Steven Kirshblum

We are thankful for the thoughtful comments regarding our pilot study and agree with many of the points raised. Importantly, our study was designed primarily as a feasibility study to determine whe...

To evaluate the feasibility of person- or caregiver-directed handheld ultrasound for bladder volume estimation in individuals with spinal cord injury (SCI) performing clean intermittent catheterization (CIC), and to assess agreement with catheterized volumes and effects on catheterization frequency. Prospective pilot feasibility study of community-dwelling individuals with SCI using CIC. Outpatient SCI center. Persons with SCI who manage their bladder with CIC. Participants and caregivers received standardized training on the Butterfly iQ+™ handheld ultrasound device. After a baseline period of usual time-based catheterization, participants used ultrasound-guided bladder assessment during a structured intervention phase and an optional self-directed phase. Feasibility, usability, and acceptability of handheld bladder ultrasound use; agreement between ultrasound-estimated and catheterized bladder volumes; and catheterization frequency. Ten participants were enrolled; nine had complete data for analysis. All achieved competency in ultrasound use within one hour of training. Ultrasound-estimated bladder volumes showed reasonable agreement with catheterized volumes, generally within 100 mL. Catheterization frequency decreased during the ultrasound-guided phase compared with baseline (5.5 ± 1.5 vs. 4.5 ± 1.4 catheterizations/day; P = 0.017), without changes in catheterized volumes or fluid intake. Participants who retained the device (n = 6) also demonstrated reduced catheterization frequency (5.9 ± 1.4 to 4.6 ± 1.6 per day; P = 0.027). Usability ratings were favorable, though portability and willingness to purchase the device varied. Handheld bladder ultrasound using a smartphone- or tablet-connected platform is feasible and may reduce unnecessary catheterization in individuals with SCI performing CIC. Larger studies are needed to evaluate sustained use and clinical impact.

The expanding application of spinal stimulation therapies in spinal cord injury (SCI) rehabilitation necessitates a critical reexamination of cardiovascular (CV) responses to these interventions. A key question arises: How should blood pressure (BP) responses to stimulation be interpreted, and does the conventional definition of autonomic dysreflexia (AD) adequately capture these phenomena? Researchers remain divided—some classify BP elevations during stimulation as AD, while others attribute them to intentional neuromodulation targeting sympathetic preganglionic neurons. This review scrutinizes the various AD definitions in the literature, including the conventional threshold (systolic BP increase >20 mmHg), revealing substantial limitations in research contexts. While symptomatic AD occurs in only 4-7% of stimulation study participants, asymptomatic BP increases are considerably more frequent. This established threshold lacks robust physiological rationale and creates significant interpretive challenges, particularly when evaluating interventions designed to modulate BP responses. The current limitations of guideline-based definitions of AD challenge research interpretation and clinical translation. Although several publications describe AD as “unregulated” or “uncontrolled,” it has not yet been incorporated into formal guideline definitions. This review underscores the need for a collaborative effort to refine AD definitions in research, particularly in the context of spinal stimulation. Future consensus development should address whether uniform thresholds should apply across different contexts, how to integrate heart rate dynamics and absolute BP values alongside symptomatic status, and how to meaningfully distinguish therapeutic BP modulation from adverse autonomic responses. This is essential for standardizing research approaches, optimizing stimulation parameters, and ensuring efficacy and safety as spinal stimulation technologies advance clinically.

Background/Objectives: Cardiovascular (CV) dysfunction and, specifically, orthostatic hypotension, may significantly impact the quality of life of individuals with spinal cord injuries (SCIs) at T6 or above. While spinal cord transcutaneous stimulation (scTS) has shown immediate effects on blood pressure regulation, its long-term effects remain largely unexplored. Methods: This case study examines the sustained effects of scTS on blood pressure regulation and orthostatic tolerance in a 33-year-old female with cervical (C4) complete SCI sustained two years earlier. This individual underwent an initial baseline tilt test without stimulation, completed six 30 min scTS-CV sessions (cardiovascular-focused stimulation) over two weeks as the “training” phase, and then had repeated tilt tests without stimulation posttraining. Results: Following training, the participant demonstrated an improvement in orthostatic tolerance, maintaining a 70° tilt for 30 min, compared to only 3 min at baseline, in a tilt test (without stimulation) conducted one day posttraining. Self-reported reduction in orthostatic burden and decreased midodrine dependence were also observed for several weeks, with improvements diminishing by 6 weeks posttraining. Conclusions: These observations suggest that brief, repeated scTS-CV sessions may lead to sustained improvements in orthostatic tolerance beyond the immediate period of stimulation. Although the duration of these effects has yet to be established, this approach could offer a non-invasive alternative for managing CV dysfunction in SCIs.

Study design: A narrative review and perspective based on the experience of a single site in the U.S recruiting participants for clinical trials during the subacute phase (2 weeks to 3 months) following a traumatic spinal cord injury (SCI). Objectives: To discuss challenges and propose strategies for enrolling individuals with SCI in research during the subacute phase within a comprehensive inpatient rehabilitation program. Setting: Acute rehabilitation hospitals where patients with SCI typically spend part of the subacute post-injury period. Methods: This review draws on the authors’ experience in research recruitment and retention. Key barriers and potential solutions are explored from both a practical and conceptual standpoint. Results: Challenges identified include heterogeneous impairments, older age, higher incidence of incomplete injuries, placement issues, competition among studies, limited patient volume, tight rehabilitation schedules, logistical and medical concerns, and misalignment of research measures with clinical practices. Based on experience and literature review, strategic planning including integration of individuals with lived experience into the study design team, patient education, simplified consent processes, flexible research protocols, collaboration between clinical and research teams, and patient-centered approaches can enhance recruitment efforts. Conclusions: Research recruitment during the subacute phase of SCI presents numerous medical, injury-specific, and systems-based challenges. However, this period remains critical for advancing research influencing long-term outcomes for individuals with SCI. We recommend a collaborative, patient-centered approach that integrates research within clinical care, guided by practical experience and informed by existing literature, which can improve recruitment efforts and ultimately support meaningful advancements in SCI rehabilitation research.

Objective: The aim of the study was to determine if a low admission Karnofsky Performance Scale score is indicative of a higher likelihood of death within 3 mos of discharge from inpatient rehabilitation with an active cancer diagnosis. Design: A retrospective, observational design was employed to analyze electronic medical records of 385 patients with a primary or concurrent diagnosis of cancer admitted from a multicenter, acute inpatient rehabilitation hospital system between January 1, 2020, and December 31, 2020. Results: Of the 385 patients, a total of 77 patients (20%) had an observed death within 3 mos. Out of the sample of patients with an observed death within a 15-mo window (n = 157), 49% died within 3 mos of discharge from the IRF. Patients with a Karnofsky Performance Scale score of 40 or less had a significantly higher risk of mortality within 3 mos of discharge (hazard ratio = 1.49, 95% confidence interval = 1.09–2.04, P = 0.013). For those surviving less than 3 mos, average survival was 32 days. Improvements in Karnofsky Performance Scale score during the inpatient stay were linked to better survival outcomes. Conclusions: These findings provide insight into the prognosis of patients with cancer in inpatient rehabilitation, emphasizing the importance of functional assessment in predicting mortality within 3 mos of discharge.

Central cord syndrome (CCS) is the most prevalent and debated incomplete spinal cord injury (SCI) syndrome, with its hallmark feature being more pronounced weakness of the upper extremities than of the lower extremities. Varying definitions encapsulate multiple clinical features under the single umbrella term of CCS, complicating evaluation of its frequency, prognosis discussions, and outcomes research. Often, people with CCS are excluded from research protocols, as it is thought to have a favorable prognosis, but the vague nature of CCS raises doubts about the validity of this practice. The objective of this study was to categorize CCS into specific subsets with clear quantifiable differences, to assess whether this would enhance the ability to determine if individuals with CCS or its subsets exhibit distinct neurological and functional outcomes relative to others with incomplete tetraplegia. This study retrospectively reviewed individuals with new motor incomplete tetraplegia from traumatic SCI who enrolled in the Spinal Cord Injury Model Systems (SCIMS) database from 2010 to 2020. Through an assessment of the prevailing criteria for CCS, coupled with data analysis, we used two key criteria, including the severity of distal upper extremity weakness (i.e., hands and fingers) and extent of symmetry, to delineate three CCS subsets: full CCS, unilateral CCS, and borderline CCS. Of the 1490 participants in our sample, 17.5% had full, 25.6% had unilateral, and 9% had borderline CCS, together encompassing >50% of motor incomplete tetraplegia cases. Despite the increased sensitivity and specificity of these subsets compared with existing quantifiable criteria, substantial variability in clinical presentation was still observed. Overall, individuals meeting CCS subset criteria showed a higher likelihood of American Spinal Injury Association (ASIA) Impairment Scale (AIS) D grade than those with motor incomplete tetraplegia without CCS. Upper Extremity Motor Score (UEMS) for those with CCS was lower on admission, a difference that diminished by discharge, whereas their Lower Extremity Motor Score (LEMS) consistently remained higher than for those without CCS. However, these neurological distinctions did not result in significant functional differences, as lower and upper extremity functional outcomes at discharge were mostly similar, with some differences observed within those with AIS D grade. The AIS grade, rather than the diagnosis of CCS, remains the foremost determinant influencing neurological and functional outcomes. We recommend that future studies consider incorporating motor incomplete tetraplegia into their inclusion/exclusion criteria, instead of relying on criteria specific to CCS. Although there remains clinical value in characterizing an injury pattern as CCS and perhaps using the different subsets to better characterize the impairments, it does not appear to be a useful research criterion.

To assess differences in autonomic function using heart rate variability (HRV) parameters between people with and without orthostatic hypotension (OH), and to determine symptoms of OH in people with spinal cord injury (SCI). R-R interval and blood pressure (BP) data were recorded using Finometer PRO^® in both the supine position and at a 60-degree tilt using a tilt table, each lasting for 6 minutes. R-R interval data were processed using the Kubios HRV analysis software to convert R-R interval into time and frequency domains for further analysis. Compared to the non-OH group, the SCI group with OH exhibited lower values for root mean square of the successive differences (RMSSD) and standard deviation of normal-to-normal interval (SDNN), along with an elevated heart rate during tilt-up. Participants with OH symptoms had a lower average heart rate in the supine and 60-degree positions compared to asymptomatic participants. Logistic regression analysis indicated that SDNN in the supine position correlated with the presence of OH, and that the mean heart rate in the 60-degree position was related to the presence of symptoms. Differences in HRV parameters were observed in people with SCI and OH, suggesting a reduced parasympathetic activity in the supine position, likely as a response to maintain homeostasis in BP regulation. Despite the presence or absence of OH symptoms, there was no difference in HRV parameters. This finding suggests that autonomic function may not be the primary determinant of these symptoms, with other factors likely being more influential.

Defecation function is negatively impacted in patients with neurogenic bowel dysfunction (NBD), who require effective bowel care for stool evacuation. NBD comprises fecal incontinence and/or constipation, which can reduce the quality of life and dignity. Transanal irrigation (TAI) is recommended by several clinical guidelines as the second-line treatment after conservative treatment and before surgical options are considered. As the only class in the second-line treatment with an established safety and efficacy profile, the mechanism of action of TAI has not fully been elucidated when administered through a rectal catheter with a balloon. This review examines the current understanding regarding the mechanism of action of TAI, with a focus on the pathophysiology of neurogenic bowel and irregular defecation. By understanding the functional implications of TAI, clinicians may be better able to integrate this modality into bowel care programs, especially for patients with NBD who have significant constipation due to delayed colonic motility and impaired stool emptying with loss of voluntary control of defecation, and those who are unresponsive to conservative treatment, including enemas.