INTRODUCTION
Although frailty has been shown to affect adverse events and length of stay in patients with traumatic spinal cord injury (SCI), the influence of frailty on the functional outcomes after rehabilitation has not been evaluated in this population. The goal of this study is to evaluate frailty as a predictor of functional outcomes at the time of hospital discharge in patients with SCI.
METHODS:
Consecutive 45 traumatic SCI patients were eligible for this study. The 11-factor modified frailty index (mFI-11), which comprised diabetic status, history of chronic obstructive pulmonary disease or pneumonia, congestive heart failure, myocardial infarction, percutaneous coronary intervention or angina, peripheral vascular disease, impaired sensorium, transient ischemic attack, cerebrovascular accident with neurological deficit, hypertension requiring medication, and non-independent functional status before injury, was calculated for each patient. The patient’s frailty was categorized into three groups (robust, prefrail, or frail). Multivariate analysis was performed to investigate the impact of mFI-11 and other variances on functional outcomes assessed by spinal cord independence measure (SCIM) and discharge destination (home and others).
RESULTS:
Of these 45 patients with a mean age at injury of 57.2 years, six (13.3%) were diagnosed as a frail, whereas 18 (40.0%) as a prefrail and 21 (46.7%) as a robust. A mean SCIM improvement ratio at the time of discharge and length of hospital stay in robust, prefrail and frail patients were 38.5%, 39.5% and 10.6% and 267 days, 243 days and 259 days, respectively. On bivariate analyses, frail condition and advanced age (+75) at injury were correlated negatively with SCIM improvement ratio and the rate of discharge to home.
CONCLUSIONS:
Although, the mFI-11 is a good predictor of functional outcomes following SCI, advanced age is also one of the factors affecting poor functional outcomes. Further prospective studies are warranted to determine clinically meaningful interventions of frail conditions especially in the elderly population.

Introduction: Japan has the highest ratio of the elderly in the world. Elderly patients with incomplete cervical spinal cord injury (SCI) are extraordinary increasing (about 30% in total population above 65 years old). We summarize the outcome of their rehabilitation treatment using the multi-hospital SCI database (Japan SCI Database Committee – Kibi Medical Rehabilitation manage-, total 5134 cases (male 83.6%), since 1997 to 2018.3).
Method: We extracted patients with incomplete cervical SCI who were hospitalized between 14 to 60 days after the injury. Incomplete was defined as American Spinal Injury Association Impairment Scale B-E. Patients with deficient data were excluded. The number of cases was 494. We divided the cases among three groups (group A: young-middle (19-64 years) 348cases, group B: younger-elderly (65-74 years) 108 cases, group C: later-elderly (75 years or older) 38cases), and analyzed motor Functional Independence Measure (FIM) at admission and discharge using student-t-test (P<0.01).
Results: There was no significant difference in motor FIM at admission among the three groups (group A 39.6±26.3, group B 34.2±24.0, group C 32.8±25.5). However, motor FIM at discharge was significantly higher in group A than group B and C. Group B was higher than group C, but was not significantly different (group A 69.4±25.0, group B 57.1±27.2, group C 50.8±26.7). At discharge, group A showed an average of 5 or more (no assist by the helpers) on 10 of the 13 sub-item of motor FIM (eating, grooming, dressing upper body, dressing lower body, toileting, bladder management, bowel management, bed/chair/wheelchair transfer, toilet transfer, walk/wheelchair), but group B and C got only one item (eating). There was also no significant difference between group B and C in the sub-items.
Conclusion: Elderly patients with incomplete cervical SCI had poorer rehabilitation outcomes than younger patients, and were discharged from hospital with a need for nursing care throughout their daily lives. This finding showed the reason why the caregiver insurance should be necessary for the elderly patients.

INTRODUCTION
Persons with spinal cord injury (SCI), due to the reduced mobility and the frequent alteration or loss of sub-lesion skin sensitivity, show a high predisposition for pressure ulcers (PUs). PUs are a common and fearful complication in SCI, with an important impact both on quality of life and health costs. In addition to traditional treatments, this study proposes the application of non-compressive adhesive elastic tape around the PUs with the aim of accelerating wound healing. It has been hypothesized a possible effect on lymphatic drainage and reactivation of the superficial bloodstream, as well as on the skin and subcutaneous tissues, notoriously compromised in PU location. The objective of this study was to evaluate the safety and tolerability of the application of adhesive elastic tape as an "add-on" treatment in the therapy of medium-severe sacral or heel PUs in patients with SCI. Secondarily the evolution of PUs was monitored to evaluate the effectiveness of tape application.

METHODS
Design: an experimental, prospective, before-after (no-yes-no scheme of treatment), single-center study. The study was approved by the local ethical committee.
Patients: patients with SCI of any etiology and neurological level, with a minimum time since injury of three months. Patients were enrolled after informed consent in a tertiary referral rehabilitation institute during a first hospitalization after injury, or during re-hospitalization in the chronic phase. All were clinically stable and had a sacral and/or heel pressure ulcer, stage III or IV (EPUAP classification), present for at least one month.
Methods: PUs treatment followed 4 weeks cycles as follows: (1) standard; (2) additional adhesive elastic tape applied near the PU; (3) standard. Clinical monitoring was performed weekly using the BWAT scale and photos during all phases.

RESULTS
Twenty-four cases were included: 11 sacral and 10 heel PUs have been completed, 2 heel and 1 sacral PUs are still under evaluation. None of the treated patients presented adverse reactions and/or complications related to the application of adhesive elastic tape; the treatment was well tolerated by all patients and did not represent an obstacle for other clinical rehabilitation activities.
The trend of the total BWAT score in the 12 weeks of the study reveals a significant reduction in the score from the beginning to the end of each phase. It emerges that on average a greater reduction of BWAT is obtained in heel Pus.

CONCLUSIONS
Tape application as an "add-on" treatment for PUs is safe and well tolerated in patients with SCI. Preliminary data also suggest that adhesive elastic may improve wound healing.

Background: Spinal cord injury (SCI) has serious adverse consequences on bowel function in a majority of subjects. Some of the challenges relate to their dependence on caregiver support, need for medications, and the extensive time requirements associated with bowel management (BM). Lower thoracic spinal cord stimulation (SCS) has been shown to restore an effective cough and some patients have reported improvement in bowel function, as well.
Objective: To determine whether usage of SCS to restore cough may improve BM in individuals with SCI.
Design/Methods: In five consecutive tetraplegics, SCS was applied at home, 2-3 times/day, on a chronic basis and also as needed for secretion management. Stimulus parameters were set at values resulting in near maximum airway pressure generation (Paw) (30-40V, 50Hz, 0.2ms). Paw was measured as an index of expiratory muscle strength. Participants also employed SCS during their bowel routine. Questionnaires related to BM, were administered before and after initiation of SCS.
Results: Mean Paw during spontaneous efforts was 30±8 cmH2O. Following a period of reconditioning over a 20-week period, SCS resulted in Paw of 124±22 cmH2O. The time required for BM routines was reduced from 118±34 min to 18±2 min (p<0.05). The amount of time required for BM was related to the magnitude of airway pressure development during SCS. Mechanical methods for BM (digital rectal stimulation and/or manual evacuation) were completely eliminated in 4 patients. The number of medications required for BM was also reduced. No patients experienced fecal incontinence as result of SCS. Each participant also reported marked overall improvement and reduction in the daily stress level associated with BM.
Conclusion: Our results suggest that SCS to restore cough may be a useful method to improve BM and life quality for both SCI patients and their caregivers. Our results indicate that the improvement in BM is secondary to restoration of intra-abdominal pressure development.
Support: NIH-NINDS (5U01NS 83696), NCATS (UL1TR000439)
Non-Financial Disclosure Statement: Dr. Anthony DiMarco owns patent rights for technology utilized in this research study.

Introduction: Four out of 5 people with traumatic spinal cord injury (tSCI) experience ongoing pain; over half of which is neuropathic pain (NeuP). The purpose of this investigation was to learn what specific treatments people with tSCI use for NeuP and how individuals rate treatment effectiveness.
Methods: Participants, all older than 18 years old and at least 1 year post tSCI, were recruited from 6 SCI Model Systems between March 2017 and July 2019 to complete a survey about their pain and pain treatment. The Spinal Cord Injury Pain Instrument (SCIPI) was used to differentiate pain types (SCIPI score ≥ 2 as NeuP), while a 7 point Likert scale was used to rate treatment effectiveness (anchors being ‘1’ for pain being ‘very much improved’ and ‘7’ for pain being ‘very much worse’).
Results: 220 (56%) out of 391 participants had at least one NeuP in the previous 7 days. The 5 most common pharmacologic treatments used for NeuP at any point during the previous 12 months were opioids (used by 43%), antiepileptics (40%), non-steroidal anti-inflammatory drugs (NSAIDs)/aspirin (39%), cannabinoids (27%), and antispasticity drugs (25%); whereas the 5 most common pharmacologic treatments currently being used at the time of interview were antiepileptics (38%), opioids (36%), NSAIDs/aspirin (34%), cannabinoids (24%), and antispasticity drugs (22%). The top 5 most effective pharmacologic treatments for NeuP, based on a report of improvement with use, were: opioids not including tramadol (89% of respondents reported as effective), antiepileptics (88%), cannabinoids (85%), tramadol (83%), and acetaminophen (72%). The median rating of treatment efficacy (effect of the treatment on pain) for opioids and cannabinoids was greater (pain was “much improved”) than for antiepileptics, tramadol and acetaminophen, for which pain was “minimally improved”.
The 5 most commonly-used non-pharmacologic treatments for NeuP at any point during the previous 12 months, and currently being used at the time of interview, were body position adjustment (59% and 57% respectively), passive exercise (56% ,and 50%), massage (31% and 24%), resistance exercise (26% and 24%), and heat therapy (23% and 18%). The top 5 non-pharmacologic treatments that were felt to be helpful were relaxation therapy (87% of users felt treatment was helpful), massage (84%), body position adjustment (83%), aerobic exercise (80%), and heat therapy (78%). The median rating of the effect of the treatment on pain for all of these non-pharmacologic treatments was that pain was “minimally improved”.
Conclusions: In this study participants found cannabinoids and opioids to be most helpful for NeuP as compared to other treatments. Relaxation therapy and aerobic exercise, also thought to be helpful, were not listed among the top used treatments. Cannabinoids, relaxation therapy, and aerobic exercise need further exploration regarding their place in the treatment of chronic neuropathic pain after tSCI. Similar to previous study results, antiepileptics were also thought to be helpful for alleviating NeuP and of all the pharmacological treatments, it was the treatment currently being used the most.

Introduction: Four out of 5 people with traumatic spinal cord injury (tSCI) experience ongoing pain; approximately half of which is non-neuropathic (non-NeuP). The purpose of this investigation was to learn what specific treatments people with tSCI use for non-NeuP and how individuals rate treatment effectiveness.
Methods: Participants, all older than 18 years old and at least 1 year post tSCI, were recruited from 6 SCI Model Systems between March 2017 and July 2019 to answer a survey about their experienced pain and treatment of such. The Spinal Cord Injury Pain Instrument (SCIPI) was used to differentiate pain types (SCIPI score < 2 as non-NeuP) while a 7-point Likert scale was used to rate treatment effectiveness (anchors being ‘1’ for pain being ‘very much improved’ and ‘7’ for pain being ‘very much worse’).
Results: 190 (49%) out of 391 participants related having at least one non-NeuP during the previous 7 days. The 5 most common pharmacologic treatments used for non-NeuP at any point during previous 12 months and at the time of interview (current use of treatment) were nonsteroidal anti-inflammatory drugs (NSAIDs)/aspirin (used by 46% sometime during the previous 12 months, and 37% currently using, respectively), antiepileptics (33% and 29%), opioids (33% and 27%), acetaminophen (31% and 24%), and cannabinoids (25% and 21%). However, the 5 self-reported most effective pharmacologic treatments were opioids other than tramadol (86% of users felt treatment was helpful), tramadol (82%), cannabinoids (81%), acetaminophen (81%), and NSAIDs/aspirin (77%). The median rating of treatment efficacy (effect of the treatment on pain) for cannabinoids and opioids including tramadol was greater (pain was “much improved”) as compared to the other 5 most-helpful pharmacologic treatments for all of which pain was “minimally improved”.
The 5 most common non-pharmacologic treatments used to treat non-NeuP at any point during the previous 12 months and currently being used at the time of interview were: body position adjustment (used by 51% and 49%, respectively), passive exercise (50% and 44%), massage (32% and 24%), resistance exercise (22% and 20%), and heat (19% and 15%). The non-pharmacologic treatments that were felt to be most helpful were heat therapy (92% of users felt treatment was helpful), aerobic exercise (90%), passive exercise (81%), position adjustment (79%), and massage (77%). The median rating of treatment efficacy (effect of the treatment on pain) for massage and heat was greater (effect of the treatment on pain was “much improved”) as compared to the other 5 most-effective non-pharmacologic treatments for all of which pain was “minimally improved”.
Conclusions: The prevalence of pain after tSCI in this study matched that found in previous studies. In this study opioids and cannabinoids were treatments that were among the most commonly used and also thought by participants to be the most helpful treatments for non-NeuP . Given these findings, it is clear that these treatments as well as other treatments noted to be helpful need further exploration regarding their place in the treatment of chronic non-NeuP after tSCI.

Introduction: Pain is a common and debilitating phenomenon for people with spinal cord injury (SCI). Renewed attention to sex and races in research has been raised recently in response to the failure of multiple clinical trials and noted racial health disparities. This study was conducted to examine sex and racial differences in pain prevalence and severity among people with SCI over 45 years of injury.
Methods: This was a cross-sectional analysis of survey data of 17,213 adults enrolled in the National SCI Model Systems Database in the USA (Non-Hispanic white 68.6%, non-Hispanic black 21.3%, and Hispanic 10.1%; Men 79.4%; Age 48.4±15.3 years; Years since injury 13.7±11.9; Violent etiology 15.0%), whose most recent follow-up assessment occurred during 2000-2019. Pain experience was evaluated by asking participants to rate the usual level of pain over the last 4 weeks, using a scale ranging from 0 (no pain) to 10 (too severe to stand). We calculated the prevalence of any pain (pain score >0), prevalence of severe pain (pain score >6), and average pain scores across sex, races, and other demographic and injury characteristics. We also conducted multiple logistic regression analysis to identify the extent of sex and racial differences in pain, after controlling for potential confounding factors.
Results: The overall prevalence of pain (pain score >0) was 85.6%, relatively stable over 45 years post-injury and consistent regardless of sex and races. The severity of pain averaged 4.5±2.9 (median 5.0), slightly higher for post-injury years 1-35 vs years 40-45 (median score 5 vs 4), higher for blacks and Hispanics vs whites (median 6 and 5 vs 4), higher for paraplegic vs tetraplegic injuries (median 5 vs 4), and higher for violent etiology vs others (median 6 vs 4). Severe pain, defined by pain score >6, was more common in blacks (39.9%) and Hispanics (37.3%) than whites (24.8%, P<0.001). The prevalence of severe pain was significantly higher among people with SCI caused by violent etiology vs others (43.8% vs 26.7%, P<0.001) and also slightly increased in women (30.8%) than men (28.9%, P=0.03), complete vs incomplete injuries (30.8% vs 27.9%, P<0.001), and paraplegic vs tetraplegic injuries (31.5% vs 27.2%, P<0.001). Racial and sex differences in severe pain remained significant after taking into account age, duration of injury, marital status, education, employment, violent etiology, and neurological status.
Conclusions: Study findings of sex and race influences on pain could help health care professionals to target at-risk group for pain management after SCI. It also provides foundation for future research into identifying different types of pain related to SCI and factors that contribute to sex and racial differences.