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Study design Feasibility and preliminary clinical efficacy analysis in a single-arm interventional study. Objectives We developed a brain-computer interface-triggered functional electrical stimulation therapy (BCI-FEST) system for clinical application and conducted an interventional study to (1) assess its feasibility and (2) understand its potential clinical efficacy for the rehabilitation of reaching and grasping in individuals with sub-acute spinal cord injury (SCI). Setting Spinal cord injury rehabilitation hospital-Toronto Rehabilitation Institute-Lyndhurst Centre. Methods Five participants with sub-acute SCI completed between 12 and 40 1-hour sessions using BCI-FEST, with up to 5 sessions a week. We assessed feasibility by measuring participants' compliance with treatment, the occurrence of adverse events, BCI sensitivity, and BCI setup duration. Clinical efficacy was assessed using Functional Independence Measure (FIM) and Spinal Cord Independence Measure (SCIM), as primary outcomes. In addition, we used two upper-limb function tests as secondary outcomes. Results On average, participants completed 29.8 sessions with no adverse events. Only one of the 149 sessions was affected by technical challenges. The BCI sensitivity ranged between 69.5 and 80.2%, and the mean BCI setup duration was ~11 min. In the primary outcomes, three out of five participants showed changes greater than the minimal clinically important differences (MCIDs). Additionally, the mean change in secondary outcome measures met the threshold for detecting MCID as well; four out of five participants achieved MCID. Conclusions The new BCI-FEST intervention is safe, feasible, and promising for the rehabilitation of reaching and grasping after SCI.

First Place Award Submission - CA147Category: Clinical ApplicationManagement of obesity after spinal cord injury: a systematic reviewMir Hatef Shojaei1, Mohammad Alavinia1, B. Catharine Craven1,21N...

To examine agreement between digitized tracing and digital photography methods in measuring wound area and healing rate, and to compare and contrast the 2 methods on feasibility and utility in patient care and research settings.Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.A total of 20 subjects aged 18 years or older with a spinal cord injury and pressure ulcers that were Stage II or higher, and who had received in- or outpatient wound care at the hospital for at least 3 consecutive weeks.Wound area was measured at weekly intervals. One assessor calculated wound area from a digitized tracing. A second assessor calculated wound area using a wound photograph. Both assessors used Image-J software. The 2 methods were compared for differences in weekly wound area and weekly healing rate.Methods were different for wound area (P.0001), whereas there was no difference between methods in weekly healing rate (P = .9429).The 2 methods are in agreement on the important parameter of healing rate. Both methods are feasible in clinical settings. Wound photography may be more useful than digitized tracings because it simultaneously captures wound appearance.

Previous work has shown that information technology (IT), such as personal computers and other digital devices (e.g. tablets, laptops, etc.), software, online resources and hand-held communication tools (e.g. cellphones), has benefits for health and well-being for persons with chronic health conditions. To date, the ways that persons with spinal cord injury (SCI) use IT in their daily activities has not been fully explored. Thus, the purpose of the study was to obtain an in-depth perspective of how people with SCI regularly use IT to gain insight on ways IT can be used to support health and well-being in the community for this population.Semi-structured interviews were conducted with community-dwelling persons with SCI (N = 10) who identified themselves as frequent-or-daily-users of IT. Qualitative content analysis was used to identify the ways that persons with SCI use personal IT.Ten themes related to IT use were identified: (1) Modifications allowing access to IT; (2) Convenience of IT and its perceived value; (3) IT as a scheduler/planner; (4) Challenges; (5) Contributions of IT to participation; (6) Access to information; (7) Influence of IT on well-being; (8) IT as a connector; (9) Issues of IT acquisition; and (10) Desires for future devices/technology.The findings suggest that IT use by people with SCI contributes to general health and well-being, by increasing access to SCI-related health information and opportunity for social participation. Despite the benefits offered by IT, persons with SCI have identified a degree of skepticism about the reliability and applicability of the health information they find online. Future work on developing and implementing IT for health and well-being post-SCI should take into account consumers' perspectives to facilitate uptake. Implications for Rehabilitation There is a need for a more refined understanding of how people with spinal cord injury (SCI) use information technology (IT) in their daily lives in order to understand how IT can support health and well-being post-injury in the community. IT use holds implications for the physical and mental well-being of persons with SCI. IT allows access to a variety of information, and facilitates participation in the community. The enthusiasm for the use of IT is tempered by a degree of skepticism about the reliability and applicability of the health information available online. This highlights the need to raise awareness of existing sources vetted for this population, and to develop content that meets the particular health needs for SCI.

Elevated aortic arterial stiffness (aortic pulse wave velocity: aPWV) is an independent coronary artery disease predictor among the general population. The purpose of this study was to: (1) report aPWV values in a representative cohort of patients with spinal cord injury (SCI); (2) to compare aPWV values in people with SCI based on neurological level of injury; and (3) to contrast the reported aPWV values with available normal values for the general population.Adults with chronic SCI (n = 87) were divided into two groups (TETRA group, n = 37 and PARA group, n = 50). aPWV and potential confounders of aPWV were assessed. Analysis of covariance was used for comparisons between groups and adjusted for the confounders. Subjects' aPWV values were contrasted with reference values for general population determined by "The Reference value for arterial stiffness' collaboration" and prevalence of abnormal aPWV defined as greater than or equal to the age-specific 90th percentile was reported.Prevalence of abnormal aPWV in the cohort was 25.3%. After adjusting for covariates, the mean aPWV values were significantly different between two groups (TETRA: 8.0 (95% confidence interval (CI): 7.5-8.6) m/second, PARA: 9.0 (95% CI: 8.5-9.4) m/second, P = 0.010). The prevalence of abnormal aPWV was significantly higher in the PARA group (36%) compared to the TETRA group (11%) (P = 0.012).One-quarter of the total cohort had an abnormal aPWV. Subjects with paraplegia had higher aPWV values and a higher frequency of abnormal aPWV than subjects with tetraplegia. Elevated aPWV in people with SCI, particularly those with paraplegia, may impart significant adverse cardiovascular consequences.

Objectives : The purposes of this observational study were to: 1) describe and compare the intakes of nutrients related to bone health among a group of individuals with traumatic spinal cord injury (SCI) versus a group of age, gender and weight matched non–SCI peers; and 2) contrast the participant’s nutrient intakes against current dietary reference intakes (DRIs). Methods : Consenting participants included: 87 individuals with SCI (C2-T10 AIS A-D) aged 18-68 years and 85 non-SCI individuals. Participants’ nutrient intakes were determined using a 24-hour dietary recall. Participants were grouped by gender, age (19-30yrs, 31-50yrs, 51-68yrs), and impairment (SCI and non-SCI). Additionally, the nutrient intakes were contrasted with the DRIsparameters. Results : The range for mean calcium intakes across all age strata was 870-1087mg/day for SCI men and 848-1087mg/day for SCI women. The range for mean calcium intakes of the non-SCI participants were similar (men: 900-909mg/day; women: 796-1160mg/day). The majority of SCI and non-SCI men (64 - 86% of participants) in all age groups and SCI and non-SCI women in the 52-68 yrs group (72 and 73% of participants) did not meet the DRIs recommendation for calcium.. Additionally many participants did not meet the DRIs recommendation for magnesium (38-55%) and potassium (71-95%) regardless of gender and impairment. The majority (60-70%) of participants consumed excessive amounts of sodium with the exception of non-SCI women. Conclusions : Dietary calcium intakes among SCI and non-SCI participants were not significantly different from each other. However, the dietary calcium intakes of both impairment groups were less than the recommended DRIs; SCI men and women are a target for nutritional interventions based on their calcium, magnesium potassium and sodium intakes.

Although pressure ulcers may negatively influence quality of life (QoL) post-spinal cord injury (SCI), our understanding of how to assess their impact is confounded by conceptual and measurement issues. To ensure that descriptions of pressure ulcer impact are appropriately characterized, measures should be selected according to the domains that they evaluate and the population and pathologies for which they are designed.To conduct a systematic literature review to identify and classify outcome measures used to assess the impact of pressure ulcers on QoL after SCI.Electronic databases (Medline/PubMed, CINAHL, and PsycInfo) were searched for studies published between 1975 and 2011. Identified outcome measures were classified as being either subjective or objective using a QoL model.Fourteen studies were identified. The majority of tools identified in these studies did not have psychometric evidence supporting their use in the SCI population with the exception of two objective measures, the Short-Form 36 and the Craig Handicap Assessment and Reporting Technique, and two subjective measures, the Life Situation Questionnaire-Revised and the Ferrans and Powers Quality of Life Index SCI-Version.Many QoL outcome tools showed promise in being sensitive to the presence of pressure ulcers, but few of them have been validated for use with SCI. Prospective studies should employ more rigorous methods for collecting data on pressure ulcer severity and location to improve the quality of findings with regard to their impact on QoL. The Cardiff Wound Impact Schedule is a potential tool for assessing impact of pressure ulcers-post SCI.

The purpose of this single-site randomized control trial was to assess the short-term and long-term efficacy of functional electrical stimulation (FES) therapy over conventional occupational therapy in improving voluntary hand function in incomplete C4-C7 spinal cord injury individuals. All 22 participants recruited in this randomized control trial received treatment for both the left and right upper extremities. Every participant, irrespective of group allocation, received one dose (60 min per day, 5 days per week for the duration of 8 weeks) of conventional occupational therapy for hand function. Of the 22 participants, 12 individuals received an additional dose of conventional occupational therapy, while the remaining 10 participants received a dose of FES hand therapy. The primary outcome measure was Functional Independence Measure (FIM) self-care subscore. The secondary outcome measures were Spinal Cord Independence Measure (SCIM) self-care subscore and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT). The participants who received FES therapy showed significantly greater improvements in hand function at discharge, and were able to maintain their gains at long-term follow-up as assessed using FIM self-care subscore, SCIM self-care subscore, and TRI-HFT. The FES therapy effectively increased independence and thereby improved quality of life of individuals with tetraplegia when compared with conventional occupational therapy.

Background. Functional electrical stimulation therapy (FET) has a potential to improve voluntary grasping among individuals with tetraplegia secondary to traumatic spinal cord injury (SCI). Objective. This single-site, randomized controlled trial examined the efficacy of 40 hours of FET with conventional occupational therapy (COT) compared with COT alone to improve grasping. Methods. Twenty-four subjects with subacute traumatic incomplete SCI (C4-C7, AIS B-D) consented to participate in 40 hours of therapy over 8 weeks, beyond the conventional rehabilitation program. Subjects were randomized to receive FET + COT (n = 9) or COT (n = 12). The key outcomes were changes in Functional Independence Measure (FIM) self-care subscores, Spinal Cord Independence Measure (SCIM) self-care subscores, and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT) performed at baseline and follow-up. Results. At the end of the treatments, the change in mean FIM self-care subscore for the FET + COT group was 20.1 versus 10 ( P = .015) for the COT group. Subjects randomized to FET + COT also had greater improvements in the SCIM and TRI-HFT. No longer term follow-up was feasible. Conclusion. FET significantly reduced disability and improved voluntary grasping beyond the effects of considerable conventional upper extremity therapy in individuals with tetraplegia.

Longitudinal cohort. To determine whether changes in secondary health conditions (SHC) associated with spinal cord injury (SCI) were effectively modeled from a longitudinal or cross-sectional perspective, and whether the changes in SHCs were attributable to age or years post-injury (YPI). Toronto Rehabilitation Institute, Lyndhurst Centre. Telephone survey methods were used to collect data on (1) demographics, (2) impairment, (3) health status, and (4) self-reported SHCs at two time intervals (1995–1997; 2003–2004) from 344 adults with SCI. Generalized estimating equations were applied to model the longitudinal and cross-sectional effects. Health status decreased over time (P

Autonomic dysreflexia (AD) is a potentially life-threatening complication of spinal cord injury (SCI) characterized by episodic paroxysmal hypertension and bradycardia in response to a noxious stimulus below the level of injury. Recognition of AD is crucial for individuals with SCI and their family members to facilitate timely and appropriate management. The objectives of this study were to (a) evaluate knowledge of AD among SCI consumers and their family members and (b) identify the preferred format and timing of education regarding AD recognition and management for these stakeholders.Cross-sectional descriptive study on a cohort of community-dwelling individuals with chronic SCI (N = 100) and their family members (N = 16) by self-report mail survey. Frequency distributions were used to tabulate survey responses on AD knowledge level and to characterize learning preferences and 2 x 2 chi2 analyses were conducted to determine whether there were factors (ie, impairment) associated with AD knowledge (ie, how to treat AD).Individuals with SCI and their family members have gaps in their knowledge of AD. Traumatic SCI etiology (vs nontrauma) was associated with greater knowledge about treating AD. Although the SCI sample was a high-risk group, 41% had not heard of AD. More concerning was that 22% of individuals with SCI reported symptoms consistent with unrecognized AD. Respondents indicated that AD education would be best delivered during rehabilitation by a healthcare professional.Further work is needed to promote knowledge about recognizing and managing AD. This may help reduce risk of cardiac and cerebrovascular disease in the SCI population.

This study describes self-reported incidence of secondary health complications (SHCs) and their associations with age, years postinjury (YPI), and impairment among a Canadian spinal cord-injured (SCI) cohort.Cross-sectional telephone survey methods were used to collect data on (1) sociodemographics, (2) impairment, (3) health status, and (4) self-reported SHCs on 781 adultsor=1 yr post-SCI living in Ontario, Canada.Logistic regression analyses were used to determine associations between self-reported incidences of SHCs with the following covariates: (1) age, (2) YPI, and (3) impairment. The odds ratios for cardiac complications, high blood pressure (HBP), and respiratory complications increased per year with age, whereas autonomic dysreflexia (AD), bladder infections, heterotopic ossification, psychological distress, and drug addiction decreased. The odds ratios for pressure ulcers, AD, and heterotopic ossification increased per YPI, whereas HBP, bowel problems, psychological distress, and depression decreased. Complete injuries were associated with bladder infections, pressure ulcers, and AD. Paraplegia was associated with HBP and bowel problems, and tetraplegia was associated with AD.The findings provide some clarification on factors associated with the occurrence of SHCs after SCI and are useful for informing health-promotion planners, clinicians, and stakeholders regarding the odds of SHCs with aging or among specific impairment groups.

Buchholz AC, McGillivray CF, Pencharz PB. The use of bioelectric impedance analysis to measure fluid compartments in subjects with chronic paraplegia. Objectives: To determine the sensitivity and specificity of body mass index (BMI) as a surrogate marker of obesity in individuals with chronic paraplegia and to validate bioelectric impedance analysis (BIA) as a method of measuring body composition in this group. Design: Cross-sectional study. Setting: University hospital. Participants: Convenience sample of 31 subjects with paraplegia (19 men, 12 women; mean age, 34.2±8.8y) and 62 able-bodied control subjects (30 men, 32 women; mean age, 28.6±7.2y). Interventions: Not applicable. Main Outcome Measures: Total-body water (TBW) by deuterium dilution; extracellular water (ECW) by corrected bromide space. Fat-free mass (FFM)=TBW/.732; fat mass (FM)=weight−FFM. Single-frequency whole-body and segmental BIA, and multifrequency whole-body BIA. Results: BMI had 100% specificity and 20% sensitivity in distinguishing obese from nonobese subjects with paraplegia. TBW was predicted by using the equation: TBW (inL)=2.11−0.1age+3.45sex+.34wt+.28(ht 2 /R)−.086sex×wt( r 2 =.95, standard error of the estimate [SEE]=1.86L, P 2 /X c ) −.033sex×wt ( r 2 =.75, SEE=1.62L, P Conclusions: BMI has excellent specificity but poor sensitivity in distinguishing obese from nonobese individuals with paraplegia. TBW (and therefore FFM and FM) and ECW can be reasonably well predicted by using single-frequency BIA.

Objective To compare the effects of ultraviolet-C (UVC) with placebo-UVC on pressure ulcer healing in individuals with spinal cord injury (SCI). Design Double-blind randomized trial with stratification for ulcer location to buttock or lower extremity. Subjects were followed up for 1 year postintervention. Setting Rehabilitation institution. Participants Adult inpatients and outpatients (N=43) with SCI and stage 2 to 4 pressure ulcers (n=58). Interventions Ulcers and periwound skin were irradiated 3 times per week using UVC or placebo-UVC. The endpoint was wound closure or hospital discharge without closure. Main Outcome Measures Primary outcome was weekly percent area relative to baseline. Secondary outcomes were mean percent area change between consecutive weeks, surface appearance, weeks to closure, and impact on quality of life and wound status postintervention. Results Groups were similar at baseline for all demographic characteristics except ulcer duration ( P =.02). Groups were similar when healing was compared overall. Subgroup analysis showed that the percent area relative to baseline for stage 2 buttock ulcers was significantly smaller in the group receiving UVC compared with placebo at weeks 3, 5, and 7. During weeks 1 through 8, these ulcers were 26% to 76% of baseline area using UVC versus 111% to 180% for placebo (achieved significant level [ASL], .03–.08; effect size, 0.5–0.8). Groups were similar in the percent area relative to baseline for stage 2 lower extremity ulcers. Group mean percent area change between consecutive weeks for all stage 2 ulcers was 36.6% with the use of UVC and 5.8% for placebo (ASL=.09). There were no group differences in the percent area relative to baseline and the mean percent area change between consecutive weeks for stage 3 to 4 ulcers. Groups were similar for all other secondary outcomes. Conclusions UVC is beneficial for stage 2 buttock ulcers. Further studies are warranted using a larger sample size, carefully considered exclusion criteria, and strategies to ensure homogeneity of the groups that are being compared.

Cross-sectional, survey. To extend current theoretical models predicting life satisfaction post-spinal cord injury (SCI). Our primary model predicting life satisfaction as measured by the Satisfaction with Life Scale (SWLS) examined demographic characteristics, elements of the International Classification of Functioning and subjective and objective measures of health. A second model was developed to examine factors that are associated with successful community participation as measured by the Reintegration to Normal Living Index (RNL). In addition, the effects of psychological distress and chronic pain on life satisfaction and community participation were examined. Toronto Rehabilitation Institute, Spinal Cord Rehabilitation Program, Lyndhurst Centre. Prospective data collection via semi-structured telephone interview on an established SCI Canadian sample. In predicting life satisfaction, our model accounted for 35.3% of the variance with demographic characteristics, objective and subjective health, and community participation significantly contributing to the model. In particular, psychological complications, current health rating and community participation were the only variables that made significant contributions in predicting life satisfaction. With regards to community participation, the presence of psychological complications and number of medical complications were associated with decreased reintegration. Increased time since injury onset, higher health ratings and being employed were positively related to RNL. It would appear that factors involving functional decline and aging are associated with lower participation but not life satisfaction. Further, models predicting quality of life should incorporate measures of psychological functioning. Toronto Rehabilitation Institute

To determine the sensitivity and specificity of body mass index (BMI) as a surrogate marker of obesity in individuals with chronic paraplegia and to validate bioelectric impedance analysis (BIA) as a method of measuring body composition in this group.Cross-sectional study.University hospital.Convenience sample of 31 subjects with paraplegia (19 men, 12 women; mean age, 34.2+/-8.8y) and 62 able-bodied control subjects (30 men, 32 women; mean age, 28.6+/-7.2y).Not applicable.Total-body water (TBW) by deuterium dilution; extracellular water (ECW) by corrected bromide space. Fat-free mass (FFM)=TBW/.732; fat mass (FM)=weight-FFM. Single-frequency whole-body and segmental BIA, and multifrequency whole-body BIA.BMI had 100% specificity and 20% sensitivity in distinguishing obese from nonobese subjects with paraplegia. TBW was predicted by using the equation: TBW (inL)=2.11-0.1age+3.45sex+.34wt+.28(ht(2)/R)-.086sex x wt(r(2)=.95, standard error of the estimate [SEE]=1.86L, P.0001). This equation had 81.8% specificity and 68.4% sensitivity. ECW was predicted by using the equation: ECW (in L)=-.025+1.03sex+.187wt+.0041(ht(2)/X(c)) -.033sex x wt (r(2)=.75, SEE=1.62L, P.0001). Multifrequency BIA offered no greater prediction of TBW or ECW than single-frequency BIA.BMI has excellent specificity but poor sensitivity in distinguishing obese from nonobese individuals with paraplegia. TBW (and therefore FFM and FM) and ECW can be reasonably well predicted by using single-frequency BIA.

BACKGROUND Little is known about the relation between body composition and energy metabolism in paraplegia. OBJECTIVE We investigated the relation between body composition and energy metabolism in healthy paraplegics as compared with able-bodied control subjects. We hypothesized that paraplegics would have lower fat-free mass (FFM), body cell mass (BCM), resting metabolic rate (RMR), and thermic effect of feeding (TEF). DESIGN This cross-sectional study included 34 control subjects and 28 paraplegics (mean age: 29.1 +/- 7.6 and 33.9 +/- 9.2 y, respectively) with body mass indexes (in kg/m(2)) of 23.5 +/- 1.8 and 24.3 +/- 6.0, respectively. We measured RMR and TEF with indirect calorimetry, total body water with deuterium dilution, and extracellular water with corrected bromide space. We calculated FFM (total body water/0.732) and BCM [(total body water - extracellular water)/0.732)]. RESULTS FFM was higher in control subjects than in paraplegics (77.2 +/- 7.2% and 69.2 +/- 8.7%, respectively; P = 0.0002), as were BCM (47.4 +/- 6.7% and 35.9 +/- 8.1%, respectively; P < 0.0001) and RMR (7016 +/- 935 and 6159 +/- 954 kJ/d, respectively; P = 0.0007). FFM was the single best predictor of RMR in both groups (r(2) = 0.83 for control subjects and 0.70 for paraplegics, P < 0.0001 for both). RMR adjusted for FFM did not differ significantly between control subjects and paraplegics (6670 +/- 504 and 6588 +/- 501 kJ/d, respectively). TEF also did not differ significantly between control subjects and paraplegics (6.25 +/- 2.2% and 5.53 +/- 1.8% of energy intake, respectively). CONCLUSIONS FFM, BCM, and RMR, but not obligatory TEF, are lower in paraplegics than in control subjects. RMR does not differ between control and paraplegic subjects after adjustment for FFM, indicating similar metabolic activity in the fat-free compartment of the body.