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Talking Poster 2

Track 2
Saturday, September 5, 2020
11:00 AM - 12:30 PM
Auditorium - Track 3


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Dr Sonja De Groot
Senior Researcher

Development and usability study of the WHeelchair ExercisE and Lifestyle Study (WHEELS) app

11:00 AM - 11:10 AM


Introduction: Physical inactivity, excessive weight and low vitality are common in wheelchair users with spinal cord injury (SCI) or lower limb amputation. Since mobile applications (apps) are used more and more to support rehabilitation, a mobile app may be a powerful tool to encourage a healthy lifestyle during and after rehabilitation. The aim of this study was to develop and evaluate a digital lifestyle intervention, using a mobile app to stimulate physical activity, healthy diet and relaxation in wheelchair users with spinal cord injury or lower limb amputation.

Methods: Intervention Mapping was used to develop the digital lifestyle intervention. Insights from the literature and focus groups with wheelchair users and rehabilitation professionals (i.e. exercise therapists, physical therapists, occupational therapists and dieticians) were collected to identify key determinants of lifestyle behavior. Subsequently, intervention goals were set, behavioral change strategies were selected, and the app was designed with the input of an expert panel consisting of rehabilitation professionals, health promotion and e-health experts and wheelchair users. The usability and effects of the intervention were investigated in a usability study among 21 wheelchair users (N=14 with SCI) who used the app for 12 weeks. Half of the participants in this usability study used the app stand-alone, and the other half used the app in a blended manner. In the case of blended use, the participant received remote coaching from a lifestyle coach. At the end of the usability study user satisfaction with and usability of the app were assessed using interviews and a short questionnaire.

Results: Given the many functionalities and reach of the existing lifestyle app ‘Virtuagym’, this app was selected and adapted to wheelchair users with SCI or lower limb amputation. Strategies to involve the social environment and to change awareness, knowledge, self-efficacy, attitude and outcome expectations related to physical activity, healthy diet and relaxation were built into the app.
All but 1 completing participants (N=14, 67%) would recommend the app to others and most (N=10) had come closer to one or more lifestyle goals. Several participants had lost weight. There was enthusiasm about the animations showing how to perform the exercises but the ease of use could be improved. Due to the nutrition part, there was an increased awareness about calorie and nutrient intake. However, the algorithm for calculating daily calorie intake advice still needs to be tailored. Lastly, the relaxation part was not much used. Most participants indicated not to have relaxation or sleeping problems.

Conclusions: A mobile lifestyle app was developed that wheelchair users and health professionals can use to stimulate physical activity, healthy diet and relaxation in wheelchair users with spinal cord injury or lower limb amputation. The content and design of the app is based on scientific evidence and behavioral change theory. Insights from the usability study will be used to further develop the lifestyle app. Thereafter, the lifestyle app will be evaluated in a larger study with objective outcome measures.


Sonja de Groot studied Human Movement Sciences and graduated in 1997. She attained her PhD from the Faculty of Human Movement Sciences of the VU University in Amsterdam, the Netherlands. Since 2004, she has worked as a senior researcher at the Reade, Center for Rehabilitation and Rheumatology in Amsterdam. In 2009 she was appointed Assistant Professor at the Center of Human Movement Sciences at the University of Groningen. Dr De Groot was the coordinator of the Dutch multi-center research program titled: 'Restoration of mobility in SCI rehabilitation' and 'ALLRISC' (see: www.nvdg.org/scionn). She is the secretary of the research committee of the Dutch Flemish Spinal Cord Society (DuFScoS). Dr De Groot's current research interests include the study of spinal cord injury rehabilitation, exercise physiology, wheelchair propulsion and configuration, and adapted sports. She has published more than 100 articles in peer-reviewed journals.
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Ms Aimi Forrest
Ventilation And Weaning ESP Physiotherapist
North West Regional Spinal Injuries Centre

A Matter of Life or Death? Factors Impacting on Survival of Adult Spinal Cord Injured Patients Discharged Requiring Long-Term Ventilatory Support from a UK Spinal Injury Centre.

11:10 AM - 11:20 AM



Spinal Cord Injury (SCI) can lead to patients requiring long-term ventilatory support. Data on factors impacting on survival are lacking and most studies are from the USA where the healthcare system is different, or include short-term or non-ventilated patients. We investigated characteristics at discharge on survivability of patients requiring long-term ventilatory support post discharge from an UK SCI centre.


Retrospective analysis was undertaken of the records of 64 adult ventilated patients discharged after their initial SCI admission. Demographics on discharge were recorded including SCI level, ASIA grades, age, gender, nutritional route, traumatic or atraumatic injury, ventilatory status, residential status, and co-morbidities using ICD-10 coding. Survival was analysed until 31/01/2020 using Kaplan-Meier and Cox regression analyses (SPSS).


72% of patients were male. Greater numbers of high SCI (C0-2 n=22, C3-4 n=27) and ASIA A patients (n=41) required ventilation on discharge.

Univariate analysis showed that only age and cancer significantly impacted on overall survival. The median discharge age of survivors and non-survivors was 38 and 59 years respectively (p=0.006). Median survival was 2715 days (CI 95%, 1867-6373). Cumulative survival at 1, 3, 5 and 10 years was 89%, 74%, 63% and 46% respectively. The risk of death overtime was significantly increased with age (HR 1.05, CI 95%, 1.03-1.07, p=0.000) and a cancer diagnosis (HR 3.01, CI 95%, 1.30-6.98, p=0.010). Median (SE) survival time of those with cancer was significantly lower than those without (1580 [1867] versus 7140 [3837], p=0.007).

Non-significant trends (p=0.068) showed those discharged with injuries below C6 had the longest median survival (8220 days), followed by C0-2 (7140 days). Patients with C5-6 injuries on discharge had an increased risk of death compared to those with injury below C6 (HR 9.20, CI 95%, 1.07-79.30, p=0.044).

Compared to normal diet, those receiving enteral feed (HR 2.58, 1.0-6.68, p=0.051) and those having mixed enteral and normal diets (HR 3.15, 1.01-9.85, p=0.049) had trends towards increased mortality risk.

Median survival for those who went home or to temporary placement before home was 7140 days (CI 95%, 1308-12972) whilst those discharged to an institution was 1396 days (CI 95%, 1047-1745). Those going home were 64.5 less likely to die than those going to an institution (HR 0.36, CI 95%, 0.15-0.82, p=0.015). After adjusting for age, discharge location was not significant.


Survival of at least 10 years was 46% although older age increases mortality risk. With the exception of cancer, none of the co-morbidities documented on discharge significantly contributed to likelihood of death. Known co-morbidities maybe monitored well in ventilated SCI community patients. Higher SCI and ASIA grades demonstrated increased ventilatory needs and lower SCIs showed longest cumulative survival. Interestingly, high SCI levels, often ventilator dependent, showed longer survival than mid-cervical SCI who may have had less ventilatory needs. These could have had more risk at times of physiological stress in the community when their ventilatory and secretion clearance needs may have increased.
Increasing the sample of our cohort may increase the likelihood of further significant results in future studies.


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Mr Tim Crul
De Hoogstraat Rehabilitation

Use and experienced effectiveness of non-pharmacological treatments for chronic spinal cord injury related pain in the Netherlands: A cross-sectional survey

11:20 AM - 11:30 AM


Introduction: Chronic pain is a common secondary condition in spinal cord injury (SCI), with an impact on physical, cognitive and emotional wellbeing. SCI-related pain can be distinguished into nociceptive and neuropathic pain. Pharmacological interventions to reduce the pain are associated with an increased risk of side effects, and reported effects of non-pharmacological treatments are unclear. This study aims to get insight into the amount of non-pharmacological treatments used per pain condition, and the effect of commonly used non-pharmacological treatments in daily practice on the different pain conditions.
Methods: A cross-sectional survey is sent to former rehabilitation patients from two Rehabilitation Centres in the Netherlands between July 2016 and July 2018.
Results: A total of 371 participants returned the questionnaire. 262 participants experienced pain following SCI. Neuropathic pain was reported most often (74.4%), followed by musculoskeletal pain (51.5%). Of patients with pain, 78.2% reported past or current use of non-pharmacological treatments for their pain. Most non-pharmacological treatments used were physiotherapy (48.5%), exercise (39.5%), cannabis (19.5%) and massage (17.2%). For all pain conditions, most positive effects were reported for exercise and physiotherapy. For musculoskeletal pain, massage was also reported as effective. For neuropathic pain, TENS was also reported as effective. Most side effects were reported for cannabis and injections.
Conclusion: People with SCI who experience pain often use non-pharmacological pain interventions. The most used are exercise, physiotherapy, cannabis, and massage. This study showed that exercise and physiotherapy are most often perceived as effective, without a difference between the different pain conditions. More comparative research is needed into the effectiveness of non-pharmacological interventions.


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Dr Ralph Marino
Thomas Jefferson University

Relationships among impairment, capabilities, self-care and fine motor activities with and without equipment in persons with cervical spinal cord injury at discharge from rehabilitation

11:30 AM - 11:40 AM


Introduction: Persons with cervical spinal cord injury (SCI) often use assistive technology or devices (AT) to increase independence. There is little information on the impact of AT on function or the injury characteristics of those who benefit from AT. The purpose of this project was to explore the impact of AT on self-care (SC) and fine motor (FM) function in persons with cervical SCI, and to examine the functional capabilities of those who benefit from AT.
Methods: Subjects were persons with acute cervical SCI, all levels and AIS grades, with an upper extremity motor score (UEMS) > 0. At discharge from rehabilitation, we obtained the UEMS, the Capabilities of Upper Extremity questionnaire (CUE-Q), and the combined SC and FM questions of the SCI Functional Index (SCI-FI) and SCI-FI/AT short forms. The arm with the highest CUE-Q side score was designated the better side. Correlations among the measures were assessed using Spearman correlation coefficients. The impact of AT on SC and FM function was evaluated by looking at the difference in SCI-FI and SCI-FI/AT scores. The impact of AT was also evaluated by severity of injury: high tetraplegia (best motor level C4-C5), low tetraplegia (best motor level C6-T1), and motor complete (MC) vs. motor incomplete (MI).
Results: Subjects included 63 males and 20 females with cervical SCI, 30 MC, 53 MI, average age 43.6 +/- 16.4 years. The total scores of SC, SC/AT, FM AND FM/AT had correlations with the UEMS ranging from 0.77-0.79, with the total CUE-Q scores ranging from 0.84-0.88, and with CUE-Q better side score ranging from 0.83-0.86. Overall, 55.4% of participants improved with AT by at least one item in SC, and 43.4% improved in FM. Of the injury severity groups, the greatest number of participants improving with AT in SC was MC low tetraplegia (88.2%), with MI low tetraplegia the fewest (33.3). For FM tasks, the greatest number improving with AT was MC high tetraplegia (69.2%), and again participants with MI low tetraplegia the fewest (22.2%). For SC, AT helped most often with brushing teeth (45.1%), while for FM it was using a cell phone (31.2%). CUE-Q scores of the best arm and hand increased (p< 0.05) for persons who could not brush teeth with or without equipment (mean ARM = 10.7 ± 8.3; HAND = 2.1 ± 4.6 points), were helped by equipment (mean ARM = 23.7 ± 7.7; HAND = 9.0 ± 6.7 points), or had no improvement with equipment (mean ARM = 28.6 ± 6.9; HAND = 16.2 ± 7.0 points).
Conclusion: Many persons with tetraplegia are able to perform self-care and fine motor tasks easier using AT, but the benefit depends on the level and severity of injury. Persons with moderate deficits in arm and hand function benefit the most. Future work will evaluate changes in the impact of AT after discharge from rehabilitation.


Ralph J. Marino, MD is Professor of Rehabilitation Medicine at the Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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Dr Vanessa Noonan
Director, Research And Best Practice Implementation
Praxis Spinal Cord Institute

Updates to the National Institute of Neurological Disorders and Stroke (NINDS) Spinal Cord Injury (SCI) Common Data Element Recommendations

11:40 AM - 11:50 AM


Introduction: As part of a continuing review, the NINDS Spinal Cord Injury (SCI) Common Data Element (CDE) project convened the SCI CDE Oversight Committee (OC) in March 2018 to update the SCI CDEs and the International SCI Data Sets. Comprised of subject matter experts from domestic and international research, industry, and patient advocates the NINDS SCI CDE OC periodically reviews the SCI CDEs based on recommendations and feedback to make decisions regarding suggested corrections and updates. This review ensures that the SCI CDEs remain a current and useful tool for investigators and their research teams.

Methods: Version 1.0 of the adult SCI and pediatric SCI CDEs were posted to the NINDS CDE website in 2014 and 2016, respectively, with an OC update in 2016 as well. In 2018, the SCI OC began a comprehensive review of the SCI CDE recommendations by domain and evaluated whether the current CDE or measure classifications were still accurate; considered new CDEs or measures to recommend for inclusion; and indicated a context for use for those measures classified as Supplemental–Highly Recommended. The SCI OC also developed and systematically applied classification criteria to facilitate their review and recommendations of the SCI CDEs.

Results: Following review of 87 SCI measures, the SCI OC determined that eight should be reclassified from Exploratory to Supplemental, seven from Supplemental to Exploratory, two from Supplemental to Supplemental – Highly Recommended, and one from Supplemental – Highly Recommended to Supplemental. The SCI OC also recommended the inclusion of two new measures, the Spinal Cord Ability Ruler and the Mini-Balance Evaluation Systems Test (MiniBESTest), and the removal of six measures, THAQ, ABLE Scale, Berlin Questionnaire, FOSQ, Infant Sleep Questionnaire and the OSA-18. Summary documents of these 87 SCI measures will be posted on the NINDS CDE website in Spring 2020 for public review before they are finalized and available on the website in late Summer 2020. Of the 1,882 SCI CDEs, 69 were downgraded from Supplemental to Exploratory and 5 were upgraded from Supplemental to Supplemental – Highly Recommended. Finally, of the 28 International SCI Data Sets, the SCI OC reclassified three from Supplemental to Exploratory, four from Supplemental to Supplemental – Highly Recommended and one from Supplemental – Highly Recommended to Supplemental. The recommended updates to the SCI CDEs and International SCI Data Sets will also be reviewed by the research community prior to finalizing.

Conclusions: The NINDS encourages the use of CDEs for clinical research in neuroscience. The SCI OC is working with the NINDS and SCI organizations to promote the uptake and use of the SCI CDEs.


Dr. Vanessa Noonan is a physical therapist and the focus of her research and clinical practice has been in the area of spinal cord injury. Clinically, she has practiced in both the SCI acute and rehabilitation settings. Her research examines processes and outcomes of care following SCI rehabilitation, with the goal of moving research into practice and creating standards of care. Vanessa obtained her PhD from the UBC School of Population and Public Health in 2009. Her doctoral thesis examined measures of participation in persons with SCI that are based on the International Classification of Functioning, Disability and Health (ICF) model. She later received a post-doctoral fellowship award from the National Institute on Disability and Rehabilitation Research and had the opportunity to work with the NIH-sponsored project PROMIS (Patient-Reported Outcomes Measurement Information System) at the University of Washington. As Director of Research & Best Practice Implementation, Vanessa is responsible for leading translational research and best practice implementation projects at Praxis Spinal Cord Institute. She has been actively involved with the Rick Hansen Spinal Cord Injury Registry since it started in 2002 and co-led the development of a new community follow-up questionnaire for the Registry. In addition, she is part of the International SCI Data Set Committee, which has overseen the development of 16 data sets that are used internationally.
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Prof Muneharu Ando
Kansai Medical University

Clinical feasibility of muscle evoked potential after electrical stimulation to the spinal cord during spine and spinal cord surgery, rationale and clinical relevance

11:50 AM - 12:00 PM


Background: Muscle evoked potentials after electrical stimulation of the spinal cord [Sp(E)-MsEPs] serve well to monitor spine and spinal cord surgeries. The pathway for this recording remains unsettled as some argue it may involve the posterior cord, which then can activate the motoneurons through antidromic sensory impulse. We wish to document that this technique, in fact, monitor the motor tract through the corticospinal trunk.
Methods: Study 1 analyzed the data from10 consecutive myelopathic patients who underwent a posterior spinal surgery for cervical spondylosis or ossification of the ligamentum flavum of the thoracic spine. We applied a train stimulation, 5 shocks at interstimulus interval of 2 ms, as follows: 1) transcranial stimulation to the brain, 2) epidural stimulation to the spinal cord and 3) both 1) and 2) simultaneously and recorded MsEPs from the abductor hallucis muscle (AH). Study 2 dealt with an investigation in 4 patients, who underwent paired train stimulation to the spinal cord at intertrain interval of 50 ms for recording AH-MsEPS.
Results: In study 1, stimulation of the spinal cord and combined stimulation of the brain and spinal cord elicited the nearly the same AH-MsEPs in all 10 patients. In study 2, the first and second train stimuli elicited almost identical AH responses in all 4 patients.
Discussion: The study 1 data suggest that the corticospinal tract volley elicited by brain stimulation collide with the antidromic volley induced by spinal cord stimulation, which, therefore, must activate the corticospinal tracts. In study 2, a full recovery of MsEPs elicited by paired train stimulation by 50 ms also speaks for mediation via the corticospinal tract known to have a quick recovery time of less than 60 ms (Deletis 2018). This stands in contrast to a partial recovery time of approximately 70 ms and a complete recovery time of over 150–300 ms for the dorsal column (Shils 2012),which would have blocked the second of the paired stimuli given 50ms after the first.
Conclusion: The Sp(E)-MsEP, mediated by the corticospinal tract, can serve to monitor the motor tract of the spinal cord.


School Attended: April 1979 - March 1985; Wakayama Medical College, Japan April 1987 - March 1991; Graduate Course of Wakayama Medical College, Japan Education and licensure: April 1985; M.D. Wakayama Medical College May 1985; Ministry of Health and Welfare, Japan March 1991; Ph.D. (Dr. of Medical Science) No. A184, Wakayama Medical College (Thesis: A study on the effect of ulnar nerve stimulation to the somatosensory evoked potential following the median nerve stimulation.) February 1992; Board-certificated Orthopaedics No. 109240, Japanese Orthopaedic Association October 2003; Board-certificated Spine Surgeon (approved by the Board of the Japanese Society for Spine Surgery and Related Research) No. 10553 March 2006; Board-certificated Spine Surgeon No. 117, Japanese Orthopaedic Association October 2017; Board-certificated Clinical Neurophysiology Instructor (EMG/NCS section) No. 33, Japanese Society of Clinical Neurophysiology Professional Training and Employment: April 1985 - March 1987; 2-year postgraduate program at Wakayama Medical College Hospital, Japan August 1988 - August 1989; Research fellow, Division of Clinical Electrophysiology, Department of Neurology, University of Iowa, USA April 1991 - March 1994; Medical staff of Department of Orthopedic Surgery, Hashimoto Municipal Hospital, Japan April 1994 - December; 2000; Medical staff of Department of Orthopedic Surgery, Wakayama Medical University, Japan January 2001 - October 2002; Director of Department of Orthopedic Surgery, Shingu Medical Center, Japan November 2002 – March 2007; Assistant Professor of Department of orthopedic Surgery, Wakayama Medical University, Japan April 2007 - December 2017; Director of Spine Center, Wakayama Rosai Hospital, Japan January 2018 – Jun 2018 ; Deputy of Wakayama Rosai hospital July 2018 – March 2019 ; Professor of Department of Orthopedic Surgery, Kansai Medical University Medical Center, Japan April 2019 – ; Professor of Department of Orthopedic Surgery, Kansai Medical University, Japan Award ; Scientific Achievement Award, American Society of Neurophysiological Monitoring. 2017