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IntroductionFemale sexual dysfunction (FSD) impacts an estimated 40% of women. Unfortunately, female sexual function is understudied, leading to limited treatment options for FSD. Neuromodulation has demonstrated some success in improving FSD symptoms. We developed a pilot study to investigate the short-term effect of electrical stimulation of the dorsal genital nerve and tibial nerve on sexual arousal in healthy women, women with FSD, and women with spinal cord injury (SCI) and FSD.MethodsThis study consists of a randomized crossover design in three groups: women with SCI, women with non-neurogenic FSD, and women without FSD or SCI. The primary outcome measure was change in vaginal pulse amplitude (VPA) from baseline. Secondary outcome measures were changes in subjective arousal, heart rate, and mean arterial pressure from baseline. Participants attended one or two study sessions where they received either transcutaneous dorsal genital nerve stimulation (DGNS) or tibial nerve stimulation (TNS). At each session, a vaginal photoplethysmography sensor was used to measure VPA. Participants also rated their level of subjective arousal and were asked to report any pelvic sensations.ResultsWe found that subjective arousal increased significantly from before to after stimulation in DGNS study sessions across all women. TNS had no effect on subjective arousal. There were significant differences in VPA between baseline and stimulation, baseline and recovery, and stimulation and recovery periods among participants, but there were no trends across groups or stimulation type. Two participants with complete SCIs experienced genital sensations.DiscussionThis is the first study to measure sexual arousal in response to acute neuromodulation in women. This study demonstrates that acute DGNS, but not TNS, can increase subjective arousal, but the effect of stimulation on genital arousal is inconclusive. This study provides further support for DGNS as a treatment for female sexual dysfunction.

Objective This study investigated factors influencing surgical decision-making (DM) to treat neurogenic bladder and bowel (NBB) dysfunction for veterans and civilians with spinal cord injury (SCI) in the United States (US). Design Semi-structured interviews complemented by survey measures. Setting Community-dwelling participants who received treatment at a major Midwestern US medical system, a nearby Veterans Affairs (VA) facility, and other VA sites around the US. Participants Eighteen participants with SCI who underwent surgeries; completed semi-structured interviews and survey measures. Interventions Not applicable. Outcomes measures Semi-structured interviews were coded to reflect factors, DM enactment, and outcomes, including surgery satisfaction and quality of life (QOL). Quantitative measures included COMRADE, Ways of Coping Questionnaire, Bladder and Bowel Treatment Inventory, PROMIS Global Health and Cognitive Abilities scales, and SCI-QOL Bladder and Bowel short form. Results Themes identified about factors influencing DM included: recurrent symptoms and complications; balancing dissatisfaction with NBB management against surgery risks; achieving independence and life style adjustments; participant's driven solutions; support and guidance and trust in doctors; and access and barriers to DM. DM enactment varied across surgeries and individuals, revealing no clear patterns. Most participants were satisfied with the surgery outcomes. Some differences in demographics were observed between veterans and civilians. Conclusions We have attempted to illustrate the process of NBB DM as individuals move from factors to enactment to outcomes. Attending to the complexity of the DM process through careful listening and clear communication will allow clinicians to better assist patients in making surgical decisions about NBB management.

Objectives People with neurogenic bladder and/or bowel dysfunction experience diverse challenges that can be difficult to evaluate with standardized outcome measures. Goal attainment scaling (GAS) is an individualized, patient-centric outcome measure that enables patients/caregivers to identify and track their own treatment goals. Because creating goals de novo can be cumbersome, we aimed to develop a neurogenic bladder/bowel dysfunction goal menu to facilitate goal attainment scaling uptake and use. Methods We conducted a workshop with 6 expert clinicians to develop an initial menu. Individual interviews with 12 people living with neurogenic bladder and/or bowel dysfunction and 2 clinician panels with 5 additional experts aided us in refining the menu. A thematic framework analysis identified emergent themes for analysis and reporting. Results Interview participants were adults (median = 36 years, range 25-58), most with spinal cord injury (75%; 9/12). Of 24 goals identified initially, 2 (8%) were not endorsed and were removed, and 3 goals were added. Most participants listed “Impact on Life” goals (eg, Exercise, Emotional Well-Being) among their 5 most important goals (58%; 35/60). Three main themes emerged: challenges posed by incontinence, limitations on everyday life, and need for personalized care. Conclusions We developed a clinical outcome assessment tool following a multistep process of representative stakeholder engagement. This patient-centric tool consists of 25 goals specific to people living with neurogenic bladder and/or bowel dysfunction. Asking people what matters most to them can identify important constructs that clinicians might have overlooked.

Financial support provided by the Craig H. Neilsen Foundation.© Copyright 2020, Paralyzed Veterans of AmericaThese guidelines have been prepared based on scientific and professional information ava...

People with spinal cord injury (SCI) suffer from the sequela of neurogenic bowel and its disabling complications primarily constipation, fecal incontinence, and gastrointestinal (GI) symptoms. Neurogenic bowel is a functional bowel disorder with a spectrum of defecatory disorders as well as colonic and gastrointestinal motility dysfunction. This manuscript will review the anatomy and physiology of gastrointestinal innervation, as well as the pathophysiology associated with SCI. It will provide essential information on the recent guidelines for neurogenic bowel assessment and medical management. This will allow medical providers to partner with their patients to develop an individualized bowel plan utilizing a combination of various pharmacological, mechanical and surgical interventions that prevent complications and ensure successful management and compliance. For people with SCI and neurogenic bowel dysfunction, the fundamental goal is to maintain health and well-being, promote a good quality of life and support active, fulfilled lives in their homes and communities.

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D). Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines. Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental. Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

Disorders of bowel function are prevalent, particularly among patients with spinal cord injuries and other neurological disorders. An individual's bowel control significantly impacts quality of life, as predictable bowel function is necessary to actively and independently participate in everyday activities. For many patients with bowel dysfunction, initial lifestyle adjustments and other conservative therapeutic interventions (eg, digital stimulation, oral laxatives, suppositories) are insufficient to reestablish regular bowel function. In addition to these options, rectal irrigation (RI) is a safe and effective method of standard bowel care that has been used for several decades in adults and children suffering from bowel dysfunction associated with neurogenic or functional bowel etiologies. Rectal irrigation is an appropriate option when conservative bowel treatments are inadequate. Unlike surgical options, RI can be initiated or discontinued at any time. This report summarizes the clinical, humanistic, and economic evidence supporting the use of RI in clinical practice, noting features (eg, practical considerations, patient education) that can improve patients' success with RI treatment.

Financial support provided by the Craig H. Neilsen Foundation.© Copyright 2020, Paralyzed Veterans of AmericaThese guidelines have been prepared based on scientific and professional information ava...

BACKGROUND CONTEXT Individuals living with a spinal cord injury (SCI) are at heightened risk for a number of chronic health conditions such as secondary comorbidities that may develop or be influenced by the injury, the presence of impairment, and/or the process of aging. PURPOSE The objective of this study was to compare the incidence of and adjusted hazards for cardiovascular and metabolic (cardiometabolic) morbidities among adults following SCI compared to adults without SCIs. STUDY DESIGN/SETTING Longitudinal cohort from a nationwide insurance claims database. PATIENT SAMPLE Privately-insured beneficiaries were included if they had an ICD-9-CM diagnostic code for traumatic SCI (n=9,081). Adults without SCI were also included (n=1,474,232). OUTCOME MEASURES AND METHODS Incidence estimates of common cardiometabolic morbidities were compared at 4-years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident cardiometabolic morbidities. RESULTS Adults living with traumatic SCIs had a higher 5-year incidence of any cardiometabolic morbidities (56.2% vs. 36.4%) as compared to adults without SCI, and differences were to a clinically meaningful extent. Survival models demonstrated that adults with SCI had a greater hazard for any cardiometabolic morbidity (Hazard Ratio [HR]: 1.67; 95%CI: 1.58, 1.76) and all cardiometabolic disorders; this ranged from HR: 1.45 (1.32, 1.59) for non-alcoholic fatty liver disease to HR: 3.55 (3.36, 3.76) for heart failure. CONCLUSIONS Adults with SCIs have a significantly higher incidence of and risk for common cardiometabolic morbidities, as compared to adults without SCIs. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of cardiometabolic disease onset/progression in this vulnerable population.

Neurogenic bowel dysfunction (NBD) results from a constellation of interacting impairments that prevent the voluntary control, process and personal management of defecation. NBD results in colonic dysmotility and pelvic floor defecation disorder and directly contributes to symptoms of constipation, fecal incontinence, and abdominal complaints. Taken together, the severity of these often preventable sequelae cause serious medical problems, retract severely from quality of life and increase the expense of care. This chapter presents pertinent anatomy, contemporary physiology, and pathophysiological processes to prepare the clinician to understand NBD issues, and recognize impairments as targets for patient-centered multiple intervention rehabilitation designs. Informed history taking and guided physical examination reveal patterns of impairment such as reflexic upper motor neuron versus areflexic!lower motor neuron NBD, and limitations related to the primary disease processes. Problem and goal-based care plans are assembled as the Bowel Program which is the comprehensive treatment and rehabilitation system including essential components: diet, fluids, physical activity, medications, scheduled Bowel Care, and rectal stimulation. Bowel Care is the process of assisted defecation which includes one or more of the following components: positioning, assistive techniques, rectal stimulation, and adaptive equipment. Innovative and validated surgical procedures accomplish improvements in independence, reductions in care time, and prevention of incontinence. Research and expert opinion have provided evidence-based best practices outlined in randomized studies, very recently updated clinical practice guidelines and patient education media. This chapter meets the education goals required to prepare clinicians to establish interdisciplinary programs of intervention to detect impairments, educate to implement effective treatments and achieve unique life participation outcomes for each patient and family.

Background People living with spinal cord injuries (SCIs) experience motor, sensory and autonomic impairments that cause musculoskeletal disorders following the injury and that progress throughout lifetime. The range and severity of issues are largely dependent on level and completeness of the injury and preserved function. Objective High risk of developing musculoskeletal morbidities among individuals after sustaining a traumatic SCI is well known in the clinical setting, however, there is a severe lack of evidence in literature. The objective of this study was to compare the incidence of and adjusted hazards for musculoskeletal morbidities among adults with and without SCIs. Methods Privately-insured beneficiaries were included if they had an ICD-9-CM diagnostic code for SCI (n = 9081). Adults without SCI were also included (n = 1,474,232). Incidence estimates of common musculoskeletal morbidities (e.g., osteoporosis, sarcopenia, osteoarthritis, fractures, etc.) were compared at 5-years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident musculoskeletal morbidities. Results Adults living with traumatic SCIs had a higher incidence of any musculoskeletal morbidities (82.4% vs. 47.5%) as compared to adults without SCI, and differences were to a clinically meaningful extent. Survival models demonstrated that adults with SCI had a greater fully-adjusted hazard for any musculoskeletal morbidity (Hazard Ratio [HR]: 2.41; 95%CI: 2.30, 2.52), and all musculoskeletal disorders, and ranged from HR: 1.26 (1.14, 1.39) for rheumatoid arthritis to HR: 7.02 (6.58, 7.49) for pathologic fracture. Conclusions Adults with SCIs have a significantly higher incidence of and risk for common musculoskeletal morbidities, as compared to adults without SCIs. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of musculoskeletal disease onset/progression in this higher risk population.

Prospective, cohort study. To evaluate the effectiveness of bi-level positive airway pressure (PAP) therapy and the patterns of use for sleep-disordered breathing (SDB) in individuals with spinal cord injury (SCI). Academic tertiary care center, USA. Overall, 91 adults with C1-T6 SCI for ≥3 months were recruited and 74 remained in the study to be evaluated for SDB and follow-up. Individuals with SDB but no nocturnal hypercapnia (NH) were prescribed auto-titrating PAP. Those with NH were prescribed PAP with volume-assured pressure support. Device downloads and overnight transcutaneous capnography were performed at 3, 6, and 12 months to quantify PAP use and effectiveness. Participants kept daily event logs, and quality of life (QOL) questionnaires were performed after 3, 6, and 12 months. Overall, 45% of 91 participants completed the study. There was great diversity among SCI patients in PAP utilization; after 3 months, 37.8% of participants used PAP for ≥70% nights and ≥240 min per night, whereas 42.2% seldom used PAP and 20% used PAP sporadically or for short periods. PAP therapy was effective in improving OSA in 89% and nocturnal hypercapnia in 77%. Higher PAP pressures predicted higher levels of device use. There were marked reductions in symptoms of autonomic dysreflexia (AD) and orthostatic hypotension as well as some improved indices of QOL. Despite widely diverse patterns of use, PAP therapy may have short-term benefits with regard to QOL and reducing episodes of dizziness and autonomic dysreflexia.

Objectives To (1) assess the factors associated with methods of bowel management and bowel-related complications; and (2) determine the risk factors associated with bowel complications and overall bowel dysfunction, using multivariate modeling. Design Cross-sectional observational study. Setting A Spinal Cord Injury Model System, with additional participants recruited from other sites. Participants Subjects (N=291) who incurred traumatic spinal cord injury (SCI) with resultant neurogenic bowel who were ≥5 years postinjury at the time of interview. Interventions Not applicable. Main Outcome Measures Constipation, bowel incontinence, and neurogenic bowel dysfunction questionnaire scores. These measures were all derived from the Bowel and Bladder Treatment Index. Data analyses included descriptive and bivariate statistics as well as logistic and linear regression modeling. Results Risk factors contributing to bowel incontinence included overall bowel dysfunction as measured by the neurogenic bowel dysfunction score, timing of bowel program, being married or having a significant other, urinary incontinence, constipation, and use of diuretics. Constipation was best predicted by age, race/ethnicity, using laxatives/oral medications, incomplete tetraplegia, frequency of bowel movements, abdominal pain, access to clinicians and caregivers, and history of bowel surgeries. Neurogenic bowel dysfunction scores were predicted by neurologic classification; use of laxatives, oral medications, or both; bowel incontinence; and frequency of fiber intake. Conclusions These results suggest a number of factors that should be considered when treating neurogenic bowel complications and dysfunction in persons with SCI.

Objective To evaluate a strategy of home-based testing to diagnose sleep-disordered breathing and nocturnal hypercapnia in individuals with spinal cord injury (SCI). Design Case series. Setting Referral center. Participants Adults with C1-T6 SCI (N=81). Individuals were eligible if ≥18 years old, with SCI of ≥3 months' duration, living within 100 miles of the study site, and not meeting exclusion criteria. Of the 161 individuals recruited from the SCI Model System database who were not enrolled, reasons were not interested in participating, change of location, prior positive pressure ventilation use, or medical contraindication. Ten individuals did not complete the study. Interventions Performance of an unsupervised home sleep apnea test combined with transcutaneous partial pressure of carbon dioxide/oxygen saturation by pulse oximetry monitoring. Main Outcome Measures Prevalence of sleep-disordered breathing and nocturnal hypercapnia. Clinical and physiological variables were examined to determine which, if any, correlate with the severity of sleep-disordered breathing. Results Obstructive sleep apnea (OSA) was found in 81.3% of individuals, central sleep apnea (CSA) was found in 23.8%, and nonspecific hypopnea events, where respiratory effort was too uncertain to classify, were present in 35%. Nonspecific hypopnea events correlated strongly with CSA but weakly with OSA, suggesting that conventional sleep apnea test scoring may underestimate central/neuromuscular hypopneas. Nocturnal hypercapnia was present in 28% and oxygen desaturation in 18.3%. Neck circumference was the primary predictor for OSA, whereas baclofen use and obstructive apnea/hypopnea index weakly predicted CSA. Awake transcutaneous partial pressure of carbon dioxide and CSA were only marginally associated with nocturnal hypercapnia. Conclusions Unsupervised home sleep apnea testing with transcutaneous capnography effectively identifies sleep-disordered breathing and nocturnal hypercapnia in individuals with SCI.

Background: The management of neurogenic bowel and bladder by individuals with spinal cord injury (SCI) often requires a complicated set of behaviors to optimize functioning and reduce complications. However, limited research is available to support the many recommendations that are made. Objective: To describe the occurrence of behaviors associated with the management of neurogenic bowel and bladder among individuals with chronic SCI and to explore whether relationships exist between the performance of those behaviors and outcomes related to health and quality of life. Methods: A survey was developed based on clinical guidelines to collect self-report information about the performance of specific behaviors associated with the management of neurogenic bowel and bladder by individuals with SCI. It was administered to 246 individuals with chronic SCI living in the community as part of a larger ongoing study. Results: Results suggest that the methods that those with SCI use to manage neurogenic bowel and bladder are multifaceted. Many methods are performed with significant consistency, but significant variations exist for some and are often associated with neurological status, methods of evacuation, and quality of life. Conclusion: Many people with SCI of long duration are not sure of the sources of recommendations for some of the management activities that they or their personal care assistants conduct. It is prudent for clinicians working with these people to review their recommendations periodically to ensure that they are current and understood.

Severe debilitating lower urinary and bowel dysfunction is unfortunately common in patients with neurological conditions such as spinal cord injury (SCI), multiple sclerosis (MS), spina bifida and transverse myelitis on top of their physical disabilities. Despite the extraordinarily high prevalence of neurogenic bladder (87–95%) [1, 2] and neurogenic bowel (62–95%) [3, 4] in these populations, only the bladder has received the attention of medical providers with neurogenic bowel physiology is less understood and characterized compared to neurogenic bladder [5]. Neurogenic bowel has a significant impact on these patients and is characterized by combination of symptoms including lower gastrointestinal symptoms of constipation, diarrhea and or fecal incontinence. It could also have upper gastrointestinal impairment which can lead to bloating, nausea earlier satiety, reflux symptoms and gaseousness [6–10].

Background Ischemic cardiomyopathy ( ICM ) and dilated cardiomyopathy ( DCM ) differ in histopathology and prognosis. Although transendocardial delivery of mesenchymal stem cells is safe and provides cardiovascular benefits in both, a comparison of mesenchymal stem cell efficacy in ICM versus DCM has not been done. Methods and Results We conducted a subanalysis of 3 single‐center, randomized, and blinded clinical trials: (1) TAC‐HFT (Transendocardial Autologous Mesenchymal Stem Cells and Mononuclear Bone Marrow Cells in Ischemic Heart Failure Trial); (2) POSEIDON (A Phase I/II, Randomized Pilot Study of the Comparative Safety and Efficacy of Transendocardial Injection of Autologous Mesenchymal Stem Cells Versus Allogeneic Mesenchymal Stem Cells in Patients With Chronic Ischemic Left Ventricular Dysfunction Secondary to Myocardial Infarction); and (3) POSEIDON‐DCM (Percutaneous Stem Cell Injection Delivery Effects on Neomyogenesis in Dilated Cardiomyopathy). Baseline and 1‐year cardiac structure and function and quality‐of‐life data were compared in a post hoc pooled analysis including ICM (n=46) and DCM (n=33) patients who received autologous or allogeneic mesenchymal stem cells. Ejection fraction improved in DCM by 7% (within‐group, P =0.002) compared to ICM (1.5%; within‐group, P =0.14; between‐group, P =0.003). Similarly, stroke volume increased in DCM by 10.59 mL ( P =0.046) versus ICM (−0.2 mL; P =0.73; between‐group, P =0.02). End‐diastolic volume improved only in ICM (10.6 mL; P =0.04) and end‐systolic volume improved only in DCM (17.8 mL; P =0.049). The sphericity index decreased only in ICM (−0.04; P =0.0002). End‐diastolic mass increased in ICM (23.1 g; P DCM (−4.1 g; P =0.34; between‐group, P =0.007). The 6‐minute walk test improved in DCM (31.1 m; P =0.009) and ICM (36.3 m; P =0.006) with no between‐group difference ( P =0.79). The New York Heart Association class improved in DCM ( P =0.005) and ICM ( P =0.02; between‐group P =0.20). The Minnesota Living with Heart Failure Questionnaire improved in DCM (−19.5; P =0.002) and ICM (−6.4; P =0.03; δ between‐group difference P =0.042) patients. Conclusions Mesenchymal stem cell therapy is beneficial in DCM and ICM patients, despite variable effects on cardiac phenotypic outcomes. Whereas cardiac function improved preferentially in DCM patients, ICM patients experienced reverse remodeling. Mesenchymal stem cell therapy enhanced quality of life and functional capacity in both etiologies. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifiers: TAC ‐ HFT : NCT 00768066, POSEIDON : NCT 01087996, POSEIDON ‐ DCM : NCT 01392625.

Patients with neurological conditions often experience severe debilitating lower urinary and bowel dysfunction in addition to the physical disabilities. However, only the bladder has received the attention of medical providers with neurogenic bowel being poorly understood and characterized.This is a cross-sectional analysis of a prospective institutional neurogenic bladder database from 2010 to 2013.Of the 175 patients 60.6% had traumatic spinal cord injury and 18.3% had multiple sclerosis. Median ± SD FISI (Fecal Incontinence Severity Index) scores were 18.0 ± 1.39 (moderate). The median neurogenic bowel dysfunction score was 11.0 ± 0.63 (moderate). Those scores were worse in those patients with spinal cord injury and spina bifida compared to those with other diseases and in younger patients (each p = 0.020), and those in the spinal cord injury group with higher levels of injury (p = 0.0046). Based on the Bristol stool scale 65% of patients had abnormal stool consistency, mostly constipation. None of the FISI, Bristol or neurogenic bowel dysfunction scores correlated significantly with SF-12® quality of life measures. However, bladder symptom scores on M-ISI (Michigan Incontinence Symptom Index) (p = 0.05) and AUA-SI (American Urological Association symptom index) (p = 0.03) correlated with FISI severity while the neurogenic bowel dysfunction score correlated with M-ISI (ρ = 0.29, p = 0.02). Patients with abnormal stool consistency on the Bristol scale reported more urgency and stress incontinence on M-ISI.Bowel dysfunction is common among patients with neurogenic bladder. Those with worse bladder symptoms also experience worse bowel dysfunction. This highlights the importance of addressing both bowel and bladder dysfunction in this often poorly understood population.

STUDY DESIGN: Presentation of implementation of International Spinal Cord Injury (SCI) Data Sets, International Standards for Neurological Classification of SCI (ISNCSCI), and other structured SCI tools in to the Electronic Medical Record (EMR) Epic. OBJECTIVES: To describe the implementation of SCI tools in Epic at Rigshospitalet, University of Hospital, Capital Region of Denmark, and the ambitions for the future development of SCI related structured data and their reporting in the Epic EMR to be able to standardize data collection to facilitate research within institutions and collaboratively with other institutions locally and globally. SETTING: Denmark and United States of America. METHODS: The general content of the EMR Epic and the SCI-specific structured data implemented are described as well as the tools for reporting. RESULTS: The ISNCSCI is made available via access to http://isncscialgorithm.azurewebsites.net/. After filling in the test data on the website, one can save the completed form as an image within the patient’s chart. The International SCI Core Data Set and 13 International SCI Basic Data Sets (Table 1) are nearly completely implemented in the Danish version of Epic as SmartForms. In addition, 14 functional measures, including the Spinal Cord Independence Measure III, are implemented as flowsheets (Table 2). CONCLUSIONS: The possibility of entering international recognized structured data into the EMR gives better possibility for data sharing across SCI centers worldwide. SPONSORSHIP: Gianna Maria Rodriguez, Stacey Cohen, and Fin Biering-Sørensen are users of Epic, but have no economic relationship with Epic. Kelly Tausk and Josh Martin are employees of Epic.

The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) is routinely used to determine levels of injury and to classify the severity of the injury. Questions are often posed to the International Standards Committee of the American Spinal Injury Association (ASIA) regarding the classification. The committee felt that disseminating some of the challenging questions posed, as well as the responses, would be of benefit for professionals utilizing the ISNCSCI. Case scenarios that were submitted to the committee are presented with the responses as well as the thought processes considered by the committee members. The importance of this documentation is to clarify some points as well as update the SCI community regarding possible revisions that will be needed in the future based upon some rules that require clarification.

Cameron AP, Wallner LP, Forchheimer MB, Clemens JQ, Dunn RL, Rodriguez G, Chen D, Horton J III, Tate DG. Medical and psychosocial complications associated with method of bladder management after traumatic spinal cord injury. Objectives To determine the relationships between bladder management method and medical complications (renal calculi or decubitus ulcers), number of hospital days, and psychosocial factors. We hypothesized that indwelling catheterization would be associated with more complications, more hospitalizations, and worse psychosocial outcomes compared with other bladder management methods. Design Inception cohort study. Setting Model spinal cord injury (SCI) centers funded by the National Institute on Disability and Rehabilitation Research from 1973 to 2005. Participants Persons with new traumatic SCI (N=24,762) enrolled in the National SCI Database entire data set forms I and II. Patients were stratified according to the bladder management method recorded at each time of data collection into 1 of 4 groups as follows: indwelling catheterization, spontaneous voiding, condom catheterization, and intermittent catheterization. Those who reported no management method or errors in reporting were excluded (n=1564). Interventions Not applicable. Main Outcome Measures Medical complications, including pressure ulcer number and grade of worst ulcer, kidney stones, and hospitalizations, as well as psychosocial factors (satisfaction with life, perceived health status, societal participation), were stratified by bladder management method. Results were adjusted for level and completeness of neurologic injury and other confounding and modifying factors. Results Compared with other forms of bladder management, use of an indwelling catheter was associated with more pressure ulcers and longer and more hospitalizations for all causes and urology-specific causes. Indwelling catheter use was associated with the lowest levels of participation, but similar satisfaction with life and perceived health status. Conclusions Indwelling catheterization was associated with more medical complications and lower levels of participation than other bladder management methods, but more research is required to ascertain the causality of these complications.

Studies have shown that bladder management with an indwelling catheter for patients with spinal cord injury is associated with more urological complications such as stones, urinary infection, urethral strictures and bladder cancer. However, little is known about actual bladder management for these patients in clinical practice.Using the National Spinal Cord Injury Database the bladder management method was determined at discharge from rehabilitation and at each 5-year followup period for 30 years.At discharge from rehabilitation (24,762 patients) the selection of bladder management with a condom catheter decreased steadily from a peak of 34.6% in 1972 to a low of 1.50% in 2001. The use of clean intermittent catheterization increased from 12.6% in 1972 to a peak of 56.2% in 1991. Indwelling catheter use initially decreased from 33.1% in 1972 to 16.5% in 1991 but increased to 23.1% in 2001. Of 12,984 individuals with followup data those originally using an indwelling catheter for bladder management were unlikely to switch to another method, with 71.1% continuing to use an indwelling catheter at 30 years. Individuals using clean intermittent catheterization and condom catheterization at discharge home did not continue to use these methods with only 20% and 34.6% remaining on the same management, respectively.With time bladder management with clean intermittent catheterization has increased in popularity. However, only 20% of patients initially on clean intermittent catheterization remained on this form of bladder management. More research on the safety of each of these methods needs to be performed to provide better guidance to aid with this decision.

Kalpakjian CZ, Quint EH, Bushnik T, Rodriguez GM, Terrill MS. Menopause characteristics and subjective symptoms in women with and without spinal cord injury. Objective To examine menopause transition characteristics and symptom bother in women with spinal cord injury (SCI). Design Prospective cohort (4 data collection periods across 4 years). Setting Community. Participants Women (n=62) with SCI (injury levels C6–T12, nonambulatory, >36mo postinjury; 86.1% retention) and women without SCI (n=66; 92.9% retention) with intact ovaries, not using hormone therapy, and between the ages of 45 and 60 years volunteered. A total of 505 observations were collected and analyzed. Interventions None. Main Outcome Measures Age at final menstrual period (FMP), transitions through menopause status classifications, and menopause symptom bother (vasomotor, somatic, psychologic symptoms). Results The number of women transitioning through a menopause status classification over the course of the study did not significantly vary by group ( P =.263), nor did age at FMP ( P =.643). Women with SCI experienced greater bother of somatic symptoms (a subscale, P P P =.012). Women without SCI had significantly greater bother of vasomotor symptoms ( P =.020). There were no significant group by menopause status interactions; main effects for menopause status were significant only for vasomotor symptoms and vaginal dryness. Conclusions Results suggested that women with SCI experience greater symptom bother in certain areas, but that patterns of symptom bother across menopause, transition through menopause, and age at FMP are similar to those of their peers. Larger studies are needed to examine menopause outcomes with respect to level of injury and completeness of injury. These findings provide a framework that women with SCI and their health care providers can use to address the menopause transition and highlight the importance of multidisciplinary involvement to maximize health and well being during this transition.

The matrix of stroke rehabilitation is evolving as we look outside the box of traditional therapy type, timing, and intensity of rehabilitation techniques. For inpatient wards, the goal of medical stability and prompt resolution of complications to maximize participation in therapy remains paramount. In the current medical model, we focus on teaching compensatory strategies and rarely on restorative approaches because of time and financial limitations. Researchers aim to identify new technologic and molecular approaches to improve functional outcomes and more accurately predict disability. This article examines different concepts surrounding the comprehensive rehabilitation paradigm of stroke survivors.

Rodriguez GM, Aruin AS. The effect of shoe wedges and lifts on symmetry of stance and weight bearing in hemiparetic individuals. Arch Phys Med Rehabil 2002;83:478-82. Objective: To determine the effect of shoe wedges and lifts on symmetry of stance and weight bearing in hemiparetic individuals. Design: Weight bearing on the paretic side was measured in patients with hemiparesis during quiet standing and in conditions of compelled weight shift. Setting: Free-standing acute inpatient rehabilitation hospital. Participants: Nine individuals with hemiparesis as a result of unilateral stroke who were able to stand for 3 to 5 minutes without assistance or rest, and satisfied other inclusion criteria. Interventions: Compelled shift of the body weight was induced with different shoe wedges (5°, 7.5°, 12.5°) or shoe lifts (0.6, 0.9, 1.2cm), which extended under the entire shoe of the unaffected limb. Weight-bearing symmetry scores were used to characterize the symmetry of stance. Main Outcome Measures: Weight-bearing symmetry scores. Results: Without a shoe wedge or a shoe lift, weight-bearing symmetry was characterized by underloading of the paretic limb (39.90% ±.80% of body weight). Weight shift induced by shoe wedges or shoe lifts applied to the unaffected limb promoted improved symmetry of weight bearing and stance. A shoe wedge of 5° provided the most symmetrical weight distribution (51.44% ± 1.88% of body weight). Conclusion: Shoe wedges and shoe lifts under the unaffected limb induced compelled weight shift toward the paretic limb, resulting in improved symmetry of stance of individuals with mild hemiparesis. We suggest that improved symmetry of bipedal standing obtained with a shoe wedge or a shoe lift applied to the unaffected limb can help overcome the learned disuse of the affected limb. We further suggest that weight distribution induced by shoe wedges or shoe lifts may help in the treatment of ambulatory hemiparetic individuals with asymmetrical stance caused by unilateral stroke. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Objective To determine the utility of home-based, unsupervised transcutaneous partial pressure of carbon dioxide (tc-Pco 2 ) monitoring/oxygen saturation by pulse oximetry (Spo 2 ) for detecting nocturnal hypoventilation (NH) in individuals with neuromuscular disorders. Design Retrospective case series analyzed consecutively. Setting Multidisciplinary neuromuscular respiratory failure (NMRF) clinic at an academic institution. Participants Subjects (N=35, 68.6% men; mean age, 46.9y) with spinal cord injury (45.7%) or other neuromuscular disorders underwent overnight tests with tc-Pco 2 /Spo 2 monitoring. Fifteen (42.9%) were using nocturnal ventilatory support, either bilevel positive airway pressure (BiPAP) or tracheostomy ventilation (TV). Interventions A respiratory therapist brought a calibrated tc-Pco 2 /Spo 2 monitor to the patient's home and provided instructions for data collection during the subject's normal sleep period. Forced vital capacity (FVC), body mass index (BMI), and exhaled end-tidal Pco 2 (ET-Pco 2 ) were recorded at a clinic visit before monitoring. Main Outcome Measures Detection of NH (tc-Pco 2 ≥50mmHg for ≥5% of monitoring time). Data were also analyzed to determine whether nocturnal oxygen desaturation (Spo 2 ≤88% for ≥5% of monitoring time), FVC, BMI, or daytime ET-Pco 2 could predict the presence of NH. Results NH was detected in 18 subjects (51.4%), including 53.3% of those using BiPAP or TV. NH was detected in 43.8% of ventilator-independent subjects with normal daytime ET-Pco 2 (present for 49.4%±31.5% [mean ± SD] of the study period), and in 75% of subjects with an elevated daytime ET-Pco 2 (present for 92.3%±8.7% of the study period). Oxygen desaturation, BMI, and FVC were poor predictors of NH. Only 3 attempted monitoring studies failed to produce acceptable results. Conclusions Home-based, unsupervised monitoring with tc-Pco 2 /Spo 2 is a useful method for diagnosing NH in NMRF.

There is no consensus on the appropriate urological followup of individuals after spinal cord injury but it is well known that they are at risk for renal deterioration, bladder cancer and stones. We systematically reviewed the literature to evaluate evidence of urological screening in this population.We reviewed 385 abstracts, of which 50 met study inclusion criteria. We rated evidence using American Academy of Neurology 2004 guidelines.A total of 12 articles evaluated urinary tract infection screening. Patient reported symptoms used to predict urinary tract infection yielded mixed results and urine dipstick testing had the same accuracy as microscopy. Routine urine culture was unnecessary in healthy, asymptomatic individuals with normal urinalysis. Urodynamics probably must be done periodically (6 articles) but there was no information on frequency. In 11 articles ultrasound was recommended as a useful, noninvasive and possibly cost-effective screening method. Renal scan was a good method for further testing, especially if ultrasound was positive (11 articles). Evidence was sufficient (11 articles) to recommend ultrasound of the urinary tract to detect urinary tract stones with good sensitivity but not plain x-ray of the kidneys, ureters and bladder (2 articles). There was insufficient evidence to recommend urine markers or cytology for bladder cancer screening (9 articles).Based on this review no definitive recommendations for screening can be made except routine renal ultrasound. Urodynamics are an important part of screening but the frequency is unclear. The optimum bladder cancer screening method has not been defined.