Kerstin Wahman

INCReASed CARdIoVASCuLAR dISeASe RISK IN SwedISH PeRSoNS wITH PARAPLegIA: THe SToCKHoLM SPINAL CoRd INJuRy STudy

OBJECTIVE Comparison of prevalence of cardiovascular disease risks in persons with chronic traumatic paraplegia with those in the general population. DESIGN Cross-sectional comparative study. SUBJECTS A total of 135 individuals, age range 18-79 years, with chronic (> or = 1 year) traumatic paraplegia. METHODS The prevalences of diabetes mellitus, dyslipidaemia, hypertension, overweight, and smoking, were assessed in the study population and were compared with an age- and gender-matched sample of the general population in the region under study. History of myocardial infarction and medication for dyslipidaemia, hypertension, and diabetes mellitus were also recorded. chi2 tests were used to compare the paraplegic cohort with the general population sample. RESULTS Significantly more persons with paraplegia reported a history of myocardial infarction (5.9%) than those in the comparison group (0.7%). The prevalences of diabetes mellitus (5.9%), dyslipidaemia (11.1%), and hypertension (14.1%) were also significantly higher in the paraplegic group, as were drug treatment for these disorders. CONCLUSION Persons with paraplegia report increased prevalences of diabetes mellitus, hypertension, and dyslipidaemia, in particular, compared with the general population. Population-based screening and therapeutic counter-measures for these conditions may therefore be particularly indicated for this patient group.

CARDIOVASCULAR DISEASE RISK FACTORS IN PERSONS WITH PARAPLEGIA: THE STOCKHOLM SPINAL CORD INJURY STUDY

OBJECTIVE To examine cardiovascular disease risk factors and risk clusters in Swedish persons with traumatic wheelchair-dependent paraplegia. DESIGN Prospective examination. SUBJECTS A total of 135 individuals aged 18-79 years with chronic (>or= 1 year) post-traumatic paraplegia. METHODS Cardiovascular disease risk factors; dyslipidemia, impaired fasting glucose, hypertension, overweight, smoking, and medication usage for dyslipidemia, hypertension, and diabetes mellitus, were analyzed according to authoritative guidelines. Stepwise regression tested the effects of age, gender, and injury characteristics on cardiovascular disease risks. RESULTS High-prevalence risk factors were dyslipidemia (83.1%), hypertension (39.3%), and overweight (42.2%) with pervasive clustering of these risks. Being older was related to increased cardiovascular disease risk, except for dyslipidemia. Hypertension was more common in low-level paraplegia. Prevalence of impaired fasting glucose was lower than previously reported after paraplegia. A high percentage of persons being prescribed drug treatment for dyslipidemia and hypertension failed to reach authoritative targets for cardiovascular disease risk reduction. CONCLUSION Swedish persons with paraplegia are at high risk for dyslipidemia, hypertension, and overweight. Impaired fasting glucose was not as common as reported in some previous studies. Pharmacotherapy for dyslipidemia and hypertension often failed to achieve recommended targets. Population-based screening and therapeutic countermeasures to these cardiovascular disease risks are indicated.

Effects of an exercise programme on musculoskeletal and neuropathic pain after spinal cord injury—results from a seated double-poling ergometer study

Objectives:To assess pain relieving effects of an intensive exercise programme on a seated double-poling ergometer in individuals with spinal cord injury (SCI).Setting:Stockholm, Sweden.Methods:A total of 13 wheelchair-dependent individuals with a thoracic or lumbar SCI were recruited to a 10-week training period (three times weekly) assessing the effects of regular training on upper-body strength, aerobic and mechanical power, and crossover effects on functional performance, as well as cardiovascular risk factors. Eight of the participants reported pain and were included in this exploratory pain protocol and assessed using the International SCI Basic Pain Data set, the Wheelchair Users’ Shoulder Pain Index and International SCI Quality of Life Basic Data set.Results:For those with neuropathic pain, median pain intensity ratings decreased from 5 on a 0–10 numerical rating scale at base-line to 3 at the end of study, and four of seven participants reported an improvement on the Patient Global Impression of Change scale. For those with musculoskeletal pain (n=5), median pain intensity ratings improved from 4 at baseline to 0 at the end of study. All but one rated no musculoskeletal pain at all at the end of study and number of days with pain per week decreased from 5.5 to 0.7. None of the participants developed pain, because of overuse during the training period and few reported unwanted side effects.Conclusion:Considering its promising effects and safety, an intensive exercise programme can be tried for treating musculoskeletal pain and also neuropathic pain following SCI.

Incidence and aetiology of traumatic spinal cord injury in Cape Town, South Africa: a prospective, population-based study

Study design:Prospective, regional population-based study.Objectives:To provide the incidence, aetiology and injury characteristics of traumatic spinal cord injury (TSCI) in the City of Cape Town, South Africa.Setting:All government-funded hospitals within the City of Cape Town, South Africa.Methods:All survivors of acute TSCI, given that they met the inclusion criteria, were prospectively included for a 1-year period. The International Spinal Cord injury Core Data Set was used and systematically completed by specialist doctors. Further, international standards for neurological classification were adhered to.Results:In total, 147 cases of acute TSCI were identified and 145 were included in the study. The male to female ratio was 5.9:1 and the mean age was 33.5 years, ranging from 18 to 93. The crude incidence rate was 75.6 per million (95% CI: 64.3–88.8) with assault as the main cause of injury, accounting for 59.3% of the cases, followed by motor vehicle accidents (26.3%) and falls (11.7%). Most injuries occurred in the cervical spine (53.1%), and American Spinal Injury Association Impairment Scale A severity was most common (39.3%) in the cohort.Conclusion:The incidence rate of TSCI in a region of South Africa was high when compared to previously postulated figures for the country. There is a need for primary preventative strategies to target younger men that are exposed to violent activities. A national study is required to learn whether these findings are only locally applicable or generalisable.

Falls and fear of falling predict future falls and related injuries in ambulatory individuals with spinal cord injury: a longitudinal observational study

QUESTIONS What is the 1-year incidence of falls and injurious falls in a representative cohort of community-dwelling ambulatory individuals with chronic spinal cord injury? What are the predictors of recurrent falls (more than two/year) and injurious falls in this population? DESIGN One-year longitudinal observational multi-centre study. PARTICIPANTS A representative sample of 68 (of 73 included) community-dwelling ambulatory individuals with traumatic SCI attending regular follow-up programs at rehabilitation centres. OUTCOME MEASURES Primary outcome measures were incidence and predictors of recurrent falls (more than two/year) and injurious falls reported every 2 weeks for 1year. RESULTS A total of 48% of participants reported recurrent falls. Of the 272 reported falls, 41% were injurious. Serious injuries were experienced by 4% of participants, all of whom were women. Multivariate logistic regression analysis showed that recurrent falls in the previous year (OR=111, 95% CI=8.6 to 1425), fear of falling (OR=6.1, 95% CI=1.43 to 26) and longer time taken to walk 10m (OR=1.3, 95% CI=1.0 to 1.7) were predictors of recurrent falls. Fear of falling (OR=4.3, 95% CI=1.3 to 14) and recurrent falls in the previous year (OR=4.2, 95% CI=1.2 to 14) were predictors of injurious falls. CONCLUSION Ambulatory individuals have a high risk of falling and of fall-related injuries. Fall history, fear of falling and walking speed could predict recurrent falls and injurious falls. Further studies with larger samples are needed to validate these findings. [Jørgensen V, Butler Forslund E, Opheim A, Franzén E, Wahman K, Hultling C, Seiger Å, Ståhle A, Stanghelle JK, Roaldsen KS (2017) Falls and fear of falling predict future falls and related injuries in ambulatory individuals with spinal cord injury: a longitudinal observational study. Journal of Physiotherapy 63: 108-113].

Energy expenditure in people with motor-complete paraplegia

Study design:The present descriptive clinical and laboratory study is cross-sectional in design.Objectives:The primary aim is to describe and compare resting energy expenditure (REE) and energy expenditure (EE) during different standardized sedentary, non-exercise and exercise activities in people with motor-complete paraplegia (Th7 to Th12.). A secondary aim was to compare men and women.Methods:Thirty-eight adults (10 women) with SCI, T7-T12 AIS A-B, were recruited. All the data were collected through indirect calorimetry. REE was measured in supine for 30 min after 8 h of overnight fasting. Activity energy expenditure (AEE) for activities was measured for seven minutes during sedentary, non-exercise physical activity (NEPA) and exercise activities.Results:AEE increased four to eight times when engaging in NEPA compared to that in sedentary activities. Men had significantly higher resting oxygen uptake compared to women, 0.19 vs 0.15 l min−1 (P=0.005), REE per 24 h, 1286 vs 1030 kcal (P=0.003) and EE during weight-bearing activities. However, these became nonsignificant after adjustment for body weight and speed of movement, with a mean resting oxygen uptake of 2.47 ml O2 per kg min−1 for the whole group (women 2.43 and men 2.57 ml O2 kg−1 min−1, P=0.49).Conclusions:NEPA increases AEE up to eight times compared to sedentary activities. Gender differences in oxygen uptake during both rest and weight-bearing activities were diminished after adjustment for body weight. The mean resting oxygen uptake for the whole group was 2.47 ml O2 kg−1 min−1. These results highlight the importance, especially of NEPA, for increasing total daily EE in the target population.

High incidence of falls and fall-related injuries in wheelchair users with spinal cord injury: A prospective study of risk indicators.

OBJECTIVE To identify risk indicators for, and incidence of, recurrent falls and fall-related injuries in wheelchair users with traumatic spinal cord injury. DESIGN Prospective multi-centre study. SUBJECTS One hundred and forty-nine wheelchair users with spinal cord injury attending follow-up in Sweden and Norway. METHODS Inclusion criteria: wheelchair users ≥ 18 years old with traumatic spinal cord injury ≥ 1 year post-injury. EXCLUSION CRITERIA individuals with motor complete injuries above C5. Falls were prospectively reported by text message every second week for one year and were followed-up by telephone interviews. Outcomes were: fall incidence, risk indicators for recurrent (> 2) falls and fall-related injuries. Independent variables were: demographic data, quality of life, risk willingness, functional independence, and exercise habits. RESULTS Of the total sample (n = 149), 96 (64%) participants fell, 45 (32%) fell recurrently, 50 (34%) were injured, and 7 (5%) severely injured. Multivariate logistic regression analysis showed that reporting recurrent falls the previous year increased the odds ratio (OR) of recurrent falls (OR 10.2, p < 0.001). Higher quality of life reduced the OR of fall-related injuries (OR 0.86, p = 0.037). CONCLUSION Previous recurrent falls was a strong predictor of future falls. The incidence of falls, recurrent falls and fall-related injuries was high. Hence, prevention of falls and fall-related injuries is important.

Concerns about falling in wheelchair users with spinal cord injury--validation of the Swedish version of the spinal cord injury falls concern scale.

Objective:Translation of the Spinal Cord Injury Falls Concern Scale (SCI-FCS); validation and investigation of psychometric properties.Design:Translation, adaptation and validation study.Subjects/patients:Eighty-seven wheelchair users with chronic SCI attending follow-up at Rehab Station Stockholm/Spinalis, Sweden.Methods:The SCI-FCS was translated to Swedish and culturally adapted according to guidelines. Construct validity was examined with the Mann–Whitney U-test, and psychometric properties with factor and Rasch analysis.Results:Participants generally reported low levels of concerns about falling. Participants with higher SCI-FCS scores also reported fear of falling, had been injured for a shorter time, reported symptoms of depression, anxiety and fatigue, and were unable to get up from the ground independently. Falls with or without injury the previous year, age, level of injury, sex and sitting balance did not differentiate the level of SCI-FCS score. The median SCI-FCS score was 21 (range 16–64). Cronbachs alpha (0.95), factor and Rasch analysis showed similar results of the Swedish as of the original version.Conclusion:The Swedish SCI-FCS showed high internal consistency and similar measurement properties and structure as the original version. It showed discriminant ability for fear of falling, time since injury, symptoms of depression or anxiety, fatigue and ability to get up from the ground but not for age, gender or falls. Persons with shorter time since injury, psychological concerns, fatigue and decreased mobility were more concerned about falling. In a clinical setting, the SCI-FCS might help identifying issues to address to reduce the concerns about falling.

Energy expenditure after spinal cord injury in people with motor-complete tetraplegia or motor-complete paraplegia

Study designCross-sectional.ObjectivesThis study aimed to describe and compare VO2 and energy expenditure at rest (REE) and during standardized sedentary, non-exercise physical activity, and exercise activities, in people with motor-complete tetraplegia (C5–C8). Further, REE and energy expenditure (EE) for the different activities were compared to data from a reference group of people with motor-complete paraplegia (T7–T12).SettingSweden.MethodsThe sample of people with motor-complete tetraplegia consisted of 26 adults (seven women) with SCI, C5–C8 AIS A–B. REE and EE for the different activities were measured with indirect calorimetry. The results were further compared to people with motor-complete paraplegia.ResultsResting VO2 was 2.57 ml O2 kg−1 min−1, 2.54 for men and 2.60 for women. The VO2 or activity energy expenditure related to body weight increased three to four times during non-exercise physical activity compared to sedentary activities for the people with motor-complete tetraplegia, and up to six times during exercise activity. No significant differences were seen in resting or sedentary activity VO2 between the people with motor-complete tetraplegia and those with motor-complete paraplegia. Activities of daily life revealed no or small differences in VO2, except for setting a table, while the people with tetraplegia had ∼50% lower VO2 during exercise activities.ConclusionsNon-exercise physical activities of daily life may be significant for increasing total daily EE in people with motor-complete tetraplegia. This might act to motivate the individual, and might be clinically important when designing adapted lifestyle intervention programs for the target group.

Client Perspectives on Reclaiming Participation After a Traumatic Spinal Cord Injury in South Africa.

Background The development of rehabilitation services promoting participation in people living with a traumatic spinal cord injury (TSCI) is of major concern for physical therapists. What the client sees as effective participation, barriers, and facilitators might be different due to their particular context. This study was conducted to gain insight into the experiences of attaining an important outcome in a developing context. Objective The aim of this study was to explore the experiences of reclaiming participation in community-dwelling people with TSCI in South Africa. Design This was an explorative, qualitative study with inductive content analysis. Methods Individual semistructured interviews were conducted with 17 adults living with a TSCI in order to explore their experience of participation. The verbatim transcripts were analyzed, and the end result was an overall theme that included 4 emerging categories. Results The theme “participation possibility” denotes the eventual involvement in life situations. Within this theme, there were 4 categories that emerged as a representation of essential aspects along the continuum of reclaiming participation: (1) dealing with the new self, (2) a journey dominated by obstacles, (3) the catalyst of participation, and (4) becoming an agent. Dealing with and recognizing these intervening conditions seem critical for clients to reconstruct the meaning that is necessary for a broader conception of participation. Limitations The transferability of these findings to dissimilar contexts may be limited. Conclusion Client perspectives on reclaiming participation after injury affirm the notion of eventual participation, with each person finding strategies to succeed. In order to help clients reclaim participation, health professionals should develop contextually sensitive programs that include peer mentoring and reduce the influence of hindering factors.