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DEAR EDITOR, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the consequent coronavirus disease 2019 (COVID-19) are spreading all over the world, with human, economic and health consequences that are, at present (April 12th, 2020), still difficult to fully predict. [...]

This consensus paper is derived from a meeting of an international group of 19 neurological rehabilitation specialists with a combined experience of more than 250 years (range 4-25 years; average 14.1 years) in treating post-stroke spasticity with botulinum toxin A. The group undertook critical assessments of some recurring practical challenges, not yet addressed in guidelines, through an extensive literature search. They then discussed the results in the light of their individual clinical experience and developed consensus statements to present to the wider community who treat such patients. The analysis provides a comprehensive overview of treatment with botulinum toxin A, including the use of adjunctive therapies, within a multidisciplinary context, and is aimed at practicing clinicians who treat patients with post-stroke spasticity and require further practical guidance on the use of botulinum toxin A. This paper does not replicate information published elsewhere, but, instead, aims to provide practical advice to help optimize the use of botulinum toxin A and maximize clinical outcomes. The recommendations for each topic are summarized in a series of statements. Where published high-quality evidence exists, the recommendations reflect this; however, where evidence is not yet conclusive, the group members issued statements and, in some cases, made recommendations based on their clinical experience.

COVID-19 pandemic is rapidly spreading all over the world, creating the risk for a healthcare collapse. While acute care and intensive care units are the main pillars of the early response to the disease, rehabilitative medicine should play an important part in allowing COVID-19 survivors to reduce disability and optimize the function of acute hospital setting. The aim of this study was to share the experience and the international perspective of different rehabilitation centers, treating COVID-19 survivors. A group of Physical Medicine and Rehabilitation specialists from eleven different countries in Europe and North America have shared their clinical experience in dealing with COVID-19 survivors and how they have managed the re-organization of rehabilitation services. In our experience the most important sequelae of severe and critical forms of COVID-19 are: 1) respiratory; 2) cognitive, central and peripheral nervous system; 3) deconditioning; 4) critical illness related myopathy and neuropathy; 5) dysphagia; 6) joint stiffness and pain; 7) psychiatric. We analyze all these consequences and propose some practical treatment options, based on current evidence and clinical experience, as well as several suggestions for management of rehabilitation services and patients with suspected or confirmed infection by SARS-CoV-2. COVID-19 survivors have some specific rehabilitation needs. Experience from other centers may help colleagues in organizing their services and providing better care to their patients.

Scuba diving with an intrathecal baclofen pump is encouraged for people with spinal cord injury who are suffering from spasticity. However, the diving depth is limited to 10 metres in this context. Proper physician and patient education in this respect is mandatory since non-compliance can lead to an irreversible loss of drug reservoir capacity due to collapse of the bottom shield. We report such an incident in a paraplegic diver diving to depths down to 30 metres' water.

BACKGROUND: Little is known about the use of antibiotics and the extent of antibiotic-associated diarrhoea (AAD) in patients with spinal cord injuries (SCIs).\ud \ud AIMS: To record the use of antibiotics, establish the prevalence of AAD and Clostridium difficile infection (CDI), and assess if there was any seasonal variation in antibiotic use and incidence of AAD in patients with SCIs.\ud \ud METHODS: A retrospective study was conducted in six European SCI centres between October 2014 and June 2015. AAD was defined as two or more watery stools (Bristol Stool Scale type 5, 6 or 7) over 24 h.\ud \ud FINDINGS: In total, 1267 adults (median age 54 years, 30.7% female) with SCIs (52.7% tetraplegia, 59% complete SCI) were included in this study. Among the 215 (17%) patients on antibiotics, the top three indications for antibiotics were urinary tract infections (UTIs), infected pressure ulcers and other skin infections. Thirty-two of these 215 (14.9%) patients developed AAD and two patients out of the total study population (2/1267; 0.16%) developed CDI. AAD was more common in summer than in spring, autumn or winter (30.3% vs 3.8%, 7.4% and 16.9%, respectively; P

Background This case raises questions about the pathophysiology of muscle ruptures in highly functional patients with hereditary spastic paraplegia (HSP) who have only minor spasticity and no significant muscle shortening. Literature on the skeletal muscle changes secondary to spasticity or to the underlying disease, HSP, has been explored and compared with this clinical case. Two theoretical hypotheses are discussed. Firstly, chronic spasticity might be a risk factor for histopathological muscle alterations. Secondly, altered protein synthesis due to the underlying genetic mutation may play a role in the mechanical integrity of muscle tissue. Case report This is the first case report of a sequential bilateral complete disruption of the rectus femoris muscle after minimal trauma, in a 55-year-old man with HSP. Pain was the main complaint, without significant increase in spasticity. Walking ability was not significantly impaired. Conservative treatment resulted in resolution of the complaints. Clinical rehabilitation impact This unique case of a bilateral complete rectus femoris muscle rupture after minimal trauma in a patient with HSP presenting with minor spasticity raises questions on the pathophysiology of the skeletal muscle changes in HSP patients and more generally in spastic patients.

Study design: Review. Objectives:The aim is to highlight the epidemiology of spinal cord injuries (SCIs) in Sub-Saharan Africa in order to improve prevention strategies. Setting: University Hospitals Leuven, Belgium. Methods: Pubmed was searched over August and September 2010. A combination of the following MeSH-terms was used: 'Africa South of the Sahara', 'Spinal Cord Diseases', 'Paraplegia' and 'Spinal Cord Injuries'. Limits were set on articles published as from 1990. The World Health Organization database was also consulted. Results: We obtained 243 hits of which 13 articles were relevant to the case. These papers covered seven countries: Ethiopia, Ghana, Nigeria, Senegal, Sierra Leone, South Africa and Zimbabwe. In traumatic SCIs, motor vehicle accidents are the most frequent cause of injury followed by falling from a height and thirdly violence, being the most important cause of SCI in South Africa. In the Plateau State of Nigeria, collapsing tunnels in illegal mining are the most prevalent cause. For the non-traumatic SCIs, tuberculosis appeared to be the most important cause, followed by malignant illnesses. Human immunodeficiency virus (HIV) serology tests were only available in the article concerning Ethiopia. Relatively more men were involved in traumatic SCIs and the average age was higher in the non-traumatic than in the traumatic group. Conclusion: Although literature on the subject is scarce, prevention should focus on road-safety, tuberculosis and HIV. Standardized registration of SCI is needed for prevention and further research. The use of the current International SCI core data set should be encouraged worldwide as a uniform classification method. Language: en

Introduction/Background Spinal cord induced osteoporosis is a significant health condition associated with fragility fractures beneath the level of injury. In the scientific literature several treatment options have been proposed. The aim of this paper is to review the current literature about treatments’ efficacy for osteoporosis in spinal cord injury. Material and method A systematic literature search is conducted in four electronic databases: PubMed, Embase, The Cochrane Library and PEDro. All identified records are analysed by title, abstract and if relevant by full text to determine if they meet all inclusion criteria. Additionally, the included RCTs are judged to a quality control according to the Cochrane Handbook for Systematic Reviews of Interventions, Risk of Bias Assessment. Due to the heterogeneity of the included trials no meta-analysis is performed. Results Thirty-two randomized controlled trials are included. Bisphosphonate therapy, if applied correctly, is effective to optimize bone quality, in both the early and chronic phase of the disease, although the evidence is debatable. Moderate-quality evidence suggests that intravenous administration of zoledronic acid is potentially the best approach to tackle this condition. Rehabilitation techniques, although widely used, show no proven efficacy on this matter. In addition, numerous experimental therapies have been proposed, but require further research to prove their applicability. Conclusion This systematic review suggests that bisphosphonate administration could attenuate sublesional bone loss, while we did not find conclusive evidence about various rehabilitation techniques. Although this paper does not provide final evidence, it could be a useful tool for future research purposes.

Objective: To investigate the long-term dosage evolution and complication rate of intrathecal baclofen use in multiple sclerosis and spinal cord injury patients, based on a large population with a long follow-up. Design: Retrospective data analysis Setting: Academic hospital Subjects: Patients with multiple sclerosis ( n = 81) or spinal cord injury ( n = 49) having an intrathecal baclofen pump implanted at the University Hospitals Leuven between 1988 and 2009. Intervention: Medical records review of included patients in August 2010. Main measures: Complications linked to intrathecal baclofen therapy. Daily baclofen dosage after 3 and 6 months, and yearly thereafter. Data on dosage evolution were analysed using a mixed-effect linear model. Results: In 130 patients with a mean follow-up of 63 months, comprising 797 pump years, 104 complications were recorded. This corresponds to a complication rate of 0.011 per month, equally divided among both groups. Seventy-eight of these complications were catheter related. The mean dosage of baclofen stabilizes two years after implantation at 323 µg/day in the multiple sclerosis population. In spinal cord injury patients the daily dose only stabilizes after five years at a significantly higher dosage (504 µg/day). No significant increase in dosage is seen in the long term. Conclusions: In multiple sclerosis and spinal cord injury patients, intrathecal baclofen therapy has a complication rate of 1% per month. Complications are mainly due to catheter-related problems (74%). The intrathecal baclofen dosage stabilizes in the long term, indicating that long-term tolerance, defined as progressive diminution of the susceptibility to the effects of a drug, is not present.

Case report.To describe the case of a spinal cord injury patient that went scuba diving resulting in a mechanical deformation of his intrathecal baclofen pump.University Hospitals Leuven, Belgium.Case report.Diving below 10 meters of depth can result in irreversible mechanical damage of the drug reservoir of an intrathecal baclofen pump.Patients with an intrathecal baclofen pump should be warned for the risks associated with scuba diving and should not dive more than 10 meters below sea level.