Respiratory Changes After Spinal Cord Injury

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Author: Sharon Jang | Reviewer: Tova Plashkes | Published: 24 September 2020 | Updated: 7 December 2021

This page provides an overview of how spinal cord injury (SCI) affects breathing and coughing, and the acute treatments used to address these issues.

Key Points

  • Spinal cord injury can damage the muscles of breathing, affecting the ability to take a deep breath, cough and clear mucus, and maintain adequate oxygen levels. The extent of these changes depends on the level and completeness of the SCI with higher cervical injuries being more affected.
  • A wide range of management options may be used to assist or improve the effectiveness of breathing and coughing in acute and chronic SCI, including tracheostomy and intubation in severe cases, non-invasive ventilation, along with assisted coughing techniques.
  • A number of secondary respiratory complications can affect people with SCI long after injury, including lung infections like pneumonia.
  • Preventative strategies such as flu shots, smoking cessation, and healthy living are an important component of respiratory care.

The breathing process: During inhalation, the diaphragm (dark pink) moves down and the ribs expand. During exhalation, the diaphragm moves up and the ribs contract.1

The respiratory system is responsible for helping you breathe in (inhaling) and out (exhaling). Breathing is done through the nose and mouth, although the nose is more often used. One reason the nose is used more often is because it acts as a filter for debris, which protects the lungs. Coughing is another important part of the respiratory system, as it helps to clear mucus from your lungs and airways.

Many muscles help with respiratory functions. The muscles used for inhaling are controlled from the spinal nerves of the neck (C3-C5 primarily), with some help from the nerves of the lower neck and thorax (C6-T12). Inhaling is mostly facilitated by your diaphragm, which is a large dome shaped muscle underneath the lungs. When you breathe in, your diaphragm lowers and the space in your chest increases, pulling air into the lungs. When you exhale, your ribs move back in and the diaphragm moves back up.

Breathing during exercise and coughing requires extra effort. To help, the abdominal muscles (over your belly) and the intercostal muscles (which help to squeeze the ribs) are activated, allowing for a stronger inhalation and a forceful cough.

When someone is unable to breathe or cough by themselves, their function, independence, and health are affected. These respiratory complications arise in 36-83% of individuals after SCI. This is due to disruption of the breathing nerves after an injury, and to secondary complications of an SCI, such as spasticity. After an SCI, breathing muscles may be partially or completely affected, depending on the completeness of the injury. However, breathing ability may improve over time.

Many muscles are required for breathing. The diagram above shows the main muscles of breathing, and the sections of the spinal cord that innervate them.2

The chances of experiencing respiratory complications depend on a variety of factors, including:

  • The level of injury (dictates which muscles are spared)
  • The completeness of an injury
  • Timing of a tracheostomy*
  • The cause of injury
  • Age*

* Conflicting evidence

Refer to our page on Evidence Rating for more information on conflicting evidence.

Changes in breathing

Changes in amount of air getting into the lungs

After injury, the amount of air that can be inhaled and exhaled are significantly reduced for people with cervical and higher thoracic (neck and upper back) level injuries. More specifically, the amount of air that can fill the lungs (known as the total lung capacity) is reduced to 60-80% of normal values. Additionally, the amount of air that can be exhaled after the biggest breath in (known as the vital capacity) is reduced to 50-80% of normal values. This contributes to inefficient breathing that may be tiresome and difficult. In addition, a lower vital capacity can impact voice volume, making it difficult to speak at louder volumes.

Changes to the lung

An SCI can affect the lung itself. The main change is a reduction in lung compliance, or the lung’s ability to stretch and expand. As a result, the lung does not spring back “closed” after being open. In addition, the compliance of the rib cage (chest wall) may also decrease, causing the chest to become rigid in individuals with tetraplegia. Reduced compliance results in a decreased ability to take a deep breath independently or with the help of a breathing bag or ventilator.

Changes in coughing

Coughing is important to keep the airway and lungs clear from mucus. This is because a build up of mucus can collapse the lungs, and mucus in the airways can result in infection. In order to perform a cough, one needs to inhale deeply then have a forceful exhale while a structure called the glottis closes the entrance to the windpipe. The intercostal muscles and the abdominal muscles assist with the ability to increase the force of exhaled air. As these muscles are innervated by nerves in the chest region, individuals with spinal cord injuries may have an impaired coughing function. Cough function may be completely absent in some individuals, while others may have limited or ineffective coughing abilities.

Changes in lung irritability and mucous production

Soon after injury, it is common for individuals with high-level SCI to produce a lot of mucus in their lungs and have smaller airways deep in the lung. The lungs are also very irritable to stimuli like too much suctioning of mucus, or smoking.  This may be due to the increased influence of the parasympathetic nervous system after SCI. In people with acute tetraplegia, it has been reported that an excess of up to 1 liter of mucus is produced each day. In combination with an inability to cough, this excess production of mucus can result in a buildup of fluid in the lungs and airway.

Changes in swallowing

Although swallowing is important for eating, it is also important for clearing the throat to prevent food, drink, stomach contents, or saliva from entering the lungs (also known as aspiration). After SCI, the risk of aspiration increases as:

    • Your ability to cough may be limited by medical conditions and weakness due to your injury
    • Surgical procedures on the spine may compress your throat
    • You may feel less alert due to sedative medications
    • Some medications you may be on can lead to dry mouth
    • Your sensation may be impaired, which prevents you from feeling food or liquid in the spaces at the back of your throat

The lack of effective swallowing can cause mucus to collect in your airway. Over time, the stagnant mucus can encourage the growth of bacteria, which may travel down to your lungs and potentially result in pneumonia.

Secretion Removal Techniques

Efficient removal of mucus from the airways is important to prevent choking and lung infections, especially when independent coughing is difficult. Although research on the topic of secretion removal techniques is scarce, one study with moderate evidence showed that manual removal techniques combined with mechanical removal techniques are effective in SCI early after injury. Different techniques are outlined below:

Postural drainage

Certain body positions can use gravity to drain mucus towards the throat to be excreted easier. For example, laying on your side with your feet elevated can help drain the lower lung. In order for these positions to be effective, your body must be positioned in specific angles. Refer to your healthcare professional for more information. To facilitate breakup and movement of the mucus buildup in the lungs, postural drainage can be paired with applying pressure to the chest (chest percussion) or shaking the chest (vibration).

Manual assisted coughing

Physical pressure is applied to the chest or abdomen right before expiration to help the individual breathe out. This can be done on yourself or by a trained family member or caregiver.

Mechanically assisted coughing (insufflation-exsufflation)

There are machines that help loosen secretions, clear mucus, and can trigger a cough. They work by delivering a deep breath by pushing air into the lungs, then facilitate exhalation by sucking the air out.

Suction

A tube can be inserted through the mouth or tracheostomy site to suction mucus that is stuck in the upper airways. Suctioning may also reflexively trigger a cough.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, refer to the SCIRE Community Evidence Ratings.

Respiratory Muscle Training

Weak inspiratory muscles can result in breathlessness. Like exercise training, inspiratory muscle strength and endurance can increase with training and decrease bouts of shortness of breath (dyspnea) and coughing. Inspiratory muscle training involves using devices that create resistance when breathing in.

Resistive trainers have adjustable settings that allow individualized training programs.5

Refer to our article on Inspiratory Muscle Training for more information!

Drug Treatments

Bronchodilators

People with tetraplegia have increased sensitivity of their airways, resulting in more frequent narrowing. To treat this, a family of drugs called bronchodilators can be used to enlarge the airways for air to pass through with more ease. The use of bronchodilators is supported by multiple (weak evidence) studies, which have found that bronchodilators can help improve expiration among individuals with tetraplegia. There is also one strong evidence study that indicates that the bronchodilator salmeterol can improve both respiratory functioning and the strength of breathing muscles. While bronchodilators can help positively influence respiratory functioning, their use carries a potential negative side effect of thickening mucus.

Mechanical ventilation, or machine assisted breathing, is becoming more common as there has been an increase in the number of people who survive cervical level injuries over the past 40 years. Mechanical ventilation is used by people who are unable to breathe independently, often right after injury. The machine works by pushing air into the lungs until a pre-set volume or pressure is reached. Once the pre-set value has been met, the machine stops pushing air in and the air is exhaled by the person.

In general, there are two forms of mechanical ventilation: a non-invasive approach where a mask is placed over the mouth and nose (known as a Bilevel Positive Airway Pressure (BiPAP) or Continuous Positive Airway Pressure (or CPAP)), or an invasive approach where a tube is inserted into the windpipe via the mouth and throat (intubation) or directly into the windpipe through a surgical incision (tracheostomy). Intubation or tracheostomy is used in more severe cases to ensure air gets to the lungs and that mucus is filtered out of the lung. Factors that increase the chances of requiring invasive mechanical ventilation include having a complete injury, having a higher level of injury, or having a compound injury Whenever possible, the healthcare team tries to help people breathe on their own and “weans” the person off the ventilator if possible.

Intubation

The process of intubation consists of running a tube into the trachea either through the nose or mouth. This process is completed as soon as someone is in respiratory distress, which is normally at the scene of the accident or upon admission to the hospital. Intubation is often used for a short term (i.e., less than 10 days), as prolonged use can lead to severe weakness of breathing muscles, pneumonia, more difficulty in breathing, mobility limitations, prolonged ventilator weaning, and can make lung and mouth hygiene difficult.

Tracheostomy

A tracheostomy is a surgical procedure that involves placing a tube through an opening in the throat and windpipe. This creates a pathway for air delivery from a ventilator and to facilitate secretion removal. However, after the tracheostomy tube is taken out, speaking and eating may be difficult as the throat muscles become weakened and uncoordinated.

A tracheostomy tube is inserted into the throat through a surgical hole.6

A tracheostomy is performed in the event that breathing support is required for a minimum of 3 weeks. Individuals who may require a tracheostomy (weak to moderate evidence) include: having a complete or higher level of injury, having a complete injury or a lower AIS motor grade, and old age.

Once an individual is able to independently breathe, the tube is removed from the windpipe. Weak evidence suggests that tube removal is more successful in individuals with certain characteristics:

  • Those who have lower level spinal cord injuries.
  • Those who have not had a tracheostomy but have only been intubated.

Continuous Positive Airway Pressure (CPAP) Ventilation

Continuous Positive Airway Pressure (CPAP) is a form of mechanical ventilation commonly used to address obstructive sleep apnea. Sleep apnea occurs when breathing ceases in short bouts during sleep, and can result in feeling tired during the day. CPAP machines are used to manage this condition by acting as a “pneumatic splint”, keeping airways open during sleep.

Loss of independent breathing and cough function can lead to secondary respiratory issues. These issues need to be medically addressed, as they may be life-threatening if left untreated.

Common secondary respiratory issues following SCI

Atelectasis

A collapsed lung in comparison to a healthy lung.7

A condition where a part of the lung becomes partially or fully collapsed due to a lack of air. This results in a reduced ability to exchange oxygen and carbon dioxide. When the body does not get enough oxygen, organs will start to shut down. Atelectasis can result from anything that prevents the lungs from fully expanding, including:

    • Weak or paralyzed muscles, which can prevent being able to take in a deep full breath. This is the most important cause in SCI.
    • A buildup of mucus, which may block an area of the lung from fully expanding.
    • Shallow breathing due to surgery or pain, which can result in poor inflation of the lungs.
Pneumonia

Pressure from outside the lungs, which can result in the inability to fully inflate. This external pressure may stem from fluid or air, abdominal organs, or external hardware such as a brace.

Pneumonia is a medical name for a lung infection. After an SCI, several factors make pneumonia very common:

Requiring a ventilator, suctioning (removal of secretions with a special machine), or a tracheostomy may often be necessary, but tends to introduce bacteria despite best efforts at hygiene and air filtration. The risk of getting pneumonia increases if someone:

  • is unable to cough and clear mucus,
  • is reliant on mechanical ventilation to assist with breathing,
  • has a severe injury,
  • has a traumatic higher-level injury involving fractures, or,
  • has had a surgical tracheostomy.

Refer to our article on Infectious Respiratory Conditions for more information!

Pulmonary embolism

A pulmonary embolism occurs when a clot (red groups) gets caught in the lungs.8

A pulmonary embolism is a blockage of an artery in the lungs by a blood clot that has moved from elsewhere in the body through the bloodstream (embolism). As a result of paralysis or immobility, a blockage may develop in a vein, often in the lower leg. This is called a blood clot, or deep vein thrombosis. The clot may travel to the lung and block blood vessels, resulting in sudden shortness of breath. The prevalence of this condition is highest within the first three months of injury. Weak evidence suggests that pulmonary embolisms occur in a range of 1.25% to 4.5% of people with SCI in the first 90 days. However, pulmonary embolisms have been considered to occur rarely after the first three months of SCI, and have decreased significantly due to preventative measures (e.g., blood thinners). That said, weak evidence suggests that pulmonary embolisms may still be an issue in chronic SCI, but may not be severe enough to cause any symptoms.

Pulmonary edema

Pulmonary edema is a build-up of fluid in the lung. This often occurs in early stages following injury. It can affect as much as 50% of individuals with acute tetraplegia. There are several causes, with the most common being excess fluids given to people with SCI. After an SCI, blood pressure may drop to very low levels. Depending on the cause and type of injury, this may be due to blood loss from a traumatic injury, or impairment of nerves that keep blood pressure at its normal level with a cervical or high thoracic injury. As a result, a lot of fluids are given to patients to help their blood pressure recover.

Respiratory failure

Respiratory failure occurs when the respiratory system is damaged to the extent where the body does not get enough oxygen and is unable to get rid of carbon dioxide. Oxygen levels in the body may drop to critically low values and carbon dioxide, which is poisonous at very high levels, builds up. The risk of a respiratory failure increases with higher levels of injury, and most commonly occurs in acute SCI. This usually results in the need for mechanical ventilation.

Getting vaccinated is one of the ways to prevent secondary complications such as pneumonia.9

Prevention is important to avoid getting respiratory illnesses when you have an SCI. Some things you can do to stay as healthy as possible include:

  • Avoiding smoking any substances and taking in second hand smoke. The lungs of people with SCI are easily irritated, and those who smoke are more susceptible to lung infections.
  • Staying hydrated – drink plenty of water. This helps to keep mucus in the lungs from being too thick.
  • Ensuring proper nutrition to help maintain a healthy weight and ensure the body has enough vitamins, minerals and protein to heal well when sick.
  • Exercising, as it can help by:
    • Helping you maintain a healthy weight, as lung complications become more prevalent in people who are overweight or obese,
    • Strengthening your breathing muscles.
  • Getting vaccinated for influenza (the flu) and pneumonia. This can help decrease your odds of getting these illnesses.
  • Coughing on a regular basis. Coughing is important for keeping your airways clear of secretions. If you have difficulties coughing by yourself, have someone help you perform manual assist coughs, or use a cough assist machine.
  • Maintaining mobility and proper posture. In order to prevent build up in the lungs, try to sit up everyday and turn when laying in bed.

Secretion removal techniques

Equipment used for lung volume recruitment.10

Upon returning to the community, common secretion removal techniques include glossopharyngeal breathing and the use of lung volume recruitment (LVR) bags with an assisted cough. Glossopharyngeal breathing (or frog breathing) is a technique that is used to get a deeper breath. This is done by rapidly taking “gulps” of breaths one after the other, followed by exhaling. This can help create a cough, or facilitate assisted coughing.

LVR, or “breath stacking” is done with an LVR kit which consists of a resuscitation bag connected with a flexible tube to a mouth piece with a one-way valve. The individual will inhale the most they can, and once this point is reached, a clinician (or second person) will squeeze the bag to “stack” breaths to fully inflate the lungs. This allows the individual to breathe more air than they are able to themselves, and to exhale more air more quickly to produce an improved cough. This also can help with maintaining chest mobility and flexibility.

Exercise Training

Exercise training involving arm and leg movements can improve muscle strength and cardiovascular endurance. Breathing muscles are also challenged with exercise and may become stronger with exercise. This increase in strength can help decrease the effort of breathing at rest and with functional activity, like transfers. An example of a method of exercise training for individuals with higher levels of injuries include the use of a Functional Electrical Stimulation (FES) bike. Other exercises like arm cycling or strengthening exercises are commonly prescribed by a physiotherapist or health care professional. While exercise can help strengthen respiratory muscles, low-moderate evidence studies debate whether lung volumes are impacted. This is to say, exercising may help make breathing feel easier, but it is unknown whether the amount of air you can take into your lungs is affected. High intensity exercise three times per week for six weeks has shown to significantly improve respiratory function. However, standard guidelines for high intensity exercise have not yet been established.

An abdominal binder wrapped around the abdomen to correct the positioning of the diaphragm.12

Refer to our article on Functional Electrical Stimulation for more information!

Girdle/Abdominal Binder

Girdles or abdominal binders are garments that apply pressure around the abdominal area to help keep the diaphragm in an optimal position. Abdominal binders are also used for managing orthostatic hypotension and blood pooling. Although there may be short-term improvements when using a girdle or binder, more research is needed in determining their long-term utility.

Refer to our article on Abdominal binders for more information!

Electrical Stimulation

For people who are ventilator dependent, various electrical stimulation techniques are available to assist with breathing. This includes phrenic nerve stimulation/diaphragm pacing, abdominal electrical stimulation, and epidural stimulation.

Phrenic nerve stimulation/Diaphragm pacing

The diaphragm is the main muscle responsible for breathing and is activated by the phrenic nerve to contract. After SCI, the connection between the brain and the phrenic nerve is disrupted, which contributes to impaired breathing. Researchers have been looking at ways we can stimulate this nerve to reactivate the diaphragm through a process called phrenic nerve stimulation. This process involves surgically implanting electrodes and a receiver close to the phrenic nerve, either in the chest or the neck, and a receiver in the chest wall. This device is controlled with an external remote and antenna (which is used to connect to the electrode receiver).

For phrenic nerve stimulation to work, the diaphragm must have normal function, and the phrenic nerve needs to be intact (i.e., sends a signal when stimulated). As a result, individuals who have a C3, C4, or C5 level injury may not be eligible as they often have impaired phrenic nerve function. It is important to note that this procedure can only facilitate inspiratory functions, but not expiratory. As a result, an individual who receives phrenic nerve stimulation may not require mechanical ventilation, but will still require assistance with coughing and clearing secretions. Tracheostomies and mechanical ventilation are often still used in combination with phrenic nerve stimulation as a back-up.

Some weak evidence supports the use of phrenic nerve stimulation. One study found that diaphragm pacemakers have better results with long term implantation (i.e., 6.3 years in the study). Another study showed that diaphragmatic paces can improve survival rates, decrease the cost of care, improve the quality of speech, increase rates of social participation, and improve management of using a powered wheelchair. Many complications have been reported in the research in regards to using a phrenic nerve stimulator. These complications include wires breaking or getting displaced, device failure, inhaling food when eating, shoulder or abdominal pain, and infections.

Abdominal electrical stimulation

As diaphragm pacing only helps with inhalation, limited research suggests that electrically stimulating the abdominal muscles helps with expiration and coughing. Ideally, the abdominal muscles would be used to support voluntary efforts to cough. There have been mixed findings on the effectiveness of stimulating the abdominal muscles to enhance cough. While some weak studies have found abdominal stimulation to improve cough, other weak evidence studies have found no noticeable changes. More research is required to determine the efficacy of stimulating the abdominal muscles to enhance cough in SCI.

Epidural Stimulation

Epidural stimulation is conducted through surgically implanting an electrode over the spinal cord. Once done, the electrode, which is controlled with a remote outside of the body, stimulates various parts of the spinal cord. Emerging research on epidural stimulation suggests that it may benefit respiratory function after SCI. By directly stimulating nerve cells in the spinal cord, weak evidence suggests that breathing muscles can be activated. The muscles are activated in a pattern that resembles normal breathing, while reducing fatigue. Additionally, weak evidence suggests that epidural stimulation can improve other respiratory functions including coughing and speaking.

Respiratory problems are common after SCI. The extent and type of these problems depend on the level of injury and completeness of injury. Both conservative and invasive options for managing respiratory health following an SCI are available. Due to impaired respiratory function, a variety of secondary complications to the lungs frequently occur after SCI. While prevention using proper respiratory hygiene is best, should you experience a secondary respiratory complication, a variety of management techniques can be applied. Some techniques are more common in the acute stages of SCI, while others are more suited to chronic SCI. It is best to discuss all treatment options with your health providers to find out which treatments are suitable for you.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

Parts of this page has been adapted from SCIRE Project (Professional) “Respiratory Management during the Acute Phase of Spinal Cord Injury” Chapter:

Mullen E, Mirkowski M, Vu V, McIntyre A, Teasell RW. (2015). Respiratory Management during the Acute Phase of Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Research Evidence. Version 5.0: p 1-50.

Available from: https://scireproject.com/evidence/acute-evidence/respiratory-management-during-acute-phase-of-spinal-cord-injury/

 

Evidence for “How does an SCI affect the respiratory system” is based on

Warren, P. M., Awad, B. I., & Alilain, W. J. (2014). Drawing breath without the command of effectors: The control of respiration following spinal cord injury. Respiratory Physiology & Neurobiology. https://doi.org/10.1016/j.resp.2014.08.005

Lemons, V. R., & Wagner, F. C. (1994). Respiratory Complications After CSCI. In Spine (Vol. 19, Issue 20, pp. 2315–2320).

Romero-Ganuza, J., Gambarrutta, C., Merlo-Gonzalez, V. E., Marin-Ruiz, M. Á., Diez De La Lastra-Buigues, E., & Oliviero, A. (2011). Complications of tracheostomy after anterior cervical spine fixation surgery. American Journal of Otolaryngology – Head and Neck Medicine and Surgery, 32(5), 408–411. https://doi.org/10.1016/j.amjoto.2010.07.020

Romero, J., Vari, A., Gambarrutta, C., & Oliviero, A. (2009). Tracheostomy timing in traumatic spinal cord injury. European Spine Journal, 18(10), 1452–1457. https://doi.org/10.1007/s00586-009-1097-3

Aarabi, B., Harrop, J. S., Tator, C. H., Alexander, M., Dettori, J. R., Grossman, R. G., Fehlings, M. G., Mirvis, S. E., Shanmuganathan, K., Zacherl, K. M., Burau, K. D., Frankowski, R. F., Toups, E., Shaffrey, C. I., Guest, J. D., Harkema, S. J., Habashi, N. M., Andrews, P., Johnson, M. M., & Rosner, M. (2012). Predictors of pulmonary complications in blunt traumatic spinal cord injury. Journal of Neurosurgery: Spine, 17, 38–45.

Jain, N. B., Higgins, L. D., Katz, J. N., & Garshick, E. (2010). Association of shoulder pain with the use of mobility devices in persons with chronic spinal cord injury. PM and R, 2(10), 896–900. https://doi.org/10.1016/j.pmrj.2010.05.004

Anke, A., Aksnes, A. K., Stanghelle, J. K., & Hjeltnes, N. (1993). Lung volumes in tetraplegic patients according to cervical spinal cord injury level. Scandinavian Journal of Rehabilitation Medicine, 25(2), 73–77. http://www.ncbi.nlm.nih.gov/pubmed/8341994

Brown, R., DiMarco, A. F., Hoit, J. D., & Garshick, E. (2006). Respiratory dysfunction and management in spinal cord injury. Respiratory Care, 51(8), 853-68;discussion 869-70. http://www.ncbi.nlm.nih.gov/pubmed/16867197%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC2495152

Berlly, M., & Shem, K. (2007). Respiratory management during the first five days after spinal cord injury. Journal of Spinal Cord Medicine, 30(4), 309–318. https://doi.org/10.1080/10790268.2007.11753946

Schilero, G. J., Spungen, A. M., Bauman, W. A., Radulovic, M., & Lesser, M. (2009). Pulmonary function and spinal cord injury. Respiratory Physiology and Neurobiology, 166(3), 129–141. https://doi.org/10.1016/j.resp.2009.04.002

Schilero, G.J., Grimm, D.R., Bauman, W.A., Lenner, R., Lesser, M. (2005). Assessment of airway caliber and bronchodilator responsiveness in subjects with spinal cord injury. Chest, 127(1), 149-155. http://dx.doi.org/10.1378/chest.127.1.149

Bhaskar, K. R., Brown, R., O’Sullivan, D. D., Melia, S., Duggan, M., & Reid, L. (1991). Bronchial Mucus Hypersecretion in Acute Quadriplegia: Macromolecular Yields and Glycoconjugate Composition. American Review of Respiratory Disease, 143(3), 640–648. https://doi.org/10.1164/ajrccm/143.3.640

Chaw, E., Shem, K., Castillo, K., Wong, S., & Chang, J. (2012). Dysphagia and associated respiratory considerations in cervical spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 18(4), 291–299. https://doi.org/10.1310/sci1804-291

Evidence for “How does an SCI affect the respiratory system” is based on

Almenoff PL, Alexander LR, Spungen AM, Lesser MD, Bauman WA. Bronchodilatory effects of ipratropium bromide in patients with tetraplegia. Paraplegia 1995; 33: 274-7.

Spungen AM, Dicpinigaitis PV, Almenoff PL, Bauman WA. Pulmonary obstruction in individuals with cervical spinal cord lesions unmasked by bronchodilator administration. Paraplegia 1993;31:404-7.

Schilero GJ, Grimm D, Spungen AM, Lenner R, Lesser M.  Bronchodilator responses to metaproterenol sulfate among subjects with spinal cord injury. J Rehabil Res Dev 2004; 41: 59-64.

Grimm DR, Schilero GJ, Spungen AM, Bauman  WA, Lesser M. Salmeterol improves pulmonary function in persons with tetraplegia. Lung 2006; 184: 335–339.

Evidence for “How can mechanical ventilation be used to help with breathing” is based on

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Como, J. J., Sutton, E. R. H., McCunn, M., Dutton, R. P., Johnson, S. B., Aarabi, B., & Scalea, T. M. (2005). Characterizing the need for mechanical ventilation following cervical spinal cord injury with neurologic deficit. Journal of Trauma – Injury, Infection and Critical Care, 59(4), 912–916. https://doi.org/10.1097/01.ta.0000187660.03742.a6

Montoto-Marqués, A., Trillo-Dono, N., Ferreiro-Velasco, M. E., Salvador-De La Barrera, S., Rodriguez-Sotillo, A., Mourelo-Fariña, M., Galeiras-Vázquez, R., & Meijide-Failde, R. (2018). Risks factors of mechanical ventilation in acute traumatic cervical spinal cord injured patients. Spinal Cord, 56(3), 206–211. https://doi.org/10.1038/s41393-017-0005-7

Seidl, R. O., Wolf, D., Nusser-Müller-Busch, R., & Niedeggen, A. (2010). Airway management in acute tetraplegics: A retrospective study. European Spine Journal, 19(7), 1073–1078. https://doi.org/10.1007/s00586-010-1328-7

Velmahos, G. C., Toutouzas, K., Chan, L., Tillou, A., Rhee, P., Murray, J., & Demetriades, D. (2003). Intubation after cervical spinal cord injury: to be done selectively or routinely? The American Surgeon, 69, 891–894. https://doi.org/10.1257/0002828041464551

Durbin, C. G., Bell, C. T., & Shilling, A. M. (2014). Elective intubation. Respiratory Care, 59(6), 825–849.

Shirawi, N., & Arabi, Y. (2005). Bench-to-bedside review: Early tracheostomy in critically ill trauma patients. In Critical Care (Vol. 10, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/cc3828

Biering-Sorensen, M. (1992). Tracheostomy in spinal cord injured: frequency and follow up. 30, 656–660.

Ganuza, J. R., Forcada, A. G., Gambarrutta, C., Buigues, E. D. D. L. L., Gonzalez, V. E. M., Fuentes, F. P., & Luciani, A. A. (2011). Effect of technique and timing of tracheostomy in patients with acute traumatic spinal cord injury undergoing mechanical ventilation. Journal of Spinal Cord Medicine, 34(1), 76–84. https://doi.org/10.1179/107902610X12886261091875

McCully, B. H., Fabricant, L., Geraci, T., Greenbaum, A., Schreiber, M. A., & Gordy, S. D. (2014). Complete cervical spinal cord injury above C6 predicts the need for tracheostomy. American Journal of Surgery, 207(5), 668–669. https://doi.org/10.1016/j.amjsurg.2014.01.001

Yugué, I., Okada, S., Ueta, T., Maeda, T., Mori, E., Kawano, O., Takao, T., Sakai, H., Masuda, M., Hayashi, T., Morishita, Y., & Shiba, K. (2012). Analysis of the risk factors for tracheostomy in traumatic cervical spinal cord injury. Spine, 37(26), 1633–1638. https://doi.org/10.1097/BRS.0b013e31827417f1

Leelapattana, P., Fleming, J. C., Gurr, K. R., Bailey, S. I., Parry, N., & Bailey, C. S. (2012). Predicting the need for tracheostomy in patients with cervical spinal cord injury. Journal of Trauma and Acute Care Surgery, 73(4), 880–884. https://doi.org/10.1097/TA.0b013e318251fb34

Menaker, J., Kufera, J. A., Glaser, J., Stein, D. M., & Scalea, T. M. (2013). Admission ASIA motor score predicting the need for tracheostomy after cervical spinal cord injury. Journal of Trauma and Acute Care Surgery, 75(4), 629–634. https://doi.org/10.1097/TA.0b013e3182a12b86

O’Keeffe, T., Goldman, R. K., Mayberry, J. C., Rehm, C. G., & Hart, R. A. (2004). Tracheostomy after anterior cervical spine fixation. Journal of Trauma – Injury, Infection and Critical Care, 57(4), 855–860. https://doi.org/10.1097/01.TA.0000083006.48501.B2

Harrop, J. S., Sharan, A. D., Scheid, E. H., Vaccaro, A. R., & Przybylski, G. J. (2004). Tracheostomy placement in patients with complete cervical spinal cord injuries: American Spinal Injury Association Grade A. Journal of Neurosurgery, 100(Spine 1), 20–23.

Peterson, W., Charlifue, W., Gerhart, A., & Whiteneck, G. (1994). Two methods of weaning persons with quadriplegia from mechanical ventilators. Paraplegia, 32(2), 98–103. https://doi.org/10.1038/sc.1994.17

Kornblith, L. Z., Kutcher, M. E., Callcut, R. A., Redick, B. J., Hu, C. K., Cogbill, T. H., Baker, C. C., Shapiro, M. L., Burlew, C. C., Kaups, K. L., DeMoya, M. A., Haan, J. M., Koontz, C. H., Zolin, S. J., Gordy, S. D., Shatz, D. V, Paul, D. B., Cohen, M. J., & Western Trauma Association Study Group. (2013). Mechanical ventilation weaning and extubation after spinal cord injury: a Western Trauma Association multicenter study. The Journal of Trauma and Acute Care Surgery, 75(6), 1060–1069; discussion 1069-70. https://doi.org/10.1097/TA.0b013e3182a74a5b

Evidence for “What secondary respiratory issues occur with acute SCI?” is based on

Berlly, M., & Shem, K. (2007). Respiratory management during the first five days after spinal cord injury. Journal of Spinal Cord Medicine, 30(4), 309–318. https://doi.org/10.1080/10790268.2007.11753946

Garcia-Arguello, L. Y., O’Horo, J. C., Farrell, A., Blakney, R., Sohail, M. R., Evans, C. T., & Safdar, N. (2017). Infections in the spinal cord-injured population: a systematic review. Spinal Cord, 55(6), 526–534. https://doi.org/https://dx.doi.org/10.1038/sc.2016.173

Alabed, S., De Heredia, L. L., Naidoo, A., Belci, M., Hughes, R. J., & Meagher, T. M. (2015). Incidence of pulmonary embolism after the first 3 months of spinal cord injury. Spinal Cord, 53(11), 835–837. https://doi.org/10.1038/sc.2015.105

Aito, S., Pieri, A., D’Andrea, M., Marcelli, F., & Cominelli, E. (2002). Primary prevention of deep venous thrombosis and pulmonary embolism in acute spinal cord injured patients. Spinal Cord, 40(6), 300–303. https://doi.org/10.1038/sj.sc.3101298

Frisbie, J. H., & Sharma, G. V. R. K. (2012). The prevalence of pulmonary embolism in chronically paralyzed subjects: A review of available evidence. Spinal Cord, 50(6), 400–403. https://doi.org/10.1038/sc.2011.154

Sezer, N., Akkuş, S., & Uğurlu, F. G. (2015). Chronic complications of spinal cord injury. World Journal of Orthopaedics, 6(1), 24–33. https://doi.org/10.5312/wjo.v6.i1.24

Evidence for “What is the emerging research on processes to help with breathing” is based on

DiMarco, A. F., Kowalski, K. E., Hromyak, D. R., & Geertman, R. T. (2014). Long-term follow-up of spinal cord stimulation to restore cough in subjects with spinal cord injury. The Journal of Spinal Cord Medicine, 37(4), 380–388. https://doi.org/10.1179/2045772313Y.0000000152

Carter, R. E. (1993). Experience with ventilator dependent patients ! In Paraplegia (Vol. 31). https://doi.org/10.1038/sc.1993.28

Hirschfeld, S., Exner, G., Luukkaala, T., & Baer, G. A. (2008). Mechanical ventilation or phrenic nerve stimulation for treatment of spinal cord injury-induced respiratory insufficiency. Spinal Cord, 46(11), 738–742. https://doi.org/10.1038/sc.2008.43

Esclarin, A., Bravo, P., Arroyo, O., Mazaira, J., Garrido, H., & Alcaraz, M. A. (1994). Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury. Paraplegia, 32(10), 687–693. https://doi.org/10.1038/sc.1994.111

DiMarco, A. F., Kowalski, K. E., Geertman, R. T., & Hromyak, D. R. (2006). Spinal cord stimulation: a new method to produce an effective cough in patients with spinal cord injury. American Journal of Respiratory and Critical Care Medicine, 173(12), 1386–1389. https://doi.org/10.1164/rccm.200601-097CR

Hachmann, J. T., Grahn, P. J., Calvert, J. S., Drubach, D. I., Lee, K. H., & Lavrov, I. A. (2017). Electrical Neuromodulation of the Respiratory System After Spinal Cord Injury. Mayo Clinic Proceedings, 92(9), 1401–1414. https://doi.org/10.1016/j.mayocp.2017.04.011

Harkema, S. J., Wang, S., Angeli, C. A., Chen, Y., Boakye, M., Ugiliweneza, B., & Hirsch, G. A. (2018). Normalization of Blood Pressure With Spinal Cord Epidural Stimulation After Severe Spinal Cord Injury. Frontiers in Human Neuroscience, 12, 83. https://doi.org/10.3389/fnhum.2018.00083

Image Credits:

  1. The breathing process ©The SCIRE Community Team
  2. Modified from: Musculi colli base © Olek Remesz, CC-BY-SA 2.5; Muscles that move the humerus ©OpenStax, CC BY 4.0; Thorax ©OpenStax, CC BY 4.0; Respiratory System ©Theresa Knott, CC BY-SA 3.0, Vertebral Column ©Servier Medical Art, CC BY 3.0; Outline ©Servier Medical Art, CC BY 3.0
  3. Lungs ©Mahmure Alp, CC BY 3.0
  4. Sneezing icon ©j4p4n, CC 0
  5. POWERbreathe Plus, ©POWERbreathe
  6. Tracheostomy NIH ©National Heart Lung and Blood Institute, CC 0
  7. Blausen 0742 Pneumothorax ©Bruce Blaus, CC BY 3.0
  8. Pulmonary embolism ©Servier Medical Art, CC BY 3.0
  9. Cure medical care medication pharmacology vaccination ©Bicanski, CC 0
  10. Lung volume recruitment set ©The SCIRE Community Team
  11. Using the FES ©The SCIRE Community Team
  12. Abdominal Binder ©The SCIRE Community Team
  13. Modified from: Diagram 1 of 3 showing stage 3A lung cancer CRUK 008 ©Cancer Research UK, CC BY 4.0; Breathing ©Servier Medical Art, CC BY 3.0

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Infectious Respiratory Conditions After SCI

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Author: Sharon Jang | Reviewers: Phillip Popovich, Katherine Mifflin | Published: 2 September 2020 | Updated: 24 August 2022

The adverse effects of a spinal cord injury (SCI) on the respiratory and immune systems can increase the risk of getting an infectious respiratory condition. This page reviews the relationship between SCI and infectious respiratory conditions.

Key Points

  • Many respiratory changes occur after SCI, including a weakened ability or a loss of breathing and/or coughing function.
  • Individuals with acute SCI are more susceptible to infectious respiratory conditions due to a weakened immune system and a potentially lessened ability to cough or clear secretions.
  • As individuals with SCI transition from the acute to chronic, they are less likely to catch infectious respiratory conditions. However, if they do, the condition may present more severely.
  • The best thing to do is to try to prevent these conditions! Strategies such as vaccinations and good hand washing practice can help.

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The upper respiratory system (red) and lower respiratory system (blue).1

The respiratory system involves the lungs, and is responsible for breathing, coughing, and speaking. It consists of the upper respiratory tract (nose, mouth, and the throat (pharynx)), and the lower respiratory tract (voice box (larynx), airways (windpipe or trachea), and lungs). Breathing and coughing both depend on various muscles in the chest and neck. Changes to respiratory function after SCI depend on the level of injury and completeness of the injury. After SCI, especially high cervical level injury, some muscles required for breathing may be affected. These include:

  • The diaphragm, which is the main muscle that pulls air into the lungs,
  • The abdominal muscles, which helps to expel air from the lungs and produce a forceful cough, and
  • The muscles in between your ribs (intercostal muscles), which help squeeze air out of the lungs.

The muscles used to breathe are mostly controlled by the upper parts of the spine.2

As a result, sustaining a higher-level injury may result in impaired respiratory function. Some of these changes include:

  • A reduction in the amount of air you are able to breathe,
  • A stiffer lung, making it difficult to take a full, deep breath,
  • A weak or ineffective cough,
  • An increased amount of mucus, and
  • Difficulties with swallowing.

Despite these changes, many technologies and techniques are available that can assist with breathing and coughing. Moreover, the greatest amount of air you are able to blow out after taking your biggest breath in increases over time from injury.

For more information, refer to our article on Respiratory Changes After SCI.

The immune system is responsible for fighting infections and preventing illness. To keep our bodies healthy, the immune system does three main things:

  1. Recognizes harmful germs, such as bacteria and viruses, when they enter the body,
  2. Kills germs and removes them from the body, and
  3. Fights changes in the body that may cause illness (e.g., cancer cells)

Who are the key players in the immune system?

The immune system is comprised of two main parts: the innate immune system and the adaptive (or acquired) immune system. The innate immune system refers to a non-specific line of defence (i.e., it acts against all germs in the same manner) that you are born with. It is often the first line of defense, which is made up of parts of your body that prevent germs from entering. This includes:

  • The outer layer of the skin, which acts as a physical barrier to germs,
  • Mucus and hair, which traps germs,
  • Saliva, which rinses out germs from the mouth,
  • Bodily fluids, such as stomach acid, which kills bacteria, and
  • Urination and defecation, which excretes germs from the body.

Many organs throughout the body contribute to producing cells required to keep you healthy.3

If germs manage to invade the body, the innate immune system is the first system to recognize them. The innate immune system will then trigger a general attack, such as inflammation and fever. This attack affects the entire body, and does not directly target the germ. Innate immune cells then enlist the help of the adaptive immune system.

The second line of defense involves the adaptive immune system, which initiates specific defences for each germ that enters your body. For example, the body will react differently to a virus that causes influenza versus one that causes measles. The main players in the second line of defense are various types of white blood cells. This includes: natural killer cells, which kill any cell that is not recognized as part of the body, lymphocytes, which help the body remember the invaders for the future and destroy them, and phagocytes, which help “eat” and break up invading organisms.

The cells that contribute to the first and second line of defence are produced in organs all over the body, including the bone marrow, spleen, lymph nodes, adrenal glands, tonsils, and thymus.

Spinal Cord Injury Immune Depression Syndrome (SCI-IDS) is a condition that weakens the immune system after SCI. Weak evidence suggests that SCI-IDS commonly occurs among those with acute SCI. That said, there is also early evidence that SCI-IDS can persist and be present in those with chronic (>1 year) SCI. Although researchers are unsure why the immune system is weakened after SCI, hypotheses have been made:

  • SCI-IDS may be a self-defence mechanism that lowers the body’s immunity to prevent the body from attacking itself after the damage that has occurred in the spinal cord.
  • Many of the organs associated with the immune system, such as the spleen, thymus, and lymph nodes, are controlled by the sympathetic nervous system. These nerves are impaired when an individual sustains an injury at T6 or above. As a result, the immune system may not be as active.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, refer to the SCIRE Community Evidence Ratings.

A natural killer cell. The number of these cells is decreased after SCI.4

Weak evidence suggests that immune system changes may occur regardless of level of injury. For example, the amount of natural killer cells are reduced in adults with SCI, regardless of level of injury, in comparison to an able-bodied population. This reduces the body’s ability to fight off germs, which may cause infections, disease, and illnesses. Moreover, early animal research suggests that individuals with SCI may be more susceptible to viruses, such as the flu due to impairments in the body’s immunity. However, it is important to note that these findings have not yet been replicated in humans.

Although the immune system recovers after acute SCI, some (weak) evidence suggests that lowered immunity may extend into the chronic stage of SCI. One study investigated the genes responsible for programming and developing immune cells. The authors found that the genes that normally create natural killer cells are reduced, resulting in lower amounts of these germ-fighting cells throughout the body. A second study supported these findings, as individuals with SCI were found to have lower amounts of natural killer cells in their blood compared to an able-bodied population.

Having an SCI in combination with a weakened immune system has many implications for secondary complications. For example, after SCI many individuals may have difficulties with or be unable to effectively void urine, which encourages the growth of bacteria. This, in combination with a weakened immune system, may explain why urinary tract infections (UTIs) are a common secondary complication of SCI. Although SCI complications and a weakened immune system may contribute to many other secondary complications (e.g., UTI, pressure sores), this article will focus on infectious respiratory conditions that are common with SCI.

For more information, refer to our articles on UTIs and Pressure Injuries!

Respiratory infections can occur in anyone, but people with SCI are at a higher risk for the following reasons:

  • Weakened immune system: After SCI, individuals may have a weakened immune system, some researchers believe that this may make them more prone to infections.
  • Reduced/absent respiratory functioning: As people with SCI may have an inability/weakened ability to cough, mucus begins to build up in the airways and the lung. This accumulation of mucus creates a breeding ground for bacteria and viruses.
  • Inhaling your food, drinks, or saliva (aspiration) is common after SCI. This results in these substances collecting in your lung, which may result in pneumonia.
  • Use of mechanical respiratory devices: The use of mechanical ventilation can cause ventilator-assisted pneumonia, especially in hospital environments. If parts of the ventilation system (e.g., tubing) are not cleaned properly, bacteria can grow

The heart (in the center) and lungs are complexly interconnected. The lungs help oxygenate the blood, which is pumped by the heart.7

Infectious respiratory diseases can target either the upper respiratory tract (i.e., the nose, mouth, and throat), or the lower respiratory tract (i.e., the voice box, windpipe, airways into the lungs, and the lungs). Oxygen is required for each organ to function properly. When a part of your respiratory system becomes infected, the amount of air you breathe in may be reduced. This reduces the amount of oxygen available for the body, and may quickly affect the function of the brain and other organs. Moreover, these infections can spread all over the body (sepsis). Once it spreads, it becomes more difficult to treat.

As an SCI can negatively affect respiratory and immune function, the rates of respiratory diseases, such as bacterial pneumonia and influenza, among individuals with SCI is high. In fact, respiratory diseases account for just over 80% of all deaths after SCI. In addition, respiratory conditions often present more severely in SCI. This was shown in a (weak evidence) study, where people with SCI who contracted influenza or pneumonia were 37 times more likely to die from the infection compared to an able-bodied population. Two of the most common respiratory infections in people with SCI are pneumonia and the flu. These conditions are particularly infectious, and are caught through tiny droplets of fluid in the air that may be released as a cough or a sneeze. These droplets may fall on surfaces, and can spread if someone touches the surface, then touches their mouth or eyes.

Some (weak evidence) research done to predict who is more likely to experience respiratory illness after SCI indicated that those with a complete injury and those with tetraplegia are at an increased risk of dying from a respiratory related infection. Another study found that during acute care, those with a complete injury were at a greater risk of getting pneumonia. This is related to the lack of/weakened ability to cough and clear mucus from the airways. Secondary complications that may predispose people with SCI to respiratory illnesses include: obesity, heart disease, asthma, chronic obstructive pulmonary disease (COPD), chronic coughing, chronic existence of phlegm, wheezing, and the use of pulmonary medications.

Pneumonia and SCI

Pneumonia is an infection caused by a bacteria or virus, which leads to an infection of the small air sacs in the lungs. It is one of the most common infections in acute SCI with about 30% of individuals with acute SCI experiencing pneumonia (weak evidence), dropping to about 3.5% in the chronic stages of SCI (i.e., 1-20 years post injury). Although the chance of getting pneumonia decreases after acute SCI, it is important to remember that pneumonia manifests more severely in people with SCI. That is to say, while your chances of getting pneumonia may be reduced at longer times after SCI, if you do get it, it is more severe.

Influenza and SCI

Influenza, or the flu, is a respiratory condition caused by a virus. There are multiple types and sub-types of influenza, although type A and B are the strains that most often cause the flu season. The flu virus affects the nose, throat, and sometimes the lungs, and can lead to secondary conditions such as pneumonia. Flu vaccines are recommended, especially for people with SCI as they are a vulnerable population. There is weak evidence that supports the use of flu vaccines for people with SCI, as their immune system responds similarly to the vaccine compared to able-bodied individuals. That said, those with tetraplegia may have a reduced response to the vaccine. Animal studies suggest that vaccines may be less effective with higher levels of SCI. More research is required to determine the response to influenza vaccines after SCI.

Other infectious respiratory conditions and SCI

There are many other infectious respiratory conditions that exist, such as the common cold, tuberculosis, and coronaviruses. However, little to no research has been done on the impact of these conditions in the SCI population. Although the available research is limited, it is important to note that individuals with SCI are still at an increased risk of contracting these conditions. The following section describes various respiratory infections in the able-bodied population unless otherwise noted.

Common Cold

The common cold (or simply, the cold) is a general term for a mild upper respiratory tract condition affecting the nose and throat. Common symptoms include stuffy nose, sneezing, sore throat, and cough. Unlike other conditions, there are multiple types of viruses that can cause a cold. Rhinoviruses, coronaviruses, and influenza viruses account for the majority of cases. The cold occurs most frequently in the fall, and decreases upon the arrival of spring. On average, a person will catch the cold once a year, but it is likely that this rate is underestimated.

Coronaviruses

A coronavirus (above), which gets its name from the spikes on the outside that resemble a crown, which is “corona” in Latin.10

Coronaviruses are responsible for many health conditions including the common cold, Middle East Respiratory Syndrome (MERS), Severe Acute Respiratory Syndrome (SARS), and novel coronavirus disease 2019 (COVID-19). These are the four strains of coronavirus now known to affect humans, and they are responsible for 10-30% of upper respiratory tract infections. Although these viruses are genetically related, they cause very different conditions. The severity of the conditions they may cause varies from mild (such as the common cold, described above), to severe (such as MERS, SARS, and COVID-19). Though MERS, SARS, and COVID-19 can all lead to pneumonia, each condition affects the body differently: MERS has a greater impact on the digestive system and kidneys, while SARS and COVID-19 most heavily impact the respiratory system, clotting function, and heart activity.

The 2019 Novel Coronavirus (COVID-19)

The COVID-19 outbreak began in 2019 in Wuhan, China, and has since spread around the world in 2020. Currently, little is known about the virus and the infection it causes, though research is on-going. The virus appears to attack the respiratory system, resulting in symptoms such as cough, shortness of breath, and pneumonia, in addition to fever and kidney failure. The extent of the symptoms ranges from mild to severe, and it is possible for someone to be infected without symptoms. This virus has caused a sense of unease among the SCI community. In a survey conducted by a group of researchers, some of the most common concern included increased vulnerability to infection, decreased availability of caretakers, inability to obtain medical supplies, the inability to be appropriately tested, an inability to travel to medical appointments, and an inability to self-quarantine.

To date, few weak evidence studies on COVID-19 and SCI have been completed. This biggest take away is that the typical symptoms of COVID-19 as reported by the World Health Organization (i.e., cough, fever, and shortness of breath) are not necessarily applicable to people with spinal cord injuries. As coughing is often impaired with SCI, it can be absent in reported cases of COVID-19 in people with SCI.

Instead, common symptoms of COVID-19 in people with SCI include a fever and feeling weaker than normal. Other symptoms that have been reported include shortness of breath, body aches/worsening pain, sweating, chest pain, and increased spasticity, a worsened ability to clear secretions, and abnormally fast breathing. Although people with SCI may have fewer of the typical COVID-19 symptoms, one study has found that they are more likely to experience COVID-19 more severely compared to able-bodied individuals.

Tuberculosis

Tuberculosis is an infection of the lungs that can be caused by Mycobacterium tuberculosis bacteria. The presence of tuberculosis is higher in developing countries in comparison to developed countries. This is related to factors such as lower rates of vaccination and higher rates of HIV (an immune compromising condition) in developing countries. Treating tuberculosis is particularly difficult, as many strains of the virus/bacteria are resistant to drugs.

Upper respiratory tract infections

Upper respiratory tract infections are a group of conditions that affect the nose and throat. Some conditions include pharyngitis (sore throat) and laryngitis (inflammation of the voice box; when you lose your voice). These infections are of particular note to those using ventilators, as over 90% of pneumonia and hospitalizations start with an upper respiratory tract infection.

In order to avoid getting infectious respiratory conditions, prevention is key, especially in the community. Here is what you can do to stay healthy:

  • Wash your hands with warm water and soap for 20-30 seconds
  • Get vaccinated for pneumonia and the flu. Vaccinations are especially important, as weak evidence suggest that rates of vaccination are still low.
  • Stay hydrated! Drinking water can help loosen up the mucus in your lungs.
  • Clean surfaces that may have been in contact with a sick person. This includes parts of your wheelchair, including the joystick, pushrims, etc.
  • Avoid smoking. Smoking can damage the lung’s ability to fight infections, which can compound issues with an already weak immune system.
  • Practice good health habits, such as exercising and having a healthy diet.
  • Stay home if you are sick.
  • Let the people around you know you are feeling unwell. This way they can check up on you and know to avoid close contact.

After an SCI, respiratory functions (i.e., breathing and coughing) and the immune system are compromised. Researchers are still unsure about why the immune system is suppressed. While there is some weak evidence for why the immune system changes after SCI, more clinical trials are required to determine the specific effects of SCI on the immune system.

Given the changes to respiratory and immune functioning after SCI, there is a higher risk of getting an infectious respiratory disease. The best thing to do is to work at prevention, which can be done through a variety of ways such as getting vaccinated and staying hydrated. Discuss all treatment options with your health providers to find out which treatments are suitable for you.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

SCIRE Community. “Respiratory Changes After SCI”. Available from: https://community.scireproject.com/topic/respiratory-changes/

SCIRE Community. “COVID-19 & SCI Infographic”. Available from: https://community.scireproject.com/covid-19/infographics/

Parts of this page has been adapted from SCIRE Project (Professional) “Respiratory Management Following Spinal Cord Injury” Chapter:

Sheel AW, Welch JF, Townson AF (2018). Respiratory Management Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, Sproule S, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0. Vancouver: p. 1-72.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/respiratory-management/ 

 

Evidence for “What is the immune system” is based on:

Tortora, G.J., and Derrickson .B.(2013).The Lymphatic System and Immunity. In Roesch, B. (Eds.), Principles of Anatomy and Physiology (pp. 366-447). Biologtical Science Textbooks

Evidence for “What happens to the immune system after SCI” is based on:

Allison, D. J., & Ditor, D. S. (2015). Immune dysfunction and chronic inflammation following spinal cord injury. Spinal Cord, 53(1), 14–18. https://doi.org/10.1038/sc.2014.184

Campagnolo, D. I., Dixon, D., Schwartz, J., Bartlett, J. A., & Keller, S. E. (2008). Altered innate immunity following spinal cord injury. Spinal Cord, 46(7), 477–481. https://doi.org/10.1038/sc.2008.4

Popovich, P., & McTigue, D. (2009). Beware the immune system in spinal cord injury. Nature Medicine, 15(7), 736–737. https://doi.org/10.1038/nm0709-736

Schwab, J. M., Zhang, Y., Kopp, M. A., Brommer, B., & Popovich, P. G. (2014). The paradox of chronic neuroinflammation, systemic immune suppression, autoimmunity after traumatic chronic spinal cord injury. Experimental Neurology, 258, 121–129. https://doi.org/10.1016/j.expneurol.2014.04.023

Riegger, T., Conrad, S., Schluesener, H. J., Kaps, H. P., Badke, A., Baron, C., … Schwab, J. M. (2009). Immune depression syndrome following human spinal cord injury (SCI): A pilot study. Neuroscience, 158(3), 1194–1199. https://doi.org/10.1016/j.neuroscience.2008.08.021

Herman, P., Stein, A., Gibbs, K., Korsunsky, I., Gregersen, P., & Bloom, O. (2018). Persons with Chronic Spinal Cord Injury Have Decreased Natural Killer Cell and Increased Toll-Like Receptor/Inflammatory Gene Expression. Journal of Neurotrauma, 35(15), 1819–1829. https://doi.org/10.1089/neu.2017.5519

Evidence for “Why are people with SCI at higher risk for respiratory infections” is based on:

Brommer, B., Engel, O., Kopp, M. A., Watzlawick, R., Müller, S., Prüss, H., … Schwab, J. M. (2016). Spinal cord injury-induced immune deficiency syndrome enhances infection susceptibility dependent on lesion level. Brain, 139(3), 692–707. https://doi.org/10.1093/brain/awv375

Burns, S. P. (2007). Acute Respiratory Infections in Persons with Spinal Cord Injury. Physical Medicine and Rehabilitation Clinics of North America, 18(2), 203–216. https://doi.org/10.1016/j.pmr.2007.02.001

Evidence for “What infectious respiratory conditions should I be aware of?” is based on:

Northwest Regional Spinal Cord Injury System. (2004, October 12). Common respiratory problems in SCI – What you need to know. http://sci.washington.edu/info/forums/reports/common_respiratory.asp

DeVivo, M. J., Black, K. J., & Stover, S. L. (1993). Causes of death during the first 12 years after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 74(3), 248–254. https://doi.org/10.5555/uri:pii:000399939390132T

Stolzmann, K. L., Gagnon, D. R., Brown, R., Tun, C. G., & Garshick, E. (2010). Risk factors for chest illness in chronic spinal cord injury: a prospective study. American Journal of Physical Medicine & Rehabilitation, 89(7), 576–583. https://doi.org/10.1097/PHM.0b013e3181ddca8e

Berlly, M., & Shem, K. (2007). Respiratory management during the first five days after spinal cord injury. Journal of Spinal Cord Medicine, 30(4), 309–318. https://doi.org/10.1080/10790268.2007.11753946

McKinley, W. O., Jackson, A. B., Cardenas, D. D., & DeVivo, M. J. (1999). Long-term medical complications after traumatic spinal cord injury: A Regional Model Systems Analysis. Archives of Physical Medicine and Rehabilitation, 80(11), 1402–1410. https://doi.org/10.1016/S0003-9993(99)90251-4

Trautner, B. W., Atmar, R. L., Hulstrom, A., & Daroiuche, R. O. (2004). Inactivated Influenza Vaccination for People With Spinal Cord Injury. Arch Phys Med Rehabil, 85(11), 1886–1889. https://doi.org/10.1038/jid.2014.371

Centers for Disease Control and Prevention. (2020a). Understanding influenza viruses. https://www.cdc.gov/flu/about/viruses/index.htm

Centers for Disease Control and Prevention. (2020b). Prevent seasonal flu. https://www.cdc.gov/flu/prevent/index.html

Burns, S. P. (2007). Acute Respiratory Infections in Persons with Spinal Cord Injury. Physical Medicine and Rehabilitation Clinics of North America, 18(2), 203–216. https://doi.org/10.1016/j.pmr.2007.02.001

Rao, N. M. (2015). Swine flu the pandemic disease – preventive measures to take. Journal of Medical Science and Technology, 4(1), 1–2.

Heikkinen, T., & Järvinen, A. (2003). The common cold. Lancet, 361(9351), 51–59. https://doi.org/10.1016/S0140-6736(03)12162-9

Paules, Catharine, I., Marston, H. D., & Fauci, A. S. (2020). Coronavirus Infections – More than Just the Common Cold. Journal of the American Medical Association, 323(8), 707–708. https://doi.org/10.1007/82

Stillman, M. D., Capron, M., Alexander, M., Di Giusto, M. L., & Scivoletto, G. (2020). COVID-19 and spinal cord injury and disease: results of an international survey. Spinal Cord Series and Cases, 6(1), 21.

Rodriguez-Cola, M., Jimenez-Velasco, I., Henares-Gutierrez, F., Lopez-Dolado, E., Gambarrutta-Malfatti, C., Vargas-Baquero, E., & Gil-Agudo, A. (2020). Clinical features of coronavirus disease 2019 (COVID-19) in a cohort of patients with disability due to spinal cord injury.

Righi, G., Del, G., & Popolo, G. Del. (2020). COVID-19 tsunami : the first case of a spinal cord injury patient in Italy. Spinal Cord Series and Cases, 3–7. https://doi.org/10.1038/s41394-020-0274-9

Mayo Clinic (2020). Tuberculosis. https://www.mayoclinic.org/diseases-conditions/tuberculosis/symptoms-causes/syc-20351250

World Health Organization. (2020). Tuberculosis. https://www.who.int/news-room/fact-sheets/detail/tuberculosis

Evidence for “What can you do to prevent infectious respiratory conditions” is based on:

LaVela, S. L., Smith, B., & Weaver, F. M. (2007). Perceived Risk for Influenza in Veterans With Spinal Cord Injuries and Disorders. Rehabilitation Psychology, 52(4), 458–462. https://doi.org/10.1037/0090-5550.52.4.458

Ronca, E., Miller, M., Brinkhof, M. W. G., Jordan, X., Léger, B., Baumberger, M., … Fekete, C. (2020). Poor adherence to influenza vaccination guidelines in spinal cord injury: results from a community-based survey in Switzerland. Spinal Cord, 58(1), 18–24. https://doi.org/10.1038/s41393-019-0333-x

Weaver, F. M., Smith, B., LaVela, S., Wallace, C., Evans, C. T., Hammond, M., & Goldstein, B. (2007). Interventions to increase influenza vaccination rates in veterans with spinal cord injuries and disorders. Journal of Spinal Cord Medicine, 30(1), 10–19. https://doi.org/10.1080/10790268.2007.11753908

Image credits

  1. Modified from 2301 Major Respiratory Organs ©Anatomy and Physiology, Betts et al., CC BY 3.0
  2. Modified from Neck muscles, lateral view ©Olek Remesz, CC-BY-SA 2.5; A cutout of the thoracic wall showing the three layers of intercostal muscle – from the left wall ©CFCF, CC BY-SA 4.0; Pectoralis Major ©Anatomy and Physiology, Betts et al., CC BY 3.0; Respiratory system ©Theresa knott, CC BY-SA 3.0
  3. Modified from: Outlines ©Servier Medical Art, CC BY 3.0; Lymph Node ©Servier Medical Art, CC BY 3.0; Thymus ©Servier Medical Art; Spleen ©Servier Medical Art; Colon ©Servier Medical Art; File 603: Anatomy of long bone ©Anatomy and Physiology, Betts et al., CC BY 3.0
  4. Human Natural Killer Cell ©NIH NIAID, CC BY 2.0
  5. DNA ©Servier Medical Art, CC BY 3.0
  6. Coronavirus infographic symptoms and prevention©Freepik, Freepik License
  7. Modified from Heart ©Servier Medical Art CC BY 3.0; Pulmonary circulation ©Servier Medical Art, CC BY 3.0
  8. Lobar pneumonia illustrated ©NIH
  9. Sneezing ©Andrei Yushchenko, CC BY 3.0
  10. 3D medical animation coronavirus ©Scientific Animations
  11. Infographic with details about coronavirus with illustrated sick man ©Freepik, Freepik License
  12. Syringe shot medicine bottle medical needle ©qimono, Pixabay License

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

COVID-19 Factsheet: Guidance for SCI Caregivers

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Author: The SCIRE Professional Team | Reviewers: Cynthia Morin, Andrea Townson | Published: 5 August 2020 | Updated: ~

People living with spinal cord injuries (SCI) have a greater risk of developing more serious symptoms of COVID-19. It is critical for caregivers and attendant services to take the necessary precautions and preventive actions outlined in this document in order to minimize the risk of transmission.

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Wash hands often

  • Use soap and water to wash hands for 30 seconds before and after contact with your client.
  • Use a hand sanitizer (with at least 70% alcohol) if soap/water are not available.

Clean and disinfect

  • Clean frequently touched surfaces in client’s home (e.g. doorknobs, light switches, counters, cabinets, phones, remote controls, handles on toilets and faucets) once every few days using soapy water to wipe away debris/dirt.
  • After cleaning, use only disinfectants (e.g., Clorox, Lysol, Microban) that have a Drug Identification Number (DIN) and have been approved by Health Canada for use against COVID-19 in Canada/your country’s standards.
  • For clients who use mobility aids or other equipment, regularly clean the: wheelchair joystick, armrest, wheel rims, mechanical lift controller and other frequently used surfaces.
  • If approved disinfectants are not available, a diluted bleach solution can be prepared for household disinfection in accordance with the instructions on the label, or follow instructions for proper handling of household (chlorine) bleach.
  • Place contaminated laundry (including non-medical cloth masks), into a container with plastic liner.
    • wash using regular laundry detergent and hot water (60-90°C)
    • wear gloves when handling laundry
    • clean hands with soap and water for 30 seconds immediately after removing gloves

Protective equipment

  • If your caregiving role requires the need to be within 2 metres (6 feet) to assist with daily tasks (ex. Bathing, brushing teeth, dressing) wear personal protective equipment such as: a medical mask, disposable gloves, and eye protection.
  • Do not re-use medical masks or gloves. However, under extreme supply limitations, masks may be re-used if not visibly damaged, contaminated, or wet.
    • If a mask is re-used, prevent contamination by storing it in a clean paper/plastic bag, or cleanable container with a lid (discard bags after each use)
    • Healthcare practitioners have been instructed to use 1 mask/day (put on when entering facility/home and removed when eating or leaving facility/home at end of shift)
  • Place used medical masks, gloves, and other contaminated items in a lined container, secure the contents and dispose of them with other household waste.
    • Take gloves off first, wash hands, then remove mask
    • Clean your hands again with soap/water/hand sanitizer before touching your face/other surfaces

Caregivers should create a back-up care plan for clients

  • Decide who can step in if you are unable to provide care for your client.
  • Consider the specialized tasks you manage for people with SCI and expand your circle of care to include a person with SCI’s family members or friends who may be able to help if necessary.
  • Use video platforms (Facetime, Skype, Zoom) to review the plan with your circle and recipient to ensure they are comfortable with the backup-plan.

The care plan should include the following:

  • Contact information for: doctors, clinics, pharmacy, family, friends, neighbours, home and community care case managers, and food delivery.
  • Information regarding the client’s condition (medical history, allergies, specific needs etc.).
  • A schedule of what your typical tasks look like with enough detail for someone to follow and take over if need be.
  • A list of names and doses of medications and when they are given to the recipient.
  • A list of important supplies that need to be purchased regularly (e.g., toilet paper, cleaning supplies, hygiene products).
  • Information about their likes and dislikes, self-care routines, and food preferences.
  • Additional non-perishable food items to ensure your client has continued access to healthy meals.
  • A list of essential items your client needs if they need to leave their home or require hospitalization.

A podcast created by caregivers of BC who share their experiences, “highlighting the joys, trials, and self-discoveries that come along with this rewarding and taxing position”: Caregiving Out Loud Podcast

Advice provided from the Government of Canada for Caregivers in caring for a person with COVID-19 at home

Tip sheet created by the Ontario Caregiver Organization. Provides resources/education on improving caregiver mental health during COVID-19.: Tips for Caregivers Mental Health During COVID-19

The Family Caregivers of BC provide multiple tips and resources for caregivers to practice self-care.: Self-Care Tips During Uncertain Times

Coronavirus Disease 2019 (COVID-19) Fact Sheet. (2020, March 4). Retrieved from: (https://shepherd.org/docs/Coronavirus2019_FactSheet_3.4.20.pdf

Public Health Ontario (2020, February 14). Coronavirus Disease 2019 (COVID-19) Self-isolation: Guide for caregivers, household members and close contacts. Retrieved from:  https://publichealthontario.ca/-/media/documents/ncov/factsheet-covid-19-guide-isolation-caregivers.pdf?la=en

Public Health Agency of Canada (2020, May 1). How to care for a person with COVID-19 at home: Advice for caregivers. Retrieved from: https://canada.ca/en/public-health/services/publications/diseases-conditions/how-to-care-for-person-with-covid-19-at-home-advice-for-caregivers.html

Public Health Ontario (2020, April 10). Coronavirus Disease 2019 (COVID-19) When and How to Wear a Mask Recommendations for the General Public. Retrieved from: https://www.publichealthontario.ca/-/media/documents/ncov/factsheet/factsheet-covid-19-how-to-wear-mask.pdf?la=en

The Ontario Caregiver Foundation (2020, March 31). COVID-19 – Do you have a plan? Retrieved from: https://ontariocaregiver.ca/wp-content/uploads/2020/03/Ontario-Caregiver-Organization-Caregiver-Contingency-Plan.pdf

Family Caregivers of British Columbia (2020, March 11). COVID-19. Retrieved from: https://familycaregiversbc.ca/community-resources/covid-19-virus/

Image credits

  1. Hand Washing ©AnnaliseArt, Pixabay
  2. Cleaning Supplies ©MarCuesBo, Pixabay
  3. Protective Equipment ©artpolka Pixabay
  4. Checklist©OpenClipart-Vectors, Pixabay

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication. SCIRE receives no compensation and there are no conflicts declared with sources of information on this factsheet.

COVID-19 Factsheet: Mental Health Support and SCI

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Author: SCIRE Professional Team | Reviewer: Rachael Neal | Published: 5 August 2020 | Updated: ~

Living during the COVID-19 pandemic can be stressful, and it is common to feel worried, sad, or anxious from time to time. This sheet contains information about some resources, techniques, and tips to help support your mental health in the time of COVID-19.

Key Points

  • The COVID-19 pandemic may cause increased mental health concerns in people who have already experienced sweeping changes in life due to spinal cord injury (SCI).
  • Feelings of worry and anxiety in times of global uncertainty are common, and it is important to know that you are not alone.
  • Learning to recognize and acknowledge your anxiety and to engage in concrete, meaningful actions and activities can help you manage your worries.
  • Refer only to reliable sources of news about COVID-19. Limiting yourself to appropriate information consumption can reduce the likelihood of feeling overwhelmed or in danger.

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How can I organize and structure my day to benefit my wellbeing?

Our normal daily routines and activities are changing with the current pandemic situation, which can feel unsettling. You may find that some things you usually did to look after your wellbeing have become difficult to carry on. Though you may not have control over those changes, you can focus on what choices and coping strategies you have that are within your control.

Maintain balance

Try organizing your days to include a variety of activities that you know will improve your general mood. You can strive for a routine that is a balance of activities that give you feelings of pleasure, achievement, and closeness.

You will get a sense of accomplishment when you, for instance, choose to finish a work task, complete an exercise routine, or learn to cook a new recipe. A pleasure activity may be reading a book or watching a favourite comedy show. Schedule a video call with a friend or family to feel connected.

If you feel overwhelmed or unmotivated, break tasks down to pieces that you can work on, or set a goal to work for a small chunk of time rather than having the goal to finish something all at once.

What can I do to deal with this time of uncertainity to help me to stay in a healthier place?

As someone with a SCI, you have likely already experienced uncertainty. It is the ‘not knowing’ how things are going to turn out that can be difficult to cope with. The coronavirus uncertainty and isolation can be particularly worrying when you have additional health care needs.

There are different levels of worry and anxiety. Anxiety is a natural emotion and worrying is common during change. Remind yourself that you will not feel this way forever and that there are things you can do to cope. Use the diagram on the left to see if you are in the ‘fear zone’ and identify specific steps you will try to move towards learning and growth zones.

 

Why do I worry even when nothing seems wrong, and how do I stop it?

It is common during times of uncertainty, like the COVID-19 pandemic, that you may notice more worry thoughts, some even leading to worst-case scenarios. The graphic below illustrates how worries can quickly escalate even from something relatively minor that you would not have recognized as being a worry trigger before.

To reduce this type of worry, the first step is to practice noticing when your thoughts are reaching a later, more catastrophic point. For instance, if you first notice a feeling of anxiety, ask yourself, “What was I just thinking?”. Step back to the event that began your worries, and ask yourself if you have reasonable evidence to believe that the initial event is likely to lead to the worst-case scenario, or whether there may be other explanations you can consider. Are you are assuming a negative outcome when the situation is actually an unknown?

Think of a strategy that may have helped you with a similar problem in the past. Make a list of things that generally help you relax and choose one that is possible to do now.

Which category does your worry fall into?

Worry becomes a problem when it stops you from living the life you want to live, or if it leaves you feeling helpless or exhausted.

Assess the impact of your worries on your life. Seek professional help if you are noticing that you are not able to carry out important roles or activities in your life because of interference from worry.

Worry Time

Another effective strategy is designating a specific Worry Time – schedule a time for later in the day when you allow yourself to worry as much as you feel the need to. This can be helpful in two ways:

  1. It can prevent worry from interfering with your important daily activities, and
  2. Postponing worry can sometimes circumvent the worry from happening at all (at the scheduled time, you may not even feel like worrying, in other words, it was an ‘in the moment’ worry).

Worry Time may be particularly effective if your worry is hypothetical or in the future (and action is not possible). The worry should be put aside, and your attention focused on a technique or activity that will distract you from your worry thoughts (re-focus on something that is in the present).

The current pandemic has brought many changes to the lives of people with SCI, and you may notice yourself having new or different concerns for your well-being. Awareness and reminders of active, positive coping strategies are especially important.

Even though there is much about the COVID-19 situation that you cannot control, you can shift your focus to what you can influence and have power over:

  • Choose your routine. Plan how you spend your time and what you focus on during the day.
  • Choose your distractions. Have a list of small, practical, or creative tasks that you can easily accomplish.
  • Choose your information. Limit how much news you watch and when you take in new information.

“With awareness and active steps, we can exercise the positive power of being able to recognize our fear and patterns of survival” (Vicki Enns, Clinical Director, Crisis & Trauma Resource Institute)

Duff, J. (2000). Coping Effectiveness Training reduces depression and anxiety following traumatic spinal cord injury. Proceedings of the British Psychological Society, 8(1): 17.

Whalley, M. & Kaur, H. (2020, March 19). Free Guide To Living With Worry And Anxiety Amidst Global Uncertainty. Retrieved from https://www.psychologytools.com/articles/free-guide-to-living-with-worry-and-anxiety-amidst-global-uncertainty/

Enns, V. (2020, May). How to Cope with Post-Traumatic Stress During COVID-19. Retrieved from:  https://ca.ctrinstitute.com/blog/how-to-cope-with-post-traumatic-stress-during-covid-19/

Wilkinson, A., Meares, K., Freestones, M. (2011). CBT for worry & generalised anxiety disorder. London: Sage.

Image credits

  1. Learning Zone model by Tom Senninger. Creative Commons BY-NC-SA 4.0
  2. Escalator clip art © DLPNG Creative Commons
  3. Afraid © Stephanie Heendrickxen Creative Commons
  4. Man © corpus delicti Creative Commons
  5. Stop Light Icon #432967 © Free Icons Library Creative Commons
  6. Woman © Crello Creative Commons
  7. Clock © Crello Creative Commons
  8. Thought bubble © Crello Creative Commons
  9. Man on computer © user:cth103_t Creative Commons

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication. SCIRE receives no compensation and there are no conflicts declared with sources of information on this factsheet.

COVID-19 Factsheet: Spinal Cord Injury Specifics

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Author: SCIRE Professional Team | Reviewers: Cynthia Morin, Andrea Townson | Published: 4 August 2020 | Updated: ~

Key Questions

  • Are you at a higher risk for COVID-19 because of your SCI?
  • What are the precautions you can take to prevent exposure to the virus?
  • How can you keep your assistive devices/equipment clean and virus-free?
  • How can you keep your assistive devices/equipment clean and virus-free?
  • What can you do to ensure your interactions with others are safe?
  • When should you seek medical attention, and what do your healthcare providers need to know?

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What we know about the risks for people with spinal cord injury (SCI) is based on how SCI and COVID-19 both affect the body.

Respiratory function

Everyone with SCI has some level of impairment in respiratory function given how SCI weakens breathing muscles, however people with cervical and upper thoracic levels of injury may have greater impairments than those with lower thoracic levels of injury. Still, all levels of SCI above T12 have a reduced ability to both inspire air maximally and to forcefully expel air through coughing. With an impaired cough, individuals are less able to manage respiratory secretions.

Other risk factors

  • Some complications (common secondary health issues of SCI), such as cardiovascular disease or higher body mass index (BMI), may increase the risks of a more serious case of COVID-19.

People with SCI may also have a greater risk of exposure to COVID-19, as those who require assistance cannot avoid contact with caregivers.

Given that there is no current treatment for COVID-19 other than supportive care, it is best to take precautions to avoid exposure to the virus whenever possible.

  • Practice physical distancing (6 feet), avoid large groups and stay home when possible.
  • Clean all surfaces regularly with soap and warm water or antibacterial solution.
  • Wash your face and hands after being in public or having in-person conversations.
  • Wash clothes after each wear and if possible separate indoor and outdoor clothes.
  • Learn about home delivery options from grocery stores, pharmacies, and other institutions providing essential services.
  • Keep 30 days of medications and medical supplies on hand (i.e., catheters, wound dressings, disposable gloves).
  • If you require the assistance of caregivers, ensure that they use PPE and follow protocols re: minimizing the transmission of COVID-19.
  • Learn how you can connect with your local SCI organization (e.g., SCI-BC).

Maintaining a clear respiratory tract

• Stay hydrated to keep lung secretions thin.
• Change positions frequently, and use gravity to help clear your lungs.
• Practice deep breathing and coughing exercises to strengthen respiratory muscles.
• Eat healthy, well-balanced meals to boost your immune system.

Wheelchair users

As a wheelchair user, it is especially important to keep at least 6 feet from another person. Because your head is lower than people who are standing you may be more vulnerable to respiratory droplets. You may consider wearing eye protection when you are not able to maintain physical distancing.

Manual wheelchairs
  • If possible, avoid making contact between your hands and your tires when pushing (and launder your pushing gloves frequently).
  • Remove your pushing gloves and/or put on disposable gloves before touching or cleaning your chair.
  • Use antibacterial solution to clean wheels, brakes, and push rims.
  • Wash your hands then avoid touching your tires if possible (use paper towels or cloth to cover when transferring).
Power wheelchairs
  • Use antibacterial solution on a cloth to clean the joystick (and any other controls), armrests, tray, and headrest (have someone help you if needed).
  • Get assistance to help wash or sanitize your hands if unable to do so independently.

Things to note about assistive devices

  • Regularly clean assistive devices with antibacterial products (i.e., splints, cuffs, braces, “reachers”, canes, crutches, handgrips and brakes, storage compartments).
  • Refresh your memory about best practices for using your devices safely.
  • Complete a maintenance check.
Ventilators and respirators
  • Wash hands before and after working with the ventilator.
  • Ensure caregivers wear a mask or eye shield when suctioning secretions.
  • Clean and disinfect medical equipment according to manufacturing descriptions.
  • Change filters according to manufacturing descriptions.

Avoid using your mouth: Ask for help, especially if others are in contact with the materials.

On the following list, check off which guidelines you already practice. Determine where you can make improvements to ensure your own safety, and the safety of those around you.

Ensure someone is available to address any of your urgent needs

Wear a mask, and request that those around you also wear a mask

Have others wash their hands when they arrive and each time interacting with you

Avoid having others directly touch your face, or their own

Ask others to stay home if they are unwell (temperature >38° or 100.4°F), if they are exhibiting any symptoms of COVID-19, or if they have possibly been exposed to an unwell person

Plan backup caregivers, and prepare others who may be needed to support you in an emergency

Let sick employees who are sent home know that there is an EI sickness benefit for those forced to quarantine due to COVID-19

Read through the SCIRE Project Caregiver Fact-sheet

Medical appointments

Confirm that you provider is still seeing patients, or if an online virtual health service is available. In deciding whether to attend regular medical appointments, discuss the urgency of appointments with your doctor/care provider. Some appointments if delayed can lead to serious health risks, but others can be safely postponed (especially given additional COVID exposure risks).

When to seek medical care if you think you have COVID-19:

  • If you think you are infected with COVID-19, read what to do from a reputable diagnostic source (e.g., the BC CDC website).
  • If you are at a greater risk of developing severe symptoms (i.e., upper thoracic and cervical levels of SCI), visit the hospital when experiencing any shortness of breath.
  • If it becomes harder to breathe, you are unable to swallow, or you feel much worse than when you got tested, seek immediate medical care at an urgent care clinic or Emergency department.

When interacting with emergency services be sure to:

  • Inform medical providers/emergency responders about your SCI and how it affects your respiratory system.
  • Provide breathing equipment, assistive devices, and/or a personal directive.

Evidence for “COVID and SCI Specifics” is based on:

FAQs About COVID-19 and SCI/D with Mount Sinai’s Dr. Bryce (2020, March 30). Retrieved from: https://newmobility.com/2020/03/faqs-about-covid-19-and-sci-d/

Information for people with paraplegia about the corona virus. (2020, March 26) Retrieved from: https://iscos.org.uk/uploads/CV-19/Factsheets/ENG_SCI_and_COVID_19_information.pdf

COVID-19 Guidance for People Living with Spinal Cord Injury. (2020, March 12). Retrieved from: https://iscos.org.uk/uploads/CV-19/ENG_COVID_19_Guidance_for_People%20-%20Copy%201.pdf

Public Safety Canada and Emergency Management Ontario. (2010). Emergency Preparedness Guide for People with Disabilities/Special Needs. Retrieved from: https://getprepared.gc.ca/cnt/rsrcs/pblctns/pplwthdsblts/pplwthdsblts-eng.pdf

Vetkasov, A. & Hoskova, B. (2014). Special Breathing Exercises in Persons with SCI and Evaluate their Effectiveness by Using X-ray of Lungs and Other Tests. Athens Journal of Sports. 1. 217-223. https://doi.org/10.30958/ajspo.1-4-1

Health and Safety in the Time of COVID-19. (2020, May 1). Retrieved from: https://newmobility.com/2020/05/covid-19-questions-answered/

COVID-19 Guidance for the SCI Community. (2020, March 19). Retrieved from: https://scimanitoba.ca

Spinal Injuries Association on SCI and Coronavirus. (2020, March 6). Retrieved from: https://spinal.co.uk/wp-content/uploads/2020/03/Briefing-1-SIA-briefing-on-SCI-and-Coronavirus.pdf

Maffin, J (2020, May 25) SCI and COVID-19 Frequently Asked Questions (FAQ). Retrieved from: https://sci-bc.ca/covid-19-sci-faq/

ACI-NSW Agency for Clinical Innovation (2020, March 19). Information on Coronavirus (COVID-19) for people with Spinal Cord Injury. Retrieved from: https://iscos.org.uk/uploads/CV-19/Factsheets/ENG_COVID_19_in_SCI_Factsheet_N%20-%20Copy%201.pdf

Image credits

  1. Virus © Freepik, Flaticon licence
  2. Spine © Freepik, Flaticon licence
  3. Washing Hands © Freepik, Flaticon licence
  4. Groceries © Freepik, Flaticon licence
  5. Infected Lungs © Freepik, Flaticon licence
  6. Wheelchair © Freepik, Flaticon licence
  7. Controller © Freepik, Flaticon licence
  8. Walker © Freepik, Flaticon licence
  9. Broken Arm © Freepik, Flaticon licence

 

 

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication. SCIRE receives no compensation and there are no conflicts declared with sources of information on this factsheet.

COVID-19 Factsheet: Social Isolation and SCI

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Author: SCIRE Professional Team | Reviewer: Rachael Neal | Published: 23 July 2020 | Updated: ~

In the time of COVID-19, physically distancing is necessary to limit virus transmission and to keep everyone as safe as we possibly can. However, social isolation can have serious effects on mental health for everyone, including those with spinal cord injury (SCI).

Key Points

  • Social isolation is the absence of relationships and interactions with one another and is linked to mental health issues like depression and anxiety.
  • People with SCI may be at increased risk for the negative effects of social isolation.
  • Consider seeking help if you experience symptoms such as marked changes in personality, difficulty coping with daily activities, prolonged sadness, or excessive worry.
  • Strategies to maintain good health while physically distancing include daily structure, reaching out to others, good diet/hydration, and regular exercise.

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What is social isolation?

Social isolation is described as the absence of relationships, often due to physical separation from others. This differs from loneliness, which is a state of distress caused by feeling alone or separated.

Social isolation has been linked to various mental health issues, such as higher fatigue and depression rates. People who are socially isolated often report more difficulties with access and fewer close relationships.

Am I at increased risk for these potential effects if I have an SCI?

People with SCI are not necessarily more vulnerable to the effects of social isolation. However, research shows a higher proportion of depression and anxiety in people with SCI compared to the general population. The COVID-19 pandemic may limit access to caregivers or peer support networks that people with SCI depend on which can worsen symptoms of depression and anxiety.

You may want to reach out to a professional if you experience any of the following symptoms to the extent that it is concerning to you or close others:

  • Marked changes in mood, eating or sleeping patterns
  • Excessive anxiety
  • Prolonged sadness, depression, or apathy (disinterest)
  • Thoughts or statements about hurting yourself, harming others, or suicide
  • Increased substance use or using substances in ways that could be harmful
  • Excessive anger, irritability, hostility, or violent behavior

Look after your general health

There are direct links between mental health and physiological health. So, it is especially important at a time like this to take care of your general health. Stay mentally and physically active, have proper nutrition, hydrate well, and get enough sleep. Maintaining physical health can help serve as a buffer for emotional stress as we are more likely to feel that we have the resources to cope with stress when we are rested and eating well versus when we are tired and hungry.

Manage your worry

Some degree of worrying at a time like this is normal, but it is important to note if your worry is excessive, or if worry thoughts are interfering with your ability to do other things.
Strategies you can employ if you are feeling worried include:
• Noticing and limiting your exposure to things that trigger your worry,
• Practice postponing your worry to a later time, and
• Relying on reputable news sources to ensure your information regarding the pandemic is up-to-date and accurate.

Set a routine

Setting a routine can help you maintain a sense of normalcy during the pandemic. Stick to the usual structure of your day as best as you can by eating, exercising, and sleeping at the same times that you normally would. By setting a routine, many people find that they feel have a sense of purpose and predictability that is comforting. Using structure can also encourage us to work on tasks, which can bring feelings of accomplishment, and that feeling of accomplishment is naturally rewarding.

Stay connected

In the digital age, there are many ways to stay connected virtually to your loved ones. Videochatting, calling, and messaging is possible through many different platforms. ForaHealthyMe SCIO: Home is an example of a virtual platform established for connecting people with SCI.
As restrictions to physical distancing are slowly relaxing, it is possible to physically meet some of your loved ones in small numbers and at a safe distance from each other (it is still important be cautious and maintain physical distancing).

Be knowledgeable and take appropriate precautionary measures

A study has shown that being up-to-date with accurate health information (e.g., treatment, local outbreak situation) and taking particular precautionary measures (e.g., hand hygiene, wearing a mask) was associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression. Taking recommended steps to protect your health (e.g., washing your hands, mask use) can also remind you of the strategies that are currently within your control, which can also increase your self-confidence in coping with uncertainty over time.

Reach out for help if needed

Most of us are currently facing challenges that we have never faced before. It is natural and encouraged that you seek help if you require assistance in any aspect of your life. Seeking help when you need it is a sign of strength and good judgment!
There are many resources you can currently access that provide information, emotional support, and advice to people with SCI. Below are a few examples of such resources.

Resources to access

BC Government COVID-19 mental health support: Virtual Mental Health Supports During COVID-19 – Province of British Columbia

BC Mental Health Hotline: dial 310-6789, and do not add 604, 778 or 250 before the number. It’s free and available 24 hours a day.

We also recommend: keltyskey.com/, BounceBack bouncebackbc.ca/ and a “FACE COVID” e-book that can be found at actmindfully.com.au.

For good plain language information on COVID in multiple languages, visit flattenthecurve.com and for reliable data on COVID cases worldwide, visit coronavirus.jhu.edu/map.html.

You can also check out the other resources listed on our site: scireproject.com

Physical distancing is a necessary precaution that needs to be taken during the COVID-19 pandemic, but it can have adverse mental health effects if you do not take steps to stay socially connected. To maintain good mental health when isolation is inevitable, we recommend maintaining good physical health, managing your worry, setting a routine, staying connected with family and friends, and staying knowledgeable about the current situation.

Frank, M., Heinemann, A. and Wong, A., 2016. An Empirical Investigation of a Biopsychosocial Model of Social Isolation in Persons with Neurological Disorders. Archives of Physical Medicine and Rehabilitation, 97(10), p.e20.

Brooks, S., Webster, R., Smith, L., Woodland, L., Wessely, S., Greenberg, N. and Rubin, G., 2020. The Psychological Impact of Quarantine and How to Reduce It: Rapid Review of the Evidence. SSRN Electronic Journal, 395(10227).

Migliorini C, Tonge B, Taleporos G. Spinal cord injury and mental health. Aust N Z J Psychiatry. 2008;42(4):309‐314. doi:10.1080/00048670801886080

Mayoclinic.org. 2020. Mental Health: What’s Normal, What’s Not – Mayo Clinic. [online] Available at: <https://mayoclinic.org/healthy-lifestyle/adult-health/in-depth/mental-health/art-20044098?p=1> [Accessed 10 June 2020].

Ohrnberger J, Fichera E, Sutton M. The relationship between physical and mental health: A mediation analysis. Soc Sci Med. 2017;195:42-49. doi:10.1016/j.socscimed.2017.11.008

Wang C, Pan R, Wan X, et al. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int J Environ Res Public Health. 2020;17(5):1729. Published 2020 Mar 6. doi:10.3390/ijerph17051729

Image credits

  1. Woman in House © Mohamed Hassan, CC0 1.0
  2. Image by SCIRE Team
  3. Doctor © CO. Department of Health Care Policy and Financing, CC0 1.0
  4. Image by SCIRE Team
  5. Notebook © Gentaur CC0 1.0
  6. Image by SCIRE Team
  7. Man on computer © user:cth103_t CC0 1.0
Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication. SCIRE receives no compensation and there are no conflicts declared with sources of information on this factsheet.

Wheelchair Seating

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Author: Sharon Jang | Reviewer: Emma M. Smith | Published: 25 May 2020 | Updated: ~

Wheeled mobility devices like wheelchairs and scooters are an important part of independent living after spinal cord injury (SCI). This page provides an overview of the basics of wheelchair seating after SCI.

Key Points

  • Wheelchair seating includes parts of the wheelchair that help you maintain a proper and comfortable posture when seated. This includes the backrest, foot rests, and cushion.
  • Proper wheelchair seating is important to prevent pressure sores, maintain posture, and promote function.
  • There are many different types of seating cushion, each with its own benefits and drawbacks.
  • There are three main aspects of backrests to be considered when getting fitted to a wheelchair: the height, the shape, and the stiffness.

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A wheelchair seating assessment is a complex process where healthcare professionals assess your body and fit you to a wheelchair to suit your needs. How you fit in your wheelchair can significantly impact your health and comfort while using your device. A proper seating assessment can be used to prevent conditions (for example, spine deformation) from getting worse, to correct posture, and to accommodate for other aspects that are not changeable. The seating process is done in combination with other rehabilitation interventions (such as exercises, physical therapy, and spasticity management), and should be done with specific therapeutic goals in mind.

In this document, we will focus on the components on seating. Seating components consist of backrests, cushions, and accessories (e.g., footrests and arm rests). Having appropriate seating is important to having good posture while in your wheelchair, being able to function while using the wheelchair, and maintaining good skin health.

Refer to our article on Wheelchair Provision for more information!

Pressure sores

As you may be spending the majority of your time in your wheelchair, sitting pressures are of concern to skin health. Research (moderate evidence) has suggested that the sitting postures of individuals with SCI are different than able-bodied individuals. In the SCI population, higher sitting pressures are exhibited. Up to half of pressure ulcers occur on the sit bones, and are likely to have developed when sitting. Having a proper cushion suited to the way you sit can help to prevent pressure sores by redistributing pressure.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, refer to the SCIRE Community Evidence Ratings.

Maintaining posture

Your wheelchair setup can have a major effect on your posture while seated.1

The way your wheelchair is set up can impact your sitting posture. After an SCI, you may not be able to control the stability of your trunk, which can lead to spinal deformities and abnormal sitting positions. However, the use of a proper cushion and supports can help address sitting posture. For example, one study (weak evidence) suggests that the use of lateral supports (i.e., pads supporting the side to prevent side to side leaning) can help improve the alignment of the spine and to help improve posture while reducing the amount of effort required by muscles for postural control.

Psychosocial concerns

The way you are able to present yourself while sitting in your wheelchair may impact your psychosocial health, or your sense of confidence and self-esteem.

Quality of life

Having proper seating may impact your quality of life. Good seating can allow you to fully participate in leisure activities, and may allow you to go to school or to work. These activities depend on your sitting tolerance (how long you are able to sit in your chair comfortably) and your ability to effectively travel in your wheelchair.

There are two main purposes of wheelchair cushions: 1) to help improve function and achieve a balanced posture, and 2) to redistribute the pressure applied by the sit bones when seated. Taken together, the cushion can impact the amount of support provided, which in turn determines how long someone can sit for, how easily transfers can be done, and posture of the hips. There are many types of cushions available on the market, as no one cushion is suitable for all individuals with SCI. To determine which is best suited for your needs, various factors are considered, including:

  • The amount of pressure reduction/redistribution required
  • Temperature effects (warm temperatures may lead to sweating, which may make the skin more vulnerable to injury and infections)
  • Your level of injury
  • Your ability to relieve pressure off your sit bones
  • Your transfer techniques
  • Your lifestyle

Although new cushions may be able to provide support and redistribute pressure applied by the sit bones, the effectiveness of a cushion decreases over time. Some research studies have looked into factors that impact deterioration of a cushion. Weak evidence suggests that how a cushion is used is a bigger indicator of deterioration compared to age of the cushion. For example, factors such as how you transfer in and out of your wheelchair, frequency of curb jumps or high vibration activities, exposure to the elements (rain, snow, etc.), moisture, and exposure to extreme temperatures can negatively impact the quality of your cushion.

When sitting, pressures are created (orange) from the force of your sit bones on your buttock.2


During offloading, a greater surface area of the buttock is in touch with the cushion.3

Pressure sores develop when there is a lot of pressure applied at one point. We can counter this focussed pressure through pressure redistribution, i.e. spreading out the sitting pressures. This can be done in three ways: offloading, immersion, and immersion and envelopment.

When offloading, pressure is distributed over a greater surface area. To achieve this, pressure is distributed over the majority of the buttock (i.e., more of the buttock is in contact with the cushion) rather than just on the sit bones (see top right image). To encourage this position, a piece of the cushion may be taken out so there is a grooved surface.

Immersion and envelopment is a combination of sinking into the cushion and having the cushion form to the shape of your buttock.5


During immersion, the buttock sinks into the cushion.4

Immersion refers to a property of the cushion material, which allows the body to “sink” into it. Given the material’s ability to be compressed, pressure is redistributed by increasing the amount of body surface area that is in contact with the cushion.

Immersion and envelopment redistributes pressure by allowing the body to sink into the material, while the material conforms to the body’s shape. This maximizes pressure distribution by increasing the amount of surface area in contact with the cushion.

There are five common types of cushion material: foam, gel, air, honeycomb urethane, and alternating pressure.

Foam cushions

Foam cushions require protection from getting wet. The cushion above features an extra lining under the cushion cover to help keep it dry.6

Foam cushions are a cheaper option, and come in a variety of densities, ranging from soft memory foam to higher density foam. Foam is able to adapt to shapes, is low maintenance, and can provide support while spreading sitting pressures. One downside to using foam is that it wears out and loses its shape quickly. In addition, foam cushions are only able to provide a limited amount of pressure relief and comfort. Foam cushions also must be protected from getting wet. The use of foam cushions is recommended for those with basic sitting needs.

Gel cushions

A variety of gel cushions exist. These include a gel matrix (left) and a gel cushion (right).7

There are different types of gel cushions including gel matrix and gel cushions. Gel cushions aim to provide seating comfort by using gel placed on top of a layer of supportive foam. Gel cushions are able to relieve pressure points and distribute pressure over a larger area, while providing a stable surface to support positioning. They may also help counter effects of high temperatures with its cooling properties. Some drawbacks to using a gel cushion include heavier weight and a lack of shock absorption. Gel cushions also have the potential to “bottom out” (when all the gel is pushed aside, massaging may be required to redistribute the gel), and a potential for leaks.

Air cushions

Air cushions are often comprised of a group of small air-filled cells. In some air cushions, the cells are interconnected, while other versions contain multiple separate air sacs contained within a cushion cover. These cells support the weight of the user, and spread out the pressure of sitting through shifting air to the surrounding cells. These cushions are customizable in regards to the number of cells and the amount of air each cell is able to hold. If the cells are interconnected, the amount of air in the cushions can be adjusted using a pump. Moderate evidence has suggested that the use of air cushions can reduce the risk of a pressure sore through reducing the amount of pressure produced while sitting and promotion of air flow. Furthermore, air cushions are generally waterproof. Although these cushions are great for providing pressure distribution, they are not optimal for stability and postural support. In addition, they may be considered high maintenance as the pressure of the cushion has to be checked frequently and manual pumping of air into the cushion is required.

Honeycomb urethane cushions

These light-weight durable cushions resemble a honeycomb in that they are composed of multiple open cells. These cells are able to distribute pressure evenly while avoiding the risk of being punctured. Air flow is also promoted throughout the open cells to prevent skin breakdown. As these cushions are made out of urethane, a material that resembles rubber, they also provide good shock absorbance. However, compared to other cushions, they provide moderate positioning capabilities and are not modifiable in shape.

Alternating pressure cushions

Alternating pressure cushions consist of multiple air bladders (similar to an air cushion) with an added battery-operated microprocessor that controls the amount of air in each part of the cushion. Every 4-6 minutes, the air in each segment of the cushion alternates (i.e., inflates or deflates) to help relieve pressure of the users’ bottom. This cushion is suitable for individuals who are unable to effectively relieve seated pressure. There has been weak evidence suggesting that alternating pressure cushions have provide good user satisfaction and comfort. Some negatives for this cushion include its high cost, heavy weight (as it requires a pump and a motor), and susceptibility to punctures.

While cushion marketing may promote a reduction in sitting pressure, more research is required to determine whether reducing the pressure on the sit bones or decreasing risk factors will prevent pressure ulcers. Pressure mapping is one technique that may be used to help determine the areas that are prone to pressure sore.

Refer to our article on Pressure Mapping for more information!

Custom Contour Cushions

These cushions are made custom to the shape of your buttock in an attempt to reduce pressure. Often, custom contour cushions are made with a combination of the aforementioned materials, accounting for the high pressure areas identified by pressure mapping. There is moderate research evidence that suggests that custom contoured cushions may create a safe sitting surface for individuals with SCI through the ability to redistribute sitting pressures. There is also weak evidence that using a custom contour cushion may help increase sitting stability and posture. If using a custom contour cushion, avoid getting the cushion wet as it may deform, and be careful to properly position yourself on the cushion as there is only one position that is optimal for comfort and pressure distribution.

The main purposes of backrests are to provide stability and support to the trunk and the hips. Backrests are adjustable in three different ways: the height, the shape, and the stiffness.

Height

For manual wheelchair users, the height of the backrest can vary. Low backrests provide support for the lower back, and are often preferred by active users as they allow for more mobility in the upper spine. However, the use of a low backrest requires complete or partial trunk control, as it does not provide much stability. Higher backrests typically span the majority of the back, but should come up to just under the shoulder blades. A higher back rest can provide more support, but a backrest that is too high may hinder mobility.

There has been some research on the impact of various backrest heights on the range of motion required for propulsion and reaching/grasping motions. One study (weak evidence) has shown that the height of the backrest may influence the efficiency of pushing a manual wheelchair. In particular, the authors suggest that a low back rest may be more beneficial for wheelchair propulsion, as it allows for greater movement in the shoulder, a greater push rate (i.e., more pushes per minute), and a greater propulsion stroke. In addition, a lower back rest has been found to allow paraplegics to apply more force when propelling their wheelchairs. However, with regards to reaching, a (weak evidence) study found that backrest height did not have an effect.

As power wheelchair users do not need to manually propel their wheelchair, the height of the backrest is typically higher. These backrests typically span the entire length of the back, and provide more support to the spine. Moreover, having a taller backrest can provide a resting position for tilt or recline functions.

Shape

Backrests generally come in three different shapes: flat, general contour, and custom contoured.

Flat backrests

Flat backrests are flat or slightly curved in shape, and often consist of a stiff flat surface (e.g., plastic, plywood) that is layered with foam and covered with material. This style of back allows for the greatest range of motion of the arms, thus creating increased freedom. Another advantage of the flat backrest is that it is very adjustable and can accommodate a large variety of support accessories, such as lateral supports, chest straps, and headrests. A drawback to this style of back is that it provides limited support. It does not accommodate for the shape of the spine, making it less suitable for individuals with lordosis (i.e., sway back) or kyphosis (i.e., a hunched back).

General contoured backrests

General contoured backrests are off-the-shelf backs that are shaped, but are not customized to your back. These backs provide more support than a flat back, as they have a deeper contour that can provide lateral (side) support. The effectiveness of general contoured backs is based on how well the back fits your needs; they may only be effective if you can find one that suits your needs.

Custom contoured backs

Custom contoured backs provide increased support for positioning, and are made custom to the shape of your back. This cushion is often used if you require extra positioning support, and if the general control back or flat back does not meet your needs. The creation of custom contour backs can be a lengthy and costly labour-intensive process. When creating a custom contour back, a mold of your back is taken. A seating specialist then inspects the mold to ensure that it is reflective of the shape of your back and that the contour information is accurate. The backrest is then carefully made to the specifications obtained from the measuring process. As custom contour backs are designed to fit the shape of your back to provide more support, they also impose limitations on flexibility. When transferring in and out of your wheelchair, it is also important to be properly aligned in your custom contoured backrest, as improper fitting may lead to pressure sores or skin breakdown.

Stiffness

A rigid back on a manual wheelchair.13


Soft backs are often found on folding manual wheelchairs.14

The stiffness of wheelchair backs are either soft or rigid. Soft backs (i.e., sling backs) are able to accommodate to the shape of the spine and can be effective if they are properly adjusted. However, they provide less support compared to rigid backs and can stretch over time depending on the fabric. Tension adjustable backs consist of interwoven straps that can be tightened or loosened to accommodate for posture. One weak study found that the use of a tension adjustable back provides more support than a normal sling back. While it provides more support for the hips, it may still result in poor posture. Rigid backs generally provide more support and can help with stability. However, rigid backs are less adjustable, and do not accommodate for the shape of the spine. Although rigid backs may be more supportive, weak evidence has suggested that rigid backs are less comfortable than sling backs among individuals with tetraplegia.

Footrests (or leg rests) are an important part of a wheelchair. They function to stabilize your legs for optimal hip and back posture, help promote redistribution of sitting pressures, and may promote circulation. Footrests come in a variety of options. Footrests may be fixed (as one plate or two), swing-away (i.e., can be moved away from the front or removed), or flip up (particularly in powered wheelchairs). Elevating footrests allow for the leg to be in a raised position, which may help alleviate some leg pain.

Having a foot rest that is too high may result in more pressure on your buttock.15

The length of the footrest hanger (i.e., the distance from the back of the knee to the heel) can impact how you are seated in the wheelchair. Having a footrest that is too short will push your knees upward, so that the bottom of your thighs are no longer in contact with the top of the seat cushion. As a result, more pressure is applied to your sit bones and there is a lessened ability to shift your weight backward if you slide forward. On the other hand, a footrest that is too long may result in sliding forward in the wheelchair. Consequently, someone with a footrest that is too long may tend to slide forward often in their chair, leading to a hunched back.

Some weak evidence suggests that footrests can affect how activities of daily living are performed, but not the types of activities performed. The use of footrest may help improve the sitting balance of individuals with a lumbar SCI, but not those with a thoracic SCI.

Arm rests on wheelchairs serve multiple purposes and offer more benefits than simply acting as a place to rest the arms. In addition to acting as an arm rest, this part is also used to help maintain posture, redistribute pressure, and to enhance functioning (e.g., transfers, stability). The benefit of using armrests is dependent on an individual’s level of injury and abilities. An individual with more control of their torso and arms will be less likely to need armrests. Some active individuals tend to find that arm rests get in the way.

Maintaining posture

Using armrests can help maintain a good seated posture for an individual using a wheelchair. By supporting the arms and forearms, weight is alleviated from the shoulders. Without armrests, the weight of your arms may pull your shoulder down, resulting in a hunched position. It is also important that your armrests are set to an appropriate height. Armrests that are too low may require the individual to lean forward to use the armrest, which may lead to hunching. If the armrests are too high, the shoulders may be pushed up too high, which can lead to discomfort.

Redistributing pressure

Armrests can act as a source of support for repositioning to alleviate pressure on the sit bones. Weak evidence suggests that individuals with paraplegia rely on armrests more than tetraplegics during weight shifting (9% of their body weight vs 5%). The researchers think that this may be the case because individuals with tetraplegia have weak arm extensor muscles, making weight relieving difficult. In addition to acting as a support to push off from, armrests can also help alleviate pressure on the sit bones by supporting the weight of your arms. By removing the weight of hanging arms, the hips are unloaded and pressure forces are redistributed.

Enhancing function

Armrests can be helpful for everyday activities such as transferring, picking up objects, and stability. When transferring, the armrests act as a source of support and are used to push up and off from, or they can be a firm object to hang onto when transferring back in. In addition, armrests may act as a source of stability when completing tasks that may challenge someone’s balance, such as picking up objects off the ground, reaching for high objects, and leaning.

There are a variety of seating accessories that can be used to optimize comfort and posture. Although accessories can be used to enhance your seating, the majority of your posture should be supported through your seating set up (i.e., the backrest, cushion, foot rest), and not through accessories.

Upper extremity accessories

Arm supports to prevent the arm from falling off the side (A) and the elbow from sliding back (B).18

Seating accessories for the arms are more often found on power wheelchairs than manual wheelchairs. This group of accessories include armrest side supports and elbow blocks. Armrest side supports help prevent the forearm from falling off the side of the wheelchair, while elbow blocks prevent your elbows from sliding backwards. The use of these accessories can help keep your arm in place, especially when driving over rough terrain, and can help with repositioning.

Lower extremity support accessories

A two-point seatbelt (left) and a four-point seatbelt (right).19-20

Various accessories are available to help support and position all parts of the lower limb including: the hips and buttock, knees, lower legs, and feet. To support the hips and the buttock, positioning belts (sometimes referred to as seat belts) can be used. When used on wheelchairs, positioning belts can help prevent the hips from sliding forward and help to keep the hips properly aligned (i.e., not tilted or rotated). Different types of positioning belts are available depending on your needs: two-point belts or four-point belts. Four-point belts offer more support to the hips if required. It is also important to note that safety belts are not the same as positioning belts. Although both may contribute towards safety, positioning belts are more specialized to help maintain your hip posture.

A pommel connected to the wheelchair.21

There are also an assortment of accessories to address knees that press inward, splay outward, or are windswept. To address knees that press inward, pommels are cushions mounted either to the wheelchair or cushion, which go between the knees to keep them separated; however, pommels that are too big may interfere with transferring. To address knees that splay outward, adductor pads can be used. These pads are placed on the outer edges of the wheelchair cushion, which support the thigh and prevent the knees from falling outward.

Some accessories for the feet and lower leg include strapping and pads. Heel and toe straps can be connected to the footplate to help prevent the foot from moving forward or backward. After SCI, this can be particularly useful to help manage tone in the lower legs, and ensure the person remains stable in their wheelchair. To support the calves, pads can be attached to the footrest. Calf pads are particularly used with power wheelchairs, as they can provide support to the calves during tilting or reclining.

Trunk Support

Lateral supports on a power wheelchair, circled in red.22

Lateral supports, straps, or upper body positioning belts are used by individuals who have difficulty maintaining an upright posture that may be caused by muscle weakness or other conditions. Lateral supports are square or rectangular pads that connect to the back of the wheelchair and rest against the trunk to promote balance and stability. Moreover, the lateral pads can also act as a clear indicator that you are out of alignment (e.g., when you notice you are heavily leaning on a lateral support, try to consciously correct your posture if possible). Chest supports, including chest straps, can help prevent tipping forward due to weakness in the abdominal and back muscles. When used properly, accessories can help with trunk support, stability, balance, and posture. Correct positioning and support of the trunk may prevent further progression of some spinal conditions, such as scoliosis. If placed incorrectly, these supports may be ineffective. For example, if they are placed too low they may not provide the support needed, while if they are placed too high they may irritate your shoulder, the nerves in your arm, or limit arm movement. When changing sitting positions, ensure to also readjust your trunk supports as they may shift as well.

Wheelchair seating is a complex procedure which includes multiple assessments by healthcare professionals to ensure that your wheelchair is best suited for your needs. Given that the majority of your day may be spent in a wheelchair, it is important to consider ways to relieve sitting pressures and to maintain your postures. To do so, some parts of your wheelchair that may be customized include the cushion, back, and leg rests. It is best to discuss all treatment options with your health providers to find out which treatments are suitable for you.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, please see SCIRE Community Evidence Ratings.

SCIRE Community. “Powered Mobility Devices”. Available from: https://community.scireproject.com/topic/powered-mobility/

SCIRE Community. “Manual Wheelchairs”. Available from: https://community.scireproject.com/topic/manual-wheelchairs/

SCIRE Community. “Wheeled mobility video series”. Available from: https://community.scireproject.com/videos/wheeled-mobility/

Parts of this page has been adapted from SCIRE Project (Professional) “Wheeled Mobility and Seating Equipment Following Spinal Cord Injury” Chapter:

Titus L, Moir S, Casalino A, McIntyre A, Connolly S, Mortenson B, Guilbalt L, Miles S, Trenholm K, Benton B, Regan M. (2016). Wheeled Mobility and Seating Equipment Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-178.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/wheeled-mobility-and-seating-equipment/ 

Evidence for “Why is proper seating important” is based on:

Bogie K, Wang X, Fei B, Sun J. New technique for real-time interface pressure analysis: Getting more out of large image data sets. Journal of rehabilitation and research development, 45, 5236.

Mao HF, Huang SL, Lu TW, Lin YS, Liu HM, Wang YH, et al. Effects of lateral trunk support on scoliotic spinal alignment in persons with spinal cord injury: a radiographic study. Archives of Physical Medicine and Rehabilitation, 87, 764-71.

Thomson, D., Tully, P., Blochlinger, S. (n.d.). Laying the foundation for proper positioning: introduction to positioning for functional ability and wheelchair seating. [Powerpoint]. Retrieved from: https://seatingsymposium.com/images/pdf/PS/PS2_Tully_Thomson_Blochlinger.pdf

Evidence for “Why are cushions important” is based on:

Sprigle, S. (2014). Measure it: proper wheelchair fit is key to ensuring function while protecting skin integrity. Advanced wound skin care, 27, 561-72.

Sprigle S, Delaune W. (2014) Factors That Influence Changes in Wheelchair Cushion Performance Over Time. Assistive Technology, 26, 61-68.

Evidence for “How can a cushion redistribute pressure” is based on:

Endsjo, A., Mullis, S, Sharpe, L. 2019. Wheelchair seating and positioning guide. Retrieved from: https://hub.permobil.com/wheelchair-seating-positioning-guide

Evidence for “What kinds of cushions are there” is based on:

Sprigle S, Chung KC, Brubaker CE. (1990) Reduction of sitting pressures with custom contoured cushions. Journal of rehabilitation research and development, 27, 135-40.

Stewart, D. (2019). Comfort wheelchair cushions. Retrieved from: https://mobilitybasics.ca/seating/basic

Stewart, D. (2019). Comfort wheelchair cushions. Retrieved from: https://mobilitybasics.ca/seating/basic

Wheelchair seat cushions. (2019). Retrieved from: https://www.wheelchair-works.com/wheelchair-seat-cushion.html

Waugh, K. (2014). Custom contoured seating: Ensuring Successful Outcomes. [Powerpoint slides]. Retrieved from: https://seatingsymposium.com/images/pdf/PS/PS3_Waugh.pdf

Evidence for “Backrest” is based on:

Fontein, J. (2017). What’s in a back? [Abstract]. Canadian seating and mobility conference.

Hong EK, Dicianno BE, Pearlman J, Cooper R, Cooper RA. (2016). Comfort and stability of wheelchair backrests according to the TAWC (tool for assessing wheelchair discomfort). Disability and Rehabilitation: Assistive Technology, 11, 223-227.

Samuelsson K., Bjork, M., Erdugan, A.M., Hansson, A.K., Rustner, B.  (2009). The effect of shaped wheelchair cushion and lumbar supports on under-seat pressure, comfort, and pelvic rotation. Disability and rehabilitation: assistive technology, 4, 329-336.

Schmeler, M.R., Buning, M.E. (1999). Wheelchair back supports. [Powerpoint slides]. Retrieved from: https://www.wheelchairnet.org/WCN_WCU/SlideLectures/MS/4SeatBacks.pdf

Yang YS, Koontz AM, Yeh SJ, Chang JJ. (2012). Effect of backrest height on wheelchair propulsion biomechanics for level and uphill conditions. Archives of physical medicine and rehabilitation, 93, 654-659.

Evidence for “Footrest” is based on:

Janssen-Potten YJ, Seelen HA, Drukker J, Spaans F, Drost MR. The effect of footrests on sitting balance in paraplegic subjects. Archives of Physical Medicine and Rehabilitation, 83, 642-8.

Sprigle, S. (2014). Measure it: proper wheelchair fit is key to ensuring function while protecting skin integrity. Advanced wound skin care, 27, 561-72.

Evidence for ” What accessories are used for seating?” is based on:

Stewart, D. (2019). Wheelchair seating products – accessories. Retrieved from: https://mobilitybasics.ca/seating/accessories

Image credits
  1. Wheelchair Posture. ©Shannon Sproule
  2. Sitting pressures. ©The SCIRE Community Team
  3. Offloading pressures ©The SCIRE Community Team
  4. Immersion ©The SCIRE Community Team
  5. Immersion and Envelopment ©The SCIRE Community Team
  6. Foam cushion ©The SCIRE Community Team
  7. Gel cushions ©The SCIRE Community Team
  8. Air cushions ©The SCIRE Community Team
  9. Honeycomb Cushion ©The SCIRE Community Team
  10. Jay basic back ©Sunrise Medical 2017
  11. Jay J2 Series Back ©Sunrise Medical 2017
  12. Ride designs custom 2 cushion ©Action Seating and Mobility
  13. ZR Back Right Product Detail ©Permobil 2020
  14. Wheelchair. ©George Hodan. CC0 1.0
  15. Modified from Disabled people set ©macrovector Freepik License
  16. Polio Wheelchair Lady ©jackcast2015, CC BY 2.0
  17. This was one of five images (PHIL #9170-9174), depicting the action of two different mobility-challenged women getting into a bathtub ©Richard Duncan, Public Domain
  18. Permobil original elbow & armrest side supports ©Permobil, 2020
  19. Hip belt, push button, 1” webbing, center pull, 6” pads. ©Adaptive Engineering Lab (AEL) 2015
  20. Hip stabilizing belt, push button, rear pull, large. ©Adaptive Engineering Lab (AEL) 2015
  21. Heavy duty flipdown abductor hardware. ©Therafin corporation
  22. BodiLink® Accessories. ©Permobil 2020

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Wheelchair Propulsion Assist Devices

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Author: Sharon Jang | Reviewer: Jaimie Borisoff | Published: 15 May 2020 | Updated: ~

Wheelchair propulsion assist devices are pieces of equipment that can facilitate the use of a manual wheelchair. This page provides an overview of the different options available. SCIRE Community is not affiliated with and does not endorse any of the specific products mentioned on this page.

Key Points

  • Propulsion assist devices are technologies that attach to your manual wheelchair to facilitate propulsion
  • There is limited research on the effectiveness of these devices, but they are clinically well-accepted with perceived benefits associated with their use
  • There are options for both powered and non-powered propulsion assist devices, depending on your needs
  • Propulsion assist devices can be either front frame-mounted, replace your rear wheels, or rear frame-mounted
  • Propulsion assist devices are rapidly developing and changing; specific products in this article may no longer be available or unavailable in your area

An example of a front-mounted propulsion assist device.1

Propulsion assist devices are pieces of equipment that can be attached to a manual wheelchair to facilitate the ease of using a wheelchair, or expand the capabilities of a manual wheelchair. These devices generally work by reducing the amount of effort required by the user to move their wheelchair. Use of these devices may help individuals go up hills, reduce the amount of force required to start moving the wheelchair, or travel over difficult terrain such as grass. Propulsion assist devices are normally added onto the front or back of the chair frame, but also sometimes replace the rear wheels. These devices can be further split up into two categories: powered and non-powered.

As technology is rapidly progressing, novel devices are being frequently released. The development of multiple devices to fill a niche market has resulted in some products becoming unavailable in certain areas, or leaving the market altogether. The quick changes and developments in this area make conducting research on propulsion assist devices difficult. Currently, there is limited research on the use of propulsion assist devices for manual wheelchair users and most of the research is focussed on the devices that replace the rear wheels.

Using a propulsion assist device can be beneficial to manual wheelchair users. The man on the left is using a powered add-on.2

Power assist devices may be purchased by individuals with or without a prescription. Some indications for propulsion assist device use are limited strength in the upper body, or for those that are at a higher risk of an injury or pain to the arms and/or shoulders. These devices may improve participation in the community by enabling increased travel distance and access to more difficult environments.

In two studies (weak evidence), users of propulsion assist devices have reported benefits including:

  • Less strain on the cardiovascular and respiratory systems; this results in reduced overall feelings of fatigue.
  • Being able to go further with less effort (improved propulsion efficiency). This may help prevent overuse injuries.
  • Increased distance you are able to travel before feeling tired.
  • Travelling up and down hills.
  • Improved ability to travel on non-paved roads (e.g., grass, gravel, dirt), which increases the variety of spaces a wheelchair user may access.

Although there is limited research on propulsion assist devices, Pushrim Activated Power-Assist Wheelchairs (PAPAW) are the most researched device. Evidence has suggested that using PAPAWs have multiple benefits. One study provided moderate evidence for the use of PAPAWs to help individuals with SCI who have shoulder pain to propel their wheelchair further distances. The participants in this study also required less energy to wheel, and perceived that wheeling was easier with the use of PAPAWs. Other (weak) evidence has also shown that using a PAPAW may reduce the frequency of arm/shoulder injuries and the amount of energy required. Additional (weak) evidence suggests that individuals with tetraplegia using PAPAWs have improved ability to manoeuvre through a variety of textured surfaces and to complete activities of daily living.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, refer to the SCIRE Community Evidence Ratings.

Although propulsion assist devices can facilitate the use of a manual wheelchair, there are also some risks associated with their use. While this is not an exhaustive list, risks include:

Increased risk of wheelchair damage

Most manual wheelchair frames may not have been designed to withstand the different forces applied by propulsion assist devices. This may lead to premature wear and tear, or possible breakage, on some parts of the wheelchair, such as the footplate. Sudden breakage during use may lead to injury of the wheelchair user.

Using a propulsion assist device may increase the risk of tipping when going up or down hills.3

Decreased stability

The addition of a propulsion assist device either in front or behind the wheelchair may alter the center of gravity on the wheelchair. This may result in greater instability, increasing the risks of tipping backwards when going up and down steep hills. Forward stability may be compromised as well and induce tipping (e.g. when moving down at the bottom of a curb cut).

Greater impact forces when encountering an obstacle

Propulsion assist devices, especially motorized ones, allow wheelchair users to travel at a greater speed. However, hitting obstacles such as a rock or a curb in your wheelchair at a higher speed can result in greater forces, which may lead to a decrease in stability and increase the risk of falls.

Potential lateral stability issues

Propulsion assist devices that attach to the front pose a risk of tipping sideways. Particularly when travelling at higher speeds, sudden turns can result in tipping over.

Prior to obtaining a propulsion assist device, you should always consult your health professional. That said, some factors to consider when deciding whether to invest in an add-on include the following factors:

Upper limb function

Upper limb function is required to use these devices. For example, the individual may be responsible for attaching/detaching the device to the wheelchair, and some degree of hand function is needed for operation. Some products do have adapted controls for use by individuals with limited hand function.

Terrain

The device should facilitate the transportation of the user over surfaces that they frequently travel on, or wish to travel on. Some terrain considerations include indoor travel, outdoor travel, uneven surfaces, soft terrains e.g. grass, and hills.

Transfer ability

It is important to take into consideration how a device may impact transferring in and out of a wheelchair. Will it make transfers more difficult?

Transport

If a car is used for transportation, consideration of the weight of the propulsion device should be considered. Will the weight of the propulsion assist device and the wheelchair be manageable to lift into a car? Will the propulsion assist device fit into the car?

Weight

Is the device light enough for the user to remove by themselves? Will the weight make manual propulsion more difficult when not in use (e.g. if battery is drained before end of travel)?

Interaction with wheelchair

Propulsion assist devices require a certain part of a wheelchair to connect to, which may vary between types of wheelchair (e.g., rigid vs folding wheelchairs) and types of add-on. How the device mounts to a wheelchair should be considered, including the user’s capability for performing the attachment/detachment. Additional consideration may be needed if the device is going to be used between different wheelchairs.

Addressing casters

Casters help provide stability to a wheelchair, but become a limiting factor when a wheelchair user wishes to travel off a smooth even surface. There are some devices that connect to the front of the wheelchair via the foot plate and lift up the front caster wheels. This allows the wheelchair user to travel over uneven surfaces easier, such as dirt paths, sand, and gravel. An example of this kind of device is a FreeWheel.

Mechanical advantage

There are some devices that facilitate pushing by amplifying your efforts (a mechanical advantage) using gears or levers. Using a device with a mechanical advantage will allow you to go further with a given push. One example of a device that provides mechanical advantage is a lever-propelled wheelchair. There are some lever devices that can be connected to your wheel (others require replacement of the rear wheels) that allow the user to propel by pushing the lever forward. Using a lever has two purported benefits: 1) using a longer lever to propel a wheelchair requires less force, and 2) using a lever enables a more favorable movement pattern of the hands, wrists, and shoulder. Together these may reduce the risk of injury. An example of this device is the NuDrive.

Pushrim-Activated Power-Assist Wheelchairs (PAPAWs)

A PAPAW is a manual wheelchair with motorized rear wheels. The wheels are powered by a battery, which is attached to the back of the wheelchair. This type of wheelchair is controlled by normal pushing movements using the pushrims. PAPAWs assist individuals with limited strength or arm function by amplifying the force applied to the wheels. Each push on the pushrim by the user is sensed and proportionally amplified to increase the force to continue the forward movement. This also occurs for braking and turning (e.g., the wheels would detect a backwards force and apply a stronger braking force). This allows for users to go further with a given push, or to brake more efficiently with less force. When desired, the power assist function can be turned off. One limitation of using PAPAWs is the significantly increased weight of the wheelchair, which is especially noticeable when turned off. Another limitation is that the pushrims are damaged more easily, as this is where the sensors are located. Some examples of PAPAWs include the Alber E-motion and the Quickie Xtender.

Front mounted systems

These systems attach to the front of the wheelchair frame and typically lift up the front casters. Non–powered versions exist which are propelled via cranks and chains similar to handcycles. Most often powered, these devices are able to turn manual wheelchairs into a three-wheeled “scooter”. Front mounted systems are usually controlled with a throttle controller, which removes the need to manually propel the wheelchair. They are also able to reach significantly higher speeds in comparison to other power add-ons. A disadvantage to front mounted systems is that they add length to the wheelchair, which may impact the ability to move around indoors. In addition, the devices can be fairly heavy (e.g., the typical Batec system is 25 kg), and little to no customizations can be made. Examples of front mounted systems include the Rio Mobility Firefly, Triride, Klaxon, and Batec.

Rear mounted systems

Rear mounted propulsion device generally connect to the bar underneath the wheelchair seat (i.e., the camber tube). These devices can power the wheelchair so that no manual propulsion is required, although turning and braking still require constant user control. Currently, there are two models commercially available that are light, compact, and easily attached: the SmartDrive and the Smoov. The SmartDrive is controlled with a wristband worn by the user. A double tap of the wristband (or similar accelerometer-sensed motion of the hand/arm when tapping the wheel or other surface) will activate the motor and begin accelerating the wheelchair. Another tap sets the speed, while the next double tap will stop the motor. Gripping on the handrim is usually still needed to slow down and stop the chair. Users are not required to propel the wheelchair once it is in motion; they are only required to steer. Good reaction time is required to operate the device; a learning curve is involved when first using the device. The Smoov operates via a frame mounted control knob to set the desired speed. Starting and stopping the motor is accomplished through tapping the knob. Turning, slowing, and stopping are similar to the SmartDrive operation.

Other rear-mounted systems, such as the Spinergy ZX-1, convert manual wheelchairs into a power wheelchair. The user backs up into the device, which connects to the wheelchair with a push of the button. This add-on lifts up the rear wheels of the wheelchair, converting it into a power wheelchair that is controlled with a joystick.

The use of propulsion assist devices has the potential to protect your arms and shoulders from pain and overuse injuries, and allow you to travel further with less energy and more various terrain. Many different kinds of technologies are being rapidly developed and introduced to the market to facilitate manual wheelchair use. Thus, the world of powered propulsion assist devices is ever changing. Due to this factor, the devices discussed in this article may change, or may no longer be available for purchase.

Any reference to a specific product does not constitute or imply an endorsement by SCIRE Community. Professional advice should be sought before making any health care and treatment decisions.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, refer to the SCIRE Community Evidence Ratings.

SCIRE Community. “Powered Mobility Devices”. Available from:  https://community.scireproject.com/topic/powered-mobility/

SCIRE Community. “Manual Wheelchairs”. Available from: https://community.scireproject.com/topic/manual-wheelchairs/

SCIRE Community. “Wheeled mobility video series”. Available from: https://community.scireproject.com/videos/wheeled-mobility/

SCIRE Community. “Wheelchair Add-ons”. Available from: https://community.scireproject.com/resources/products-and-devices/

Parts of this page has been adapted from SCIRE Project (Professional) “Wheeled Mobility and Seating Equipment Following Spinal Cord Injury” Chapter:

Titus L, Moir S, Casalino A, McIntyre A, Connolly S, Mortenson B, Guilbalt L, Miles S, Trenholm K, Benton B, Regan M. (2016). Wheeled Mobility and Seating Equipment Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-178.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/wheeled-mobility-and-seating-equipment 

Evidence for “What are wheelchair propulsion devices” is based on:

Choukou, M.-A., Best, K. L., Potvin-Gilbert, M., Routhier, F., Lettre, J., Gamache, S., … Gagnon, D. (2019). Scoping review of propelling aids for manual wheelchairs. Assistive Technology, 0(00), 1–15. Retrieved from https://doi.org/10.1080/10400435.2019.1595789

Evidence for “What are the benefits of using a propulsion assist device” is based on:

Morgado Ramirez, D. Z., & Holloway, C. (2017). “But, I Don’t Want/Need a Power Wheelchair.” Proceedings of the 19th International ACM SIGACCESS Conference on Computers and Accessibility  – ASSETS ’17, 120–129. Retrieved from http://dl.acm.org/citation.cfm?doid=3132525.3132529

Evidence for “What are the risks of using a propulsion assist device” is based on:

Medicines and healthcare products regulator agency (2004). Guidance on the Stability of Wheelchairs, (March). Retrieved from http://www.unece.org/fileadmin/DAM/trans/doc/2004/wp29grsg/GRSG-ig-access-03-10.pdf

Ogilvie, C. (2019). Finite Element Analysis of a Wheelchair when Used with a Front-Attached Mobility Add-On by (November).

Evidence for “What should I consider when contemplating propulsion assist device” is based on:

Agency for clinical innovation (2019). Prescribing manual wheelchair with propulsion assist devices. Retrieved from: https://www.aci.health.nsw.gov.au/networks/spinal-cord-injury/spinal-seating/module-9/prescribing-manual-wheelchair-with-propulsion-assist-devices

Evidence for “What are the options for powered propulsion assist device” is based on:

Choukou, M.-A., Best, K. L., Potvin-Gilbert, M., Routhier, F., Lettre, J., Gamache, S., … Gagnon, D. (2019). Scoping review of propelling aids for manual wheelchairs. Assistive Technology, 0(00), 1–15. Retrieved from https://doi.org/10.1080/10400435.2019.1595789

Corfman TA, Cooper RA, Boninger ML, Koontz AM, Fitzgerald SG. Range of motion and stroke frequency differences between manual wheelchair propulsion and pushrim-activated power-assisted wheelchair propulsion. J Spinal Cord Med 2003;26(2):135-40

Nash MS, Koppens D, van Haaren M, Sherman AL, Lippiatt JP, Lewis JE. Power-assisted wheels ease energy costs and perceptual responses to wheelchair propulsion in persons with shoulder pain and spinal cord injury. Arch Phys Med Rehabil 2008;89:2080-5.

Image credits
  1. Batec Handbike. © SCIRE Community Team
  2. Moving in the community. © SCIRE Community Team
  3. Men in wheelchairs at heather lake, Mt. Baker Snoqualmie National Forest. © U.S. Forest Service – Pacific Northwest Region.
  4. Hand © Sandra. CC BY 3.0
  5. Mountain © iconcheese. CC BY 3.0
  6. Transfer © romzicon. CC BY 3.0
  7. Car © Priyanka, IN. CC BY 3.0
  8. Scales © Made, AU. CC BY 3.0
  9. Wheelchair © Satawat Anukul, TH. CC BY 3.0
  10. FreeWheel Wheelchair Attachment © FreeWheel 2020
  11. Stanley handling NuDrive Air © NuDrive Air 2020
  12. Alber E-Motion M25 © Manston mobility 2018
  13. Firefly Electric Attachable Handcycle for Wheelchair © Rio Mobility 2020
  14. Smart Drive © MAX Mobility, LLC 2019
  15. Spinergy ZX-1 © Spinergy 2020

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Stem Cells and Spinal Cord Injury

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Author: Sharon Jang, Vanessa Mok | Reviewer: Peggy Assinck | Published: 13 May 2020 | Updated: ~

Since the discovery of stem cell therapy, researchers have attempted to determine whether it can be a safe and effective treatment for spinal cord injury (SCI). This page addresses what stem cell therapy is and its current place in SCI.

Key Points

  • Stem cells are cells that have the ability to self-renew indefinitely and specialize into different types of functioning cells
  • Stem cells treatment following SCI has been proposed to prevent further damage to the spinal cord, bridge lesion sites, and promote the regrowth of nerves
  • There is limited evidence that stem cell therapy is safe and effective in humans (across different disorders) and therefore more work needs to be done to confirm safety and potential effectiveness
  • There are currently no stem cell therapies approved for SCI. However, many clinics worldwide continue to offer cell transplantation-based treatments including stem cell therapies that have very little scientific evidence to back them up
  • It is important to stay well-informed about ongoing research and importantly the potential risks involved in stem cell-based treatments

Stems cells have the ability to self-renew (blue arrow), and turn into different cell types such as muscle cells, skin cells, and nerve cells (pictured).1

All tissues and organs in the body originate from stem cells. Stem cells are unspecialized, blank cells that have the ability to turn into specialized cells (e.g., neural cells, muscle cells, etc) through chemical signals in the body. These cells are responsible for maintaining and repairing the tissue they are found in. Stem cells are defined by two characteristic features: 1) their ability to self-renew (i.e., make copies of themselves) and 2) their ability to differentiate into functioning cell types (i.e., they can turn into specialized cells). Some stem cells are only found in certain parts of the body or at certain stages of life. There are four main types of stem cells that are currently used in stem cell therapy or research.

Neurons extending from a group of embryonic stem cells.2

Embryonic stem cells

Embryonic stem cells are sourced from embryos that are about a week old. In Canada, embryos cannot be specifically created for research purposes. Instead, these stem cells originate from unused embryos from fertility clinics. Their use in research raises ethical controversies as the embryos are destroyed during the harvesting process. These cells are pluripotent which means that they can turn into any cell in the body except for the umbilical cord and placenta.

Adult stem cells

Adult stem cells (also known as somatic stem cells or tissue-specific stem cells) are sourced from organ tissues (e.g., the heart, bone marrow, fat) found in the bodies of infants, children, and adults. They can also be produced from discarded placentas and umbilical cords. They have less capability to self-divide and specialize into different cell types compared to embryonic stem cells. Rather, adult stem cells more commonly produce tissue types in which they are found, so are multipotent. For instance, blood stems cells only have the potential to generate red blood cells, white blood cells, and platelets.

Induced pluripotent stem cells

Advancements in technology have allowed researchers to reprogram specialized adult cells back into their pluripotent state to resemble embryonic stem cells. These cells are known as induced pluripotent stem cells. These cells are often obtained from taking a small sample from adult tissue, such as the skin. Because this process does not harm the donor nor does it involve embryos, the same ethical issues facing above-discussed cells are not encountered with induced pluripotent stem cells. Induced pluripotent stem cells can also reduce the risk of rejection by the body because the adult cells are derived from the person’s own body. Despite this exciting discovery, there are lots of obstacles to overcome before they are used in human studies.

Stem cell therapy is the use of stem cells to help replace or repair damaged tissue in the human body. In this type of therapy, stem cells are either differentiated into the cell of interest outside of the body prior to transplantation (exogenous), or directly transplanted into the site of injury (endogenous). In exogenous repair, scientists differentiate specific stem cells types in a laboratory and then implant the cells into the body. On the other hand, endogenous repair consists of directly transplanting stem cells into the body, and depends on the body’s ability to transform the cells into the specific type required for repair. These cells can be sourced from various places: autologous transplantation involves the use of stem cells from the person who is receiving the transplant, whereas allogenic transplantation involves receiving stem cells from a donor.

Cell transplantation versus stem cell transplantation

Cell transplantation is an umbrella term for stem cell transplantation. Different cells can be transplanted into the body including fat cells, bone marrow cells, and nose cells. Cell transplantation is the process of transferring cells into areas of the body that are damaged or injured. These transfers work in 2 main ways: 1) the cells can be transplanted into the injury site for direct repair, or 2) the cells can be transplanted into the blood where they can circulate around the body and cause system-wide changes. Most work in SCI focuses on putting a more specialized cell into the injury site (not just stem cells). For example, a stem cell can be pushed towards becoming a myelinating cell and then the myelinating cell could be transplanted into the injury site, or a Schwann cell could be harvested from the leg and then transplanted at the injury site.

Currently, only a small number of conditions are approved to be treated with stem cell therapy. Bone marrow transplants for leukemia have been performed for many years. Epithelial stem cell transplants are also done to regenerate cells in those who have suffered burns or disorders of the cornea. Stem cell therapy for other purposes, including SCI, is still relatively new and much of the research is still in its early stages. The figure below highlights important landmarks in the history of stem cells research.

Healthcare professionals preparing for a stem cell transplant.18

With SCI, stem cells could theoretically be used to replace injured or destroyed nerve cells or protect further attack by the immune system around the injury site. The main goal of stem cell therapy for SCI is to improve the conduction of information past the injury. As of yet, there are no stem cell treatments that can reverse or repair a SCI. While there is some thought that stem cells may be used to help recovery, researchers are still currently unsure of exactly how stem cells/cell transplantation can help recovery from a spinal cord injury. However, many hypotheses have been made:

  • Neuroprotection: Stem cells may help prevent further damage to the tissue in the area surrounding a spinal cord injury. By limiting the amount of damage, more function may be saved.
  • Supporting the host cell: Stem cells may help enhance the survival of nearby cells by secreting molecules that control inflammation and/or improve the regeneration of blood cells
  • Creating new blood vessels: Stem cells may help promote faster regrowth of new blood vessels and protection of the existing ones. Having more blood vessels may increase the amount of oxygen and nutrients available for surviving cells.
  • Regrowth of axons: Stem cells may help axons regrow through developing bridges across the site of the lesion and decreasing scars. However, it is important to note that the regeneration of axons may not always lead to functional benefits and could even lead to adverse effects such as increased pain.

    The anatomy of a neuron.19

  • Regeneration of myelin: Myelin forms insulation around nerves, allowing electrical signals to transmit efficiently to other nerve cells. Stem ce­lls may also be used to replace the support cells that wrap myelin around nerves.

Refer to our article on Neuroprotection for more information

SCI research on stem cells has largely focused on laboratory and animal experiments. Human studies are in their initial phase.20

There are a number of ongoing and completed studies of weak to moderate evidence that evaluates the safety and efficacy of stem cells in people with SCI. Given that stem cells are still experimental, there is no specific stem cell type that is proven to be more effective over another. In research, studies have tested a large variation of stem cell sources, including blood, bone marrow, the nose, umbilical cords, and other nerves. While some of these stem cell sources come from fetuses, most studies have used stem cells from the person’s own body.

Care should be taken when interpreting these findings as they are derived from small trials with flaws in study design and documentation. Many more large-scale studies are required to determine whether stem cells have a role in treating people with SCI and if so, how transplantation should be done to minimize the health risks and maximize the potential of stem cell-based therapy.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, refer to the SCIRE Community Evidence Ratings.

Improved AIS score

In research, a common way to determine the success of any treatment is through comparing ASIA Impairment Scale (AIS) scores before and after transplantation. An individual’s AIS score consists of their muscle strength and sensation below their level of injury, in addition to anal sensation and contraction. Two weak evidence studies with a small number of participants (less than 10) found that stem cell treatments improved the AIS score of all participants. Conversely, two weak evidence studies found that only a portion (29-66.7%) of their participants saw an improvement in AIS scores.

Refer to our article on Spinal Cord Injury Basics for more information on AIS scores.

Natural recovery after SCI

Although some studies have shown improvements to movement and sensory AIS scores, it is also important to note that natural (or spontaneous) recovery can occur within the first year of a spinal cord injury. In individuals with SCI, natural recovery of movement and sensation may occur up to 12-18 months post injury. Some stem cell studies have been conducted with newly injured individuals (i.e., less than 1 year after sustaining a spinal cord injury). As a result, spontaneous recovery may have played a role in the findings of improved function and sensation, not stem cell therapy.

Improved sensation

There have been some mixed findings on the efficacy of stem cells on sensation. Some weak evidence research studies have seen improvements in sensation for some individuals, but no large-scale study has found improvements for their entire sample. A moderate evidence study found significant changes in sensation when compared to individuals who did not receive stem cell therapy. However, a second moderate evidence study found that sensation improved over a year, but the amount of improvement was not significantly different than individuals who did not receive stem cell therapy. Currently, it is hard to conclude whether the use of stem cells is effective for the restoration of sensation.

Improved motor function

There is some weak to moderate evidence showing that stem cells may help the recovery of motor function. The type of recovery in these studies has been quite diverse, ranging from a tetraplegic individual regaining the ability to hold their head up and move their upper limb, to the ability to walk with crutches and braces. However, the percentage of people who re-develop the ability to walk again in studies is low (i.e., 1-2 people out of 10-20 total participants). Moderate evidence suggests that stem cells may be more beneficial for movement in the arms and hands than the legs compared to people who did not receive stem cell therapy. Similar to sensation, no large-scale study has shown a high success rate in the recovery of motor functioning in response to stem cell therapy. In fact, there have been several studies that have found no improvements in motor function amongst their participants.

Improved neural connectivity

The signals relayed from the brain to the muscles are disrupted when a spinal cord injury occurs. To observe what connection remains, researchers apply stimulation to the brain and observe whether or not a signal is received at the arms/legs. If there is a signal present, researchers then note of how long it takes for the signal to get to the arms/legs, and the strength of the signal. As stem cells are supposed to theoretically help repair the spinal cord, it is thought that these signals would start to reappear/improve with stem cell therapy.

Motor evoked potentials

Motor evoked potentials are used to evaluate the connections between the brain and the muscles. Four low to moderate evidence studies have seen a reappearance of motor evoked potentials in individuals who were lacking them before, although the proportion of individuals who see a return is quite low (i.e., a range of 3-10 participants out of 20). Weak-moderate evidence research has also found improvements in the time it takes for signals to go through after stem cell therapy. It is important to note that these improvements are not always associated with improvements in AIS grades. Contrary to the previous findings, one research group found that the time taken for signals to travel from the brain to the muscle did not change, despite increases in AIS grade. This means that while functional improvements were seen, the connections between the brain and the muscle did not improve.

Somatosensory evoked potentials

The brain normally interprets sensation through a pathway (in green) of nerves that travel from the limb, to the spinal cord, to the brain.24

are used to evaluate the sensory connections between the brain and the rest of the body. Several studies have found a reappearance of sensory signals in the wrist and/or ankles in a portion of their participants. For participants with sensory signals present prior to receiving stem cells, evidence shows that these signals may be strengthened, and that these signals may travel faster. Although these findings appear promising, the longevity of the strengthening effect is brought to light by one group of researchers who showed that the newly obtained sensory signals disappeared after one year. More research is required to determine how to consistently obtain these results, and to determine whether these effects are truly non-lasting.

Refer to our article on Understanding Research Evidence for more information on spontaneous recovery.

Bladder & Bowel

Individuals with spinal cord injury often experience a lack of sensation and control of their bowel and bladder. Some research suggests that stem cell therapy may restore some sensation of bladder fullness and anal sensation. There are also some positive reports on the restoration of voluntary bladder contractions and anal control. Moreover, one study (moderate evidence) indicates that stem cell therapy may further improve bladder function by allowing individuals to hold more urine in their bladder, to increase the rate of urine passage, and to empty urine with less effort from by the bladder. However, the proportion of people in these studies who receive these bladder benefits are low.

Functional Independence and Quality of Life

There is limited evidence that stem cell therapy has a positive impact on functional independence and quality of life. Participants from three studies (weak evidence) reported that their self-care ability has improved in areas including bowel/bladder management, grooming, feeding, transferring, dressing, and mobility.

Sexual functioning

Most of the research on the effects of stem cell therapy and sexual functioning has been conducted with men. One weak study found that 31% of the men had improved erections while another found that sexual functioning improved as a result of increased sensitivity in the genital area. More research is required to determine the consistency of the effects in addition to the impact on sexual functioning of women.

Evidence for no improvement

While there have been some successful findings from stem cell therapy use in SCI, there are trials that have found no effects. Three studies found that none of their participants experienced any changes in their sensory or motor function. Meanwhile, other studies with a small number of participants (e.g., 5-20) have found that stem cell therapy may have an effect for some individuals, but not others. The number of people who do not experience any positive benefits from stem cell therapy is unpredictable, and has ranged from 40-87%.

Even though Health Canada and USA Food and Drug Administration (FDA) have not yet approved of any stem cell therapies for SCI in Canada, some private clinics around the world are already selling these treatments before establishing safety and effectiveness. In Canada, offering stem cell therapies is illegal unless it is for research purposes. Before you decide, consider the following points below with a health care provider. Use these points to think critically about what is being advertised.

There is no consensus on whether stem cell therapy is effective.

As described in this article, there is a lack of evidence supporting the use of stem cell therapy for spinal cord injury. Stem cell therapy is being explored as a treatment for many types of medical conditions; however, there is only strong evidence that supports its use with blood or immune system disorders that are often experienced after cancer. Currently, scientists are unsure how to repeatedly produce positive effects with the use of stem cell therapy for individuals with SCI. In addition, there remain many uncertain aspects of stem cell therapy such as knowing which type of stem cell is most effective for replacing different tissues, how these stem cells should be manipulated to produce the required cells, and what is the best way to deliver stem cells to the target area.

There are a variety of risks associated with stem cell therapy

Safety

There are many safety risks associated with stem cell treatments, and these risks may be higher for individuals with spinal cord injuries. Some stem cell marketers may emphasize that a treatment is safer if the cells are coming from your own body; however, this does not guarantee safety. If the stem cells are grown and multiplied before being injected into your spinal cord, the cells may lose some important properties and traits in the process, such as the ability to control growth. This may lead to the development of various tumors and/or cancers. In addition, when the cells are removed from your body, it is possible that they be exposed to bacteria or viruses prior to being re-transplanted into your spine. There is also a chance that complications may arise which may lead to short- or long-term health problems. This may lead to your injury or symptoms becoming more difficult to manage.

In clinical trials with people with SCI, there have been multiple adverse events resulting from stem cell therapy. The majority of stem cell studies conclude that transplantation is relatively safe due to the lack of serious safety problems or complications observed. Mild adverse events are infrequently reported in studies, but some have been documented. Some examples that have been reported include urinary tract infections, pain, hypothermia, headaches, increased spasticity, pressure sores, and depression. Serious adverse events that have been noted in research studies include:

    • the worsening of motor functioning
    • development of a cyst on the spine (which causes a concern for cancer)
    • collection of fluid along the surgical site
    • meningitis, resulting in a decrease in AIS score
    • worsening of sensation (e.g., worsened symptoms of tingling, decrease in sensation)

However, it is important to note that these adverse effects were only monitored over the period of the study. Currently, long term effects and side effects of stem cell therapy is unknown. Further longitudinal research is required.

Financial

As the use of stem cell therapy is not currently approved by the government, most often government health programs and insurance companies will not cover the costs. The costs of receiving stem cell therapy can be very high. On top of the cost for the treatment (being in the tens of thousands of dollars itself), there is the cost of travel, accommodations, and other fees. In addition, travelling for stem cell therapy may require you to go through a medical procedure without the support of all your family and friends.

Research

Receiving an experimental treatment is not the same as participating in a clinical trial. If you choose to receive stem cell therapy from a private clinic, you may be ineligible from participating in future clinical trials. Participating in a clinical trial is advised over receiving stem cell therapy from an unregulated private clinic, as:

    • Clinical trials are overseen by an independent medical ethics committee. This group of people is there to protect your rights and safety as a participant.
    • Clinical trials require some safety and efficacy testing before trying it in humans. This ensures that the treatment is relatively safe and effective.
    • By participating in a clinical trial (research), you are contributing back to the pool of knowledge. When you partake in a research study, you help scientists learn more about stem cell therapy and the safety or effectiveness of it.
    • There is no cost for the treatment in a clinical trial, as participants are not required to pay to partake in research studies.

Stem cell marketing sites are likely misleading

Private stem cell clinics often use overly positive/ optimistic advertisements that may be misleading.32

Unapproved stem cell marking websites often feature many patient testimonials in addition to references to research studies. The use of testimonials may be very persuasive, but may be misleading. Some of the positive benefits that these individuals may be feeling may be the result of the placebo effect. Given that many people who go in for stem cell therapy treatment have a strong belief that it will work, they may perceive less pain or greater sensation after their treatment. Patient anecdotes should not be held equal to research evidence supporting the use of stem cell therapy.

Additionally, many private stem cell therapy clinics will try to sell the treatment by citing multiple research studies to build credibility. In reality, these research articles often have no direct association with stem cell therapy specific to spinal cord injuries. Currently, there is a lack of high-quality research studies on stem cell therapy. As a result, many of the human-based studies cited are low quality and are not specific to spinal cord injury, and some reports are based on animal trials.

Before taking part in a research trial, it is important to seek medical advice from your healthcare team. Your healthcare providers can direct you to SCI studies that are available, assess whether you are a suitable candidate, and provide you with educational resources. There are also online databases containing registered clinical trials such as SciTrialsFinder.net, ClinicalTrials.gov, ISRCTN Registry, and the International Clinical Trials Registry Platform (ICTRP).

Refer to our article on Understanding Research Evidence for more information about different types of research studies.

Ensure that the trial you wish to partake in is approved by:

  • An independent review committee such as an Institutional Review Board (IRB) or Ethics Review Board (ERB) to protect your rights as a participant
  • A regulatory agency such as Health Canada, USA Food and Drug Administration (FDA), or European Medicines Agency (EMEA) to make sure the treatment will be conducted in a safe manner

Experimental Treatments for Spinal Cord Injury: What you should know is a guide that outlines other important considerations to think about before agreeing to participate in a clinical trial for an experimental treatment.

Stem cells continue to be a hot topic in SCI research. Their therapeutic potential in preventing further damage to the spinal cord and promoting regrowth of nerve cells has inspired a vast number of studies. However, it is important to note that there is a lack of consistency in the research in regards to the effectiveness and reported benefits of stem cell therapy for individuals with SCI. While there has been some positive evidence for stem cell therapy in these studies, it remains unclear whether this treatment is safe and effective for people with SCI.

There are currently no approved stem cell treatments for SCI. Stem cell treatments have not been proven to be safe and effective in clinical trials. Even so, many clinics around the world offer stem cell therapies that do not have proper evidence to back up their claims. Although stem cells therapy is taking a long time to get approved as a regulated treatment, remember that the process by which research is translated into medical practice is in place to minimize harms and to maximize benefits and effectiveness. If you wish to undergo a stem cell treatment, the risks should be weighed against the benefits. It is best to discuss all treatment options with your health providers to find out which treatments are suitable for you.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, refer to the SCIRE Community Evidence Ratings.

Evidence for “What are stem cells” is based on:

Canadian Stem Cell Foundation (2016). About Spinal Cord Injury. 1–4.

Evidence for “What are stem cells used for” is based on:

Insoo, H. (2010). The bioethics of stem cell research and therapy. Journal of Clinical Investigation. https://doi.org/10.1172/jci40435

International Society for Stem Cell Research. (2008). Patient Handbook on Stem Cell Therapies. 8.

Science learning hub. (2016). Stem cell research – timeline. Retreived from: https://sciencelearn.org.nz/resources/1967-stem-cell-research-timeline

What is biotechnology? (n.d.). Stem cells. Retrieved from: https://whatisbiotechnology.org/index.php/science/summary/stem/stem-cells-repair-tissues-and-regenerate-cells

New Scientist. (2014). Stem cell timeline: the history of a medical sensation. Retreived from: https://newscientist.com/article/dn24970-stem-cell-timeline-the-history-of-a-medical-sensation/

Evidence for “How can stem cells be used for SCI” is based on:

Assinck, P., Duncan, G. J., Hilton, B. J., Plemel, J. R., & Tetzlaff, W. (2017). Cell transplantation therapy for spinal cord injury. Nature Neuroscience, 20(5), 637–647. https://doi.org/10.1038/nn.4541

Evidence for “What stem cell research has been done in SCI” is based on:

Al-Zoubi, A., Jafar, E., Jamous, M., Al-Twal, F., Al-Bakheet, S., Zalloum, M., … Al-Zoubi, Z. (2014).  Transplantation of Purified Autologous Leukapheresis-Derived CD34 + and CD133 + Stem Cells for Patients with Chronic Spinal Cord Injuries: Long-Term Evaluation of Safety and Efficacy . Cell Transplantation, 23(1_suppl), 25–34. https://doi.org/10.3727/096368914×684899

Cheng, H., Liu, X., Hua, R., Dai, G., Wang, X., Gao, J., & An, Y. (2014). Clinical observation of umbilical cord mesenchymal stem cell transplantation in treatment for sequelae of thoracolumbar spinal cord injury.https://doi.org/10.1186/s12967-014-0253-7

Chotivichit, A., Ruangchainikom, M., Chiewvit, P., Wongkajornsilp, A., & Sujirattanawimol, K. (2015). Chronic spinal cord injury treated with transplanted autologous bone marrow-derived mesenchymal stem cells tracked by magnetic resonance imaging: a case report. https://doi.org/10.1186/s13256-015-0535-6

Cristante, A. F., Barros-Filho, T., Tatsui, N., Mendrone, A., Caldas, J. G., Camargo, A., … Marcon, R. M. (2009). Stem cells in the treatment of chronic spinal cord injury: evaluation of somatosensitive evoked potentials in 39 patients. Spinal Cord, 47, 733–738. https://doi.org/10.1038/sc.2009.24

Dai, G., Liu, X., Zhang, Z., Wang, X., Li, M., Cheng, H., … An, Y. (2013). Comparative analysis of curative effect of CT-guided stem cell transplantation and open surgical transplantation for sequelae of spinal cord injury. Retrieved from http://www.translational-medicine.com/content/11/1/315

Deda, H., Kürekçi, A. E., Kayıhan, K., Zgün, E. O. ¨, Stünsoy, U. ¨, & Kocabay, S. (2008). Treatment of chronic spinal cord injured patients with autologous bone marrow-derived hematopoietic stem cell transplantation: 1-year follow-up. Cytotherapy, 10(6), 565–574. https://doi.org/10.1080/14653240802241797

Fawcett, J.W., Curt, A., Steeves, J.D., Coleman, W.P.,Tuszynski, M.H., Lammertse, D…& Short, D. (2007). Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials. Spinal cord, 45(3), 190-205. doi:10.1038/sj.sc.3102007

Frolov, A. A., & Bryukhovetskiy, A. S. (2012). Effects of Hematopoietic Autologous Stem Cell Transplantation to the Chronically Injured Human Spinal Cord Evaluated by Motor and Somatosensory Evoked Potentials Methods. Cell Transplantation, 21, 49–55. https://doi.org/10.3727/096368912X633761

Jarocha, D., Milczarek, O., Kawecki, Z., Wendrychowicz, A., Kwiatkowski, S., & Majka, M. (2014). Preliminary study of autologous bone marrow nucleated cells transplantation in children with spinal cord injury. Stem Cells Translational Medicine, 3(3), 395–404. https://doi.org/10.5966/sctm.2013-0141

Jarocha, D., Milczarek, O., Wedrychowicz, A., Kwiatkowski, S., & Majka, M. (2015). Continuous improvement after multiple mesenchymal stem cell transplantations in a patient with complete spinal cord injury. Cell Transplantation, 24(4), 661–672. https://doi.org/10.3727/096368915X687796

Kang, K.-S., Kim, S. W., Oh, Y. H., Yu, J. W., Kim, K.-Y., Park, H. K., … Han, H. (2005). A 37-year-old spinal cord-injured female patient, transplanted of multipotent stem cells from human UC blood, with improved sensory perception and mobility, both functionally and morphologically: a case study. International Society for Cellular Therapy, 7(4), 368–373. https://doi.org/10.1080/14653240500238160

Liu, J., Han, D., Wang, Z., Xue, M., Zhu, L., Yan, H., … Wang, & H. (2013). Clinical analysis of the treatment of spinal cord injury with umbilical cord mesenchymal stem cells. Cytotherapy, 15, 185–191. https://doi.org/10.1016/j.jcyt.2012.09.005

Moviglia, G. A., Fernandez Viña, R., Brizuela, J. A., Saslavsky, J., Vrsalovic, F., Varela, G., … Shuster, G. S. (2006). Combined protocol of cell therapy for chronic spinal cord injury. Report on the electrical and functional recovery of two patients. Cytotherapy. https://doi.org/10.1080/14653240600736048

Oh, S. K., Choi, K. H., Yoo, J. Y., Kim, D. Y., Kim, S. J., & Jeon, S. R. (2016). A Phase III Clinical Trial Showing Limited Efficacy of Autologous Mesenchymal Stem Cell Therapy for Spinal Cord Injury. Neurosurgery, 78(3), 436–447. https://doi.org/10.1227/NEU.0000000000001056

Oraee-Yazdani, S., Hafizi, M., Atashi, A., Ashrafi, F., Seddighi, A.-S., Hashemi, S. M., … Zali, A. (2016). Co-transplantation of autologous bone marrow mesenchymal stem cells and Schwann cells through cerebral spinal fluid for the treatment of patients with chronic spinal cord injury: safety and possible outcome. https://doi.org/10.1038/sc.2015.142

Park, H. C., Shim, Y. S., Ha, Y., Yoon, S. H., Park, S. R., Choi, B. H., & Park, H. S. (2005). Treatment of complete spinal cord injury patients by autologous bone marrow cell transplantation and administration of granulocyte-macrophage colony stimulating factor. Tissue Engineering, 11(5–6), 913–922. https://doi.org/10.1089/ten.2005.11.913

Park, J. H., Kim, D. Y., Sung, I. Y., Choi, G. H., Jeon, M. H., Kim, K. K., & Jeon, S. R. (2012). Long-term results of spinal cord injury therapy using mesenchymal stem cells derived from bone marrow in humans. Neurosurgery, 70(5), 1238–1247. https://doi.org/10.1227/NEU.0b013e31824387f9

Shin, J. C., Kim, K. N., Yoo, J., Kim, I. S., Yun, S., Lee, H., … Park, K. I. (2015). Clinical Trial of Human Fetal Brain-Derived Neural Stem/Progenitor Cell Transplantation in Patients with Traumatic Cervical Spinal Cord Injury. Neural Plasticity, 2015. https://doi.org/10.1155/2015/630932

Vaquero, J., Zurita, M., Rico, M. A., Bonilla, C., Aguayo, C., Montilla, J., … Reina, L. De. (2016). An approach to personalized cell therapy in chronic complete paraplegia: The Puerta de Hierro phase I/II clinical trial. Cytotherapy, 18(8), 1025–1036. https://doi.org/10.1016/j.jcyt.2016.05.003

Vaquero, J., Zurita, M., Rico, M. A., Bonilla, C., Aguayo, C., Fernández, C., … Fernández, M. V. (2017). Repeated subarachnoid administrations of autologous mesenchymal stromal cells supported in autologous plasma improve quality of life in patients suffering incomplete spinal cord injury. Cytotherapy, 19, 349–359. https://doi.org/10.1016/j.jcyt.2016.12.002

Yazdani, S. O., Hafizi, M., Zali, A. R., Atashi, A., Ashrafi, F., Seddighi, A. S., & Soleimani, M. (2013). Safety and possible outcome assessment of autologous Schwann cell and bone marrow mesenchymal stromal cell co-transplantation for treatment of patients with chronic spinal cord injury. Cytotherapy. https://doi.org/10.1016/j.jcyt.2013.03.012

Evidence for “What are the risks and considerations of using stem cells” is based on:

A Closer Look at Stem Cells. (2019). Nine things to know about stem cell treatments. Retreived from: https://closerlookatstemcells.org/stem-cells-medicine/nine-things-to-know-about-stem-cell-treatments/

Al-Zoubi, A., Jafar, E., Jamous, M., Al-Twal, F., Al-Bakheet, S., Zalloum, M., … Al-Zoubi, Z. (2014).  Transplantation of Purified Autologous Leukapheresis-Derived CD34 + and CD133 + Stem Cells for Patients with Chronic Spinal Cord Injuries: Long-Term Evaluation of Safety and Efficacy . Cell Transplantation, 23(1_suppl), 25–34. https://doi.org/10.3727/096368914×684899

Anderson, K. D., Guest, J. D., Dietrich, W. D., Bunge, M. B., Curiel, R., Dididze, M., … Levi, A. D. (2017). Safety of Autologous Human Schwann Cell Transplantation in Subacute Thoracic Spinal Cord Injury. Journal of Neurotrauma, 34, 2950–2963. https://doi.org/10.1089/neu.2016.4895

Assinck, P., Duncan, G. J., Hilton, B. J., Plemel, J. R., & Tetzlaff, W. (2017). Cell transplantation therapy for spinal cord injury. Nature Neuroscience, 20(5), 637–647. https://doi.org/10.1038/nn.4541

Blight, A., Curt, A., Ditunno, J. F., Dobkin, B., Ellaway, P., Fawcett, J., … Guest, J. D. (2009). Position statement on the sale of unproven cellular therapies for spinal cord injury: The international campaign for cures of spinal cord injury paralysis. Spinal Cord, 47(9), 713–714. https://doi.org/10.1038/sc.2008.179

Cheng, H., Liu, X., Hua, R., Dai, G., Wang, X., Gao, J., & An, Y. (2014). Clinical observation of umbilical cord mesenchymal stem cell transplantation in treatment for sequelae of thoracolumbar spinal cord injury. https://doi.org/10.1186/s12967-014-0253-7

Chotivichit, A., Ruangchainikom, M., Chiewvit, P., Wongkajornsilp, A., & Sujirattanawimol, K. (2015). Chronic spinal cord injury treated with transplanted autologous bone marrow-derived mesenchymal stem cells tracked by magnetic resonance imaging: a case report. ??? https://doi.org/10.1186/s13256-015-0535-6

Cristante, A. F., Barros-Filho, T., Tatsui, N., Mendrone, A., Caldas, J. G., Camargo, A., … Marcon, R. M. (2009). Stem cells in the treatment of chronic spinal cord injury: evaluation of somatosensitive evoked potentials in 39 patients. Spinal Cord, 47, 733–738. https://doi.org/10.1038/sc.2009.24

Curt, A., Hsieh, J., Schubert, M., Hupp, M., Friedl, S., Freund, P., … Guzman, R. (2019). Safety and preliminary efficacy of allogenic neural stem cell transplantation in chronic spinal cord injury: A translational phase I/IIa trial. Preprints with the Lancet, 73, 1–21.

Dai, G., Liu, X., Zhang, Z., Wang, X., Li, M., Cheng, H., … An, Y. (2013). Comparative analysis of curative effect of CT-guided stem cell transplantation and open surgical transplantation for sequelae of spinal cord injury. Retrieved from http://www.translational-medicine.com/content/11/1/315

Deda, H., Kürekçi, A. E., Kayıhan, K., Zgün, E. O. ¨, Stünsoy, U. ¨, & Kocabay, S. (2008). Treatment of chronic spinal cord injured patients with autologous bone marrow-derived hematopoietic stem cell transplantation: 1-year follow-up. Cytotherapy, 10(6), 565–574. https://doi.org/10.1080/14653240802241797

Dlouhy, B. J., Awe, O., Rao, R. C., Kirby, P. A., & Hitchon, P. W. (2014). Autograft-derived spinal cord mass following olfactory mucosal cell transplantation in a spinal cord injury patient. Journal of Neurosurgery: Spine, 21(4), 618–622. https://doi.org/10.3171/2014.5.SPINE13992

Fawcett, J. W., Curt, A., Steeves, J. D., Coleman, W. P., Tuszynski, M. H., Lammertse, D., … Short, D. (2007). Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: Spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials. Spinal Cord, 45(3), 190–205. https://doi.org/10.1038/sj.sc.3102007

Féron, F., Perry, C., Cochrane, J., Licina, P., Nowitzke, A., Urquhart, S., … Mackay-Sim, A. (2005). Autologous olfactory ensheathing cell transplantation in human spinal cord injury. Brain : A Journal of Neurology, 128(Pt 12), 2951–2960. https://doi.org/10.1093/brain/awh657

Foundation, C. S. C. (2016). About Spinal Cord Injury. 1–4.

Frolov, A. A., & Bryukhovetskiy, A. S. (2012). Effects of Hematopoietic Autologous Stem Cell Transplantation to the Chronically Injured Human Spinal Cord Evaluated by Motor and Somatosensory Evoked Potentials Methods. Cell Transplantation, 21, 49–55. https://doi.org/10.3727/096368912X633761

Insoo, H. (2010). The bioethics of stem cell research and therapy. Journal of Clinical Investigation. https://doi.org/10.1172/jci40435

International Society for Stem Cell Research. (2008). Patient Handbook on Stem Cell Therapies. 8.

International Society for Stem Cell Research. (2020). Nine Things To Know About Stem Cell Treatments – A Closer Look at Stem Cells. Retrieved April 9, 2020, from https://www.closerlookatstemcells.org/stem-cells-medicine/nine-things-to-know-about-stem-cell-treatments/

Jarocha, D., Milczarek, O., Kawecki, Z., Wendrychowicz, A., Kwiatkowski, S., & Majka, M. (2014). Preliminary study of autologous bone marrow nucleated cells transplantation in children with spinal cord injury. Stem Cells Translational Medicine, 3(3), 395–404. https://doi.org/10.5966/sctm.2013-0141

Jarocha, D., Milczarek, O., Wedrychowicz, A., Kwiatkowski, S., & Majka, M. (2015). Continuous improvement after multiple mesenchymal stem cell transplantations in a patient with complete spinal cord injury. Cell Transplantation, 24(4), 661–672. https://doi.org/10.3727/096368915X687796

Kang, K.-S., Kim, S. W., Oh, Y. H., Yu, J. W., Kim, K.-Y., Park, H. K., … Han, H. (2005). A 37-year-old spinal cord-injured female patient, transplanted of multipotent stem cells from human UC blood, with improved sensory perception and mobility, both functionally and morphologically: a case study. International Society for Cellular Therapy, 7(4), 368–373. https://doi.org/10.1080/14653240500238160

Lima, C., Escada, P., Pratas-Vital, J., Branco, C., Arcangeli, C. A., Lazzeri, G., … Peduzzi, J. D. (2010). Olfactory Mucosal Autografts and Rehabilitation for Chronic Traumatic Spinal Cord Injury. Neurorehabilitation and Neural Repair, 24(1), 10–22. https://doi.org/10.1177/1545968309347685

Lima, C., Pratas-Vital, J., Escada, P., Hasse-Ferreira, A., Capucho, C., & Peduzzi, J. D. (2006). Olfactory mucosa autografts in human spinal cord injury: A pilot clinical study. Journal of Spinal Cord Medicine, 29(3), 191–203. https://doi.org/10.1080/10790268.2006.11753874

Liu, J., Han, D., Wang, Z., Xue, M., Zhu, L., Yan, H., … Wang, & H. (2013). Clinical analysis of the treatment of spinal cord injury with umbilical cord mesenchymal stem cells. Cytotherapy, 15, 185–191. https://doi.org/10.1016/j.jcyt.2012.09.005

Mackay-Sim, A., Feron, F., Cochrane, J., Bassingthwaighte, L., Bayliss, C., Davies, W., … Geraghty, T. (2008). Autologous olfactory ensheathing cell transplantation in human paraplegia: a 3-year clinical trial. Brain, 131, 2376–2386.

Master, Z., & Caulfield, T. (2014). What you need to know about stem cell therapies. Retrieved from https://oirm.ca/sites/default/files/about-orim/sc_patient_booklet_feb_2014.pdf

Moviglia, G. A., Fernandez Viña, R., Brizuela, J. A., Saslavsky, J., Vrsalovic, F., Varela, G., … Shuster, G. S. (2006). Combined protocol of cell therapy for chronic spinal cord injury. Report on the electrical and functional recovery of two patients. Cytotherapy. https://doi.org/10.1080/14653240600736048

Oh, S. K., Choi, K. H., Yoo, J. Y., Kim, D. Y., Kim, S. J., & Jeon, S. R. (2016). A Phase III Clinical Trial Showing Limited Efficacy of Autologous Mesenchymal Stem Cell Therapy for Spinal Cord Injury. Neurosurgery, 78(3), 436–447. https://doi.org/10.1227/NEU.0000000000001056

Oraee-Yazdani, S., Hafizi, M., Atashi, A., Ashrafi, F., Seddighi, A.-S., Hashemi, S. M., … Zali, A. (2016). Co-transplantation of autologous bone marrow mesenchymal stem cells and Schwann cells through cerebral spinal fluid for the treatment of patients with chronic spinal cord injury: safety and possible outcome. https://doi.org/10.1038/sc.2015.142

Park, H. C., Shim, Y. S., Ha, Y., Yoon, S. H., Park, S. R., Choi, B. H., & Park, H. S. (2005). Treatment of complete spinal cord injury patients by autologous bone marrow cell transplantation and administration of granulocyte-macrophage colony stimulating factor. Tissue Engineering, 11(5–6), 913–922. https://doi.org/10.1089/ten.2005.11.913

Park, J. H., Kim, D. Y., Sung, I. Y., Choi, G. H., Jeon, M. H., Kim, K. K., & Jeon, S. R. (2012). Long-term results of spinal cord injury therapy using mesenchymal stem cells derived from bone marrow in humans. Neurosurgery, 70(5), 1238–1247. https://doi.org/10.1227/NEU.0b013e31824387f9

Rao, Y., Zhu, W., Liu, H., Jia, C., Zhao, Q., & Wang, Y. (2013). Clinical application of olfactory ensheathing cells in the treatment of spinal cord injury. Journal of International Medical Research. https://doi.org/10.1177/0300060513476426

Shin, J. C., Kim, K. N., Yoo, J., Kim, I. S., Yun, S., Lee, H., … Park, K. I. (2015). Clinical Trial of Human Fetal Brain-Derived Neural Stem/Progenitor Cell Transplantation in Patients with Traumatic Cervical Spinal Cord Injury. Neural Plasticity, 2015. https://doi.org/10.1155/2015/630932

Sipski, M. L., & Arenas, A. (2006). Female sexual function after spinal cord injury. Progress in Brain Research. https://doi.org/10.1016/S0079-6123(05)52030-2

Vaquero, J., Zurita, M., Rico, M. A., Bonilla, C., Aguayo, C., Fernández, C., … Fernández, M. V. (2017). Repeated subarachnoid administrations of autologous mesenchymal stromal cells supported in autologous plasma improve quality of life in patients suffering incomplete spinal cord injury. Cytotherapy, 19, 349–359. https://doi.org/10.1016/j.jcyt.2016.12.002

Vaquero, J., Zurita, M., Rico, M. A., Bonilla, C., Aguayo, C., Montilla, J., … Reina, L. De. (2016). An approach to personalized cell therapy in chronic complete paraplegia: The Puerta de Hierro phase I/II clinical trial. Cytotherapy, 18(8), 1025–1036. https://doi.org/10.1016/j.jcyt.2016.05.003

Yazdani, S. O., Hafizi, M., Zali, A. R., Atashi, A., Ashrafi, F., Seddighi, A. S., & Soleimani, M. (2013). Safety and possible outcome assessment of autologous Schwann cell and bone marrow mesenchymal stromal cell co-transplantation for treatment of patients with chronic spinal cord injury. Cytotherapy. https://doi.org/10.1016/j.jcyt.2013.03.012

 

Image credits

  1. Embryonic Stem Cell ©Gorkem Oner, CC BY 3.0 US
  2. Human Embryonic Stem Cells ©Russo E, CC BY 2.5
  3. Stem cell ©DailyPM, CC BY 3.0 US
  4. Rat ©Ayub Irawan, CC BY 3.0 US
  5. Waving ©Adrien Coquet, CC BY 3.0 US
  6. Spine ©Sahua D, CC BY 3.0 US
  7. Heart ©Alfa deisgn, CC BY 3.0 US
  8. Blind ©Adrien Coquet, CC BY 3.0 US
  9. Idea ©ibrandify, CC BY 3.0 US
  10. Bone ©Saeful Muslim, CC BY 3.0 US
  11. Liver ©Fauzan, CC BY 3.0 US
  12. Blood ©Evgeny Filatov, CC BY 3.0 US
  13. Eye ©Harpal Singh, CC BY 3.0 US
  14. White Cells ©Prosymbols, CC BY 3.0 US
  15. Brain ©Redouane Sayah, CC BY 3.0 US
  16. Person ©Andre Ru, CC BY 3.0 US
  17. Human ©Andrejs Kirma, CC BY 3.0 US
  18. Stem cells ©Bryan Jones, CC BY-NC-ND 2.0
  19. Neuron ©US National Cancer Institute’s Surveillance, Epidemiology, and End Results Program, CC BY-SA 3.0
  20. Research ©jarmoluk, CC0 1.0
  21. Neuropathy ©Servier Medical Art, CC BY 3.0
  22. Silhouette walking crutches man ©Mohamed Hassan, Pixabay
  23. Neuron brain nervous system neurons nerve cell CC0 1.0
  24. Sensory nervous system activation and response ©Openstax CC BY 4.0
  25. Bladder ©fauzan akbar, CC BY 3.0 US
  26. Large intestine ©BomSymbols, CC BY 3.0 US
  27. Transferring out of car. © The SCIRE Team
  28. Modified from Male ©Centis MENA, CC BY 3.0 US and Female © Centis MENA, CC BY 3.0 US
  29. Warning ©Oliver Silvérus, CC BY 3.0 US
  30. Money ©binpodo, CC BY 3.0 US
  31. Research ©Tezar Tantular, CC BY 3.0 US
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Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

The Microbiome in Spinal Cord Injury

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Authors: Sharon Jang, Vanessa Mok, Dominik Zbogar | Reviewer: Phillip Popovich | Published: 5 May 2020 | Updated: ~

The gut microbiome, also known as gut flora or gut microbiota, refers to the organisms that live in our digestive system. Research suggests that changes to the gut microbiome can affect the development of long-term complications and recovery following spinal cord injury (SCI).

Key Points

  • The microbiome is a community of organisms in the gut that contribute to the body’s day-to-day functions
  • Factors such as diet, medications, physical activity, sleep, smoking, and stress have been shown to affect the balance of the gut microbiome in the general population.
  • After SCI, the gut microbiome experiences unique challenges and changes. The implications of these changes are poorly understood.
  • Currently, very few studies exist regarding the gut microbiome in people with SCI.

Examples of bacteria that can be found in the digestive system.1-4

The microbiome refers to the trillions of viruses, fungi, and bacteria living all over the body. Although you may see the terms “microbiota” and “microbiome” sometimes used interchangeably, the microbiome technically refers to the genetic makeup (i.e. the DNA) of these organisms, while the microbiota refers to the organisms themselves. The core microbiota in humans is similar between people, however each of us has their own distinct variation of bacteria, viruses, and fungi that comprises their microbiota. These organisms exist in many areas of the body, including on the skin, in the nose, in the vagina, and in the bladder. However, microbiota have the highest density and variation in the large intestine.

Our past view of microbiota was focused on their potential to cause infection. However, more recent research has shown that microbiota play a substantial role in normal development and daily body functions. The greater the diversity or variation of the microbiota, the healthier and more resilient it is. The opposite has been associated with negative long-term effects on diseases later in life. Although research on the microbiome is still emerging, researchers have discovered that the microbiome is responsible for:

  • Preventing the growth of other harmful organisms
  • Stimulating the immune system to help fight off infections
  • Preventing the development of allergies
  • Food digestion and nutrient absorption
  • Sugar and fat metabolism
  • Brain development
  • Drug metabolism

In recent years, the microbiome has gained a lot of interest in research. This is partly due to new technology which allow scientists to observe the DNA of bacteria, resulting in a more specific analysis. Bacteria is primarily prevalent in the intestines, and amount to 10 times more than all the cells in the human body. This adds up to 1-3% of body mass, or 2-6 lbs of your weight. This article will focus on the gut microbiota, specifically the bacterial component of the microbiota, as most of the research on the microbiome thus far has focused on bacteria rather than fungi and viruses.

Development of the gut microbiome

While recent studies have shown that transmission of bacteria from the mother to the fetus is possible and occurs even before birth, it appears that much of the gut microbiome is established during delivery as the baby comes into contact with the microbes present in the mother’s birth canal and skin. Hence, a baby that is born through a C-section will have a different microbial composition. The gut microbiome continues to change due to organisms in the breastmilk; formula-fed infants will present with a different gut microbiome. The diversity of the microbiome increases until it resembles that of an adult around 3 years of age when a solid food diet is established.

Dysbiosis occurs when disease-causing organisms become more dominant than beneficial organisms.6

The microbiota is comprised of both good and bad bacteria, as well as bacteria that may be good or bad depending on the environment and circumstances. When your body is healthy, the good bacteria are able to keep pathogens in check, thus preventing illness. However, there are certain situations when disease-causing organisms become more prevalent than the beneficial bacteria.  Known as dysbiosis, this state in which the microbiota is not in balance may be caused by stress, antibiotic use, and dysfunction of the intestines. Traumatic SCI can cause neurological and psychological complications which requires care that may predispose these individuals to dysbiosis. These include:

  • Psychological stress after injury and during adaptation
  • Having a neurogenic bowel/bladder
  • A weakened immune system, which creates a greater need for antibiotics

Dysbiosis can also lead to short-term negative effects such as food intolerances, stomach upset, and an increased risk of developing infections. It is also linked to chronic conditions such as:

  • Allergies
  • Psychiatric conditions (e.g. depression, anxiety)
  • Autoimmune diseases (e.g. rheumatoid arthritis, Crohn’s disease, inflammatory bowel disease)
  • Metabolic disorders (e.g. obesity, diabetes)
  • Neurologic conditions (e.g. pain, Alzheimer’s, neurogenic bowel dysfunction)
  • Non-alcoholic fatty liver disease

Many of these conditions are already common in people living with SCI. Hence, a healthy microbiome may be important in maintaining the regular functions of the microbiome and preventing the consequences of dysbiosis following SCI.

Movement of the gut slows as a consequence of neurogenic bowel, which is a common in SCI, especially with higher levels of injury.7

After SCI, one of the main group of nerves that innervates the gut, the sympathetic nervous system, becomes impaired. This can impact the gut microbiota in 3 ways: through slowing gut movement, through modifying the ability for microbiota to thrive, and through modifying the immune system in the gut. The slower movement of the gut contents, one of the results of impaired bowel function (known as neurogenic bowel dysfunction) after SCI, can impact the microbiota at the far end of the intestines by delaying the delivery of important nutrients. This is of concern because bacteria in the gut thrive by fermenting or breaking down foods such as starches and fiber, and produce metabolites such as butyrate. One study with weak evidence found that people with chronic (at least 12 months post-injury) complete SCI had significant decreases in butyrate-producing bacteria compared to the non-SCI population. As butyrate has anti-inflammatory effects on the nervous system, researchers believe that low butyrate levels can negatively affect long-term recovery following SCI due to increased inflammation.

Refer to our chapter on Bowel Changes After Spinal Cord Injury for more information about how the bowel changes after SCI.

Millions of bacteria grow on the mucus in the gut, forming a biofilm.8

Secondly, the sympathetic nervous system is responsible for stimulating mucus secretion within the gut. With a lack of input from the sympathetic nervous system, the production of mucus is decreased. This has important implications for the microbiota in the intestines, as mucus acts as a surface that allows for bacteria to bind to it, thus creating a biofilm. A biofilm is a group of bacteria that has formed a structured community on a surface. With a reduced amount of area for bacteria to thrive, the types of bacteria living in the gut may be altered.

For a review of what we mean by “strong”, “moderate”, and “weak” evidence, refer to the SCIRE Community Evidence Ratings.

Thirdly, the gut has a protective barrier to prevent bad bacteria from entering the body through the intestinal walls. This immune system within the gut is known as the gastrointestinal-associated lymphoid tissue (GALT) and is controlled by the sympathetic nervous system. With a lack of signaling from the sympathetic nervous system, functioning of the GALT may become compromised. In addition, chronic stress or trauma (which can be brought on by SCI) may change the permeability of the wall of the intestine, allowing harmful bacteria into the body. This may be a potential source of inflammation following SCI and may partly explain why people with SCI are more prone to long-term complications. While research with SCI rat models shows this compromise of the protective barrier and movement of bacteria into places it does not usually reside, (like the blood), it is not yet known if the same is true for humans.

Individuals with SCI are found to have different bacteria comprising their microbiota, compared to able-bodied individuals. For example, one study (weak evidence) found that the diversity of gut bacteria and number of overall bacteria of individuals with chronic tetraplegia were less than in able-bodied individuals. Conversely, another study found individuals with SCI to harbour greater bacterial diversity in their gut relative to people without SCI. However, the greater variation of bacteria in people with SCI consist of bacteria less commonly found in able-bodied individuals. The implications of these differences are unknown and have yet to be researched.

Comparing gut bacteria between different populations

Differences in bacterial composition have been noted in people with other health conditions (such as schizophrenia and diabetes), but whether these differences contributed to the progression of the disease or arose due to the condition is unclear. Also, differences between countries exist and may be attributed to differences in environmental conditions (e.g. diet, lifestyle). However, impacts of these alterations are largely unknown.

Previously, it was thought that urine was clean and sterile – that urine should be free from bacteria and white blood cells, which are both signs of infection. In recent years, researchers have discovered that healthy urine is not always sterile. In a conditioned called asymptomatic bacteriuria, non-harmful bacteria are found in the urine, but the individual does not experience any symptoms of a urinary tract infection (UTI) or other illness. Although certain strains of bacteria in urine may be healthy, after SCI, the proportion and composition of bacteria found in urine changes. One (weak evidence) study suggests that individuals with SCI and neurogenic bladders have microbiomes with more unhealthy bacteria, which may be a precursor for UTIs.

With the knowledge that pre-existing bacteria live in the bladder, some researchers have questioned whether it would be possible to modify the microbiota to prevent UTIs. Bacterial interference is a process whereby non-harmful bacteria are injected into the bladder. Ideally, the benign bacteria prevent the growth of harmful bacteria by creating competition for nutrients and space to colonize. Multiple studies (weak evidence) indicate bacterial interference may decrease the occurrence of UTIs in individuals with SCI, and may delay the recurrence of UTIs. However, there are barriers to using bacterial interference, including:

  • The process of injecting bacteria into the bladder, which is a cumbersome process that requires multiple administrations over consecutive days.
  • The maintenance of the injected bacteria, which may not successfully colonize the bladder.

Given these limitations to bacterial interference in the bladder, other researchers have attempted to change the microbiome through indwelling catheters. Individuals who use indwelling catheters are at risk for UTIs, as bacteria can grow in the catheter and make its way back up into the bladder. To counter this, some researchers have observed the impact of coating indwelling catheters with non-harmful bacteria in attempts to reduce rates of UTI. Using the concept of bacterial interference again, the purpose of coating an indwelling catheter is to prevent harmful bacteria from growing inside it, thus preserving the bladder microbiota. These studies (weak evidence) found this method decreased the average number of UTIs experienced per year, and that using bacterial interference in catheters is a successful strategy for preventing the growth of harmful bacteria.

Refer to our chapter on Urinary Tract Infections for more information on reducing UTI risk for individuals with SCI.

Changes to the vaginal microbiome after SCI

The vaginal microbiota is primarily dominated by Lactobacilli bacteria, which act as a first line of defence against harmful bacteria. This is done by Lactobacilli creating an acidic environment, competing for nutrients and growth sites, and stimulating the immune system. As a result, the vagina is protected from the growth of harmful bacteria, including those causing sexually transmitted infections (STIs). In one study (weak evidence), researchers found that women with SCI have less Lactobacilli bacteria and more bacteria associated with UTIs and yeast infections.

Overall, there is limited evidence demonstrating microbiome differences in the urinary and reproductive systems of people with SCI. More research is needed to determine the implications of these variations and whether intervention is beneficial or necessary.

Lifestyle factors can have a large impact on the bacterial composition in the gut. This in turn can cause biological changes that may predispose an individual to long-term diseases.11

The numerous factors known to affect the balance of the gut microbiome, and their relationship to SCI are discussed below.

Diet

Diet has a large impact on the composition of the bacteria in the gut. In particular, processed foods in the Western diet may contribute to decreases in microbiome function and diversity. Conversely, a diet that is comprised of a variety of whole foods and probiotics can promote a diverse community of bacteria. Many studies with weak to moderate evidence have demonstrated an association between the bacterial community in the gut and the development of diseases such as diabetes and obesity. However, there is still much to learn about the functions of the gut microbiome before we can find an optimal approach to diet that will control microbiome-induced chronic diseases.

Alcohol

Drinking alcohol can affect the integrity of the gut microbiome, but these effects may be dependent on the type of alcohol consumed. One study in able-bodied males found that those who consumed gin had decreased numbers of beneficial gut bacteria. On the other hand, those who consumed red wine had decreased numbers of harmful bacteria and increased numbers of beneficial bacteria. The researchers believed that moderate consumption of red wine provided a source of polyphenols which may explain differences seen between the two groups. Polyphenols are compounds found in plants that may have prebiotic-like effects. While the effects of alcohol on the microbiome in SCI are unknown, alcohol should be limited to avoid the known health risks on other body systems.

Medications

Antibiotics are a well-known class of drugs that can disrupt the growth of both harmful and beneficial organisms in the gut. This can effectively decrease the number and diversity of the bacteria. Susceptibility to urinary tract and lung infections and pressure ulcers is increased following SCI. Because antibiotics are frequently used to treat these conditions, people with SCI may experience further disruptions to an already disrupted microbiome. Some may also report fatigue, emotional, or neurological issues with antibiotic use, suggesting that what is happening in the gut can have an effect in other parts of the body.

Physical Activity

There is large variability in the amount of exercise performed by people with SCI, but most do not engage in any. Various studies on able-bodied individuals report a greater amount of certain healthy gut bacteria in physically active people compared to less active people. Thus, in SCI there may be a missed opportunity for physically inactive people to benefit from these healthy bacteria in their gut, some of which have anti-inflammatory effects and can protect from obesity.

Refer to our chapter on Exercise Guidelines to learn more about physical activity following SCI.

Sleep

Sleep problems occur more commonly in individuals with SCI compared with the general population. This is important because sleep deprivation can cause disruptions in cognition, immune function, and many other body functions. A recent study looked at how the lack of sleep impacted bacteria in the gut among the general population. It found that just two consecutive days of sleep deprivation lead to increased amounts of bacteria that are implicated in conditions such as weight gain and diabetes. These conditions are already prevalent in people living with SCI.

Smoking

Smoking can lead to unwanted effects on the gut microbiome.14

There is evidence that smoking can cause negative changes in the diversity of the gut microbiome. Notably, the bacterial composition changes caused by smoking appear to be similar to the changes brought about by conditions like inflammatory bowel disease and obesity. Not only does smoking upset the balance of the microbiome, but it can lead to many short-term and long-term consequences like pneumonia which is especially harmful in people with SCI who have pre-existing breathing problems.

Stress

Recent evidence suggests a link between stress and negative changes in the gut microbiome. Stress may play a role in gut bacteria disruptions following spinal cord injury as people with SCI experience both massive physical stress from the injury itself and significant psychological stress due to dramatic life changes.

There is limited data on interventions that affect the gut microbiome in the SCI population. Proposed interventions include the use of probiotics, prebiotics, and fecal transplantation.

Probiotics

Probiotics are live organisms that can be consumed to replenish the microbiome. Probiotics are available as supplements and are often present in cultured/fermented food products like yogurt, kefir, sauerkraut, kimchi, and miso. However, some of these food sources contain high levels of salt, saturated fat, or other ingredients associated with health risks, so ensuring moderation and variety of these types of food is important. Often times, many of these products to not contain large enough concentrations of probiotic bacteria to have a meaningful benefit. Also, production of supplements is not government regulated so there is no way to know if the amount and type of bacteria listed on a supplement label is actually found in that product.

Individuals with SCI frequently receive antibiotics given their increased risk of bacterial infections and this puts people with SCI at risk for antibiotic-associated diarrhea. One study with moderate evidence showed that probiotic drinks may prevent dysbiosis in people with SCI who are at risk of antibiotic-associated diarrhea. Another study with moderate evidence supported the use of probiotics after SCI as treatment for antibiotic-associated diarrhea by shortening the course of diarrhea by about 2 days. More research is needed to confirm these results and determine the safety and effectiveness of probiotics in people with SCI.

Antibiotic-associated diarrhea vs. C. difficile-associated diarrhea

The bacterium Clostridium difficile is responsible for C. difficile-associated diarrhea.16

Antibiotic-associated diarrhea is defined as the passing of three or more loose, watery stools per day due to taking oral antibiotics. This form of diarrhea generally requires little to no treatment and stops after discontinuation of the antibiotics.

Antibiotics can cause dysbiosis in the gut, leading to increased vulnerability to Clostridium difficile bacteria (also known as C. difficile or C. diff). This pathogenic bacterium releases a toxin that can cause diarrhea as well as other signs of infection such as fever and inflammation. This form of diarrhea, known as C. difficile-associated diarrhea requires treatment to get rid of the bacteria

Prebiotics

Prebiotics are dietary substances that are fermented or broken down by bacteria. In this way, prebiotics support the growth of beneficial gut bacteria by acting as a nutrient source. Foods high in fermentable fibres contain prebiotics. Examples of prebiotic-containing sources include whole grain products like barley as well as fruits and vegetables like bananas, onions, and asparagus.

Refer to our chapter on Dietary Fibre for more information about fibre intake and considerations for individuals with SCI.

The prebiotic lactulose is widely known as a treatment for constipation and hepatic encephalopathy (decreased brain function due to liver failure). Research suggests that prebiotics may also be a potential treatment for irritable bowel disease, but less is known about the use of prebiotics in other conditions. Although consuming 5-20 g/day of prebiotics was shown to significantly increase gut bacteria, there is insufficient data on the use of prebiotics in SCI to draw any conclusions at this time

Fecal transplantation

In one case study (weak evidence), a male with tetraplegia experiencing recurrent C. difficile infection was successfully treated with antibiotics following fecal transplantation (also known as fecal microbiota transplant or FMT). The researchers reported that transplants given through the oral route may be more feasible to avoid adverse effects related to transplants given through colonoscopies.

In another case study (weak evidence) of a male with tetraplegia, fecal transplantation resulted in resolution of C. difficile infection. Other noted benefits following his fecal transplant included a reduction in antibiotic-resistant organisms, episodes of sepsis (blood poisoning), infections, and antibiotic use.

What are fecal transplants

Stool can be freeze-dried and placed into capsules in preparation for fecal transplantation.17

Fecal transplantation involves the replacement of gut bacteria by transferring stool from a healthy donor into the digestive tract of the recipient. Delivery methods include enemas, oral capsules of frozen stool, colonoscopies, rectal tubes, or feeding tubes. Fecal transplants are currently used as a treatment option after multiple failed courses of antibiotics in people with recurrent infections due to C. difficile bacteria. It is believed that introducing stool containing organisms into a recipient’s gut enhances microbiome diversity and increases resistance to pathogenic organisms. However, fecal transplants are not without risk. Side effects that have been reported in studies include constipation, diarrhea, stomach upset, and fever. Other negative effects may result from the endoscopy procedure (e.g. bleeding) or the transmission of pathogenic organisms (ex. infection).

Fecal transplantation has been gaining attention as a potential management option for other conditions like inflammatory bowel disease, inflammatory bowel syndrome, hepatic encephalopathy, autism, metabolic syndrome, and obesity. Long-term safety data is not well-defined, but with the surge of ongoing studies, this gap may be filled in the near future.

Differences in bacterial composition have been identified in people with SCI and people without. As dysbiosis has been linked to various chronic diseases, maintaining a healthy gut microbiome may be a target to prevent or reduce the development of many long-term complications that develop after SCI.

There are currently limited studies on interventions affecting the gut microbiome in people with SCI. Diet has been demonstrated to have a significant role in shaping the microbiome and can be optimized by eating a healthy, plant-based diet. Probiotics may also be consumed to counteract some negative effects of antibiotics. Research in the able-bodied population also suggests that engaging in regular physical activity, achieving adequate sleep, avoiding smoking, and reducing stress may be key in supporting good bacteria and reducing bad gut bacteria.

We have only just begun to scratch the surface of how important the role of the microbiome is in various functions, and its relationship with genetics and the physical environment. Until more research evidence is available, the best course of action is to consult your health provider to find out how lifestyle factors can be modified to enhance the health of your microbiome.

For a review of what we mean by ‘strong’, ‘moderate’, and ‘weak’ evidence, please refer to the SCIRE Community Evidence Ratings.

Evidence for “What is the gut microbiome” is based on:

 

Valdes, A. M., Walter, J., Segal, E., & Spector, T. D. (2018). Role of the gut microbiota in nutrition and health. BMJ (Online), 361, 36–44. https://doi.org/10.1136/bmj.k2179

Rescigno, M. (2014). Intestinal microbiota and its effects on the immune system. Cellular Microbiology, 16(7), 1004–1013. https://doi.org/10.1111/cmi.12301

Darouiche, R. O., & Hull, R. A. (2012). Bacterial interference for prevention of urinary tract infection. Clinical Infectious Diseases, 55(10), 1400–1407. https://doi.org/10.1093/cid/cis639

Rescigno, M. (2014). Intestinal microbiota and its effects on the immune system. Cellular Microbiology, 16(7), 1004–1013. https://doi.org/10.1111/cmi.12301

Ma, B.; Forney, L.; Ravel, J. (2013). The vaginal microbiome: rethinking health and diseases, 371–389.

Bull, M. J., & Plummer, N. T. (2014). Part 1: The Human Gut Microbiome in Health and Disease. Integrative medicine (Encinitas, Calif.), 13(6), 17–22

Bäckhed, F., Ding, H., Wang, T., Hooper, L. V, Koh, G. Y., Nagy, A., … Gordon, J. I. (2004). The gut microbiota as an environmental factor that regulates fat storage. Proceedings of the National Academy of Sciences of the United States of America, 101(44), 15718–15723. https://doi.org/10.1073/pnas.0407076101

Kigerl, K. A., Hall, J. C. E., Wang, L., Mo, X., Yu, Z., & Popovich, P. G. (2016). Gut dysbiosis impairs recovery after spinal cord injury. The Journal of Experimental Medicine, 213(12), 2603–2620. https://doi.org/10.1084/jem.20151345

Collins, S. M., Surette, M., & Bercik, P. (2012). The interplay between the intestinal microbiota and the brain. Nature Reviews Microbiology, 10(11), 735–742. https://doi.org/10.1038/nrmicro2876

Jandhyala, S., Talukdar, R., Subramanyam, C., Vuyyuru, H., Sasikala, M., & Reddy, D. (2015). Role of the normal gut microbiota. World Journal of Gastroenterology, 21(29), 8836–8847. https://doi: 10.3748/wjg.v21.i29.8787

Linsenmeyer, T. (2018). Catheter-associated urinary tract infections in persons with neurogenic bladders. Journal of Spinal Cord Medicine, 41(2), 132-141. https://doi.org/10.1080/10790268.2017.1415419

Tanaka, M., & Nakayama, J. (2017). Development of the gut microbiota in infancy and its impact on health in later life. Allergology International, 66(4), 515–522. https://doi.org/10.1016/j.alit.2017.07.010

Voreades, N., Kozil, A., & Weir, T. L. (2014). Diet and the development of the human intestinal microbiome. Frontiers in Microbiology, 5, 494. https://doi.org/10.3389/fmicb.2014.00494

Evidence for “What happens when the gut microbiome is out of balance?” is based on:

Kigerl, K.A., & Popovich, P.G. (2019). Gut Dysbiosis and Recovery of Function After Spinal Cord Injury. Oxford Research Encyclopedia of Neuroscience. https://doi.org/10.1093/acrefore/9780190264086.013.242

Cao, S., Feehley, T. J., & Nagler, C. R. (2014). The role of commensal bacteria in the regulation of sensitization to food allergens. FEBS Letters, 588(22), 4258–4266. https://doi.org/10.1016/j.febslet.2014.04.026

Foster, J. A., & McVey Neufeld, K.-A. (2013). Gut–brain axis: how the microbiome influences anxiety and depression. Trends in Neurosciences, 36(5), 305–312. https://doi.org/10.1016/j.tins.2013.01.005

Maeda, Y., & Takeda, K. (2017). Role of Gut Microbiota in Rheumatoid Arthritis. Journal of Clinical Medicine, 6(6). https://doi.org/10.3390/jcm6060060

Hold, G. L., Smith, M., Grange, C., Watt, E. R., El-Omar, E. M., & Mukhopadhya, I. (2014). Role of the gut microbiota in inflammatory bowel disease pathogenesis: what have we learnt in the past 10 years? World Journal of Gastroenterology, 20(5), 1192–1210. https://doi.org/10.3748/wjg.v20.i5.1192

Castaner, O., Goday, A., Park, Y.-M., Lee, S.-H., Magkos, F., Shiow, S.-A. T. E., & Schröder, H. (2018). The Gut Microbiome Profile in Obesity: A Systematic Review. International Journal of Endocrinology, 2018, 1–9. https://doi.org/10.1155/2018/4095789

Aw, W., & Fukuda, S. (2018). Understanding the role of the gut ecosystem in diabetes mellitus. Journal of Diabetes Investigation, 9(1), 5–12. https://doi.org/10.1111/jdi.12673

Tilg, H., Kaser, A. (2011). Gut microbiome, obesity, and metabolic dysfunction. Journal of Clinical Investigation, 121(6), 2126-32. https://doi.org/10.1172/JCI58109

Murri, M., Leiva, I., Gomez-Zumaquero, J. M., Tinahones, F. J., Cardona, F., Soriguer, F., & Queipo-Ortuño, M. I. (2013). Gut microbiota in children with type 1 diabetes differs from that in healthy children: a case-control study. BMC Medicine, 11(1), 46. https://doi.org/10.1186/1741-7015-11-46

Rousseaux, C., Thuru, X., Gelot, A., Barnich, N., Neut, C., Dubuquoy, L., … Desreumaux, P. (2007). Lactobacillus acidophilus modulates intestinal pain and induces opioid and cannabinoid receptors. Nature Medicine, 13(1), 35–37. https://doi.org/10.1038/nm1521

Jiang, C., Li, G., Huang, P., Liu, Z., & Zhao, B. (2017). The Gut Microbiota and Alzheimer’s Disease. Journal of Alzheimer’s Disease, 58(1), 1–15. https://doi.org/10.3233/JAD-161141

Zhang, C., Zhang, W., Zhang, J., Jing, Y., Yang, M., Du, L., … Li, J. J. J. (2018). Gut microbiota dysbiosis in male patients with chronic traumatic complete spinal cord injury. Journal of Translational Medicine, 16(1), 353. https://doi.org/10.1186/s12967-018-1735-9

Waldman, A. J., & Balskus, E. P. (2018). The Human Microbiota, Infectious Disease, and Global Health: Challenges and Opportunities. ACS Infectious Diseases, 4(1), 14–26. https://doi.org/10.1021/acsinfecdis.7b00232

Myers, J., Lee, M., & Kiratli, J. (2007). Cardiovascular Disease in Spinal Cord Injury. American Journal of Physical Medicine & Rehabilitation, 86(2), 142–152. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17251696

Sauerbeck, A.D., Laws, J.L., Bandaru, V.V., Popovich, P.G., Haughey, N.J., & McTigue, D.M. (2015). Spinal cord injury causes chronic liver pathology in rats. Journal of Neurotrauma, 32(3), 159–169. https://doi.org/10.1089/neu.2014.3497

Boekamp, J. R., Overholser, J. C., & Schubert, D. S. P. (1996). Depression following a Spinal Cord Injury. The International Journal of Psychiatry in Medicine, 26(3), 329–349. https://doi.org/10.2190/CMU6-24AH-E4JG-8KBN

Elliott, T. R., & Frank, R. G. (1996). Depression following spinal cord injury. Archives of Physical Medicine and Rehabilitation, 77(8), 816–823. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8702378

Mehta, S., Robert, M. A., Loh, E., Short, C., Frcpc, M. D., Wolfe, D. L., … Msc, H. (2013). Pain Following Spinal Cord Injury. Retrieved from www.scireproject.com

Evidence for “What changes occur in the gut microbiome after SCI?” is based on:

Kigerl, K.A., Zane, K., Adams, K., Sullivan, M.B., & Popovich, P.G. (2020). The spinal cord-gut-immune axis as a master regulator of health and neurological function after spinal cord injury.  Experimental Neurology, 323, 113085. https://doi.org/10.1016/j.expneurol.2019.113085

Gungor, B., Adiguzel, E., Gursel, I., Yilmaz, B., & Gursel, M. (2016). Intestinal Microbiota in Patients with Spinal Cord Injury. PLOS ONE, 11(1), e0145878. https://doi.org/10.1371/journal.pone.0145878

Choong, S., & Whitfield, H. (2000). Biofilms and their role in infections in urology. BJU International, 86, 935–941

Noller, C.M., Groah, S.L., Nash, M.S. (2017). Inflammatory Stress Effects on Health and Function After Spinal Cord Injury. Topics in Spinal Cord Injury Rehabilitation, 23(3), 207–217. https://doi.org/10.1310/sci2303-207

Liu, J., An, H., Jiang, D., Huang, W., Zou, H., Meng, C., Li, H. (2004). Study of bacterial translocation from gut after paraplegia caused by spinal cord injury in rats. Spine, 29(2):164–169. https://doi.org/10.1097/01.BRS.0000107234.74249.CD

Kigerl, K. A., Hall, J. C. E., Wang, L., Mo, X., Yu, Z., & Popovich, P. G. (2016). Gut dysbiosis impairs recovery after spinal cord injury. The Journal of Experimental Medicine, 213(12), 2603–2620. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2781092

Zhang, C., Zhang, W., Zhang, J., Jing, Y., Yang, M., Du, L., … Li, J. (2018). Gut microbiota dysbiosis in male patients with chronic traumatic complete spinal cord injury. Journal of Translational Medicine, 16(1), 353. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/30545398

Jeffrey, E. (2018). Investigation of Spinal Cord Injury-Induced Gastrointestinal Dysfunction and Related Microbiota, Fungal, and Intestinal Alterations in a Rat Model and Humans with Spinal Cord Injury. University of Miami. Retrieved from https://scholarlyrepository.miami.edu/cgi/viewcontent.cgi?article=1738&context=oa_theses

Evidence for “Comparing gut bacteria between different populations” is based on:

Nguyen, T.T., Kosciolek, T., Maldonado, Y., Daly, R.E., Martin, A.S., McDonald, D., … Jeste, D.V. (2019) Differences in gut microbiome composition between persons with chronic schizophrenia and healthy comparison subjects. Schizophrenia Research, 204, 23–29. https://doi.org/10.1016/j.schres.2018.09.014

Sedighi, M., Razavi. S., Navab-Moghadam, F., Khamseh, M.E., Alaei-Shahmiri, F., Mehrtash, A., Amirmozafari, N. (2017). Comparison of gut microbiota in adult patients with type 2 diabetes and healthy individuals.  Microbial Pathogenesis, 111, 362–369. https://doi.org/10.1016/j.micpath.2017.08.038

Schnorr, S. L., Candela, M., Rampelli, S., Centanni, M., Consolandi, C., Basaglia, G., … Crittenden, A. N. (2014). Gut microbiome of the Hadza hunter-gatherers. Nature Communications, 5, 3654. https://doi.org/10.1038/ncomms4654

Martínez, I., Stegen, J. C., Maldonado-Gómez, M. X., Eren, A. M., Siba, P. M., Greenhill, A. R., & Walter, J. (2015). The gut microbiota of rural papua new guineans: composition, diversity patterns, and ecological processes. Cell Reports, 11(4), 527–538. https://doi.org/10.1016/j.celrep.2015.03.049

De Filippo, C., Cavalieri, D., Di Paola, M., Ramazzotti, M., Poullet, J.B., Massart, S., Collini, S., Pieraccini, G., Lionetti, P.. (2010). Impact of diet in shaping gut microbiota revealed by a comparative study in children from Europe and rural Africa. Proceedings of the National Academy of Sciences of the United States of America, 107, 33, 14691–14696. https://doi.org/10.1073/pnas.1005963107

Evidence for “What changes occur to the bladder microbiome after SCI?” is based on:

Groah, S. L., Pérez-Losada, M., Caldovic, L., Ljungberg, I. H., Sprague, B. M., Castro-Nallar, E., … Pohl, H. G. (2016). Redefining Healthy Urine: A Cross-Sectional Exploratory Metagenomic Study of People With and Without Bladder Dysfunction. Journal of Urology, 196(2), 579–587. https://doi.org/10.1016/j.juro.2016.01.088

Fouts, D. E., Pieper, R., Szpakowski, S., Pohl, H., Knoblach, S., Suh, M.-J., … Groah, S. L. (2012). Integrated next-generation sequencing of 16S rDNA and metaproteomics differentiate the healthy urine microbiome from asymptomatic bacteriuria in neuropathic bladder associated with spinal cord injury. Journal of Translational Medicine, 10, 174. https://doi.org/10.1186/1479-5876-10-174

Darouiche, R. O., & Hull, R. A. (2012). Bacterial interference for prevention of urinary tract infection. Clinical Infectious Diseases, 55(10), 1400–1407. https://doi.org/10.1093/cid/cis639

Bossa, L., Kline, K., McDougald, D., Lee, B. B., & Rice, S. A. (2017). Urinary catheter-associated microbiota change in accordance with treatment and infection status. PloS One, 12(6), e0177633. https://doi.org/10.1371/journal.pone.0177633

Darouiche, R. O., Green, B. G., Donovan, W. H., Chen, D., Schwartz, M., Merritt, J., … Hull, R. A. (2011). Infectious Diseases Multicenter Randomized Controlled Trial of Bacterial Interference for Prevention of Urinary Tract Infection in Patients With Neurogenic Bladder. Infectious Diseases, 78(2), 341–610. https://doi.org/1016/j.urology.2011.03.062

Hull, R., Rudy, D., Donovan, W., Svanborg, C., Wieser, I., Stewart, C., & Darouiche, R. (2000). Urinary tract infection prophylaxis using Escherichia coli 83972 in spinal cord injured patients. Journal of Urology, 163(3), 872–877.

Prasad, A., Riosa, S., Darouiche, R. O., & Trautner, B. W. (2009). A bacterial interference strategy for prevention of UTI in persons practicing intermittent catheterization. Spinal Cord, 47, 565–569. https://doi.org/10.1038/sc.2008.166

Sundén, F., Håkansson, L., Ljunggren, E., & Wullt, B. (2010). Escherichia coli 83972 Bacteriuria Protects Against Recurrent Lower Urinary Tract Infections in Patients With Incomplete Bladder Emptying. Journal of Urology, 184(1), 179–185. https://doi.org/10.1016/j.juro.2010.03.024

Trautner, B.W., Hull, R.A., & Darouiche, R.O. (2003). Escherichia coli 83972 inhibits catheter adherence by a broad spectrum of uropathogens. Urology, 61(5),1059–1062. https://doi.org/0.1016/s0090-4295(02)02555-4

Ceccarani, C., Foschi, C., Parolin, C., D’Antuono,A., Gaspari, V., Consolandi, C., …  Marangoni, A. (2019). Diversity of vaginal microbiome and metabolome during genital infections. Scientific Reports, 9, 14095. https://doi.org/10.1038/s41598-019-50410-x

Evidence for “Changes to the vaginal microbiome after SCI” is based on:

Pires, C.V., Linhares, I.M., Serzedello, F., Fukazawa, E.I., Baracat, E.C., & Witkin, S.S. (2016). Alterations in the Genital Microbiota in Women With Spinal Cord Injury. Obstetrics & Gynecology127(2), 273-278. https://doi.org/10.1097/AOG.0000000000001257

Evidence for “What affects the gut microbiome?” is based on:

Coyle, D. (2017). 8 Surprising Things That Harm Your Gut Bacteria. Retrieved February 12, 2019, from https://www.healthline.com/nutrition/8-things-that-harm-gut-bacteria

Makki, K., Deehan, E. C., Walter, J., & Bäckhed, F. (2018, June 13). The Impact of Dietary Fiber on Gut Microbiota in Host Health and Disease. Cell Host and Microbe. Cell Press.

Claesson, M. J., Jeffery, I. B., Conde, S., Power, S. E., O’Connor, E. M., Cusack, S., … O’Toole, P. W. (2012). Gut microbiota composition correlates with diet and health in the elderly. Nature, 488(7410), 178–184. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22797518

Lozupone, C. A., Stombaugh, J. I., Gordon, J. I., Jansson, J. K., & Knight, R. (2012). Diversity, stability and resilience of the human gut microbiota. Nature, 489(7415), 220–230. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22972295

Singer-Englar, T., Barlow, G., & Mathur, R. (2019, January 2). Obesity, diabetes, and the gut microbiome: an updated review. Expert Review of Gastroenterology and Hepatology. Taylor and Francis Ltd.

Górowska-Kowolik, K., & Chobot, A. (2019). The role of gut micorbiome in obesity and diabetes. World Journal of Pediatrics, 15(4), 332–340.

David, L. A., Maurice, C. F., Carmody, R. N., Gootenberg, D. B., Button, J. E., Wolfe, B. E., … Turnbaugh, P. J. (2014). Diet rapidly and reproducibly alters the human gut microbiome. Nature, 505(7484), 559–563. Retrieved from http://www.nature.com/articles/nature12820

Queipo-Ortuño, M. I., Boto-Ordóñez, M., Murri, M., Gomez-Zumaquero, J. M., Clemente-Postigo, M., Estruch, R., … Tinahones, F. J. (2012). Influence of red wine polyphenols and ethanol on the gut microbiota ecology and biochemical biomarkers. The American Journal of Clinical Nutrition, 95(6), 1323–1334. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22552027

Evans, C. T., LaVela, S. L., Weaver, F. M., Priebe, M., Sandford, P., Niemiec, P., … Parada, J. P. (2008). Epidemiology of Hospital-Acquired Infections in Veterans With Spinal Cord Injury and Disorder. Infection Control & Hospital Epidemiology, 29(03), 234–242. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18248306

Wolfe, D., McIntyre, A., Ravenek, K., Martin-Ginis, K., Cheung, A. L., Eng, J. J., … Hsieh, J. T. (2014). Physical Activity Participation Levels in SCI. Retrieved February 11, 2019, from https://scireproject.com/evidence/rehabilitation-evidence/physical-activity/increasing-physical-activity-participation-in-sci/physical-sci/

Zbogar, D., Eng, J. J., Miller, W. C., Krassioukov, A. V, & Verrier, M. C. (2016). Physical activity outside of structured therapy during inpatient spinal cord injury rehabilitation. Journal of Neuroengineering and Rehabilitation, 13(1), 99. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27846851

Monda, V., Villano, I., Messina, A., Valenzano, A., Esposito, T., Moscatelli, F., … Messina, G. (2017). Exercise Modifies the Gut Microbiota with Positive Health Effects. Oxidative Medicine and Cellular Longevity, 2017, 1–8. Retrieved from https://www.hindawi.com/journals/omcl/2017/3831972/

Clarke, S. F., Murphy, E. F., O’Sullivan, O., Lucey, A. J., Humphreys, M., Hogan, A., … Cotter, P. D. (2014). Exercise and associated dietary extremes impact on gut microbial diversity. Gut, 63(12), 1913–1920. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25021423

Bressa, C., Bailén-Andrino, M., Pérez-Santiago, J., González-Soltero, R., Pérez, M., Montalvo-Lominchar, M. G., … Larrosa, M. (2017). Differences in gut microbiota profile between women with active lifestyle and sedentary women. PLOS ONE, 12(2), e0171352. Retrieved from https://dx.plos.org/10.1371/journal.pone.0171352

Estaki, M., Pither, J., Baumeister, P., Little, J. P., Gill, S. K., Ghosh, S., … Gibson, D. L. (2016). Cardiorespiratory fitness as a predictor of intestinal microbial diversity and distinct metagenomic functions. Microbiome, 4(1), 42. Retrieved from http://microbiomejournal.biomedcentral.com/articles/10.1186/s40168-016-0189-7

Biering-Sørensen, F., Jennum, P., & Laub, M. (2009). Sleep disordered breathing following spinal cord injury. Respiratory Physiology and Neurobiology, 169(2), 165–170.

Benedict, C., Vogel, H., Jonas, W., Woting, A., Blaut, M., Schürmann, A., & Cedernaes, J. (2016). Gut microbiota and glucometabolic alterations in response to recurrent partial sleep deprivation in normal-weight young individuals. Molecular Metabolism, 5(12), 1175–1186. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27900260

Savin, Z., Kivity, S., Yonath, H., & Yehuda, S. (2018). Smoking and the intestinal microbiome. Archives of Microbiology, 200(5), 677–684. Retrieved from http://link.springer.com/10.1007/s00203-018-1506-2

Stolzmann, K. L., Gagnon, D. R., Brown, R., Tun, C. G., & Garshick, E. (2010). Risk factors for chest illness in chronic spinal cord injury: a prospective study. American Journal of Physical Medicine & Rehabilitation, 89(7), 576–583. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20463565

Clark, A., & Mach, N. (2016). Exercise-induced stress behavior, gut-microbiota-brain axis and diet: a systematic review for athletes. Journal of the International Society of Sports Nutrition, 13(1), 43. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27924137

Tillisch, K., Mayer, E. A., Gupta, A., Gill, Z., Brazeilles, R., Le Nevé, B., … Labus, J. S. (2017). Brain Structure and Response to Emotional Stimuli as Related to Gut Microbial Profiles in Healthy Women. Psychosomatic Medicine, 79(8), 905–913. Retrieved from http://insights.ovid.com/crossref?an=00006842-201710000-00010

Knowles, S. R., Nelson, E. A., & Palombo, E. A. (2008). Investigating the role of perceived stress on bacterial flora activity and salivary cortisol secretion: A possible mechanism underlying susceptibility to illness. Biological Psychology, 77(2), 132–137. Retrieved from https://www.sciencedirect.com/science/article/pii/S0301051107001597

Kigerl, K. A., Hall, J. C. E., Wang, L., Mo, X., Yu, Z., & Popovich, P. G. (2016). Gut dysbiosis impairs recovery after spinal cord injury. Journal of Experimental Medicine, 213(12), 2603–2620.

Boekamp, J. R., Overholser, J. C., & Schubert, D. S. P. (1996). Depression following a Spinal Cord Injury. The International Journal of Psychiatry in Medicine, 26(3), 329–349. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8976473

Elliott, T. R., & Frank, R. G. (1996). Depression following spinal cord injury. Archives of Physical Medicine and Rehabilitation, 77(8), 816–823. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8702378

Evidence for “What treatments have a positive effect on the gut microbiome in people with SCI?” is based on:

Wong, S., Jamous, A., O’Driscoll, J., Sekhar, R., Weldon, M., Yau, C. Y., … Forbes, A. (2014). A Lactobacillus casei Shirota probiotic drink reduces antibiotic-associated diarrhoea in patients with spinal cord injuries: A randomised controlled trial. British Journal of Nutrition.

Curtin,P., Casella,G.D., & Turk, M.A. (2017). P7 Can probiotics shorten the duration of antibiotic associated diarrhea in spinal cord injury patients with neurogenic bowel? The Journal of Spinal Cord Medicine, 40(5), 605–625. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/28758546

Hod, K., & Ringel, Y. (2017). Treatment of Functional Bowel Disorders With Prebiotics and Probiotics. In The Microbiota in Gastrointestinal Pathophysiology: Implications for Human Health, Prebiotics, Probiotics, and Dysbiosis (pp. 355–364). Elsevier Inc.

Roberfroid, M. B. (2005). Introducing inulin-type fructans. British Journal of Nutrition, 93(S1), S13–S25.

Tuohy, K. M., Probert, H. M., Smejkal, C. W., & Gibson, G. R. (2003, August 1). Using probiotics and prebiotics to improve gut health. Drug Discovery Today.

Gibson, G. R., Probert, H. M., Loo, J. Van, Rastall, R. A., & Roberfroid, M. B. (2004). Dietary modulation of the human colonic microbiota: updating the concept of prebiotics. Nutrition Research Reviews, 17(2), 259–275.

Brechmann, T., Swol, J., Knop-Hammad, V., Willert, J., Aach, M., Cruciger, O., … Hamsen, U. (2015). Complicated fecal microbiota transplantation in a tetraplegic patient with severe Clostridium difficile infection. World Journal of Gastroenterology, 21(12), 3736–3740.

Crum-Cianflone, N. F., Sullivan, E., & Ballon-Landa, G. (2015). Fecal Microbiota Transplantation and Successful Resolution of Multidrug-Resistant-Organism Colonization. Journal of Clinical Microbiology, 53(6), 1986–1989. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25878340

Khanna, S., Vazquez-Baeza, Y., González, A., Weiss, S., Schmidt, B., Muñiz-Pedrogo, D. A., … Kashyap, P. C. (2017). Changes in microbial ecology after fecal microbiota transplantation for recurrent C. difficile infection affected by underlying inflammatory bowel disease. Microbiome, 5(1), 55. Retrieved from http://microbiomejournal.biomedcentral.com/articles/10.1186/s40168-017-0269-3

Wang, J. W., Kuo, C. H., Kuo, F. C., Wang, Y. K., Hsu, W. H., Yu, F. J., … Wu, D. C. (2019, March 1). Fecal microbiota transplantation: Review and update. Journal of the Formosan Medical Association. Elsevier B.V.

Rossen, N. G., Fuentes, S., Van Der Spek, M. J., Tijssen, J. G., Hartman, J. H. A., Duflou, A., … Ponsioen, C. Y. (2015). Findings From a Randomized Controlled Trial of Fecal Transplantation for Patients With Ulcerative Colitis. Gastroenterology, 149(1), 110-118.e4.

Paramsothy, S., Paramsothy, R., Rubin, D. T., Kamm, M. A., Kaakoush, N. O., Mitchell, H. M., & Castaño-Rodríguez, N. (2017). Faecal microbiota transplantation for inflammatory bowel disease: A systematic review and meta-analysis. Journal of Crohn’s and Colitis, 11(10), 1180–1199.

Moayyedi, P., Surette, M. G., Kim, P. T., Libertucci, J., Wolfe, M., Onischi, C., … Lee, C. H. (2015). Fecal Microbiota Transplantation Induces Remission in Patients With Active Ulcerative Colitis in a Randomized Controlled Trial. Gastroenterology, 149(1), 102-109.e6.

Johnsen, P. H., Hilpüsch, F., Cavanagh, J. P., Leikanger, I. S., Kolstad, C., Valle, P. C., & Goll, R. (2018). Faecal microbiota transplantation versus placebo for moderate-to-severe irritable bowel syndrome: a double-blind, randomised, placebo-controlled, parallel-group, single-centre trial. The Lancet Gastroenterology and Hepatology, 3(1), 17–24.

Bajaj, J. S., Kassam, Z., Fagan, A., Gavis, E. A., Liu, E., Cox, I. J., … Gillevet, P. M. (2017). Fecal microbiota transplant from a rational stool donor improves hepatic encephalopathy: A randomized clinical trial. Hepatology, 66(6), 1727–1738.

Millan, B., Laffin, M., & Madsen, K. (2017, September 1). Fecal Microbiota Transplantation: Beyond Clostridium difficile. Current Infectious Disease Reports. Current Medicine Group LLC 1.

Kootte, R. S., Levin, E., Salojärvi, J., Smits, L. P., Hartstra, A. V., Udayappan, S. D., … Nieuwdorp, M. (2017). Improvement of Insulin Sensitivity after Lean Donor Feces in Metabolic Syndrome Is Driven by Baseline Intestinal Microbiota Composition. Cell Metabolism, 26(4), 611-619.e6.

Krajicek, E., Fischer, M., Allegretti, J. R., & Kelly, C. R. (2019, January 1). Nuts and Bolts of Fecal Microbiota Transplantation. Clinical Gastroenterology and Hepatology. W.B. Saunders.

Wang, Y., Wiesnoski, D. H., Helmink, B. A., Gopalakrishnan, V., Choi, K., DuPont, H. L., … Jenq, R. R. (2018). Fecal microbiota transplantation for refractory immune checkpoint inhibitor-associated colitis. Nature Medicine, 24(12), 1804–1808.

 

Image credits

  1. Modified from: Lactobacillus casei ©AJC1, CC BY-SA 2.0
  2. Modified from: Campylobacter bacteria ©Microbe World, CC BY-NC-SA 2.0
  3. Modified from: Koli Bacteria ©geralt geralt / 18959 images, CC0 1.0
  4. Modified from: jpg ©Lamiot, CC0 1.0
  5. Baby ©Nick Abrams, CC BY 3.0 US
  6. Modified from: Mazmanian SK, Lee YK. (2014). Interplay between intestinal microbiota and host immune system. Journal of Bacteriology and Virology, 44(1),1-9. CC BY-NC 3.0.
  7. Intestine segmentation ©Servier Medical Art, CC BY 3.0
  8. Modified from: Colon ©Servier Medical Art, CC BY 3.0
  9. The Earth seen from Apollo 17 ©NASA, Public Domain
  10. Modified from: Bacteria ©Maxim Kulikov, CC BY 3.0 US; urethra ©Prettycons, CC BY 3.0 US; and Zoom Out ©fahmionline, CC BY 3.0 US
  11. Modified from: Singh RK, Chang HW, Yan D, Lee KM, Ucmak D, Wong K. (2017). Influence of diet on the gut microbiome and implications for human health. Journal of Translational Medicine, 15, 73. CC BY 4.0.
  12. Red Wine bottle pouring ©Push Doctor, CC BY-NC 2.0
  13. Army Trials at Fort Bliss 160306-A-QR477-037 ©Adasia Ortiz, CC0 1.0
  14. Smoke ©Joffrey, CC BY-NC-ND 2.0
  15. yoghurt pack ©Oleksandr Panasovskyi, CC BY 3.0 US
  16. Clostridium difficile ©CDC, CC0 1.0
  17. Freeze-dried poop pills ©Patrik Nygren, CC BY-SA 2.0

 

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