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Oral Presentations: Secondary Health Conditions II

Track 1
Thursday, September 3, 2020
3:00 PM - 4:30 PM
Auditorium - Track 1


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Dr. Ilaria Baroncini
Montecatone Rehabilitation Institute

Correlation between pre-injury comorbidities, post-injury complications in SCI patients and the realization of the rehabilitation potential during acute phase hospitalization calculated using the SCI-ARMI algorithm

3:00 PM - 3:15 PM


INTRODUCTION: Recovery after spinal cord injury depends in part on inherent mechanisms in the spinal cord itself and in part on adequate rehabilitation treatment.
The SCI-ARMI index quantifies the achievement of skills and assesses the patient’s rehabilitation potential regardless of spontaneous neurological recovery. The SCI-ARMI index, calculated at a given moment, expresses the percentage of the theoretical maximum recovery for that patient.
This prospective and multicenter observational study aims to investigate how this index changes during hospitalization and which parameters have an influence on it and, consequently, on the chances of recovery.
METHODS: We present preliminary results on 186 SCI patients in the acute phase (within 30 days from injury), admitted to two Italian spinal units, aged ≥ 18 years, suffering from SCI of any etiology (both traumatic and non-traumatic) and of any neurological level, complete or incomplete, classified as AIS A (38.2%), B (11.8%), C (18.8%), D (31.2%) according to the ISNCSCI criteria. In particular, 137 men and 49 women, with an average age of 50.22, range 18-84. 127 suffer from traumatic SCI of which 84 with associated lesions, and 59 from non-traumatic SCI.
For each patient, impairment, disability, pre-injury comorbidities and post-injury complications were collected using specific scales.
A multiple regression model was used to identify the predictors of SCI-ARMI variations from admission to discharge from the rehabilitation center.
RESULTS: The mean value of SCI-ARMI increases progressively during hospitalization from admission to discharge with a mean variation of 56.9±25.4.
SCI-ARMI values at admission are significantly lower for patients with traumatic than non-traumatic injuries. These differences are no longer present at discharge.
The variation of SCI-ARMI is accounted for by pre-injury comorbidities, the presence of complications during hospitalization and the baseline value of SCI-ARMI. In particular, the SCI-ARMI variation decreases as the severity index (pre-injury comorbidities) increases. Moreover, it decreases as the score of secondary complications increases. Length of hospitalization and time between injury and hospitalization do not affect the observed improvement.
Etiology, location and completeness of lesion do not add relevant information when the initial condition and the presence of complications during hospitalization are included in the regression model.
CONCLUSIONS: The sample size that we are planning to reach at the end of the study will allow to determine which individual complications mainly influence SCI-ARMI and, consequently, achievement of skills.
An accurate predictive model including information on complications will help define the patient's functional prognosis, identify patients with greater rehabilitation needs, and ultimately allow a better targeted resource allocation.


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Dr Sophie Jörgensen
Md, Post-doc
Skåne University Hospital/Lund University


3:15 PM - 3:30 PM


Introduction: As a result of advances in healthcare and rehabilitation, many people with spinal cord injury (SCI) have lived several decades with their injury and into old age. Nevertheless, knowledge of living with long-term SCI into older age is very limited and there is no consensus on how to design rehabilitation interventions and follow-up programs to meet the specific needs of this group. In particular, little is known about changes over time in functioning and disability among older adults with long-term injury. We therefore initiated a large longitudinal study, the Swedish Aging with Spinal Cord Injury Study (SASCIS), including individuals at least 50 years of age and at least 10 years after a traumatic or non-progressive, acquired non-traumatic SCI. The overarching aim of the SASCIS is to increase our knowledge of factors associated with healthy aging in persons with long-term SCI. The aim of the present longitudinal study from the SASCIS is to assess changes in secondary health conditions (SHCs; ie, bowel-related and bladder-related problems, nociceptive and neuropathic pain, spasticity), physical independence and life satisfaction over six years among older adults with long-term SCI.

Methods: From the original SASCIS sample (year 2011-2012), including 123 participants (29% women, injury levels C1-L5, American Spinal Injury Association Impairment Scale (AIS) A-D, mean age 63 years, mean time since injury 24 years), 101 were still alive for the follow-up (year 2017-2018) and the final sample comprised 78 participants (32% women, injury levels C1-L3, AIS A-D, mean age 68 years, mean time since injury 31 years). Data were collected during home interviews using a study-specific questionnaire, the Spinal Cord Independence Measure (SCIM-III) and the Satisfaction With Life Scale (SWLS). Changes from baseline to follow-up were assessed using the Wilcoxon signed-rank test and the McNemar’s test.

Results: The total number of SHCs increased over time (mean 2.0 to 2.5, p=0.002, r=-0.25). More participants reported bowel-related problems (eg, incontinence, constipation; 31% to 47%, p=0.015) and spasticity (41% to 62%, p<0.001) at follow-up. No significant changes were seen in the occurrence of bladder-related problems or pain. Overall physical independence decreased significantly over time (SCIM-III total score mean 67 to 61, p<0.001, r=-0.44), as did independence in all subscales of the SCIM-III. The largest difference was seen in the subscale Respiration and Sphincter Management (mean 32 to 28, p<0.001, r=-0.38). The SWLS total score remained unchanged (mean 21.0 and 21.4, respectively) and just above the midpoint between satisfied and dissatisfied with life.

Conclusions: This is the first study to assess changes over time in SHCs, physical independence and life satisfaction in a population of older adults with long-term SCI in Northern Europe. Over six years, these individuals experienced a medium to large decrease in physical independence and the occurrence of SHCs increased. However, life satisfaction remained relatively high and stable over time, indicating that older adults with long-term SCI receive adequate psychosocial support. The results call for a proactive approach in clinical practice to mitigate the decreasing independence in daily activities and increasing problems with bowel management and spasticity.


I'm a postdoc at Lund University and a resident in rehabilitation medicine at Skåne University Hospital in Sweden. To increase our knowledge of aging with long-term SCI we initiated the Swedish Aging with Spinal Cord Injury Study (SASCIS) in 2010. It is the first longitudinal study on aging with SCI in a Northern European perspective, and the results can be used to design rehabilitation interventions and follow-up programs tailored to older adults with long-term SCI.
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Dr Chloe Lefèvre
University Hospital Of Nantes

Remodelling of the intestinal and bladder epithelial barrier after spinal cord injury and its impact on function in a mouse model.

3:30 PM - 3:45 PM


Introduction :
Spinal cord injured patients have a chronic pathology resulting of progressive pelvic organs dysfunctions (bladder and distal colon). Bladder and distal colon have a similar extrinsic innervation, their dysfunctions (detrusor overactivity, alteration of colonic peristalsis, anal and bladder-sphincter dyssynergia) are partly explained by “neophysiology” induced by the spinal injury. However, epithelial barriers may be involved in the physiopathology of these dysfunctions and their scalability. Involvement of intestinal epithelium and urothelium has been well identified in other pathology resulting of similar dysfunctions such as irritable bowel syndrome or the bladder pain syndrome / interstitial cystitis but there is a scarcity of data reporting their role in chronic visceral dysfunctions related to spinal cord injury (SCI). The objective of this work is to characterize colon and bladder epithelial barriers remodeling after SCI and the impact on their functions.

We used a male mouse model: group SCI by spinal cord transection between T3-T4 vertebrea (SCI group, n=31) and group sham, with a sham operation (n=15). At three weeks post injury, both groups underwent in vivo experimentation to measure distal colonic transit time. Euthanasia was realized at 1 month and bladder and distal colon were removed for tissue processing. Fresh tissues were mounted in Ussing chambers for measurements of bladder and distal colon paracellular permeability to sulfonic acid (SA) (400Da) and transcellular permeability to horseradish peroxidase (HRP) (44kDa). Urothelium superficial cellular morphology was also assessed using Full Field optical coherence tomography (FF-OCT).

Results :
Using FF-OCT, superficial urothelium modifications was observed in SCI group with smaller and more round cells compared to sham group polygonal superficial cells (p<0.01). A higher rate of bi-nucleated small cells was also observed in SCI group (p<0.05), that may correspond to a transitional state between intermediate cells and superficial umbrella cells.
Distal colonic transit time was longer in SCI group compared to sham group (med 6.7min vs 2.7min; p<0.0001). Ussing chambers experiments revealed a decreased HRP permeability in SCI bladder compared to sham bladder (p<0.01), without any difference for SA permeability.
For distal colon, there was no significant difference for HRP and SA permeability between groups. There was no significant difference between sham bladder and sham distal colon for HRP and SA permeability, whereas there was a significant decreased in HRP and AS permeability in SCI bladder compared to SCI distal colon (p<0.01).

Conclusion :
Our preliminary study suggests a predominant bladder urothelial remodeling compared to distal colonic epithelium after chronic SCI. However distal colon peristalsis function seems to be altered.


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Dr Chloe Lefèvre
University Hospital Of Nantes

Efficacy of anterograde irrigation via endoscopic per-cutaneous caecostomy and link with paracellular intestinal permeability in patients with spinal cord injury.

3:45 PM - 4:00 PM


Spinal cord injuries are associated with vegetative deficiencies, in particular neuro-gastroenterological deficiencies. Patients have a difficult feeling with regard to these digestive disorders and the management often seems to them insufficient. Our clinical study, the preliminary results of which are presented here, aims to evaluate the impact of anterograde enemas by caecostomy placed endoscopically. An ancillary study has allowed us to take colonic biopsies and evaluate colonic permeability on different segments (right, transverse, left).

This is a multicentric, randomised, controlled study. To date, the patients included are spinal cord injuries of all levels, with an initial NBD score greater than 14, i.e. severe neurological bowel dysfunction. In the caecostomy group, the device was placed endoscopically and patients were followed up in consultation at M1, M3, M6, M9 and M12. In the control group, maximum medical treatment was continued 12 months before the endoscopic caecostomy was performed and patients were followed up again 12 months after the start of irrigation. The primary endpoint was improvement in the gastrointestinal symptom-related quality of life (GIQLI) score. Secondary endpoints were improvement in NBD score, Kess score, and Cleveland score. The ancillary study aimed to evaluate colonic permeability on different segments (right, transverse, left colon), in Ussing chambers, in comparison with known data from 5 healthy control patients (right colon). The permeability was compared between the different colonic segments, and compared to the results of the irrigations.

To date 15 patients have been included, 4 women and 11 men. The neurological level of the lesion was cervical for 5 patients, thoracic for 9 patients, lumbar for 1 patient. There were 13 spastic patients and 2 flaccid patients. 7 patients were randomized in the per-endoscopic caecostomy (PEC) group and 8 in the control group "continuation of medical treatment" (CT). Colonic biopsies were performed in 10 patients. Treatment with PEC resulted in an increase in quality of life related to gastrointestinal disorders in 90% of cases (mean GIQLI score of 55 before and 86 after PEC). On the other hand, continuing medical treatment alone did not increase the GIQLI score. Constipation improved on the Kess score. Incontinence also improved (Cleveland). Colonic permeability of patients with spinal cord injury was (not significantly) increased compared to healthy patients in the right colon (p=0.1119). There was no significant difference between the right, transverse, left colonic segments (p=0.3854). There was no association between increased intestinal permeability and the success or failure rate of EPC (p=0.8029).

PEC may be part of the algorithm for the management of severe neurological bowel-related constipation in the context of spinal cord injury. Irrigation by anterograde route is effective regardless of the neurological level. To date, colonic permeability does not seem to be a marker of success or failure of anterograde enemas.


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Dr Gianna Rodriguez
Associate Professor
University of Michigan

Comparing Recto-Anal Inhibitory Reflex Parameters in Spinal Cord Injured Subjects Compared to Healthy Controls

4:00 PM - 4:15 PM


Comparing Recto-Anal Inhibitory Reflex Parameters in Spinal Cord Injured Subjects Compared to Healthy Controls
Gianna Rodriguez, Moira Armstrong, Jason R. Baker, Richard Saad, Ellen Wolgat, William Chey

Introduction: Normal defecation requires precise coordination of the rectum, internal and external anal sphincters, pelvic floor muscles modulated by the autonomic nervous system. The Recto-Anal Inhibitory Reflex (RAIR) influences Internal Anal Sphincter (IAS) relaxation in response to rectal distention. RAIR is mediated by the parasympathetic nervous system and is intimately coordinated with the Extrinsic Anal Sphincter (EAS) mediated by the somatic nervous system. Pathophysiology of neurogenic bowel in spinal cord injury is not well elucidated. The use of the High Resolution-Anorectal Manometry (HR-ARM) to evaluate dysfunction in neurogenic bowel in SCI is limited.

Objectives: 1. Compare RAIR parameters (IAS resting pressure, reflex duration(s), and amplitude relaxation (%)) in SCI patients to published healthy control (HC) values (Thiruppathy,K. (2012). DigDs Sci.) 2. Determine correlation between RAIR parameters in SCI level and completeness of injury. 3. Determine correlations between RAIR parameters in SCI injury duration (yrs).

Methods: SCI subjects underwent HR-ARM at a single tertiary care center from July 2018 – February 2020. The RAIR was tested by rapidly inflating 50 ml into the rectal balloon and then immediately deflating. Two attempts were performed to elicit the RAIR response. The presence of RAIR was equated to ≥25% of internal anal sphincter (mmHg) amplitude reduction. RAIR parameters included: IAS resting pressure (mmHg), reflex duration (seconds), and amplitude reduction (%). SCI subject’s RAIR parameters were compared to published HC. Balloon Expulsion Test (BET) was completed in all subjects. Subjects were categorized by AIS level (cervical vs. thoracic) and completeness of injury (A – E). One-sample, independent t-tests, and bivariate correlations were performed. A p-value of less than 0.05 was considered significant.

Results: 35 SCI subjects (cervical = 26, thoracic = 9) underwent HR-ARM. The mean duration of SCI was 26.5 yrs. (SD = 12.6 yrs.; Range: 3 – 56 yrs.). AIS included: A=49%, B=17%, C=6%, D=27%, and E=3%. SCI subjects have significant mean differences, RAIR duration (p= <0.001), and amplitude reduction (p= <0.001), compared to HC. However, there was no significant mean differences in IAS pressure. No significant correlations between SCI injury duration and IAS (r = -.17; p = NS), RAIR duration (r=0.31; p= NS) and amplitude reduction (r=-0.09; p= NS). There were no significant mean differences between AIS level and completeness for RAIR parameters. Interestingly, BET was found to be normal = 17%, abnormal = 83%.

Discussion: There is sparse evidence for the pathophysiology in SCI. Cervical and Thoracic SCI subjects demonstrate RAIRs on HR ARM. These results provide good scientific basis for the use of digital rectal stimulation (DRS) for bowel evacuation effective in promoting anal sphincter relaxation for stool evacuation. HR-ARM may be used in the future to determine the most effective and ideal protocol for DRS for bowel management with regards to duration, frequency and timing. It may be used to determine efficacy of rectal medications and methods for bowel evacuation.


My clinical practice in Physical Medicine and Rehabilitation (PM&R) mainly revolves around evaluation and management of people with Spinal Cord Injuries/Disorders (SCI/Ds) and associated multi-organ complications. Despite a busy clinical practice, I have been actively involved in medical writing and research. In addition to traditional scientific journals, I have written for large, web-based medical journals and for PM&R textbooks. My research efforts and endeavors have focused on collaborative work with specialists in PM&R, Urology, Neurosurgery, Gastroenterology, Gynecology, Pulmonary, Wound Care, Wheelchair Seating who I work with in various clinical settings in interdisciplinary clinics with which I am involved. I have participated in the research projects of the Model Systems SCI Care System and have contributed to the team’s research mission and endeavors. I have authored chapters in a primary textbook for physiatry knowledge and techniques. My current and future interests include SCI/D and its sequelae including neurogenic bladder, neurogenic bladder, respiratory failure, pressure sores, wheelchair seating, community reintegration, etc. In addition, clinical and research mentorship is a significant part of my work with residents and fellows in the Department of PM&R. On a national and international level, I serve on the International Standards Committee and Autonomic Standards Committee of the American Spinal Injury Association (ASIA). These committees bear responsibility for overseeing the development of any new standards documents related to SCI, for continuous review and improvement of the existing ASIA documents on neurological and autonomic standards, and for the development of the online training program for ASIA standards and for the development and oversight of the International Data Sets project. Because I work regularly with a large population of people with spinal cord injuries, I am confident that I can guide the design of the study to best serve the needs of this community.
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Ms Jennifer Coker
Research Associate
Craig Hospital

Evaluation of a self-report method to obtain ASIA Impairment Scale grade in people with traumatic and non-traumatic SCI

4:15 PM - 4:30 PM


INTRODUCTION: The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) are the gold standard classification of spinal cord injury (SCI) severity in research and practice. The American Spinal Injury Association Impairment Scale (AIS), which categorizes motor and sensory impairments, is widely used in research and has been found to predict outcomes after SCI. However, obtaining an AIS grade requires assessment by a trained clinician, and the exam often is not conducted for people with non-traumatic injuries. This limits the use of the ISNCSCI and AIS in research in community-residing people with SCI and people with non-traumatic injuries. The objective of this project was to evaluate a self-report method to determine AIS grade in people with traumatic and non-traumatic SCI.

METHODS: After obtaining IRB approval from participating sites, people with traumatic (tSCI) and non-traumatic SCI (ntSCI) completed an in-person or telephone interview as part of a Neilsen Foundation-funded study. The interview included seven self-report questions regarding functional and physical motor and sensory abilities; an algorithm developed by investigators at the Praxis Spinal Cord Institute was applied to responses to calculate AIS. We then measured the agreement between self-report (SR) and medical record (MR) data using a Cohen's Kappa (κ) statistic and the association between the calculated AIS and the MR AIS using Somers' D index and concordance index (C-index). Separate analyses were conducted for tSCI and ntSCI.

RESULTS: A total of 221 people with tSCI and 74 people with ntSCI were included in this analysis. Participants with tSCI were significantly more often male (78.3% versus 54.1%), younger at the onset of injury (33.8 versus 50.5 years old) and younger at the time of the study (48.7 versus 60.5 years old) than participants with ntSCI.

For individuals with tSCI, agreement between SR and MR was very strong for level of injury (tetraplegia, paraplegia; κ=0.95) and for level of injury (cervical, thoracic, lumbar; κ=0.92). Agreement between SR and MR was substantial for injury completeness (complete, incomplete; κ=0.69) and AIS grade (A, B, C, D; κ=0.73). The Somers’ D and the C-index between the calculated AIS and the MR AIS were high, 0.77 and 0.89, respectively.

For those with ntSCI, agreement between SR and MR was substantial for level of injury (tetraplegia, paraplegia; κ=0.77), level of injury (cervical, thoracic, lumbar; κ=0.86), and injury completeness (complete, incomplete; κ=0.78). The Somers’ D between the calculated AIS and the MR AIS was low (0.37) and the C-Index was moderate (0.69). However, the ntSCI sample was small and there was substantial missing MR AIS data (only 44 participants had complete data).

CONCLUSIONS: Agreement between calculated AIS and MR AIS was high and fairly consistent for people with tSCI, so using the self-report questions is a promising method to generate an AIS grade for that group. For people with ntSCI, the results were less promising, and probably due to low model power owing to the historical lack of AIS assessment in ntSCI. Future research to examine and validate these results in a larger sample is required.


Jennifer Coker, MPH, is a Research Associate in the Research Department at Craig Hospital. Ms. Coker has worked in the field of traumatic SCI for more than 20 years. She obtained a Master of Public Health (MPH) from the Rollins School of Public Health at Emory University in May 2001, where she won the James W. Alley Award for Outstanding Service to Disadvantaged Populations. Ms. Coker is currently a PhD student in the Clinical Sciences program at the University of Colorado-Anschutz Medical Campus. She has presented research at national and international conferences of American Spinal Injury Association (ASIA) where she is Chair of the Early Career Committee, the American Society of Spinal Cord Injury Professionals (ASCIP), the American Congress of Rehabilitation Professionals (ACRM), and the International Spinal Cord Society (ISCoS). Ms. Coker has won several awards for research presentations and publications. She is Co-Project Director for the RMRSIS, Co-Principal Investigator (PI)I for a National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR)-funded multisite randomized clinical trial to increase self-efficacy in people with SCI, and PI for two studies on utilization of complementary and integrative healthcare, one in people with SCI and one in people with TBI. Ms. Coker currently sits on the Board of the Colorado TBI Trust Fund.