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Abstract Book
Vancouver Convention Centre
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Table of Contents
Executive Summaries.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Order: Summaries are listed in order of appearance per the Interdependence 2012 Program. Only summaries received at the time of
printing are included.
Krassioukov, Andrei. Autonomic Dysfunctions and Sexual Health Following Spinal Cord Injury.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Wyndaele, Jean-Jacques. Advancements in the Management of Bladder and Male Sexual Function
after Spinal Cord Lesion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Zhou, Mouwang. Urodynamic Investigation after Spinal Cord Injury: One-Channel
Cystometry vs. Multichannel Urodynamics.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Elliott, Stacy L. Sexual and Fertility Rehabilitation: What’s New and Productive. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Fehlings, Michael. Bioengineered Strategies to Promote Repair of the Injured Spinal Cord. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Fawcett, James. Targeting the Extracellular Matrix to Repair Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Tetzlaff, Wolfram. Dietary Strategies for Acute Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
McKerracher, Lisa. The Cethrinphase I/IIA Trial to Treat Acute Spinal Cord Injury: Update on Results.. . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Biering-Sørensen, Fin. Accelerating Progress Through Global Standards: The International Spinal Cord
Injury Data Sets .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hayes, Keith C. Implementation of Best Practices: A Multi-Layered Global Challenge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Noreau, Luc. The SCI Community Survey: Toward a Better Understanding of Support Services that
Enhance Community Living.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Martin Ginis, Kathleen A. Best Practices Implementation Through Community-University Partnerships. . . . . . . . . . . . . . . . . . . . . . . 11.
Williams, Stephanie. Communicate, Collaborate, Cure... Networking Down Under .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Harrop, James S. Building and Maintaining a Multispecialist SCI Center.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Young, Wise. China SCI Net Clinical Trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Krassioukov, Andrei. Latest Advances in Evaluation of Autonomic Dysfunctions Following Spinal Cord Injury. . . . . . . . . . . . . . . . . . 13
Wecht, Jill M. The Presentation and Consequences of Decentralized Autonomic Cardiovascular Control
in Persons with SCI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Claydon, Victoria. The Influence of Injury to Autonomic Pathways on Cardiovascular Disease Risk after
Spinal Cord Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Bauman, William A. Metabolic and Endocrine Disorders in Individuals with Chronic Spinal Cord Injury:
Predisposition to Cardiovascular Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Kwon, Brian. The Challenge of Deciding What to Translate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Curt, Armin. Preclinical Studies Provide Limited Prediction of Safety and Efficacy in human SCI trials. . . . . . . . . . . . . . . . . . . . . . . . 15
Grossman, Robert G. Organizational, Regulatory and Financial Barriers to Conducting Clinical Trials in SCI. . . . . . . . . . . . . . . . . . . 15
Guest, James D. Regulatory Considerations to Initiate an Invasive Experimental Treatment for Spinal Cord Injury. . . . . . . . . . . . . . 15
McKerracher, Lisa. The Importance of Innovation and Collaboration in Developing New Treatments for
Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1
Wirth III, Edward D. Clinical Translation of Absorbable Biopolymers and Hydrogels for Acute Spinal Cord Injury. . . . . . . . . . . . . . . 16
Kenneth Galbraith. Commercialization of SCI Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Lebkowski , Jane S. Achievements and Challenges in the Development of Human Embryonic Stem Cell
Based Therapies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Kurzweil, Ray. The Accelaration of Technology in the 21st Century: The Impact on Healthcare and Medicine.. . . . . . . . . . . . . . . . . 17
Prochazka, Arthur. Neuroprostheses and Tele-supervised Exercise to Improve Hand Function: Benefits
and limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Harkema, Susan. Strategies for Neuromuscular Recovery after Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Peckham, P. Hunter. Institute for Functional Restoration, A New Model for Deployment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Kirshblum, Steven. Technological Advances in SCI .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Spungen, Ann M. Walking with an Exoskeleton for Persons with Paraplegia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Krassioukov, Andrei. Is There a Relationship Between Paralympic Classification, Autonomic symptoms and
Altered Cardiovascular Control Among Elite Wheelchair Athletes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Warburton, Darren. Advancements in the Physiological Evaluation of the High Performance Paralympic Athlete. . . . . . . . . . . . . . . 19
West, Christopher. Cardiorespiratory limitations to Exercise Performance in Paralympic Athletes with
Cervical Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Taunton, Jack. Paralympic Medical Services for the 2010 Paralympic Winter Games.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Phillips, Aaron A. Arterial Stiffness on Physically Active Individuals with Spinal Cord Injury.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Wong, Shirley. Assessing Autonomic Completeness of Spinal Cord Injury: A Missing Piece of Paralympic
Athlete Classification.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Fehlings, Michael. Repair and Regeneration of the Injured Spinal Cord with Neural Stem Cells: “Hope or Hype”.. . . . . . . . . . . . . . 21
Guest, James D. Understanding the Challenges to Proving Efficacy with Cell Therapy in Clinical Subjects . . . . . . . . . . . . . . . . . . . . 21
Tetzlaff, Wolfram. Preclinical Approaches to Spinal Cord Repair: Transplantation of Schwann Cells
Generated from Skin-Derived Precursors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Curt, Armin. Development of Appropriate Stratification and Outcome Algorithms
in Clinical SCI Trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Podium Abstracts.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Order: Abstracts are listed in order of appearance per the Interdependence 2012 program.
O1-01 - Expectations of Risk, Benefit, and Preclinical Scientific Rigor in Experimental Treatments for
Spinal Cord Injury: A Survey of SCI Individuals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
O1-02 - PTEN Deletion Promotes Regenerative Sprouting in the Aged Rubrospinal Tract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
O1-03 - Assessment of Cervical Spinal Cord Injury Models: Comparison and Validation Using Extensive
Neurobehavioural Assessment and Stem Cell Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
O1-04 - Objective Spinal fMRI Metrics Distinguish Complete and Incomplete Clinical Grade in Chronic
Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
O1-05 - Elevated Circulating Levels of the Pro-Inflammatory Cytokine Macrophage Migration Inhibitory
Factor (MIF) in Chronic Spinal Cord Injury (SCI) Patients... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2
O1-06 - Semaphorin 5B is Critical to Axonal Guidance in the Chick Spinal Cord. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
O1-07 - Creation of an Anatomic Atlas of Cervical Spine Intradural Anatomy using Fiesta MRI.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
O1-08 - Vegf and Pdgf as an Immunomodulatory Strategy for the Reduction of Secondary Degeneration
after a Model Spinal Cord Contusion Injury in Rats.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
O2-01 - Exercise Capacity and Tolerance During Inpatient Spinal Cord Injury Rehabilitation: Preliminary Findings. . . . . . . . . . . . . 27
O2-02 - Improving Muscle Co-Activation in Spinal Cord Injured Individuals Using Body-Weight Supported
Treadmill Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
O2-03 - Effects of Varying Forward Trunk Inclination During Sitting Pivot Transfers on Upper Limb Loads
in Individuals with a Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
O2-04 - Exercise Self-Efficacy Following Discharge from Inpatient Spinal Cord
Injury Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
O2-05 - Controlled Nerve Lesioning with Direct Current. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
O2-06 - Antiosteoporotic Effects of Alendronate on Younger Patients with Acute Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . 31
O2-07 - Quantifying Proprioception in the Lower Limbs Using a Robotic Exoskeleton.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
O2-08 - Online Delphi to Identify Targets for Best Practice Implementation and Associated
Performance Measures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
O3-01 - The Brain and Spinal Cord Response to Sensory Stimuli: An fMRI Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
O3-02 - Influence of Surgical Delay on Hospitalization Costs and Length of Stay Following a Traumatic
Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
O3-03 - Responsiveness of a Clinical Impairment Measure Specific for Traumatic Tetraplegia:
A Multi-Centre Assessment of the Grassp Outcome Measure.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
O3-04 - Walking Measures Inform SCI Rehabilitation Practice and Research.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
O3-05 - Classifying Neurological Impairment and Spinal Column Injuries: Does Administrative Coding
Accurately Represent Clinical Diagnoses?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
O3-06 - Rick Hansen Spinal Cord Injury Registry and Ontario Spinal Cord Injury Registry: Relationships
Between Respiratory Status and Length-Of-Stay in Acute Care and Rehabilitation.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
O3-07 - Prognostic Value of Multimodal Neurophysiological Evaluation in Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
O3-08 - Outcomes in the Va Sci/D System of Care: Collection, Analysis, Utilization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
O4-01 - Spinal Cord Injury Model Systems Database: Continuing 40 Years of Progress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
O4-02 - The Rick Hansen Spinal Cord Injury Registry: An Update.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
O4-03 - Review of Knowledge Translation and Implementation Strategies in Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
O4-04 - Intramuscular Diaphragm Pacing for Respiratory Support in Tetraplegics: Current Worldwide
Status in 2010. Why isn’t Available Technology Utilized?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
O4-05 - A Global Perspective on the Frequency of the Leading Causes of Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
O4-06 - Spinal Cord Injury in the Majority World: Challenges and Opportunities in Providing Standard Care. . . . . . . . . . . . . . . . . . . 41
O4-07 - Addressing Privacy Requirements for the Development of a National Health Registry in Canada. . . . . . . . . . . . . . . . . . . . . 41
O4-08 - The Development of Canadian Best Practice Guidelines for the Prevention and Treatment of
Pressure Ulcers in the Spinal Cord Injured Population.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
3
Poster Abstracts.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Order: Abstracts are listed in order of appearance per the Interdependence 2012 program.
P1-01 - Regaining Functionality Following a Spinal Cord Injury (SCI): Central Issues for SCI Consumers. . . . . . . . . . . . . . . . . . . . . . 43
P1-02 - Patient Advocacy as a Force to Advance SCI Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
P1-05 - Scoping the Field of Research and Management of Neuropathic Pain After Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . 44
P1-08 - An Inter-Professional Clinical Initiative in an Outpatient Spinal Cord Injury (SCI) Rehabilitation
Setting: Pathways to Well-Being Following SCI Community Reintegration Service.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
P1-09 - The Case for Transvenous Phrenic Nerve Pacing After a High-Level Spinal Cord Injury.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
P1-10 - A Kinetic Evaluation of a Novel Forearm Crutch with a Shock Absorption System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
P1-11 - Creating the Winning Conditions to Ensure Sustainable Best-Practice
Implementation - The Irglm Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
P1-12 - The Effects of Pharmacological Agents on Walking in People with Spinal Cord Injury:
A Systematic Review.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
P1-13 - UTI’s and Intermittent Catheterization, What Does the Evidence Say?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
P1-14 - The Osteoporosis Guidelines of the Joint Organizations of the German-Speaking Bone
Research Societies and their Meaning for Paralyzed Elderly Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
P1-15 - Evidence Based Management of Depression Following Spinal Cord Injury: A Meta-Analysis.. . . . . . . . . . . . . . . . . . . . . . . . . 49
P1-16 - Using Scoping Review Methodology to Conduct a Canadian Spinal Cord Injury (SCI)
Rehabilitation Environmental Scan.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
P1-17 - My Life, My Health Chronic Disease Self-Management Program in Rehabilitation.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
P1-18 - SCIRE 3.0: A Platform for Developing Initiatives to Enhance Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
P1-19 - Gabapentinoids are Effective in Decreasing Neuropathic Pain Intensity Post SCI: A Meta-Analysis. . . . . . . . . . . . . . . . . . . . 51
P1-20 - Effectiveness of Botulinum Toxin in Treating Neurogenic Detrusor Overactivity Post SCI:
A Systematic Review and Meta-Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
P1-21 - Leveling the Playing Field - Making SCI Primary Care Accessible.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
P1-22 - Factors Influencing Return to Community Living of Persons with SCI and their Family Members :
for an Ecosystemic Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
P1-23 - The Effects of the “Discovering The Power In Me” Program in Spinal Cord Injury.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
P2-01 - Icd-10 Coding Accuracy for Spinal Cord Injured Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
P2-02 - Development of an Integrated, Distributed Clinical Research Database for Spinal Cord Injury.. . . . . . . . . . . . . . . . . . . . . . . . 55
P2-03 - Effects of Seated Double-Poling Ergometer Training on Aerobic and Mechanical Power
in Paraplegics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
P2-04 - Design and Progress of the Swiss Spinal Cord Injury Cohort Study (Swisci). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
P2-05 - Best Practice Implementation in Inpatient Spinal Cord Rehabilitation – The Challenges of
a Multi-Unit Site.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
P2-06 - Systematic Review of Economic Studies in Spinal Cord Injury.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
P2-07 - A National Approach to Implementing and Sustaining Evidence-Based Practices for Treatment
and Prevention of Secondary Complications for Individuals with Spinal Cord Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
4
P2-08 - First Year Anniversary of the Rick Hansen Spinal Cord Registry in Western Quebec: Facts and
Figures at a Glance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
P2-09 - Muscle Strength Changes Recorded Using Dynamometry During Robot Assisted Gait Training. . . . . . . . . . . . . . . . . . . . . . . 60
P2-10 - The Development of an Outdoor Experiential Therapy (OET) Cottage Program for Persons
with Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
P2-11 - Evaluating the Effects of an Inter-Professional Therapeutic Cottage Program on Improving
Well-Being in Persons with Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
P2-12 - Cardiovascular Control in the Acute Period after Spinal Cord Injury: A Case Series.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
P2-13 - Systems Thinking Perspectives in Spinal Cord Injury Research and Practice.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
P2-14 - Examining Workplace Activity Limitations Among Young Adults Living with Spinal Cord Injuries:
A Pilot Study.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
P2-15 - Economics of Traumatic Spinal Cord Injury in Canada. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
P2-16 - Non-Neurological Complication Rate Following Surgical Stabilization of Vertebral Fracture
with Neurological Impairment. Does Surgical Timing Matter?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
P2-17 - Patient-Centred Care: Using Operations Research Techniques to Improve Care for Persons
with Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
P2-18 - Does Autonomic Dysfunction Play a Role in the Development ff Cardiovascular Disease
After Spinal Cord Injury?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
P2-19 - Access to Primary Care for Persons with SCI: A Health Service Delivery Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
P2-21 - Use of the Spine Adverse Events Severity (Saves) Instrument for Traumatic Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . 66
P2-22 - Long-Term Follow-Up of Bladder Function in Patients with Spinal Cord Injury.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
P2-23 - Does Bacteriuria Matter in Patients with Neurogenic Lower Urinary Tract Dysfunction?.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
P2-25 - Self-Reported Physical Activity of Individuals With SCI at Admission and Discharge from
Inpatient Rehabilitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
P3-01 - The Acute Effects of Circulating Cytokines on Peripheral Nerve Function in Humans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
P3-02 - Mapping the Interactions of Chronic and Acute Noxious Sensations in the Spinal Cord.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
P3-03 - Influence of Classical Music on Neural Activity and Pain Response in the Spinal Cord
Using Functional Magnetic Resonance Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
P3-04 - An In Vivo Experimental Platform for Chronic Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
P3-05 - Dietary Treatments for Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
P3-06 - Establishing a Model Spinal Cord Injury in the African Green Monkey for the Preclinical
Evaluation of Biodegradable Polymer Scaffolds Seeded with Human Neural Stem Cells. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
P3-07 - A Model for Bridging the Translational Valley of Death in Spinal Cord Injury.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
P3-08 - Development of a Knowledge Translation Program Among Spinal Cord Injury Patients in
Acute Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
P3-09 - Critical Appraisal Tools for Preclinical Studies in Spinal Cord Injury Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
P3-10 - Investigating Knowledge Translation Between Biomedical Researchers, Knowledge Facilitators
and Wheelchair Users. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
P3-11 - Practical Steps Towards Knowledge Mobilization in Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
5
P3-12 - Evaluation Of Diffusion Tensor Magnetic Resonance Imaging to Improve Fiber Tract Assessment
in Humans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
P3-13 - Early Surgical Decompression for Traumatic Cervical Spinal Cord Injury (SCI): A Cost-Utility Analysis
and Feasibility Study.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
P3-14 - Institute for Functional Restoration (IFR).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
P3-16 - Identifying Quality of Life Outcome Tools for Measuring the Impact of Pressure Ulcers in Persons
with Spinal Cord Injury.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
P3-17 - Spinal Cord Injury Quality of Life Instruments: Do They Measure What They Are Supposed to Measure?.. . . . . . . . . . . . . . 80
P3-18 - On a Roll: Creating a Provincial Action Strategy to Address Quality of Life Issues for People
with Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
P3-19 - Towards Interventions Focusing on Community Living and Quality of Life for Individuals with
Spinal Cord Injury: The Com-Qol Team. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
P3-20 - Effect of Motor Score on Adverse Events and Quality of Life in Patients with Traumatic SCI. . . . . . . . . . . . . . . . . . . . . . . . . . 82
P3-21 - Investigating Life Satisfaction of Community-Dwelling Individuals Living with a Traumatic
Spinal Cord Injury in Ontario, Canada – A Pilot Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
P3-22 - Housing for Everyone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
P3-23 - Translation, Transition, & Transformation - Mental Health for Persons with SCI, Families,
and Care-Givers.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
P3-24 - Altering Inflammation After Spinal Cord Injury Using Biomaterials.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Author index.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6
Executive Summaries
Order: Summaries are listed in order of appearance per the
Interdependence 2012 Program. Only summaries received at the
time of printing are included.
of treatment has occurred. This has resulted in a lower risk
of death from urologic causes during follow up and a better
related quality of life.
Autonomic Dysfunctions and
Sexual Health Following Spinal Cord
Injury
It is generally accepted that kidney function depends for an
important part on lower urinary tract (LUT) function. In the LUT
pressure development during bladder filling and during voiding
should be low. Proper regular bladder emptying is needed.
Continence of urine is important but being continent all the time
does not mean functional safe bladder or kidneys. Diagnosis will
be done with history, clinical evaluation, including neurological
tests of the lumbosacral innervations. Most guidelines advocate
the urodynamic testing and simultaneous imaging if possible.
Intermittent catheterization and self catheterization have
become the treatment of choice. But in some individuals
indwelling catheter, suprapubic catheter can be indicated.
Bladder relaxing drugs in proper dosage can help keep bladder
pressure low. Most frequent complication is urinary tract
infection. Regular follow up is important with history, urine and
eventually blood analysis, imaging and other test as needed.
During urological management the comprehensive complete
management should be looked at. Major decisions will be
finally made by the patient. Urological management should also
involve those who are close to the patient during rehabilitation
and when back in the community, implicating education and
communication.
Andrei Krassioukov, MD, PhD, FRCPC
University of British Columbia (Canada)
Both men and women commonly suffer sexual dysfunction
secondary to spinal cord injury (SCI). SCI disrupts the
neurological pathways required for the sexual spinal reflexes,
including arousal, orgasm and ejaculation. Sexual consequences
of SCI not only significantly alters quality of life, but sexual activity
itself can result in life- threatening changes in cardiovascular
responses. The cause of these changes is disruption of spinal
autonomic circuits vulnerable to trauma of the spinal cord.
However, autonomic control of sexual function is one of the least
investigated systems in humans, despite the priority of sexuality
that has been indicated by persons with SCI themselves. Our
data and data from literature suggest that during the sexual
activities the systolic arterial blood pressure could be elevated up
to 300 mmHg as a result of autonomic dysreflexia (AD). Nearly all
episodes of AD occurred in individuals with SCI above the T6 level
with the severity increasing with higher lesion levels. Commonly
individuals with SCI associated these episodes as new perception
of orgasm. We still do not fully appreciate the significance of
partial preservation of the descending autonomic pathways and
their role in ejaculation predictability and provoked episodes of
AD. The likelihood of AD being triggered during sexual activity
largely depends on the nature of the stimulation with selfstimulation being less likely to trigger AD than vibrostimulation,
and the nature of the injury with higher injury levels resulting in
a higher likelihood of AD. Future research needs to characterize
exact changes in cardiovascular parameters during sexual activity
in SCI patients at home during usual sexual activity in order to
develop recommendations for managing AD at home during
these activities.
Advancements in the Management
of Bladder and Male Sexual
Function After Spinal Cord Lesion
Jean-Jacques Wyndaele, MD
Antwerp University Hospital (Belgium)
The prevalence of neurologic dysfunction of the lower urinary
tract is high when a spinal lesion occurs. The last decades
have seen some important evolutions mostly in knowledge
and understanding. Also optimization of diagnostics and forms
Sexual function is part of the post spinal lesion rehabilitation.
Discussion about it should be offered to all spinal cord
lesioned individuals and the relatives involved. There are
different modalities to permit a proper erection. For fertility,
actual methods of sperm retrieval and fertility clinic techniques
have made pregnancies possible in many couples.
The International Spinal Cord Injury DATA SETS developed
by ISCOS-ASIA on different subjects are very helpful to guide
diagnosis, treatment and follow up (see relevant web sites
ISCOS.org.uk and asia-spinalinjury.org).
Urodynamic investigation After
Spinal Cord Injury: One-Channel
Cystometry vs. Multichannel
Urodynamics
Mouwang Zhou, MD
Peking University 3rd Hospital (China)
It is important to identify the type of neurogenic lower urinary
tract dysfunction after spinal cord injury (SCI). It could
not be predicted by the location of injury and neurological
examination. Regular multichannel urodynamic observation
should be performed to assess the function of bladder and
7
urethral. Unfortunately multichannel urodynamic system
was not a standard equipment in every SCI rehabilitation
center in China. In this situation, one channel device with
transurethral catheter provide an alternative way. It is easy
to get and perform, cheap and applicable. And it also
revealed significant contribution in assessing lower urinary
tract function, especially in measuring parameters during
filling phase. We compared one-channel cystometry with
multichannel urodynamics in 35 patients after SCI. The
simple one-channel cystometry immediately followed by
a regular multichannel urodynamics. It has shown good
correlation between these 2 methods for the detection
of neurogenic detrusor overactivity. We also found that
the autonomic dysreflexia (AD) was not rare in the SCI
patient above T6 while used electrocardio and blood
pressure monitoring during urodynamic investigation. It is
recommended that blood pressure measurement during
filling phase in urodynamic observation maybe a proper
method to diagnosis potential AD after SCI.
and videos on sexual and fertility issues are allowing for
better educational dissemination to clients and health care
practitioners.
Bioengineered Strategies to
Promote Repair of the Injured
Spinal Cord
Michael Fehlings, MD, PhD, FRCSC, FACS
Toronto Western Hospital (Canada)
This talk will summarize recent work examining promising
bioengineered strategies which address key therapeutic targets
for spinal cord injury:
1) Bioengineered transcription factors that upregulate
VEGF (ZFP-VEGF constructs)
2) Self-assembling peptides (SAPS) to target the glial
scar and act as a structural scaphold and
Sexual and Fertility Rehabilitation:
What’s New and Productive
Stacy L. Elliott, MD
University of British Columbia (Canada)
There is a noticeable improvement in attitude and interest
around sexuality after spinal cord injury in the last decade.
Specifically, some of the newer medications for erection
enhancement are being delivered daily instead of prn use,
allowing for more normalcy in function. Vacuum devices
are being utilized for penile rehabilitation well as erection
enhancement, and may improve the capacity of other
medications. Erectile enhancement in men with cauda
equina still continues to be a challenge. There are no new
vibrators adequate for ejaculation: prototype production
of the ICORD/BCIT has halted due to lack of market
funding. Viberect, a new vibrator on the market, may only
be adequate for erection promotion. Female sexual issues
still respond poorly to medication and are addressed more
symptomatically, including the use mindfulness techniques,
lubricants and vibrators. Neuroplasticity remains the major
focus on maximizing sexual potential for both men and
women following SCI. Improvement in pelvic floor tone may
also assist sexual function and continence in both sexes.
Condom use is not favored by men with SCI due to the
unreliability of erection in many cases. The use of hormonal
birth control methods are utilized more frequently than not,
depending on mobility. Furthermore, data are encouraging
for men with SCI to pursue lower cost/invasive procedures
for fertility prior to higher reproductive technology. Newer
data is also accumulating on the risk of hypogonadism
in men following SCI and the accelerated health risks for
post-menopausal women with SCI. On a positive note, new
Clinical Practice Guidelines put out by the PVA on Sexuality,
as well as informative books and downloadable manuals
8
3) A polymeric mixture of hyaluronic acid and methyl
cellulose (HAMC) to act as a drug delivery system and
reduce the inflammatory response to neural injury. The three approaches could be complementary to cell-based
strategies and other regenerative techniques
Targeting the Extracellular Matrix to
Repair Spinal Cord Injury
James Fawcett, PhD
Cambridge Centre for Brain Repair (United Kingdom)
Repair of damage to the nervous system requires axon
regeneration, plasticity and cell replacement. The
extracellular matrix plays a central role in restricting these
processes, mainly through the action of chondroitin sulphate
proteoglycans (CSPGs). An important agent in removing
this restriction has been the enzyme chondroitinase, which
removes glycosaminoglycan (GAG) chains from CSPGs.
CSPGs are upregulated in glial scar tissue around injuries to
restrict axon regeneration, and digestion of the scar tissue with
chondroitinase enhances axon regeneration and sprouting.
An unexpected finding has been the role of CPSGs in the
restriction of plasticity. This effect is mediated by cartilage-like
structures surrounding neurons, known as perineuronal nets
(PNNs). Plasticity, one of the main mechanisms for recovery
after nervous system injury, is greatly reduced after the critical
periods of childhood. This reduction depends on deposition
of PNNs around some classes of neurons throughout the
CNS. PNNs are particularly prolific in the spinal cord. They
contain inhibitory CSPGs, hyaluronan, link protein and
tenascin‑R, partly produced by the neurones themselves and
partly by surrounding glial cells. Animals lacking PNNs, or
after PNN digestion by chondroitinase, possess enhanced
levels of plasticity into adulthood. After CNS damage they
show greatly increased recovery. However, for recovery of
many functions, opening a window of plasticity must be
combined with appropriate rehabilitation in order for recovery
to occur. Chondroitinase treatment is still effective if given one
month after injujry. If given with anti NogoA the combination
treatment is more effective than either treatment alone.
Dietary Strategies for Acute Spinal
Cord Injury
Wolfram Tetzlaff, PhD
University of British Columbia (Canada)
The current guidelines for nutrition after spinal cord injury
(SCI) are not based on evidence but rather expert opinions.
We studied the effects of dietary strategies in animal models
of spinal cord injury. Previously, we discovered that fasting
every other day improved functional outcomes after cervical
SCI in rats. However, a fasting regimen may be met with little
enthusiasm from patients, dietitians and physicians, due to
possible weight losses in addition to those seen already caused
by paralysis. Hence, we explored the effects of a high-fat, and
very low-carbohydrate regimen known as ketogenic diet (KD)
which mimics some aspects of fasting (e.g. high blood levels
of ketones). KD is effectively used in humans for cases of drug
resistant epilepsy.
We used a clinically relevant cervical hemi-contusion injury
in adult male rats and allowed access to either a standard
carbohydrate-based diet, or KD beginning at 4 hours after
injury. KD-treated rats showed improved usage and range
of movement of the affected forepaw during rearing and
grooming behavior. In addition, KD regimen improved
grasping success with recovery of wrist and digit movements.
Importantly, after returning to a standard carbohydrate-based
diet after 12 weeks of KD treatment, the beneficial effects on
forelimb function remained stable for at least 6 weeks. No
effects on body weight, cholesterol levels or bone morphology/
density were observed.
A short term KD regimen enhances functional recovery
from SCI in rats and has lasting therapeutic effects without
apparent side effects. From a translational perspective, our
results mandate the reconsideration of standard clinical
practices, which have traditionally promoted high carbohydrate
nutritional content in acute SCI patients. We encourage
opening further dialogue on this important aspect of patient
care in acute SCI, given the limited interventions currently
available for this devastating injury.
The Cethrinphase I/IIA Trial to Treat
Acute Spinal Cord Injury: Update on
Results
Lisa McKerracher, PhD
BioAxone BioSciences Inc. (United States)
Cethrin™ is an investigational biologic drug has completed
a Phase 2a study in patients with spinal injury (SCI). Cethrin
acts on Rho, a signaling protein important in controlling
axon regeneration and cell survival after acute SCI. A dose
escalation, open-label, clinical study was undertaken to
test the safety and tolerability of the drug and neurological
status following a single application during surgery following
acute SCI. We treated 32 patients with thoracic SCI and
16 patients with cervical SCI at 9 clinical sites in the USA
and Canada. Cethrin was safe and well tolerated, with no
serious adverse events associated with administration of
the drug. Thoracic patients treated with Cethrin showed a
positive trend to improvement for both light touch and pin
prick scores. Cervical patients treated with Cethrin averaged
motor scores of 18.6 across all dose groups; the 3 mg dose
appeared most effective, with a 27 point improvement, over
double that expected from historical controls. We examined
time to recruitment to detect if the positive trends in motor
recovery might be explained by early surgery. Surprisingly,
we found that patients who had late surgery showed the most
interesting trend of motor improvement. We also detected
a trend to improved bladder function in the Cethrin treated
cervical population. Motor scores were compared in patients
who received steroids as part of standard of care with those
who did not, and no trends for treatment effects of steroids
were evident. The trends we report here are not validated as
significant endpoints, but indicate that further study of Cethrin
is warranted.
Accelerating Progress Through
Global Standards: The International
Spinal Cord Injury Data Sets
Fin Biering-Sørensen, MD, DMSc
University of Copenhagen (Denmark)
Survival of spinal cord injury (SCI) with a reasonable quality
of life has become an expected outcome, and there is
an increasing need for data pertaining to SCI. Therefore
common International SCI Data Sets should be collected
on individuals with SCI to facilitate comparisons regarding
injuries, treatments, and outcomes between patients, centers
and countries.
The International SCI Core Data Set was developed to
standardize the collection and reporting of a minimal amount
of information necessary to evaluate and compare results of
published studies, e.g. including information on the gender and
age at the time of injury, the current age, length of time after
injury, calendar time frame when the study was conducted,
9
causes of spinal cord lesion, and neurologic status. Data from
the Core Data Set are recommended, as a descriptive table in
most publications including individuals with SCI.
International SCI Basic Data Sets are the minimal number
of data elements, which should be collected in daily clinical
practice for a particular topic. Therefore the various Basic
Data Sets can be the basis for a structured record in centers
worldwide caring for individuals with SCI. In addition these
Basic SCI Data Set elements should be included in future SCI
research for the relevant topics. Today International SCI Basic
Data Sets are available regarding Spinal Column Injury, Lower
Urinary Tract Function, Urodynamic, Urinary tract imaging,
Bowel Function, Female Sexual and Reproductive Function,
Male Sexual Function, Cardiovascular Function, Pulmonary
Function, Endocrine and Metabolic Function, Skin and
Thermoregulation Function, Muscleskeletal Function, Pain,
and Quality of Life.
International SCI Extended Data Sets are more detailed data
sets, which may be recommended for specific research
studies within the particular area.
All data sets are available at the web sites of ISCoS (www.
iscos.org.uk).
International SCI Data Sets development. Working groups are
established in cooperation with relevant international societies
and organizations. For each data set a syllabus with data
collection form and instructions on how to collect data are
developed.
Organizations and societies within the fields of SCI,
neurosurgery, orthopaedic surgery, rehabilitation and others
are being invited to review the International SCI Data Set.
Anybody else is also welcome to join the review process.
Process for approval of International SCI Data Sets. An iterative
process for approval of the data sets has been established,
including review by ISCoS Scientific Committee, ASIA Board,
relevant and interested (International) Organizations and
Societies and persons. In addition the data sets are on the
web sites of ISCoS and ASIA for at least one month.Variable
names and Data base structure. For the data elements in
each International SCI Data Set are consistent variable names
and a common database structure developed in cooperation
with the National Institute of Neurological Disorders and
Stroke (NINDS), the National Institutes of Health (NIH),
embarked on a Common Data Element (CDE) Project. The
database structure allows data to be stored in a uniform way in
databases to promote sharing data from different studies.
Implementation of Best Practices:
A Multi-Layered Global Challenge
Keith C. Hayes, PhD
University of Western Ontario (Canada)
The tortuous journey from discovery to implementation of
best practices encounters mountains, chasms and different
forms of hostile environments; these challenges are especially
daunting when the destination is global. With no clear atlas
to guide the journey many travellers fall by the wayside.
Fortunately the past decade has witnessed a proliferation of
traveller’s aids to help navigate the path. In this presentation
we examine the models, tools, infrastructures and resources
that facilitate the translation of robust new evidence into
clinical practice. The road travelled by investigator-driven
clinical innovation parallels that taken by for-profit commercial
research and development (biotech, medical devices and
pharma developments) with slight variants in the filters that
are applied with respect to good manufacturing process,
risk management, professional uptake, health technology
assessment, regulatory approval, market considerations,
reimbursement and investment opportunity. Innovation in
both domains impact practice and outcomes and are often
interdependent. Travellers along both paths will benefit from
the emerging science of implementation and initiatives that are
underway to encourage globalization of best practices.
The SCI Community Survey: Toward
a Better Understanding of Support
Services That Enhance Community
Living
Luc Noreau, PhD
Universite Laval (Canada)
Introduction and objective: The SCI Community Survey is
the largest study of its kind. Its aim is to confirm the most
important SCI-specific needs of Canadians with SCI and their
relationship with the access/barriers to service utilization and
major outcomes impacting community living.
Methods: The study design process led to the identification
of 13 needs for services (e.g., housing, transportation,
attendant services) favoring community living and a series
of major outcomes (secondary complications, participation,
employment, quality of life). Participants were recruited
through a nationwide consumer awareness program with
the partnership of The Canadian Paraplegic Association and
several rehabilitation facilities. Respondents accessed the
survey in a web-based format or via telephone interview.
Preliminary Results: Initial results with more that 900
participants with traumatic SCI indicated that needs for
services are highly prevalent in the SCI population (> 85%)
for dimensions like equipment and devices, health care,
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accessible housing, transportation. While a significant
proportion of participants (60-70%) considered that, overall,
their health care needs were largely met, this proportion
decreased when secondary complications (often untreated)
negatively impacted daily activities. Results on social
participation suggest that a significant proportion of people
with SCI cannot participate at all in specific life domains in
which they would like to be involved.
activities undertaken by SCI Action Canada with an emphasis
on strategies used to maximize the reach and implementation
of our best practices both nationally and internationally.
Recommendations will be presented regarding the use of
the community-university partnership approach to develop,
evaluate, and implement best practices.
Conclusion: When completely, the SCI Community Survey will
inform stakeholders about the living situation of people with
SCI and their needs for services from the Canadian social
service system. For example, we know that the Canadian
health care system must address the issue of untreated
SCs that significantly impact daily living and must consider
strategies to increase social participation of those who cannot
participate. Such results from the SCI Community Survey are
preliminary steps before establishing and prioritizing best
practices for an enhanced community living after SCI.
Communicate, Collaborate, Cure...
Networking Down Under
Support: The Rick Hansen Institute and The Ontario
Neurotrauma Foundation.
Acknowledgement: The authors gratefully acknowledge
the initial support of the Community Integration Practice
Network Team (K. Boschen, G. Jacquemin, K. Martin Ginis,
M.A. McColl, B. Miller, D. Wolfe, T. Clarke, B Adair) and the
invaluable commitment of the survey participants
Best Practices Implementation
through Community-University
Partnerships
Kathleen A. Martin Ginis, PhD
McMaster University (Canada)
SCI Action Canada (www.sciactioncanada.ca) is an
example of a community-university partnership approach to
developing and implementing best practices. It is an alliance
of 30 community-based organizations and university-based
researchers working together to increase physical activity
participation among people living with SCI. The alliance is
underpinned by a commitment to the rigorous development
and testing of physical activity-enhancing resources and
interventions, and the translation of those innovations into
products and services for implementation within the SCI
community. Some examples of SCI Action Canada’s research
and knowledge translation activities include: development
and the launch of the first ever evidence-based physical
activity guidelines for adults with SCI; development and the
launch of an evidence-based, SCI-specific physical activity
Toolkit; translation of two randomized controlled trials into
a nation-wide, telephone-based physical activity counseling
service for people with SCI; development and evaluation of
evidence-based, print and video physical activity resources for
persons with SCI. This presentation will provide an overview of
Stephanie Williams, PhD
Spinal Cord Injury Network (Australia)
The Spinal Cord Injury Network (SCI-N) was established
in 2008 to unite scientists, clinicians, the community and
other key stakeholders across Australia and New Zealand
(ANZ) around promoting recovery from spinal cord injury
(SCI). As well as providing a suite of communication
and education initiatives that bring our stakeholders
together, a key focus of the Network is to facilitate
research development and multi-centre clinical trials. A
recent survey conducted by SCI-N reviewed barriers and
facilitators for conducting clinical trials into SCI in NSW.
Fifty-eight percent of respondents ranked funding as the
most important barrier to conducting clinical trials. The
second most common identified barrier was lack of staff,
third was lack of time, and fourth was recruitment. All but
one of the respondents said they were planning to build
on their existing research. Patient enrollment is the most
time-consuming aspect of the clinical trial process. The
leading cause of missed clinical trial deadlines is patient
recruitment, taking up to 30 percent of the clinical timeline.
Improving patient recruitment rates offers researchers
one of the biggest opportunities to accelerate the pace of
clinical trials. Approximately one person a day sustains
a SCI in ANZ with an estimated prevalence of more than
12,000 individuals. Most participants in clinical trials are
recruited through the nine spinal units based in capital
cities. Participant recruitment also occurs via specialized
databases, State-based databases or through advertising.
To overcome recruitment barriers, studies need to be
conducted at multiple centres across ANZ. There are
several examples of multi-centre clinical trials currently
underway, which include SCIPA (Spinal Cord Injury Physical
Activity study), COSAQ (CPAP for Obstructive Sleep Apnea
in Quadriplegia) and AusCAN (risk assessment for sitting
acquired pressure ulcers).To further facilitate the conduct of
clinical trials, SCI-N has formed a Clinical Trials Committee
with bi-national representation that meets quarterly. Its aims
include:
• To facilitate collaboration and support multi-centre SCI
clinical trials in ANZ;
• Register local researchers/research groups and areas of
expertise / interest, to assist planning of clinical trials,
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and provide advice and information to researchers on
SCI clinical trials and to potential subjects considering
participation
• Promote the development and use of appropriate
standardized clinical trial protocols, and internationally
recognized and evidence-based data collection tools
and assessment measures.
• In support of this last aim, in 2011 SCI-N commissioned
Professor John McNeil’s team at Monash University
to provide advice on how to build on the existing
infrastructure of the Australian SCI Registry (ASCIR)
and redevelop the ASCIR as a data platform capable of
supporting issues relevant to management, outcomes
and research in the future. The update will align with
a partnership grant on access to care in NSW and
VIC called “Right care, right time, right place” led by
Professor James Middleton, Director of the NSW State
SCI Service. The study will examine key processes along
the early care pathway from scene of injury to definitive
care, and lay the foundation for future trials involving
early interventions.
The above summarizes activities SCI-N has undertaken to
assist in optimizing the conduct of clinical trials in ANZ. SCI-N
would fully support the use of this infrastructure to coordinate
with other networks on an international level as part of a global
clinical trials network.
Building and Maintaining a
Multispecialist SCI Center
James S. Harrop, MD
Thomas Jefferson University (United States)
Optimal SCI patient care requires a multidisciplinary care of
the patient. The aim of this talk is to discuss the evolution of
this concept to present treatment facilities. Jefferson Medical
College is one of the oldest national model SCI centers. It
has continually changed and evolved in the care of patients
through a direct physician interaction. The talk with review
our system and collaborations between the Orthopedic,
Neurological and Trauma surgeons as well as Physiatrists
ChinaSCINet Clinical Trials
Wise Young, MD, PhD
Rutgers University (United States)
Three decades ago, most scientists believed that the spinal
cord cannot regenerate. In the early 1980’s, David & Aguayo
from Montreal reported that spinal cord axons regenerate
when placed into peripheral nerve. This stimulated an intense
search for axon growth inhibitors in spinal cord. Several
inhibitors were identified, including Nogo and chondroitin-
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6-sulfate proteoglycan (CSPG). In the 1990’s, many
investigators reported that blockade of Nogo or its receptors,
and use of chondroitinase to break down CSPG, will stimulate
axon regeneration and functional recovery in animals.
The past decade, however, yielded conflicting results.
Knocking out Nogo-A (and similar molecules) did not
promote spinal cord regeneration. Likewise, chondroitinase
was not always effective in spinal cord contusion models.
Combinations of neurotrophins or cAMP stimulate axon growth
and improve functional recovery in animal models despite
continued presence of Nogo and CSPG in spinal cord. Liu, et
al. recently reported that blocking the gene PTEN in mouse
motor cortex allows massive regeneration of corticospinal
axons, suggesting that certain genes constrain corticospinal
axon growth.
Together, these studies suggest that spinal axons will
regenerate if provided growth factor support or blockade
of PTEN, despite continued presence of Nogo or CSPG in
the spinal cord. In 2004, Wu, et al. at HKU reported that
lithium and chondroitinase markedly enhanced regeneration
in hemisected rat spinal cords. Su, et al. found that lithium
stimulates neural stem cells to proliferate and to produce
neurotrophins. In 2008, Gill, et al. reported that lithium
alone stimulates axonal growth in vitro and in the spinal cord,
promoting functional recovery.
We found that lithium stimulates umbilical cord blood
mononuclear cells (UCBMC) to proliferate and to produce
the neurotrophins NGF, NT3, and GDNF known to stimulate
long tract growth in spinal cord. Many groups reported that
UCMBC not only survive for weeks in mouse, rat, and dog
spinal cords but improve neurological recovery after spinal
cord injury (SCI). We proposed that lithium will enhance
beneficial effects of UCBMC in SCI.
To assess the effects of UCBMC and lithium on chronic SCI,
we are doing the following clinical trials. The first (CN101)
showed that lithium can be safely given to people with chronic
SCI. The second (CN102A) showed that lithium does not
improve neurological recovery but reduces neuropathic pain
in chronic SCI. The third (CN102B) compares safety and
efficacy of increasing UCMBC doses (4, 8, and 16 µliter of
100,000 UCBMC/µliter), UCBMC with methylprednisolone
(MP) and a 6-week course of lithium.
To date, we have transplanted UCBMC into 28 subjects with
chronic SCI in Hong Kong and China. The treatment appears
to be safe. Twenty subjects will have received 3 months of
intensive locomotor training. The trial will ascertain whether
UCBMC + lithium is safe and improves function. If so, we
will initiate multicenter phase 3 trials in China, USA, Norway,
and India to assess safety and efficacy of UCBMC plus lithium
therapy of chronic SCI. A total of 600 subjects will be tested in
this trial starting 2013.
Latest Advances in Evaluation of
Autonomic Dysfunctions Following
Spinal Cord Injury
Andrei Krassioukov, MD, PhD, FRCPC
University of British Columbia (Canada)
It is well known that autonomic dysfunctions, including
abnormal cardiovascular control, are common consequences
of spinal cord injury (SCI) in humans. However, the
International Standards for Neurologic Assessment, commonly
referred to as the American Spinal Injury Association (ASIA)
neurological examination, only evaluates motor and sensory
functions following SCI. In order to improve the evaluation of
autonomic function in individuals with SCI, and in the future
to assess the effects of therapeutic interventions, ASIA and
the International Spinal Cord Society (ISCoS) established a
committee to develop a set of definitions and classifications
for disorders of autonomic function in SCI. Four major areas
were identified: general autonomic dysfunction, bowel, bladder
and sexual dysfunctions. For each area, a comprehensive
set of definitions was also identified. It is recommended that
these dysfunctions following SCI be assessed and documented
by clinicians. For example, among general autonomic
dysfunctions the recognition and assessment of the following
conditions should be performed: level of arterial blood
pressure, presence of orthostatic hypotension, autonomic
dysreflexia, arrhythmias, temperature dysregulation, sweating
dysfunctions and broncho-pulmonary dysfunctions. Members
of the committee propose that in the future, in addition to
already established motor and sensory assessment standards,
the assessment of autonomic functions be a part of clinical
evaluation of individuals with SCI. Autonomic standards
were recently translated into Chinese and have already been
introduced into practice at numerous centres around the
world. Finally, our clinical practice could also benefit from
use of recently published series of SCI data sets focused on
various aspects of autonomic functions.
The Presentation and
Consequences of Decentralized
Autonomic Cardiovascular Control
in Persons with SCI
Jill M. Wecht, EdD
James J Peters VA Medical Center (United States)
Spinal cord injury (SCI) results in motor and sensory
impairments which may be classified by the American Spinal
Injury Association Impairment Scale (AIS). SCI also adversely
affects autonomic nervous system (ANS) function; however
the AIS classification does not consider ANS dysfunction.
Notwithstanding the absence of an accurate measurement
tool for ANS dysfunction, it is appreciated that autonomic
regulation of the cardiovascular system is altered following
SCI and the degree of impairment may relate to AIS. In
general, persons with tetraplegia present with low resting
heart rate (≤60 bpm) and blood pressure (≤90/60), and
orthostatic hypotension (OH), which may limit rehabilitation,
independence and quality of life. In fact, although many
individuals with tetraplegia remain asymptomatic, we have
documented significant deficits in memory and attention
processing speed in hypotensive individuals with SCI
compared to a normotensive SCI group. Evidence suggests
a possible association between chronic hypotension and
cerebral hypoperfusion which relate to poor cognitive test
performance, and we have preliminary evidence that this
may be the case in persons with SCI. Level of SCI may relate
to ANS dysfunction and the model of paraplegia highlights
this association. Individuals with paraplegia in the upper
thoracic cord (T1-T6) often present with hypotension, whereas
individuals with low paraplegia (T7 and below) are generally
normotensive. Interestingly however, regardless of the
level of paraplegia, we and others have reported increased
resting heart rate (≥ 84 bpm) and arterial stiffness in these
individuals, which may have a deleterious effect on cognitive
function. There is evidence of an association between
increased arterial stiffness and accelerated cognitive decline
and we have preliminary evidence that the proportion of mild
to moderate cognitive impairment is increased in individuals
with paraplegia. This presentation will review relevant
literature and discuss findings on the impact of decentralized
cardiovascular autonomic control in persons with SCI.
The Influence of Injury to
Autonomic Pathways on
Cardiovascular Disease Risk After
Spinal Cord Injury
Victoria Claydon, PhD
Simon Fraser University (Canada)
The leading cause of morbidity and mortality in individuals
with spinal cord injury (SCI) is cardiovascular disease. The
mechanisms underlying this increase in risk are unclear.
Leading a sedentary lifestyle after SCI has been proposed to be
the main contributing factor. However, injury to cardiovascular
autonomic pathways may also play an important role in the
predisposition to cardiovascular disease after SCI.
Individuals with high level autonomically complete SCI have
impaired cardiovascular reflex control, with an increased
susceptibility to orthostatic hypotension (profound falls in blood
pressure when upright) and to autonomic dysreflexia (marked
hypertensive episodes following afferent stimuli below the lesion
level). This is compounded by impaired cerebral autoregulatory
responses that minimise the ability of the cerebral circulation to
buffer these marked changes in blood pressure.
Individuals with autonomically complete lesions also
have abnormal cardiac electrical activity, evidenced by
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electrocardiographic characteristics that are associated with
an increased risk of cardiac arrhythmia. This may explain why
cardiac arrhythmia are also common after SCI, particularly
during episodes of autonomic dysreflexia.
Glucose tolerance and insulin sensitivity are impaired only in
individuals with autonomically complete SCI. The severity of
impairment in glucose tolerance is positively correlated with
the severity of autonomic injury. However, abnormal lipid
profiles are evident in both individuals with autonomically
complete, and incomplete, lesions.
These findings support the need to target treatment towards
autonomic dysfunction after SCI, in addition to lifestyle
modification, in order to reduce morbidity and mortality due to
cardiovascular disease.
This work was supported by the Heart and Stroke Foundation
of Canada, Christopher and Dana Reeve Foundation, and
Simon Fraser University.
Metabolic and Endocrine Disorders
in Individuals with Chronic Spinal
Cord Injury: Predisposition to
Cardiovascular Disease
William A. Bauman, MD
James J Peters VA Medical Center (United States)
Persons with chronic spinal cord injury (SCI) have an
increased prevalence of disorders of carbohydrate and
lipid metabolism. Diabetes mellitus and impaired glucose
tolerance are more prevalent in persons with chronic SCI
than in able-bodied individuals. Persons with higher cord
lesions are generally more insulin resistant than those with
lower cord lesions. Depressed serum HDL cholesterol levels
in persons with SCI have been demonstrated, and those
with the greatest neurological impairment tend to have the
lowest levels. Extreme inactivity and unfavorable changes
in body composition (i.e., loss of lean body mass and gain
of fat mass) most likely play a major role in these metabolic
dysfunctions. An inverse relationship has been shown between
serum high density lipoprotein (HDL) cholesterol levels and
abdominal circumference, and a direct relationship has been
observed between measures of abdominal adiposity and
triglyceride levels and small, dense low density lipoprotein
(LDL) cholesterol levels. One contributing factor to the adverse
changes in body composition in those with SCI may be the
unfavorable endocrine milieu, with a reduction of anabolic
hormones. Serum growth hormone is reduced to provocative
stimulation, and insulin-like growth factor is depressed in
younger individuals with SCI. Serum testosterone levels
are also lower by decade of life in those with SCI than in
the able-bodied, and testosterone levels also appears to
decrease with longer duration of injury. In those with SCI and
testosterone deficiency, testosterone replacement therapy
14
(TRT) has been demonstrated to improve body composition
and increase resting energy expenditure, with other potential
beneficial effects or TRT yet to be shown. Alterations in
serum catecholamines in the general population influence
carbohydrate tolerance and lipid metabolism. Thus, autonomic
dysreflexia in SCI may be speculated to be associated with
insulin resistance and carbohydrate intolerance, whereas
depressed basal levels of norepinephrine in those with higher
cord lesions may contribute to reduced serum HDL-cholesterol
values with associated increased cardiovascular risk. Persons
with long-standing SCI have been reported to have increased
conventional and emerging risk factors for coronary heart
disease (CHD), and they appear to have premature CHD.
Niaspan has been demonstrated to safely and effectively raise
serum HDL cholesterol levels in a cohort of individuals with
SCI.
The Challenge of Deciding What to
Translate
Brian Kwon, MD, PhD, FRCSC
University of British Columbia (Canada)
The need to establish effective treatments for spinal cord injury
has led to the development of many therapeutic strategies over
the past 30 years. A handful have been evaluated in human
trials and many more are emerging from scientific laboratories
and vying for clinical translation. History has revealed,
however, that once promising SCI experimental treatments
reach the point of translation into human evaluation, their
passage through clinical trials is exceedingly challenging. With
a relatively low annual incidence of traumatic SCI (compared to
other acute neurologic conditions such as stroke or traumatic
brain injury), patient recruitment into acute SCI trials can be an
agonizingly slow process. And yet, large numbers of patients
are typically needed to demonstrate neurologic efficacy in such
trials, as spontaneous neurological recovery can occur with
substantial variability. The sheer enormity of this process (both
in terms of time and money) compels the scientific community
to carefully decide which of the many experimental treatments
available is to be advanced into human trials. Clearly, the
decision to proceed with the clinical translation of experimental
treatments is not one to be taken lightly. Despite this, no
objective method exists for characterizing the extent to which a
particular therapy for spinal cord injury has been scientifically
investigated and evaluated for its readiness for translation. The
stroke field, having suffered great frustration in the clinical
evaluation of neuroprotective treatments that appeared
“promising” in animal studies has generated guidelines to direct
the preclinical development of such interventions. Developing
analogous guidelines in spinal cord injury would seemingly
be quite valuable, not only to provide some direction about
the testing of potential SCI therapies, and to identify important
gaps in the scientific validation and preclinical refinement/
optimization of specific treatments.
Preclinical Studies Provide Limited
Prediction of Safety and Efficacy in
Human SCI Trials
NACTN is a consortium of nine Clinical Centers composed of
neurosurgery department faculty and staff caring for spinal
cord injured patients at university-affiliated hospitals, a Data
Management Center and a Pharmacological Center.
Armin Curt, MD, FRCPC
Balgrist University Hospital (Switzerland)
As NACTN developed it addressed the requirements of
conducting trials of therapy in SCI:
The translation of preclinical knowledge into the therapeutic
application in humans is inherently challenged by many
unpredictable interactions and effects. Safety issues reside
but are not limited to toxicological effects, an area where
pharmacology has rather well established pathways to estimate
adverse events (like the therapeutic index defined as the LD
/ED50 (LD=letal dose; ED=effective dose)). The latter are
50
related to organ specific or systemic effects while reference
values (i.e. levels of confidence) can be employed from
various established animal models. However safety aspects
related to the mode of application (like surgical procedures)
are less established and common landmarks of safety are
not yet well understood. Measures of efficacy as applied in
human studies are even less related or predictable based on
outcome measures gained in animal studies (like the BBB
score in rats). There are no established relations between
observed changes of (sensori-)motor functions in animals
(like ambulation or upper limb function) to potential effects
in humans (true not only for rodents but also non-human
primates). This is even more complicated when the potential
magnitude of improvement (beneficial expectation) needs to
be balanced against safety concerns (risk of adverse events)
to consider the initiation of a clinical trial. Nevertheless these
challenges don’t argue per se against the initiation of clinical
trials but ask for the introduction of rigorous trial protocols
that are positioned to discern both subtle aspects of safety
and efficacy. The obvious challenges in translational research
can be only overcome by a consorted interaction of basic
and clinical research with the application of innovative trial
protocols that are beyond rather basic outcome measures (like
ASIA scores).
Organizational, Regulatory and
Financial Barriers to Conducting
Clinical Trials in SCI
Robert G. Grossman, MD
The Methodist Hospital (United States)
Promising research developments have not been brought
to phase 3 clinical trials that have the design and statistical
power to demonstrate efficacy because of the formidable
organizational, regulatory and financial barriers that must
be overcome to conduct such trials. The North American
Clinical Trials Network (NACTN) for Treatment of Spinal Cord
Injury was created with the support of the Christopher Reeve
Foundation with the goal of overcoming these barriers.
1. Organization of a multicenter network of hospitals
capable of enrolling a sufficient number of SCI patients
for conducting trials. Establishing governance policies,
committees and a system of communications between
centers.
2. Creating a Data Management Center and a database of
the natural history of recovery after SCI, from the time of
injury through the stages of recovery as a prior control
group for evaluating the efficacy of new therapies.
3. Creating a database of the incidence and severity of
medical and surgical complications that occur during
treatment after SCI as a prior control group for evaluating
the safety of new therapies.
4. Developing sensitive, quantitative measures of motor,
sensory and autonomic outcomes.
5. Developing standards to evaluate the suitability of
translating new pharmacological and cell based basic
discoveries to clinical trials.
6. Developing the designs and writing the protocols for
clinical trials of a new therapy.
7. Developing a pharmacological center with the capability
of carrying out pharmacokinetic and pharmacodynamic
studies of therapeutic drugs.
The steps that NACTN has taken to address the requirements
of conducting clinical trials of new therapies in SCI will be
presented.
Regulatory Considerations to
Initiate an Invasive Experimental
Treatment for Spinal Cord Injury
James D. Guest
The Miami Project to Cure Paralysis (United States)
The key issues related to gaining regulatory approval to
transplant an autologous cellular product into the spinal cord
will be reviewed based on recent experience with Schwann
cells. It may be beneficial to understand these concepts during
preclinical testing and proof of principle experimentation. In
preclinical studies the actual human cell product should be
used and prepared to near cGMP standards. Since there is
a strong emphasis on safety and toxicology the assessment
of tissues and outcomes in the pivotal data set must be very
15
through and well documented. For cell therapy key issues
related to the cell product testing in animals are cell identity,
product stability, product potency, post-implant cell survival
and evidence of cell function. Examination of the entire neural
axis is needed which is challenging in large animal models. Autologous preparations are especially challenging given that
each is derived from a unique donor but offer the important
advantage of reduced probability of immune rejection.
The Importance of Innovation and
Collaboration in Developing New
Treatments for Spinal Cord Injury
Lisa McKerracher, PhD
BioAxone BioSciences Inc. (United States)
Translational neuroscience and CNS clinical trials present
unique challenges to drug development companies. BioAxone
BioSciences’s CEO Lisa McKerracher led bench to bedside
clinical development for Cethrin, a drug in Phase 2b
development for acute spinal cord injury. Dr. McKerracher will
provide insight to successes and challenges in translational
neuroscience research and early clinical development. She
will discuss translational preclinical success factors, and
lessons learned from a biotechnology company perspective.
She will discuss the challenge of keeping clinical costs
down in the face of a stringent regulatory environment. Her
presentation will touch on the recruitment success, training
considerations, and how partnerships can help leverage
resources.
Clinical Translation of Absorbable
Biopolymers and Hydrogels for
Acute Spinal Cord Injury
Edward D Wirth III, MD, PhD
InVivo Therapeutics Inc. (United States)
InVivo Therapeutics Corporation was founded in 2005
with a core mission to develop and commercialize new
technologies for the treatment of spinal cord injuries. Our
most advanced product is an absorbable biopolymer
scaffold that is designed for implantation into an acute
spinal cord lesion. This technology was developed through
a collaborative effort between the Massachusetts Institute of
Technology’s Langer labs and clinician-scientists at Harvard
Medical School.
Preclinical safety and efficacy of the scaffold alone or
seeded with either neural stem cells or growth factors was
evaluated in both rodent and non-human primate models
of acute spinal cord injury (SCI). These studies showed
that animals receiving scaffolds exhibited a greater degree
of locomotor recovery than control animals. In addition,
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no scaffold-related adverse effects were observed in any
animal. Based on these data, an Investigational Device
Exemption (IDE) was filed with the FDA in 2011 to begin a
pilot clinical study of the scaffold in patients with acute SCI.
Our second product platform is a self-assembling
injectable hydrogel for the local, controlled release of
methylprednisolone (MP). Intravenous administration of
MP has demonstrated therapeutic potential for acute SCI,
but has significant side effects including: increased risk of
death due to infection, delayed wound healing, pneumonia
and sepsis. Hydrogel with MP can be injected directly
into the spinal cord lesion and is designed to counteract
the inflammatory environment in the acutely injured spinal
cord. Limiting release of MP to within the spinal cord
should avoid the side effects associated with systemic
administration of high-dose steroids. Initial preclinical
testing showed that administration of hydrogel with MP led
to greater locomotor recovery versus controls in an acute
non-human primate SCI model. Additional rodent and
non-human primate studies are being conducted to further
evaluate the therapeutic potential of this technology for
acute SCI.
Commercialization of SCI Research
Kenneth Galbraith
Ventures West Capital Ltd. (Canada)
In order to ensure the effective commercialization of SCI
research, substantial investment will be required by the
private sector to fund promising SCI research projects and
ensure that the results of such research will be made broadly
available to patients and consumers. Such investment will only
be provided by the private sector if the environment provides
a predictable path to regulatory approval and market for
products and a reasonable return on such investment that is
consistent with the high level of risk and complexity associated
with all medical research. A close working relationship
between researchers, industry, regulators, government and
payors on a global basis will also be necessary in the area of
SCI research. A summary of the risks and opportunities for the
commercialization of SCI research will be discussed from the
viewpoint of a venture capitalist.
Achievements and Challenges in the
Development of Human Embryonic
Stem Cell Based Therapies
Jane S Lebkowski, PhD
Geron Corporation (United States)
Human Embryonic Stem Cells (hESCs) can proliferate
indefinitely yet, upon appropriate cues, differentiate into all
somatic cell lineages. These two properties of hESCs enable the
development of hESC-derived therapeutic cell populations which
can be batch manufactured in central manufacturing facilities,
cryopreserved, and distributed for “on demand” use. Protocols
have been developed to differentiate hESCs into neural,
cardiomyocyte, hepatocyte, islet, osteoblast, chondrocyte, and
hematopoietic cell populations which are functional in either in
vitro or in vivo animal models of human disease. For example,
hESCs have been differentiated into oligodendrocyte progenitors
that upon transplantation into animals with spinal cord injuries
can remyelinate denuded axons, induce axonal sprouting,
and improve locomotor activity. Extensive preclinical studies
have been completed to examine the activity, biodistribution,
dosing, delivery, and potential toxicity and tumorigenicity of
the oligodendrocyte progenitors. The safety of these and other
human embryonic stem cell based therapies is now being tested
in the clinic in subjects with complete spinal cord injuries and
aged related macular degeneration.
The Acceleration of Technology in
the 21st Century: the Impact on
Healthcare and Medicine
Ray Kurzweil
Kurzweil Technologies (United States)
Up until recently, health and medicine was basically a hit or miss
affair. We would discover interventions such as drugs that had
benefits but also many side effects. Until recently, we did not
have the means to actually design interventions on computers.
All of that has now changed. We now have the information code
of the genome and are making exponential gains in modeling and
simulating the information processes they give rise to. We also
have new tools, also just a few years old, that allow us to actually
reprogram our biology in the same way that we reprogram our
computers. RNA interference, for example, can turn genes off
that promote disease and aging. New forms of gene therapy,
especially in vitro models that do not trigger the immune system,
have the ability to add new genes. Stem cell therapies, including
the recently developed method to create “induced pluripotent
cells” (IPCs) by adding four genes to your own skin cells to create
the equivalent of an embryonic stem cell but without use of an
embryo, are being developed to rejuvenate organs and even
grow then from scratch. There are now hundreds of drugs and
processes in the pipeline using these methods to modify the
course of obesity, heart disease, cancer, and other diseases.
Health and medicine is now an information technology and is
subject to the “law of accelerating returns,” which is a doubling of
capability (for the same cost) each year. As a result, technologies
to literally reprogram the “software” that underlie human biology
will be a thousand times more powerful than they are today in a
decade, and a million times more powerful in two decades.
Neuroprostheses and Telesupervised Exercise to Improve
Hand Function: Benefits and
Limitations
Arthur Prochazka, PhD
University of Alberta (Canada)
Although electrical stimulation is widely used to strengthen
muscles, only a small minority of people with SCI use
neuroprostheses to augment hand function in activities of daily
life. Surface stimulators are able to activate two or three groups
of muscles, to restore hand grasp and release. Though this
is limited when compared with dexterous hand movements,
nonetheless it can sometimes make an important difference
to independence. The only commercially available hand
stimulator is suitable for use in the clinic, but its design does
not lend itself to use in daily life. I will discuss the HandStim, a
wristlet we have developed that fills this gap.
Implanted neuroprostheses can target more muscles. I will
discuss three neuroprosthetic approaches, the Freehand
system, the Stimrouter system and intraspinal microstimulation.
Exercise therapy plays an important role in maximizing residual
function. Devices have emerged over the last decade that
encourage exercise in a structured and entertaining way. Cost
is an important factor. I will review and compare robotic and
passive exercise devices, with a focus on our experience and
future plans of in-home tele-supervised exercise with the ReJoyce
computer-gaming device, now in use in several countries.
Supported by Alberta Innovates Health Solutions and the
Canadian Institutes of Health Research
Strategies for Neuromuscular
Recovery after Spinal Cord Injury
Susan Harkema, PhD
University of Louisville (United States)
Studies in animals and humans have shown that the
functionally isolated human spinal cord maintains specific
properties recognized to generate locomotion in other species.
These concepts now have been translated into the clinic by
the Christopher and Dana Reeve NeuroRecovery Network
of seven rehabilitation centers that provide standardized
Locomotor Training to individuals with chronic incomplete
spinal cord injury.
17
In seven outpatient rehabilitation centers from the Christopher
and Dana Reeve Foundation NeuroRecovery Network
(NRN), 206 individuals ranging from 0.9 to 26 years post
injury were assessed during intensive Locomotor Training,
including step training using body weight support and manual
facilitation on a treadmill followed by overground assessment
and community integration. While significant improvement
from enrollment to final evaluation was observed in balance
and walking measures for AIS C and AIS D patients, the
magnitude of improvement differed significantly between
AIS groups for all measures. These results indicate that
rehabilitation that provides intensive activity-based therapy can
result in functional improvements in individuals with chronic
incomplete SCI even years after injury.
Institute for Functional Restoration,
a New Model for Deployment
In another study we hypothesized the human spinal
locomotor circuitry has sufficient automaticity potential to
generate postural control and rhythmic, coordinated weight
bearing stepping and that we can recruit this locomotor
and postural circuitry with a tonic epidural stimulation of
selected lumbosacral segments. We implanted a 23 years
old individual and 3.4 years post injury at the time of surgery.
He was clinically assessed as an ASIA B, i.e., some sensory,
but no motor function below the lesion (C7). We implanted
a 5-6-5 electrode array epidurally spanning L2-S1 spinal
cord segments and a neurostimulator (Medtronic) capable
of stimulating any combination of the 16 electrodes in the
array at intensities up to 10.5V and with frequencies ranging
from 2-50 Hz. While sitting, without epidural stimulation,
we observed minimal EMG activity in all leg muscles. While
standing in a supportive system without stimulation and with
assistance provided at both knee joints by a trainer, little or
no observable EMG activity occurred in the leg muscles. With
epidural stimulation the transition from sitting to standing
was accompanied by an increase in the EMG amplitude
by orders of magnitude beyond that observed in the sitting
position. In addition, after several months of training he was
able to voluntarily move his legs in the presence of epidural
stimulation. These results demonstrate the interaction
between sensory and epidural regulation of locomotor circuitry.
The results also show that a physiological state can be
achieved with epidural stimulation so that the sensory input
can effectively control the locomotor circuitry to stand and to
step.
In many cases, clinically important technologies remain in the
limbo of “research” because they lack the financial model
demanded for commercialization. Dr. Hunter Peckham, of Case
Western Reserve University, has spent the past 30 years leading
a team of investigators to develop and demonstrate feasibility in
clinical trials, implantable devices that restore function to those
with neurological diseases like SCI. After waiting for a corporate
strategy to succeed, he decided that in the case of smaller
markets, like this one, perhaps a new model would be needed
to transition the research into a fully deployed and approved
product. To that end, The Institute for Functional Restoration
(IFR) was created within Case Western Reverse University
(Case) to fulfill the mission of enabling the clinical deployment
of new treatments to orphan populations like spinal cord injury
(SCI) and stroke in a sustainable manner.
Supported by National Institute of Health and Christopher and
Dana Reeve Foundation.
Persons with spinal cord injury (SCI) at all levels of injury may
benefit from advances in technology. Robotic exoskeletons are
a relatively new intervention to allow the wheelchair dependent
individuals to enhance the upright position with the ultimate
goal of community. The ekos (Ekso Bionics) has completed
trials in SCI with the use of assistive devices. Clinical findings
of this trial will be presented, as well as a discussion of recent
advances made from professionals and users (study subjects
input), and goals for future advances. Lastly, technology
based updates for the wheelchair user will be presented and
its role in the rehabilitation of persons with SCI.
18
P. Hunter Peckham, PhD
Case Western Reserve University (United States)
Making a real difference in the functional level and quality of
life for those with spinal cord injury (SCI) is a goal for countless
groups and individuals throughout the world. Billions of dollars
in funding has been spent over the past decade on research
with the intention of impacting those with SCI, yet the options
and innovations available today are strikingly similar to those
available a decade before. Why are we not seeing more come
from the innovation pipeline into full clinical deployment?
Structured as a non-profit, the IFR takes proven feasible
research interventions, like those in the Cleveland FES Center,
through regulatory approval and production. A key mandate
of the IFR mission to ensure a long-term access to the
technology and support for those implanted. This presentation
will explore the strategy of the IFR model, assumptions made,
products planned and status to date.
Technological Advances in SCI
Steven Kirshblum, MD
Kessler Institute for Rehabilitation (United States)
Walking with an Exoskeleton for
Persons with Paraplegia
Ann M. Spungen, EdD
James J Peters VA Medical Center (United States)
Persons with spinal cord injury (SCI) who are wheelchairdependent are at increased risk for several secondary medical
consequences of paralysis and immobilization including:
osteoporosis, muscle atrophy, obesity, coronary heart disease,
diabetes, insulin resistance, impairments in bowel/bladder
function, and pressure ulcers. These medical conditions extract
a tremendous toll on veterans and non veterans with SCI, as
well as the medical system responsible for their care. Of note,
many persons with SCI have significant reduction in quality of
life due to loss of home, work, and/or community integration.
A robotic exoskeleton suit, the ReWalk, was FDA approved
for institutional use in January 2011. This exoskeleton suit
is indicated for persons with complete motor paraplegia and
this device allows them to stand, walk over ground and to
ascend and descend stairs. The device requires the use of arm
crutches to maintain balance as the participant stands and
ambulates. The VA Rehabilitation Research & Development
National Center of Excellence for the Medical Consequences
of Spinal Cord Injury at the James J Peters VA Medical Center,
Bronx, NY is currently performing a clinical trial to determine
the potential benefits of frequent upright standing posture and
ambulation on blood pressure and cardiovascular regulation,
bowel/bladder function, body composition, metabolism, and
quality of life. A brief overview and history of walking devices
for SCI and our preliminary findings will be presented. Mobility
gains from the exoskeletal device and data from the following
mobility measures: 10-meter walk test, 6-minute walk for
distance, and the timed up and go will also be presented. The
observations and findings to date on the changes in secondary
medical consequences of SCI from participation in the
exoskeletal walking program will be reported.
Is There a Relationship Between
Paralympic Classification,
Autonomic Symptoms and Altered
Cardiovascular Control among Elite
Wheelchair Athletes
Andrei Krassioukov MD, PhD, FRCPC
University of British Columbia (Canada)
Low resting arterial blood pressure, episodic hypertension
(autonomic dysreflexia, AD), or episodes of orthostatic
hypotension (OH) are common among individuals with
spinal cord injury (SCI). Paralympic athletes are exposed to
tremendous physical and emotional stress during their training
and competition. Specifically, athletes with SCI have unique
disadvantages during competition due to the nature of their
injury, one of which is unstable blood pressure control.
Methods: A prospective evaluation of cardiovascular
parameters and their correlation with responses to an
autonomic questionnaire of 22 Paralympic wheelchair rugby
athletes was performed. Data on demographics, neurological
injury, and Paralympic classification were also collected.
Results: We examined two groups of individuals with complete
(AIS A&B, n=11) and incomplete (AIS C&D, n=11) SCI who
had similar Paralympic wheelchair rugby classification (1.80
and 1.88 respectively). Individuals with complete SCI very
frequently experienced episodes of sweating and headaches
(88% and 75% respectively). During training, there was also
a significantly high frequency of lightheadedness (63%),
fatigue (75%) and blurred vision (38%) among of individuals
with complete SCI. Interestingly, both groups of athletes
demonstrated presence of OH during evaluation.
Conclusion: These data showed that, despite continuous
training, symptomatic OH is still common among
Paralympians. The presence of OH could interfere
with athletic performance and exacerbate fatigue in a
subpopulation of athletes. These conditions may explain why
wheelchair athletes use “boosting” to increase their blood
pressure in order to improve their athletic performance.
Research into new ways of classifying athletes of similar
impairments and activity or sport limitations gets to the
very heart of fair play. A possible addition of autonomic
assessment to the athlete evaluations could add a purely
technical improvement in the fairness of the class system,
team grouping and possibly judging of the results. (Support:
C. Neilsen Foundation; Endorsed by International Paralympics
Committee).
Advancements in the Physiological
Evaluation of the High Performance
Paralympic Athlete
Darren Warburton, PhD
University of British Columbia (Canada)
This lecture will include an overview of the physiological
demands of various Paralympic sports. It will highlight
advancements in the assessment of physiological function
of high performance athletes. This will include an in-depth
analyses of current methodologies employed in the evaluation,
training, and rehabilitation of high performance Paralympic
athletes. This lecture will critically evaluate currently held
axioms and myths in high performance physiology. It will also
include an in-depth analysis of the role the cardiovascular
system plays in optimal sport performance. At the end of the
session, attendees will have a better understanding of recent
advancements in the training and physiological assessment of
the high performance Paralympic athlete.
19
Objectives
•
To provide a brief overview of the physiological demands
of Paralympic sports.
•
To provide insight into novel physiological assessment
techniques.
•
To analyze and debate currently held beliefs in high
performance physiology.
•
•
•
To demonstrate the importance of the cardiovascular
system in optimal sport performance.
To evaluate critically the current training methodologies
used with high performance Paralympic athletes.
To highlight areas warranting special consideration
when training the high performance Paralympic athlete.
therefore, that the disequilibrium between increased demand and
reduced capacity of the cardiorespiratory system may conspire to
limit exercise capacity in this population.
Paralympic Medical Services for the
2010 Paralympic Winter Games
Jack Taunton, M.Sc., MD
University of British Columbia (Canada)
Objective: To present the planning and medical encounters for
the 2010 Paralympic Winter Games.
Design: Prospective medical encounter study.
Setting: 2010 Paralympic Winter Games.
Participants: Athletes, coaches, officials, workforce,
volunteers, and media.
Cardiorespiratory Limitations
to Exercise Performance in
Paralympic Athletes with Cervical
Spinal Cord Injury
Christopher West, PhD
University of British Columbia (Canada)
Over the past 50 years the Paralympics has evolved from a small
gathering of 12 athletes to the second largest sporting event in
the world that attracts over 4000 athletes from 150 countries.
Despite the surge in competitor numbers, research investigating
Paralympic athletes is sparse, and the majority of this research
has focused on improving technology for the disabled athlete,
such as prosthetics and wheelchair design. Few studies have
investigated the physiology of elite wheelchair athletes, especially
those with cervical SCI who present with the most severe
deviation from ‘normal’ homeostasis. Studies in the patient
population have demonstrated that individuals with a cervical
SCI have reduced aerobic capacity due to a small active muscle
mass, an inability to activate the venous muscle pump, and an
absence of the sympathetically-mediated adjustments to exercise,
including cardiac chronotropy, cardiac inotropy, and redistribution
of blood from the splanchnic bed to the locomotor muscles.
Such disturbed cardiovascular control may impair central
hemodynamics, culminating in a reduced stroke volume, cardiac
output, and oxygen uptake. Furthermore, individuals with cervical
SCI have weak respiratory muscles, present with a restrictive
pulmonary defect, and exhibit dynamic lung hyperinflation during
high-intensity exercise. Despite these impairments, the potential
of the cardiorespiratory system to limit exercise performance has
rarely been investigated, especially in the elite athletic population
with cervical SCI. This is surprising since highly-trained athletes
with cervical SCI are able to exercise at higher intensities
than their untrained counterparts. There is also an additional
requirement for many of the respiratory muscles to assist in
wheelchair propulsion and postural control. It is plausible,
20
Assessment of Risk Factors: Sport type: alpine, Nordic, and
sledge hockey and curling. Participant type: athlete, workforce,
and spectators. Terrain and speed.
Main Outcome Measures: Medical encounters entered in
database at competitive (alpine skiing, biathlon, cross-country
skiing, sledge hockey, and curling) and noncompetitive
(Whistler and Vancouver Polyclinics, presentation centers,
opening and closing ceremonies, media center, Paralympic
Family Hotel) venues.
Results: Forty-two nations participated with 1350 Paralympic
athletes, coaches, and officials. There were 2590 accredited
medical encounters (657 athletes, 25.4%; 682 International
Federation/National Paralympic Committee officials, 26.3%;
57 IPC, 2.2%; 8 media, 0.3%; 1075 workforce, 41.5%; 111
others, 4.3%) and 127 spectator encounters for a total of 2717
encounters. During the preopening period medical services
saw 201 accredited personnel. The busiest venues during the
Paralympic Games were the Whistler (1633 encounters) and
Vancouver (748 encounters) Polyclinics. Alpine, sledge hockey,
and curling were the busiest competitive venues. The majority
of medical encounters were musculoskeletal (44.6%, n =
1156). Medical services recorded 1657 therapy treatments, 977
pharmaceutical prescriptions dispensed, 204 dental treatments,
353 imaging examinations (more than 50% from alpine skiing),
and 390 laboratory tests. There were 24 ambulance transfers
with 7 inpatient hospitalizations for a total of 24 inpatient days
and 4 outpatient visits.
Conclusions: The mandate to have minimal impact on the health
services of Vancouver and the Olympic Corridor while offering
excellent medical services to the Games was accomplished. This
data will be valuable to future organizing committees.
Clin J Sports Med 2012: 22(1):10.
Arterial Stiffness on Physically
Active Individuals with Spinal Cord
Injury
Aaron A. Phillips, M.Sc.
University of British Columbia (Canada)
Through a partnership with the Paralympics and local
developmental teams, we aimed to compare arterial stiffness
between those with spinal cord injury (SCI) and able bodied (AB)
individuals when matched for habitual level of physical activity
across a range of participation levels. A total of 17 SCI and 17
AB were matched for sex, age, weight, blood pressure and levels
of self reported habitual physical activity (Godin-Shephard).
Measures included central (cfPWV) and lower limb (ftPWV)
pulse wave velocity and large and small arterial compliance. The
cfPWV was significantly elevated (7.3 ± 2.1 vs. 5.7 ± 1.4 m/s, P
< 0.05) in the SCI in comparison to AB. No other measures of
arterial stiffness were different between groups. In those with SCI,
moderate to vigorous physical activity was significantly correlated
with both large (r = 0.48, P < 0.05) and small (r = 0.65, P <
0.01) artery compliance, but not cfPWV or ftPWV. Both large and
small artery compliance appear to be affected highly by habitual
physical activity in active individuals with SCI. However, physical
activity does not appear to influence PWV in physically active
individuals with SCI. These findings suggest that habitual, wheelchair based physical activity may influence arterial diameter
and not stiffness per se. Other factors such as leg mass and
sympathetic dysfunction may mediate the increase in arterial
stiffness seen in the SCI population.
Assessing Autonomic
Completeness of Spinal Cord Injury:
A Missing Piece of Paralympic
Athlete Classification
Shirley Wong
University of British Columbia (Canada)
The standard assessment of spinal cord injury (SCI) (American
Spinal Injury Association Impairment Scale (AIS) traditionally
evaluated only motor and sensory pathways. Only recently have
guidelines for the standard assessment of autonomic function been
incorporated into clinical practice. This resulted from recognition
of the importance of documenting the impact of SCI on autonomic
function, through noted changes in certain organ system functions.
A parallel movement to improve International Paralympic
Committee (IP) classification to acknowledge autonomic
impairments is a current and significantly pressing issue since
exclusive use of remaining motor function to classify athletes does
not consider conditions that affect the autonomic nervous system.
Impaired autonomic function may lead to altered cardiovascular
control and for athletes with SCI, this is a major concern since
it is well accepted that cardiovascular function and athletic
performance are intimately coupled. Autonomic dysfunction may
lead to a decrease in heart rate and blood pressure at rest and
abnormal cardiovascular responses to exercise. Since the current
IPC classification does not consider athletes’ cardiovascular
status in their classification, this creates a unique and often
disadvantageous situation for athletes with SCI since they are
grouped with individuals who have similar motor control but
varying degrees of autonomic, and subsequently, cardiovascular
control.
Analysis of the data we have previously collected on Paralympic
athletes reveals that there are autonomic differences amongst
athletes with cervical injuries that may either have motor
and sensory complete or incomplete injuries. By examining
our cardiovascular data and other measures of autonomic
function, we have found that motor and sensory completeness
of injury is not related to autonomic completeness of injury.
This further emphasizes the importance of incorporating
autonomic assessment into the classification of athletes to get
a better of understanding of all the potential limitations for sport
performance in athletes with SCI.
Repair and Regeneration of the
Injured Spinal Cord with Neural
Stem Cells: “Hope or Hype”
Michael Fehlings, MD, PhD, FRCSC, FACS
Toronto Western Hospital (Canada)
The presentation will examine the opportunities and limitations
related to the use of neural stem cells as a regenerative strategy
for spinal cord injury. New approaches of generating neural
stem cells including non-viral IPS strategies will be discussed.
Understanding the Challenges to
Proving Efficacy with Cell Therapy
in Clinical Subjects
James D. Guest, MD, PhD, FRCS (C), FACS
The Miami Project to Cure Paralysis (United States)
Cell therapy is a promising but complex therapy for SCI.
Ultimately, cells must be part of the solution to SCI since their
complex roles govern nervous system signaling, and they are
lost after SCI. There is no “best” cell, different cell types are
suited to different aspects of repair. It is not yet clear which SCI
patients will experience the most benefit from cell therapies and
application in both subacute and chronic subjects has supportive
preclinical evidence. The outcomes to be assessed in clinical
subjects should mirror those in which preclinical studies showed
efficacy. Further, the effectiveness of cell therapy may require that
other additional treatments are administered. In the current early
stage of testing cell therapy for SCI it is very important that subtle
beneficial effects be detectable. Setting expectations too high
risks interpreting trial outcomes as falsely negative and leading to
premature disillusionment with cell therapy.
21
Preclinical Approaches to Spinal
Cord Repair: Transplantation of
Schwann Cells Generated from
Skin-derived Precursors
Wolfram Tetzlaff, PhD
University of British Columbia (Canada)
Cell transplantation has emerged as an exciting therapeutic
approach for spinal cord injury (SCI) in animals, and unproven
cell treatments in humans are performed in many centers
worldwide. The best candidate cell for transplantation after SCI
is intensely debated. We demonstrated previously that skinderived precursors pre-differentiated into Schwann cells (SKPSC) enhance growth and myelination of endogenous axons
as well as functional recovery when transplanted 7 days after
spinal cord injury (SCI). We envision to develop this approach
for autotransplantation which would circumnavigate the need for
immunosuppression and therefore tested the efficacy of SKPSC transplantation in the early chronic stage at 8 weeks post
injury. This treatment strategy would allow us to harvest skin
from a person with acute spinal cord injury undergoing surgery
for spine stabilization. Culturing this skin for the generation
of Schwann cells will likely take 5-8 weeks. Here we report
that SKP-SC transplanted at 8 weeks after a thoracic spinal
cord contusion in rats survived and integrated for more than
4 months and arranged in bridges which span these lesions
in rostro-caudal direction. Numerous regenerated host axons
crossed the host-transplant interface and extended through
these bridges, with some re-entering into the spinal cord below
the injury. SKP-SC transplantation improved locomotion,
(including limb co-ordination and stride length), and reduced
abnormal paw rotation and abnormal gait patterns. Post-hoc
analysis of the bladders revealed fewer wall thickenings in the
SKP-SC group which correlated with improved motor functions.
The efficacy of SKP-SC transplantation after chronic SCI opens
the door for an autologous treatment approach that greatly
enhances the relevance of this candidate therapy for clinical
translation.
Development of Appropriate
Stratification and Outcome
Algorithms in Clinical SCI Trials
Armin Curt, MD, FRCPC
Balgrist University Hospital (Switzerland)
Research discoveries and their translation into clinical
applications are predominantly hypothesis driven with the
assumption that detailed and rather specific drug or cell effects
might be achieved that eventually translate into a changed
(obviously improved) outcome in patients. Therefore, clinical
trial protocols need to meet these specific requirements to allow
for a best stratification of patients (patients that will most likely
respond successfully to the intervention) and identification of
outcome measures that are most sensitive to reveal changes
22
(i.e. improvements) which are considered to be amendable by
the specific mode of action. So far most SCI trials apply rather
unspecific outcome measures (like ASIA scores) that although
are of clinical relevance (albeit MCID issues are not yet resolved)
are not able to reveal underlying mechanisms of recovery in SCI.
This creates a dilemma where the considered interventions are
rather specific (it has to be admitted that in many interventions
the main mode of action is at best hypothesized and not
necessarily proven) but clinical trial protocols fail to monitor
the mode of actions (both in the sense of drug/cell activity and
specific consequences in body function). This remains the field
in the unfortunate situation that translational information gained
in clinical trials mirrored back to basic research are rather weak
(if any) and the potential reasons in failures of interventions
(like complete failure or insufficient induction of drug/cell
activity etc.) can not be discerned which is a requirement to
modify interventions for an improved efficacy. In this aspect
SCI research falls behind other areas in neuroscience (like
MS research) where also surrogates have been successfully
introduced to overcome the above mentioned shortcomings.
Podium Abstracts
Order: Abstracts are listed in order of appearance per the
Interdependence 2012 program.
Disclosure: No significant relationships for the abstracts listed
unless otherwise noted.
O1-01
Expectations of Risk, Benefit,
and Preclinical Scientific Rigor
in Experimental Treatments for
Spinal Cord Injury: A Survey of SCI
Individuals
B.K. Kwon1, A. Ghag1, M. Dvorak1, W. Tetzlaff2, J. Illes3
1
, Combined Neurosurgical and Orthopaedic Spine Program
(CNOSP), Department of Orthopaedics, University of British
Columbia, Vancouver/BC/CANADA, 2, International Collaboration
on Repair Discoveries (ICORD, University of British Columbia,
Vancouver/BC/CANADA, 3, Department of Neurology, University
of British Columbia, Vancouver/BC/CANADA
Background: The question of what preclinical evidence
should be generated in order to justify moving an experimental
therapy forward to a human SCI clinical trial has yet to be
fully addressed.1,2 A recent survey garnered researchers
perspectives on the need for safety and efficacy data in animal
models and on the importance of independent replication
prior to translation.2 We contend that it is also important to
consider the perspectives of arguably the most important
stakeholder: the individuals who have sustained a SCI.3 As
they are ultimately the potential recipients of the experimental
therapies, it seems only rational to include their perspectives
in the dialogue on translational research.4 Our objective was to
determine what potential benefits individuals with SCI would
anticipate, what risks they would deem acceptable, and what
expectations they would have for the extent of preclinical
research done on therapies prior to translation. We also sought
to compare these perspectives with those of SCI clinicians.
Methods: A survey was distributed to SCI individuals identified
through a provincial database. 214 respondents with cervical
or thoracic SCI and baseline AIS of A, B, C, or D completed
the survey.
Results: Individuals with SCI expressed their expectation
that experimental therapies were tested in large animal
studies and their efficacy independently replicated prior to
being advanced into human trials. The majority listed their
expectations for “percent chance of recovery” as either 5 to
25% or 25-50%. For invasive cell transplantation trials, while
most would require the risk of spinal cord damage, cancer,
infection, and nerve pain to be 1% or less, a considerable
proportion (15-30%) would participate regardless of the risk
of these complications. A greater acceptance of high risk
was demonstrated in males, individuals over age 60 years,
and in those who described their level of knowledge about
SCI research to be high. There was no difference in the
proportion of AIS A, B and C individuals willing to accept high
or low risk. While they may not understand the details of the
science, individuals with SCI have high expectations about
the level of preclinical evidence that is supporting therapies
that go into clinical trial, although the receptivity to such
trials is high. While most of our current trials focus on safety,
the respondents of our survey expressed high hopes for the
possibility of neurologic benefit. A considerable proportion
of individuals are anxious to participate in invasive stem cell
trials “regardless of risk”, highlighting their vulnerability to
commercial enterprises selling unproven therapies.
References: 1. Dietrich WD (2003) Confirming an experimental
therapy prior to transfer to humans: what is the ideal? J Rehabil
Res Dev 40:63-69. 2. Kwon BK et al (2010) Translational
research in spinal cord injury: a survey of opinion from the SCI
community. J Neurotrauma 27:21-33. 3. Illes J et al (2011) Stem
Cell Clinical Trials for Spinal Cord Injury: Readiness, Reluctance,
Redefinition. Stem Cell Rev. 4. Abma TA (2005) Patient
participation in health research: research with and for people with
spinal cord injuries. Qual Health Res 15:1310-1328.
O1-02
PTEN Deletion Promotes
Regenerative Sprouting in the Aged
Rubrospinal Tract
B. Hilton, W. Tetzlaff
International Collaboration on Repair Discoveries (ICORD),
University of British Columbia, Vancouver/CANADA
Background: The paralysis that occurs following spinal cord
injury (SCI) is largely the result of transected central nervous
system (CNS) axons failing to regenerate. Previous research has
indicated that a major contributor to this regenerative failure is a
diminished intrinsic capacity of adult CNS axons to grow, based
largely on inactivity in the phosphoinositide 3-kinase (PI3K)/
Akt/mammalian target of rapamycin (mTOR) molecular growth
pathway, which is negatively regulated by phosphatase and
tensin homolog (PTEN) [1,2]. Without activity in this pathway,
it is hypothesized that neurons cannot efficiently translate
proteins, a key component of axon elongation [3]. By inhibiting
PTEN, it may be possible to functionally regenerate CNS
neurons following SCI and re-establish connections between the
brain and the rest of the body.
The rubrospinal tract (RST), which originates in the red nucleus
of the midbrain and travels contralaterally in the dorsolateral
23
funiculus of the spinal cord, functions in movement and fails
to regenerate after transection. This failure results in paralysis.
Here, we assessed whether PTEN deletion would promote
axon regeneration in the RST by genetic means, with deletion
occurring in aged (7-8 month old) mice.
Background: Thoracic rodent models of spinal cord injury
(SCI) are the predominate preclinical translational model used
[1]; however, cervical SCI represents the majority of clinical
cases with highly significant personal impact and societal
burden.
Methods: Floxed PTEN mice were injected with adenoassociated virus serotype 2 expressing Cre and GFP (AAV2-Cre)
or GFP alone for control (AAV2-GFP) into the right red nucleus.
Four weeks later, mice underwent a left dorsolateral crush at
cervical level C4/C5, transecting the entire RST on this side.
Six weeks later, mice were injected with biotinylated dextran
amine (BDA) into the right red nucleus to anterogradely trace
the RST. Two weeks later, mice were sacrificed, transcardially
perfused with fixative, and their spinal cord tissue cryoprotected
and cut longitudinally into 20 µM sections. These sections
were then immunocytochemically stained for GFP and BDA
via standard protocols. Digital images of cervical spinal cord
longitudinal sections were collected using a Zeiss Axio-Observer
with Yakogawa Spinning-disc confocal device. To quantify axon
regenerative sprouting, a horizontal line was drawn through the
center of the lesion site and at every 100µM rostral and caudal
from the center to a total distance of 1mm rostral and caudal.
The number of intersections of BDA- or GFP-labeled fibers with
each line was counted on four slides, corresponding to the most
dense population of axons in the RST. These values were then
normalized to fluorescence intensities at cervical level 1.
Methods: The applicability and utility of thoracic and lower
cervical SCI preclinical models was evaluated using clip
contusion-compression injury paradigm in rats: considered
most highly relevant for translation of preclinical data [1].
Spinal injuries were realized in female Wistar rats at the C5,
C6, C7 and T7 vertebral levels (controls: laminaectomyonly) using severe clip contusion-compression (28g for 60s).
Animals were assessed for 10 weeks using: grip strength
meter, Inclined Plane test, WARP contracture scale, BBB
locomotor scale, bladder recovery, motor- and somatosensoryevoked potentials (MEP, SEP), and H reflex. LFB/HE
histological staining and T1-weighted MR imaging were used
to assess tissue loss and cavitation. Adult neural precursor
(aNPC) cells were transplanted (2x10^6 cells, or vehicle only)
into C6-injured rats at 2 weeks post-injury and followed with
similar neurobehavioural assessment.
Results: Based on independent analyses of BDA and GFP
labeling, AAV2-Cre injected animals showed significantly
decreased dieback and increased regenerative sprouting
of rubrospinal axons through the lesion site in comparison
to AAV2-GFP injected animals, for up to 100µm caudal
measured from the middle of the lesion site.
References: 1. Park KK, Liu K, Hu Y, Smith PD, Wang C, et
a. 2008. Promoting axon regeneration in the adult CNS by
modulation of the PTEN/mTOR pathway. Science 322:963-66
2. Liu K, Lu Y, Lee JK, Samara R, Willenberg R, et al. 2010.
PTEN deletion enhances the regenerative ability of adult
corticospinal neurons. Nat. Neurosci. 13:1075-81
3. Park KK, Liu K, Hu Y, Kanter JL, He Z. 2010. PTEN/mTOR
and axon regeneration. Exp. Neurol. 223:45-50
O1-03
Assessment of Cervical Spinal
Cord Injury Models: Comparison
and Validation Using Extensive
Neurobehavioural Assessment and
Stem Cell Therapy
J. Wilcox, K. Satkunendrarajah, Y. Nasirzadeh, F. Nassiri, M.
Fehlings
Toronto Western Research Institute, Toronto/ON/CANADA
24
Results: Spontaneous neurological recovery was observed
with expected plateaus in all injury groups. Grip strength
exhibited marked impairment with C5 and C6 injuries (291+/38g and 566+/-80g, respectively, p 0.01), compared to C7,
T7 and laminectomy-only shams (1315+/-65g, 1665+/-49g
and 1130+/-50g, respectively) (p 0.0001). Inclined Plane
test showed stratification between all groups in grasping and
trunk support (p 0.05 between and p 0.0001 among groups).
Contracture measured with WARP scale demonstrated
significantly higher manual dexterity/utility in C6 compared
to C5 rats (p 0.05). No differences were seen in BBB and
Subscore. T1-weighted MR revealed similar and overt signal
changes in all injuries, as confirmed with quantitative lesion
analysis using LFB/H&E. Axonal conduction declined with
ascending injury, as measured by peak latency and amplitude
(p 0.01) with SEP and MEP. Forelimb spasticity was evident
by H/M reflex ratios in C6 and C5 groups. Following aNPC
transplantation in C6 animals, grip strength increased 2-fold
compared to vehicle controls (417+/-59g vs. 211+/-55g,
p=0.007), while Inclined Plane and BBB showed no difference
(p=0.15 and 0.88, respectively). Electrophysiology revealed
significant improvements to lower peak amplitude and latency
in SEP of forelimbs in C6-injured rats compared to controls (p
0.05). Conclusion: The level of injury is highly determinant of
forelimb deficit, and precludes using C7 or T7 level injuries to
study cervical SCI. The C6 clip paradigm appropriately models
neurobehavioural recovery and spasticity of cervical SCI, with
utility as a preclinical cervical model exhibited by forelimb
recovery following adult NPC transplantation.
References: 1) Kwon et al. A Grading System To Evaluate
Objectively the Strength of Pre-Clinical Data of Acute
Neuroprotective Therapies for Clinical Translation in Spinal
Cord Injury. Journal of neurotrauma (2010)
O1-04
Objective Spinal fMRI Metrics
Distinguish Complete and
Incomplete Clinical Grade in Chronic
Spinal Cord Injury
D. Cadotte1, P.W. Stroman2, D. Mikulis1, R. Bosma2, M.G.
Fehlings1
1
, University of Toronto, Toronto/CANADA, 2, Center for
Neuroscience Studies, Queen’s University, Kingston/CANADA
Background: In an effort to define quantitative spinal cord
functional magnetic resonance imaging (fMRI) metrics that
can be used to distinguish between ASIA complete and
incomplete injury, we compare a cohort of healthy controls
to those with chronic SCI (>1 year) who are either complete
(ASIA A) or incomplete (ASIA B, C, or D). This is an important
step to be able to use quantitative spinal fMRI to follow the
integrity of different spinal circuits after injury and during
treatment. Here, we investigate the spinothalamic tract.
Methods: Using an automated thermal delivery system,
heat (44°C) was applied to 2 dermatomes above and
2 below the level of SCI. Spinal fMRI data was collected
on a 3T system using a SEEP-based protocol developed
by our group (SSFSE, TE=30msec, TR=1sec). Data were
spatially normalized and analyzed using the general linear
model (P=0.001). We divided the cervical spinal cord into
zones based on known anatomical relationships of nerve
rootlets entering the cord from the segmental nerve root.
We calculated the number of active voxels in the stimulated
zones of the spinal cord.
Results: 32 people were examined: 20 control, 3 ASIA A
complete SCI and 9 incomplete SCI. The average number of
active voxels in the dorsal quadrant of the spinal cord zone
(corresponding to the dermatome stimulated) was calculated.
The average number of active voxels are: (significance set
at p< 0.001, 95% confidence interval) Chronic SCI patients:
14 ± 9.4 (complete injury); 10.1 ± 2.5 voxels (incomplete
injury) and 4.6 ± 1.9 in healthy controls. Conclusions: This
work represents the first attempt to define objective metrics
that distinguish between clinical grades of injury. The number
of active voxels in the dorsal quadrant of the spinal cord zone
(corresponding to the dermatome stimulated) shows a robust
ability to distinguish between ASIA complete, incomplete injury
and healthy controls.
References: Stroman PW. Magnetic resonance imaging
of neuronal function in the spinal cord: spinal FMRI. Clin
Med Res. 2005 Aug;3(3):146-56. Figley CR, Stroman PW.
Development and validation of retrospective spinal cord motion
time-course estimates (RESPITE) for spin-echo spinal fMRI:
Improved sensitivity and specificity by means of a motioncompensating general linear model analysis. Neuroimage.
2009 Jan 15;44(2):421-7. Stroman PW, Tomanek B, Krause V,
Frankenstein UN, Malisza KL. Functional magnetic resonance
imaging of the human brain based on signal enhancement by
extravascular protons (SEEP fMRI). Magn Reson Med. 2003
Mar;49(3):433-9.
O1-05
Elevated Circulating Levels of
the Pro-Inflammatory Cytokine
Macrophage Migration Inhibitory
Factor (MIF) in Chronic Spinal Cord
Injury (SCI) Patients.
A. Panjwani1, C. Sison2, A. Papatheodorou3, M. Bank4, A.
Stein5, O. Bloom6
1
, The North Shore-Long Island Jewish Health System, Great
Neck/NY/UNITED STATES OF AMERICA, 2, The North ShoreLong Island Jewish Health System, Manhasset/NY/UNITED
STATES OF AMERICA, 3, The Feinstein Institute for Medical
Research, Manhasset/NY/UNITED STATES OF AMERICA,
4
, North Shore University Hospital, Manhasset/NY/UNITED
STATES OF AMERICA, 5, The Hofstra North Shore-LIJ School
of Medicine, Great Neck/NY/UNITED STATES OF AMERICA, 6,
Hofstra North Shore LIJ School of Medicine/Feinstein Institute
for Medical Research, Manhasset/NY/UNITED STATES OF
AMERICA
Background: Traumatic spinal cord injury (SCI), which
includes all injuries to the spinal cord, conus medullaris and
cauda equina, affects more than 12,000 people per year
in North America. Both acutely and chronically after SCI,
inflammation may deleteriously impact functional recovery(1).
The pro-inflammatory cytokine macrophage migration
inhibitory factor (MIF) is toxic to spinal neurons in vitro and
is elevated acutely in pre-clinical models of SCI(2-4). Genetic
deletion of MIF in mice enhances recovery of hind limb
function(5). Thus, our hypothesis is that MIF is elevated in
patients after SCI, where it is pro-inflammatory. The objective
of this study was to measure and compare levels of MIF in
chronic SCI and in uninjured subjects.
Methods: This prospective pilot study was performed in the
outpatient clinic of the Department of Physical Medicine and
Rehabilitation within an academic medical center. “Chronic
SCI” was defined as at least 12 months from initial injury.
Participants included 25 chronic SCI and 25 uninjured subjects.
Our Institutional Review Board approved this study; all subjects
provided informed consent. SCI subjects included 6 females
and 19 males, ages 25-73. Uninjured subjects included 7
females and 18 males, ages 23-62. For SCI subjects, time
from initial injury ranged from 1-30 years. Mechanisms of
injury included: motor vehicle accident (n=10), fall (n=6),
sports (n=3), other (n=2), unknown (n=4). A physiatrist board
certified in spinal cord injury medicine evaluated the subjects’
injuries according to International Standards for Neurologic
25
Classification of Spinal Cord Injury (ISNCSCI). The subjects’
ASIA Impairment Scale Grades were: A (n=16), C (n=3), D
(n=5) and one was unclassified. MIF was measured in subjects’
plasma using commercially available multiplex cytokine assays.
Results: Our results show that SCI subjects exhibited
significantly higher levels of MIF than uninjured subjects
(median: 1004 v. 567 pg/ml, SCI v. uninjured subjects
respectively, P <0.0028 by Mann Whitney test). The MIF
interquartile range was 877.6 and 470.2 pg/ml for SCI and
uninjured subjects, respectively. These data provide the first
evidence that MIF is elevated in the circulation of chronic
SCI patients. Inflammatory mediators are hypothesized to
contribute to several complications of chronic SCI, including
accelerated atherogenesis, increased risk of pressure ulcers,
metabolic changes and perhaps, to the non-permissive
environment inhibiting nerve regeneration(1). Anti-MIF
therapies reduce symptoms in several pre-clinical models of
inflammatory diseases(6). Further studies with an increased
number of subjects are needed to assess the generality of the
present findings and to evaluate the potential utility in pursuing
MIF as a therapeutic target for inflammation after SCI.
References: 1. Alexander, Popovich Prog Brain Res (2009). 2.
Chalimoniuk, et al., Neuroscience (2006). 3. Koda et al., Acta
Neuropathol (2004). 4. Yang et al., Brain Res (2006).
5. Nishio et al., Acta Neuropathol (2009).
6. Calandra, Roger Nat Rev Immunol (2003).
O1-06
Methods: We generated cDNA expression constructs by
cloning the full length chick Sema5B as well as individual
TSR- and semaphorin-domains into the pDisplay vector.
Stable HEK293 cell lines were transfected with the vectors
and cultured with neural tissue explants obtained from E7.5
chicks including dorsal root ganglia (DRG), retinal galion
cells (RGCs), and sympathetic ganglia (SG) in order to test
the in vitro To test the functions of Sema5B in a physiological
condition, we knocked-down its expression in one side of the
spinal cord grey matter by electrporating short hairpin RNAs
(shRNAs) directed against Sema5B. We then examined the
projections of small diameter and proprioceptive sensory axons
by immunocytochemically labelling them using antibodies
against TrkA or TrkC receptors respectively. Furthermore, by
expressing only one of the two domains of Sema5B in HEK293
cells, we showed the semaphorin and TSR domains have
opposing functions of attraction and repulsion, respectively.
Results: We show that sensory axons of the dorsal root ganglia
avoid Sema5B-expressing HEK293 cells in vitro, therefore
confirming that Sema5B can function as a guidance cue for
these neurons. We also test the function of Sema5B in vivo
by electroporating vectors that express short hairpin RNAs
targeted against Sema5B into one side of the developing
spinal cord grey matter. Immunohistochemical examination
of proprioceptive sensory axons show aberrant projections
into the side of the spinal cord where Sema5B was knocked
down. Thus, Sema5B is a guidance cue that is dynamically
expressed throughout the embryonic spinal cord and it plays
a critical role in the correct circuit formation of sensory axons
during development.
Semaphorin 5B is Critical to Axonal
Guidance in the Chick Spinal Cord
References: Pekarik et al. Nat. Biotechnol. 21, 93-96 (2003).
Mendelson and Frank. Neuroscience Let. 138, 72-76 (1992).
Messersmith et al. Neuron. 14, 949-959 (1995).
Q.Q. Liu1, A. Legg2, W. Wang2, T.P. O’Connor2
1
, Life Sciences Institute, UBC, Vancouver/BC/CANADA, 2, Life
Sciences Institute, Vancouver/BC/CANADA
O1-07
Background: Semaphorins, characterized by a conserved
sema domain at the N-terminus, are a large family of
molecules that guide growing axons to their targets during
nervous system development. Thus far, little is known about
the function of the transmembrane class 5 semaphorins
which are distinguished from other classes by the presence
of seven type-1 and type-1-like thrombospondin repeats
(TSRs) C-terminal to the sema domain. Here we present the
expression and function of one class 5 semaphorin, Sema5B,
in various regions of the developing chick nervous system. The
dynamic expression of Sema5B in the developing spinal cord
is particularly intriguing as it appears to correlate with sensory
axon targeting in the grey matter. Our research addresses
the hypothesis that Sema5B regulates the timing and extent
of penetration of sensory axons into the dorsal horn of the
developing spinal cord.
26
Creation of an Anatomic Atlas of
Cervical Spine Intradural Anatomy
Using Fiesta MRI
D. Cadotte, D. Mikulis, M.G. Fehlings
University of Toronto, Toronto/CANADA
Background: We use MRI to visualize the intradural
components of cervical spine with optimal CNS / CSF contrast.
Clinically, this may be useful to plan operative approaches
for intradural pathology and to correlate MR signal changes
with functional neurological changes. We have conducted
measurements that demonstrate the population variability
of the spinal column relative to spinal nerve rootlets. This
anatomic atlas will be advantageous for defining precise
location of activity when using spinal fMRI.
Methods: MRI acquisition: FIESTA, 3T GE magnet; 384 x
384, NEX 2.0, FOV 20, Slice thickness 0.6 mm. Total scan
time: approx. 12 min. Images were analyzed using open
source software, OsiriX 3.9.2. The ponto-medullary junction
(PMJ) and the mid-sagittal bony landmarks of the foramen
magnum (FM) are landmarks. Intradural anatomy is compared
to vertebral body anatomy in terms of distance from fixed
landmarks.
Results: N=10; 2 data sets were excluded due to motion. The
distance between the PMJ and the FM was relatively constant
between subjects (17.4 mm; +/- 0.4 mm). The rostral-caudal
extent of nerve rootlets entering the cervical spinal cord was
also relatively constant for each level (example: 10.2 mm
+/- 0.2 mm at C3; 11.4 mm +/- 0.5 mm at C7). There was
considerable heterogeneity between the location where the
nerve rootlets enter the cervical spine and the associated
vertebral body. The distance from the foramen magnum to
the C7 base plate ranged from 104.4 mm to 125.6 mm. The
associated position of the entering nerve rootlets ranged from
85.3 mm from the foramen magnum to 99.4 mm. Discussion:
This work represents the first attempt at delineating the
intradural anatomy of the cervical spinal cord using MRI at
3T. Our study is novel as it outlines the variability between
the nerve rootlets (as they enter the spinal cord) and the
associated vertebral body. This discrepancy is of fundamental
importance to spinal fMRI studies; these methods will help
delineate precise locations of neural activity in both SCI
patients and controls.
References: Lang J, Bartram CT. [Fila radicularia of the ventral
and dorsal radices of the human spinal cord]. Gegenbaurs
Morphol Jahrb. 1982;128(4):417-62.
O1-08
Vegf and Pdgf as an
Immunomodulatory Strategy
for the Reduction of Secondary
Degeneration After a Model Spinal
Cord Contusion Injury in Rats
B. Goss1, Y.W. Young1, C. Lutton1, R. Williams1, A. MackaySim2
1
, Queensland University of Technology, Brisbane/AUSTRALIA,
2
, National Centre for Adult Stem Cell Research, Griffith
University, Brisbane/AUSTRALIA
Background: Inflammation in most tissues is initially a
protective attempt to facilitate the removal of damaged tissue
which ultimately transitions to an anti-inflammatory nature
thereby initiating a healing response. However, after spinal
cord injury (SCI), the inflammatory response is prolonged and
the anti-inflammatory response delayed, leading to secondary
degeneration and glial scarring. Based on our previous
findings in hemisection injuries [1], we investigated the
potential of sustained delivery of vascular endothelial growth
factor (VEGF) and platelet derived growth factor (PDGF) to
increase early inflammatory events and promote inflammatory
resolution and functional changes in a contusion injury model
of SCI.
Methods: Animal ethics approval was obtained from the
Queensland University of Technology. Adult Wistar rats (12-16
weeks old) were subjected to laminectomies 150 kDyne T10
contusion with an infinite horizions impactor. Animals were
then randomised to treatment (implantation of osmotic pump
(Alzet) loaded with 15μg VEGF & 15 μg PDGF) or control
groups (lesion control or lesion plus pump delivering PBS).
Rats were sacrificed at one month and the spinal cords were
harvested and examined by immunohistology, using antineurofilament-200(NF200) and anti- ionized calcium binding
adapter molecule 1 (Iba1) and the chondroitin sulphate
proteoglycan NG2. Behaviour was assessed using open field
and digigait analysis. One way ANOVA was used for statistic
analysis.
Results: At 1 month, both high and low dose active pumptreated cords showed a high level of axonal filament
throughout the defects. Digigait analysis showed significant
improvment in hindlimb base of support, and stride length,
while open field BBB score improved with treatment to 17.3±2
compared with control 14.2±1.3 at 2 weeks post injury,
indicative of signifcant functional sparing.
Animals undergoing a contusion injury also showed that the
lesion area was reduced to 5% of the control animals. Iba-1
and NG2 co-staining also showed significant differences in the
post-injury inflammatory response and indicating the presence
of a novel phenotype of inflammatory cells.
References: [1] Combined VEGF and PDGF Treatment
Reduces Secondary Degeneration after Spinal Cord Injury
Cameron Lutton, Yun Wai Young, Richard Williams, Adrian
C.B. Meedeniya, Alan Mackay-Sim, and Ben Goss. J.
Neurotrauma. doi:10.1089/neu.2010.1423.
O2-01
Exercise Capacity and Tolerance
During Inpatient Spinal Cord Injury
Rehabilitation: Preliminary Findings
C. Pelletier1, G. Jones2, A. Hicks1
1
, Department of Kinesiology, McMaster University, Hamilton/
ON/CANADA, 2, Department of Medicine, McMaster Univeristy,
Hamilton/ON/CANADA
Background: Although there are physical activity guidelines
for adults with chronic spinal cord injury (SCI; >1 year post
injury),1 there is limited evidence about exercise and fitness
in the acute SCI population. Furthermore, there is currently
no protocol in place to determine when it is safe for patients
27
to begin an exercise program after a SCI. The purpose of
this study is to describe the exercise capacity and baseline
cardiovascular fitness status in a group of adults with acute
SCI in an inpatient rehabilitation program.
Methods: Twenty participants (mean age 36 ± 12.7 years)
were recruited in the final weeks of inpatient SCI rehabilitation
(93 ± 43.4 days post injury). Participants were categorized as
having either tetraplegia (n = 8, C3-C7, AIS A-D) or paraplegia
(n=12, T4-L5, AIS A-D) and completed a physician supervised
maximal graded exercise stress test on an arm ergometer.
Resistance was increased by 5W/minute for participants with
tetraplegia and 10W/minute for participants with paraplegia2
and was terminated if the participant was unable to maintain a
cadence of 50 rpm, or reached volitional fatigue.
Results: All participants were able to complete the test
to volitional fatigue and there were no adverse events or
abnormal cardiovascular findings observed with a 12 lead
electrocardiogram. Mean absolute VO2peak values were
significantly different (p = 0.02) between participants with
tetraplegia (0.79 ± 0.30 L/min) and paraplegia (1.10 ± 0.19 L/
min). When expressed relative to body weight, VO2peak values
were not significantly different (p = 0.06) between participants
with tetraplegia (11.49 ± 3.37 mL/kg/min) and paraplegia
(14.97 ± 4.42 mL/kg/min). Time (min:sec) to VO2peak was
6:42 ± 2:48 for the group with tetraplegia and 6:34 ± 1:02
for the group with paraplegia (p = 0.89). Mean respiratory
exchange ratio (RER) values of 1.16 ± 0.12 and 1.27 ± 0.15
for participants with tetraplegia and paraplegia (p = 0.09)
indicate that participants successfully reached maximal
effort. Mean peak heart rate values were significantly different
between groups (p = 0.02) with values of 113 ± 21 bpm and
137 ± 20 bpm for participants with tetraplegia and paraplegia,
respectively. Findings indicate that exercise is well tolerated
in patients with acute SCI in their final weeks of inpatient
rehabilitation. Exercise capacity appears to be decreased
compared to the chronic SCI population; 2 indicative of
significant detraining during the acute/sub-acute rehabilitation
process. Further work should aim to develop physical activity
guidelines for people with acute SCI and suitable training
programs in order to improve physical fitness early in the
rehabilitation process.
References: 1. Martin Ginis KA, Hicks AL, Latimer AE,
Warburton DE, Bourne C, Ditor DS, Goodwin DL, Hayes KC,
McCartney N, McIlraith A, Pomerleau P, Smith K, Stone JA,
Wolfe DL. The development of evidence-informed physical
activity guidelines for adults with spinal cord injury. Spinal
Cord 2011; 49:11. 2. Hol AT, Eng JJ, Miller WC, Sproule S,
Krassioukov AV. (2007). Reliability and validity of the six-minute
arm test for the evaluation of cardiovascular fitness in people
with spinal cord injury. Arch Phys Med Rehabil, 88: 489-495.
28
O2-02
Improving Muscle Co-Activation in
Spinal Cord Injured Individuals Using
Body-Weight Supported Treadmill
Training
S.S. Lee1, K. Pauhl2, E. Harder1, T. Lam2, J. Wakeling1
1
, Simon Fraser University, Burnaby/CANADA, 2, University of
British Columbia, Vancouver/BC/CANADA
Background: For individuals with incomplete spinal cord injury
(SCI), locomotor training with partial body weight support
(PBWS) on a treadmill is a commonly used rehabilitation tool1.
The purpose of this study was to investigate whether muscle
function and coordination of the primary ankle and knee
antagonistic muscles are improved after PBWS training. Using
electromyography (EMG), wavelet analysis, a time-frequency
decomposition technique, and principal component analysis
(PCA), we were able to determine the frequency-dependent
correlation between EMG intensities of antagonistic muscles,
and to calculate an EMG-normalcy score to evaluate muscle
dysfunction3.
Methods: We tested individuals (n=7, 42.0±14.3yrs,
1.75±0.12m, 79.7±22.6kg) who had incurred an incomplete
spinal cord injury due to a non-progressive lesion above the
thoracic level of T10, at least 12 months prior to recruiting to
the study. Subjects were tested pre-and post- PWBS Lokomat
training. Subjects walked on a treadmill while in a bodyweight supported harness (0 to 50% range, Lokomat) at their
comfortable and maximum velocities. EMG data were collected
bilaterally: tibialis anterior (TA), medial gastrocnemius (MG),
biceps femoris (BF), and rectus femoris (RF). Age-, gender-,
and height-matched healthy individuals were also tested at the
same % body weight support and velocities as their matched
SCI. 50 strides per subject from the pre- and post-training
tests were analysed. Intensities of the EMG signals were
resolved into time-frequency space using wavelet analysis,
2,3
. The correlation coefficient, r2, was calculated for the
EMG intensities between pairs of antagonistic muscles at 10
frequency bands (across the range 19.29Hz to 395.4Hz). An
EMG-normalcy score was calculated using PCA.
Results: For the TA-MG muscles, the correlation coefficient
of pre-training SCI was significantly greater than that of
healthy controls (p=0.02)and tended to be greater than that
of post-training SCI (Figure 1a). PBSW training decreased the
correlation between the MG-TA muscles especially at the midrange frequencies (Figure 1a). Correlation and coordination
of the RF and BF also improved after PBWS training (Figure
1b). The EMG normalcy-score was significantly less after
training (p=0.03), indicating that muscle function improved
during training. We have shown that muscle dysfunction
and coordination improves after PBWS treadmill training.
Application of this EMG analysis to quantify and evaluate
muscle dysfunction and coordination in SCI offers new insights
into the fundamental mechanisms behind SCI impaired
gait and into the effectiveness of rehabilitation treatments.
assessment system that allows simultaneous recording of
kinematics and kinetics [2]. Bilateral 3D net joint moments
at the wrist, elbow and shoulder were computed [3]. Data
obtained from both trials for each SPT technique were
averaged. Peak net joint moments were computed during each
SPT phases for the three techniques [3] and compared using
repeated measures ANOVAs (p < 0.05) with Tukey post-hoc
tests performed as needed.
References: 1. Barbeau, H and Fung, J (2001) Curr Opin
Neurolo. 2. Von Tscharner, V (2000) J Electromyo Kines. 3.
Wakeling, JM (2007) Gait and Posture.
O2-03
Effects of Varying Forward Trunk
Inclination During Sitting Pivot
Transfers on Upper Limb Loads in
Individuals with a Spinal Cord Injury
G. Desroches1, D. Gagnon2, P. Desjardins2, P. Gourdou2, M.
Vermette2, S. Nadeau1, M. Popovic3
1
, University of Montreal, Montreal/QC/CANADA, 2,
Pathokinesiology Laboratory, Institut de réadaptation GingrasLindsay-de-Montréal, Montreal/QC/CANADA, 3, Rehabilitation
Engineering Laboratory, Toronto Rehabilitation Institute,
Toronto/ON/CANADA
Background: The substantial and repetitive mechanical
loads imposed on the upper limbs (U/Ls) during sitting pivot
transfers (SPTs) likely contribute to the development and
perpetuation of secondary U/L impairments in individuals with
spinal cord injury (SCI). Increasing forward trunk inclination
while performing SPTs has been proposed as an alternative to
reduce mechanical loads imposed on the U/Ls and minimize
risks of secondary impairments during SPTs [1]. However,
no scientific evidence yet supports this hypothesis. This
study aimed to determine the effects of varying forward trunk
inclination on the load sustained at the wrist, elbow and
shoulder joints during SPTs among individuals with SCI.
Methods: Thirty-five individuals who sustained a SCI and
use a manual wheelchair as their primary mean of mobility
participated in this study (Level of SCI: C4-L4, ASIA: A-D).
Participants were asked to perform sitting pivot transfers using
three techniques: natural (NAT), exaggerated forward trunk
inclination (FLEX) and as close as possible to an upright trunk
posture (UP). Two trials were randomly realized for each of
the three techniques with the right U/L assuming the leading
role. All SPTs were assessed using an instrumented transfer
Results: Significant differences were found for peak forward
trunk inclination (FLEX > NAT > UP) during all SPT phases
across the three conditions. Significant main effects (i.e.
technique) were found for net joint moments at the leading
and also at the trailing wrist, elbow and shoulder joints.
The UP technique yielded higher net joint moment at
the wrist and elbow joints but lower at the shoulder joint.
Inversely, significant higher shoulder joint net moments
were found for the FLEX technique compared to the wrist
and elbow. The results of the current study support the
hypothesis that forward trunk inclination influences the
loads sustained at the U/L joints during SPT [1]. Overall,
compare to NAT technique, a FLEX technique reduced the
load sustained at the wrist and elbow joints whereas an UP
technique minimized loads at the shoulder joints. Thus,
from a clinical perspective, it is indicated to teach both
alternative techniques (FLEX & UP) to individuals with SCI as
compensatory strategies to modulate load distribution at the
U/Ls during SPTs. These strategies may allow one to alleviate
U/L joint discomfort and to preserve the ability to perform
SPTs in individuals with a SCI, for example.
References: 1 . Gagnon, D., et al., Clin. Biomech, 2008. 23:
p. 279-290.
2. Gagnon, D., et al., J Biomech, 2008. 41: p. 1104-1110.
3. Desroches, G., et al., J Neuroengineering Rehabil, 2011, (in
press).
O2-04
Exercise Self-Efficacy Following
Discharge from Inpatient Spinal
Cord Injury Rehabilitation
C. Pelletier1, A. Latimer2, A. Hicks1
1
, Department of Kinesiology, McMaster University, Hamilton/
ON/CANADA, 2, Queen’s University, Kingston/ON/CANADA
Background: Few studies have evaluated physical activity
in the acute spinal cord injury (SCI) population. The weeks
surrounding discharge from inpatient SCI rehabilitation might
be an ideal to time to implement a physical activity intervention
and to promote lifelong participation as patients begin to
transition into the community. Social cognitive theory provides
a framework that has been shown to predict physical activity
participation in people with SCI and includes self-efficacy, selfregulation, and outcome expectations as determinants.1 The
29
purpose of this study was to profile self-efficacy and outcome
expectations for physical activity in the months following
discharge from rehabilitation.
Methods: Twenty participants (mean age 36 ± 12.7 years) with
either tetraplegia (n=8, C3-C7, AIS A-D) or paraplegia (n=12,
T4-L5, AIS A-D) were recruited in the final weeks of inpatient
SCI rehabilitation and were on average 93 ± 43.4 days post
injury. With the assistance of a trained interviewer, participants
completed a questionnaire to assess physical activity task
and scheduling self-efficacy, 1 and outcome expectations.2
Answers were rated on a scale from 1 = strongly disagree to
7 = strongly agree or 1= not at all confident to 7 = completely
confident.
Results: In terms of outcome expectations, participants most
strongly endorsed increased mobility, energy, confidence to
perform activities of daily living, self-esteem, and confidence
in social situations as benefits associated with being active.
There was no significant difference in the composite score for
outcome expectations between participants with tetraplegia
(6.07 ± 0.79) or paraplegia (5.56 ± 1.00; p = 0.22).
Participants in both groups had a high level of scheduling
self-efficacy, with mean composite scores of 5.94 ± 1.16 and
5.19 ± 1.23 for participants with tetraplegia and paraplegia,
respectively (p = 0.18). Task self-efficacy for aerobic and
strengthening activity did not differ between groups. The
mean composite scores for participants with tetraplegia were
4.29 ± 1.21 for aerobic physical activity and 4.40 ± 1.69
for strengthening physical activity (p = 0.52). The results for
participants with paraplegia were also not significantly different
between aerobic (4.54 ± 1.20) and strengthening (4.74 ±
1.30; p = 0.80) physical activity. Taken together, participants
had an overall high level of self-efficacy to participate in
regular physical activity after being discharged from inpatient
SCI rehabilitation regardless of their lesion level. This may
be a critical time to provide physical programming so that
individuals can act upon their positive thoughts about physical
activity.
References: 1. Martin Ginis KA, Latimer AE, ArbourNicitopoulos KP, Bassett RL, Wolfe DL, Hanna SE.
Determinants of physical activity among people with spinal
cord injury: A test of social cognitive theory. Ann Behav Med
2011: 42; 127-133. 2. Latimer AE, Martin Ginis KA, Craven
BC. Psychosocial predictors and exercise intentions and
behavior among individuals with spinal cord injury. Adapt Phys
Act Quart 2004: 21; 71-85.
O2-05
Controlled Nerve Lesioning with
Direct Current
E.N. Ravid, L.S. Gan, A. Prochazka
University of Alberta, Edmonton/CANADA
Background: One of the most debilitating outcomes of stroke
and cervical spinal cord injury is the loss of voluntary hand
and arm movement. The reduction of upper extremity function
may be further complicated by spastic hypertonus, a chronic
reflexive over-activity of muscle nerves. This impedes voluntary
movement, causes spasms, contractures and discomfort.
Treatments such as stretching or casting, have limited efficacy
[1]. Anti-spastic drugs often have side effects such as fatigue
and dizziness [2]. Treatment with Botulinum toxin type A (BtA)
is costly, may take up to two weeks to take effect and requires
repeated administration. A recent study has shown that
repeated BtA treatments can cause atrophy in target muscles
and in muscles elsewhere in the body [3].
It has long been known that direct current (DC) applied to
nerves blocks conduction in large axons, but it was deemed
unsuitable for clinical use since it appeared to cause nerve
damage. However, it is precisely this aspect that could be of
interest clinically. Recently we showed that DC can produce
controlled, long-term, graded ablation of nerves and we
proposed it as a possible new cost-effective method of treating
spastic hypertonus [4]. In the context of SCI rehabilitation,
implanted nerve electrodes could be used for two functions:
DC ablation and subsequent functional electrical stimulation
of the remaining axons. Here we present experimental data
exploring the parameters of DC enabling controlled nerve
ablation as well as DC ablation following nerve regeneration.
Methods: Acute experiments: DC was delivered via a cuff on
the tibial nerve in three anesthetized rabbits. The triceps surae
muscle was stretched with a muscle puller at 0.08 Hz through
its full physiological range. Test muscle twitches were elicited
at 2Hz by a more proximal nerve cuff. DC was delivered via a
distal cuff in the range of 0.75mA -1mA for varying durations.
Chronic experiments: Three cats were implanted with similar
nerve cuffs on the common peroneal nerve. DC at levels
between 0.3 and 1mA was delivered for periods of up to 40
minutes.
Results: Acute experiments: DC amplitudes and durations
producing graded attenuation of muscle force were explored.
Chronic experiments: In all three cats force was attenuated or
completely abolished. It remained attenuated for 6-8 weeks
after which it slowly recovered, presumably due to nerve
regeneration. In one of the cats, after nerve regeneration, a
second administration of DC at 1mA for 9 minutes abolished
force again, showing that DC ablation could be repeated
successfully.
30
References: 1. Bovend’Eerdt, T.J., et al., The effects of
stretching in spasticity: a systematic review. Archives of
physical medicine and rehabilitation, 2008. 89(7): p. 1395406.
2. Kita, M. and D.E. Goodkin, Drugs used to treat spasticity.
Drugs, 2000. 59(3): p. 487-95.
I, et al. Long-term changes in bone metabolism, bone
mineral density, quantitative ultrasound parameters, and
fracture incidence after spinal cord injury: a cross-sectional
observational study in 100 paraplegic men. Osteoporos Int.
2004 Mar;15(3):180-9. Lofvenmark I, Werhagen L, Norrbrink
C. Spasticity and bone density after a spinal cord injury. J
Rehabil Med. 2009 Nov;41(13):1080-4.
3. Fortuna, R., et al., Changes in contractile properties of
muscles receiving repeat injections of botulinum toxin (Botox).
Journal of biomechanics, 2011. 44(1): p. 39-44.
O2-07
4. Ravid, E.N., et al., Nerve lesioning with direct current.
Journal of neural engineering, 2011. 8(1): p. 016005.
O2-06
Antiosteoporotic Effects of
Alendronate on Younger Patients
with Acute Spinal Cord Injury
Y.B. Kalke, R. Brenner, H. Reichel
SCI Centre Ulm, Orthopaedic Department of the University of
Ulm, Ulm/GERMANY
Background: Acute spinal cord injury (SCI) is associated with
rapid bone loss followed by an increasing risk of fractures.
Bisphosponates are used successfully in treating patients
with post-menopausal and senile osteoporosis. The question
arises whether bisphosphonates have also a positive effect on
reduction of early onset osteoporosis in patients with acute
SCI and whether there are differences between patients with
complete and incomplete status.
Quantifying Proprioception In
the Lower Limbs Using a Robotic
Exoskeleton
A. Domingo, C. Cheung, J. Liang, T. Lam
University of British Columbia, Vancouver/BC/CANADA
Background: Proprioception is a sensory modality that
provides information about the position and movement of
our limbs in space. It is critical for posture, locomotion [1],
motor learning [2] and for negotiating the environment safely
and efficiently. Proprioception is often compromised after
spinal cord injury (SCI); however, the role of proprioception in
the recovery of walking has scarcely been studied. In order
to better characterize sensory deficits after SCI and during
recovery, it is imperative to use more precise assessment tools.
The purpose of this study was to develop a valid and reliable
quantitative assessment tool to measure static position sense
in the legs using the Lokomat, a robotic exoskeleton.
Results: 6 patients were females, 18 males, 8 patients tetraand 16 patients paraplegic > L 1. The average age was 37,3
years. In lumbar spine there was in all patients no significant
difference in bone density between the alendronate and
the placebo group within 12 months, but in femur T-score
decreased significantly in the placebo group of AIS A and
B > AIS C and D patients in comparison to the alendronate
group. Weekly alendronate seem to have a positive effect on
early onset osteoporosis of the femur in younger complete and
incomplete paralyzed male and female patients with acute
spinal injury.
Methods: We used the Lokomat and custom software to
assess static position sense in 9 able-bodied (AB) subjects
and 7 persons with incomplete SCI (American Spinal Injury
Association Impairment Scale level B, C or D). Subjects
memorized a target position at either the hip or knee. The
Lokomat then moved the test joint to a distractor position.
Subjects were then asked to bring the joint back to the target
position with a joystick controller. All movements were passive
and vision of the legs was obscured. Two hip angles and 2
knee angles were tested, repeated 5 times each. Absolute
differences between final and target angles were recorded as
errors. Internal validity was assessed by the ability of the test to
discriminate between AB and SCI subjects. To measure testretest reliability, subjects were evaluated twice, at least one
week apart, and the intra-class correlation coefficient (ICC)
comparing errors from each session was calculated. We also
performed a clinical test of proprioception in subjects with SCI,
where the leg was moved (either the hip or knee) ~10° by an
experimenter from a random starting position, and the subject
had to indicate whether the movement was “up” or “down.”
This was repeated 10 times, and scores were compared to
those of the robotic assessment with Spearman’s Rank Order
Correlation.
References:
Zehnder Y, Luthi M, Michel D, Knecht H, Perrelet R, Neto
Results: Preliminary data show the test was reliable (ICC:
all=0.824; AB=0.644; SCI=0.688, all P<0.004). Hip and
Methods: In a prospective, randomised, double blind study
70 mg alendronate or placebo was given weekly to 12 patients
with AIS A and B and to 12 patients with AIS C and D 6
weeks after the acute injury for the duration of 12 months.
Additionally calcium and vitamin D was administered daily to
all patients. Bone mineral density was measured at baseline,
3, 6, 9 and 12 months after injury.
31
knee angle errors (mean±SEM, (°), repeated measures
ANOVA) in subjects with SCI (hip: mean=8.94±2.02,
SD=6.14±1.01; knee: mean=16.09±2.02, SD=4.44±0.67)
were greater (P<0.001) and more variable (P<0.001) than in
AB subjects (hip: mean=2.76±0.29, SD=2.04±0.18; knee:
mean=3.17±0.31, SD=0.79±0.15). Errors were greater
at the knee than at the hip (P=0.004), and an interaction
effect (P=0.009) showed that knee errors were greater in
SCI subjects. In subjects with SCI, clinical scores were more
strongly correlated to robotic assessment scores at the knee
than at the hip (knee: r=0.75, P=0.04; hip: r=0.68, P=0.10).
This study shows that the Lokomat may potentially be used
as a measurement tool for assessing static position sense in
persons with incomplete SCI.
References: [1] Lajoie Y, Teasdale N, Cole JD, Burnett M,
Bard C, Fleury M, Forget R, Paillard J and Lamarre Y. (1996).
Gait of a deafferented subject without large myelinated sensory
fibers below the neck. Neurology. 47:109-115. [2] Hasan Z.
(1992). Role of proprioceptors in neural control. Curr Opin
Neurobiol. 2:824-829.
O2-08
Online Delphi to Identify Targets for
Best Practice Implementation and
Associated Performance Measures
D. Wolfe1, J. Hsieh1, A. Kras-Dupuis2, K. Campbell1, H. Flett3,
C. Koning4, S. SCI KMN Team5
1
, Lawson Health Research Institute, London/ON/CANADA,
2
, St. Joseph’s Health Care London, London/ON/CANADA,
3
, Lyndhurst Spinal Cord Centre, Toronto/ON/CANADA, 4,
Glenrose Rehabilitation Hospital, Edmonton/AB/CANADA, 5,
ONF RHI APF, Toronto/ON/CANADA
Background: The SCI Knowledge Mobilization Network
involves six Canadian rehabilitation centres uniformly applying
the principles of Implementation Science to facilitate best
practice adoption in pressure ulcers, bladder and pain.
Consensus development methods enabled identification
of initial best practice implementation (BPI) targets and
performance measures (PMs) in the area of pressure ulcer
prevention and management. Typically, agenda-setting
exercises in research or healthcare fall short with respect to
utilization of representative and systematic processes. BPI
initiatives often have inadequate attention to performance
measurement – thereby placing their sustainability at risk.
A modified Delphi approach which featured online methods
and a collaborative platform was employed to overcome these
challenges.
Methods: Consensus development and decision-making were
achieved via 6 voting rounds over 3 months using an online,
modified-Delphi, characterized by the following: • Inclusivity
of stakeholders (n = 5 across 6 sites; various disciplines,
site leaders, researchers and consumers as well as funding
32
representatives; n = 32) • Provision of evidence-based
information including draft CPGs (Houghton et al.-in progress)
and the SCIRE evidence-based review (www.scireproject.
com) • Use of collaborative platform (Sharepoint) which
enabled access to evidence-based resources and betweenround discussions • A priori Delphi rules/principles included
anonymous voting, set criteria to guide voting and betweenround decision-making, between-round data synthesis
and presentation, continuous monitoring and capability
for adaptation Delphi voting rounds: 1: Cull best practice
recommendations (BPR) from 45 to 23 2: Rank top 12 BPRs
3: Select top 2 non-negotiable and 3 optional BPRs. 4: Revise/
delete/suggest PMs relating to the BPRs selected in Round 3
5: Cull and rank PMs (small, representative sub-committee) 6:
Select final PMs
Results: The two priority non-negotiable BPR targets included
pressure ulcer-related comprehensive risk assessment and
systematic approach to patient education. PMs included
indicators to assess the proportion of patients with pressure
ulcers during different phases of care as well as the proportion
of patients for which a risk assessment is conducted and
education is delivered. Also, a patient report survey will assess
the effectiveness of the education delivered. The Delphi
process laid the foundation to systematically implement
and evaluate BPRs and just as importantly, set the stage
for a successful BPI initiative that engaged personnel from
across the participating sites in establishing a cross-discipline
community of practice.
References: Jones J, Hunter D. Using the Delphi and nominal
group technique in health services research. In Qualitative
Research in Health Care, 2nd ed. London: BMJ Books, 2000.
URL: http://www.bmjpg.com/qrhc/chapter5.html
O3-01
The Brain and Spinal Cord Response
to Sensory Stimuli: An fMRI Study
R.L. Bosma, C.E. Dobek, M.E. Beynon, P.W. Stroman
Center for Neuroscience Studies, Queen’s University, Kingston/
ON/CANADA
Background: The ability to see the function of the spinal
cord immediately following a spinal cord injury would provide
essential information for thorough and accurate assessment
of a person’s condition. Currently, this information is not
available to doctors, and assessments are based largely on
what the patient can report about their condition. Special
imaging techniques based on MRI, such as functional
magnetic resonance imaging (fMRI) have been used to
assess the spinal cord and brain neuronal function. These
methods have the potential to dramatically increase the
amount of information available to aid in the development
of individualized treatment strategies for people with spinal
cord injuries. The aim of this study was to use spinal cord
and brain fMRI to determine the neural response to sensory
stimuli in healthy controls, as a means of providing reference
data for patient populations.
Methods: Functional MRI studies of the spinal cord,
brainstem and brain were carried out in healthy controls (N
= 20). Images were acquired in two stages which included
areas of overlap, the first spanned the cervical spinal cord
and brainstem; the second spanned the brain and upper
brainstem (1,2,3,4). During imaging, thermal stimulation
of sensory dermatomes was applied at 44 °C to both the
right and left shoulders (C5 dermatomes) and hands (C8
dermatomes). Data were analyzed by means of a general
linear model (GLM) and connectivity analyses.
Results: Results demonstrate that, in the spinal cord,
the GLM can be used to distinguish distinct responses to
multiple stimuli, while the same analysis does not robustly
reveal sensory regions in the brain. However, connectivity
calculations projecting from region-to-region, starting from the
cord, can identify distributed components of the sensorimotor
network in individuals. This study combines spinal cord and
brain fMRI to reveal the entire neuroaxis responding to thermal
sensory stimulation. The current study lays the foundation
for ongoing studies to assess the changes that occur at each
of these relay points as a result of trauma. Results from this
study contribute to our overall research program which aims
to develop fMRI as into a clinical assessment tool in order to
provide greater insight to both doctors and patients, guide
rehabilitation efforts, and enable better outcome measures for
clinical trials of new treatments.
References: 1.Stroman, P.W., Bosma, R.L., Tsyben, A.
Somatotopic arrangement of thermal sensory regions in the
healthy human spinal cord determined by means of fMRI.
Magnetic Resonance in Medicine, In Press. 2.Figley, C.R.,
Leitch, J.K., Stroman, P.W. (2010) In contrast to BOLD: signal
enhancement by extravasular water protons (SEEP) as an
alternative mechanism of endogenous fMRI signal change.
Magnetic Resonance Imaging 3.Figley, C.R., Stroman, P.W.
(2009) Development and validation of retrospective spinal cord
motion time-course estimates (RESPITE) for spin echo fMRI:
Improved sensitivity and specificity by means of a motioncompensating general linear model analysis. NeuroImage
O3-02
Influence of Surgical Delay on
Hospitalization Costs and Length of
Stay Following a Traumatic Spinal
Cord Injury
J. Mac-Thiong, S. Parent Hôpital du Sacré-Coeur de Montréal,
Montréal/CANADA, C. Thompson, �. Bourassa-Moreau,
improving the neurological outcome and decreasing the
complication rate. From an economic point of view, this could
also result in a shorter hospitalization in the Level-I trauma
center and, consequently, lower costs for the healthcare
system. Thus, the objective of this study was to evaluate the
influence of the delay between the spine trauma and the
stabilization surgery on the length of stay in the acute care
hospital and the associated costs.
Methods: A total of 452 adults who sustained a traumatic
SCI and had their spinal stabilization surgery done at SacréCœur Hospital between April 2003 and March 2011 were
included in this study. Patients were excluded if they were
diagnosed with a central cord syndrome associated with
pre-existing spinal stenosis, or sustained a spine injury below
L1. Socio-demographic and clinical data were retrieved
from the Québec Trauma Registry (QTR), which includes
all patients that have been treated for a traumatic injury
in a healthcare facility in the province of Québec. Costs in
CAD$ were calculated using the NIRRU index, obtained
through the hospital database. The NIRRU index reflects the
financial burden of each patient and the actual length of stay,
but excludes physicians’ costs. Costs were then adjusted
according to the Canadian rate of inflation between the year
of trauma for each patient and 2011.
Results: 70 patients underwent spine surgery within the
first 24 hours following their traumatic SCI. They were
significantly younger and the severity of their trauma,
estimated by the ISS, was significantly more important than
for patients operated more than 24h after their trauma. When
controlling for the differences in age and severity of trauma,
patients who had their surgery within 24h post-trauma had
a 1-week shorter length of stay in the acute care hospital,
which represented an economy of approximately 3500 CAD$
per patient.
Decreased delays between spine trauma and stabilization
surgery were associated with shorter length of stay in the
trauma center, as well as smaller costs. From an economic
perspective, an early surgery following a traumatic spinal
cord injury is beneficial and results in a lower financial
burden on the national healthcare system.
This project was funded by the Québec Health Research Fund
(FRQS).
References: Albert, TJ & Kim, DH. (2005). Timing of surgical
stabilization after cervical and thoracic trauma. J. Neurosurg.
Spine, 3: 182-190.
Dryden, DM, Saunders, LD, Jacobs, P et al. (2005). Direct
health care costs after traumatic spinal cord injury. J. Trauma,
59: 441-447.
Background: The optimal timing for spinal surgery following
a traumatic spinal cord injury is still controversial. There is
a trend towards performing the stabilization surgery early
after the SCI, which would be beneficial to the patients by
33
O3-03
Responsiveness of a Clinical
Impairment Measure Specific for
Traumatic Tetraplegia: A MultiCentre Assessment of the Grassp
Outcome Measure.
S. Kalsi-Ryan1, M. Verrier2, D. Beaton3, M. Popovic2, A. Curt4,
M.G. Fehlings1
1
, Toronto Western Hospital, Toronto/ON/CANADA, 2,
Rehabilitation Engineering Laboratory, Toronto Rehabilitation
Institute, Toronto/ON/CANADA, 3, St. Michaels Hospital,
Mobility Program, Clinical Research Unit, Toronto/
ON/CANADA, 4, University Hospital Balgrist, Zürich/
SWITZERLAND
Background: GRASSP was developed to capture subtle
changes in neurological impairment of the upper extremity
after cervical spinal cord injury (SCI) during the acute, subacute, and chronic phases1. The psychometric properties of
reliability and validity are well established for the GRASSP
with the chronic tetraplegic population2. Responsiveness
testing is required as subtle changes in impairment are
important because small improvements can have a significant
impact on functional independence and may be the only
changes occurring when evaluating the development and
implementation of emerging therapies. Scientific Aims: 1) To
develop the psychometric attribute of responsiveness for the
GRASSP Version 1.0; 2) To establish what meaningful change
and minimally clinical important differences (MCID) are to
the tetraplegic population compared to clinicians and 3) To
establish a method to measure neurological impairment and
recovery for the upper limb after acute cervical SCI.
Methods: A prospective longitudinal study including individuals
with acute tetraplegia (C Occiput to T1, AIS A, B, C or D) is
currently being conducted as a multi-centre/multi-national
study. Serial testing consists of GRASSP, International Standards
for Neurological Classification for Spinal Cord Injury (ISNCSCI),
Spinal Cord Independence Measure (SCIM), Capabilities of
Upper Extremity Questionnaire (CUE), Questionnaires and Life
Satisfaction Survey (LISAT-11) administered 0 to 10 days, 1,
3, 6, and 12 months post injury. Analysis for responsiveness
will consist of observed change, standardized effect size,
and standardized response mean for the following pairs of
information: times 2 to 1, time 3 to 1, time 4 to 1, 5 to 1, 2 to 3,
2 to 4, 2 to 5, 3 to 4, 3 to 5 and 4 to 5.
Results: Sample: Total enrollment in Ontario to 36, with
6 month follow up for 16 and 12 month follow up for 10.
Enrollment in Ontario will close in July 2012, with follow up
data collection closing in July 2013. The data have been
collected by the GRASSP multidisciplinary research teams at
4 sites of the Ontario Spinal Cord Injury Research Network.
Results: Sub-analysis of small datasets within the study show
increased sensitivity of the measurement of sensorimotor
deficits across the recovery of one year. The GRASSP
34
defines the tetraplegic sample with greater sensitivity than
the current “gold standard” and the relationships between
GRASSP subtests elucidate functional gains made with greater
accuracy. Conclusion: GRASSP Version 1.0 is a sensitive
upper limb impairment measure which will be useful in
clinical and research settings to assess the sensory, motor
and functional changes occurring after injury, with greater
sensitivity to the subtle change. This methodology should
allow clinicians and researchers to elucidate the underlying
approaches to improve concomitant hand function and define
efficacy of new interventions.
References: Kalsi-Ryan S et al. Top Spinal Cord Inj Rehabil
(2009);14(4):34-46 Kalsi-Ryan S et al. J Neurotrauma 2011
Aug 12 (Epub ahead of print)
O3-04
Walking Measures Inform SCI
Rehabilitation Practice and
Research
M. Verrier1, K. Guy1, H. Morris1, J. Williams1, A. Marinho1, M.
Popovic2, B.C. Craven1, H. Flett1
1
, Toronto Rehabilitation Institute, Toronto/ON/CANADA, 2,
Rehabilitation Engineering Laboratory, Toronto Rehabilitation
Institute, Toronto/ON/CANADA
Background: Walking is a complex sensorimotor function
and understanding internal individual patient factors i.e.
posture, balance, strength and coordination etc., must
be aligned with external environment factors i.e. collision
avoidance and attention demands for successful community
mobility. The ability to walk is one of the top six articulated
goals of individuals with Spinal Cord Injury (SCI) 1 making
gait training a major focus of many in-patient and out-patient
rehabilitation programs. Therefore, when developing best
practices in assessment and therapeutic interventions for
walking programs physical therapists always consider the
individual, their goals in concert with the specific environments
patients will routinely encounter longitudinally. The use of
walking measures to characterize patients’ walking status
along the recovery continuum informs treatment planning and
programming and requires a systematic approach.
Methods: The SCIMobility Team at the Toronto Rehabilitation
Institute program has developed a standardized approach to
the measurement of walking for the purposes of informing
treatment planning and delivery and translational research.
Over the last five years they have: 1) continuously reviewed the
literature for best practices, 2) completed a retrospective study
of 180 patient records to determine the feasibility of collection
of admission and discharge walking status, 3) developed and
trained all physical therapy practitioners to use a standard
set of assessments at specific times during the course of
recovery, 4) prospectively collected walking data from 62
SCI patients at admission and discharge, 5) collected cross-
sectional Gait Rite data (n=52) and 6) captured pre /post-test
walking data for an randomized functional electrical therapy
trial on a chronic population. Timed measures (10-metre Walk
Test (10mWT), 6-Min Walk Test (6MWT) Timed Up and Go
Test (TUG) and spatial temporal assessment using Gait Rite
(n= and categorical measures of ambulation (Spinal Cord
Independence Measure (SCIM III), Walking Index for Spinal
Cord Injury (WISCI-II) and the locomotor component of the
Functional Independence Measure (FIML) have been routinely
captured during rehabilitation stay at admission or when the
patient is first able to initiate walking during the course of
rehabilitation, at discharge and during outpatient rehabilitation
and pre and post interventional trials.
Results: Data from selected time points has been analyzed
to determine and predict patients’ ability to achieve optimal
functional walking levels as measured by velocity and distance
coupled with in-home and community mobility profiles for subcohorts of patients. Developing these benchmarks is important
for determining the metrics of an “episode of care” for in-/outpatient rehabilitation in an environment where rehabilitation
length of stay and readiness for discharge may not always be
determined by optimal outcome due to the fiscal pressures
for efficiencies. Precisely determining these benchmarks for
different cohorts will be important for long-term maintenance
of health status and well-being of individuals with SCI caused
by both traumatic and non traumatic etiologies. Supported in
part by funding from the Ontario Neurotrauma Foundation and
the Craig Neilson Foundation.
References: 1 Andersen KD. Targeting recovery: priorities
of the spinal cord injured population. J Neurotrauma. 2004
21:1371-1383.
O3-05
Classifying Neurological Impairment
and Spinal Column Injuries: Does
Administrative Coding Accurately
Represent Clinical Diagnoses?
V. Noonan1, N. Thorogood1, B.K. Kwon1, J. Batke2, M. Dvorak1
1
, Rick Hansen Institute, Vancouver/CANADA, 2, Combined
Neurosurgical and Orthopaedic Spine Program (CNOSP),
Department of Orthopaedics, University of British Columbia,
Vancouver/BC/CANADA
Background: The International Classification of Diseases
(ICD) codes are used to document patient morbidity in
administrative databases. Although ICD codes are often used
for research purposes, the validity of these codes to accurately
capture clinical diagnoses has been questioned.1 We
examined the validity of ICD-10 codes compared to the clinical
diagnoses for spinal injuries from the Rick Hansen Spinal Cord
Injury Registry (RHSCIR).
Methods: We compared RHSCIR clinical diagnoses and ICD10 codes from the Discharge Abstract Database (DAD) for
patients with traumatic SCI. All patients enrolled in RHSCIR at
Vancouver General Hospital from 2004 to 2010 were included.
ICD-10 codes used for spinal column and cord injuries were
mapped to the RHSCIR spinal column injury diagnosis and
the International Standards for Neurological Classification of
Spinal Cord Injury, respectively. RHSCIR was applied as the
gold standard to estimate validity of the ICD-10 codes with
sensitivity, specificity and positive predictive value (PPV).
Results: There were 603 participants enrolled in RHSCIR
with a spinal cord injury and 341 had a spinal column injury
diagnosis. When the RHSCIR diagnoses were compared to
the ICD-10 codes from the DAD, 5.3% of the spinal column
injuries and 10.9% of the spinal cord injuries were missed with
ICD-10 coding. Both the spinal column and cord injuries had
highly variable sensitivity (0.140 to 0.868) and PPV (0.070
to 0.865). The most valid column injury ICD-10 code was
fractures of cervical vertebrae C3-7 (S12.2); 76.3% (122 of
160) of these fractures in RHSCIR were correctly coded in the
DAD. The least valid ICD-10 code was the dislocation of the
cervical vertebra (S13.1); only 14.0% (8 of 57) of dislocations
of the cervical vertebrae in RHSCIR were correctly coded in
the DAD. The most valid cord injury ICD-10 code was the
incomplete lesion of the cervical spinal cord (S14.1X); 86.8%
(198 of 228) of the incomplete lesions of the cervical spinal
cord in RHSCIR were correctly coded in the DAD. The least
valid ICD-10 code was the incomplete lesion of the lumbar
spinal cord (S34.1X); 66.7% (16 of 24) of incomplete lesions
of the lumbar spinal cord in RHSCIR were correctly coded
in the DAD. Of all the RHSCIR participants coded with a
complete SCI (S14.10, S24.10, and S34.10) in the DAD,
10.5% (22 of 208) had a contradictory incomplete AIS B-D
classification based on RHSCIR diagnosis. We have shown
that the validity of ICD-10 codes is variable and that ICD-10
codes cannot be reliably used to classify all types of spinal
injuries. Compared to previous studies,2, 3 we have reported
persons with spinal column and cord injuries that are missed
by ICD-10 coding. Prospective clinical registries, such as
RHSCIR, should be used if accurate detailed diagnostic data is
required.
References: 1. van Walraven C et al. Administrative database
research infrequently used validated diagnostic or procedural
codes. J Clin Epidemiol. 2011;64:1054-1059. 2. Hagen EM
et al. Diagnostic coding accuracy for traumatic spinal cord
injuries. Spinal Cord. 2009;47:367-371. 3. Thurman DJ et al.
Surveillance of spinal cord injuries in Utah, USA. Paraplegia.
1994;32:665-669.
35
O3-06
Rick Hansen Spinal Cord Injury
Registry and Ontario Spinal Cord
Injury Registry: Relationships
Between Respiratory Status and
Length-Of-Stay in Acute Care and
Rehabilitation.
D. Tsui1, B. Drew1, B. Ansley1, L. Macrae1, B.C. Craven2, M.
Verrier3
1
, Hamilton Health Sciences, Hamilton/ON/CANADA, 2, Toronto
Rehabilitation Institute, Spinal Cord Injury Rehabilitation
Program, Toronto/ON/CANADA, 3, Toronto Rehabilitation
Institute, Toronto/ON/CANADA
Background:
Respiratory complications are leading causes of morbidity
and mortality in people with spinal cord injury (SCI).1-5 Studies
have found a significant relationship between the number
of respiratory complications and length-of-stay (LOS), and
respiratory variables can explain 60% of variance in acute
care LOS.6-7 The Rick Hansen SCI Registry (RHSCIR) and the
Ontario SCI Registry (OSCIR) are Canadian databases that
store information about traumatic SCI. This study examined
the relationship between respiratory status and hospital LOS
in adults with traumatic SCI who participated in RHSCIR and
OSCIR.
Methods: This multicentre prospective cohort study recruited
adult patients with traumatic SCI admitted to RHSCIR/OSCIR
acute or rehabilitation hospitals in Hamilton and Toronto from
April 2007 to May 2009. Respiratory status, neurological
status, and hospitalization data of consenting participants were
collected by chart review. Data analyses utilized the T-Test and
Pearson’s Correlation Coefficient to evaluate the relationship
between respiratory status indicators and LOS.
Results: One hundred and twenty-four patients consented
to participate in the study. All were admitted to acute care
and 90 were admitted to rehabilitation. Acute care LOS
was significantly longer for participants who required an
endotracheal tube for more than 24 hours (n=24) than for
participants who did not require an endotracheal tube or
used one for 24 hours or less (n=67) [mean(SD): 51(48)
vs. 20(16) days; p=0.006]. Participants who required
tracheostomy (n=15) had significantly longer acute care LOS
than participants who did not require tracheostomy (n=83)
[mean(SD): 60(51) vs. 21(18) days; p=0.011]. Rehabilitation
LOS was significantly longer for participants who required
volume augmentation (n=24) than for participants who did
not require volume augmentation (n=40) [mean(SD): 134(78)
vs. 81(40) days; p=0.004]. Respiratory function measured
by peak cough flow significantly correlated with rehabilitation
LOS; participants who had greater peak cough flow were more
likely to have shorter rehabilitation LOS (r = −0.538; p=0.001).
36
Respiratory status is related to LOS in acute care and
rehabilitation. Improving respiratory care through
implementation of best respiratory practices8 may reduce
respiratory complications and associated costs.
References: 1. Carter RE. Respiratory aspects of spinal
cord injury management. Paraplegia. 1987;25:262-266. 2.
Devivo MJ, Kartus PL, Stover SL, Phillip RD, Fine R. Cause
of death for patients with spinal cord injury. Arch Intern
Med. 1989;149:1761-1766. 3. Jackson AB, Groomers TE.
Incidence of respiratory complications following SCI. Arch
Phys Med Rehabil. 1994;75:270-275. 4. Lemons VR, Wagner
FC Jr. Respiratory complications after cervical spinal cord
injury. Spine. 1994;19:2315-2320. 5. Winslow C, Rozovsky
J. Effect of spinal cord injury on the respiratory system.
Am J Phys Med Rehabil. 2003;82:803-814. 6. Winslow C,
Bode R, Felton D, Chen D, Meyer PR. Impact of respiratory
complications on length of stay and hospital costs in acute
cervical spine injury. Chest. 2002;121:1548-1554. 7. Tator
CH, Duncan EG, Edmonds VE, Lapczak LI, Andrews DF.
Complications and costs of management of acute spinal cord
injury. Paraplegia. 1993;31:700-714. 8. Berney S, Bragge
P, Granger C, Opdam H, Denehy L. The acute respiratory
management of cervical spinal cord injury in the first 6 weeks
after injury: a systematic review. Spinal Cord. 2011;49:17-29.
O3-07
Prognostic Value of Multimodal
Neurophysiological Evaluation in
Spinal Cord Injury
M. Schubert1, A. Curt1, R. Rupp For The Emsci Study Group2
1
, Spinal Cord Injury Centre Uniklinik Balgrist, Zuerich/
SWITZERLAND, 2, EMSCI Study Network, Klinik für
Paraplegiologie, Universitätsklinikum Heidelberg,, Heidelberg/
GERMANY
Background: The disability secondary to traumatic spinal cord
injury (SCI) is known to be highly variable among patients due
to the vast variety of lesion levels and varying severity, resulting
in a mixture of central and peripheral neural lesion burden. In
this context prognostication of outcome becomes a challenge,
yet is paramount in planning rehabilitation and clinical trials.
Next to ASIA assessments 1 neurophysiological techniques
have been proposed for prognostication as they are objective
and early available2. Evoked potentials (EPs) have been used
as diagnostic and prognostic tool in SCI 3, although their
importance and prognostic value has not been completely
established.
Methods: The aim of this study was to analyze the prognostic
significance of multimodal EPs in a cohort of SCI cases. From
the prospective European Multicenter Study about Spinal Cord
Injury database (EMSCI ) we evaluated 633 SCI patients who
underwent complete neurophysiological evaluation (NPE),
including nerve conduction studies, somatosensory and motor
EPs within 4 weeks and who were followed for 12 months
after SCI. EP abnormalities were quantified through an index
of global EP alteration (EP score). The relationship between
EP score and disability in terms of Spinal Cord Independence
Measure (SCIM)4,5 was analyzed by the Kaplan-Meier survival
method and Spearman ρ correlation coefficient. ROC curves
were used to determine the best EP score cut off to predict
different SCIM endpoints. For each endpoint, sensitivity,
specificity, positive and negative predictive values of EP score
were calculated.
Results: We found a significant correlation (p < 0.0001)
between EP score and SCIM total score at the time of NPE and
at 3, 6 and 12 months of follow-up, particularly for motor and
somatosensory EPs. Multimodal EPs are reliable and objective
procedures to predict disability in traumatic SCI patients
independent of lesion level and ASIA grade.
References: 1 Marino RJ, Barros T, Biering-Sorensen F, Burns
SP, Donovan WH, Graves DE, et al. International standards
for neurological classification of spinal cord injury. J Spinal
Cord Med. 2003 Spring;26 Suppl 1:S50-6. 2 Curt A, Schwab
ME, Dietz V. Providing the clinical basis for new interventional
therapies: refined diagnosis and assessment of recovery after
spinal cord injury. Spinal Cord. 2004 Jan;42(1):1-6. 3 Spiess
M, Schubert M, Kliesch U, Halder P. Evolution of tibial SSEP
after traumatic spinal cord injury: baseline for clinical trials. Clin
Neurophysiol. 2008 May;119(5):1051-61. 4Catz A, Itzkovich
M, Steinberg F, et al. The Catz-Itzkovich SCIM: a revised
version of the Spinal Cord Independence Measure. Disabil
Rehabil. Apr 15 2001;23(6):263-268. 5Catz A, Itzkovich M,
Tesio L, et al. A multicenter international study on the Spinal
Cord Independence Measure, version III: Rasch psychometric
validation. Spinal Cord. Apr 2007;45(4):275-291.
O3-08
Outcomes in the Va Sci/D System of
Care: Collection, Analysis, Utilization
P. Ullrich1, P. Carter2, B. Frazier1, B. Goldstein1, M.
Hammond1, R. Hendricks1
1
, Department of Veterans Affairs, Seattle/WA/UNITED STATES
OF AMERICA, 2, Department of Veterans Affairs, Seattle/
UNITED STATES OF AMERICA
Background: In the United States, the Department of Veterans
Affairs (VA) Spinal Cord Injury and Disorder (SCI/D) System
of Care provides SCI specialty care to about 21,000 Veterans
each year, making the VA one of the largest single networks of
SCI care in the world. Central to the mission of the VA SCI/D
System of Care (VASSC) is the monitoring of patient outcomes
to direct program evaluation and data-driven continuous
quality improvement activities. The VA recently launched a
program of outcomes collection and utilization at all of the
24 VA SCI Centers nationwide. This presentation describes
methods implemented by the VASSC to collect, analyze, and
utilize outcomes to improve patient care. The presentation has
three primary objectives: 1) describe the novel information
technology infrastructure in place to collect and analyze
outcomes, 2) describe the outcomes program in place in the
VASSC, and 3) report on primary outcomes collected to date.
Methods: The VASSC utilizes an innovative user interface
called Spinal Cord Injury and Disorders Outcomes (SCIDO).
SCIDO is a customized outcomes and assessment application
that supports healthcare delivery while facilitating outcomes
data collection and utilization for SCI patients. SCIDO
is linked to other electronic medical records, allowing
SCI providers to access consolidated clinically pertinent
information and to coordinate care across sites. SCIDO gives
providers tailored displays of outcomes and complications at
the level of individual patients or across groups of patients
under their care. SCIDO uploads data from all SCI care
sites in the VA into a national repository for aggregation
and analysis. Outcomes collection in the VASSC involves
on-site coordinators at each SCI Center who manage data
collection and lead quality improvement efforts. Outcomes
data are aggregated and analyzed at a national level and
shared with providers and leadership at the SCI Centers.
Outcomes are collected from inpatient and outpatient
rehabilitation programs, long-term care settings, and from
annual evaluations. Outcomes of focus include neurological
status, functioning (FIM), community participation (CHARTSF), health status (SF-8), and satisfaction with life (Diener’s
SWLS).
Results: The primary characteristics of Veterans with SCI/D
participating in the program will be highlighted, and key
outcomes in this population will be reported.
References: Consortium for Spinal Cord Medicine. (1999).
Outcomes Following Traumatic Spinal Cord Injury: Clinical
Practice Guidelines for Health Care Professionals. Department
of Veterans Affairs Office of Public Affairs [home page on the
Internet]. Washington (DC): Department of Veterans Affairs;
c2009 [updated 2009 Jan; cited 2010 May]. Fact sheet: VA
and spinal cord injury; [about 5 screens]. Available from: .
Fonseca JE. J Am Paraplegia Soc. 1987;10(1):8-11.
O4-01
Spinal Cord Injury Model Systems
Database: Continuing 40 Years of
Progress
Y. Chen, V. Allen, M. Devivo
University of Alabama at Birmingham, Birmingham/AL/
UNITED STATES OF AMERICA
Background: There has been an increase in collecting
and archiving large amounts of information on spinal cord
37
injury (SCI) by federal and non-federal agencies for various
purposes. Advances in statistical and information technology
have promoted high quality databases, easier access, and
potential toward universal global datasets.
O4-02
Methods: A systematic review and analysis of the 40-year
history of the US Spinal Cord Injury Model Systems (SCIMS)
program and associated database was conducted to: 1)
summarize history, design, content, data management,
data sharing, and current status; 2) identify its strengths,
weaknesses, and continued relevance; and 3) evaluate
suitability and public availability for future research and
collaboration.
C. Rivers1, V. Noonan1, K. Walden1, J. Zander1, L. Cartar1, E.
Cherban1, B. Sun1, M. Dvorak2
1
, Rick Hansen Institute, Vancouver/BC/CANADA, 2, Combined
Neurosurgical and Orthopaedic Spine Program (CNOSP),
Department of Orthopaedics, University of British Columbia,
Vancouver/BC/CANADA
Results: The SCIMS database (https:\\\\www.nscisc.uab.
edu) captures data from approximately 13% of new SCI
cases that occur in the US every year. Since its inception in
1970, 28 federally funded SCIMS centers across the US have
contributed data to the database, including information on
demographics, injury characteristics, neurological recovery,
medical complications, and psychosocial outcomes. The
database is structured longitudinally with data collected during
the initial hospitalization and at post-injury 1, 5, 10, and every
5 years thereafter. As of March, 2011, the database included
abbreviated registry records on 11,656 patients, more complete
initial injury and hospitalization records on 27,969 patients, and
103,758 follow-up records successfully obtained by phone,
face-to-face, and chart review and surveyed by mail, with the
longest follow-up of 35 years post injury. Although stability
and continuity of the database has been a priority, a number
of changes have been implemented to meet current needs
and reflect changes in health services, health care policy, and
new technology. A variety of methods are used to strengthen
the quality of the data being reported and maintained in the
database, including error checks built into data entry and
management software, standardized operation procedures and
data dictionary, data collectors training and technical assistance,
site visits, on-site quality assurance procedures, and periodical
monitoring of enrollment, follow-up, and missing data. Access
to the SCIMS database is open to investigators who are within
or outside of the SCIMS centers through a standard review and
approval process. Strengths include large sample size, use of
valid and reliable measures, geographic and patient diversity,
long-term outcomes, and rigorous quality control procedures.
Limitations include lack of population basis, loss to followup issue, and over-representation of more severe injuries.
Conclusion: The SCIMS database remains a valuable resource.
Current developments include linkage to other databases to
enhance research capability, online tools that allow users to
build their datasets and data dictionaries, SCIMS dummy
datasets for hands-on experiences, and algorithms and codes
for data management and database linkage.
References: 1. Stover SL, DeVivo MJ, Go BK. History,
implementation, and current status of the National Spinal Cord
Injury Database. Arch Phys Med Rehabil 1999; 80:13651371. 2. DeVivo MJ, Go BK, Jackson AB. Overview of the
national spinal cord injury statistical center database. J Spinal
Cord Med 2002; 25:335-8.
38
The Rick Hansen Spinal Cord Injury
Registry: An Update.
Background: The Rick Hansen Spinal Cord Injury Registry
(RHSCIR) was started in 2002 and was the first nationwide SCI patient-registry within Canada, and includes the
International SCI Core Dataset[1]. Currently, RHSCIR has been
implemented in 14 cities located in 9 provinces (including 31
acute and rehabilitation centres across Canada) and includes
over 1950 individuals who have sustained an acute traumatic
SCI. Data are captured from the pre-hospital, acute, and
rehabilitation phases of care, and participants are followed in
the community at 1, 2, 5 and then every 5 years post-injury.
The data collected will provide researchers and clinicians
with an invaluable pool of SCI patient information to better
understand SCI and the effectiveness of specific treatments,
practices or programs for improving functional outcomes and
quality of life after SCI.
Methods: Aggregate data from all registry participants is
presented to provide a description of individuals living with
SCI from a Canadian perspective. The RHSCIR data will be
compared with data from other large international SCI studies
or registries to determine if there are any unique similarities
and differences. Preliminary results are presented in this
abstract; data presented at the meeting will be updated with
the latest available registry information.
Results: There are currently over 1950 individuals with
traumatic SCI who are participating in the registry. 78.3% of
participants are male, 21.7% are female. Mean age at injury is
46.5 years of age; 18.1% are < 25, 15.1% are 25-24, 22.6%
are 35-49, 23.1% are 50-64, 21.2% are >/= 65 years of age.
Falls accounted for most of the injuries (42.8%), followed by
transport accidents (33.7%), sports-related injuries (14.7%),
and other causes (8.8%). Falls were more common as the
mechanism of injury in older people; transport accidents as
the mechanism of injury in younger people. Cervical injuries
were the most common (65%), followed by thoracic (22%)
and lumbar (13%) injuries. Neurological scores (AIS): 41.9%
A (complete), 8.4% B (incomplete), 18.1% C (incomplete),
31.6% D (incomplete). Cervical incomplete injuries (40.9%)
are the most prevalent neurological syndrome, followed by
thoracic and lumbar complete injuries (17.4%), thoracic and
lumbar incomplete injuries (14.7%), cervical complete injuries
(13.0%), high cervical complete injuries (10.3%), and cauda
equina injuries (3.7%). We will discuss general applications
of the data, including investigation of data quality, assisting/
supplementing clinical trials, administrative use for health care
management, and development of best practice initiatives.
These research topics will demonstrate the value of the registry
in improving outcomes and quality of life in people living with
SCI.
References: 1: Noonan VK, Kwon BK, Soril L, Fehlings MG,
Hurlbert RJ, Townson A, Johnson M, Dvorak MF. The Rick
Hansen Spinal Cord Injury Registry (RHSCIR): a national
patient-registry. Spinal Cord. 2011 Nov 1.
O4-03
Review of Knowledge Translation
and Implementation Strategies in
Spinal Cord Injury
V. Noonan1, D. Wolfe2, K. Boily3, N. Thorogood1, S.E. Park1, J.
Hsieh4, J. Eng3
1
, Rick Hansen Institute, Vancouver/CANADA, 2, University of
Western Ontario, London/ON/CANADA, 3, University of British
Columbia, Vancouver/CANADA, 4, Lawson Health Research
Institute, London/CANADA
Background: Challenges with translating research evidence
into the clinical setting are well known. The science of
knowledge translation (KT) is relatively new and the factors
which ensure the successful implementation of research
evidence are still being determined. In the area of spinal
cord injury (SCI), projects such as the Consortium for Spinal
Cord Medicine have developed clinical practice guidelines,
and the Spinal Cord Rehabilitation Evidence (SCIRE) project
has conducted over 30 systematic reviews. To facilitate the
translation of evidence from these and emerging initiatives
into SCI clinical practice, there is a need to identify factors
critical for successful implementation and to assess if KT
initiatives have impacted clinical outcomes. This study
presents a systematic review of the literature and evaluates
the KT strategies used throughout the SCI continuum of care
(pre-hospital phase to life in the community) and its effect on
clinical outcomes.
Methods: Four electronic databases MEDLINE/Pubmed,
CINAHL, EMBASE and PsycINFO were searched for English
studies published from January 1980 to July 2011. Studies
were included if there was a SCI KT initiative that described
the process of implementation. Two reviewers independently
screened the abstracts and consensus was obtained in cases
where there was disagreement. The full articles were then
acquired and independently reviewed by the same individuals.
Articles included in the final selection were abstracted by one
of the reviewers. Study quality was independently assigned by
two raters using Downs and Black1 for non-randomized control
studies and Physiotherapy Evidence Database (PEDro) scale2
for randomized control studies.
Results: A total of 2902 publications were identified in the
initial search, 94 full articles were reviewed and 20 studies
met the inclusion criteria. Strategies used for implementing
research evidence included disseminating clinical practice
guidelines, incorporating standardized assessments into
routine clinical practice and educating clinical staff. Frequently
cited barriers included lack of knowledge, time, cost and
facilitators were management support, engagement of staff
and providing regular feedback. Impact of the implementation
on clinical outcomes was only reported in 10 of the 20 studies.
Results from this systematic review provide an overview of
the state of KT research in SCI. The barriers and facilitators
identified in this review may also inform ongoing KT initiatives
both in SCI and other health conditions.
References: 1. Downs SH, Black N. The feasibility of
creating a checklist for the assessment of the methodological
quality both of randomised and non-randomised studies of
health care interventions. J Epidemiol Community Health.
1998;52:377-384. 2. Sherrington C, Herbert RD, Maher CG,
et al. PEDro. A database of randomized trials and systematic
reviews in physiotherapy. Man Ther. 2000;5:223-226.
O4-04
Intramuscular Diaphragm Pacing
for Respiratory Support in
Tetraplegics: Current Worldwide
Status in 2010. Why Isn’t Available
Technology Utilized?
R. Onders
University Hospitals Case Medical Center, Cleveland/UNITED
STATES OF AMERICA
Background: Objective: Direct phrenic nerve pacing to replace
ventilators for tetraplegics was initially developed in the 1960’s
but through the 2000’s less than 5% of the estimated annual
300-500 eligible patients utilized the available devices in
the United States (US) (HCUPnet database 1997-2004).
Intramuscular diaphragm pacing (DP) was first implanted in
2000, European approval in 2007 and US in 2008.
Methods: Design: Review DP patients world-wide and
published literature in 2010. Participants/methods: All
ventilator dependent spinal cord injured (SCI) patients who
were implanted with DP per country and per state in absolute
numbers
Results: Results: A total of 65 DP implants were done in
9 countries: Canada, France, Norway, Spain, Switzerland,
Australia, Saudi Arabia, Jordan and the US. The US total
was 43 in 13 states with the majority in only 5 states- Ohio,
Colorado, Texas, Illinois and Georgia. In Canada in 2010 all
DP implants were done in one province, British Columbia. In
2011, another province implanted DP only when the injured
patient’s First Nation local community guaranteed payment.
Nine children were implanted worldwide with the youngest
age 2. DP technology is being utilized in other respiratory
problems and at the largest US site SCI accounts for less
than 30% of DP implants. There were 5 peer-reviewed
39
publications on phrenic or DP in 2010 all with positive results.
Conclusion: Published research continues to show the clinical
benefit of removing patients from mechanical ventilation yet
there is still an overwhelmingly low adoption of phrenic or
diaphragm pacing. A disparity of technology utilization exists
between countries, states or provinces. In the US, individual
state Medicaid programs are an obstacle. Recent reports of
DP utilization by trauma surgeons early after injury will help
expand this technology and decrease ventilator associated
pneumonias, diaphragm dysfunction and length of stay.
There is also growing experience that early DP implantation
has neuroplasticity effects and can help recovery of phrenic
motor neuron control and volitional breathing. Fortunately, the
expanding use of DP in other diseases such as Amyotrophic
Lateral Sclerosis (ALS) will maintain this option for SCI
patients. In ALS, DP delays the need for a ventilator by 18
months which improves their quality of life.
References: Onders RP, Ponsky TA, Elmo MJ, Lidsky K,
Barksdale E. First Reported experience with intramuscular
diaphragm pacing in replacing positive pressure mechanical
ventilators in Children. J Pediatr Surg. 2011 Jan;46(1):72-6.
Onders RP, Khansarinia S, Weiser T, Chin C, Hungness E,
Soper N, DeHoyos A, Cole T, Ducko C. Multi-Center Analysis
of Diaphragm Pacing in Tetraplegic with Cardiac Pacemakers:
Positive Implications for ventilator weaning in Intensive Care
Units. Surgery 2010; 148: 893-7 Gonzalez-Bermejo J, MorelotPanzini C, Salachas, F, Redolfi S, Straus C, Becquemin M,
Arnulf I, Pradat P, Bruneteau G, Ignagni A, Diop M, Onders R,
Nelson T, Menegaux F, Meininger V, Similowski T. Diaphragm
pacing improves sleep in patients with amyotrophic lateral
sclerosis. Amyotrophic Lateral Sclerosis, 2011
Disclosure: My university, my hospital and myself developed
the technology that was used in this abstract
O4-05
A Global Perspective on the
Frequency of the Leading Causes of
Spinal Cord Injury
B.M. Sakakibara1, W.C. Miller2, J.C. Furlan3, E. Von Elm4, A.
Krassioukov5, -. The Scire Research Team1
1
, University of British Columbia - Graduate Program in
Rehabilitation Sciences, Vancouver/BC/CANADA, 2, University
of British Columbia - Department of Occupational Sciences
and Occupational Therapy, Vancouver/BC/CANADA, 3, Division
of Genetics and Development, Toronto Western Research
Institute, University Health Network, Toronto/ON/CANADA, 4,
Swiss Paraplegic Research Group, Nottwil/SWITZERLAND,
5
, University of British Columbia - Physical Medicine and
Rehabilitation, Vancouver/BC/CANADA
Background: In many cases, the prevention of spinal cord
injuries (SCI) is possible by using safe practices while
40
engaging in various activities . Although significant efforts have
been made towards the prevention of SCI, such as developing
safety guidelines and policies, as well as education programs,
further improvements are possible by identifying and studying
the leading causes of SCI around the world. The purposes of
this research were to systematically identify and report on the
etiology of traumatic SCI in different countries worldwide.
Methods: A systematic review of the literature was undertaken
to identify the leading causes of SCI around the world. Papers
were included for review if they were an epidemiological study
reporting on the causation of traumatic SCI among adults (≥18
years), and published between 1949 and 2009 in English in
a peer-reviewed journal. The MEDLINE/PubMed, CINAHL,
EMBASE and PsycINFO online databases were searched for
papers. The reference lists of the relevant papers were also
reviewed to identify additional articles that the online database
search missed.
Results: Despite a lack of uniform SCI data collection and
reporting techniques, this review identified the most common
causes of SCI around the world to be: 1) motor vehicle
crashes; 2) falls; 3) sports; 4) violence; 5) self-harm; 6) work;
and 7) natural disasters. Table 1 outlines the review’s findings.
Table 1: Cause and Frequency of SCI
Cause of
SCI:
# of
studies:
Motor
vehicle
crash
59
Falls
58
Sports
71
Violence
47
Self-harm
19
Work
12
Natural
disasters
10
Most studies
from:
North
America,
Europe
North
America,
Europe
North
America,
Europe
North
America,
Europe
North
America,
Europe, Asia
Europe,
Oceania
China, Japan,
Iran
Frequency
Minimum:
Maximum:
Most
prevalent:
6.9% (Nepal)
89% (Nigeria)
40.0 –
49.9%
2.2% (Italy)
77.6% (Nepal)
20.0 –
30.0%
1% (Italy)
23.8% (Russia) 7.0 – 16.0%
0.97% (USA)
-and- 1%
(Germany)
18.9% (USA)
-and- 36.0%
(South Africa)
1.0 – 9.9%
1.3% (Canada)
25.9%
(Greenland)
0.5 – 4.5%
26.8% (Israel)
2.2 – 7.2%
1.2% (China)
<1.0%
3% (New
Zealand)
0.02% (Japan
and Iran)
Although this study was thorough in its review, it was limited by
the inconsistent data collection and reporting techniques used
in the different studies, making it difficult to compare results;
a similar concern noted in previous reviews.1-2 In order to
truly understand the implications of the differing causes of
SCI there is a need for a common approach to evaluate and
report on the causes of SCIs worldwide.1 Therefore, future
epidemiological studies on SCI are needed to be conducted
with common data collection and reporting techniques.
Such information will lead not only to greater understanding
of worldwide statistics on SCI, but also to better developed
international injury prevention programs.
References: 1 Ackery A, Tator C, Krassioukov A. A global
perspective on spinal cord injury epidemiology. J Neurotrauma
2004;21(10):1355-1370. 2 Wyndaele M, Wyndaele JJ.
Incidence, prevalence and epidemiology of spinal cord
injury: what learns a worldwide literature survey? Spinal Cord
2006;44(9):523-529.
O4-06
Spinal Cord Injury in the Majority
World: Challenges and Opportunities
in Providing Standard Care
A. Burns1, C. O’Connell2
1
, Toronto Rehabilitation Institute, Toronto/ON/CANADA, 2, Stan
Cassidy Centre for Rehabilitation, Fredericton/CANADA
Background: In the 21st century, acute care and rehabilitation
challenges for persons with spinal cord injury (SCI) in lowresource settings remain large, despite significant advances
in reducing morbidity and mortality in the developed world.
Average survival for a person with paraplegia in developing
countries is two years, whereas those with tetraplegia
rarely survive initial injury. Progress in improved long-term
health and community participation has not been realized
globally. This presentation will review global epidemiology
and outcomes of spinal cord injury, highlighting the critical
challenges and realities impacting delivery of standardized
SCI care in the majority of the world. Attention to SCI post
disaster has recently resulted in increased awareness and
resources directed towards providing standardized SCI care in
a number of low-resourced regions; the successful strategies,
including registries and training programs, will be described
with recommendations on the role of the international
SCI community in addressing needs of persons with SCI
worldwide.
Complications resulting in high mortality both during
hospitalization and post-discharge include pressure ulcers
and bowel and bladder management. There is poor access
to durable medical equipment including wheelchairs. Home
and community accessibility limits community reintegration,
return to work, and ability to access follow-up care. This is
compounded by poor acceptance and recognition of the
rights and value of persons with disability in many developing
countries. The implementation of training programs in SCI
care for local health providers has improved care delivery,
enhanced by standardized checklists for key outcomes prior
to discharge. Regional and national databases of patients has
allowed for patient monitoring post discharge. International
attention to SCI in such regions has increased awareness of
issues faced by those with injuries, improving advocacy and
promoting disability rights initiatives.
References: Burns AS, O’Connell C, Landry MD. Spinal cord
injury in postearthquake Haiti: lessons learned and future
needs. PM&R 2010; 2(8):695-697. Chiu W, Lin H, Lam
C, Chu S, Chiang Y, Tsai S. Review paper: epidemiology of
traumatic spinal cord injury: comparisons between developed
and developing countries. Asia Pac J Public Health 2010;
22(1):9-18. Priebe MM. Spinal cord injuries as a result of
earthquakes: lessons from Iran and Pakistan. J Spinal Cord
Med 2007; 30(4):367-368.
O4-07
Addressing Privacy Requirements
for the Development of a National
Health Registry in Canada
Methods: The International Spinal Cord Society established
a Disaster Committee following recent natural disasters with
resulting high numbers of persons affected by spinal cord
injury (SCI). Tasked with evaluating the current state of SCI
care globally, with a focus on low-resourced regions, and
establishing a framework for future responses, the authors
conducted literature reviews and consultations with both SCI
organizations and experts with field and research experience
in the developing world.
P. Joshi1, V. Noonan1, N. Thorogood1, M.G. Fehlings1, B.C.
Craven2, A..G. Linassi3, D.R. Fourney4, B.K. Kwon1, C.S.
Bailey5, E. Tsai6, B. Drew7, H. Ahn8, M. Dvorak1
1
, Rick Hansen Institute, Vancouver/CANADA, 2, Toronto
Rehabilitation Institute, Toronto/ON/CANADA, 3, University
of Saskatchewan, Department of Physical Medicine
and Rehabilitation, Saskatoon/CANADA, 4, Division of
Neurosurgery, University of Saskatchewan, Saskatoon/
CANADA, 5, London Health Science Centre, London/CANADA,
6
, Ottawa Hospital Research Institute, Ottawa/ON/CANADA,
7
, Department of Surgery, Division of Orthopaedic Surgery,
McMaster University, Hamilton/CANADA, 8, St Michael’s
Hospital, Toronto/CANADA
Results: There is a paucity of information available on
epidemiology and outcomes of SCI in the developing world.
There is a higher incidence of SCI in the developing world,
with falls being a leading cause of injury. Survival rates
are poor, particularly for cervical levels of injury. Acute
care, including appropriate immobilization, transportation
and delays of days before hospital presentation, are major
contributors to poor acute outcomes. There is a lack
of trained acute care and rehabilitation professionals.
Background: Personal health information is one of the
most sensitive types of personal information. Inappropriate
disclosure of such identifiable information can result in
harm and discrimination. In Canada, privacy legislation has
addressed concerns regarding personal health information.
Both national and provincial privacy legislation influences the
collection, management, use and disclosure of personal health
information for health research purposes; however, differing
interpretations of the legislation has created challenges in
41
forming multi-centre, collaborative, national health research
initiatives. We will describe the successful strategies utilized
by the Rick Hansen Spinal Cord Injury Registry (RHSCIR)
to address the privacy requirements and maintain beneficial
health research.
Methods: The development of a privacy and security
framework at Rick Hansen Institute (RHI) for the operation
of RHSCIR and other studies required a series of steps that
will be presented. 1) Assessment of privacy requirements
2) Development of a RHI privacy and security strategy
3) Development of a governance structure within RHI 4)
Development of standard operating procedures 5) Establishing
agreements with RHSCIR sites and researchers 6) Providing a
privacy and security training program 7) Undertaking a Privacy
Impact Assessment 8) Physical and technical security
Results: Based on these steps, a national privacy and security
framework was created for the RHSCIR that complied with
applicable privacy requirements and integrated the principles
of privacy into the technologies, business practices and
physical design of the registry. The framework meets a “highwater mark” of best practices in ensuring privacy and security
of personal health information across Canada. The lessons
learned in the development of this national registry may assist
the development of other national or international research
initiatives.
References: Not applicable
O4-08
The Development of Canadian
Best Practice Guidelines for the
Prevention and Treatment of
Pressure Ulcers in the Spinal Cord
Injured Population.
P. Houghton1, K. Campbell2
1
, University of Western Ontario, London/ON/CANADA, 2,
ARGC, Lawson Research, London/ON/CANADA
Background: Pressure ulcers are a major complication of
spinal cord injury (1). Several evidence-based pressure ulcer
guidelines deal with the general population and two guidelines
focus on people with spinal cord injury (PVA & SCIRE).
Identification of a need for updated guidelines focusing on
the Canadian situation prompted the development of these
guidelines. Funding was obtained from Ontario Neurotrauma
Foundation and Rich Hansen Institute. Building on the solid
foundation established by previous guidelines, this document
provides a unique Canadian perspective.
This guideline aimed to provide experts in spinal cord injury
and wound care information they require to deal effectively
with this special population. The two project leads: · Develop
the framework, process, and scope of the proposed Canadian
42
guidelines · Identify Canadian experts in the relevant
disciplines · Invite them to join an interdisciplinary Canadian
expert panel and participate in a consensus conference.
Methods: A literature search strategy was developed with
the assistance of a medical librarian. The CINAHL, EMBASE,
PubMed, Scopus, and Cochrane databases were searched.
Papers reviewed in the Consortium for Spinal Cord Medicine
Clinical Practice Guidelines (2001) or the Spinal Cord Injury
Rehabilitation Evidence (SCIRE), Version 2.0 (2008) were
excluded from the review list, unless they were pivotal papers.
(1,2) Published articles were included in the review list for
the new guideline if they included at least 50% spinal cord
injury patients in the study population. The articles were
divided into topic areas, each of which was associated with
specific guideline topics. An expert panel was formed included
representatives from consumer advocacy, as well as a variety
of health care professionals. The panel had the responsibility
of reviewing the spinal cord injury-specific guidelines and the
new literature and of identifying any recommendations that
should be updated, revised or added to reflect the Canadian
context.(1,2) To facilitate this process, the panel was divided
into working groups, according to areas of expertise and
guideline topic. These groups meet prior to the planned
meeting.
Results: A two day meeting was held, and group members
presented recommendations to the entire panel, to facilitate
input and discussion with other specialty areas.
The entire panel then reviewed the working group
recommendations and came to a consensus on the new
guidelines and supporting levels of evidence. Discussion at
the meeting demonstrated the need for additional guidelines
dealing with 24-hour positioning and support surfaces as well
as activity, mobility and conditioning; the steering committee
formed two task force, which addressed these topics in more
depth. The entire expert panel then reviewed a complete
revised draft. After revisions from the entire panel will be
incorporated, the document will be circulated to a broad group
of stakeholders for external review. The document will then be
finalized.
References: 1. National Spinal Cord Injury Statistical Center .
Annual Report for the Model Spinal Cord Injury Care Systems.
Birmingham, AL: NSCISC; 2005. Model Spinal Cord Injury
Care Systems.
Poster Abstracts
Order: Abstracts are listed in order of apperance per the
Interdependence 2012 program.
Disclosure: No significant relationships for the abstracts listed
unless otherwise noted.
P1-01
Regaining Functionality Following
a Spinal Cord Injury (SCI): Central
Issues for SCI Consumers
C. Jeanmaire1, J. Horsewell2, H. Sihota2, M. Codyre2
1
, ESCIF (European SCI Federation), EINDHOVEN/
NETHERLANDS, 2, ESCIF (European SCI Federation)
Research Working Group, EINDHOVEN/NETHERLANDS
Background: Accounts of the history of the treatment of SCI
cite the Edwin Smith papyrus (3,000 – 2,500 BC) in which
Imhotep, an Egyptian physician, describes the consequences of
a spinal cord injury and concludes “an ailment not to be treated
(cured)”.
In the last century, breakthroughs were made in the
comprehensive management of SCI – combating infection,
avoiding pressure ulcers, improvements in bladder and bowel
management, education and monitoring – making it possible for
people to live with SCI.
Over the last two decades, a new focus has emerged. Progress
in neurological research has presented the possibility that SCI is
not an incurable condition and that some degree of functional
recovery is possible. Unfortunately, this has also opened a
market in “unproven therapies”. Lacking scientific evidence for
the results claimed, these therapies harm the progress of good
translational science towards functional recovery.
Methods: An internet search of advertised therapies and
ongoing research into functional recovery after SCI. Ongoing
collaboration with other sources, sites and databases to update
published material.
Results: Information gathered is presented on the SCI
research section of www.escif.org.
The aim is to provide easily accessible information and
guidelines to assist people with SCI who may be interested in
undertaking therapies or participating in clinical trials.
Discussion: Although the working group discourages
participation in “unproven therapies”, it seeks to promote
serious, scientific research into SCI regeneration. While
the numbers of people with SCI are relatively small – the
psychological and financial impact on the individual and
family can be enormous. These costs are passed on to the
community and to society.
The current debate among SCI professionals and consumers
tends to underline the following dilemma: should we invest
time, money and resources into improving the lives of those
with SCI, or should we invest in finding a “cure”? We do not
support this “either/or” scenario.
While the present generation of SCI consumers may not
benefit personally from regenerative research, the issue may
be – can we afford NOT to invest in research to find “the cure”
for SCI?
References: http://www.escif.org/ESCIF,,extra_navi,unproven_
therapies.htm
http://www.escif.org/ESCIF,,extra_navi,sci_research.htm
P1-02
Patient Advocacy as a Force to
Advance SCI Research
M. Smith, D. Sullivan
Unite 2 Fight Paralysis, Hood River/OR/UNITED STATES OF
AMERICA
Background: When research scientists, clinicians, investors,
and other professionals gather to discuss progress, strategies,
and priorities in SCI research, an important voice is often
missing - that of persons living with a spinal cord injury.
Survivors and their family members have the greatest stake in
the pace and direction of research, and they bring a valuable
perspective to the conversation.
The greatest example of the power of patient advocacy comes
from the work of the AIDS community in the United States. Its
members took it upon themselves to study the science and
the politics behind advancing therapies, and they became
empowered by their knowledge. Their activism and pressure
on funding and regulatory agencies led to major changes in
AIDS clinical trials and drug regulation.
Methods: Today we have patient representatives on many
FDA (U.S. Food & Drug Administration) advisory committees,
but as a group they still struggle to exert influence. At the
same time, the California Institute of Regenerative Medicine
has embraced the concept of patient advocacy to great effect
through its Independent Citizens Oversight Committee. Fully
one-third of this decision-making committee is composed of
patient advocates. They are a well-educated group that has
no special interest to answer to other than finding effective
therapies; they ask questions and express urgency on
behalf of all those who have life-threatening illnesses.
43
In the SCI community, we have a patient population that
can be very difficult to galvanize. From the moment they
are injured, survivors are told repeatedly about all the things
they cannot do. Living with a spinal cord injury, particularly
cervical injuries, is a physical, financial, and emotional drain
on patients and family members. It’s hard to find the time or
energy for advocacy.
Results: On the other hand, if you can impart knowledge
and a belief in the promise of science to achieve effective
therapies, you have the basis for action. As we watch
promising therapies stall on the way to translation due to
funding and regulatory hurdles, we believe that an educated,
empowered patient advocate community can help overcome
these barriers. We must believe and then expect that people
living with spinal cord injury can “get smart” about the science
and the translational process. It is then up to our leading
organizations to provide education and training. Patient
advocates can:
Appreciate and advise in concert with other disease groups to
explore and support common therapies;
•
Help prioritize the needs and desires of the community;
•
Question and advise the research, regulatory, and
funding individuals and agencies;
•
Raise money to support targeted SCI research.
Spinal cord injury is a life-altering experience to survivors
and family members; by nature it takes away ability and
power. Advocacy, on the other hand, empowers. If we can
offer opportunities whereby SCI survivors have the means to
take action and have a voice in determining their future, the
research and clinical communities will benefit.
References: Duane Roth, A Third Seat at the Table: An
Insider’s Perspective on Patient Representatives (Hasting
Center Report)
publications focused on the causes and management of
neuropathic pain (NeP) in individuals with spinal cord injury
(SCI). Scoping studies map key concepts in a research area as
well as the sources and types of evidence available.
Methods: Utilizing the methodology of Arksey and O’Malley
(2005), this study has two phases. We are reporting on phase
one, in which we undertook a database search with key words
‘neuropathic pain’ and ‘spinal cord injury’. The electronic
databases searched included MEDLINE, Embase, CINAHL,
CCTR, PsycINFO, AMED, WOS, and SCOPUS from years
1950 to 2009. Data extracted were: author, year, study design,
objective, intervention, and study population. The first author
(JH) reviewed the abstracts to select studies addressing the
research question. Data were then coded by two independent
reviewers, based on the criteria listed in the results, below.
Results: The MEDLINE search yielded 2,397 articles, of which
926 met inclusion criteria (human in-vivo studies, English,
with abstract). Of these 103 were identified as “best fit” to
the NeP/SCI question. Data revealed the following numbers:
classification/measurement (n=10); descriptive/review (n=29);
treatment/pharmacologic (n=20); surgical (n=7); nonpharmacologic (n=6); CNS stimulation (n=6); neuroscience/
mechanism (n=11); personal impact (n=8); patient needs
(n=0); predictors/correlates (n=5).
Despite NeP being one of the most debilitating secondary
medical complications of SCI, research about the cause and
care for NeP in this population has been largely neglected.
These findings, combined with data from the remaining
abstracts, will be used for phase two - stakeholder consultation
(with clinicians, policy makers, consumers and their family) to
review, assess, and refine the phase one output and identify
key research priorities that will inform policy and practice
regarding best management strategy for people with NeP after
SCI.
References: Arksey, H., & O’Malley, L. (2005). Scoping
studies: towards a methodological framework. International
Journal of Social Research Methodology, 8(1), 19-32.
P1-05
Scoping the Field of Research and
Management of Neuropathic Pain
After Spinal Cord Injury
J. Hunter1, T. Jeji2, C.A. Mattison3, Y. Shantharam3, E. Uleryk4,
J.L. Henry5
1
, University of Toronto, Toronto/ON/CANADA, 2, Ontario
Neurotrauma Foundation, Toronto/CANADA, 3, McMaster
University, Hamilton/ON/CANADA, 4, Hospital for Sick
Children, Toronto/ON/CANADA, 5, McMaster University,
Hamilton/CANADA
Background: To conduct a scoping review of the literature to
determine the current breadth and depth of the peer-reviewed
44
P1-08
An Inter-Professional Clinical
Initiative in an Outpatient Spinal
Cord Injury (SCI) Rehabilitation
Setting: Pathways to Wellbeing Following SCI Community
Reintegration Service
S. Haycock, S.L. Hitzig, P. Bain
Lyndhurst - Spinal Cord Rehab Program, Toronto Rehab,
UHN, Toronto/CANADA
Background: Identifiable barriers to community participation
post-spinal cord injury (SCI) include reduced employment,
limited access to recreational and leisure activities, and a
lack of accessible transportation. Equally important are the
“invisible” barriers, which stem from attitudes and beliefs of
the individual and from society as a whole. For instance, some
persons with SCI may not be proactive in community life due
to the belief that they are not capable of accomplishing the
same things they were able to do pre-injury1. As such, the
process of community reintegration requires new learning,
problem solving and adaptation to lifestyle changes. To
facilitate the coping process, there is a need to provide
knowledge about these barriers, and strategies that could be
used to help circumvent them. Doing so may lead to better
outcomes in relation to individual well-being and quality
of life. The objective is to provide an overview of an interprofessional clinical initiative, the Community Reintegration
Out-Patient (CROP) Service, which aims to improve well-being
in community dwelling persons with SCI (less than 3 years).
Methods: The Community Reintegration Out-Patient (CROP)
Service is a 12-session, closed psycho-education group,
co-facilitated by 2 inter-professional team members, where
the clients have opportunities to: 1) discuss topics relevant
to emotional, physical and social well-being; 2) learn and
understand the role of ‘self’ in the recovery process 3) share
experiences and learn from one another within a group setting;
and 4) develop a roadmap for improving coping, well-being
and overall self management skills while reintegrating back
into the community. The group composition is comprised of
10-12 participants, and is guided by group processes. The
topics for weekly discussion include: 1) self-care; 2) problemsolving and goal setting; 3) stress management; 4) transition
and adjustment; 5) emotions; 6) self-talk; 7) communication
and energy management; 8) pain management; 9) happiness
and hope; and 10) community resources. The domains of
focus across topics are self-esteem, self-efficacy, mood, and
coping styles and behaviour. Each session provides each
participant an opportunity to share and seek feedback on their
goal. A variety of techniques are used to facilitate discussions
and accommodate different learning styles including:
education, brainstorming, audiovisual devices, creative art,
small and large group activities, and experiential learning. In
addition, a community outing is organized to allow participants
to practice learned concepts in a “real-world” setting. A
teaching manual is provided, which includes take home
assignments.
Results: Although program evaluation is on-going, preliminary
reports by participants have been positive regarding the
service. As such, the CROP service may provide persons
with SCI the skills and knowledge needed to live more active
and fulfilling lifestyles post-injury. Noted challenges included
managing individual differences within the group, time
management, and sustainability due to lack of resources.
Overall, the described CROP Service provides a model that
can be adapted by rehabilitation professionals at different
settings to help persons with SCI better manage emotional,
environmental, and social stressors that challenge community
participation.
References: 1. Boschen KA, Tonack M, Gargaro J. Long-term
adjustment and community reintegration following spinal cord
injury. Int J Rehabil Res 2003;26:157-64.
P1-09
The Case for Transvenous Phrenic
Nerve Pacing After a High-Level
Spinal Cord Injury
A. Hoffer1, L. Tindale1, C. Francis1, R. Meyyappan1, R.
Sandoval1, B. Afram1, S. Reynolds2
1
, Simon Fraser University, Burnaby/BC/CANADA, 2, Royal
Columbian Hospital, New Westminster/BC/CANADA
Background: High-level spinal cord injuries often affect
the control of breathing because the diaphragm, the main
muscle of inspiration, is innervated by the phrenic nerves that
originate from C3-C5.
In 50-67% of all acute SCI patients, life is sustained with
mechanical ventilation (MV) in intensive care units (ICU).
However, MV dependence is known to be associated with
acute pulmonary complications such as pressure-induced
lung injury, ventilator-acquired pneumonia and nosocomial
infections.
Recent research indicates that MV and sedation cause rapid,
profound disuse atrophy of the diaphragm, with all muscle
fibers typically shrinking >50% in the first 3 days (Levine
2008). Diaphragm atrophy is likely to contribute to the high
weaning failure rate in ventilator-dependent ICU patients.
Furthermore, incomplete SCI patients may have salvageable
diaphragmatic muscle fibers which initially atrophy while on
MV and may never have the opportunity to regain sufficient
strength to breathe independently.
Methods: We are developing an intravenous catheter electrode
system and method to transvenously activate the phrenic
nerves in critically ill patients who depend on MV, with the dual
objective of
1) reducing or preventing diaphragm atrophy and
2) greatly reducing the injurious positive pressure that
mechanical ventilation inflicts on the lungs, by rhythmically
producing negative inspiratory pressure through diaphragmatic
activation.
The catheter can be installed in a minimally invasive
procedure performed under local anesthesia, and easily
removed when a patient is ready to wean (Hoffer 2010).
Results: We anticipate three categories of high-level SCI
survivors who may benefit from our proposed pacing
technology.
45
First, SCI patients who did not suffer permanent neurological
damage to the diaphragm control system but required MV for
several days, may be able to wean sooner from MV if risks of
ventilator-associated lung injuries are reduced and diaphragm
strength and endurance are preserved by pacing during the
acute inflammatory phase.
Second, a larger percentage of incomplete SCI survivors
may be able to regain voluntary control of breathing if those
diaphragm muscle fibers that remain connected can be
protected from undergoing rapid atrophy by pacing them
during the acute phase.
Third, for SCI survivors with irreversible neurological damage
who require permanent breathing assistance, an implantable
version of our transvascular pacing system may provide more
natural, negative-pressure diaphragmatic breathing, similar to
surgically implanted systems (Elefteriades, 2002) but requiring
only a simple out-patient surgical installation procedure, with
no risk of damaging the fragile phrenic nerves and much
lower stimulation amplitudes than intramuscular diaphragm
electrodes.
Our proposed transvascular phrenic nerve pacing approach
is expected to benefit many persons who require breathing
assistance acutely and/or chronically after SCI, for whom no
comparable therapeutic solution is currently available.
References: Levine S et al. Rapid disuse atrophy of diaphragm
fibers in mechanically ventilated humans. N Engl J Med,
358:1327-35, 2008.
Hoffer JA et al. Diaphragm Pacing with Endovascular
Electrodes. IFESS 2010 - Int’l. Functional Electrical Stimulation
Soc., 15th Ann. Conf., Vienna, Austria, pp 40-42, 2010.
Elefteriades J et al., Long-term follow-up of pacing of the
conditioned diaphragm in quadriplegia. PACE 25:897-902,
2002.
Funded by NSERC I2I and Lungpacer Medical, Inc.
Disclosure: I am the founder of Lungpacer Medical Inc., an
SFU spin-off R&D company developing a diaphragm pacing
system.
P1-10
A Kinetic Evaluation of a Novel
Forearm Crutch with a Shock
Absorption System
M. Macgillivray, R. Manocha, B. Sawatzky
University of British Columbia, Vancouver/BC/CANADA
Background: The forearm crutch enhances control during
gait for individuals with mobility impairments (Opila 1987).
46
Forearm crutches have been used by individuals with
long-term disabilities for centuries and have been used
with increasing frequency, in recent years, for short-term
disabilities. Compared to advancements in other forms of
assistive devices, such as wheelchairs, the forearm crutch has
evolved minimally.
An innovative forearm crutch has recently entered the market.
The device includes more ergonomic handles and footpads,
as well as a shock absorption system that aims to reduce
peak forces and impulse. Such modifications are theorized to
minimize joint loading.
Methods: Thirteen able-bodied individuals (5 males and 8
females) participated in this study. Three different crutches
were compared: the SideStix™ Discovery (no shock with a
Fetterman™ footpad), the SideStix™ Ultimate (shock with
a rotating footpad) and a traditional model (the style sold in
pharmacies).
Two force plates were used to measure ground reaction
forces at the crutch footpads during the body swing phase of
swing-through gait. The force plates were sampled at 1000
Hz and data were low-pass filtered with a cut-off frequency
of 50Hz using a fourth-order Butterworth filter. Peak force
and impulse were normalized to body weight and converted
to units of percent body weight. Velocities were calculated
for each trial. Each participant’s data was averaged across
the 5 trials. Statistics were performed on the averaged data
from all 13 able-bodied participants. A repeated measures
ANOVA was used to determine differences between crutch
types. Data from the left and right sides were combined for
statistics involving peak force, impulse and time spent in the
body swing-through phase. Bonferroni pairwise comparisons
were used to determine which conditions were different when
crutch type was significant.
Results: Peak Force: There was a significant difference in
peak values for braking and propulsive forces between crutch
types (F=13.240, p<0.001). The Ultimate crutch demonstrated
a significantly smaller peak braking force compared to the
Discovery model (p=0.009) and the Traditional model (p=0.001)
according to a Bonferonni pairwise comparison. The Ultimate
crutch demonstrated significantly greater propulsive force
than the Discovery model (p=0.008) and the Traditional model
(p<0.001) according to a Bonferonni pairwise comparison.
There were no differences in either peak vertical force
between the three crutch types (F=2.804, p=0.07) or in peak
medial-lateral force between the three crutch types (F=0.027,
p=0.973).
Impulse: There was a significant difference in vertical impulse
between crutch types (F=5.724, p=0.006). The Ultimate crutch
had a significantly smaller impulse compared to the Traditional
model according to a Bonferonni pairwise comparison
(p=0.013). There was no difference in medial-lateral impulse
between the three crutch types (F=1.530, p=0.058).
Implementing a shock absorption system may provide some
benefit to a forearm crutch user. Our study revealed a 17%
relative reduction in peak braking force, a 7% increase in peak
propulsive force, and a 3% decrease in vertical impulse for the
Ultimate crutch (containing a shock system), compared to a
typical drugstore model.
References: Opila KA, Nicol AC, Paul JP. Forces and impulses
during aided gait. Arch Phys Med Rehabil. 1987;68(10):715–
722.
Disclosure: I received funding through MITACS for this
research internship. The partner organization was SideStix who
provided 1/4 of the funding and MITACS provided 1/2. The
funding was reviewed and administered through the MITACS
Accelerate student program.
P1-11
Creating the Winning Conditions
to Ensure Sustainable BestPractice Implementation—The Irglm
Experience
V. Tam1, C. Joly1, M. Laramée1, . SCI KMN2
1
, Institut de Réadaptation Gingras-Lindsay-de-Montréal,
Montréal/CANADA, 2, SCI KMN, Toronto/ON/CANADA
Background: Continuous Quality Improvement (CQI) is
essential for sustaining the adoption of best practices in
spinal cord injury (SCI) rehabilitation. An evidence-informed
implementation science (IS) framework provides the structure
to ensure the continued accuracy (eg. fidelity) of improved
practices in the ever-changing real world clinical environment.
Through the funding partnership of the Ontario Neurotrauma
Foundation (ONF), the Rick Hansen Institute (RHI), and the
Alberta Paraplegic Foundation (APF), six SCI rehabilitation
centres of excellence across Canada (in three provinces,
Quebec, Ontario and Alberta) have engaged in a Community
of Practice (CoP) that is focused on implementing best
practices in up to three key areas (pressure ulcer prevention,
bladder management and pain management). Methodological
support of the evidence-informed IS process, is facilitated
by the expertise of the National Implementation Research
Network (NIRN) of the University of North Carolina. The
CoP engaged in a Delphi consensus exercise to select two
“best practices” (BP) and associated performance measures
(PM) in the prevention and management of pressure ulcers
-- risk assessment and patient education. This presentation
will describe the organizational transformation experience at
IRGLM that includes activities to create a state of readiness
for change, and replication and expansion of the best practice
implementation (BPI) process into other clinical areas.
Methods: Two BPs for the prevention and management of
pressure ulcers and associated PMs were agreed upon using
a Delphi process that engaged all CoP participants. Based on
an IS conceptual framework with guidance from NIRN, a Site
Implementation Team (SIT) led by a Transformation Specialist
(TS) was assembled to analyse the organizational context and
prepare a state of “organizational readiness” for BPI. Despite
competing organizational priorities (including a merger-inprogress), commitment at all levels of the organization resulted
in very active contribution to the BPI CoP. In addition, the TS/
SIT model was replicated and transposed to other clinical
programs in the organization.
Results: The TS/SIT model led to the development of a work
plan and a site-specific implementation roadmap. This process
was replicated with success and a BPI structure now exists in
all clinical programs at the IRGLM.
References: Fixsen, D. L., Naoom, S. F., Blase, K. A.,
Friedman, R. M., & Wallace, F. (2005). Implementation
research: A synthesis of the literature. Tampa, FL: University of
South Florida, Louis de la Parte Florida Mental Health Institute,
The National Implementation Research Network. Duda, M.,
Brown, J. (2011). Important Implementation Reference Slides.
National Implementation Research Network. University of
North Carolina-Chapel Hill.
P1-12
The Effects of Pharmacological
Agents on Walking in People with
Spinal Cord Injury: A Systematic
Review
A. Domingo1, A. Al-Yahya2, Y. Asiri2, J. Eng1, T. Lam1
, University of British Columbia, Vancouver/BC/CANADA, 2,
King Saud University, Riyadh/SAUDI ARABIA
1
Background: The recovery of walking is an important goal
for people with motor-incomplete spinal cord injury (SCI)
[1]. Increasing mobility after spinal cord injury can positively
impact participation and quality of life, as well as improve
cardiovascular health, muscle composition and metabolism,
bone health, and psychological well-being [2]. Studies on
spinalized animals indicate that some pharmacological
agents may act on receptors in the spinal cord, helping to
produce coordinated locomotor movement. Other drugs may
help to ameliorate neuropathological changes resulting from
spinal cord injury (SCI), such as spasticity or demyelination,
to improve walking. The purpose of this study was to
systematically review the effects of pharmacological agents on
gait in people with SCI.
Methods: A keyword literature search of articles that evaluated
effects of drugs on walking after SCI was performed using the
databases MEDLINE/PubMed, CINAHL, EMBASE, PsycINFO
and hand searching. Two reviewers evaluated each study,
using the Physiotherapy Evidence Database (PEDro) tool for
47
randomized clinical trials (RCT), and the modified Downs &
Black scale for other studies. Levels of Evidence were also
assigned.
Results: Eleven studies met the inclusion criteria. The
median PEDro score for RCTs was 7 out of 10, and the
median Downs & Black score for non-RCTs studies was 12
out of 28. One RCT provided Level 1 evidence that GM-1
ganglioside combined with physical therapy improved motor
scores, walking velocity and distance better than placebo and
physical therapy in persons with incomplete SCI. Multiple
studies (Levels of Evidence 1-5) showed that Clonidine and
Cyproheptadine may improve locomotor function and walking
speed in severely impaired individuals with incomplete SCI.
Gains in walking speed associated with GM-1, Cyproheptadine,
and Clonidine are low compared to those seen with locomotor
training. There was also Level 1 evidence that 4-aminopyridine
and L-Dopa were no better than placebo in helping to improve
gait. Two Level 5 studies showed that Baclofen had little to no
effect on improving walking in persons with incomplete SCI.
The lower levels of evidence and the small effects of the drugs
on walking were in part related to methodological limitations
of the reviewed studies. Across studies, the chronicity, level
and severity of injury, age, dose and frequency of medications,
and outcome measures varied greatly. Most studies also did
not take into consideration drug interactions or organ system
health of the subjects. Although there is limited evidence so far
that pharmacological agents would facilitate walking recovery
after SCI, more work should be done that takes these factors
into account. In addition, more studies are needed to better
understand the effects of drugs combined with other therapies
(e.g., gait training and electrical stimulation) on walking
outcomes in people with SCI.
References: 1. Ditunno, P., et al., Who wants to walk?
Preferences for recovery after SCI: a longitudinal and crosssectional study. Spinal Cord, 2008. 46(7): p.500-6. 2. Hicks,
A. and K.A. Ginis, Treadmill training after spinal cord injury: it’s
not just about the walking. Journal of rehabilitation research
and development, 2008. 45(2): p 241-8.
P1-13
UTI’s and Intermittent
Catheterization, What Does the
Evidence Say?
T. Hill1, R. Parmar2
1
, CPA Alberta, Calgary/CANADA, 2, Canadian Paraplegic
Association (Alberta), Calgary/AB/CANADA
Background: Bladder dysfunction (neurogenic bladder)
resulting in symptoms of urgency, day and night-time
frequency, urinary retention, incontinence and urinary tract
infections (UTI) is pervasive issue in spinal cord injury
(SCI). UTI has substantial negative psychological effects on
48
individuals and is a major burden on the health care system.
Treatment involves non-invasive continence management
through toileting, fluid management, containment products,
medications, and intermittent catheterization. The purpose of
this review of clinical guidelines and best practice literature
is to suggest a treatment approach for UTI in the neurogenic
bladder for those who are using intermittent catheterization as
the primary method of bladder emptying.
Methods: Three methods were used to create these
educational materials and translate the research evidence into
a form useable by consumers and their primary caregivers.
First a review of the scientific literature,secondly a working
group of consumers and experts formulated the evidence into
a UTI prevention brochure and a UTI treatment brochure and
supporting background documentation. Thirdly the brochures
and the in-depth supporting material was circulated within the
expert clinical community where feedback was provided and a
consensus was built.
Results: Two evidence based pamphlets were developed
entitled “Bladder Health For intermittent catheterization users”
and Treating Frequent Bladder Infections For intermittent
catheterization users”. The supporting evidence resides in a
peer reviewed paper entitled “Best practices for the treatment
and prevention of UTI in the spinal cord injured population
The Alberta Context”.
References: 1 De Ridder DJMK, Everaert K, Garcia Fernandez
L, et al. “Intermittent catheterisation with hydrophilic-coated
catheters (Speedicath) reduces the risk of clinical urinary
tract infection in spinal cord injured patients: a prospective
randomised parallel comparative trial.” European Urology,
August 2005 2005;Article in Press. 2 Cain M, King S, Rink R.
“Managing Recalcitrant Urinary Tract Infections in Patients
with Bladder Augmentation.” US Pediatrics, 2008: 41, 42. 3
Spinal Cord Injury Rehabilitation Evidence (SCIRE). Bladder
Health and Function Following Spinal Cord Injury Version 3.0.
Vancouver: SCIRE, 2010, 133. 4 Hooton TM, Bradley SF,
Cardenas DD, et al. “Diagnosis, prevention, and treatment of
catheter-associated urinary tract infection in adults.” 2009
International Clinical Practice Guidelines from the Infectious
Diseases Society of America. Vol. 50. Clin Infect Dis, 2010.
625-63. 5 Moore K, Fader M, Getliffe K. “Long-term bladder
management by intermittent catheterisation in adults and
children” 2009 The Cochrane Collaboration. Published by
John Wiley & Sons, Ltd. 6 Cardenas DD, Moore KN, DannelsMcClure A, Scelza WM, Graves DE, Brooks M, Busch AK.
“Intermittent catheterization with a hydrophilic-coated
catheter delays urinary tract infections in acute spinal cord
injury: a prospective, randomized, multicenter trial.” Physical
Medicine and Rehabilitation (PM R), 2011: 3(5):408-17. 7
Consortium of Spinal Cord Medicine. Baldder Management
for Adults with Spinal Cord Injury. Clinical Practice Guideline,
Washington D.C: Paralyzed Veterans of America, 2006, 50. 8
Casey, R.G., Cullen I.M., Crotty, T., Quinlan, D.M. “intermittent
self-catheterization and the risk of squamous cell cancer of
the bladder: An emerging clinical entity?” Canadian Urological
Association Journal, 2009 3(5) E51-E54. 9 Newman, D.K.,
Willson M.M. “Review of Intermittent Catheterization and
Current Best Practices” Urologic Nursing 2011, 31(1): 12-28.
P1-14
The Osteoporosis Guidelines of the
Joint Organizations of the GermanSpeaking Bone Research Societies
and Their Meaning for Paralyzed
Elderly Patients
Y.B. Kalke , H. Reichel
1
, SCI Centre Ulm, Orthopaedic Department of the University
of Ulm, Ulm/GERMANY, 2, Orthopaedic Department of the
University of Ulm, Ulm/GERMANY
1
2
Background: In the German speaking SCI centres an
increasing number of elderly patients with spinal cord disease
or injury get admitted. A lot of these elderly patients have
osteoporosis or are even admitted because of osteoporotic
fractures with spinal cord involvement. The guidelines of the
joint organizations of the German-speaking bone research
societies should be used in this very special patient group.
Methods: The subjects of the guidelines are prevention,
diagnostic assessment and treatment of osteoporosis in postmenopausal women and in older men. For the special case
of glucocorticoid-induced osteoporosis there are separate
guidelines.
Results: Diagnostic assessment means specific medical
history, x-ray, laboratory studies and osteodensitometry with
DXA measurements of lumbar spine and femur. In the next
step measures like nutrition rich in calcium, evaluation of
osteoporosis supporting medication and if necessary further
work up of secondary causes are initiated. Depending on
vertebral fractures, gender, age, the result of the DXA T-score
and on defined risk factors pharmacological treatment
with alendronate, ibandronate, zoledronate, raloxifene,
risedronate, strontium ranelate or teriparatide together with
supplementation of calcium and vitamin D is mandatory.
These osteoporosis guidelines should be used definitely in
the SCI centres but require special knowledge for diagnostic
tools, medical therapy and secondary effects of the different
antiosteoporotic drugs.
P1-15
Evidence Based Management of
Depression Following Spinal Cord
Injury: A Meta-Analysis
S. Mehta, S. Orenczuk, R. Teasell
Lawson Health Research Institute, London/CANADA
Background: Objective: To conduct a systematic review
and meta-analysis examining the effectiveness of cognitive
behavioural therapy for the treatment of depression post SCI.
Methods: Medline, CINAHL, EMBASE and PsycINFO
databases were searched for all relevant articles published
1980 to February 2010. Studies were selected by two
reviewers and were only included for analysis if: ≥ 50% of
the subjects had a SCI and study subjects participated in a
treatment or intervention involving the treatment of depressive
symptoms. Two independent reviewers assessed studies
for inclusion criteria. Study results were pooled using a
random effects model. was used to calculate standardized
mean difference (±SE, 95% CI) for the post treatment effect
on depressive symptoms in intervention vs. control groups
for each study. Effect sizes were interpreted as: small=0.2,
moderate=0.5, large=0.8.
Results: Nine studies met inclusion criteria, of these 2
were RCTs, 6 prospective controlled trials and 1 cohort
study, with a total pooled sample size of 531. The analysis
demonstrated a significant reduction in depressive symptoms
in the treatment group compared to the control, with a pooled
SMD=0.612±0.152 (95% CI 0.314, 0.910; p=0.0001).
Assessment of depressive symptoms was conducted
primarily using the BDI and CESD tools. Clinical evaluation
of major depressive disorder was present in only 2 studies.
Hence, the effect size calculated may be over or under
inflated. Conclusion(s): There was moderate evidence for the
effectiveness of cognitive behavioural treatment to reduce
depressive symptoms following SCI. More comprehensive
clinical evaluation should be conducted in order to fully
evaluate the effect of this treatment.
References: Orenczuk S, Slivinski J, Mehta S, Teasell RW
(2010). Depression Following Spinal Cord Injury. In Eng JJ,
Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC,
Connolly SJ, Mehta S, Sakakibara BM, editors. Spinal Cord
Injury Rehabilitation Evidence. Version 3.0.
References: Zehnder Y, Risi S, Michel, D, Knecht H, Perrelet
R, Kraenzlin M, Zach GA, and Lippuner K. Prevention of
bone loss in paraplegics over 2 years with alendronate. J
Bone Miner Res, July 1, 2004: 19(7):1067-74 Bauman
WA, Kirshblum S, CirnigliaroC, Forrest GF, Spungen AM.
Underestimation of bone loss of the spine with posterioranterior dual-energy X-ray absorptiometry in patients with
spinal cord injury. J Spinal Cord Med. 2010;33(3):214-20
DVO Guideline 2009 for Prevention, Diagnosis and Therapy of
Osteoporosis in Adults. Osteologie 2011;20:55-74
49
P1-16
Using Scoping Review Methodology
to Conduct a Canadian Spinal
Cord Injury (SCI) Rehabilitation
Environmental Scan
C. Craven1, C. Balioussis2, M. Verrier2, J. Hsieh3, V. Noonan4,
A. Raschid5, D. Wolfe3, E. Cherban4
1
, Toronto Rehab, Lyndhurst Centre, Toronto/CANADA, 2,
Toronto Rehabilitation Institute-University Health Network,
Toronto/ON/CANADA, 3, Lawson Health Research Institute,
London/CANADA, 4, Rick Hansen Institute, Vancouver/
CANADA, 5, University of British Columbia, Vancouver/BC/
CANADA
Background: To date, there has not been a comprehensive
review of Canadian SCI Rehabilitation Service Provision
Methods: The Rehabilitation Environmental Scan (E-scan) is
a joint translational research project between the Invetigative
team, Rick Hansen Institute (RHI) and Canadian Tertiary
Academic SCI Rehabilitation Centers. This project informs
future service delivery and policy development by first
describing the spectrum of current clinical SCI rehabilitation
services in Canada, and analyzing the findings for trends and
gaps. The final product, the Escan Atlas, will be published in
2012. The content of the Atlas will be organized around 17
rehabilitation goals (e.g., Skin Integrity, Bladder Continence,
Mobility, etc.), each presented in a separate chapter.
The scoping review methodology employed in the Escan
enables triangulation of data from multiple sources. The
methodology was based on the York Framework developed
by Arksey and O’Malley (2005). Data were obtained from
12 tertiary rehabilitation sites across Canada, and were
supplemented and analytically interpreted by content experts
and stakeholders (researchers, practitioners, funders,
and policy makers). The Atlas will therefore provide an
overview of current Canadian patient demographics, site
administrative structure, service providers, equipment, and
services/programs, local clinical and research expertise, and
assessment tools in current use. The research will lead to
identification of trends, gaps, and parameters for change. In
addition, new research questions will be generated through the
amalgamation of information from interpolation of the E-scan
data. Key priorities, and best practices in spotlight institutions
will be identified. Data elements will be charted, collated,
summarized and validated through consultation with content
experts and stakeholders to ensure relevance to current
Canadian SCI rehabilitation practices. Each Atlas chapter will
feature a “Report Card” that will provide priority ratings in each
of three domains: Knowledge Generation, Clinical Application,
and Policy Change. Ratings will specify where efforts and
resources should be directed so that rehabilitation practice
can evolve effectively and efficiently by the year 2020.
Results: The scoping review methodology used in the E-scan
50
will initiate critical re-evaluation of current SCI rehabilitation
practices, thus enabling health care professionals and
stakeholders to advance the field thereby enhancing outcomes
for the patients we serve.
References: Levac D, Colquhoun H, O’Brien KK Scoping studies:
advancing the methodology. Implement Sci. 2010 Sep 20;5:69
P1-17
My Life, My Health: Chronic Disease
Self-Management Program in
Rehabilitation
A. Kras-Dupuis1, T. Jeji2
1
, st.joseph’s health care london, London/ON/CANADA, 2,
Ontario Neurotrauma Foundation, Toronto/ON/CANADA
Background: Background In 2009 the Rehabilitation
Program at St. Joseph’s Health Care Parkwood Hospital,
with support from the Ontario Neurotrauma Foundation,
engaged in establishing a “My Life, My Health” patient
self-management program based on the Stanford Chronic
Disease Self Management (CDSM) model. Our rehabilitation
program delivers service to patients with stroke, spinal
cord injury, acquired brain injury, amputation and other
neurological conditions. We believed that self-management
skills were valuable for people with a spinal cord injury
and other similar neurological conditions. We felt that an
intervention like the CDSMP could be an effective adjunct
to existing patient education and rehabilitation and support
patients in taking a more effective, proactive role in better
managing the day-to-day challenges of living with a
permanent health condition. The major goal of the CDSM
model is to empower individuals by increasing their efficacy
to take charge and responsibility to manage their health
conditions. This process involves the systematic provision
of education, to increase individual’s skills and confidence
in managing their health and life habits through regular
assessment, goal setting, and problem-solving support. Selfmanagement support takes the form of validated evidencebased behaviour change, by developing a personalized,
collaborative action plan with specific behavioural goals and
tactics for overcoming the barriers to achieve the desired
goals. We hypothesized that the CDSM intervention would
assist individuals with chronic disability to take responsibility
to manage their health and life activities
Methods: Methods We designed and delivered the program
based on the original CDSMP with respect to the content
and process. CDSMP is a six week once a week 21/2
hour program delivered in a group setting. We ensured
that the workshop is tailored for maximum accessibility
in every respect (time of the day, location, environment,
support). We tested the CDSM intervention from these
perspectives: · effectiveness across the continuum: from
rehabilitation inpatients/recent injuries through outpatients
in the community · logistical issues: location (accessibility),
scheduling, transportation, contacting participants ·
customization: branding, language/translation, charts,
handouts, incentives, evaluation
Results: The “My life, My health” program was designed and
delivered as a 6-week series of free interactive workshops
facilitated by trained leaders. Over the two year period (20092011) seven workshop series were held at our center. Our
evaluation revealed positive impact on those individuals
who attended these workshops. We would like to share
our experience including: · Workshop participation data ·
Marketing and recruitment strategies · Facilitation and Leader
Training · Evaluation strategies and results · Partnerships with
other agencies The “My Life, My Health” program has been
featured in several publications. We will share our next steps
and plans for sustainability.
References: Lorig, K. et al. Effect of a Self-Management
Program on Patients with Chronic Disease. Effective Clinical
Practice 2001; 4:256-262 Lorig, K. et al. Living a Healthy
Life with Chronic Conditions. For Ongoing Physical and
Mental Health Conditions. 2010 Canadian Edition: 3d edition
Revised and Updated. Hirsche, R. et al. Chronic Disease Selfmanagement for Individuals with Stroke, Multiple Sclerosis
and Spinal Cord Injury. Disability and Rehabilitation 2011;
33:1136-1146
Results:
•
SCI Best-Practice Review using a Delphi Approach
– Consumers, clinicians, researchers and decisionmakers participated in an online Delphi consensus
panel and identified priority areas for translation into
clinical practice including 1) skin care; 2) primary care;
and 3) pain management. Potential strategies, barriers
and facilitators for implementation were also identified.
•
Case-Based Continuing Medical Education Modules – A
number of case-based modules have been developed
to facilitate continuing medical education of health care
professionals across a variety of disciplines and settings.
•
SCI Outcome Measures Toolkit – An online Delphi
consensus panel involving a variety of stakeholders
identified the key outcome measurement tools for SCI
rehabilitation which would be pragmatic and relevant to
clinicians and researchers alike.
Conclusion: SCIRE (www.scireproject.com), even though
relatively new, has enabled the development of specific
initiatives designed to facilitate adoption of better clinical
practice in SCI rehabilitation. Development of other initiatives
that promote best practice among using SCIRE as a platform
will result in improved outcomes for individuals with SCI.
References: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson
AF, Hsieh JTC, Connolly SJ, Mehta S, Sakakibara BM, editors.
Spinal Cord Injury Rehabilitation Evidence. Version 3.0.
P1-18
Scire 3.0: A Platform for Developing
Initiatives to Enhance Practice
S. Mehta1, D. Wolfe1, J. Eng2, R. Teasell1, W. Miller2, A.
Townson2, J. Hsieh1, B.M. Sakakibara3, S. Connolly1
1
, Lawson Health Research Institute, London/CANADA,
2
, University of British Columbia, Vancouver/CANADA, 3,
University of British Columbia - GF Strong Rehabilitation
Research Lab, Vancouver/BC/CANADA
Background: Purpose and Relevance: To illustrate the utility
of the Spinal Cord Injury Rehabilitation Evidence (SCIRE)
systematic review as a platform to enable best practice
adoption by describing 3 SCIRE-based knowledge mobilization
projects.
Methods: Abstract Overview: SCIRE, recently updated (Version
3.0), is a systematic review of SCI rehabilitation evidence
incorporating over 1000 studies (including > 200 RCTs).
Bottom line evidence-based statements have been created
for interventions across 23 topic areas to facilitate knowledge
mobilization by clinicians. Three initial initiatives based on
SCIRE include:
P1-19
Gabapentinoids are Effective in
Decreasing Neuropathic Pain
Intensity post SCI: A Meta-Analysis
S. Mehta1, A. Mcintyre1, K. Salter1, C. Short2, K. Cheung1, J.
Hsieh1, D. Wolfe1, R. Teasell1
1
, Lawson Health Research Institute, London/CANADA, 2,
Dalhousie University, Halifax/CANADA
Background: Purpose: This meta-analysis examines the
effectiveness of gabapentinoids (gabapentin and pregabalin)
in improving neuropathic pain in individuals with spinal
cord injury (SCI). Relevance: Pain has a negative impact on
quality of life in an individual with SCI quality of life. Hence,
it’s important to determine effective treatment as a part of
evidence based practice.
Methods: Methods: A systematic search was conducted
using Medline, CINAHL, EMBASE and PsycINFO databases
for all relevant articles published 1980 to March 2010.
Randomized controlled trials (RCTs) involving gabapentinoids
in the treatment of neuropathic pain post SCI, with at least 3
individuals with SCI and ≥ 50% of study population with SCI.
51
Two independent reviewers assessed study quality using the
PEDro assessment scale. Study results were pooled using a
random effects model. was used to calculate standardized
mean difference (±SE, 95% CI) for the post treatment effect
on pain intensity assessed in intervention vs. control groups
for each study. Effect sizes are commonly interpreted as:
small=0.2, moderate=0.5, large=0.8.
Results: Results: 5 RCTs (3 crossover and 2 parallel study
designs) met inclusion criteria providing a total pooled
sample size of 226 individuals. Pooled analysis demonstrated
a significant reduction in the intensity of neuropathic
pain associated with gabapentinoid treatment compared
to placebo. The pooled SMD was 0.797±0.114 (95% CI
0.574,1.02; p=0.0001). Funnel plot analysis revealed no
significant publication bias (Egger’s regression intercept=x;
p=0.67).
References: Teasell RW, Mehta S, Aubut J, Foulon BL, Wolfe
DL, Hsieh JTC, Townson AF, Short C (2010). Pain Following
Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL,
Townson AF, Hsieh JTC, Connolly SJ, Mehta S, Sakakibara
BM, editors. Spinal Cord Injury Rehabilitation Evidence.
Version 3.0.
sizes were interpreted as: small=0.2, moderate=0.5, or
large=0.8.
Results: Eleven studies, (5 controlled, 6 uncontrolled)
representing data from 484 subjects were included. Post BTX
A injection, large treatment effects were observed in post-void
residual urine volume, reflex volume, bladder capacity, bladder
compliance, and catheterization frequency (p<0.0001). Rate
of incontinence episodes was reduced from 23% to 1.31%
post BTX-A treatment. No significant improvement in max flow
rate was observed (p=0.403). Conclusion: Results of the metaanalysis indicate BTX-A is effective in treating bladder filling
dysfunction post SCI. The use of BTX-A was associated with a
decrease in incontinence episodes, catheter use and bladder
pressures.
References: Wolfe DL, Ethans K, Hill D, Hsieh JTC, Mehta S,
Teasell RW, Askes H (2010). Bladder Health and Function
Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller
WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Mehta
S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation
Evidence. Version 3.0. Vancouver: p 1-19.
P1-21
P1-20
Effectiveness of Botulinum Toxin
in Treating Neurogenic Detrusor
Overactivity post SCI: A Systematic
Review and Meta-Analysis
S. Mehta1, D. Hill2, A. Mcintyre1, N. Foley1, D. Wolfe1, J.
Hsieh1, K. Ethans3, E. Loh1, R. Teasell1
1
, Lawson Health Research Institute, London/CANADA, 2,
Foothills Hospital, Calgary/CANADA, 3, University of Manitoba,
Winnipeg/CANADA
Background: To examine the effectiveness of botulinum toxin
(BTX) on neurogenic detrusor overactivity in individuals with
spinal cord injury (SCI).
Methods: Medline, CINAHL, EMBASE and PsycINFO
databases were searched for all relevant articles published
from 1980 to October 2011. Ttrials examining the use of
BTX-A injections into the detrusor wall in treatment of bladder
filling post SCI were included if ≥ 50% of study sample was
comprised of subjects post SCI, outcomes of interest were
assessed before and after treatment with a single injection
of BTX and if the sample size was ≥3. A standardized mean
difference (SMD) ± standard error (95% confidence interval,
CI) was calculated for at least one of the following outcomes
in every study: post-void residual urine volume, reflex volume,
bladder capacity, bladder compliance, catheterization
frequency, and max flow rate. Results from all studies were
then pooled using a random effects model. Treatment effect
52
Leveling the Playing Field - Making
Sci Primary Care Accessible
C. Mcmillan1, J. Lee1, J. Milligan1, T. Jeji2
1
, Centre for Family Medicine, Kitchener/ON/CANADA, 2,
Ontario Neurotrauma Foundation, Toronto/ON/CANADA
Background: Family Health Teams are positioned to make
significant inroads in how primary care responds to individuals
and their families with spinal cord injuries. Primary care
delivered by a Family Health Team is the diagnosis, treatment
and management of health problems by a inter disciplinary
team of physician, nurse, social worker, pharmacist and
occupational therapist. Access to these professionals is critical
for the timely management of common secondary medical
complications of SCI such as urinary tract infections, pressure
sores and respiratory infections and to reduce unnecessary
emergency room visits and acute care hospitalization (Jeji,
2010). However, this population has been traditionally
marginalized by mainstream primary health care and routinely
encounter substandard care due to accessibility issues,
provider attitudinal barriers, lack of knowledge and training
(Kroll, Beatty, Bingham, 2003).The absence of special
equipment within physicians’ offices to accommodate SCI
patients restricts the degree in which preventative services
occur (Wolf-Branigin & LeRoy, 2004). Imaging equipment,
adjustable exam tables, space clearances to accommodate
wheelchairs and other accessibility concerns result in a
diminished standard of care (Kaplan, 2006). Augmenting the
structural challenges, many primary physicians are unlikely
or even hesitant to have an SCI patient on their caseload,
resulting in being unknowledgeable about SCI issues (Kaplan,
2006). The combination of objective (equipment) and
subjective (knowledge & attitudinal) barriers has led to many
patients accessing primary care in the emergency room.
Methods: The Ontario Neurotrauma Foundation responded
by initiating a number of projects that look at the delivery
of services to those with a physical disability. The Centre of
Family Medicine in Kitchener, Ontario was chosen based
upon the establishment of a Mobility Clinic. Guided by a
best practice model, the Clinic opened in 2010 staffed by
an interdisciplinary team; physician, chiropractor, nurse,
social worker and occupational therapist. A fully accessible
clinic (hi-lo exam table, hoyer lift, wheelchair scale) allows
many SCI patients the experience of receiving preventative
health care for the first time. Knowledge barriers were
addressed by upgrading skills through workshops and
establishing an external mentoring relationship with
a physiatrist. Attitudinal barriers are challenged by
incorporating learners (family medicine residents, social
work, nursing students) into the clinic. ONF also supported
endeavours to make consumers their own advocates to
ensure that as provider services improve, the ability of
consumers to access and manage care will also improve.
This endeavour took the form of a consumer driven advisory
committee in addition to the Spinal Cord Injury Toolkit, a
paper and electronic template that is part of the patient
record and is done collaborately with the primary care
physician. The Mobility Clinic at the Centre for Family
Medicine represents a best practice model on several
levels: partnering with external funding and knowledge
experts, redefining clinical standards for SCI patients,
fostering patient collaboration and piloting innovative
methods to build capacity and offering preventative health
care. The Mobility Clinic has made basic health care more
equitable and accessible to individuals and families living
with spinal cord injuries and other disabilities.
Results: Ontario Neurotrauma Foundation, Toronto.
P1-22
Factors Influencing Return to
Community Living of Persons with
SCI and their Family Members : For
an Ecosystemic Perspective
L. Beauregard , A. Guindon , L. Noreau , N. Boucher , H.
Lefebvre3
1
, IRDPQ-CIRRIS, Québec/CANADA, 2, Centre for
interdisciplinary research in rehabilitation and social
integration (CIRRIS), Quebec/CANADA, 3, Universite de
Montreal, Montreal/CANADA
1
1
2
1
Background: Returning to the community after intensive
functional rehabilitation can be a challenge for people
who sustained a traumatic spinal cord injury (SCI) and for
their family members (1-4). In order to develop a better
understanding of this important phase of re-integration to
society, a prospective research study was conducted to assess
the factors that affect community living.
Methods: Semi-structured interviews were carried out with
persons with SCI (n=35) and one of their family member
(n=21), between 3 and 12 months post-rehabilitation (Time
1). Participants were met once again, a year after the first
interview (Time 2) to determine whether or not their situation
had changed. Interviews were recorded and transcribed for
content analysis.
Results: Through the content analysis, main concerns
expressed by the persons with SCI and their family members
were identified. People with SCI discussed themes such as
adapting to their new situation, organizing personal care,
driving and transportation, participating in leisure activities,
etc. In total, 17 themes were identified. Family members
talked about their relations to the person with SCI, feelings
of overload, searching for information, etc. Nine themes
were identified. For each of these themes, obstacles or
facilitating elements were classified as pertaining to personal
or environmental factors. This classification allowed to identify
7 main factors that influence the experience of returning to the
community: 1) personal resources; 2) relationship between
the person with SCI and the family member; 3) injury severity
and secondary conditions; 4) cause of accident; 5) informal
and 6) formal social support (services); and 7) architectural
accessibility. For each of these factors, interventional targets
and recommendations are proposed to enhance successful
return to the community. These recommendations focus on
all levels of intervention: micro-systems (ex. emotional and
psychological support); meso-systems (ex. support from
services and social support); macro-systems (ex. laws and
regulations, raising awareness). The study emphasizes the
importance of having an ecosystemic perspective in order to
better understand the impacts interventions can have on the
person and their family members in the phase of community
reintegration. For a successful return to the community,
interventions must focus on the individuals as well as on the
immediate environment and society in general.
References:
· Anzai, K., et al., Factors influencing discharge location
following high lesion spinal cord injury rehabilitation in British
Colombia, Canada. Spinal Cord, 2006. 44: p. 11-18.
· Boschen KA, et al., Community Reintegration Following
Spinal Cord Injury., in Spinal Cord Injury Rehabilitation
Evidence. Version 2.0. , Eng JJ, et al., Editors. 2008:
Vancouver. p. 4.1-4.73.
53
· Charlifue, S. and K. Gerhart, Community integration in spinal
cord injury of long duration. NeuroRehabilitation, 2004. 19(2):
p. 91-101
· Lysack, C., et al., Environmental factors and their role in
community integration after spinal cord injury. Canadian
Journal of Occupational Therapy, 2007. 74(Special Issue): p.
243-254.
P1-23
The Effects of the “Discovering the
Power in Me” Program in Spinal
Cord Injury
A. Townson1, A. Chan1, K. Boschen2, C. Mcinnes1,
B. Williams1, , University of British Columbia, Vancouver/
CANADA, 2, University of Toronto, Toronto/ON/CANADA
Background: “Discovering the Power in Me” (DPM) is a 12unit clinical intervention developed by the Pacific Institute
to improve the self-efficacy and self-esteem of individuals
living with spinal cord injuries (SCI). It is based on cognitive
psychology and social learning theory, which focusses on
awareness of one’s thought processes in order to attain
success in one’s life. Specifically, the central principle is that
self-efficacy is the basis of well-being, human motivation, and
accomplishments; one’s belief in his own efficacy is central in
his ability to manage his functioning and use his physical and
cognitive capabilities.(1) Such efficacy is influenced by one’s
self-esteem, which is defined by the relationship between
one’s positive and negative affect. Perceived self-efficacy
corresponds accordingly with this affect, whereby a positive
affect leads to an increased perceived self-efficacy and a
negative affect leads to a decreased perceived self-efficacy.
(2,3) Ultimately, the balance in one’s affect, and thus selfesteem, impacts the quality of one’s psychosocial functioning.
(4)
Methods: The DPM program was separately implemented and
evaluated in two small pilot studies (n=19 in Vancouver and
n=7 in Toronto). In Vancouver, individuals with SCI participated
over two days, with pre-test, post-test, and 6-month follow-up.
In Toronto, individuals with either SCI or acquired brain injury
(ABI) but not both, participated in the program over three
days and were followed again after 3 months in the pre-test,
post-test, follow-up design. The Rosenberg Self-Esteem Scale
(RSES) and the Life Satisfaction Questionnaire (LISAT-11) were
used at both sites as measures of self-esteem and quality of
life. The results from these independent sites were compared.
Results: There were no statistically significant changes in the
outcome measures in Vancouver, and the small number of
participants in Toronto allowed for only a multiple n=1 design.
However, an upward trend was seen on the RSES from both
DPM sites, whereas minimal change was seen in the LISAT-11.
54
The mean change score trend in Vancouver for the RSES
went from 27.6 to 34.5 to 33.9 from pre-workshop, to postworkshop, to 6 months post-workshop. In Toronto, individuals
showed a peak RSES score immediately following the program
completion, with corresponding 3 month follow-up values
that either fell back to or remained elevated above baseline.
Although the number of evaluation participants was not large
and the research designs of the two individual studies differed
somewhat, upward trends in self-esteem were determined
from the similarly presented DPM programs.
References: (1) Benight CC, Bandura A. Social cognitive
theory of posttraumatic recovery: the role of perceived selfefficacy. Behav Res Ther 2004 Oct;42(10):1129-1148.
(2) Rosenberg M. Society and the adolescent self-image (rev.
ed.). Middletown, CT England: Wesleyan University Press;
1989.
(3) Kavanagh DJ, Bower GH. Mood and self-efficacy: Impact
of joy and sadness on perceived capabilities. Cognitive
Therapy and Research 1985;9(5):507-525.
(4) Bandura A, Caprara GV, Barbaranelli C, Gerbino M,
Pastorelli C. Role of Affective Self-Regulatory Efficacy
in Diverse Spheres of Psychosocial Functioning. Child
Development 2003 00/00;74(3):769-82.
Disclosure: Mr. Blake Williams is an unpaid consultant who
provided the original design and development assistance for
the DPM program to the Pacific Institute. He helped arrange
the donation of curriculum materials from the Pacific Institute.
P2-01
Icd-10 Coding Accuracy for Spinal
Cord Injured Patients
K. Tung, J. Shin, A. Kim, H. Ahn
St. Michaels Hospital, Toronto/CANADA
Background: Administrative databases such as the Canadian
Institute of Health Information Discharge Abstract Database
(DAD) are frequently used in health services research to
assess regional variations in care and to assess morbidity
and mortality of treatment. The purpose of this study was
to determine the accuracy of diagnostic coding for surgical
cases of spinal cord injury using ICD-10-CA codes in an
administrative database, along with an optimal search strategy.
Methods: All 1110 spinal surgery cases performed at St
Michael’s Hospital during June, 2006 - June, 2008, an urban
level 1 trauma center, were identified through a surgical
registry database. Diagnosis obtained via health record review
was used as the gold standard. We calculated for sensitivity,
specificity, positive likelihood ratio, and positive predictive
value of CIHI-DAD coding compared with the health record.
Results: Of the 1110 spinal surgery cases, 82 cases were
for acute traumatic spinal cord injuries. Fifteen different
diagnostic codes for acute traumatic spinal cord injury were
used. Combining all 15 codes using a Boolean “OR” function,
sensitivity was determined to be 47.6%, specificity was 99.4%,
positive predictive value was 86.6%, and positive likelihood
ratio was 79.33. In contrast, within this same cohort of surgical
cases, coding for myelopathy (cervical and thoracic) had a
higher sensitivity of 81.6%. Interpretation Ascertainment of
surgical cases of acute traumatic spinal cord injured patients
from administrative databases using only ICD-10 diagnostic
codes is poor. A potential source of error occurs due to missed
coding of the cord injury in polytrauma patients with numerous
injuries (many times over fifteen diagnoses in the clinical
records). In contrast, surgical cases involving myelopathy, with
typically a single diagnosis in the surgical records, are coded
with significantly improved sensitivity compared to coding for
acute spinal cord injured patients.
international developments which, when taken together,
suggest that there is a unique opportunity to be global leaders
in clinical research registry development in spinal cord injury.
Briefly, these developments are
•
the international spinal community has established
the domains of disability in spinal cord injury and has
expressed these in a manner consistent with the World
Health Organization International Classification of
Function (the Core Sets).
•
the Australian Spinal Cord Injury Register, a
comprehensive registry of spinal cord injury across
Australia could be readily extended to the Core Sets
•
the Rick Hansen Foundation is an international spinal
charity that supports the established Canadian registry.
The Core Sets are a mechanism for international
collaboration and data aggregation.
•
a body of software engineering systems encompassed
through eResearch now exists that will directly support
this bid.
References: None available
P2-02
Development of an Integrated,
Distributed Clinical Research
Database for Spinal Cord Injury
D.J. Berlowitz1, D.J. Brown2, P. Cameron3, M. Graco1, R. Sinnott4
1
, Institute for Breathing and Sleep, Melbourne/VIC/AUSTRALIA,
2
, Victorian Spinal Cord Service, Melbourne/VIC/AUSTRALIA,
3
, Department of Epidemiology and Preventative Medicine,
Melbourne/VIC/AUSTRALIA, 4, eResearch, Melbourne/VIC/
AUSTRALIA
Background: Spinal cord injury is a catastrophic injury that
predominantly affects young men, most of whom then live
for a further 50 years with substantial disability. Although
thankfully the injury is relatively uncommon, the lifetime care
costs are staggering. In 2010, Access Economics estimated
the cost of spinal cord injury in Australia to be $2.0 billion
annually, $5million per case of paraplegia (lifetime) and
almost double that ($9.5 million) for quadriplegia. In fields
of research such as spinal cord injury, where the number of
patients is low, but the personal and societal impact is high,
it is increasingly clear that integrated clinical research data
are vital to enable discovery, facilitate investigation and to
test treatments. So-called deep phenotyping of individuals
with rare disorders is imperative to maximise opportunities
for meaningful health economic evaluations, bio-bank linkage
and to fulfil the promise of individualised medicine offered
by the –omics revolution. This proposal will build such a
resource.
Methods: We will develop an integrated clinical research
registry for traumatic spinal cord injury and the process of
registry data collection will be embedded into routine clinical
care. We will build on a number of recent local, national and
Results: The primary data we require to measure the effect
of novel therapeutic approaches and to improve patient
outcomes in spinal cord injury are clinical. These phenotypic
and outcome data are rich and complex but it is also the
information that nurses, doctors and others accrue about
people living with spinal cord injury as they pass through their
care. This project will take these clinical process, map them
to international standards and provide federated aggregation
to facilitate research globally and to improve patient
outcomes locally. This paper will report progress on our local
implementation of this model.
References: AccessEconomics. The economic cost of spinal
cord injury and traumatic brain injury in Australia. 2009 June
Biering-Sorensen F et al. International spinal cord injury data
sets. Spinal Cord. 2006. 44(9):530-4.
Norton L. Spinal Cord Injury, Australia 2007-08. Canberra:
Australian Institute of Health and Welfare2010 November
2010 Contract No.: 52.
P2-03
Effects of Seated Double-Poling
Ergometer Training on Aerobic and
Mechanical Power in Paraplegics
A. Bjerkefors1, T. Lindberg2, C. Norrbrink3, K. Wahman4, A.
Arndt2
1
, Human Locomotion Laboratory, School of Kinesiology,
International Collaboration on Repair Discoveries, University
of British Columbia, Vancouver/CANADA, 2, The Swedish
School of Sport and Health Sciences, Stockholm, Sweden,
Stockholm/SWEDEN, 3, Department of Clinical Sciences,
55
Karolinska Institute Danderyd Hospital, Stockholm/SWEDEN,
4
, Department of Neurobiology, Care Sciences and Society,
Karolinska Institute, Rehab Station Stockholm/Spinalis, R & D
unit, Stockholm, Sweden, Solna/SWEDEN
Background: Post rehabilitation, the need for physical training
still remains, to maintain the acquired abilities and avoid risks
involved with a sedentary lifestyle (1). The purpose was to
study the effects of seated double-poling ergometer training,
performed by persons with spinal cord injury (SCI), on aerobic
capacity and upper-body power output.
Methods: Thirteen persons with SCI (8 M and 5 F, injury
levels T5-L1), performed 50 min double-poling ergometer
training three times per week during 10 weeks. Each session
included warm-up, four interval sessions of 6 – 7 min, and
cool-down. The intervals varied between 15 s and 3 min
(70 – 100 % peak heart rate) with 15 s – 1 min rest. Before
(test-retest) and after the training period, sub-maximal and
maximal double-poling ergometer exercises were performed.
Oxygen uptake was measured using the Douglas Bag system.
Three-dimensional movements were recorded using an
optoelectronic system and piezoelectric force sensors were
used to register force in both poles for calculation of power
output.
Results: The average intra-class correlation coefficient for
test-retest values were 0.81 (SD 0.11) for sub-maximal and
0.84 (0.11) for maximal test. Significant improvements after
training were observed in oxygen uptake (22.7 %), ventilation
(20.7 %) and blood lactate (22.0 %) during maximal exercises
(Fig 1, Table 1). Mean power per stroke and peak pole force,
calculated during the last 60 s, increased with 15.4 % and
23.7 %, respectively. At sub-maximal level, significantly lower
values were observed in ventilation (-12.8 %) and blood
lactate (-25.0 %) after the training period (Fig. 1, Table 1).
Conclusion: Regular interval training on the SPDE was effective
for individuals with SCI to improve aerobic capacity and upperbody power output. Furthermore, the training was safe and did
not cause any overload symptoms (2).
References: 1. Wahman K, Nash MS, Lewis JE, Seiger A, Levi
R. Cardiovascular disease risk and the need for prevention
after paraplegia determined by conventional multifactorial
risk models: the Stockholm spinal cord injury study. J
Rehabil Med 2011; 43 :237-242. 2. Norrbrink, C, Lindberg T,
Wahman K, Bjerkefors A. Effects of an exercise programme
on musculoskeletal and neuropathic pain after spinal cord
injury – results from a seated double poling ergometer study
(accepted for publication in Spinal Cord).
56
P2-04
Design and Progress of the Swiss
Spinal Cord Injury Cohort Study
(Swisci)
M.W.G. Brinkhof, &. The Swisci Study Group
Swiss Paraplegic Research, Nottwil/SWITZERLAND
Background: Epidemiological research in spinal cord injury
(SCI) will, similar to other rare or chronic conditions, greatly
benefit from population-based study designs. Populationbased studies may function as registries that measure both
incidence and prevalence; facilitate long-term monitoring
and studying of the natural history of a condition; and play
a role in the study of demographic and other risk factors. A
registry may also provide the framework for representative
and coordinated sampling of participants for specific studies
(or nested projects) as to prevent mutual interference of
outcomes and minimize the overall burden on individuals.
We therefore recently initiated the Swiss Spinal Cord Injury
cohort study (SwiSCI), which overall objective is advancing
optimal functioning and quality of life of persons with SCI
along the continuum of care and over the life span through
comprehensive functioning and rehabilitation research1.
Specific aims are assessing morbidity, mortality and longevity,
with respect to specific risk factors as well as in comparison
with the general population. Here we give an interim report on
the progress of SwiSCI.
Methods: SwiSCI is performed by the Swiss Paraplegic
Research in collaboration with the four major specialized
rehabilitation centers in Switzerland, including the Spinal Cord
Injury Center of the Balgrist University Hospital, Zürich; Centre
for Spinal Cord Injury and Severe Head Injury, REHAB Basel;
Clinique Romande de Réadaptation, Sion; and the Swiss
Paraplegic Centre, Nottwil. All four centers have specified
regional catchment areas and admit both patients with
traumatic and nontraumatic SCI. Other collaborating partners
include the Swiss Paraplegic Association (SPV) and Parahelp,
an organization providing home nursing services for the SCI
community.
Eligible participants in SwiSCI are Swiss residents with
traumatic or non-traumatic SCI who are aged 16 or older,
excluding SCI linked to progressive neurological disorders or
end-of-life care. Identification of SCI cases is through three
complementary pathways that, taken together, may eventually
establish an ongoing population-based dataset. A unique list of
persons with existing SCI is determined by combining personal
information extracted from the medical records in the four SCI
centers (Pathway 1; retrospective study, in Switzerland dating
back to 1967) with existing membership and client lists of
SPV and Parahelp. All persons identified living with SCI are
invited to participate in a cross-sectional survey (Pathway 2)
and asked for their consent for future follow-up. From mid
2012 onwards SwiSCI aims recruiting all Swiss persons with a
newly diagnosed SCI admitted to one of the four study centers
(Pathway 3).
Results: The data collection in Pathway 1 and Pathway 2 is in
progress. Based on the combined records of SPV, Parahelp and
three study centers we have currently (11.12.2011) identified
and contacted 3354 persons in Pathway 2. Pathway 1 data
collection now covers 1990 to 2011; completion until 1967, in
all centers and incorporating records from deceased persons, is
foreseen by mid 2012. First results from the historical cohort will
be presented at the Interdependence meeting.
References: 1. Post MW et al Design of the Swiss Spinal Cord
Injury Cohort Study. Am J Phys Med Rehab 2011;90 (Suppl
2):S5-16.
P2-05
Best Practice Implementation in
Inpatient Spinal Cord Rehabilitation
– The Challenges of a Multi-Unit Site
C. Scovil1, A. Burns1, H. Flett1, L. Nguyen1, D. Leber1, . Sci
Kmn2
1
, Toronto Rehab, Lyndhurst Centre, Toronto/ON/CANADA, 2,
SCI KMN, Toronto/ON/CANADA
Background: Secondary health complications after Spinal Cord
Injury (SCI) affect rehabilitation outcomes, and remain a risk
for individuals living with SCI. Toronto Rehab is participating
in a SCI Best Practices Implementation (BPI) initiative
focusing on three secondary complications - pressure ulcers
(PU), pain and bladder management. The SCI BPI includes
6 participating centres in Quebec, Ontario and Alberta, and
is supported by implementation expertise from the National
Implementation Research Network (NIRN). The objectives of
the BPI project are to:
•
Promote adoption and utilization of best practices in SCI
rehabilitation, and to increase implementation fluency
for future BPI.
•
Establish collaborative knowledge mobilization networks
(KMN) to identify and validate best practices.
Methods: A Site Implementation Team (SIT) was formed,
consisting of 2 Project Leads, Transformation Specialist
and professionals with content expertise in the areas of PU
prevention and patient and staff education. The SIT, supported
by NIRN, is establishing the three key domains of drivers
required to ensure effective implementation - leadership,
organizational readiness and staff competency. A multi-site
Delphi consensus process identified two PU best practices for
initial implementation:
•
Conduct comprehensive assessment of risk factors
•
Provide structured PU prevention education
Results: Challenges at our site include the size of our SCI
program (three 18-bed units), leadership turnover and hospital
merger, and the implementation of a new SCI-specific PU
risk assessment scale (SCIPUS - Salzberg et al. 1996). Each
unit has a distinct team of professionals, with individual
team dynamics, strengths and challenges. Implementation
strategies have been developed in the installation stage by the
SIT, in consultation with NIRN and the SCI KMN:
•
Professionals from each unit were involved, and
feedback gathered across units to ensure concerns
were addressed.
•
Baseline data on PU prevalence and documentation
compliance were collected across all three units.
•
Practice profiles were created that identify the
critical components of the BPI process, and who
is responsible for each component. This ensures
consistent requirements across units, and creates clear
expectations, even with changing leadership.
•
Strengths were highlighted, and specific challenges
addressed for each unit individually. Information from
the baseline PU prevalence and document compliance
audit was used to encourage and motivate units to
implement better practice.
•
Staff concerns with the existing risk assessment scale
were acknowledged, resulting in implementation of
a SCI-specific risk assessment scale. Staff view the
SCIPUS as more appropriate to the patient population,
which should improve buy-in and documentation
compliance.
•
New forms and processes replaced existing ones to
keep workload consistent and further increase front-line
staff buy-in
For the initial implementation phase, 1-2 ‘champions’ per unit
will be selected and trained. They will identify implementation
challenges on their unit, help with training, and provide on-site
coaching. The BPI project provides a framework to effectively
implement best practices for PU reduction, and lays the
groundwork for more effective BPI in the future.
References: Salzberg CA, Byrne DW, Cayten CG, van
Niewerburgh P, Murphy JG, Viehbeck M (1996). A new
pressure ulcer risk assessment scale for individuals with spinal
cord injury. Am J Phys Med Rehabil 75:96-104.
57
P2-06
Systematic Review of Economic
Studies in Spinal Cord Injury
S.L. Hitzig1, B. Chan2, N. Mittmann3
1
, Toronto Rehabilitation Institute, Toronto/CANADA, 2,
Leslie Dan Faculty of Pharmacy, Toronto/CANADA, 3, HOPE
Research Centre, Toronto/ON/CANADA
Background: It is estimated that there are 85,000 Canadians
living with spinal cord injury (SCI) and approximately
3,700 new cases discharging from Canadian hospitals
each year1. With SCI comes a sudden decrease in physical
functioning and mobility. As a result, modifications to
home and transportation are required to maintain a level
of independence and productivity. A SCI also results in an
increased risk for secondary medical complications such as
urinary tract infection, pneumonia, pain and pressure ulcers
resulting in higher rehospitalization rates and access to health
care services2. Taken together, living with an SCI results in
a significant economic burden to the individual, caregiver
and the health care system. Though several studies have
investigated economic burden in the SCI population, a review
of the literature has not been conducted. Therefore this study
will systematically review the medical and economic literature
for economic studies related to SCI.
Methods: A comprehensive literature review will be conducted
using the MEDLINE®, EMBASE, HealthStar, CINAHL®
and PubMed® databases using key words spinal cord
injury, damage, contusion, laceration, trauma or fracture in
combination with cost and cost analysis between 1980 and
2011. English language economic evaluation of spinal cord
injury will be included. Conference abstracts will be excluded.
A search of government and SCI advocacy group websites
will also be conducted to retrieve any further reports on SCI
costs. All resulting publication abstracts will be reviewed by
two individuals. Articles agreed by both reviewers will be
flagged and the full publication retrieved. The two reviewers
will discuss any discrepancies between the articles identified
for inclusion. Where there is a lack of consensus between the
reviewers, a third individual will review the articles in question
and make a final judgment. All publications eligible for the full
analysis will be summarized for methods and results. Total
costs reported will be converted and inflated to 2011 Canadian
dollars.
Results: A total of 67 articles were identified in all of the
databases searched. All articles will be reviewed and screened
for review inclusion. A preliminary review of the articles
identified cost-of-illness studies as well as cost-effectiveness
analyses from several countries. A preliminary search of
additional sites from government and advocacy group websites
has revealed cost studies from Australia and Canada. A more
comprehensive search will determine which studies to include
in the systematic review and whether additional cost studies
exist.
58
References: 1. Farry A, Baxter D. The incidence and
prevalence of spinal cord injury in canada: Overview and
estimates based on current evidence 2010 Dec 2010. 2.
Dryden DM, Saunders LD, Rowe BH, May LA, Yiannakoulias
N, Svenson LW, et al. Utilization of health services following
spinal cord injury: A 6-year follow-up study. Spinal Cord. 2004
Sep;42(9):513-25.
P2-07
A National Approach to
Implementing and Sustaining
Evidence-Based Practices for
Treatment and Prevention of
Secondary Complications for
Individuals with Spinal Cord Injuries
R. Riopelle1, M. Duda2, J. Brown2, D. Wolfe3, J. Hsieh3, A.
Dupuis4, A. Rasheed5, A. Burns6, H. Flett7, C. Joly8, J. Knox9,
B. Stoesz10, V. Tam8, C. Truchon11, P. Wright9
1
, Ontario Neurotrauma Foundation/McGill University, Toronto/
ON/CANADA, 2, University North Carolina, Carroboro/NC/
UNITED STATES OF AMERICA, 3, Lawson Health Research
Institute, London/ON/CANADA, 4, St. Joseph’s Health Care
Parkwood, London/ON/CANADA, 5, Rick Hansen Institute,
Vancouver/BC/CANADA, 6, Toronto Rehab, Lyndhurst Centre,
Toronto/ON/CANADA, 7, Toronto Rehabilitation Institute,
Toronto/ON/CANADA, 8, Institut de Réadaptation GingrasLindsay-de-Montréal, Montréal/CANADA, 9, Foothills Medical
Centre, Calgary/AB/CANADA, 10, Glenrose Rehabilitation
Hospital, Edmonton/AB/CANADA, 11, Institut de Réadaptation
en Déficience Physique de Québec, Québec/QC/CANADA
Background: The identification and use of evidence based
interventions is critical to improving patient outcomes. Many
times what is selected is not used by practitioners and/or;
what is adopted as an intervention, is not used with fidelity
with good outcomes for consumers; thus, the patient neither
receives nor experiences the intended benefits of Evidence
Based Practices(EBP).
The purpose of the Spinal Cord Injuries Knowledge
Mobilization Network(SCI-KMN) project was to address the
critical need to identify EBPs to manage common secondary
complications of SCI in three targeted domains of secondary
complications: prevention and treatment of pressure ulcers;
pain management; and bladder and bowel management.
This inter-provincial project engaged six rehabilitation sites in
three Canadian provinces to prevent and manage secondary
complications in SCI patients.
Methods: Six sites/(Centres of Excellence) across three
Canadian Provinces,(Alberta, Ontario and Quebec). were
selected based on their expertise and level of readiness for
the development of implementation capacity. A systematic
approach was used to identify and operationalize evidence-
based practices one domain of secondary complications at
a time (Delphi Process). Inter-provincial expertise and local
(site level) stakeholders ranked priority best practices and use
and implementation science informed lens to rate and rated
elements such as fit, feasibility, sustainability and scalability.
Consensus of the non-negotiable (expected) best-practices,
performance measures for fidelity to the intervention, and
fidelity to the process of implementation was achieved.
Evidence-based Implementation practices via the use and
assessment of active implementation frameworks (Fixsen_
et._al,_2005) were embedded throughout the entire process
as the method to develop implementation capacity, influence
system change and build sustainability.
Results: The results of this work defines the replicable
components necessary to operationalize best practices and
use an evidence-based approach to ensure implementation.
The first domain targeted was the prevention and treatment
of pressure ulcers. An intensive six round Delphi process
(Keeney_et_al._2001) with key stakeholders and experts,
resulted in over 49 recommended practices for treatment
and prevention of pressure ulcers which was then narrowed
down to five critical practices. Once two practices were further
identified as
“Non-Negotiables” both Performance measures and Process
fidelity measures were developed for use across all site.
Through the support of the SCI KMN communities of practice,
Implementation Teams utilized Active Implementation Science
Frameworks to create operational and scalable mechanisms,
processes and tools required to support and measure
efficient and sustained implementation. This site level stagebased implementation capacity can be generalized to future
evidence-based practices. These activities make important
contributions toward building both fidelity-based intervention
and fidelity-based implementation capacity by empowering
organizations to achieve their goals to optimize service delivery
for people with SCI, decrease burden and to improve their
quality of life.
References: Selected-References
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. &
Wallace, F. (2005). Implementation Research: A Synthesis of
the Literature. Tampa, FL: University of South Florida, Louis
de la Parte Florida Mental Health Institute, The National
Implementation Research Network (FMHI Publication #231).
Keeney S, Hasson F, McKenna HP. A critical review of the
Delphi technique as a research methodology for nursing. Int J
Nurs Studies 2001; 38:195-200.
P2-08
First Year Anniversary of the Rick
Hansen Spinal Cord Registry in
Western Quebec: Facts and Figures
at a Glance
M. Grangeon1, I. Robidoux1, D. Gagnon1, K. Drouin2, S.
Parent2, J. Mac-Thiong2
1
, Centre de recherche interdisciplinaire en réadaptation
du Montréal métropolitain (CRIR) Institut de réadaptation
Gingras-Lindsay-de-Montréal Laboratoire de pathokinésiologie,
Montreal/QC/CANADA, 2, Centre de recherche, Hôpital du
Sacré-Coeur de Montreal, Montreal, Canada, Montreal/QC/
CANADA
Background: In 2011, it is estimated that there are over 86
000 people living with spinal cord injury (SCI) in Canada and
over 4300 new SCI cases each year. Relevant information of
population with SCI is important to optimise their rehabilitation.
Since 2003, the Rick Hansen Spinal Cord Injury Registry
(RHSCIR) tracks the experiences and outcomes of people
with traumatic SCI during their journey through acute care,
rehabilitation and community reintegration. To date no study
has investigated these data through a statistical descriptive
analysis. Thus the objective of our project was to provide a
local method analysis of the RHSCIR data to draw a detailed
picture of people who sustained a SCI in the western Quebec.
Methods: At the end of 2010, 2300 participants from
all Canada had consented to have their SCI-related data
captured by the RHSCIR. The RHSCIR represents a working
collaboration of 31 Canadian data collection sites. As of may
2011, the database contained information on 172 persons
who sustained a traumatic SCI in Quebec. Our study describes
91 persons who sustained a traumatic SCI between May
2010 and May 2011 and who were admitted in the Centre
d’Expertise pour les personnes Blessées Médullaires de
l’Ouest du Québec (CEBMOQ) located in Montreal. The
CEBMOQ includes the Hôpital du Sacré-Coeur de Montréal,
the Institut de réadaption Gingras-Lindsay-de-Montréal and
the Centre de réadaptation Lucie-Bruneau. Among the 91
persons, 72 gave their informed consent including 61 males
and 11 females. All the statistics in this study are derived from
this sample.
Results: The mean age at injury was 47.3 years and most of
injury occurred over 55 years. Overall 84.7% of SCI reported
occurred among males. The majority of our sample (87.5%)
was employed at the time of injury. Most (39.7%) were single
but the majority (66.7%) was not living alone at the time of
injury. Falls accounted for 48.6% of reported SCI followed
by transport (30.6%), sport (8.3%) and assault (5.6%).
The most frequent neurologic category was incomplete
tetraplegia (32%), followed by complete paraplegia (29%),
incomplete paraplegia (23%) and complete tetraplegia (16%).
None of the participant experienced complete neurologic
59
recovery (ASIA E) upon hospital discharge. Over the last
years, the percentage of persons with incomplete paraplegia
has increased, while incomplete tetraplegia and complete
paraplegia have decreased. The median day hospitalized in
the acute care unit was 32 and 76 in the rehabilitation unit.
At discharge from the system, 86% went to a private non
institutional residence and 41.8% exhibited pain interference
in daily life. The success of participation, the efficiency in the
data collection and the synergy developed in each institution
of the CEBMOQ demonstrated the feasibility of the project.
Some clarifications in certain part of the questionnaire might
avoid misinterpretation by participants and clinicians and
might eliminate some confounding factors. Although some
improvements in the database should be done to facilitate
the data analysis (i.e. the data classification), the present
approach gave interesting information for clinicians and
researchers and should be extended to other RHSCIR local
sites.
References: Canadian Paraplegic Association.
P2-09
Muscle Strength Changes Recorded
Using Dynamometry During Robot
Assisted Gait Training
S. Galen1, C. Clarke1, A. Mclean2, D. Allan2, B. Conway1
1
, Bioengineering Unit, University of Strathclyde, Glasgow/
UNITED KINGDOM, 2, Queen Elizabeth National Spinal
Injuries Unit, Glasgow/UNITED KINGDOM
Background: Body Weight Supported Treadmill Training
(BWSTT) is being increasingly used in the rehabilitation of
incomplete spinal cord injured (ISCI) patients. The Lokomat
(Hocoma) is a commercially available robot assisted
BWSTT. Although previous studies have shown functional
improvements in gait following Lokomat training in ISCI,1 the
strength changes in lower limb muscles following BWSTT has
received little attention. Objective: The aim of this study was to
record changes in muscle strength in key lower limb muscle
groups in acute and chronic ISCI patients under going daily
Lokomat training.
Methods: All procedures were approved by the ethics
committee of the local health authority. Eighteen patients
(acute = 13, chronic= 5) with ISCI participated in this study
(Age range: 26-63 years, mean = 49.33 + 11.04 years). Each
patient underwent a six week Lokomat training programme
consisting of a daily target of 1 hour of BWSTT. Each patient
also underwent routine functional and clinical assessments.
In this study we used the Lokomat’s ability to measure
isometric hip and knee joint moment in order to chart weekly
changes in the maximal voluntary strength changes in the
flexor and extensor muscles groups of those joints. Isometric
measurements were made prior to the start of Lokomat
60
training and during the middle of each training week. Subjects
were positioned in an upright standing posture within the
Lokomat and instructed to make maximal efforts of flexor and
extensor muscle groups of the hip and knee against a fixed
orthosis. The moments generated were recorded by calibrated
sensors within the orthosis. The best of three attempts of each
exertion was taken as an estimate of the maximal voluntary
strength. Rest periods between each exertion were given in
order to avoid fatigue.
Results: For all muscle groups tested there was a
significant increase in the maximal strength recorded
in the acute patient group (p<0.05). The time course
of the changes reveals that in responding patients who
demonstrate functional improvements in gait that there
is clear evidence of strength increases in the hip and
knee musculature within 3 weeks of training onset. This
increase in strength continues to rise throughout the
training programme but not in a simple linear fashion. In
the chronic patient group strength changes were also seen
but were of a lesser magnitude than those seen in the
acute group. Conclusions: This study objectively measured
the changes in muscle strength following robot assisted
BWSTT. For patients receiving Lokomat rehabilitation
the observation that increased hip and knee moments in
responding patients can be seen by week 3 is indicative of
treatment efficacy. However, in patients lacking a positive
increase in strength by week 3 may denote that the patient
is receiving no physiological benefit from the robot assisted
BWSTT. Incorporating, regular dynamometry may therefore
assist in revising treatment planning for patients who are
considered for Lokomat or other forms of BWSTT.
References: 1. Hornby TG, Zemon DH, Campbell D.
Robotic-assisted, body-weight-supported treadmill training in
individuals following motor incomplete spinal cord injury. Phys
Ther. 2005 Jan;85(1):52-66.
P2-10
The Development of an Outdoor
Experiential Therapy (Oet) Cottage
Program for Persons with Spinal
Cord Injury
C. Alton, N. Leong, N. Saunders, S.L. Hitzig
University Health Network, Toronto Rehab, Toronto/ON/
CANADA
Background: Although the rehabilitation team offers an
inter-professional approach towards helping persons with
spinal cord injury (SCI) achieve independence within their
communities, the role of therapeutic recreation (TR) has
been identified as being particularly important for achieving
success in this domain (1,2). Unfortunately, the role of TR
and its associated benefits following SCI is under-reported in
the literature. The objective is to provide an overview of an
outdoor experiential therapy (OET) intervention, the Spinal
Cord Rehabilitation Program (SCRP) - Cottage Program, which
is a 4-day/3-night trip to an accessible campground in Ontario
where patients with SCI engage in a variety of outdoor activities
(i.e., archery, handcycling, canoeing, sailing, etc.).
Methods: The SCRP Cottage program affords patients an
opportunity to experience a decrease in the environmental
barriers that may have otherwise limited their ability
to participate in a natural outdoor environment. The
development and growth of the program have been enabled
by: 1) conducting a benchmarking process to identify best
practices on the implementation of the program; 2) adopting a
theoretical model to underlie the accountability of the program;
3) engaging key stakeholders at the clinical, management, and
community level (i.e., vendors); and 4) conducting evaluations
on the outcomes of the program using a mixed-methods
approach.
Results: First round findings from the benchmarking process
were of value and the program has advanced with involvement
from research personnel and inter-disciplinary team members.
As well, preliminary findings from the program evaluation
yielded high rates of satisfaction and positive changes in
well-being by participants. Given that people with SCI face
life-long challenges to health, community participation and
well-being, further attention is warranted on the importance
of leisure towards contributing to success in these domains.
TR interventions, such as the SCRP Cottage Program, are
needed but can only grow if they are developed and evaluated
at a higher standard. The outcomes illustrate a model of TR
program development and evaluation, which can be used to
inform the development of other SCI rehabilitation programs
aimed at improving health and well-being.
References: 1. Caldwell L, Dattilo J, Kleiber DA, Lee Y.
Perceptions of therapeutic recreation among people with
spinal cord injury. Ann Therap Rec 1994; 95: 13-6. 2. Dattilo
J, Caldwell L, Lee Y, Kleiber DA. Returning to the community
with spinal cord injury: Implications for therapeutic recreation
specialists. Therap Rec J 1998; 32: 13-27.
P2-11
Evaluating the Effects of an InterProfessional Therapeutic Cottage
Program on Improving Well-being in
Persons with Spinal Cord Injury
A. Panjwani, C. Alton, N. Leong, N. Saunders, S.L. Hitzig
University Health Network, Toronto Rehab, Toronto/ON/
CANADA
Given that depression and altered self image can dramatically
affect leisure participation [2], and that people who cope poorly
post-injury are at risk of long-term difficulties, there is a need for
interventions that address the psychological and environmental
factors early post-injury in order to improve leisure outcomes.
Hence, the purpose of the present study is to evaluate the
therapeutic benefits of attending Toronto Rehab’s Spinal Cord
Rehabilitation Program [SCRP] Cottage Program in patients with
SCI.
Methods: The SCRP Cottage is a unique outdoor experiential
therapy intervention for Toronto Rehab patients with a SCI,
which enables them to attend a 4-day/3 night visit to an
accessible campsite supported by an inter-professional team.
The program allows patients to engage in a variety of land and
water-based recreation activities (canoeing, handcycling, etc.).
Program evaluation data was collected in 2010 and 2011
and was pooled for analysis. A between subject pre-posttest
design was employed where cottage participants (n = 26) and
a comparison group of non-participants (n = 17) completed
surveys on self-esteem (Rosenberg Self-Esteem Scale), mood
(Positive Affect and Negative Affect Scale), and self-efficacy
(Moorong Self-Efficacy Scale).
Results: Repeated measures ANOVA indicated that for
patients who attended the cottage program, positive affect
increased (T1: M = 38.2, T2: M = 44.0) over time (p< 0.05)
while remaining constant for non-participants (T1: M = 36.0,
T2: M = 37.0). For both groups, self-esteem increased over
time (cottage T1: M = 22.2; T2: M = 26.0; non-participants
T1: M = 21.0, T2: M = 22.5) while negative affect decreased
(p < 0.05; cottage T1: M = 17.9; T2: M = 14.6; nonparticipants T1: M = 19.4, T2: M = 18.6). The interaction
between time and group for self-efficacy was barely nonsignificant (p =.05), suggesting there was a trend for increased
self-efficacy over time in cottage participants (T1: M = 85.0,
T2: M = 89.3) compared to non-participants (T1: M = 80.0,
T2: M = 78.0). Attending the SCRP Cottage program yielded
gains in positive mood in participants with SCI compared to
non-participants. As well, gains in self-esteem and decreases
in negative mood were demonstrated in both groups. The
findings in the cottage participants are likely attributed to
their attending the program while the gains displayed by the
controls could be due to a variety of reasons (e.g., neurological
recovery during rehabilitation, other positive life events).
Overall, the findings highlight that attending a therapeutic
cottage program improves well-being, which may hold longterm benefits for a healthy active lifestyle post-SCI.
References: 1. Vissers M, et al. Barriers to and facilitators of
everyday physical activity in persons with a spinal cord injury
after discharge from the rehabilitation centre. J Rehabil Med.
2008; 40: 461-7. 2. Carpenter C. The experience of spinal
cord injury: The individual’s perspective – Implications for
rehabilitation practice. Phys Ther. 1994; 74: 614-29.
Background: After sustaining a spinal cord injury (SCI),
opportunities for participating in outdoor recreation leisure
pursuits are reduced due to physical barriers (e.g., lack of
equipment) and emotional issues that may arise post-injury [1].
61
P2-12
P2-13
Cardiovascular Control in the Acute
Period After Spinal Cord Injury: A
Case Series
Systems Thinking Perspectives in
Spinal Cord Injury Research and
Practice
J. Inskip1, M. Mcgrath1, B.K. Kwon2, V. Claydon3
1
, Simon Fraser University, Burnaby/CANADA, 2, Combined
Neurosurgical and Orthopaedic Spine Program (CNOSP),
Department of Orthopaedics, University of British Columbia,
Vancouver/BC/CANADA, 3, ICORD, Vancouver/BC/CANADA
A. Jetha, Y. Hamdani
Dalla Lana School of Public Health, University of Toronto,
Toronto/CANADA
Background: In addition to the motor and sensory deficits
following spinal cord injury (SCI), SCI can disrupt autonomic
pathways that travel in the spinal cord, resulting in a range
of cardiovascular dysfunctions. The acute development and
evolution of these complications remains poorly understood.
Ultimately, to develop treatments to improve cardiovascular
function, we must first understand the typical progression of
these dysfunctions. Here we sought to evaluate cardiovascular
function in the acute time period after SCI.
Methods: Cardiovascular parameters were measured at
multiple time points in the first six months post-injury. Using
non-invasive equipment, resting supine beat-to-beat blood
pressure and 3-lead electrocardiography were recorded over a
15 minute period at 2-10 days, 2-4 weeks, 2-3 months and 6
months post injury, in three male subjects with SCI. Individuals
also completed a questionnaire developed in our laboratory
evaluating symptoms of cardiovascular dysfunction after SCI.
Autonomic function was quantified using spectral analyses of
heart rate and blood pressure variability.
Results: The total variability in heart rate and blood pressure
changed with time after injury; two subjects showed increased
blood pressure variability with time after injury, while one
subject showed a decrease. Heart rate variability showed less
clear effects over time. Particular frequency domains that
are related to breathing frequency, baroreflex sensitivity and
sympathetic activity showed pronounced differences over the
four recording sessions, suggesting that there may be changes
occurring in cardiovascular autonomic control during this
acute post-injury period.
The early period after SCI appears to be a time when the
cardiovascular system is changing significantly. Therefore,
we should think carefully about when we assess the
cardiovascular system following SCI. This case series shows
that spectral analyses of blood pressure and heart rate
variability are sensitive to changes in the cardiovascular
system over time. This technique may allow us to measure
cardiovascular control and the relative contributions of
sympathetic and parasympathetic activity and how they
change with time after injury.
References: No references
62
Background: Spinal cord injury (SCI) is a highly complex
health condition. From a public health perspective, the
performance of health-enhancing behaviours (e.g. selfmanagement or physical activity) by people living with SCI
can be influenced by a diversity of factors including, but not
limited to health and disability (e.g. level and completeness
of injury and presence and severity of secondary health
conditions), personal (e.g. age, gender and socioeconomic
status) and environmental (e.g. aspects of the built, physical
and social environments) factors. Although existing research
has elaborated on these different factors, little is known about
how they interact and contribute to both anticipated and
unanticipated outcomes. Systems thinking, a perspective
which has grown from business and engineering sciences,
provides an understanding of how factors interact and
influence one another within a whole and produce patterns of
behaviours.
Methods: This presentation will introduce systems thinking
and provide a discourse on complexity as applied to SCI
health promotion research and practice. Systems dynamics
methodology which involves designing a series of causal loop
diagrams will also be described as one systems method for
conceptualizing SCI research and identifying key areas of
intervention (i.e. leverage points).
Results: By understanding complex interactions and patterns
of relationships between factors, practitioners and policy
makers will be better able to determine key areas of health
promotion intervention, the impact of these interventions
on the system and the potential intended and unintended
consequences of change.
References: Hamdani, Y., Jetha, A., Norman, C.D. (2011).
Systems thinking perspectives applies to healthcare transition
for youth with disabilities: a paradigm shift for practice, policy
and research. Child: care, health & development, 37 (6) 806814.
P2-14
Examining Workplace Activity
Limitations Among Young Adults
Living with Spinal Cord Injuries: A
Pilot Study
A. Jetha1, B.C. Craven2, E. Badley1, D. Beaton3, M. Gignac1
1
, Dalla Lana School of Public Health, University of Toronto,
Toronto/ON/CANADA, 2, Toronto Rehabilitation Institute, Spinal
Cord Injury Rehabilitation Program, Toronto/ON/CANADA, 3,
St. Michaels Hospital, Mobility Program, Clinical Research
Unit, Toronto/ON/CANADA
Background: Research suggests that people living with
spinal cord injury (SCI) are less likely to be employed
compared to their able-bodied peers. However, few studies
have examined specific workplace activity limitations facing
people living with SCI and potential differences from other
chronic health conditions. As part of a larger study examining
the employment participation of young adults living with
chronic physically disabling health conditions, this pilot study
describes difficulties with work participation experienced by a
sample of young adults living with SCI. In addition, it examines
difficulties compared to a larger sample of young adults living
with juvenile arthritis (JA) and systemic lupus erythematosus
(SLE).
Methods: Eligible participants ages 18 to 30 years are
currently being recruited from clinics and community
organizations in Ontario, Saskatchewan and British Columbia.
Participants complete an online questionnaire asking about
demographics (e.g., age, gender, education), health (e.g.,
injury-level and completeness, fatigue, pain, secondary health
conditions) and employment, including questions about
employment status and career satisfaction (5-item Career
Satisfaction Scale: 1 = not at all satisfied; 5 = extremely
satisfied). Difficulties with work participation were assessed
using the Workplace Activities Limitations Scale (WALS).
WALS gauges problems with lower mobility (e.g., wheeling for
long periods, sitting, standing), upper mobility (e.g., reaching
and grasping), and job demands (e.g. the pace or schedule
of work). Items are responded to on a 4-point scale (1 = no
difficulty; 4 = unable to do). Descriptive and comparative
statistics (i.e. Analysis of Variance) were conducted.
Results: To date, 102 young adults living with SCI (n = 7), JA
(n = 35) and SLE (n = 60) have completed the questionnaire
(mean age = 23.8, SD =3.4). 57% of the sample with SCI
were employed compared to 60.3% with JA and SLE. Overall,
young adults with SCI reported moderate to low difficulties
with workplace activities (mean WALS score = 1.9 (SD =
.48)), which was not significantly different from young adults
with JA (mean WALS score = 1.5 (SD = .50)) and SLE (mean
WALS score = 1.6 (SD = .52)). Examining individual WALS
items, respondents with SCI reported significantly greater
difficulties commuting to and from work (1.8 vs. 1.3), getting
around the workplace (1.8 vs. 1.3) and reaching (2.3 vs. 1.3)
than respondents with JA and SLE (p < .05). There were no
significant differences reported with job demands, including
concentrating on work (1.8 vs. 1.6) or the scheduling and
pace of work. However, participants with SCI were significantly
less satisfied with their career progress compared to
participants with JA and SLE (2.3 vs. 3.5; p < .01).
Discussion: Although the data are preliminary, they highlight
the importance of examining, not only the overall level
of workplace activity limitations across different chronic
conditions, but also specific areas that may be problematic
(e.g., mobility versus the pace of work). The data also
suggest the need to look at links between workplace activity
limitations and career satisfaction. Interventions to improve
employment participation should include strategies to help
young adults deal with specific workplace problems, including
environmental barriers.
References: 1. Gignac MAM. Arthritis and employment: An
examination of behavioral coping efforts to manage workplace
activity limitations. Arthritis & Rheumatology. 2005;53(3):328336.
P2-15
Economics of Traumatic Spinal Cord
Injury in Canada
H. Krueger1, C. Rivers2, V. Noonan3, L. Trenaman1, P. Joshi2,
M. Dvorak4
1
, H. Krueger & Associates Inc., Delta/CANADA, 2, Rick
Hansen Institute, Vancouver/CANADA, 3, University of British
Columbia, Vancouver/BC/CANADA, 4, Rick Hansen Institute,
Vancouver/BC/CANADA
Background: An estimated 1,400 Canadians survive a tSCI
each year. These survivors suffer a high rate of preventable
secondary complications. We aim to determine the economic
burden of traumatic spinal cord injury (tSCI) in Canada, and to
evaluate the potential costs avoided by reducing the incidence
of secondary complications, particularly pressure ulcers (PUs)
and urinary tract infections (UTIs).
Methods: This health economics study uses available
information in the academic and grey literature on the
incidence, prevalence, resource use, survival and quality of
life of individuals with tSCI to estimate the lifetime economic
burden of a tSCI and the potential costs avoided if the
incidence of specific types of secondary complications (such
as PUs and UTIs) can be reduced. Both direct and indirect
costs are calculated in estimating the lifetime economic
burden of a tSCI while the focus is on direct costs avoided
by reducing the incidence of secondary complications.
Preliminary results are presented in this abstract.
63
Results: The total lifetime economic burden of a tSCI that
occurs at age 35 is between $1.47 and $3.03 million dollars
depending on type/severity of injury. Direct costs consist of
approximately 50% of this economic burden. The total annual
economic burden of tSCI in Canada is estimated at $2.67
billion. If a modest 20% reduction of PU or UTI incidence was
achieved in the Canadian tSCI population, $71.08 and $12.21
million in direct care costs, respectively, could be avoided
annually in Canada. tSCI is a huge economic burden to
healthcare systems. Advances in the prevention of secondary
complications can greatly reduce both the burden on tSCI
patients and provide a substantial reduction in economic
burden. These advances may also be applied to other relevant
patient groups, leading to even further patient and economic
benefit.
References: No references added at this time.
P2-16
Non-Neurological Complication Rate
Following Surgical Stabilization
of Vertebral Fracture with
Neurological Impairment. Does
Surgical Timing Matter?
E. Bourassa-Moreau1, S. Parent2, C. Thompson3, J. MacThiong1
1
, Université de Montréal, Montréal/CANADA, 2, Hôpital du
Sacré-Coeur, Montreal/CANADA, 3, Hôpital du Sacré-Coeur de
Montréal, Montréal/CANADA
Background: Optimal timing of surgery after vertebral fractureluxation is one of the most controversial subject in spine
surgery. We wanted to determine if early surgical stabilization
decreases non-neurological complications during acute
phase hospitalisation in vertebral trauma with neurological
impairment.
Methods: We studied a retrospective cohort comprising
314 patients with vertebral fracture or dislocation with
neurological impairment. For each patient, post-operative
complications that occurred during the acute hospitalisation
phase (pulmonary embolus, deep venous thrombosis,
pneumonia, urinary tract infection, pressure ulcers and other
complications) were collected. We examined the occurrence
of non-neurological complications during different intervals
pertaining to the timing of the surgical intervention with
respect to the spine trauma (<24h, <48h, <72h and >72h).
Logistic regression analysis model was adjusted for covariables such as age, sex, trauma mechanism, vertebral level,
completeness of injury, Injury Severity Score (ISS), Charlson
Comorbidity Index (CCI) and Surgery Invasiveness (SI).
64
Results: The rate of occurence of non-surgical complications,
except for urinary tract infection was significantly higher when
surgery was performed more than 72h after the vetebral
trauma. When controlling for confounding variables, surgical
decompression performed within 72h after post-injury was
associated with lower rates of non-neurological complications.
Higher complication rates were associated to more severe
trauma (ISS), greater number of comorbidities (CCI), age,
completeness of injury and tetraplegia. In order to decrease
the rate of complications, the authors recommend performing
spinal decompression/stabilization as soon as the patients are
stable enough to undergo surgery within the first 72 h after the
trauma.
References: Carreon LY, Dimar JR. Early versus Late
Stabilization of Spine Injuries: A Systematic Review. Spine
(Phila Pa 1976). 2011 Jan 25. Fehlings MG, Rabin D, Sears W,
Cadotte DW, Aarabi B. Current practice in the timing of surgical
intervention in spinal cord injury. Spine (Phila Pa 1976). 2010
Oct 1;35(21 Suppl):S166-73. Bellabarba C, Fisher C, Chapman
JR, Dettori JR, Norvell DC. Does early fracture fixation of
thoracolumbar spine fractures decrease morbidity or mortality?
Spine (Phila Pa 1976). 2010 Apr 20;35(9 Suppl):S138-45.
Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Murphy T,
Tepas JJ. The effect of early spine fixation on non-neurologic
outcome. J Trauma. 2005 Jan;58(1):15-21.
Croce MA, Bee TK, Pritchard E, Miller PR, Fabian TC. Does
optimal timing for spine fracture fixation exist? Ann Surg. 2001
Jun;233(6):851-8. Vaccaro AR, Daugherty RJ, Sheehan TP,
Dante SJ, Cotler JM, Balderston RA, Herbison GJ, Northrup
BE. Neurologic outcome of early versus late surgery for
cervical spinal cord injury. Spine (Phila Pa 1976). 1997 Nov
15;22(22):2609-13.
P2-17
Patient-Centred Care: Using
Operations Research Techniques
to Improve Care for Persons
with Spinal Cord Injury
V. Noonan1, D. Atkins1, A. Santos1, R. Lewis1, L. Soril2, M.G.
Fehlings3, A. Singh3, M. Dvorak2
1
, University of British Columbia, Vancouver/BC/CANADA, 2,
Rick Hansen Institute, Vancouver/CANADA, 3, University of
Toronto, Toronto/ON/CANADA
Background: The provision of care is heavily influenced by
both clinical decision-making and system (administrative)
processes. Clinical care directly impacts patient outcomes.
System processes are influenced by resources, organizational
structures, geography, patient demographics and staffing
and have direct effects on length of stay, time to surgery,
and rehabilitation intensity, which in turn also affect patient
outcomes. System and clinical processes are completely
integrated; in the case of patients with traumatic spinal cord
injury (SCI), who receive care in many different units and
require multiple interventions over significant periods of time,
the integration is particularly complex. Similar problems in
business and engineering have been addressed using the
techniques of Operations Research (OR); these techniques may
offer a unique solution to the complexities encountered in SCI
care. The objective of the Access to Care and Timing project
is to model the care continuum for persons with traumatic
SCI in Canada using OR methods. Specifically, this project will
assess whether access to specialized services and the timing
of the interventions affect system and patient outcomes; these
outcomes will be evaluated using a simulation model.
Methods: A partnership was developed between the Rick
Hansen Institute and the Centre for Operations Excellence
at UBC. A high-level overview (level 1 maps) of SCI care in
Canada was described for SCI centres participating in the
Rick Hansen SCI Registry (RHSCIR). Detailed process maps,
along with data from RHSCIR, evidence from the literature
and expert opinion were used to develop a discrete event
simulation model (DES) of the traumatic SCI continuum of
care. A second health progression model was built to examine
the long-term impacts (recurrence of complications, costs,
quality-adjusted life years, mortality) once persons with SCI
return into the community.
Results: To date, level 1 maps have been developed for 25 SCI
centres in 12 cities. The general DES model is being tailored
to SCI centres in four cities which have completed the detailed
process mapping. Validation of the models is ongoing. Results
from the models have been used to determine the direct and
indirect effects of hypothetically implementing new initiatives
(e.g. pressure ulcer guidelines), as well as to examine which
policy initiatives would facilitate early access to surgery in
two Canadian centres. Additional benefits of conducting the
process mapping include creating dialogue among health
care providers both along the continuum of care and across
Canada. With an ever increasing demand on the health care
system there is a need to critically evaluate the processes of
care to determine the attributes of a system that provides cost
effective quality care. The use of OR methods has enabled SCI
care to be examined along the continuum and identify unique
differences in care delivery across Canada. Results from the
ACT models provide the evidence required to support clinical
decision-making and inform standards of care.
References: Not applicable
P2-18
Does Autonomic Dysfunction
Play a Role in the Development of
Cardiovascular Disease After Spinal
Cord Injury?
R. Ravensbergen1, I. Sahota2, S. Lear2, A. Krassioukov3, V.
Claydon2
1
, ICORD, Vancouver/CANADA, 2, Simon Fraser University,
Burnaby/CANADA, 3, University of British Columbia - Physical
Medicine and Rehabilitation, Vancouver/CANADA
Background: Cardiovascular disease after spinal cord injury
(SCI) is the leading cause of morbidity and mortality in this
population. The mechanisms underlying this increased risk
are still unclear. Until now lifestyle changes after SCI have
been thought to be the most important factor, causing negative
changes in metabolic state (e.g. cholesterol levels) and body
composition (e.g. fat percentage), which are related to a
higher risk of cardiovascular disease. However, we propose
that injury to spinal autonomic pathways plays an important
role. It is possible that cardiovascular disease risk is increased
as a direct effect of damage to these pathways or indirectly as
a consequence of decreased exercise intolerance. Therefore,
we aimed to compare risk factors for cardiovascular disease
between individuals with an autonomically complete SCI,
autonomically incomplete SCI and able-bodied controls.
Methods: The spinal cord injury group was subdivided by
completeness of injury to cardiovascular autonomic pathways.
Individuals were determined autonomically complete based
on level of injury (above T5), low plasma noradrenaline level,
low power of low frequency (LF) oscillations in systolic arterial
pressure (SAP)1 and having symptoms or signs of orthostatic
hypotension and or autonomic dysreflexia. Risk assessment
parameters for cardiovascular disease were compared
between the groups: glucose tolerance, fasting glucose
and insulin, fasting cholesterol and triglycerides as well as
measures of obesity (fat mass, abdominal fat mass). Physical
activity was determined using the Physical Activity Scale for
Individuals with Physical Disabilities2 (PASIPD). Measurements
were conducted in 14 able-bodied controls, 11 individuals
with autonomically complete SCI and 12 individuals with
autonomically incomplete SCI.
Results: Risk factors related to glucose handling were
impaired only in the autonomically complete SCI group. Lipid
profiles were impaired in both SCI groups; HDL cholesterol
was lower, while LDL cholesterol was not different from the
able-bodied controls. Physical activity scores were similar in
the two groups with SCI.
These preliminary data are compatible with an independent
relationship between autonomic dysfunction after SCI and
adverse cardiovascular risk profiles, such as impaired glucose
handling. Impairments in lipid profiles did not seem to be
affected by autonomic dysfunction. These findings support the
65
need to target treatment towards autonomic dysfunction after
SCI, in addition to lifestyle modification, in order to reduce
morbidity and mortality due to cardiovascular disease.
References: 1. Kleiger RE et al. Noninvasive Electrocardiology
2005 (10) 88-101
2. Washburn RA et al. Archives of Physical Medicine and
Rehabilitation 2002 (83) 193-200
P2-19
Access to Primary Care for
Persons with SCI: A Health Service
Delivery Study
J. Richardson1, L. Macrae2, S. Wojkowski1, A. Moore3, D.
Oliver3, D. Price1, K. Leblanc2, T. Czajka2, S. Sinclair1, P.
Athanasopolous4, T. Jeji5
1
, McMaster University, Hamilton/ON/CANADA, 2, Hamilton
Health Sciences, Hamilton/ON/CANADA, 3, McMaster Family
Health Team, Hamilton/ON/CANADA, 4, Canadian Paraplegic
Association Ontario, Toronto/ON/CANADA, 5, Ontario
Neurotrauma Foundation, Toronto/ON/CANADA
Background: Individuals with spinal cord injury (SCI) have
difficulty accessing primary care services, specifically services
provided within family practices.1 SCI is a chronic condition
that requires ongoing management, prevention strategies and
interactions with health care professionals. This demonstration
project will develop and implement a model of care that will
formalise a health services relationship between a hospitalbased spinal cord injury specialist team at Hamilton Health
Sciences and primary care practice sites of two Hamilton
Family Health Teams (FHTs). Capacity building will occur
within the FHTs by increasing the knowledge and competency
of primary care teams to provide services to persons with
SCI. Aspects of the Expanded Chronic Care model which is
being adopted in Ontario as a framework to manage chronic
conditions will be addressed by this project. The model will
include a self-management component in which patients
will learn the skills to manage their condition. Purpose The
purpose of this project is to improve the management of care
for patients with SCI in a primary healthcare setting.
Methods: A partnership will be developed between two
Hamilton Family Health Teams, the spinal injury team at
Hamilton Health Sciences, and the Canadian Paraplegic
Association Ontario to facilitate access to timely and informed
primary care for individuals with SCI. This partnership will
facilitate the care of patients with SCI in a primary care setting
and will enable knowledge transfer and capacity building
between the specialized spine consultation team and the
physicians and patient care providers on the FHTs. It will
provide benefits to the following stakeholders: Patients without
a FP will have increased access to primary care. This model
will enhance the health of patients with SCI by increasing the
66
continuity of care between primary care and specialized SCI
services. Physicians and patient care providers will receive
increased support in practices within the FHTs through
linkages to a team of specialists in SCI at Hamilton Health
Sciences (HHS) to support them in the care of these patients.
The Spinal Cord Injury Specialist Team will benefit by providing
support which will enable the SCI patient population to gain
access to care at the most efficient point of entry to the health
care system. This approach to care is likely to result in fewer
hospital admissions and ER visits and patients are more
likely to have health complaints appropriate to primary care
managed at this level of the healthcare system.
Results: Sustainability This model of care will be tested within
the Hamilton region, however we envision it is sustainable in
other healthcare settings where there are similar resources.
We anticipate that it will be transferrable to other FHTs within
the region and the province where linkages can be made
between a SCI Specialist Team and primary care providers.
Acknowledgement: This project funded by the Ontario
Neurotrauma Foundation.
References: 1. McColl, M., et al., Physician Experiences
Providing Primary Care to People with Disabilities. Healthcare
Policy, 2008. 4: p. e129-e147.
P2-21
Use of the Spine Adverse Events
Severity (Saves) Instrument for
Traumatic Spinal Cord Injury
J. Street1, V. Noonan2, C. Fisher3, A. Cheung2, B. Sun2, M.
Dvorak1
1
, Vancouver General Hospital, Vancouver/BC/CANADA, 2,
Rick Hansen Institute, Vancouver/BC/CANADA, 3, Vancouver
General Hospital, Vancouver/CANADA
Background: Adverse events are common during acute
care in patients with traumatic spinal cord injury (tSCI).
International Classification of Diseases (ICD) codes are used
in hospital administrative databases to manage health-related
information. Administrative data is often used to report adverse
events; however, this data may not reflect patient complexity
and outcome. The Spine Adverse Events Severity (SAVES)
instrument has been validated for adverse event recording
in the spine. The objective of this study was to determine if
SAVES was superior to ICD-10 codes in measuring adverse
events in patients with tSCI.
Methods: Patients discharged between 2006 and 2010 were
identified from our prospective registry. Two cohorts were
created based on the method used to record adverse events;
Cohort 1 used ICD-10 codes from the hospital Discharge
Abstract Database and Cohort 2 used SAVES data. The ICD-10
codes were mapped to adverse events in SAVES. The five most
common adverse events were examined: neuropathic pain,
urinary tract infections (UTI), pneumonia, pressure ulcers
and delirium. There were 212 patients in Cohort 1 and 173
patients in Cohort 2. Analyses were adjusted to account for the
different sample sizes and the two cohorts were comparable
based on age, gender, mechanism of injury and motor score.
Results: There was an 18% increase in the number of patients
diagnosed as having one or more adverse events using SAVES
(76%) compared to ICD-10 codes (58%). The number of
adverse events recorded per person was doubled using
SAVES (1.3 versus 2.7). SAVES reported greater incidence
of neuropathic pain (x32), UTI (x1.4), pneumonia (x1.2),
pressure ulcers (x2.9) and delirium (x1.2). The number of
intra-operative adverse events identified was 2.3 times greater
using SAVES (7.5% versus 17.3%). The implementation
of the SAVES system for patients with tSCI captured more
patients experiencing adverse events and more adverse
events per person compared to using ICD-10 codes from an
administrative database. This study demonstrates the utility of
prospectively collecting data on adverse events using validated
tools.
References: Not applicable
P2-22
Long-Term Follow-Up of Bladder
Function in Patients with Spinal
Cord Injury
J. Wöllner, M. Walter, F. Gregorini, D. Birnböck, U. Mehnert, T.
Kessler
Neuro-Urology, Spinal Cord Injury Center, Balgrist University
Hospital, University of Zurich, Switzerland, Zurich/
SWITZERLAND
Background: Patients with spinal cord injury (SCI) often suffer
from bladder dysfunction according to the completeness and
the level of the lesion (1). Neurogenic detrusor overactivity
(NDO) frequently combined with detrusor sphincter
dyssynergia (DSD) is a common condition after suprasacral
injuries. The upper urinary tract is at risk due to high
intravesical pressure, which often causes vesico-ureteral reflux
(VUR), when adequate treatment is postponed or have never
been introduced at all. Quality of life and life expectancy are
constantly increasing due to the improvement of therapeutic
options for this group of patients over the last decades. We
assessed the long-term bladder function in patients after SCI.
Methods: An evaluation of 56 consecutive patients (12
females, 44 males) suffering from neurogenic bladder
dysfunction due to SCI for at least five years with regular
follow-up and a current urodynamic examination was
performed between January and September 2010.
Results: Our collective (mean age at SCI 31±13 years; mean
duration of urodynamic evaluation 15 years, range 5-42)
contained 51 patients suffering from a traumatic onset, while 5
had other lesions (toxic, inflammatory). The level of lesion was
divided in cervical (14/56), thoracic (32/56), lumbar (8/56),
and sacral (2/56). Clean intermittent catheterization (CIC)
was the primary way of bladder emptying (29/56), whereas
7 had an indwelling catheter and 9 voided spontaneously.
Urinary incontinence was present in 34% (19/56). The
favorite medical treatment was oxybutynin (15/56). Low
grade VUR (maximum grade 2) was detected unilaterally in
7 patients and bilateral in one patient. Mean compliance was
65 (SD±213) mL/cmH20 and mean maximum cystometric
capacity 447 (SD±136) mL. NDO was observed in 29
patients (14 were without treatment, the remaining were
mostly under oxybutynin), while 16 of them were incontinent
(mean detrusor leak point pressure of 42±29 cmH20). Most
of our regularly followed patients suffering from neurogenic
bladder dysfunction due to SCI for at least 5 years had
normal cystometric capacity and compliance. VUR was quite
rare and low grade. Thus, to allow an individual bladder
management we strongly recommend a regular follow-up with
an urodynamic evaluation.
References: (1) Stöhrer M, Blok B, Castro-Diaz D, ChartierKastler E, Del Popolo G, Kramer G, Pannek J, Radziszewski P,
Wyndaele JJ. EAU guidelines on neurogenic lower urinary tract
dysfunction. Eur Urol 2009; 56:81-8.
P2-23
Does Bacteriuria Matter in Patients
with Neurogenic Lower Urinary
Tract Dysfunction?
M. Walter, J. Wöllner, F. Gregorini, D. Birnböck, M. Kozomara,
U. Mehnert, T. Kessler
Neuro-Urology, Spinal Cord Injury Center, Balgrist University
Hospital, University of Zurich, Switzerland, Zurich/
SWITZERLAND
Background: The function and integrity of the lower urinary
tract is often affected by neurologic diseases (1). The influence
of recurrent urinary tract infections on the quality of life
is significant and still a challenging task in neuro-urology.
Therefore, we investigated in patients with neurogenic lower
urinary tract dysfunction (LUTD) the incidence of symptomatic
urinary tract infections (UTI) and asymptomatic bacteriuria to
find potential risk factors.
Methods: An evaluation of 185 consecutive patients with
neurogenic LUTD undergoing urodynamic investigation was
performed prospectively. Urine samples for urine culture were
obtained by sterile catheterization prior to the examination.
At this moment, none of the patients complained about any
symptoms of UTI. The occurrence of UTI was captured for
each patient. Data were normally distributed and the values are
67
presented as mean ± standard deviation. Uni- and multivariate
analyses (including gender, age, mode of bladder emptying,
video-urodynamic parameters as well as type and duration of
the neurologic disorder) were performed to detect predictors for
asymptomatic bacteriuria and/or symptomatic UTI.
Results: Spinal cord injury (n=120), multiple sclerosis
(n=23), spina bifida (n=2), Parkinson’s disease (n=3), and
others (n=37) were found to be the underlying neurologic
disorders (mean duration 11±15 years) in our collective of
185 patients (mean age 49±16 years). Aseptic intermittent
self-catheterization (n=71) and spontaneous voiding (n=51)
were the most common ways for bladder emptying. Evaluation
of the urine culture revealed a bacterial growth >105/mL in 76
(41%) patients and a bacterial growth <104/mL in 39 (21%)
patients, while 70 (38%) patients had no bacterial growth
at all. Although E.coli (17.8%) and Klebsiella pneumoniae
(9.7%) were the predominant bacteria, all patients were
asymptomatic. No predicting factors were found in uni- and
multivariate analyses for either asymptomatic bacteriuria or
symptomatic urinary tract infection (mean rate 1.0±1.9 per
year during follow-up). Since the incidence of symptomatic
UTI was only about 1 per year, whereas more than 60% of our
patients had a significant bacterial growth in urine culture, we
do not recommend any treatment in patients with neurogenic
LUTD presenting asymptomatic bacteriuria.
References: (1) Stöhrer M, Blok B, Castro-Diaz D, ChartierKastler E, Del Popolo G, Kramer G, Pannek J, Radziszewski P,
Wyndaele JJ. EAU guidelines on neurogenic lower urinary tract
dysfunction. Eur Urol 2009; 56:81-8.
disorders. This preliminary investigation determined the
amount and intensity of physical activity undertaken during
inpatient SCI rehabilitation.
Methods: Participants in this observational study were
consecutive admissions to two Canadian inpatient SCI
rehabilitation centres. Participants were assessed with the
Physical Activity Recall Assessment for People with Spinal
Cord Injury (PARA-SCI).2 The PARA-SCI categorizes the
intensity of activities as nothing, mild, moderate, or heavy
and documents time spent on activities. The PARA-SCI was
administered on two days near admission and again, near
discharge for each patient and averaged to obtain activity for
a typical weekday. A 2x4 mixed model ANOVA was conducted
to explore the relationship between minutes of physical activity
and physical activity intensity at admission and discharge from
inpatient SCI rehabilitation.
Results: The 22 subjects in this investigation were 48±15
years old. Average time from injury to rehabilitation
admission was 24±13 days. Nineteen individuals were
traumatic and 3 non-traumatic;16 had incomplete injuries,
6 were complete. There was no statistically significant
interaction or time effect. The main effect for intensity
yielded significance [F(3, 84)=71.7, p= 0.0005]. Post-hoc
analysis indicated that the mean score for time spent in
activities classified as nothing was significantly higher than
all other intensities. Mild physical activity also significantly
differed from heavy intensity. Time in moderate and
heavy intensity did not differ significantly from each other.
P2-25
Self-Reported Physical Activity of
Individuals with SCI at Admission
and Discharge from Inpatient
Rehabilitation
D. Zbogar1, J. Eng2, A. Krassioukov3, W.C. Miller4, M. Verrier5
1
, Rehabilitation Research Lab, GF Strong Rehab Centre,
Vancouver/BC/CANADA, 2, Department of Physical Therapy,
Faculty of Medicine, University of British Columbia,
Vancouver/BC/CANADA, 3, University of British Columbia Physical Medicine and Rehabilitation, Vancouver/BC/CANADA,
4
, Department of Occupational Sciences & Occupational
Therapy, Faculty of Medicine, University of British Columbia,
Vancouver/BC/CANADA, 5, Toronto Rehabilitation InstituteUniversity Health Network, Toronto/ON/CANADA
Background: Little is known about the amount of physical
activity experienced by individuals with spinal cord injury
(SCI) during inpatient rehabilitation. Physical activity early
after a SCI is thought to be important for its benefits in
optimizing recovery1 as well as its ability to reduce secondary
complications like cardiovascular disease and autonomic
68
That there was no significant change in activity levels from
admission to discharge is notable. We anticipated increasing
levels of physical activity with time in inpatient rehabilitation
as functional recovery occurred. Of relevance, it appears
the minimum threshold for physical activity for individuals
with chronic SCI3 is exceeded in this group, as moderate
(M=94.68) and heavy activity (M=35.69) account for above
20 minutes of time. What remains to be elucidated is whether
these activities are truly aerobic in nature. Review of heart rate
data collected during the day will be analyzed to answer this
question.
References: 1. Sumida, M., et al. (2001) Arch Phys Med
Rehabil, 82, 391-5.
2. Ginis, K. A., et al. (2005) Med Sci Sports Exerc, 37, 1099111. 3. 2011 Canadian Physical Activity Guidelines, www.
sciactioncanada.ca/guidelines
P3-01
The Acute Effects of Circulating
Cytokines on Peripheral Nerve
Function in Humans
D. Allison, L. Green, D. Gabriel, B. Roy, G. Inglis, D. Ditor
Brock University, St Catharines/ON/CANADA
Background: A chronic elevation in circulating cytokine
concentrations is typically observed following spinal cord
injury (SCI) (Davies et al., 2007). This elevation has been
shown to be particularly pronounced during the presence of a
secondary health complication but is also evident even when
no complications are apparent (Hayes et al., 2002). Although
cytokines play a pivotal role in the inflammatory response,
potential detrimental effects concerning nerve function have
also been shown. When examined in ex vivo animal models,
an acute elevation in the cytokine tumour necrosis factor-α was
shown to cause reductions in the compound action potential
and a depolarization of the resting membrane potential of the
excised spinal cord (Davies et al., 2006). If cytokines have
similar detrimental effects on the central or peripheral nerves
of humans, individuals with chronically elevated levels, such as
those with SCI, would be at the highest risk. The potential for
such molecularly-based disruptions may limit the motor and
sensory capabilities of individuals following SCI by impacting
structurally healthy neural tracts.
Methods: The notion of a peripheral neuropathy contributing
to motor and sensory impairment is often neglected following
SCI due to the more evident issues associated with central
damage. The current study investigated the acute effects of
circulating cytokines on peripheral nerve function in humans.
Nerve conduction velocity (NCV) and several measures of
physical function (grip strength, grip endurance and finger
dexterity) were examined in 12 college-aged, able-bodied
males prior to and following the induction of a cytokine spike
via one hour of vigorous cycling exercise (65% heart rate
reserve). The use of able-bodied subjects allowed for outcome
measures to be examined under basal cytokine levels as
well as exercise-induced elevated levels. Outcome measures
were examined at 1 hour, 2 hours and 24 hours following the
cytokine-inducing exercise bout due to the potential delay for
channelopathic effects.
Results: A significant positive correlation was found between
the cytokine interleukin-6 (IL-6) and NCV at 2 hours postexercise (r=0.606, p=0.048). A significant negative correlation
was found between the cytokine interleukin-1 receptor
antagonist (IL-1ra) and NCV at 24 hours post-exercise (r=0.652, p=0.021). A significant positive correlation was also
found between IL-1ra and endurance at 1 hour post-exercise
(r=0.643, p=0.033). As such, it would seem that certain
cytokines such as IL-6 may potentially act to enhance nerve
function while other cytokines such as IL-1ra may have
negative effects on the nerve and reduce NCV. If certain
cytokines are to have detrimental effects on nerve function,
future research may be directed towards methods of reducing
chronic elevations or preventing their effects. In addition,
the current evidence also indicates a potentially beneficial
neural effect from certain cytokines, and this necessitates
the examination of a wider variety of cytokines and other
molecules for such benefits. This may allow for some degree
of peripheral neurological improvement in individuals with
chronic SCI and the enhancement of motor, sensory and
autonomic function in this population.
References: Davies et al. (2006) Davies et al. (2007) Hayes et
al. (2002)
P3-02
Mapping the Interactions of Chronic
and Acute Noxious Sensations in
the Spinal Cord
M. Beynon, R.L. Bosma, C.E. Dobek, P.W. Stroman
Center for Neuroscience, Queen’s University, Kingston/
CANADA
Background: Attention and emotion play important roles in
modifying the perception of pain. By influencing attention and
emotion, interactions between two painful stimuli may alter the
perception of one or both stimuli, such as heightening pain
anxiety, or dividing attention between the two stimuli. Such
interactions are important, both for our understanding of pain
processing, and for developing means of studying effects of
chronic pain with fMRI. Therefore, the primary aim of this
study is to determine the neural responses in the spinal cord
to multiple, competing noxious thermal stimuli.
Methods: Healthy participants underwent functional MRI
of the spinal cord using our established methods for data
acquisition and analysis. Each participant was exposed
to five noxious thermal stimulation conditions involving
a hot intermittent stimulus (acute) on the right hand.
Simultaneously, a constant stimulus (chronic) at two different
temperatures (hot and cold) was applied on either the right or
left hand (C6 dermatome). Thermal stimulation was just below
(-0.3°C for hot) or above (+0.3°C for cold) participants’
measured pain thresholds. The order and combination of
stimuli was counter-balanced across participants.
Results: show that the addition of a chronic thermal stimulus
to the C6 dermatome modulates the acute pain response in
the spinal cord at the C6 segment. The patterns of activity
appear to vary with the simultaneous application of a constant
69
chronic stimulus, and whether the two stimuli (chronic and
acute) are applied to the same, or opposite, hands. However,
the magnitude of the responses do not show any dependence,
and are relatively constant across all combinations of tested
thermal stimuli. The results to date therefore suggest that
interactions between constant noxious stimuli, such as chronic
pain, and intermittent stimulation (typically used for fMRI),
may reveal important information about spinal cord function
and the characteristics of such interactions.
References: 1. Cahill, C.M. & Stroman, P.W. (2011). Mapping
of neural activity produced by thermal pain in the healthy
human spinal cord and brainstem: a Functional MRI Study.
Magnetic Resonance Imaging, 29, 342-352. 2. Figley, C.R.,
Leitch, J.K. & Stroman, P.W. (2010). In contrast to BOLD:
Signal enhancement by extravascular water protons (SEEP) as
an alternative mechanism of endogenous fMRI signal change.
Magnetic Resonance Imaging, 28, 1234-1243. 3. Figley,
C.R. & Stroman, P.W. (2009). Development and validation
of retrospective spinal cord motion time-course estimates
(RESPITE) for spin echo spinal fMRI: Improved sensitivity and
specificity by means of a motion-compensating general linear
model analysis, 44,421-427.
each participant. Data were analyzed by means of a general
linear model analysis.
Results: This study demonstrates that classical music
modulates spinal cord activity in response to thermal
stimulation just below heat pain threshold. The activity was
investigated at C8 as well as adjacent segments. Results show
distinct time course activity in both C6 and C8 that increases
or decreases in response to the change in music. No distinct
pattern of effect across participants was observed with
comparing preferred music to other types (Aversive, Neutral,
No music), or comparing activity with subjective ratings. This
study gives insight to spinal mechanisms and structures that
are involved in pain analgesia and music therapy, which may
enhance the efficiency of the techniques for its widespread
clinical use.
References: Evans, D. (2002). The effectiveness of music
as an intervention for hospital patients: a systematic review.
Journal of Advanced Nursing, 37, 8-18. Stroman, P. W., Coe,
B. C., & Munoz, D. P. (2011). Influence of attention focus
on neural activity in the human spinal cord during thermal
sensory stimulation. Magnetic Resonance Imaging, 29, 9-18.
P3-03
P3-04
Influence of Classical Music on
Neural Activity and Pain Response
in the Spinal Cord Using Functional
Magnetic Resonance Imaging
An In Vivo Experimental Platform
for Chronic Spinal Cord Injury
C.E. Dobek, R.L. Bosma, M.E. Beynon, P.W. Stroman
Center for Neuroscience Studies, Queen’s University, Kingston/
CANADA
X. Li1, J. Cui1, C. Wen1, K.D. Luk2, Y. Hu3
1
, Rm 108, Blk C, The Duchess of Kent Children’s Hospital,
Hong Kong/HONG KONG, 2, The Department of Orthopedics &
Traumatology, The University of Hong Kong, Hong Kong/HONG
KONG, 3, Flat A, 5/F, Blk D, The Duchess of Kent Children’s
Hospital, Hong Kong/HONG KONG
Background: Music therapy for pain reduction has dated back
thousands of years and is still widely used today, but little is
known about the underlying neural mechanisms involved.
With functional MRI of the spinal cord (spinal fMRI), we can
objectively view the functional changes involved in music
therapy in the spinal cord. This study aims to help identify the
mechanisms of descending pain modulation and further clarify
the analgesic effects of music.
Background: Spinal cord injury in a chronic process is
commonly happened in degenerative spinal disorders[1]. The
putative mechanism is that the compression of the enclosed
cord leading to tissue injury , ischemia and neurological
impairment. Yet the exact pathophysiology was still unclear.
An appropriate animal model, which reproduced chronic
compression of the cord, is helpful for better understanding
the disease.
Methods: Spinal fMRI studies were carried out using healthy,
English speaking, right-handed, non-musician controls.
Thermal stimulation was applied in a block paradigm of 4
stimulations per trial, with the stimulation site corresponding to
the C8 dermatome (right hand). The stimulation temperature
was set 0.3oC lower than heat pain threshold determined prior
to imaging. In addition to thermal stimulation, participants
listened to familiar classical music (Preferred) paired with
either scrambled classical music (Aversive), reverse classical
music (Neutral), or no music for each trial. After each trial,
participants reported subjective ratings for their temperature
discomfort on a scale from 0-10. There were 4 trials in total for
Methods: 1.Using adult Sprague-Dawley rats as in vivo animal
model, we inserted a water-absorbing urethane-containing
polymer, which would expand upon absorbing tissue fluid, into
the spinal canal at posterior-lateral side of the C5-C6 region to
induce chronic compression to the cervical spinal cord. At 1w,
4w and 12w post-operatively, we evaluated functional integrity
of the spinal cord by neuro-electrophysiology method and
observed the spinal cord impairment under MRI, Micor-CT
and histological studies.
2.In order to validate the chronic compression feature of this
novel animal model, we repeated the surgical intervention to
70
the rat model mentioned above. BBB score and MRI had been
employed to evaluate the functional and structure integrity of
the compressed spinal cord at 4, 12, 48, 72 hours and 1 week
post-operatively.
Results: 1.At 1w, 4w and 12w post-operatively, the
impairment of functional integrity of the spinal cord was
confirmed by neuro-electrophysiology changes respectively
which showed prolonged latency and /or decreased
amplitude. Under axial T2W and diffusion tensor images
(DTI) by 7-tesla MRI, it was revealed that the diffusivity of
the white matter of the cord dropped at the compression
site which was echoed by less myelin stained by luxol
fast blue. The increase of intensity of contrast medium
was also found in the gray matter at the compression site
under in vivo micro-CT, as well as the presence of the
cavities and increased blood vessels correspondingly. The
representative pathological changes of the injured spinal
cord were validated with histological studies. 2.The results
were well validated with the histological evaluation (HE
and myelin stain). Although spinal cord compression and
ultrastructure damage were found in MRI T2 image and
histological observation separately, BBB score didn’t show
acute motor dysfunction in different time points. None
of acute spinal cord injury changes, such as significant
decrease of motoneurons in ventral horn, blood vessel
rupture/hemorrhage[2], edema, macrophage infiltration and
inflammatory demyelination[3], presented in histological
consequences. It demonstrated that this animal model
was consistent with the early-stage pathological changes
of chronic spinal cord injury, differing acute injury. This
reliable and stable research platform may contribute to the
revelation of underlying pathological mechanism, biological
investigation and relative drug management development.
References: [1] Fehlings MG, Skaf G. A review of the
pathophysiology of cervical spondylotic myelopathy with
insights for potential novel mechanisms drawn from traumatic
spinal cord injury. Spine 1998;23:2730–7.
[2] Kakulas BA. Neuropathology: the foundation for new
treatments in Cord 42:549–563, 2004. spinal cord injury.
Spinal [3] Totoiu MO, Keirstead HS. Spinal cord injury is
accompanied by chronic progressive demyelination. J Comp
Neurol 486:373–383, 2005
P3-05
Dietary Treatments for Spinal Cord
Injury
(CNOSP), Department of Orthopaedics, University of British
Columbia, Vancouver/BC/CANADA
Background: Each year, over 1,500 Canadians sustain a new
Spinal Cord Injury, and join over 40,000 Canadians living
with traumatic SCI. Other than stabilizing the broken spinal
column surgically and providing rehabilitation training there
are no effective treatments for the spinal cord damage. Many
experimental therapies for spinal cord injury in animals aim
to prevent any further damage to the cord after the initial
injury. We are studying the effects of simple dietary strategies,
to improve functional recovery in animal models of spinal
cord injury. Previously, we have discovered that fasting
every other day is beneficial after SCI. However, given that
a fasting regimen may be met with little enthusiasm from
patients, dietitians and physicians, we felt the need to further
explore the implementation of alternative dietary strategies.
Hence, in this study we investigated a high-fat, and very
low-carbohydrate regimen known as ketogenic diet (KD) as a
possible neuroprotective treatment for acute cervical SCI using
a rodent model.
Methods: Four hours following C5 hemi-contusion injury,
adult male rats were allowed access to either a standard
carbohydrate-based diet, or KD. Forelimb function was
evaluated for 14 weeks.
Results: Following SCI, KD-treated rats showed improved
usage and motor control of the affected paw during rearing
and grooming behavior. In addition, KD regimen improved
pellet-retrieval of the ipsilateral limb and recovery of wrist and
digit movements. Importantly, after returning to a standard
carbohydrate-based diet after 12 weeks of KD treatment, the
beneficial effects on forelimb function remained stable for
at least 6 weeks. No effects on body weight gain, cholesterol
levels or bone morphology/density were observed.
References: A short term KD regimen enhances functional
recovery from SCI in rats and has lasting therapeutic effects
without apparent side effects. From a translational perspective,
our results mandate the reconsideration of standard clinical
practices, which have traditionally promoted high carbohydrate
nutritional content in acute SCI patients. The optimization of
such aspects of patient care is highly desirable, particularly
when the influence of nutritional status on secondary injury
becomes apparent in animal studies. We encourage opening
further dialogue on this important aspect of patient care in
acute SCI, given the limited interventions currently available for
this devastating injury.
F. Streijger1, W. Plunet1, J.H.T. Lee1, J. Liu1, C.K. Lam1, S.E.
Park1, B. Hilton1, B.L. Fransen1, K.A.J. Matheson1, P. Assinck1,
B.K. Kwon2, W. Tetzlaff1
1
, ICORD (International Collaboration On Repair Discoveries)
Blusson Spinal Cord Centre, Vancouver/BC/CANADA, 2,
Combined Neurosurgical and Orthopaedic Spine Program
71
P3-06
Establishing a Model Spinal Cord
Injury in the African Green Monkey
for the Preclinical Evaluation of
Biodegradable Polymer Scaffolds
Seeded With Human Neural Stem
Cells
E. Wirth1, C. Pritchard2, J. Slotkin3, D. Yu4, H. Dai5, M.
Lawrence6, R. Bronson7, F. Reynolds1, Y. Teng4, E. Woodard8,
R. Langer2
1
, InVivo Therapeutics Corporation, Cambridge/MA/UNITED
STATES OF AMERICA, 2, Department of Chemical Engineering,
Massachusetts Institute of Technology, Cambridge, MA/
UNITED STATES OF AMERICA, 3, Washington Brain & Spine
Institute, Washington, DC/UNITED STATES OF AMERICA,
4
, Department of Neurosurgery, Brigham and Women’s
Hospital, Boston, MA/UNITED STATES OF AMERICA, 5,
Department of Neuroscience, Georgetown University Medical
Center, Washington, DC/UNITED STATES OF AMERICA, 6,
RxGen, Inc., Hamden, CT/UNITED STATES OF AMERICA, 7,
Department of Pathology, Harvard Medical School, Boston,
MA/UNITED STATES OF AMERICA, 8, Department of
Neurosurgery, New England Baptist Hospital, Boston, MA/
UNITED STATES OF AMERICA
Background: Given the involvement of post-mitotic neurons,
long axonal tracts and incompletely elucidated injury and
repair pathways, spinal cord injury (SCI) presents a particular
challenge for the creation of preclinical models to robustly
evaluate longitudinal changes in neuromotor function in the
setting in the presence and absence of intervention. While
rodent models exhibit high degrees of spontaneous recovery
from SCI injury, animal care concerns preclude complete
cord transections in non-human primates and other larger
vertebrate models.
Methods: To overcome such limitations a segmental
thoracic (T9–T10) spinal cord hemisection was created and
characterized in the African green monkey. Physiological
tolerance of the model permitted behavioral analyses for
a prolonged period post-injury, extending to predefined
study termination points at which histological and
immunohistochemical analyses were performed. Four
monkeys were evaluated (one receiving no implant at the
lesion site, one receiving a poly(lactide-co-glycolide) (PLGA)
scaffold, and two receiving PLGA scaffolds seeded with human
neural stem cells (hNSC)). All subjects exhibited BrownSéquard syndrome 2 days post-injury consisting of ipsilateral
hindlimb paralysis and contralateral hindlimb hypesthesia with
preservation of bowel and bladder function.
Results: A 20-point observational behavioral scoring system
allowed quantitative characterization of the levels of functional
recovery. Histological endpoints including silver degenerative
staining and Iba1 immunohistochemistry, for microglial and
72
macrophage activation, were determined to reliably define
lesion extent and correlate with neurobehavioral data, and
justify invasive telemetered electromyographic and kinematic
studies to more definitively address efficacy and mechanism.
References: Teng YD, Lavik EB, Qu X, Park KI, Ourednik
J, Zurakowski D, Langer R, Snyder EY. Functional recovery
following traumatic spinal cord injury mediated by a unique
polymer scaffold seeded with neural stem cells. Proceedings
of the National Academy of Sciences of the United States of
America 2002;99(5):3024–9.
Courtine G, Bartlett Bunge M, Fawcett JW, et al. Can
experiments in nonhuman primates expedite the translation of
treatments for spinal cord injury in humans? Nature Medicine
2007;13(5):561–6.
Disclosure: Pritchard, Slotkin, Dai, Lawrence, Reynolds,
Woodard, and Langer are all current or former employees,
advisers, or contracted researchers of InVivo Therapeutics
Corporation, the sponsor of the study in the abstract (R&D
stage).
P3-07
A Model for Bridging the
Translational Valley of Death in
Spinal Cord Injury
N. Thorogood, B. Barrable, V. Noonan, P. Joshi, M. Dvorak
Rick Hansen Institute, Vancouver/CANADA
Background: To improve health care outcomes with costeffective treatments and prevention initiatives, basic
health research must be translated into clinical application
and implementation, a process commonly referred to as
translational research. Despite the amount of funding that
supports basic research, few basic research discoveries
achieve their fullest potential. It is estimated that only 14% of
health-related scientific discoveries enter into medical practice
and that it takes an average of 17 years for research evidence
to extend into clinical practice. 1 The transition from benchto-bedside research is so fraught with obstacles that it is often
referred to as the “valley of death”.
Methods: The Rick Hansen Institute (RHI) has developed
a unique Praxis Model for translational research in the
field of spinal cord injury (SCI). Praxis can be defined as
the process by which a theory, lesson, or skill is enacted,
practiced, embodied or realized. At RHI this means bringing
knowledge into action and represents the process by which
translational research is practiced to bridge the “valley of
death” in the research and commercialization continuum of
SCI discoveries; to improve healthcare outcomes for people
with SCI and decrease the financial impact on the healthcare
system. Translational research inherently requires multi-
disciplinary teams, multi-sector partnerships and diverse
funding; therefore, distinct from traditional research institutes,
the Praxis Model combines the attributes of a granting/sponsor
agency, early commercialization investor/incubator, as well as
a research network and centre. RHI’s Praxis Model uses four
pillars of implementation to move outputs into outcomes – for
knowledge to be translated into action – at the institutional,
professional, multi-disciplinary and commercialization level.
Results: At the hub of a research network, RHI uses the Praxis
Model to unite a diverse group of shareholders and provide
support for a national SCI registry, clinical trials, validation
studies, implementation, best practice dissemination and
early commercialization. The Network provides an opportunity
for partnerships to share data and innovative ideas for SCI
solutions. RHI has participated and supported over 60 studies
since 2007 and has engaged researchers from nine countries,
46 academic institutions and various accreditation and
professional associations. A national network was developed
into an international network and connected with additional
existing networks. Currently, the model is being independently
evaluated to determine its strengths and limitations. Examples
of RHI initiatives using the Praxis Model and results of the
evaluation will be presented. The RHI has developed an
innovative solution to move knowledge into action. The
Praxis Model strives to lead collaboration across the global
SCI community by providing resources, infrastructure and
knowledge. Lessons learned in developing the Praxis Model
may assist other organizations dealing with similar translational
research challenges.
References: 1. Balas EA, Boren SA. Yearbook of Medical
Informatics: Managing Clinical Knowledge for Health Care
Improvement. Stuttgart, Germany: Schattauer, 2000.
P3-08
Development of a Knowledge
Translation Program Among Spinal
Cord Injury Patients in Acute Care
M. Berube1, M. Albert1, J. Chauny1, D. Contandriopoulos2, A.
Dusablon1, M. Prud’Homme Lemaire1, A. Gagne1, S. Parent1,
E. Laflamme1, N. Boutin1, S. Delisle1, S. Lacroix3, F. Bedard3,
J. Macthiong1
1
, Hôpital du Sacré-Coeur, Montreal/CANADA, 2, University of
Montreal, Montreal/QC/CANADA, 3, Hôtel Dieu de St-Jérôme,
St-Jérôme/CANADA
Background: Background: Clinical guidelines are a common
tool to synthesize new knowledge and inform health care
professionals, but it turns out that these guides are sometimes
unknown or not used comprehensively. The difficulty to
change clinical practice independently of the quality of the
research findings synthesis is well documented. To overcome
this problem, an analysis of the barriers for translation of
knowledge to practice must be made. In the Western Quebec
Expertise Center, this analysis revealed that the implementation
of recommendations from clinical guidelines was complicated
by factors associated with the context, as well as available
human and financial resources. Several knowledge translation
strategies were therefore identified to reduce the scope of those
barriers, including the development of interactive educative
online activities for all health care professionals involved with
spinal cord injury patients, care map and educational activities
provided by resource persons in practice.
Purpose: This project granted by the Quebec Health
Care Research Funds aims to systematically implement
recommendations included in the Consortium for Spinal Cord
Injury Medicine guidelines (2008) in the Western Quebec
acute care continuum. To meet this objective, the development
of a knowledge translation program was recently undertaken.
Methods: Method: This project, based on the knowledge to
action cycle model (Graham et al., 2006), will be conducted
in three main phases, namely: the selection and adaptation
of knowledge to organizational contexts, the development
of knowledge transfer strategies, and the validation of those
strategies.
Results: Results: To date, the first phase of the project has
been completed. Indeed, an expert committee composed
of orthopaedists, emergency physicians, an intensivist,
nurses, physiotherapists, occupational therapists and a
respiratory therapist from different hospitals has been
created for the selection and adaptation of knowledge to
organizational contexts. The members of this committee
have selected recommendations based on level of evidence,
clinical relevance and feasibility of implementation.
Thereafter, they reviewed the literature from 2008 to 2011
considering that the guidelines were published in 2008.
Selected recommendations were reconsidered in light of new
research findings after which, indicators to evaluate clinical
practice were identified. Finally, targeted recommendations
and practice indicators were presented to clinicians of the
involved services as well as to hospital administrators. A new
category of recommendations was added and few changes
were brought to clinical indicators after this consultation
process. Conclusions: Upon completion of this project,
the gap between knowledge production and application
in practice will be reduced, and a structure to enhance
the quality of care will be implemented. Consequently, we
estimate that outcomes obtained among the concerned
population of patients will be improved. Advancements in
knowledge translation research in addition to improvements
in the training of health care professionals (current and
future) involved with spinal cord injury patients are also
expected.
References: Consortium for Spinal Cord Medicine (2008).
Early Acute Management in Adults with Spinal Cord Injury:
A Clinical Practice Guidelines for Health-Care Professionals.
Paralyzed Veterans of America: Washington, DC. Graham et al.
(2006). Lost in knowledge translation: time for a map? Journal
of Continuous Education in the Health Professions, 26, 13-24.
73
P3-09
P3-10
Critical Appraisal Tools for
Preclinical Studies in Spinal Cord
Injury Research
Investigating Knowledge Translation
Between Biomedical Researchers,
Knowledge Facilitators and
Wheelchair Users
J. Cragg, F. Warner, W. Plunet, M. Ramer, J. Borisoff
International Collaboration on Repair Discoveries, Vancouver/
CANADA
Background: Critical appraisal is an essential skill required by
clinicians and scientists alike. Critical appraisal tools exist for
several reasons. For example, critical appraisal tools facilitate
both formal (eg. peer review and systematic review) and
informal (eg. journal club) review processes. By providing a
checklist of agreed-upon components of high quality trials/
experiments, such as randomization, blinding, and use of
appropriate statistical methods, they provide a user-friendly,
standardized approach to the review process. Further, they
have the added benefit of being able to‘reverse engineer’
the criteria for study design. That is, experimenters can
implement the components into both the design and reporting
of their studies. There does not yet exist readily available,
standardized, and piloted critical appraisal tools with a specific
pre-clinical discovery science focus in the area of spinal cord
injury (SCI) research.
Methods: Because several critical appraisal tools already exist
in benchside stroke research and in clinical practice, we have
modified these tools to fit within a SCI bench science context,
and have also piloted these tools [1].
Results: Here, we describe the development, piloting, and
suggested implementation strategies of a new checklist
specifically for animal experimentation. We also take this
opportunity to highlight several areas where we feel SCI preclinical discovery science must improve with reference to
some of the areas on the checklist. Improving the quality and
consistency of conducting and reporting trials is necessary
(but perhaps not sufficient) to move forward in SCI research.
References: Richard F. Heller, Arpana Verma, Islay Gemmell,
Roger Harrison, Judy Hart, Richard Edwards, Critical appraisal
for public health: A new checklist, Public Health, Volume 122,
Issue 1, January 2008, Pages 92-98.
C. Goudie, B. Hallgrimsson
Carleton University, Ottawa/ON/CANADA
Background: Optimal wheelchair seating can play a crucial role
in the physical health of wheelchair users, especially those with
spinal cord injury related conditions. For this reason, wheelchair
users must make informed decisions when choosing appropriate
wheelchair seating systems and are encouraged to base their
choices on accessible and reliable information at the time of
assessment. Such information can be provided by therapists
and wheelchair seating specialists, which include manufacturers
and designers - also considered to be knowledge facilitators.
Recommendations by knowledge facilitators are often made using
evidence-based knowledge and practices, however a need has
been identified for future recommendations to be based on more
recent, relevant and reliable biomedical research. This need is
associated with the abundance of biomedical research conducted
annually and resulting data in the form of journal articles and
publications. The issue facing knowledge facilitators is that the
research findings are often far too complex to disseminate for
immediate or practical use. This creates a gap in the knowledge
translation process for many important stakeholders, which
can potentially impact the final decision-making process of the
wheelchair user. The following paper investigates knowledge
translation and the divide between researchers and facilitators.
The perceived benefits of converting knowledge translation
processes into that of knowledge exchange will also be explored.
The results will review the current knowledge-to-action cycle
in the translation process as used by both researchers and
designers of wheelchair seating. A focus will be placed on
identifying potential areas for improvement in delivering timely,
disseminated research findings, individually targeting each
category of wheelchair seating stakeholder.
Methods: Methodology involves the creation of a workshop
for associated wheelchair seating stakeholders. Participants
will be engaged in dialogue about existing methods of
knowledge translation, and brainstorming will be conducted to
understand how to improve processes between specific vested
stakeholders in wheelchair seating.
Results: The desired outcome will potentially result in a
revised framework and recommendations of improved
knowledge translation processes between biomedical
researchers, knowledge facilitators and wheelchair users.
References: Altenstetter, C. (2008). Medical Devices.
Transaction Publishers. New Brunswick, USA and London,
UK. pp.1-13.
74
Armstrong, R., Waters, E., Dobbins, M., Lavis, J.N., Petticrew,
M., Christensen, R. (2011). Knowledge Translation Strategies
for Facilitating Evidence-Informed Public Health Decision
Making Among Managers and Policy Makers (Protocol). The
Cochrane Collaborative. The Cochrane Library, Issue 6. John
Wiley & Sons, Ltd.
Bennett, G., & Jessani, N. (2011). The Knowledge
Translation Toolkit Bridging the Know-Do Gap, a Resource for
Researchers. Ottawa: International Development Research
Centre.
Bero, L. A., Grilli, R., Grimshaw, J. M., Harvey, E., Oxman, A.
D., & Thomson, M. A. (1998). Getting Research Findings into
Practice: Closing the Gap Between Research and Practice: An
Overview of Systematic Reviews of Interventions to Promote
the Implementation of Research Findings. BMJ: British
Medical Journal, 317(7156), 465-468.
Caplan, N. (1979). The Two Communities Theory and
Knowledge Utilization. American Behavioral Scientist. Vol 22.
No. 3, January-February, 1979. University of Michigan: Sage
Publications.
Dijkers, M., Brown, M., Gordon, W. (2008). Getting
Published and Having an Impact: Turning Rehabilitation
Research Results Into Gold. Mount Sinai School of Medicine,
Department of Rehabilitation Medicine, New York, NY. Focus:
A Publication of the National Center for the Dissemination of
Disability Research (NCDDR), Technical Brief 19, 1-16.
Dykes, T. H., Rodgers, P. A., & Smyth, M. (2009). Towards a
New Disciplinary Framework for Contemporary Creative Design
Practice. CoDesign, 5(2), 99-116.
Fiore, S. (2008). Interdisciplinarity as Teamwork. Small Group
Research, 39(3), 251-277.
Fries, R. C. (2001). Handbook of Medical Device Design. New
York: M. Dekker.
Fries, R. C. (2006). Reliable Design of Medical Devices (2nd
ed. ed.). Boca Raton, Fla: CRC/Taylor & Francis.
Freemantle, N., Grilli, R., Grimshaw, J., Oxman, A. (1994).
Implementing Findings of Medical Research: The Cochrane
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Health Care, 1995; 4:45-47. British Medical Journal.
Gagnon, M. L. (2011). Moving Knowledge to Action Through
Dissemination and Exchange. Journal of Clinical Epidemiology,
64(1), 25-31.
Gibbons, M. (2008). In Michael Gibbons. (Ed.), Why is
Knowledge Translation Important? Grounding the Conversation.
Edmonton, AB: Knowledge Utilization Studies in Practice,
University of Alberta, 2008.
Gilman, B. L., Brewer, J. E., & Kroll, M. W. (2009). Medical
Device Design Process. 2009 Annual International Conference
of the IEEE Engineering in Medicine and Biology Society, ,
5609-5612.
Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe,
J., Caswell, W., et al. (2006). Lost in Knowledge Translation:
Time for a Map? Journal of Continuing Education in the Health
Professions, 26(1), 13-24.
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into Practice: Making Better Use of Research Findings. BMJ:
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BMJ: British Medical Journal, 317(7153), 273.
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Published March 20, 2009.
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Ottawa Heart Institute. In Class Lecture, November 15, 2011,
Carleton University.
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J., Patel, V. L. (2004).
The Design Phase of Critical Care Devices: A Cognitive
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P3-11
Practical Steps Towards Knowledge
Mobilization in Spinal Cord Injury
C. Koning1, L. Mumme1, M. Mark1, C. Huitsing1, K. Bayless1,
N. Hodgkinson1, J. Hsieh2, M. Duda2, J. Brown3
1
, Glenrose Rehabilitation Hospital, Edmonton/CANADA, 2,
National Implementation Research Network, Ontario/ON/
CANADA, 3, National Implementation Research, Carrboro/
UNITED STATES OF AMERICA
Background: Effective best practices adoption requires
an implementation framework that systematically
addresses barriers and facilitators in a real-life clinical
context and that engages all members of the community
of practice (CoP) for sustained and continuous quality
improvement (CQI). Currently, a CoP comprised of six
Canadian rehabilitation sites across three provinces (AB,
ON, PQ) are engaged in a Spinal Cord Injury Knowledge
Mobilization Network (SCI KMN) using an evidence-informed
implementation framework (Fixen et al., 2005; NIRN:
National Implementation Research Network). The framework
provides implementation science tools to move through the
four phases of implementation (exploration, installation,
initial implementation, and final implementation) in order
to successfully integrate best practices in pressure ulcer
prevention and management for patients with a SCI. With
support from the NIRN, two pressure ulcer prevention and
management “best practice” areas were identified by CoP
consensus: 1) risk assessment and 2) patient education. This
presentation focuses on the implementation steps taken to
date on these two areas in the inpatient SCI Program to date
at the Glenrose Rehabilitation Hospital.
Methods: Best practices (BP) and associated performance
measures were identified through a Delphi consensus exercise
involving all members of the CoP towards operationalizing
the two BPs chosen for implementation (risk assessment
and patient education). Input was provided by a site
implementation team (SIT) assembled under guidance from
NIRN. Critical participants of the SIT included site leaders and
clinical experts, as well as mentors able to build readiness
for implementation at the clinical level. NIRN consultation
at the Glenrose provided feedback on the readiness for
implementation and solidified the local CoP at the Glenrose.
SIT participants attended a two day implementation science
(IS) educational “bootcamp” designed to increase awareness
and understanding of the implementation framework and
processes. The SIT meet weekly to apply IS tools to the
installation phase of pressure ulcer risk assessment and
patient education and provide input to CoP subcommittees
for operationalization, data management, and knowledge
communication.
Results: 1) A workplan was developed to document the
process. 2) A SIT was assembled that includes participants
76
who are able to influence site and program decision-making,
have knowledge mobilization and clinical expertise. 3) Terms
of reference outlining the function, key responsibilities and
role of team members was developed. 4) Practice profiles
outlining critical components and acceptable variations
for implementation were developed. 5) Representatives
participate in the CoP subcommittees including the Project
Leadership Team, Transformation Specialist Team, Evaluation
and Data Management Team and the Knowledge Management
and Collaboration Team 6) A site specific communication
plan was developed which is intended to build knowledge
mobilization CoP at the Glenrose and Alberta Health Services.
7) Systems for documentation of the process were developed
that enable replication of the implementation process to other
BP initiatives.
References: 1. Fixsen, D. L., Naoom, S. F., Blase, K. A.,
Friedman, R. M. & Wallace, F. (2005). Implementation
Research: A Synthesis of the Literature. Tampa, FL: University
of South Florida, Louis de la Parte Florida Mental Health
Institute, The National Implementation Research Network
(FMHI Publication #231).
P3-12
Evaluation of Diffusion Tensor
Magnetic Resonance Imaging to
Improve Fiber Tract Assessment in
Humans
E. Tsai1, K. Rajamanickam2, B. Mendis3, T. Nguyen4, S.
Chakraborty4
1
, University of Ottawa, Ottawa/ON/CANADA, 2, Ottawa Hospital
Research Institute, Ottawa/ON/CANADA, 3, Ottawa Hospital
Research Institute, Ottawa/CANADA, 4, The Ottawa Hospital,
Ottawa/CANADA
Background: Evaluation of successful therapeutic
interventions in preclinical studies includes both functional
assessments and axonal tracing studies. In humans, however,
axon fiber tracing assessments are limited1. To improve fiber
regeneration assessments in humans, we investigated the use
of magnetic resonance diffusion tensor imaging (DTI) and fiber
tractography to image spinal cord fiber tracts in humans and
improve clinical correlation in patients with motor or sensory
deficits.
images and fractional anisotropy (FA) and MD values were
measured in delineated regions of interest corresponding
to the dorsal column (DC), corticospinal tract (CST) and
spinothalamic tract (STT) bilaterally. Clinical status was
obtained from the tractography clinical database. Patients
with unilateral deficits were identified from the tractography
database.
Results: Twenty three subjects (healthy controls=8, patients
with spinal lesions=15) were analyzed for this study. Two
patients were excluded due to movement artifacts during
scanning. Two additional patients were excluded as spinal
instrumentation prevented analysis of images at the level
of instrumentation. The remaining 11 patients (8 males:3
females) had a mean age of 51 years (17-77 years). There
was no statistical difference between the left and right
side of the DC, CST and STT for controls. In patients, FA
mean values differed significantly (P < 0.05) between the
affected tract compared to the contralateral tract. In 9/11
patients, differences in CST FA measurements correlated
with clinical motor deficits. In the remaining 2, there were
CST FA differences, but no noted motor deficits on physical
examination. In patients with sensory deficits, 10/11 patients
had differences in DC or ST FA measurements which
correlated with clinical sensory deficits. In the remaining 1
patient, there were sensory tract FA measurement differences
but no noted sensory deficit. MR DTI may improve imaging
correlation with specific motor or sensory deficits and may also
allow early identification of subclinical deficits. Improving the
imaging correlation of patients with specific motor or sensory
deficits can improve the selection of patients that will respond
more appropriately to targeted and more specific therapeutic
interventions (i.e. apply therapy for CST regeneration to
patients with CST deficits as identified by MR DTI). It may also
allow the evaluation of therapeutic strategies that may facilitate
regeneration without any easily demonstrated clinical outcome
(i.e. evaluation of regeneration of the thoracic spinal cord
fibers that do not reach the level of the lumbar roots). Being
able to evaluate axonal regeneration in humans will allow
the critical evaluation and improvement of the therapeutic
intervention. Further work on improving MR DTI correlation
with clinical status is ongoing.
References: 1. Tsai EC, et al. Journal of Histochemistry and
Cytochemistry 49:1111-1122, 2001
Methods: Hospital ethics board approval was obtained and
subjects underwent an axial spin-echo single-shot echoplanar generalized auto-calibrating partially parallel acquisition
diffusion-weighted imaging sequence and routine MRI
between August 2008 to November 2011. Mean diffusivity
(MD) and first eigen vector fractional anisotropy maps were
computed for all axial sections from mid C2 to C6 and
tractography was used to visualize the course of the tracts.
Matlab software was used to generate spinal cord tracking
77
P3-13
Early Surgical Decompression for
Traumatic Cervical Spinal Cord
Injury (SCI): A Cost-Utility Analysis
and Feasibility Study
M. Fehlings, J.C. Furlan
Division of Genetics and Development, Toronto Western
Research Institute, University Health Network, Toronto/
CANADA
Background: Pre-clinical and clinical studies suggest that early
surgery is potentially beneficial. This study compares early
(≤24 hours since SCI) versus later surgical decompression of
spinal cord in order to determine which approach is more cost
effective in the management of patients with acute cervical SCI
and to examine the potential barriers and ideal timelines for
each step to early surgical decompression.
Methods: A cost-utility analysis (CUA) was performed using
data for the first year after cervical SCI. The perspective of a
public health care insurer was adopted. Utilities are from the
Surgical Trial in Acute Spinal Cord Injury Study. The reasons
for delays in the management steps were classified into:
(a) healthcare-related (“extrinsic”) and (b) patient-related
(“intrinsic”) factors.
Results: When considering the late decompression as the
baseline strategy, the incremental cost-effectiveness ratio is
US$8,523,852 per quality-adjusted life year (QALY) for patients
with complete SCI and US$275,390/QALY for patients with
incomplete SCI. The probabilistic analysis indicated that there
is no clearly dominant strategy. Patients who underwent early
surgery (n=21) and individuals who underwent later surgery
(n=42) were comparable with respect to prehospital time (137
versus 185.5 min, respectively), time in a second general
hospital prior to transfer to a spine center (369.5 versus 730.8
min) and time in the emergency department of a spine center
(221.7 versus 226.4 min). However, patients who underwent
early surgery had significantly shorter waiting time in the first
care general hospital (577.6 versus 1982.1 min, respectively;
p=0.0181), shorter waiting time for assessment by a spine
surgeon (73.5 versus 274.4 min; p<0.0001) and shorter waiting
time for a decision regarding surgical management (241.7
versus 832.3 min; p<0.0001). While both patient groups showed
comparable time periods related to intrinsic factors, patients who
underwent early surgery had a significantly shorter time period
associated with extrinsic factors when compared with individuals
who underwent later surgery (19.16 versus 71.28 hours,
respectively; p<0.0001). Of note, the percentage of cases that
were seen in one general hospital, two general hospital or three
general hospital did not significantly differ between both groups
(p=0.214).
In conclusion, the results of our economic analysis suggests
that, although no strategy is clearly superior to the other, early
decompression of spinal cord can be more cost effective than
78
delayed surgery in approximately one quarter of the patients with
complete SCI and one third of the individuals with incomplete
SCI. Our benchmarking analysis suggests that health-related
factors are key determinants of the timing from SCI to spinal cord
decompression. Time in the general hospital and time of waiting
for surgical decision were the most important causes of delays for
surgical spinal cord decompression. Early surgery is feasible in
the vast majority of the cases.
References: Furlan JC, Noonan V, Cadotte DW, Fehlings M.
Timing of decompressive surgery after traumatic spinal cord
injury: An evidence-based examination of pre-clinical and
clinical studies. JOURNAL OF NEUROTRAUMA 2010 March
4. [Epub ahead of print].
P3-14
Institute for Functional Restoration
(IFR)
P..H. Peckham
Case Western Reserve University/FES Center, Cleveland/
UNITED STATES OF AMERICA
Background: The Institute for Functional Restoration (IFR)
was created within Case Western Reverse University (Case) to
fulfill the mission of enabling the clinical deployment of new
treatments to those with spinal cord injury (SCI) and stroke.
Structured as a non-profit, the IFR incubates the proven
feasible research interventions, like those in the Cleveland FES
Center, through commercial approval and production. This
research program has demonstrated clear clinical success
with technology developed at Case, but like most products
for SCI, has a small market size that has not been sufficient
to attract and retain commercial interest at this stage. As
demonstrated time and again, this neurotechnology makes
real and extensive strides towards a true restoration of function
for those that have been devastated by neurological conditions
such as spinal cord injury. The ability of this technology to
return functions lost, like the use of a hand or bladder control
is proven. The desire of this patient population to undergo
the implantation procedure in hopes of regaining some
independence is proven. The support of this approach as the
best, near-term clinical alternative by the top physicians in this
field is established.
Methods: Unlike many new companies, the technology,
market and distribution channel are known and established.
The barrier to commercializing these devices lies in the need
to demonstrate high growth potential and large market sizes
to satisfy early investment. Given that these devices will
never reach thousands of units per year in a market size of
hundreds’ of thousands, a new approach is being proposed
that transcends the for-profit constraints and exists to make
this life-changing technology available to hundreds of people
with neural involvement. Key to achieving the overall project
goal is the establishment of a practical and sustainable nonprofit deployment strategy. Given the high costs to achieve
regulatory clearance and support a clinical distribution
channel, versus the small market opportunity, a non-profit
model can identify alternative revenue streams to mature the
products and sustain a deployment strategy without achieving
high unit sales.
Results: Funded by a combination of revenue from products
sold and supplemental grant and development funds, the
IFR will ensure a long term commitment to bringing to
market advanced technologies that transcends typical freemarket pressures. We will outline a strategy for creating a
stable financial base in order to ensure the longevity of both
the model and of the clinical and technical support for the
individual users. As stated in recent comments from a reviewer
for the Neilson Foundation, “to my knowledge this approach
is unique and the whole world will be watching to see if it is
found to be a successful way to break through the barriers of
translating new medical technology”.
References: Agarwal S. Long-term user perceptions of
an implanted neuroprosthesis for exercise, standing, and
transfers after spinal cord injury. Alon G..Persons with
C5 or C6 tetraplegia achieve selected functional gains
using a neuroprosthesis. Arch Phys Med Rehabil. 2003
Jan;84(1):119-24.
Bryden AM. Electrically stimulated elbow extension in
persons with C5/C6 tetraplegia: a functional and physiological
evaluation. Arch Phys Med Rehabil 2000;81;80-88
P3-16
Identifying Quality of Life Outcome
Tools for Measuring The Impact of
Pressure Ulcers in Persons with
Spinal Cord Injury
S.L. Hitzig1, C. Balioussis1, B.C. Craven1, E. Nussbaum2, C.
Mcgillivray1, L. Noreau3
1
, University Health Network, Toronto Rehab, Toronto/ON/
CANADA, 2, Mount Sinai Hospital, Toronto/ON/CANADA, 3,
Centre for interdisciplinary research in rehabilitation and social
integration (CIRRIS), Quebec/QC/CANADA
Background: Pressure ulcers are a frequently occurring
secondary health condition in persons with spinal cord
injury (SCI) which negatively impacts a person’s quality of
life (QoL) because of their potential to interfere in physical,
psychological, and social domains [1]. Unfortunately, our
understanding of how to assess QoL post-SCI is confounded
by conceptual and measurement issues [2], which makes it
challenging to select an appropriate outcome tool. Hence, the
purpose of this review was to identify the outcome measures
used to assess the impact of pressure ulcers on QoL and
social participation in order to enable selection of appropriate
tools by SCI professionals in a variety of clinical and research
settings.
Methods: Electronic databases (MEDLINE/PubMed, CINAHL,
and PsycInfo) using relevant keywords were searched for
studies published between 1975-2011 (N = 71). Studies were
included if 50% of the participants had traumatic SCI. Studies
examining global constructs of QoL or participation after SCI
and studies using paediatric populations (or pediatric-onset
SCI) were excluded (n = 58). From the remaining thirteen
studies, data were abstracted and then presented in summary
tables outlining study design, participant demographics,
objectives, QoL outcome measures, sample size, and study
outcomes. Using Dijker’s [2] theoretical model of QoL, the
underlying constructs for the identified outcome measures
were described.
Results: Identified studies utilized participant’s self-report
regarding the occurrence and location of pressure ulcers
except for one, which reported the presence and severity
of the pressure ulcers using the clinical stages defined by
the National Pressure Ulcer Advisory Panel. The domains
of measurement identified from the subjective perspective
(insider view) for assessing pressure ulcers included
subjective well-being, social adjustment, and self-esteem.
From the objective perspective (outsider view), the constructs
of participation (involvement in life situations) and healthrelated QoL were examined. All of the measures identified
demonstrated sensitivity to the presence of pressure ulcers in
persons with SCI compared to those without pressure ulcers.
The majority of tools do not have psychometric evidence
supporting their use in the SCI population with the exception of
the Short-Form 36, Craig Handicap Assessment and Reporting
Technique, Life Situation Questionnaire-Revised, and the
Ferrans and Powers Quality of Life Index SCI-Version. Several
QoL and social participation outcome measures are sensitive
to the presence of a pressure ulcer but only a few have been
validated for use in SCI. A significant limitation is that all
the studies, with one exception, did not collect or report the
location or severity of the pressure uclers. Qualitative findings
reinforced the notion that measures collecting information on
social support and body self-esteem may be pertinent domains
negatively impacted by pressure ulcers post-SCI. The Cardiff
Wound Impact Schedule (CWIS) is emerging as a promising
outcome tool for the SCI population for illustrating pressure
ulcer impact, although further psychometric validation is
required prior to routine implementation.
References: 1. Regan M, et al. Pressure Ulcers Following
Spinal Cord Injury. In Eng JJ et al., (eds). Spinal Cord Injury
Rehabilitation Evidence. Version 3.0. 2010. 2. Dijkers MPJM.
Individualization in quality of life measurement: Instruments
and approaches. Arch Phys Med Rehabil 2003;84:S3-S14.
79
P3-17
Spinal Cord Injury Quality of Life
Instruments: Do They Measure
What They are Supposed to
Measure?
K. Boschen1, T. Jeji2
1
, University of Toronto, Toronto/ON/CANADA, 2, Ontario
Neurotrauma Foundation, toronto/ON/CANADA
Background: Although researchers and even the general
public cannot agree on a common definition of quality of life,
a review of empirical investigations and theoretical discussions
suggests that two major approaches to studying QOL are
currently utilized. The first focuses on objective QOL, defined
as the sum total of desirable possessions, traits, and statuses,
such as having a good job, a high income, a clean and safe
community to live in, good health, and a supportive family
and friends. Once measured in quantitative terms scientists
realized that objective characteristics (level of education,
annual income, crime rate of one’s city of domicile) do not
necessarily correspond to subjective experiences, thus the
study of individual affect and cognition seemed imperative.
The focus on subjective QOL commonly refers to social,
psychological, and/or subjective well-being (Duggan &
Lysack, 1999). A spinal cord injury constitutes a significant
challenge to quality of life. SCI affects, directly or indirectly,
those aspects of life that have been defined by researchers
to constitute QOL: health and personal safety, independence,
the ability to earn an income, access to material comforts, the
likelihood of developing a close relationship with a member
of the opposite sex, the ability to have and raise children,
and having a close and supportive network of friends. Body
image, self-concept, and one’s understanding of self are also
significantly affected, directly or indirectly. In a modification of
specification provided many researchers subjective QOL can
be defined as the fit between a person’s expectations and his/
her achievements, as experienced by the person, within a time
perspective. (Dijkers,1987). A full understanding of quality of
life measurement issues for persons with both a spinal cord
injury and the challenges of having pressure ulcers requires
investigation of available and potentially relevant existing QOL
measures and the context in which they have been developed
and used.
Methods: Literature Critical Appraisal. Systematic online
search and exploration of multiple electronic databases for all
known QOL measures that could potentially be appropriate for
use in research studies to assess change in QOL resulting from
the having a SCI and develoing a pressure ulcer.
Results: Discarding of non-relevant or non-applicable
measures resulted in review of the following 6 existing QOL
measures which were briefly examined and assessed for their
suitability: 1. Life Situation Questionnaire--Revised (LSQ-R)
2. Ferrans and Powers Quality of Life Index SCI-Version III
(QLI) 3. Reciprocal Social Support Scale (RSS) 4. Cardiff
80
Wound Impact Schedule (CWIS) 5. LISAT-11 (Life Satisfaction
Scale) 6. World Health Organisation QOL Breif Though none
of these measures are specifically developed for utilizing in
QOL measurement in SCI they are objective measures of some
aspects of life, activities and satisfaction in those areas of
participation.
References: Duggan, C. H. & Lysack, C. “Quality of
Life for Persons with a Spinal Cord Injury: A Qualitative,
Longitudinal Study”. Three-year field-initiated research grant
funded (07/99) by the National Institute on Disability and
Rehabilitation Research (#H133G990219). Dijkers, M. (1997).
Quality of life after spinal cord injury: A meta analysis of
disablement components. Spinal Cord
P3-18
On a Roll: Creating a Provincial
Action Strategy to Address Quality
of Life Issues for People with Spinal
Cord Injury
H. Lissel, T. Clarke
Canadian Paraplegic Association (Alberta), Edmonton/
CANADA
Background:
On a Roll and on the Right Track: the Alberta Spinal Cord
Injury Action Strategy was created as part of the Alberta Spinal
Cord Injury Initiative. In 2007, the Government of Alberta
contributed $12 million to support this five-year initiative.
Management was shared among the Rick Hansen Foundation,
the Rick Hansen Institute, and The Alberta Paraplegic
Foundation (APF). The Canadian Paraplegic Association
(Alberta) provided secretariat support for the APF and the two
advisory committees established by the APF to help direct
use of the funds: the Alberta SCI Solutions Alliance and the
Alberta SCI Research Team. On a Roll was created in response
to the need to identify and take immediate action to address
key issues affecting the quality of life of Albertans with SCI. It
builds on the legacy of past strategic plans in both the SCI and
disability fields. Where it differs is in the focus on delivering
short-term tangible results in a small number of areas deemed
by stakeholders to be priority. On a Roll is a call to action and
a committment to produce. It defines the ‘right track’ towards
improving quality of life outcomes for Albertans with SCI and
ensuring that our collective efforts deliver the best results. It
also serves as a model for future action in this important area.
Methods: The following method was used to develop and
implement On a Roll: 1. Conduct telephone interviews with
individuals with SCI and other stakeholders from the field of
SCI. 2. Review and analyze strategic plans and policies from
relevant disciplines. Investigate best and promising practices
in high needs areas (e.g. housing, home care). 3. Conduct a
Delphi study with individuals with SCI and other stakeholders
to create a prioritized list of needs of people with SCI. 4. Hold
a Stakeholder Forum to review the draft strategy document
and confirm priority needs. 5. Create three Task Teams in the
highest ranked needs areas: housing, home care/attendant
care, adaptive equipment/devices. 6. Task Teams create eight
Action Plans to address issues in the three areas. 8. Create
working groups to implement the Action Plans. 9. Implement
Action Plans 10. Evaluate
Results: The three task teams created eight Action Plans: 1.
an online community resource guide 2. a community living
attendant training program 3. a funding and outcomes tracking
project for pressure relieving and reducing devices 4. six mobile
adapted computer stations for trial use by people with SCI
and other physical disabilities 5. a protocol paper, treatment
algorithm, and consumer brochures on the topic of urinary tract
infection 6. an evaluation of supportive housing models and
development of a sample business case 7. an online accessible
housing registry 8. a concept and framework for a builders’
award recognizing excellence in accessible home design and
construction The process of developing and implementing On a
Roll also serves as a valuable template for future endeavors.
References: Alberta Spinal Cord Injury Initiative. (2010). On
a Roll and on the Right Track: The Alberta Spinal Cord Injury
Action Strategy. Edmonton: Canadian Paraplegic Association
(Alberta).
P3-19
Towards Interventions Focusing on
Community Living and Quality of
Life for Individuals with Spinal Cord
Injury: The Com-Qol Team
K. Boschen1, F. Routhier2, L. Noreau2, L. Beauregard2, S.L.
Hitzig3, A. Latimer4, K. Martin Ginis5, K. Arbour-Nicitopoulos5,
D. Kairy6
1
, University of Toronto, Toronto/ON/CANADA, 2, Centre
for interdisciplinary research in rehabilitation and social
integration (CIRRIS), Quebec/QC/CANADA, 3, Toronto
Rehabilitation Institute, Toronto/ON/CANADA, 4, Queen’s
University, Kingston/ON/CANADA, 5, McMaster University,
Hamiltin/ON/CANADA, 6, Center for research in rehabilitation
of greater Montréal, Montréal/QC/CANADA
Background: Returning to community living is the expected
outcome for most people with Spinal Cord Injury (SCI) after
rehabilitation discharge. In 2007, the Ontario Neurotrauma
Foundation (ONF) and the Quebec Rehabilitation Research
Network (REPAR) jointly funded the COM-QoL Team with
the goal of strengthening capacity and a culture of research
collaboration between rehabilitation-based researchers in
Quebec and Ontario working in the areas of Community
Integration and Quality of life of individuals with SCI. In 2011,
the funding of the team was renewed for a second round.
The objective of this poster is to present process of building
capacity among Ontario and Quebec SCI researchers and
activities of the COM-QoL Team.
Methods: The team has built their research program on the
existing expertise of 9 university researchers, and also on the
needs of their clinical collaborators. The team address issues/
interventions in the fields of physical activity, wheelchair
skills, social support, participation/quality of life and pain
management, while encouraging the development of new
collaborations between senior and junior researchers, and
between provinces. Knowledge translation and mobilization
(KT/KM) is explored as a field of investigation on its own. When
conducting specific projects, data collection is carried out in
both provinces.
Results: Participation in physical activity was assessed in 94
people with SCI (Quebec) in line with Ontario data already
collected. Three-year follow-up is underway to support another
physical activity study in Ontario. A Wheelchair Skills Program
(WSP) infrastructure to train and assess SCI wheelchair users
was implemented at the Toronto Rehabilitation Institute. We
now aim to make the WSP content more accessible, in French
and in English, and on a larger scale through workshop
training sessions, web videos, etc. A social support project to
family members of individuals with SCI led to the development
of an intervention that will be tested in both provinces. A
cooperative project with another team (SCI-IMPACT) has
produced a set of guidelines for researchers and clinicians,
available thought the Web (www.parqol.ca), to help them make
decisions on which outcome tools should be used to assess
QOL and participation. A process of assessing the extent
of dissemination of the website and its ability to adequately
inform about quality of life will be developed. We currently
develop a pilot project to test a SCI-specific Pain Management
Group manual and program developed in Toronto. Research
activities specifically related to implementation science and
KT/KM are conducted by our team members. COM-QoL
projects are used as experimental cases. In conclusion, during
2007-2011, the COM-QoL Team has implemented projects,
collected data, and transferred its expertise across Quebec
and Ontario provinces. The 2011-2014 round of funding
will strengthen the collaborations among researchers and
clinicians. A key addition to COM-QoL work plan will be a
focus not only on the utility and utilization of the outcomes and
deliverables to come from each individual project listed, but
also on an examination of the overall KT/KM achieved from our
team’s accomplishments on behalf of individuals living in the
community with SCI.
References: No references.
81
P3-20
P3-21
Effect of Motor Score on Adverse
Events and Quality Of Life in Patients
with Traumatic SCI
Investigating Life Satisfaction of
Community-Dwelling Individuals
Living with a Traumatic Spinal Cord
Injury in Ontario, Canada—
A Pilot Study
J. Street1, V. Noonan2, C. Fisher3, A. Cheung2, B. Sun2, M.
Dvorak1
1
, Vancouver General Hospital, Vancouver/BC/CANADA, 2,
Rick Hansen Institute, Vancouver/BC/CANADA, 3, Vancouver
General Hospital, Vancouver/CANADA
Background: Neurological impairment associated with
traumatic spinal cord injury (tSCI) results in significant
health care costs and disability. If risk factors for poor patient
outcome could be identified early in the process of care,
appropriate measures can be put in place to improve outcome
and reduce costs. The purpose of this study was to assess the
impact of neurological impairment, specifically motor score on
admission, on the incidence of adverse events, length of stay
(LOS) and long-term health status in patients with tSCI.
Methods: Patients with a tSCI discharged from a quaternary
acute care centre between 2008 and 2010 were identified
from our prospective registry. Adverse event data was
prospectively collected using the previously validated Spine
Adverse Events Severity instrument. Data related to patients’
injury, diagnoses, hospital admission, and follow-up Short
Form-36 (SF-36) Physical and Mental Component Scores
(PCS, MCS) were obtained from the registry. The five most
common adverse events were identified and multivariate
analyses were performed to determine whether the initial
motor score on admission was significantly associated with
each adverse event, as well as with LOS and SF-36 scores at 1
to 2 years post-injury.
Results: 171 patients with tSCI were included, 81.3% were
male and the mean age at injury was 47.2 ± 20.3 years. A
lower motor score on admission was significantly associated
with having pneumonia, pressure ulcers and urinary tract
infections (p<0.05); no association was found with delirium
or neuropathic pain. There was also a significant association
between motor score and the incidence of adverse events and
LOS (p<0.0001). For each 10 point decrease in motor score,
LOS increased by 20%. In patients with a motor score over 50,
the SF-36 PCS increased by 3.8% for each 10 point increase
in motor score. There was no effect on the SF-36 MCS. These
findings indicate that initial motor score can predict important
outcomes such as incidence and types of adverse events, LOS
and long-term health status. Patients with low motor scores
should be identified on admission to maximize their health
outcomes.
References: Not applicable
82
S. Boulet1, L. Cremasco1, M. Finlay2, B. Drew2, D. Tsui2
1
, McMaster University, Hamilton/ON/CANADA, 2, Hamilton
Health Sciences, Hamilton/ON/CANADA
Background: There is an estimated 44,000 individuals living
with traumatic spinal cord injury (SCI) in Canada.1 Studies
investigating the quality-of-life (QoL) of individuals with SCI
have found lower QoL compared to the general population,2,3
but no differences in QoL between people with tetraplegia
versus paraplegia.3-5 QoL of individuals with SCI appear
related to subjective perception of health, participation,
community integration, relationships, social support, and
living circumstances.6 In this population, decreased QoL has
been correlated with presence of comorbidities,7,8 restricted
social participation,8 and increased pain, spasticity, and bowel
and bladder dysfunctions.2 The Rick Hansen SCI Registry
(RHSCIR) is a Canadian database that store information about
traumatic SCI. This pilot study aimed to use the RHSCIR in
Hamilton, Ontario to 1) determine whether QoL is different
between those with tetraplegia versus paraplegia, and 2)
to investigate the association between QoL and participant
characteristics in people with SCI who live in the community.
Methods: This multicentre prospective cohort study recruited
adult patients with traumatic SCI admitted to Hamilton Health
Sciences from September 2006 to April 2010. Consenting
participants who were discharged to the community and
could be contacted were interviewed by phone from August
2007 to November 2008 and from February to March 2011.
Information regarding sociodemographics, SCI characteristics,
and QoL (using the Life Satisfaction-11 (LISAT-11)
Questionnaire) was collected. Data analyses used the MannWhitney U test and Spearman’s rho correlation.
Results: In this pilot study, 26 participants completed
the community follow-up interview. QoL as measured by
LISAT-11 average scores did not significantly differ between
those with tetraplegia (4.1±1.2) and paraplegia (4.1±1.0)
(p=0.608). LISAT-11 average scores significantly correlated
with completeness of injury (r=0.509, p=0.008), employment
status (r = 0.463, p=0.017) and financial assistance status (r
= 0.450, p=0.021).
References: 1. Farry A, Baxter D. The incidence and
prevalence of spinal cord injury in Canada: overview and
estimates based on current evidence. www.rickhanseninstitute.
org. 2. Westgren N, Levi R. Quality of life and traumatic spinal
cord injury. Arch Phys Med Rehabil. 1998;79:1433-1438.
3. Post M, Noreau L. Quality of life after spinal cord injury. J
Neurol Phys Ther. 2005;29:139-146.
4. Post MWM, de Witte LP, van Asbeck FWA, van Dijk AJ,
Schrijvers AJP. Predictors of health status and life satisfaction
in spinal cord injury. Arch Phys Med Rehabil. 1998;78:395402.
5. Post MWM, Van Dijk AJ, Van Asbeck FWA, Schrijvers AJ.
Life satisfaction of persons with spinal cord injury compared to
a population group. Scand J Rehab Med. 1998;30:23-30. 6.
Geyh S, Fellinghauer BAG, Kirchberger I, Post MWM. Crosscultural validity of four quality of life scales in persons with
spinal cord injury. Health Qual Life Outcomes. 2010;8:94.
7. Koppenhagen CF, Post MW, va der Woude LH, de
Groot S, de Witte LP, van Asbeck FW et al. Recovery of life
satisfaction in persons with spinal cord injury during inpatient
rehabilitation. Am J Phys Med Rehabil. 2009;88:887-894.
8. Barker RN, Kendall MD, Amsters DI, Pershouse KJ, Haines
TP, Juipers P. The relationship between quality of life and
disability across the lifespan for people with spinal cord injury.
Spinal Cord. 2009;47:149-155.
adaptations. Designing a dwelling with the needs of more
persons in mind is not just a technical issue that we can deal
with in the future; it is a creative act we consider now, so the
future is better for everyone.
P3-22
• designed to simultaneously satisfy users with varying
disabilities. They provide on grade access, open floor plans,
adjustable kitchen counters, lever door handles, accordion
closet doors, adjustable rods and shelf heights, reinforcing
for future installation of a stair lift, and grab bars, all to help
individuals in wheelchairs.
Housing for Everyone
R. Wickman
Ron Wickman Architect, Edmonton/AB/CANADA
Background: Ron Wickman received his Master of
Architecture at the Technical University of Nova Scotia
in 1991. He set up his own Edmonton based practice in
January 1995. Ron’s interests and expertise is in barrierfree design that is accommodating the needs of individuals
with disabilities; he also has a special interest in multi-family
housing and urban and community planning. He specializes in
providing consulting services for persons with disabilities and
for projects focused on affording individuals with disabilities
greater choices for independent movement. He is responsible
for over 100 new home or home renovation projects designed
to accommodate residents with disabilities. He is also
committed to providing affordable, accessible, and adaptable
housing and has won several housing competitions. Two
built projects include the Affordable Housing Demonstration
Project, built in 1996 and initiated by the City of Edmonton
Planning and Development Department and the Innovative
Housing Committee; and the CMHC FlexHouse – Habitat for
Humanity Project built in 1997. Ron has experience as an
expert witness in cases involving persons with disabilities, and
he has also been a guest speaker and participant in numerous
session involving Barrier-Free Design, innovation housing, and
urban and community planning.
Methods: This presentation identifies alternative forms
of housing to larger senior’s apartment buildings, senior
citizens villages, and assisted living housing projects. Projects
highlighted are designed to be flexible enough to easily adapt
to a family’s future needs, thus affording a family the choice
to grow old in the same home and in the same community;
moving to a larger senior’s complex does not need to happen.
The conclusion here is that good housing is designed in the
beginning to allow for easier future changes, additions, and
Results: As a result, participants will learn more about:
• Universal Design and accommodating persons with
disabilities.
• Housing that is designed to be affordable and adaptable
• Homes designed to allow for aging in place.
• Small scale housing as an alternative to larger scale senior’s
developments.
References: Innovative housing projects that I have recently
completed in Edmonton, Alberta. All of the Projects are:
• located in an inner city community so residents may
be afforded a better access to a greater host of the
neighbourhood amenities; inner city development promotes a
safer and more positive and efficiently run city.
P3-23
Translation, Transition, &
Transformation—Mental Health for
Persons with SCI, Families, and
Care-Givers
B. Williams
Pacific Institute, Richmond/BC/CANADA
Organization overview: This presentation will focus on the
curriculum development of DISCOVERING THE POWER IN
ME - CREATING A FUTURE OF STRENGTH AND HOPE
in British Columbia, program applications, and the applied
research results for persons with SCI by the University of B.C.,
University of Toronto, University of Western Sydney (Australia)
, and current evaluations underway in Canada. Two of the
research projects were approved for funding by the Rick
Hansen Institute.
The results of the applied research in three provinces in
Canada and three states in Australia will include a focus on the
mental health and psycho-social benefits to persons with SCI,
family members, and care-givers drawn from both scientific
surveys and consumer data.
The methodology and the use of peer counsellors with SCI
both on screen and in the group setting to facilitate and
enhance the classroom experience of the curriculum will be
highlighted.
83
The program was designed by persons with SCI who identified
what they called the missing pieces on the ‘continuum of care’
both from their personal experiences and from their work with
organizations assisting persons with SCI through difficult life
transitions. The design team worked closely with the Pacific
Institute to guide the development of the program.
Disclosure: As Global Managing Director for the Pacific
Institute I do have an indirect financial interest but I do not
have control over the educational content which is owned and
has trademark protection over it.
The presentation will include both scientific findings as well
as actual feedback on the two day program’s efficacy from
participants in Canada, U.S., and Australia .
P3-24
Background: Persons with spinal cord injuries often face
significant psycho-social challenges in coping, adjusting,
and moving forward to a positive and contributive future. To
address these issues, a design team composed of persons
with SCI from British Columbia and Alberta was formed to
work with the Pacific Institute to identify ‘missing pieces’ in
the continuum of care which , when addressed, might achieve
the dual goals of: reducing the depths of despair following
the injury and through support reduce the amount of time to
successfully transition to a ‘new normal’ .
The goal was to translate the best of cognitive psychology and
social learning theories into accessible, clear concepts and
relevant skills to support difficult transitions and to help create
positive transformations in persons with SCI their families and
care-givers. Building hope, strength, resiliency, self-esteem,
and raising self-efficacy creates new confidence to self
manage and design a new future.
Methods: Since the design, development, and launch of the
program Discovering the Power in Me - Building a Future of
Strength and Hope, considerable field experience has been
gained in Canada, U.S., and Australia with the SCI population
and with other populations.
The method includes providing a two day curriculum broken
into 12 modules in which participants experience classroom
experiences including : video clips presenting specific themes
introduced and summarized by a person with SCI along with
personal insights, in class co- facilitation which includes a
person with SCI, reflective questions, individual & small group
exercises to expand and anchor the concepts drawn from the
significant works of Dr. Albert Bandura.
Scientific research using peer reviewed surveys and evaluative
questionnaires have been conducted in Canada, U.S., and
Australia....two of which were funded by the Rick Hansen
Institute.
Results: The presentation will discuss the research findings
conducted by the University of British Columbia, the University
of Toronto, and the University of Western Sydney and other
early evaluative data on both quality of life and transition to
employment.
References: and hand-out materials will be provided at the
time of the presentation.
84
Altering Inflammation After Spinal
Cord Injury Using Biomaterials
Hong Ying Lia, Yue Zhoua, Paul D. Daltona,b
Med-X Research Institute, Huashan Lu 1954, Shanghai Jiao
Tong University, Shanghai, China.
b
Institute of Health and Biomedical Innovation, 60 Musk Ave,
Brisbane, Australia.
a
Background: SCI repair is resistant to therapies due to the complex inflammatory reaction and inhibitory factors to regeneration [1]. There are diverse approaches SCI treatment, including
drug/gene delivery, cell transplantation for both regeneration
and neuroprotection. One field of research not widely used
within SCI repair is materials science yet it has many forms –
from injectable hydrogels to nanoparticles, porous scaffolds to
nerve guides [2]. The past decade has seen an unprecedented
expansion in the development of biomedical materials with new
forms and functions [3].
In this context, we describe a fundamental aspect of material
use within the spinal cord; analysing the injury parenchyma of
a biomaterial implanted within the spinal cord. Since biomaterials are known to reduce the extent of secondary injury, we
investigate how implanting a foreign body (material) could affect and alter the inflammatory cascade after SCI. This study
compares short time points to gather insights into the innate
immune reaction associated with implanting a foreign material
into the spinal cord.
Methods: A porous biomaterial (pHEMA) was implanted within
the spinal cord of Male Wistar rats T7/8, into small lesions of
either the posterior horn or dorsal funicular. The animals were
perfused after 1 to 14 days and excised spinal cord tissue used
for immunohistochemistry or quantitative PCR.
Results: The injuries were reproducible and the pHEMA fitted
well into the lesion. The recruitment of neutrophils was rapid
and after 24 hours the biomaterial was filled exclusively with
these cells. Activated macrophages migrated into the biomaterial and injury parenchyma after 3 to 6 days. In grey matter
implants, surviving neurons (NeuN) are seen near the scaffold
even after 14 days, indicating minimal secondary injury. While
similar numbers of neutrophils and macrophages infiltrate the
injury parenchyma for both the lesion and biomaterial, a higher
gene expression of TGF-β after occurs with pHEMA implants
in both the white and grey matter after 6 days. TGF- β is recognised as an important (anti-)inflammatory mediator in this injury
scenario, and influences the remodelling of ECM after SCI [3].
Future work involves modifying the surface of the biomaterial to
alter both the inflammatory cascade and regeneration, as well
as using nanotherapeutics for similar inflammatory mediating
purposes.
Acknowledgements: The Natural National Science Foundation
of China supported this research (#30970727).
References:
[1] Dalton PD, Harvey AR, Oudega M, Plant GW (2008) Tissue
Engineering of the Nervous System, in Tissue Engineering. C
Van Blitterswijk, Sohier (Ed.) Academic Press. p611-647.
[2] Tsai E, Dalton PD, Shoichet MS, Tator CH (2004) J Neurotrauma, 21, 789-804.
[3] Dalton PD, Mey J (2009) Front Biosci, 14, 769-795.
[4] Hall et al. (2004) J Neurosci Res, 76, 1.
85
Author Index
Afram B.
Ahn H.
Al-Yahya A.
Albert M.
Allan D.
Allen V.
Allison D.
Alton C.
Ansley B.
Arbour-Nicitopoulos K.
Arndt A.
Asiri Y.
Assinck P.
Athanasopolous P.
Atkins D.
Badley E.
Bailey C.S.
Bain P.
Balioussis C.
Bank M.
Barrable B.
Batke J.
Bauman, W. Bayless K.
Beaton D.
Beauregard L.
Bedard F.
Berlowitz D.J.
Berube M.
Beynon M.
Beynon M.E.
Biering-Sørensen F. Birnböck D.
Bjerkefors A.
Bloom O.
Boily K.
Borisoff J.
Boschen K.
Bosma R.
Bosma R.L.
Boucher N.
Boulet S.
Bourassa-Moreau E.
Bourassa-Moreau Boutin N.
Brenner R.
Brinkhof M.W.G.
Bronson R.
Brown D.J.
Brown J.
Burns A.
Cadotte D.
Cameron P.
Campbell K.
86
45
41, 54
47
73
60
37
69
60, 61
36
81
55
47
71
66
64
63
41
44
50, 79
25
72
35
14
76
63, 34
53, 81
73
55
73
69
32, 70
9
67, 67
55
25
39
74
54, 80, 81
25
69, 70, 32
53
82
64
33
73
31
56
72
55
58, 76
58, 41, 57
25, 26
55
32, 42
Cartar L.
Carter P.
Chakraborty S.
Chan A.
Chan B.
Chauny J.-M.
Chen Y.
Cherban E.
Cheung A.
Cheung C.
Cheung K.
Clarke C.
Clarke T.
Claydon V.
Codyre M.
Connolly S.
Contandriopoulos D.
Conway B.
Cragg J.
Craven B.C.
Craven C.
Cremasco L.
Cui J.-L.
Curt A.
Czajka T.
Dai H.
Dalton P.
Delisle S.
Desjardins P.
Desroches G.
Devivo M.
Ditor D.
Dobek C.E.
Domingo A.
Drew B.
Drouin K.
Duda M.
Dupuis A.
Dusablon A.
Dvorak M.
Elliott S. Eng J.
Ethans K.
Fawcett J. Fehlings M.
Fehlings M.G.
Finlay M.
Fisher C.
Flett H.
Foley N.
Fourney D.R.
Francis C.
Fransen B.L.
38
37
77
54
58
73
37
50, 38
66, 82
31
51
60
80
13, 62, 65
43
51
73
60
74
63, 34, 36, 79, 41
50
82
70
15, 22, 34, 36
66
72
84
73
29
29
37
69
32, 69, 70
31, 47
36, 82, 41
59
76, 58
58
73
23, 63, 64, 66, 35, 72,
82, 38, 41
8
47, 51, 68, 39
52
8
24, 78
8, 21, 25, 26, 64, 34, 41
82
66, 82
57, 58, 32, 34
52
41
45
71
Frazier B.
Frieden L.
Furlan J.C.
Gabriel D.
Gagne A.
Gagnon D.
Galen S.
Gan L.S.
Ghag A.
Gignac M.
Goldstein B.
Goss B.
Goudie C.
Gourdou P.
Graco M.
Grangeon M.
Green L.
Gregorini F.
Grossman, R.
Guindon A.
Guest, J. Guy K.
Hallgrimsson B.
Hamdani Y.
Hammond M.
Harkema S. Harder E.
Harrop J. Haycock S.
Hayes K. Hendricks R.
Henry J.L.
Hicks A.
Hill D.
Hill T.
Hilton B.
Hitzig S.L.
Hodgkinson N.
Hoffer A.
Hong Y.L.
Horsewell J.
Houghton P.
Hsieh J.
Hu Y.
Huitsing C.
Hunter J.
Illes J.
Inglis G.
Inskip J.
Jeanmaire C.
Jeji T.
Jetha A.
Joly C.
37
P3-15
40, 78
69
73
29, 59
60
30
23
63
37
27
74
29
55
59
69
67, 67
15
53
15, 21
34
74
62
37
17
28
12
44
10
37
44
27, 29
52
48
71, 23
81, 44, 58, 60, 61, 79
76
45
84
43
42
50, 51, 51, 52, 58, 32,
76, 39
70
76
44
23
69
62
43
44, 52, 66, 50, 80
62, 63
47, 58
Jones G.
Joshi P.
Kairy D.
Kalke Y.B.
Kalsi-Ryan S.
Kenneth G.
Kessler T.
Kim A.
Kirshblum, S. Knox J.
Koning C.
Kozomara M.
Kras-Dupuis A.
Krassioukov A.
Krueger H.
Kurzweil R. Kwon B.K.
Lacroix S.
Laflamme E.
Lam C.K.
Lam T.
Langer R.
Laramée M.-T.
Latimer A.
Lawrence M.
Lear S.
Leber D.
Lebkowski J. Leblanc K.
Lee J.
Lee J.H.T.
Lee S.S.
Lefebvre H.
Legg A.
Leong N.
Lewis R.
Li X.
Liang J.
Linassi A.G.
Lindberg T.
Lissel H.
Liu J.
Liu Q.Q.
Loh E.
Luk K.D.-K.
Lutton C.
Mac-Thiong J.-M.
Macgillivray M.
Mackay-Sim A.
Macrae L.
Macthiong J.-M.
Manocha R.
Marinho A.
Mark M.
27
63, 72, 41
81
31, 49
34
16
67, 67
54
18
58
32, 76
67
50, 32
7, 13, 19, 65, 68, 40
63
17
14, 23, 62, 35, 71, 41
73
73
71
47, 28, 31
72
47
29, 81
72
65
57
17
66
52
71
28
53
26
60, 61
64
70
31
41
55
80
71
26
52
70
27
59, 33, 64
46
27
66, 36
73
46
34
76
87
Martin Ginis K.
Matheson K.A.J.
Mattison C.A.
Mcgillivray C.
Mcgrath M.
Mcinnes C.
Mcintyre A.
McKerracher L. Mclean A.
Mcmillan C.
Mehnert U.
Mehta S.
Mendis B.
Meyyappan R.
Mikulis D.
Miller W.
Miller W.C.
Milligan J.
Mittmann N.
Moore A.
Morris H.
Mumme L.
Nadeau S.
Nasirzadeh Y.
Nassiri F.
Nguyen L.
Nguyen T.
Noonan V.
Noreau L.
Norrbrink C.
Nussbaum E.
O’Connell C.
O’Connor T.P.
Oliver D.
Onders R.
Orenczuk S.
Panjwani A.
Papatheodorou A.
Parent S.
Park S.E.
Parmar R.
Pauhl K.
Peckham P..H.
Pelletier C.
Phillips A. Plunet W.
Popovic M.
Price D.
Pritchard C.
Prochazka A.
Prud’Homme Lemaire M.-C.
Rajamanickam K.
Ramer M.
Raschid A.
Rasheed A.
Ravensbergen R.
88
11, 81
71
44
79
62
54
51, 52
9, 16
60
52
67, 67
49, 51, 51, 52
77
45
25, 26
51
68, 40
52
58
66
34
76
29
24
24
57
77
50, 63, 66, 35, 72, 82,
38, 41, 39, 64
10, 79, 53, 81
55
79
41
26
66
39
49
25, 61
25
59, 64, 33, 73
71, 39
48
28
18, 78
27, 29
21
71, 74
29, 34, 34
66
72
17, 30
73
77
74
50
58
65
Ravid E.N.
Reichel H.
Reynolds F.
Reynolds S.
Richardson J.
Riopelle R.
Rivers C.
Robidoux I.
Routhier F.
Roy B.
Rupp For The EMSCI Study Group R.
Sahota I.
Sakakibara B.M.
Salter K.
Sandoval R.
Santos A.
Satkunendrarajah K.
Saunders N.
Sawatzky B.
Schubert M.
Sci Kmn
Sci Kmn Team S.
Scovil C.
Shantharam Y.
Shin J.
Short C.
Sihota H.
Sinclair S.
Singh A.
Sinnott R.
Sison C.
Slotkin J.
Smith M.
Soril L.
Spungen, A. Stein A.
Stoesz B.
Street J.
Streijger F.
Stroman P.W.
Sullivan D.
Sun B.
Tam V.
Taunton, J. Teasell R.
Teng Y.
Tetzlaff W.
The Scire Research Team -.
The Swisci Study Group &.
Thompson C.
Thorogood N.
Tindale L.
Townson A.
Trenaman L.
Truchon C.
Tsai E.
Tsui D.
30
49, 31
72
45
66
58
63, 38
59
81
69
36
65
51, 40
51
45
64
24
60, 61
46
36
47, 57
32
57
44
54
51
43
66
64
55
25
72
43
64
19
25
58
66, 82
71
25, 32, 69, 70
43
66, 82, 38
58, 47
20
49, 51, 51, 52
72
9, 22, 23, 23, 71
40
56
64, 33
72, 39, 41, 35
45
51, 54
63
58
41, 77
36, 82
Tung K.
Uleryk E.
Ullrich P.
Vermette M.
Verrier M.
Von Elm E.
Wahman K.
Wakeling J.
Walden K.
Walter M.
Wang W.
Warburton, D. Warner F.
Wecht J. Wen C.-Y.
West C. Wickman R.
Wilcox J.
Williams B.
Williams J.
Williams R.
Williams S. Wirth E.
Wojkowski S.
Wolfe D.
Woodard E.
Wright P.
Wöllner J.
Wong S. Wyndaele, J.
Young W
Young Y.W.
Yu D.
Zander J.
Zbogar D.
Zhou M. Zhou Y.
54
44
37
29
50, 68, 34, 36, 34
40
55
28
38
67, 67
26
19
74
13
70
20
83
24
54, 83
34
27
11
16, 72
66
50, 51, 51, 52, 58, 39, 32
72
58
67, 67
21
7
12
27
72
38
68
7
84
89