Bonsan B. Lee

A global map for traumatic spinal cord injury epidemiology: towards a living data repository for injury prevention

Study design:Literature review.Objectives:To map traumatic spinal cord injury (TSCI) globally and provide a framework for an ongoing repository of data for prevention.Setting:An initiative of the ISCoS Prevention Committee.Methods:The results obtained from the search of Medline/Embase using search phrases: TSCI incidence, aetiology, prevalence and survival were analysed. Stratification of data into green/yellow/red quality ‘zones’ allowed comparison between data.Results:Reported global prevalence of TSCI is insufficient (236–1009 per million). Incidence data was comparable only for regions in North America (39 per million), Western Europe (15 per million) and Australia (16 per million). The major cause of TSCI in these regions involves four-wheeled motor vehicles, in contrast to South-east Asia where two-wheeled (and non-standard) road transport predominates. Southern Asia and Oceania have falls from rooftops and trees as the primary cause. High-fall rates are also seen in developed regions with aged populations (Japan/Western Europe). Violence/self-harm (mainly firearm-related) was higher in North America (15%) than either Western Europe (6%) or Australia (2%). Sub-Saharan Africa has the highest reported violence-related TSCI in the world (38%). Rates are also high in north Africa/Middle East (24%) and Latin America (22%). Developed countries have significantly improved TSCI survival compared with developing countries, particularly for tetraplegia. Developing countries have the highest 1-year mortality rates and in some countries in sub-Saharan Africa the occurrence of a spinal injury is likely to be a fatal condition within a year.Conclusion:Missing prevalence and insufficient incidence data is a recurrent feature of this review. The piecemeal approach to epidemiological reporting of TSCI, particularly failing to include sound regional denominators has exhausted its utility. Minimum data collection standards are required.

Non-pharmacological treatment and prevention of bone loss after spinal cord injury: a systematic review

Objective:Review the literature on non-pharmacological prevention and treatment of osteoporosis after spinal cord injury (SCI).Methods:PubMed, EMBASE and the Cochrane Controlled Trials Register were searched. All identified papers were read by title, abstract and full-length article when relevant. Hand search of the articles’ sources identified additional papers. For included studies, the level of evidence was determined.Results:No studies conclusively showed an effective intervention. However, there are few randomized controlled trials (RCTs), and those that exist assess interventions and outcome measures that could be improved. Five studies on weight-bearing early post-injury are conflicting, but standing or walking may help retain bone mineral. In the chronic phase, there was no effect of weight bearing (12 studies). One study found that an early commencement of sports after SCI improved bone mineral, and the longer the period of athletic career, the higher the (leg) bone mineral. Early after SCI, there may be some effects of electrical stimulation (ES) (five studies). Chronic-phase ES studies vary (14 studies, including mixed periods after injury), but improvement is seen with longer period of training, or higher frequency or stimulus intensity. Improvements correspond to trabecular bone in the distal femur or proximal tibia. Impact vibration and pulsed electromagnetic fields may have some positive effects, whereas pulsed ultrasound does not. Six studies on the influence of spasticity show inconsistent results.Conclusions:Bone mineral should be measured around the knee; the length and intensity of the treatment should be sufficiently long and high, respectively, and should commence early after SCI. If bone mineral is to remain, the stimulation has to be possibly continued for long term. In addition, RCTs are necessary.

Spinal-injured neuropathic bladder antisepsis (SINBA) trial

Objective:To determine whether Methenamine Hippurate (MH) or cranberry tablets prevent urinary tract infections (UTI) in people with neuropathic bladder following spinal cord injury (SCI).Study design:Double-blind factorial-design randomized controlled trial (RCT) with 2 year recruitment period from November 2000 and 6 month follow-up.Setting:In total, 543 eligible predominantly community dwelling patients were invited to participate in the study, of whom 305 (56%) agreed.Methods:Eligible participants were people with SCI with neurogenic bladder and stable bladder management. All regimens were indistinguishable in appearance and taste. The dose of MH used was 1 g twice-daily. The dose of cranberry used was 800 mg twice-daily. The main outcome measure was the time to occurrence of a symptomatic UTI.Results:Multivariate analysis revealed that patients randomized to MH did not have a significantly longer UTI-free period compared to placebo (HR 0.96, 95% CI: 0.68–1.35, P=0.75). Patients randomized to cranberry likewise did not have significantly longer UTI-free period compared to placebo (HR 0.93, 95% CI: 0.67–1.31, P=0.70).Conclusion:There is no benefit in the prevention of UTI from the addition of MH or cranberry tablets to the usual regimen of patients with neuropathic bladder following SCI.

Global maps of non-traumatic spinal cord injury epidemiology: towards a living data repository

Study design:Literature review.Objectives:Globally map non-traumatic spinal cord injury (NTSCI) incidence, prevalence, survival, level of injury and aetiology. Propose a research framework for NTSCI prevention and launch a repository of NTSCI data.Setting:Initiative of the International Spinal Cord Society Prevention Committee.Methods:Literature search of Medline and Embase (1959–June 2011). Relevant articles in any language regarding adults with NTSCI were included. Stratification of information about incidence and prevalence into green/yellow/orange/red data quality ‘zones’ and comparisons between World Health Organisation (WHO) regions and countries.Results:Three hundred and seventy-seven abstracts reviewed—45 of these from 24 countries in 12 of the 21 WHO global regions had relevant information. Only one publication had survival data. Prevalence data for NTSCI existed for only two countries, India (prevalence of 2 310/million population, Kashmir region) and Canada (prevalence of 1 120/million population). The incidence rates for WHO regions were: Asia Pacific, high income 20/million population/year; Australasia (26/million population/year); Western Europe median of 6/million population/year; North America, high income median 76/million population/year (based on poor-quality studies); and Oceania 9/million population/year. Developed countries tended to have a higher proportion of cases with degenerative conditions and tumours. Developing countries, in comparison, tended to have a higher proportion of infections, particularly tuberculosis and HIV, although a number also reported tumours as a major cause.Conclusions:Insufficient survival, prevalence and incidence data are a predominant finding of this review. The piecemeal approach to epidemiological reporting of NTSCI, particularly failing to include sound regional population denominators, has exhausted its utility. Minimum data collection standards are required.

Surface Functional Electrical Stimulation of the Abdominal Muscles to Enhance Cough and Assist Tracheostomy Decannulation After High-Level Spinal Cord Injury

Abstract Objective: Evaluation of noninvasive stimulation modalities to augment cough and assist tracheostomy decannulation in high-level tetraplegia. Study Design: Single case study. Methods: A 65-year-old man with C4 ASIA C tetraplegia had delayed rehabilitation due to a tracheostomy and recurrent pneumonia primarily resulting from ineffective cough. Anterior surface electrical stimulation (SES) of the abdominal musculature was conducted to train an effective cough and enable decannulation. Training occurred daily for 4 weeks. The patient was tested 1 year later with posterolateral SES to determine the relative clinical effect of this delivery method. Results: At baseline, the addition of anterior SES increased maximal expiratory pressure (80%), maximal expiratory cough pressure (67%), and peak expiratory flow rate (11 %). Three weeks after training began, the patient was decannulated following a program of SES and assisted and voluntary coughing. Upon testing 1 year later, SES with posterolaterally placed electrodes also produced an enhancement of voluntary cough attempts. Conclusions: Noninvasive SES can potentially assist decannulation of tracheostomies.

Estimating the global incidence of traumatic spinal cord injury

Study design:Population modelling—forecasting.Objectives:To estimate the global incidence of traumatic spinal cord injury (TSCI).Setting:An initiative of the International Spinal Cord Society (ISCoS) Prevention Committee.Methods:Regression techniques were used to derive regional and global estimates of TSCI incidence. Using the findings of 31 published studies, a regression model was fitted using a known number of TSCI cases as the dependent variable and the population at risk as the single independent variable. In the process of deriving TSCI incidence, an alternative TSCI model was specified in an attempt to arrive at an optimal way of estimating the global incidence of TSCI.Results:The global incidence of TSCI was estimated to be 23 cases per 1 000 000 persons in 2007 (179 312 cases per annum). World Health Organization’s regional results are provided.Discussion:Understanding the incidence of TSCI is important for health service planning and for the determination of injury prevention priorities. In the absence of high-quality epidemiological studies of TSCI in each country, the estimation of TSCI obtained through population modelling can be used to overcome known deficits in global spinal cord injury (SCI) data. The incidence of TSCI is context specific, and an alternative regression model demonstrated how TSCI incidence estimates could be improved with additional data. The results highlight the need for data standardisation and comprehensive reporting of national level TSCI data. A step-wise approach from the collation of conventional epidemiological data through to population modelling is suggested.

Abdominal Muscle Training Can Enhance Cough After Spinal Cord Injury

Background. Respiratory complications in people with high-level spinal cord injury (SCI) are a major cause of morbidity and mortality, particularly because of a reduced ability to cough as a result of abdominal muscle paralysis. Objective. We investigated the effect of cough training combined with functional electrical stimulation (FES) over the abdominal muscles for 6 weeks to observe whether training could improve cough strength. Methods. Fifteen SCI subjects (C4-T5) trained for 6 weeks, 5 days per week (5 sets of 10 coughs per day) in a randomized crossover design study. Subjects coughed voluntarily at the same time as a train of electrical stimulation was delivered over the abdominal muscles via posterolaterally positioned electrodes (50 Hz, 3 seconds). Measurements were made of esophageal (Pes) and gastric (Pga) expiratory pressures and the peak expiratory flow (PEFcough) produced at the 3 time points of before, during, and after the training. Results. During voluntary coughs, FES cough stimulation improved Pga, Pes, and PEFcough acutely, 20-fold, 4-fold, and 50%, respectively. Six weeks of cough training significantly increased Pga (37.1 ± 2.0 to 46.5 ± 2.9 cm H2O), Pes (35.4 ± 2.7 to 48.1 ± 2.9 cm H2O), and PEFcough (3.1 ± 0.1 to 3.6 ± 0.1 L/s). Cough training also improved pressures and flow during voluntary unstimulated coughs. Conclusions. FES of abdominal muscles acutely increases mechanical output in coughing in high-level SCI subjects. Six weeks of cough training further increases gastric and esophageal cough pressures and expiratory cough flow during stimulated cough maneuvers.

Posterolateral Surface Electrical Stimulation of Abdominal Expiratory Muscles to Enhance Cough in Spinal Cord Injury

Background. Spinal cord injury (SCI) patients have respiratory complications because of abdominal muscle weakness and paralysis, which impair the ability to cough. Objective. This study aims to enhance cough in high-level SCI subjects (n = 11, SCI at or above T6) using surface electrical stimulation of the abdominal muscles via 2 pairs of posterolaterally placed electrodes. Methods. From total lung capacity, subjects performed maximum expiratory pressure (MEP) efforts against a closed airway and voluntary cough efforts. Both efforts were performed with and without superimposed trains of electrical stimulation (50 Hz, 1 second) at a submaximal intensity set to evoke a gastric pressure (P ga) of 40 cm H2O at functional residual capacity. Results. In the MEP effort, stimulation increased the maximal P ga (from 21.4 ± 7.0 to 59.0 ± 5.7 cm H2O) and esophageal pressure (P es; 47.2 ± 11.7 to 65.6 ± 13.6 cm H2O). During the cough efforts, stimulation increased P ga (19.5 ± 6.0 to 57.9 ± 7.0 cm H2O) and P es (31.2 ± 8.7 to 56.6 ± 10.5 cm H2O). The increased expiratory pressures during cough efforts with stimulation increased peak expiratory flow (PEF, by 36% ± 5%), mean expiratory flow (by 80% ± 8%), and expired lung volume (by 41% ± 16%). In every subject, superimposed electrical stimulation improved peak expiratory flow during cough efforts (by 0.99 ± 0.12 L/s; range, 0.41-1.80 L/s). Wearing an abdominal binder did not improve stimulated cough flows or pressures. Conclusions. The increases in P ga and PEF with electrical stimulation using the novel posterolateral electrode placement are 2 to 3 times greater than improvements reported in other studies. This suggests that posterolateral electrical stimulation of abdominal muscles is a simple noninvasive way to enhance cough in individuals with SCI.

Preventing falls in older multifocal glasses wearers by providing single-lens distance glasses: the protocol for the VISIBLE randomised controlled trial

BackgroundRecent research has shown that wearing multifocal glasses increases the risk of trips and falls in older people. The aim of this study is to determine whether the provision of single-lens distance glasses to older multifocal glasses wearers, with recommendations for wearing them for walking and outdoor activities, can prevent falls. We will also measure the effect of the intervention on health status, lifestyle activities and fear of falling, as well as the extent of adherence to the program.Methods/DesignApproximately 580 older people who are regular wearers of multifocal glasses people will be recruited. Participants will be randomly allocated to either an intervention group (provision of single lens glasses, with counselling and advice about appropriate use) or a control group (usual care). The primary outcome measure will be falls (measured with 13 monthly calendars). Secondary measures will be quality of life, falls efficacy, physical activity levels and adverse events.DiscussionsThe study will determine the impact of providing single-lens glasses, with advice about appropriate use, on preventing falls in older regular wearers of multifocal glasses. This pragmatic intervention, if found to be effective, will guide practitioners with regard to recommending appropriate glasses for minimising the risk of falls in older people.Trial RegistrationThe protocol for this study was registered with the Clinical Trials.gov Protocol Registration System on June 7th 2006 (#350855).

Corridor Conversations: Clinical Communication in Casual Spaces

Corridor consultations are ‘part of the daily discourse of hospital medicine’ (Heard et al., 2003), however, in spite of being ‘an integral part of physicians’ medical culture … little is known’ about this widespread and significant mode of clinical communication (Peleg et al., 1999, p. 241), and corridor communications ‘are often discussed as if they were of little formal value’ (Downey et al., 1997, p. 245). Communication modes in hospitals have been extensively studied: medical records, handovers, ward rounds, case management meetings, organizational meetings and doctor–patient communication (Iedema, 2005). Corridors, however, have so far been overlooked as a site of study for health communication. And yet mentions of corridor or hallway consultations or conversations are sprinkled throughout the medical literature, and it is evident from this that corridors act as important conduits of clinical information flow. It appears then that in some respects the interactions that take place in corridors are similar to interactions in other spaces. The focus of this chapter, however, is on how corridor conversations differ from other more frequently studied kinds of clinical information exchange, such as case conferences and ward rounds, and to investigate what is typical of interactions that take place in one specific hospital-based clinic’s corridor space.