Ann M. Spungen

Between January 2020 and December 2023, the United States reported over 103 million COVID-19 cases and 1.1 million related deaths. Veterans with spinal cord injuries and disorders (VSCI/D) are particularly vulnerable due to chronic health conditions and comorbidities, which increases COVID-19 infection and mortality risk from exposure to others who they depend on for care. This manuscript highlights factors associated with COVID-19 vaccine uptake in VSCI/D. This study aimed to explore Veteran demographic and clinical factors associated with COVID-19 test positivity, vaccine uptake, and COVID-19-related mortality among VSCI/D in the 2-year period following the start of the pandemic. This observational cohort study used the Veterans Health Administration's (VHA) Spinal Cord Injuries and Disorders Registry to identify VSCI/D alive on March 20, 2020. Outcome measures included COVID-19 test positivity, vaccine uptake, and mortality within 30 days of a positive test over a 2-year period. Among 17,522 VSCI/D, 12% had a positive COVID-19 test at least once in the two-year period following March 20, 2020, 73% received at least one COVID-19 vaccine dose in the 2-year period, and 47% received at least three doses. COVID-related mortality occurred in 67 (0.4%; 67/17,522) VSCI/D in the first year of the pandemic and 46 in the second year (0.6% two-year mortality; 113/17,522). Less than half of VSCI/D received three COVID-19 vaccine doses, suggesting opportunities for quality improvement efforts. Peer support services may help improve vaccine uptake among VSCI/D in the future.

Veterans with spinal cord injuries and disorders (SCI/D) reported experiencing challenges from disrupted and deferred health services during the COVID-19 pandemic, including disrupted care coordination, supply chain, and essential services, such as wheelchair repair. This study used qualitative methods to examine the perspectives of Veterans with SCI/D (VSCI/D) and SCI/D healthcare providers on how the COVID-19 pandemic impacted health services. Virtual focus groups were conducted with both VSCI/D who received care at the Veterans Health Administration (VHA) and VHA SCI/D providers who provided services for VSCI/D between March 2020 and March 2022. Topics assessed COVID-19 pandemic experiences including healthcare access and needs, Veteran and provider perspectives of Veterans' experiences during the pandemic, Veterans' coping strategies, and future emergency preparedness strategies. There were 11 Veterans and 11 providers who participated in focus groups. Five themes were identified: (1) challenges with healthcare, care coordination, and homecare; (2) supply chain issues; (3) adapting to virtual platforms for support and therapy; (4) communication and reliable information about COVID-19; and (5) challenges with isolation and limited independence. This study highlights challenges VSCI/D faced during the COVID-19 pandemic. Recommendations to enhance VHA support for VSCI/D during future emergencies include strengthening home care support, system level changes to supply management to be more flexible, and interdisciplinary town halls to transparently share comprehensive information. Virtual peer support groups may address challenges with isolation and limited independence.

Introduction Persons with non-ambulatory spinal cord injury (SCI) undergo immediate unloading of the skeleton and, as a result, have marked loss of bone mineral density below the level of lesion that is directly associated with increased risk of long-bone fractures. There is a paucity of research that has successfully implemented rehabilitation and/or exercise training interventions to mitigate bone loss after acute SCI or reverse bone loss that has already occurred in chronic SCI. This paper describes a research protocol to compare the effect of exoskeletal-assisted walking (EAW) alone versus EAW plus transcutaneous spinal cord stimulation (EAW+tSCS) on bone density, geometry and strength in a cohort of chronic SCI participants. Methods and analysis After meeting eligibility criteria and completing baseline testing, sixteen participants will be block randomised into the EAW alone group or the EAW+tSCS combined group (n=8 each group). Each group will receive a total of 108 overground training sessions (60 min sessions, 3 times a week, for 36 weeks) for the 9-month training period. Imaging for bone density and geometry by dual-energy X-ray absorptiometry and peripheral quantitative CT will be performed prior to starting the intervention (baseline), after 72 training sessions, and again after 108 sessions in each of the intervention arms. CT imaging of both lower extremities will be performed at baseline and at the 9-month time point in each of the intervention arms. Finite element models of bone loading will be generated based on three-dimensional (3D) reconstruction of bone architecture from CT imaging prior to and 9 months after the intervention. Ethics and dissemination This study is currently approved by the Kessler Foundation and James J. Peters VA Medical Center Institutional Review Board. A member of the research team will review and explain the study consent form and will have all eligible participants sign prior to participation in the study. Results from this study will be disseminated to clinicians and researchers in the SCI community at national and international conferences. Trial registration number NCT03096197.

Spinal cord injury (SCI) negatively impacts individuals’ functional independence, and motor and sensory function. Intense walking training has been shown to facilitate recovery for individuals with chronic SCI. Powered robotic exoskeletons provide therapists with a tool that allows them to conduct walking training with less therapist effort as compared to conventional walking training. Exoskeletal-assisted walking (EAW) has been studied in the chronic SCI population with preliminary reports showing benefits in mobility, health, and quality-of-life outcomes. However, few reports have studied EAW’s benefits in the acute (F (1, 26) = 5.59, p = 0.03; total motor score: F (1, 26) = 8.06, p < 0.01; total sensory score: F (1, 19.2) = 5.08, p = 0.04], outperforming the standard AIR group. The AIR with incorporated EAW group showed 13, 14, and 22 points higher changes in the SCIM total score, total motor score, and total sensory score (respectively) by discharge compared with the standard AIR group. Incorporating EAW into AIR may facilitate functional, motor, and sensory recovery for individuals with SCI during AIR better than standard AIR. However, the study had a limited sample size. Further studies are needed to clarify the effects of EAW in AIR.

Paralysis from spinal cord injury (SCI) is a catastrophic condition with diminishing gains in functional recovery over time, often with severe walking limitations and some degree of permanent disability.^1,2 The Veterans Health Administration (VHA) cares for the single largest population of people with SCI in the US. Approximately 17 000 veterans with SCI are seen annually in 1 of 25 spinal cord injuries and disorders (SCI/D) centers (eFigure 1 in Supplement 1).³

Study design Cross-sectional validation study. Objectives The performance of previously published physical activity (PA) intensity cutoff thresholds based on proprietary ActiGraph counts for manual wheelchair users (MWUs) with spinal cord injury (SCI) was initially evaluated using an out-of-sample dataset of 60 individuals with SCI. Two types of PA intensity classification models based on raw accelerometer signals were developed and evaluated. Setting Research institutions in Pittsburgh PA, Birmingham AL, and Bronx NY. Methods Data were collected from 60 MWUs with SCI who followed a structured activity protocol while wearing an ActiGraph activity monitor on their dominant wrist and portable metabolic cart which measured criterion PA intensity. Data was used to assess published models as well as develop and assess custom models using recall, specificity, precision, as well as normalized Mathew’s correlation coefficient (nMCC). Results All the models performed well for predicting sedentary vs non-sedentary activity, yielding an nMCC of 0.87–0.90. However, all models demonstrated inadequate performance for predicting moderate to vigorous PA (MVPA) with an nMCC of 0.76–0.82. Conclusions The mean absolute deviation (MAD) cutoff threshold yielded the best performance for predicting sedentary vs non-sedentary PA and may be used for tracking daily sedentary activity. None of the models displayed strong performance for MVPA vs non-MVPA. Future studies should investigate combining physiological measures with accelerometry to yield better prediction accuracies for MVPA.

Study design Pre-post intervention. Objective To explore the potential effect of exoskeletal-assisted walking (EAW) on seated balance for persons with chronic motor complete spinal cord injury (SCI). Setting A SCI research center. Methods Eight participants who were over 18 years of age with chronic SCI and used a wheelchair for mobility were enrolled. Seven able-bodied participants were used for normal seated balance comparative values. Participants with chronic SCI received supervised EAW training using a powered exoskeleton (ReWalk^TM) for a median 30 sessions (range from 7 to 90 sessions). Before and after EAW training, seated balance testing outcomes were collected using computerized dynamic posturography, providing measurements of endpoint excursion (EPE), maximal excursion (MXE), and directional control (DCL). Modified functional reach test (MFRT) and the sub-scales of physical functioning and role limitations due to physical health from the Short Form (36) Health Survey (SF-36) were used to identify changes in functional activities. Results After EAW training, seated balance significantly improved in total-direction EPE and MXE (P < 0.01 and P < 0.017 respectively). The results of MFRT and sub-scales of physical functioning and role limitations due to physical health improved after EAW training but were not statistically significant. Conclusions EAW training may have the potential to improve seated balance for persons with chronic motor complete SCI. Due to the limitations of the study, such as small sample size and lack of a control group, further studies are needed to clarify the effect of improving seated balance through EAW training.

Persons with spinal cord injury (SCI) have neurogenic bowel disorders characterized by difficulty with evacuation (DWE), fecal incontinence, and discoordination of defecation. Six medically stable in-patients with SCI with a mean age of 57 ± 10 years (range: 39–66 years) and time since injury of 18 ± 17 years (range: 3–47 years) were investigated. Standard of care (SOC) for bowel care was followed by two weeks of SOC plus neostigmine (0.07 mg/kg) and glycopyrrolate (0.014 mg/kg) administered transcutaneously by iontophoresis thrice weekly for two weeks while patients continued to receive SOC. The primary endpoint was time to bowel evacuation. Body weights and abdominal radiographs were obtained. Ten questions related to bowel function and the Treatment Satisfaction Questionnaire for Medication were acquired after each arm. Bowel evacuation time decreased after the dual drug intervention arm (106.9 ± 68.4 vs. 40.8 ± 19.6 min; p < 0.0001). Body weight decreased (2.78 ± 0.98 kg; p < 0.0001), a finding confirmed on abdominal radiograph. Both questionnaires demonstrated improvement after the dual drug intervention arm. No major adverse events occurred. The addition of neostigmine and glycopyrrolate by transcutaneous administration to SOC for bowel care in persons with SCI and DWE resulted in the safe, effective, and predictable bowel evacuation with subjective improvement in bowel care.

Bowel function after spinal cord injury (SCI) is compromised because of a lack of voluntary control and reduction in bowel motility, often leading to incontinence and constipation not easily managed. Physical activity and upright posture may play a role in dealing with these issues. We performed a three-center, randomized, controlled, crossover clinical trial of exoskeletal-assisted walking (EAW) compared to usual activity (UA) in people with chronic SCI. As a secondary outcome measure, the effect of this intervention on bowel function was assessed using a 10-question bowel function survey, the Bristol Stool Form Scale (BSS) and the Spinal Cord Injury Quality of Life (SCI-QOL) Bowel Management Difficulties instrument. Fifty participants completed the study, with bowel data available for 49. The amount of time needed for the bowel program on average was reduced in 24% of the participants after EAW. A trend toward normalization of stool form was noted. There were no significant effects on patient-reported outcomes for bowel function for the SCI-QOL components, although the time since injury may have played a role. Subset analysis suggested that EAW produces a greater positive effect in men than women and may be more effective in motor-complete individuals with respect to stool consistency. EAW, along with other physical interventions previously investigated, may be able to play a previously underappreciated role in assisting with SCI-related bowel dysfunction.