaining its comparability when WORQ is used to assess work functioning in other health conditions.