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To address the lack of research on the information needs of spinal cord injured (SCI) patients and family members in acute care, in order to inform the provision of appropriate information supports...

Background: Employment rates among people with spinal cord injury or spinal cord disease (SCI/D) show considerable variation across countries. One factor to explain this variation is differences in vocational rehabilitation (VR) systems. International comparative studies on VR however are nonexistent. Objectives: To describe and compare VR systems and practices and barriers for return to work in the rehabilitation of persons with SCI/D in multiple countries. Methods: A survey including clinical case examples was developed and completed by medical and VR experts from SCI/D rehabilitation centers in seven countries between April and August 2017. Results: Location (rehabilitation center vs community), timing (around admission, toward discharge, or after discharge from clinical rehabilitation), and funding (eg, insurance, rehabilitation center, employer, or community) of VR practices differ. Social security services vary greatly. The age and preinjury occupation of the patient influences the content of VR in some countries. Barriers encountered during VR were similar. No participant mentioned lack of interest in VR among team members as a barrier, but all mentioned lack of education of the team on VR as a barrier. Other frequently mentioned barriers were fatigue of the patient (86%), lack of confidence of the patient in his/her ability to work (86%), a gap in the team's knowledge of business/legal aspects (86%), and inadequate transportation/accessibility (86%). Conclusion: VR systems and practices, but not barriers, differ among centers. The variability in VR systems and social security services should be considered when comparing VR study results.

Objective: To carry out a study of non-traumatic spinal cord injury (NTSCI) epidemiology in Ireland Design: Prospective study of all new incident cases of NTSCI during 2017 Setting: Republic of Ireland Participants: All persons with a newly acquired NTSCI Interventions: None Outcome measures: Crude and age/sex specific incidences; ISCoS core dataset and non-traumatic dataset; population denominator was 2016 national census figures, adjusted to 2017. Results: Overall crude incidence of NTSCI in the Republic of Ireland in 2017 was 26.9 per million per year. Mean age at onset was 56.6 (SD 17.7) years. Females accounted for 51.2% of cases. Most frequent grade of ASIA impairment scale (AIS) was AIS D. Most common etiology was degenerate conditions (48.8%) followed by neoplastic (26.4%). The most common pattern of onset (51.2%) was lengthy (greater than one month). Conclusions: Incidence of NTSCI is more than double that for traumatic SCI in the Republic of Ireland. This suggests that the delivery of rehabilitation services to patients with spinal cord injuries requires prompt review and expansion.

Background: The International Spinal Cord Society and World Health Organisation recommend the collection of epidemiological data on traumatic spinal cord injury (TSCI). A 1-year prospective study is ongoing in Ireland. While the results of this study are awaited, it was concluded from a feasibility exercise that a complete retrospective dataset, 2010–2015, could be obtained and would be useful for service planning. Methods: All patients with TSCI discharged from the national SCI acute and rehabilitation centres were included. Data was collected on gender, age, aetiology, level of injury, American Spinal Injuries Association impairment scale, length of rehabilitation admission and discharge destination. Population denominators were national census figures 2006 and 2011, rolled forward. Results: The incidence of TSCI remained constant throughout the study period, 11.5–13.3 per million per year. The mean age of injury onset was 48.9 (SD 19.8) years. Males accounted for 71.5%. The most common injury level/AIS was incomplete tetraplegia, accounting for 43.2% of all TSCI. Leading aetiology was falls, accounting for 53.3% of injuries. Patients with incomplete tetraplegia were older than those with all other injuries (p < 0.001). Conclusions: The epidemiological trends identified are similar to those prevalent elsewhere in the developed world. More incomplete tetraplegia among an older patient population necessitates a review of how acute care and rehabilitation services are delivered.

Study design Prospective population-based epidemiological study on traumatic spinal cord injury in Ireland. Objectives To provide updated data for the global TSCI repository. Setting Republic of Ireland. Methods All cases of TSCI acquired during 2016 were included. ISCoS core dataset was collected on all cases. Descriptive statistics are reported. Results Overall crude incidence of TSCI was 12.8 per million (61 cases). Males accounted for 75.4%. Mean age at onset was 52.8 (19.9) years. Falls was the most common aetiology, 60.7% and AIS D was the most common injury level/AIS classification, 32.8%. The majority of patients (59%) were discharged home. Conclusions Overall incidence of TSCI has changed very little since 2000 but many aspects of injury such as age and aetiologies are different. This data can now be included in the next TSCI global mapping update. Sponsorship Health Research Board, Ireland.

BACKGROUND Low back pain (LBP) is the most common type of musculoskeletal pain, thus it is one of the most commonly encountered conditions in Physical and Rehabilitation Medicine. The physicians who are primarily responsible for the nonsurgical management of LBP are physiatrists. OBJECTIVE The present study aimed to investigate the approaches of physiatrists to low back pain across Europe. Preferences, tendencies, and priorities in the diagnosis, management, and treatment of LBP, as well as the epidemiological data pertaining to LBP in PRM practice were evaluated in this Europe-wide study. METHODS The study was conducted under the control of the European Society of Physical and Rehabilitation Medicine (ESPRM) Musculoskeletal Disorders Research Committee. A total of 576 physiatrists from most European countries participated in the survey. RESULTS The results show that physiatrists frequently deal with patients with LBP in their daily practice. Most patients are not referred to other departments and are treated with various conservative methods. Less than one-fifth of patients are primarily referred for surgery. The physiatrists believe that a clear diagnosis to account for cases of low back pain is rarely established. The most common diagnosis is discopathy. History and physical examination remain the most valuable clinical evaluation tools for low back pain according to physiatrists. Less than half the patients require a magnetic resonance imaging. Non-steroidal anti-inflammatory drugs are the most commonly prescribed drugs for low back pain. Exercise, back care information, and physical therapy are the preferred conservative treatments. More than half of the physiatrists offer interventional treatments to patients with low back pain. CONCLUSION The present study is a preliminary report that presents the attitudes of European physiatrists in the management of low back pain. Further researches are warranted to standardize the conservative management of LBP.

Low bone mineral density (BMD) is common in older people with stroke, particularly in the paretic limb. Younger people with acquired brain injury (ABI), of all causes, are at increased risk of low BMD. To examine prevalence of low BMD, based on World Health Organisation diagnostic criteria, in patients with ABI. This is a cross-sectional study of 112 ABI patients. All completed a questionnaire, had laboratory investigations and DXA assessment of lumbar spine and one or both hips. Mean age ± SD of participants was 45.7 ± 13.7 years. Risk of vitamin D deficiency (25-OHD

Background: Chronic pain is common after spinal cord injury (SCI) and dedicated SCI cognitive behavioural therapy pain management programmes (CBT-PMPs) have a growing evidence base to support their uptake clinically. The development of internet-delivered treatment options may overcome barriers to the access and uptake of centre-based programmes. This study examines such an approach on quality of lie (QoL), pain, mood and sleep. Methods: Adults with SCI pain (>3 months) were recruited and randomly assigned to the intervention or control group. The intervention comprised a six module CBT-PMP delivered once weekly. A blinded assessor determined changes in self-reported outcome measures post-intervention and at 3 months. Linear mixed models and effect sizes based on changes between groups were reported. Significance was set p

Objective: To examine the epidemiology of pediatric traumatic (TSCI) and acquired nontraumatic spinal cord injury (NTSCI) in Ireland. There are few studies reporting pediatric TSCI incidence and fewer of pediatric NTSCI incidence, although there are several case reports. As there is a single specialist rehabilitation facility for these children, complete population-level data can be obtained. Method: Retrospective review of prospectively gathered data in the Patient Administration System of the National Rehabilitation Hospital of patients age 15 years or younger at the time of SCI onset. Information was retrieved on gender, age, etiology, level of injury/AIS. Population denominator was census results from 1996, 2002, 2006, and 2011, rolled forward. Results: Since 2000, 22 children have sustained TSCI and 26 have sustained NTSCI. Median (IQR) age at TSCI onset was 6.3 (4.4) years, and at NTSCI onset it was 7.3 (8.1) years. Most common TSCI etiology was transportation (n = 10; 45.5%), followed by surgical complications (n = 8; 36.4%); most common injury type was complete paraplegia (n = 12; 54.5%) followed by incomplete paraplegia (n = 5; 22.7%). Most common NTSCI etiology was transverse myelitis (n = 11; 42.3%) followed by vascular (n = 5; 20%); most common injury type was incomplete paraplegia (n = 17; 65.4%) followed by incomplete tetraplegia (n = 6; 24%). Incidence of TSCI ranged from 0 to 3.1 per million per year; incidence of NTSCI ranged from 0 to 6.5 per million per year. Conclusion: Incidence of SCI in Ireland seems similar to or slightly lower than other developed countries. Injury patterns are also similar, considering variations in reporting methods.

Survey.To describe and compare perceived barriers with patient flow in spinal rehabilitation units (SRUs).International. Ten SRUs (Australia, Canada, India, Ireland, Italy, Netherlands, Pakistan, Switzerland, UK and USA) that admit both traumatic and non-traumatic spinal cord injury patients.Survey completed between December 2010 and February 2013 on perception of barriers for admission into and discharge from SRUs. Opinion was sought from the participants regarding the utility of collecting data on the timeliness of access to SRUs and occurrence of discharge barriers for benchmarking and quality improvement purposes.The perceived barriers in accessing SRUs ranged from no access problem to a severe access problem (no access problems n=3; minor access problems n=3; moderate access problems n=2; severe access problem n=1 and extreme n=1). Most units (n=9/10) agreed that collecting data on timeliness of access to SRUs for acute hospital patients may help improve patient outcomes and health system processes by providing information for benchmarking and quality improvement purposes. All units reported perceived barriers to discharge from SRUs. Compared with admission barriers, a greater perception of barriers to discharge was reported (minor problem n=3; moderate problem n=3; severe problem n=3; and extreme n=1). All units agreed that collecting data on barriers to discharge from SRU may help improve patient outcomes and system processes.Perceived barriers to patient flow in SRUs are reported in many countries. Projects to identify and minimise the occurrence and impact of admission and discharge barriers could increase access to rehabilitation and improve the rehabilitation outcomes for patients.

Proximal tibia fracture in a patient with incomplete spinal cord injury associated with robotic treadmill training

Survey.Describe and compare the organisation and delivery of rehabilitation services and systems of care for patients with spinal cord injury (SCI).International. Nine spinal rehabilitation units that manage traumatic SCI and non-traumatic SCI (NTSCI) patients.Survey based on clinical expertise and literature review. Completed between November 2010 and April 2011.All units reported public/government funding. Additional funding sources included compensation schemes, private insurance and self funding. Six units had formal attachment to an acute SCI unit. Five units (Italy, Ireland, India, Pakistan and Switzerland) provided a national service; two units (the Netherlands and USA) provided regional and two units (Australia and Canada) provided state/provincial services. The median number of SCI rehabilitation beds was 23 (interquartile range=16-30). All units admitted both traumatic SCI and NTSCI patients. The median proportion of patients admitted who had traumatic SCI was 45% (IQR 20-48%) and 40% (IQR 30-42%) had NTSCI. The rehabilitation team in all centres determined patient readiness for discharge. There was great variability between units in the availability of SCI speciality services, ancillary services and staff/patient ratios.There was a wide range of differences in the organisation, systems of care and services available for patients with SCI in rehabilitation units in different countries. Understanding these differences is important when comparing patient outcomes from different settings. A standardised collection of these system variables should be considered as part of future studies and could be included in the ISCoS data set project.

To examine the prevalence and impact of back pain (BP) and residual limb pain (RLP) in ambulatory lower limb amputees (LLAs).Patients completed questionnaires regarding demographics, their amputation, occurrence of BP and RLP. Visual analogue scales assessed pain severity and effect on activities of daily living (ADLs), recreational, family and social life (RFS), and ability to work. Descriptive statistics were compiled and relationships between pain and details of amputation were examined.A total of 107 patients (88 males, 19 females) participated; mean age 51.1 years. Fifty-one patients (47.7%) suffered BP, mean intensity 5.3, mean interference with ADLs, RFS, ability to work 3.5, 3.8, 3.4, respectively. Sixty (56.1%) suffer from RLP, mean intensity 5.7; mean interference with ADLs, RFS, ability to work 2.9, 2.8, 3.9, respectively. BP intensity increased with age; RLP intensity was greatest among vasculopaths.Irish LLAs maintain functional capacity despite suffering moderate intensity BP and RLP.

To describe and compare epidemiologic characteristics of patients with spinal cord dysfunction admitted to spinal rehabilitation units (SRUs) in 9 countries (Australia, Canada, Italy, India, Ireland, The Netherlands, Switzerland, United Kingdom, and United States).Retrospective multicenter open-cohort case series.SRUs.Patients (N=956) with initial onset of spinal cord dysfunction consecutively admitted between January 1, 2008, and December 31, 2010. Median age on admission was 59 years (interquartile range [IQR], 46-70), and 60.8% of patients were men.Not applicable.Demographic characteristics (eg, age, sex), time frame over which clinical symptoms of spinal cord dysfunction developed, etiology, length of stay in hospital, level of lesion and American Spinal Injury Association Impairment Scale (AIS) grade, discharge destination, and inpatient mortality.The time frame of onset of spinal cord dysfunction symptoms was as follows: ≤1 day (28.5%); ≤1 week (13.8%);1 week but ≤1 month (10.5%), and1 month (47.2%). Most common etiologies were degenerative conditions (30.8%), malignant tumors (16.2%), ischemia (10.9%), benign tumors (8.7%), and bacterial infections (7.1%). Most patients (72.3%) had paraplegia. The AIS grade on SRU admission was grade A in 14%, grade B in 6.5%, grade C in 24%, grade D in 52.4%, grade E in 0.2%, and missing in 2.9%. AIS grade significantly improved by discharge (z=-10.1, P.0001). Median length of stay in the SRU was 46.5 days (IQR, 17-89.5). Most (80.5%) patients were discharged home. Differences between countries were found for most variables.This international study of spinal cord dysfunction showed substantial variation of etiology, demographic, and clinical characteristics across countries. Further research, including multiple centers per country, are needed to separate country effects from center effects.

BACKGROUND: Road collisions remain the leading cause of traumatic spinal cord injury (TSCI) in the world. Half of all TSCIs in Ireland in 2000 were caused by road collisions. Since then, there has been a downward trend in road fatalities coincident with implemented road safety strategies. OBJECTIVE: To examine the incidence of TSCI resulting from road collisions from 2001 to 2010. METHOD: This is a retrospective study using the hospital inpatient enquiry database of the tertiary referral center, which houses the national spinal injuries unit. Information retrieved included total numbers of patients with TSCI and number of TSCIs due to road collisions from 2001 through 2010, age groups affected, and the gender balance. RESULTS: Over the 10-year period studied, the incidence rate of TSCI due to road collisions declined, although this did not reach statistical significance. The largest numbers of all TSCIs and TSCIs due to road collisions were in the 20- to 29-year age category and the male gender. CONCLUSIONS: As mortality due to road collisions declined, so did the number of TSCIs from the same etiology. An impactful road safety campaign is likely to have influenced these trends. Language: en

Objective: To (1) examine the opinions of medical staff working in spinal cord injury (SCI) centres (SCICs); (2) evaluate their knowledge, attitudes and practices towards obesity prevention and management; (3) report the number of beds and dietitians available at each SCIC. \ud \ud Methods: A 37-item questionnaire was sent to 23 SCICs in the UK, the Netherlands, Belgium and the Republic of Ireland between September 2012 and January 2013. \ud \ud Results: Eighteen SCICs returned the questionnaires for analysis. All respondents stated that they had an interest in obesity treatment but only 2.3% of the respondents received training in obesity management. Sixty-one percent of staff did not consider body mass index (BMI) to be appropriate for use in SCI patients and subsequently less than half of the respondents use BMI routinely. The majority of respondents reported that they are confident in dealing with overweight (74.5%) and obese (66.1%) SCI adults, less than half (44.1%) are confident in treating overweight and obese SCI children. Respondents also indicated the need for nationally adopted guidelines and a lack of physical activity provision. There were 17.5 whole-time equivalent (WTE) dietitians recorded in 22 SCICs, equivalent to 47.8 beds per WTE dietitians (range 10-420). Non-UK SCIC dietitians are significantly better resourced than in UK SCICs (beds per WTE dietitian: 36 vs 124, P=0.035).\ud \ud Conclusion: Medical staff expressed the need to participate in obesity prevention and management. Appropriate training should be considered for all medical staff and the development of specific weight management guidelines and dietetic provision should be considered.

The morbidity from osteoporotic fractures for people with a disability is considerable because of the increased risk of medical complications, loss of independence and mobility, and prolonged hospitalization. The frequency with which low bone mineral density occurs in people with a disability is now well recognized, and professionals have a greater awareness of the need to investigate bone mineral density levels with a view to preventing fragility fractures. After patients with osteoporosis are identified, the challenge is to treat them appropriately. This article reviews the physical and pharmacologic measures that have been researched in the prevention and treatment of low bone mineral density in people with a disability.

This article is a review of the changes in bone mineral density (BMD), which occur in a number of acquired neurological conditions resulting in disability. For each of spinal cord injury, stroke, multiple sclerosis, Parkinson's disease, and traumatic brain injury, the following aspects are discussed, where information is available: prevalence of low BMD according to World Health Organization diagnostic categories and recommended diagnostic method, prevalence based on other diagnostic tools, comparison of BMD with a control population, rate of decline of BMD following onset of the neurological condition, factors influencing decline; mechanism of bone loss, and fracture rates. The common risk factors of immobilization and vitamin D deficiency would appear to cross all disability groups, with the most rapid phase of bone loss occurring in the acute and subacute phases of each condition.

Smith EM, Comiskey CM, Carroll AM. A study of bone mineral density in adults with disability. Objectives To examine prevalence of low bone mineral density (BMD) among adults with disability, using World Health Organization diagnostic categories. Design Cross-sectional study. Setting National Rehabilitation Hospital, Dublin, Ireland. Participants Patients (N=255; 178 men, 77 women) who were disabled for at least 3 months because of acquired brain injury, spinal cord injury, other neurologic condition, or lower-limb amputation. Interventions None. Main Outcome Measures Laboratory investigations including intact parathyroid hormone, 25-hydroxyvitamin D (25-OHD), and sex hormones; and BMD of lumbar spine and at least 1 hip, measured by dual-energy x-ray absorptiometry and expressed as T scores and z scores. Results Mean age ± SD of participants was 48.7±15.6 years. Vitamin D deficiency, 25-OHD level 50nmol/L or less, occurred in 154 (62.9%); insufficiency, a level between 51 and 72nmol/L, occurred in 36 (14.7%). Based on T scores, 108 participants (42.4%) had osteopenia, and 60 (23.5%) had osteoporosis. A z score of −1 or less but more than −2 occurred in 76 (29.8%); a further 52 (20.4%) had a z score of −2 or less. On multiple linear regression analysis, ambulatory status and duration of disability were independent predictors of BMD at neck of femur (β=.152, P =.007; β=−.191, P =.001, respectively) and total proximal femur (β=.170, P =.001; β=−.216, P Conclusions Osteopenia and osteoporosis are very common in adults with disability participating in rehabilitation, compared with the general young adult population. Duration since onset of disability and mobility status are independent predictors of BMD at the hip. Bone health monitoring should form part of the long-term follow-up in adults with newly acquired disabilities.

The locked-in syndrome is caused by an insult to the ventral pons, most commonly an infarct, haemorrhage, or trauma. The characteristics of the syndrome are quadriplegia and anarthria with preservation of consciousness. Patients retain vertical eye movement, facilitating non-verbal communication. Ten year survival rates as high as 80% have been reported. Even limited physical recovery can improve quality of life and enable patients to return to live with their families. Early referral to a specialist rehabilitation service for specialist care and technology is therefore important. We gathered information for this article through searches in Medline and Taylor and Francis Health Sciences, identifying relevant case series reviews on the locked-in syndrome and other brain stem strokes. Our own experience is also incorporated. Locked-in syndrome was first defined in 1966 as quadriplegia, lower cranial nerve paralysis, and mutism with preservation of consciousness, vertical gaze, and upper eyelid movement.1 It was redefined in 1986 as quadriplegia and anarthria with preservation of consciousness.2 This redefinition served to clarify that mutism could imply unwillingness to speak.3 Although patients are conscious, attention, executive function, intellectual ability, perception, and visual and verbal memory can be affected.4 Leon-Carrion and colleagues reviewed 44 patients with the locked-in syndrome, of whom eight reported memory problems and six attentional deficits.5 Memory difficulties were more likely when the aetiology was traumatic.5 However, in a report of two patients with chronic locked-in syndrome, neuropsychological assessment showed preserved cognitive abilities.6 A review by Zeman of consciousness indicated that cerebral metabolism, as monitored by positron emission tomography, is only mildly reduced in locked-in syndrome but severely reduced in the vegetative state.7 The electroencephalogram typically shows slow wave activity in the vegetative state but normal activity in locked-in syndrome. Anarthria is due to bilateral facio-glosso-pharyngo-laryngeal paralysis,8 which …