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Background/Objective: The purpose of this study was to investigate the impact of the COVID-19 pandemic on mortality rates in a community-dwelling spinal cord injury (SCI) population in Ontario. Methods: Using health administrative databases, monthly mortality rates were evaluated pre-pandemic, during the pandemic, and post-pandemic from March 2014 to May 2024. Data were stratified by sex, injury etiology, and mental health status. Group differences were evaluated using t-tests. Autoregressive integrated moving average (ARIMA) models evaluated the pandemic's impact on mortality rates. Results: A significant increase of 21.4% in mortality rates during the pandemic was found for the SCI cohort. With the exception of the traumatic group, all subgroups also experienced a significant increase in mortality rates (males: 13.9%, females: 31.9%, non-traumatic: 32.3%, mental health diagnoses: 19.6%, and mental health diagnoses: 29.4%). During the pandemic, females had a significantly higher mortality rate than males. The non-traumatic group had higher mortality rates than the traumatic group at all time periods. Individuals with mental health diagnoses had higher mortality rates than those without at the pre-pandemic and pandemic periods. Conclusions: The variation in mortality rates across groups highlights inequitable access to medical care in the SCI population, with further research and interventions needed. [ABSTRACT FROM AUTHOR]

Persons with disabilities experience numerous barriers to healthcare access including vaccine accessibility. The purpose of this study was to determine COVID-19 vaccine uptake in the spinal cord injury and disease (SCI/D) population of Ontario and identify potential factors influencing C OVID-19 vaccine uptake. This was a retrospective closed-cohort study using administrative health data on individuals with SCI/D of traumatic and non-traumatic causes to examine the monthly number of COVID-19 vaccine doses received between December 2020 and December 2023. Logistic regression analysis was used to examine the potential association between socio-demographic, clinical, and neighbourhood characteristics with initial COVID-19 vaccine receipt and booster dose uptake. By the end of the observation period in December 2023, 82.9% received the full two-dose coverage and 65.6% received at least one additional booster dose in a cohort of 3574 individuals with SCI/D. SCI/D individuals showed a comparable COVID-19 vaccine uptake percentage to the general population. Sociodemographic, clinical, and neighbourhood characteristics were associated with COVID-19 vaccine uptake in the SCI/D population, including age, type of injury, number of comorbidities, mental health history, and neighbourhood characteristics such as income. Further investigation is necessary to determine the causation effects of these relationships with vaccine uptake to address health equity concerns. [ABSTRACT FROM AUTHOR]

In British Columbia (BC), there are challenges accessing specialized spinal cord injury care and resources. This paper evaluated the impact of spinal cord injury health educational workshops delivered in regional communities that were informed by persons with lived experience. A community survey was conducted with 44 persons with lived experience in a BC region to identify priority SCI health-related topics. Twenty-five topics were ranked from 1–14, with bowel and bladder management ranked 1 and 4, sexual health ranked 5, and pressure injuries ranked 7. Clinical perspectives on the priorities were collected from 102 clinicians in the BC region, who independently ranked 14 of these SCI topics and considered the former 4 topics to be lower clinical priority (ranked 11–14). These priorities informed a series of SCI clinical education workshops held at healthcare facilities in three regional cities. The goals were to improve clinicians' knowledge and confidence levels when managing spinal cord injury health and to facilitate person-centred care. Positive feedback demonstrated that educational workshops supported by lived experience perspectives effectively enhanced the clinicians' understanding of spinal cord injury and their priorities. Future plans include engaging more administrators as part of this initiative and conducting workshops in other regions of BC. [ABSTRACT FROM AUTHOR]

Introduction: Increased mortality after acute and chronic spinal cord injury (SCI) remains a challenge and mandates a better understanding of the factors contributing to survival in these patients. This study investigated whether body mass index (BMI) measured after acute traumatic SCI is associated with a change in mortality. Methods: A prospective longitudinal cohort study was conducted with 742 patients who were admitted to the Acute Spine Unit of the Vancouver General Hospital between 2004 and 2016 with a traumatic SCI. An investigation of the association between BMI on admission and long-term mortality was conducted using classification and regression tree (CART) and generalized additive models (spline curves) from acute care up to 7.7 years after SCI (chronic phase). Multivariable models were adjusted for (i) demographic factors (e.g., age, sex, and Charlson Comorbidity Index) and (ii) injury characteristics (e.g., neurological level and severity and Injury Severity Score). Results: After the exclusion of incomplete datasets (n = 602), 643 patients were analyzed, of whom 102 (18.5%) died during a period up to 7.7 years after SCI. CART identified three distinct mortality risk groups: (i) BMI: > 30.5 kg/m2, (ii) 17.5-30.5 kg/m2, and (iii) < 17.5 kg/m2. Mortality was lowest in the high BMI group (BMI > 30.5 kg/m2), followed by the middle-weight group (17.5-30.5 kg/m2), and was highest in the underweight group (BMI < 17.5 kg/m2). High BMI had a mild protective effect against mortality after SCI (hazard ratio 0.28, 95% CI: 0.09-0.88, p = 0.029), concordant with a modest "obesity paradox". Moreover, being underweight at admission was a significant risk factor for mortality up to 7.7 years after SCI (hazard ratio 5.5, 95% CI: 2.34-13.17, p < 0.001). Discussion: Mortality risk (1 month to 7.7 years after SCI) was associated with differences in BMI at admission. Further research is needed to better understand the underlying mechanisms. Given an established association of BMI with metabolic determinants, these results may suggest unknown neuro-metabolic pathways that are crucial for patient survival. [ABSTRACT FROM AUTHOR]

Introduction: Multimorbidity, defined as the coexistence of two or more health conditions, is common in persons with spinal cord injury (SCI). Network analysis is a powerful tool to visualize and examine the relationship within complex systems. We utilized network analysis to explore the relationship between 30 secondary health conditions (SHCs) and health outcomes in persons with traumatic (TSCI) and non-traumatic SCI (NTSCI). The study objectives were to (1) apply network models to the 2011-2012 Canadian SCI Community Survey dataset to identify key variables linking the SHCs measured by the Multimorbidity Index-30 (MMI-30) to healthcare utilization (HCU), health status, and quality of life (QoL), (2) create a short form of the MMI-30 based on network analysis, and (3) compare the network-derived MMI to the MMI-30 in persons with TSCI and NTSCI. Methods: Three network models (Gaussian Graphical, Ising, and Mixed Graphical) were created and analyzed using standard network measures (e.g., network centrality). Data analyzed included demographic and injury variables (e.g., age, sex, region of residence, date, injury severity), multimorbidity (using MMI-30), HCU (using the 7-item HCU questionnaire and classified as "felt needed care was not received" [HCU-FNCNR]), health status (using the 12-item Short Form survey [SF-12] Physical and Mental Component Summary [PCS-12 and MCS-12] score), and QoL (using the 11- item Life Satisfaction questionnaire [LiSAT-11] first question and a single item QoL measure). Results: Network analysis of 1,549 participants (TSCI: 1137 and NTSCI: 412) revealed strong connections between the independent nodes (30 SHCs) and the dependent nodes (HCU-FNCNR, PCS-12, MCS-12, LiSAT-11, and the QoL score). Additionally, network models identified that cancer, deep vein thrombosis/pulmonary embolism, diabetes, high blood pressure, and liver disease were isolated. Logistic regression analysis indicated the network-derived MMI-25 correlated with all health outcome measures (p <0.001) and was comparable to the MMI-30. Discussion: The network-derived MMI-25 was comparable to the MMI-30 and was associated with inadequate HCU, lower health status, and poor QoL. The MMI-25 shows promise as a follow-up screening tool to identify persons living with SCI at risk of having poor health outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Following a traumatic spinal cord injury (SCI) it is critical to document the level and severity of injury. Neurological recovery occurs dynamically after injury and a baseline neurological exam offers a snapshot of the patient's impairment at that time. Understanding when this exam occurs in the recovery process is crucial for discussing prognosis and acute clinical trial enrollment. The objectives of this study were to: (1) describe the trajectory of motor recovery in persons with acute cervical SCI in the first 14 days post-injury; and (2) evaluate if the timing of the baseline neurological assessment in the first 14 days impacts the amount of motor recovery observed. Methods: Data were obtained from the Rick Hansen Spinal Cord Injury Registry (RHSCIR) site in Vancouver and additional neurological data was extracted from medical charts. Participants with a cervical injury (Cl-Tl) who had a minimum of three exams (including a baseline and discharge exam) were included. Data on the upper-extremity motor score (UEMS), total motor score (TMS) and American Spinal Injury Association (ASIA) Impairment Scale (AIS) were included. A linear mixed-effect model with additional variables (AIS, level of injury, UEMS, time, time², and TMS) was used to explore the pattern and amount of motor recovery over time. Results: Trajectories of motor recovery in the first 14 days post-injury showed significant improvements in both TMS and UEMS for participants with AIS B, C, and D injuries, but was not different for high (CI-4) vs. low (C5-T1) cervical injuries or AIS A injuries. The timing of the baseline neurological examination significantly impacted the amount of motor recovery in participants with AIS B, C, and D injuries. Discussion: Timing of baseline neurological exams was significantly associated with the amount of motor recovery in cervical AIS B, C, and D injuries. Studies examining changes in neurological recovery should consider stratifying by severity and timing of the baseline exam to reduce bias amongst study cohorts. Future studies should validate these estimates for cervical AIS B, C, and D injuries to see if they can serve as an "adjustment factor" to control for differences in the timing of the baseline neurological exam. [ABSTRACT FROM AUTHOR]

Introduction: Several clinical prediction rules (CPRs) have been published, but few are easily accessible or convenient for clinicians to use in practice. We aimed to develop, implement, and describe the process of building a web-based CPR for predicting independent walking 1-year after a traumatic spinal cord injury (TSCI). Methods: Using the published and validated CPR, a front-end web application called "Ambulation" was built using HyperText Markup Language (HTML), Cascading Style Sheets (CSS), and JavaScript. A survey was created using QualtricsXM Software to gather insights on the application's usability and user experience. Website activity was monitored using Google Analytics. Ambulation was developed with a core team of seven clinicians and researchers. To refine the app's content, website design, and utility, 20 professionals from different disciplines, including persons with lived experience, were consulted. Results: After 11 revisions, Ambulation was uploaded onto a unique web domain and launched (www.ambulation.ca) as a pilot with 30 clinicians (surgeons, physiatrists, and physiotherapists). The website consists of five web pages: Home, Calculation, Team, Contact, and Privacy Policy. Responses from the user survey (n = 6) were positive and provided insight into the usability of the tool and its clinical utility (e.g., helpful in discharge planning and rehabilitation), and the overall face validity of the CPR. Since its public release on February 7, 2022, to February 28, 2023, Ambulation had 594 total users, 565 (95.1%) new users, 26 (4.4%) returning users, 363 (61.1%) engaged sessions (i.e., the number of sessions that lasted 10 seconds/longer, had one/more conversion events e.g., performing the calculation, or two/more page or screen views), and the majority of the users originating from the United States (39.9%) and Canada (38.2%). Discussion: Ambulation is a CPR for predicting independent walking 1-year after TSCI and it can assist frontline clinicians with clinical decision-making (e.g., time to surgery or rehabilitation plan), patient education and goal setting soon after injury. This tool is an example of adapting a validated CPR for independent walking into an easily accessible and usable web-based tool for use in clinical practice. This study may help inform how other CPRs can be adopted into clinical practice. [ABSTRACT FROM AUTHOR]

This article provides an overview of the epidemiology, evidence-based care, and outcomes of spinal cord injury (SCI). It discusses studies on the incidence and prevalence of traumatic SCI in Canada and China, as well as the co-occurrence of traumatic brain injury (TBI) and SCI. The article also explores evidence-based approaches to care and patient outcomes, emphasizing the importance of timely knowledge translation. Various research efforts and studies related to SCI are described, including the development of an ambulation tool website, the use of machine learning to improve outcomes, and the evaluation of assessment tools and interventions. The article highlights the significance of these studies in improving knowledge and outcomes for individuals with SCI and their families. [Extracted from the article]

Introduction: Traumatic spinal cord injury (tSCI) is a debilitating neurological condition resulting in lifelong disability for many individuals. The primary objectives of our study were to describe national trends in incident emergency department (ED) visits for tSCI among children (less than 21 years) in the United States, and to determine the proportion of visits that resulted in immediate hospitalization each year, including stratified by age and sex. Secondary objectives were to examine associations between select characteristics and hospitalization following tSCI, as well as to assess sportsrelated tSCIs over time, including by individual sport and geographic region. Methods: We used the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample to identify ED visits among children between January 2016 and December 2020 for incident tSCI. Diagnosis codes were used to identify tSCI and sports-related injury etiologies. Census Bureau data were used to approximate annual rates of pediatric ED visits for tSCI per 100,000 children. Unconditional logistic regression modeling assessed whether select factors were associated with hospital admission. Results: We found that the annual ED visit rate for tSCI remained relatively stable between 2016 and 2020, with approximately 2,200 new all-cause pediatric ED visits for tSCI annually. Roughly 70% of ED visits for tSCI resulted in hospitalization; most ED visits for tSCI were by older children (15–20 years) and males, who were also more often admitted to the hospital. Notable secondary findings included: (a) compared with older children (15–20 years), younger children (10–14 years) were less likely to be hospitalized immediately following an ED visit for tSCI; (b) patient sex and race were not associated with hospital admission; and (c) American tackle football was the leading cause of sports-related ED visits for tSCI among children. Our findings also suggest that the proportion of sports-related tSCI ED visits may have increased in recent years. Discussion: Future research should further examine trends in the underlying etiologies of pediatric tSCI, while assessing the effectiveness of new and existing interventions aimed at tSCI prevention. [ABSTRACT FROM AUTHOR]

Objective The Standing and Walking Assessment Tool (SWAT) standardizes the timing and content of walking assessments during inpatient rehabilitation by combining 12 stages ranging from lowest to highest function (0, 0.5, 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B, 3C, and 4) with 5 standard measures: the Berg Balance Scale, the modified Timed "Up & Go" test, the Activities-specific Balance Confidence Scale, the modified 6-Minute Walk Test, and the 10-Meter Walk Test (10MWT). This study aimed to determine if the SWAT at rehabilitation discharge could predict outdoor walking capacity 1-year after discharge in people with traumatic spinal cord injury. Methods This retrospective study used data obtained from the Rick Hansen Spinal Cord Injury Registry from 2014 to 2020. Community outdoor walking capacity was measured using the Spinal Cord Independence Measure III (SCIM III) outdoor mobility score obtained 12 (±4) months after discharge. Of 206 study participants, 90 were community nonwalkers (ie, SCIM III score 0–3), 41 were community walkers with aids (ie, SCIM III score 4–6), and 75 were independent community walkers (ie, SCIM III score 7–8). Bivariate, multivariable regression, and an area under the receiver operating characteristic curve analyses were performed. Results At rehabilitation discharge, 3 significant SWAT associations were confirmed: 0–3A with community nonwalkers, 3B/higher with community walkers with and without an aid, and 4 with independent community walkers. Moreover, at discharge, a higher (Berg Balance Scale, Activities-specific Balance Confidence Scale), faster (modified Timed "Up & Go," 10MWT), or further (10MWT) SWAT measure was significantly associated with independent community walking. Multivariable analysis indicated that all SWAT measures, except the 10MWT were significant predictors of independent community walking. Furthermore, the Activities-Specific Balance Confidence Scale had the highest area under the receiver operating characteristic score (0.91), demonstrating an excellent ability to distinguish community walkers with aids from independent community walkers. Conclusion The SWAT stage and measures at discharge can predict community outdoor walking capacity in persons with traumatic spinal cord injury. Notably, a patient's confidence in performing activities plays an important part in achieving walking ability in the community. Impact The discharge SWAT is useful to optimize discharge planning. [ABSTRACT FROM AUTHOR]

Introduction: Incidence and prevalence data are needed for the planning, funding, delivery and evaluation of injury prevention and health care programs. The objective of this study was to estimate the Canadian traumatic spinal cord injury (TSCI) incidence, prevalence and trends over time using national-level health administrative data. Methods: ICD-10 CA codes were used to identify the cases for the hospital admission and discharge incidence rates of TSCI in Canada from 2005 to 2016. Provincial estimates were calculated using the location of the admitting facility. Age and sex-specific incidence rates were set to the 2015/2016 rates for the 2017 to 2019 estimates. Annual incidence rates were used as input for the prevalence model that applied annual survivorship rates derived from life expectancy data. Results: For 2019, it was estimated that there were 1,199 cases (32.0 per million) of TSCI admitted to hospitals, with 123 (10% of admissions) in-hospital deaths and 1,076 people with TSCI (28.7 per million) were discharged in Canada. The estimated number of people living with TSCI was 30,239 (804/million); 15,533 (52%) with paraplegia and 14,706 (48%) with tetraplegia. Trends included an increase in the number of people injured each year from 874 to 1,199 incident cases (37%), an older average age at injury rising from 46.6 years to 54.3 years and a larger proportion over the age of 65 changing from 22 to 38%, during the 15-year time frame. Conclusion: This study provides a standard method for calculating the incidence and prevalence of TSCI in Canada using national-level health administrative data. The estimates are conservative based on the limitations of the data but represent a large Canadian sample over 15 years, which highlight national trends. An increasing number of TSCI cases among the elderly population due to falls reported in this study can inform health care planning, prevention strategies, and future research. [ABSTRACT FROM AUTHOR]

Background: Substantial literature has highlighted the importance of patient-reported outcome and experience measures (PROMs and PREMs, respectively) to collect clinically relevant information to better understand and address what matters to patients. The purpose of this systematic review is to synthesize the evidence about how healthcare providers implement individual-level PROMs and PREMs data into daily practice. Methods: This mixed methods systematic review protocol describes the design of our synthesis of the peer-reviewed research evidence (i.e., qualitative, quantitative, and mixed methods), systematic reviews, organizational implementation projects, expert opinion, and grey literature. Keyword synonyms for "PROMs," PREMs," and "implementation" will be used to search eight databases (i.e., MEDLINE, CINAHL, PsycINFO, Web of Science, Embase, SPORTDiscus, Evidence-based Medicine Reviews, and ProQuest (Dissertation and Theses)) with limiters of English from 2009 onwards. Study selection criteria include implementation at the point-of-care by healthcare providers in any practice setting. Eligible studies will be critically appraised using validated tools (e.g., Joanna Briggs Institute). Guided by the review questions, data extraction and synthesis will occur simultaneously to identify biographical information and methodological characteristics as well as classify study findings related to implementation processes and strategies. As part of the narrative synthesis approach, two frameworks will be utilized: (a) Consolidated Framework for Implementation Research (CFIR) to identify influential factors of PROMs and PREMs implementation and (b) Expert Recommendations for Implementing Change (ERIC) to illicit strategies. Data management will be undertaken using NVivo 12TM. Discussion: Data from PROMs and PREMs are critical to adopt a person-centered approach to healthcare. Findings from this review will guide subsequent phases of a larger project that includes interviews and a consensus-building forum with end users to create guidelines for implementing PROMs and PREMs at the point of care. Systematic review registration: PROSPERO CRD42020182904. [ABSTRACT FROM AUTHOR]

Background: Timely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement.Methods: This record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013-2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications.Results: Inclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p < 0.01) but higher ICISS (p < 0.001), cervical injury (p < 0.01), and transferred by air-ambulance (p < 0.01). Indirect transfer to SCIU was more likely with two or more additional traumatic injuries (p < 0.01) or incomplete injury (p < 0.01). Patients not admitted to SCIU at all were older (p = 0.05) with lower levels of injury (p < 0.01). Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, p < 0.001). Complications included pressure injury, deep vein thrombosis, urinary infection, among others.Conclusions: Getting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. Methods: We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria.Results: We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [−0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization.Conclusions: This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions. [ABSTRACT FROM AUTHOR]

Background. Spinal cord injury (SCI) is a complex medical condition that can be difficult to monitor. Purpose. This study aimed to establish a common set of validated outcome measures specifically for SCI clinical practice. Method. In a three-round online Delphi process, experts in SCI care across Canada suggested and ranked outcome measures for clinical practice. The facilitators provided feedback between rounds and determined if consensus (at least 75% agreement) was reached on a single outcome measure per clinical area. Findings. One hundred and forty-eight outcome measures were initially considered for inclusion. After three rounds, consensus was reached for 23 out of 30 clinical areas. In the remaining seven, more than one outcome measure was recommended. The final toolkit comprises 33 outcome measures with sufficient measurement properties for use with a SCI population. Implications. An outcome measures toolkit validated specifically for SCI should lead to improved identification of best practice and enable clinicians to monitor client progress effectively. [ABSTRACT FROM AUTHOR]