Table 3 Standing Balance

By | | No Comments
Author Year; Country
Score
Research Design
Total Sample Size
Methods Outcome
Standing Balance-Acute
Dobkin et al. 2006

USA

RCT

PEDro=2

N=146

Population: 146 individuals- 116 males and 30 females; 38 AIS, and 7 AIS D; level of injury: C5-L3; median age= 25y; time since injury= 1.03 months

Treatment: The control group had 12 weeks of over ground training. The experimental group participated in 12 weeks of body weight support treadmill training. The sessions were 1 hour long for 45-60 sessions. 5 times a week for 12 weeks

Outcome Measures: Berg Balance Scale

  1. There were no differences in balance between the overground training group and the body-weight supported treadmill training group.
Standing Balance-Chronic

Virtual Reality

Villiger et al. 2013

Switzerland

Pre-post

Level 4

N=14

Population: 14 individuals- 9 males and 5 females; chronic SCI; 2 AIS C and 12 AIS D; level of injury: C4-T12. mean age= 53y; median years post-injury= 4y

Treatment: Participants received 4-5 45-minute sessions of intensive virtual reality augmented training sessions per week for a total of 16-20 sessions.

Outcome Measures: Berg Balance Scale

  1. Significant increases were found for all patients in BBS (16.5% increase post treatment and 13% at follow up).
Sayenko et al. 2010

Canada, Japan

Pre-post

Level 4

N=6

Population: 6 participants- 5 males and 1 female; chronic SCI; 4 AIS C and 2 AIS D; level of injury: C4-T12; mean age= 41y; median years post-injury= 7y

Treatment: Patients participated in 3 60-minute visual feedback training sessions, totalling 12 sessions. During training, participants stood on a force platform and were asked to shift their center of pressure (COP) in the indicated directions as represented by a cursor on the monitor.

Outcome Measures: Static standing eyes open and closed as measured by COP displacement; Dynamic standing as measured by voluntary COP displacement.

  1. All participants showed substantial improvements in the scores, which varied between 236±94 and 130±14% of the initial values for different exercises.
  2. Improvements were all statistically significant for both eyes open and closed except mean velocity in the medial/lateral direction.
  3. The balance performance during training-irrelevant tasks was significantly improved: for example, the area inside the stability zone after the training reached 221±86% of the pre-training values.
Tamburella et al. 2013

Italy

Open-case study with retrospective matched controls

Level 4

N=18

Population: 18 individuals- 9 males and 9 females; chronic SCI; 6 AIS D; level of injury: T9-L5; mean age= 52y; median time since injury: 2.3y

 Treatment: The control group participated in overground conventional rehabilitation including BWS standing and stepping on a treadmill and overground, balance exercises. The experimental group participated in 40 min of control group protocol and 20 min of specific vBFB (visual biofeedback task specific balance training). The sessions were 60 minutes long 5 times a week for a total of 8 weeks.

Outcome Measures: Berg Balance Scale, COP measures, Timed Up and Go (TUG)

  1. At T4, the experimental group saw an improvement in balance aned gait demonstrated by clinical and instrumental evaluation; the improvement was maintained at follow up examinations.
  2. In the experimental group, the enhancement in balance that existed at T1 preceded the improvement in gait, and significant correlations between the improvements in gait and balance were observed.
  3. In comparison with H data, vBFB treatment demonstrated a significant higher level of effectiveness than conventional rehab
Standing Balance-Chronic

Body Weight Support

Alexeeva et al. 2011

USA

RCT

PEDro=7

Level 1

N=35

Population: 35 individuals- 30 males and 5 females; chornic SCI; 8 AIS C and 27 AIS D; level of injury: C2-T10. mean age= 38.5y; median years post injury= 4y

Treatment: Patients participated in a 13-week training program, with three 1 hour sessions per week. The PT group is a structured rehab program individualized for each participant. The TRK group consisted of body weight supported ambulation on a fixed track. The TM group involved body weight supported ambulation on a treadmill.

Outcome Measures: Tinetti Balance Scale

  1. All three training groups showed significant improvements in maximal walking speed, muscle strength, and psychological well-being.
  2. A significant improvement in balance was seen for PT and TRK groups but not for participants in the TM group.
Effect Sizes

 

Effect Sizes

 

Wu et al. 2012

USA

Repeated assessment with crossover

PEDro=4

Level 2

N=10

Population: 10 individuals- 8 males and 2 females; chronic SCI; all AIS D; level of injury: C2-T10; mean age= 47y; median time since injury=5y

 

Treatment: Group 1 underwent 4 weeks of assistance training then 4 weeks of resistance training. Group 2 underwent 4 weeks of resistance training first, then 4 weeks of assistance training. Resistance was provided by a cable-driven robotic locomotor training system. Sessions were 45 minutes long, 3 times a week for 8 weeks.

 

Outcome Measures: Berg Balance Scale.

  1. A significant improvement in walking speed and balance in humans with SCI was observed after robotic treadmill training using the cable-driven robotic locomotor trainer.
Buehner et al. 2012

USA

Prospective Cohort Study

Level 2

N=225

Population: 225 individuals- 167 males and 58 females; chronic SCI; 57 AIS C and 167 AIS D; level of injury was not specified; mean age= 42.5y; median time since injury= 2.45y

 

Treatment: NRN Locomotor Training Program consisting of manual-facilitated BWS standing and stepping on a treadmill and overground. Sessions included 1hr of treadmill training, 30 minutes overground assessment, and 15-30 minutes of community reintegration. Sessions were 5 days per week for non ambulators, 4 days per week for ambulators with pronounced assistance, and 3 days week for independent walkers.

 

Outcome Measures: Berg Balance Scale, AIS classification, lower extremity pin prick, light touch and motor scores, 10MWT, 6MWT

  1. Significant gains occurred in lower extremity motor scores.
  2. Final Berg Balance Scale scores and initial lower extremity motor scores were positively related.
  3. Although 70% of participants showed significantly improved gait speed after locomotor training, only 8% showed AIS category conversion.
Harkema et al. 2012

USA

Prospective Cohort Study

Level 2

N=196

Population: 169 individuals- 148 males and 48 females; chronic SCI; 66 AIS C and 130 AIS D; level of injury was not specified; mean age= 41y; median time since injury= 0.9y

Treatment: NRN Locomotor Training Program consisting of manual-facilitated BWS standing and stepping on a treadmill and overground. Sessions included 1hr of treadmill training, 30 minutes overground assessment, and 15-30 minutes of community reintegration. Sessions were 5 days per week for non ambulators, 4 days per week for ambulators with pronounced assistance, and 3 days week for independent walkers.

Outcome Measures: Berg Balance Scale, 6MWT, 10MWT

  1. Outcome measures at enrollment showed high variability between patients with AIS grades C and D.
  2. Significant improvement from enrollment to final evaluation was observed in balance and walking measures for patients with AIS grades C and D.
  3. The magnitude of improvement significantly differed between AIS groups for all measures.
  4. Time since SCI was not associated significantly with outcome measures at enrollment, but was related inversely to levels of improvement.
Lorenz et al. 2012

USA

Prospective Cohort Study

Level 2

N=337

Population: 337 participants- 255 males and 82 females; chronic SCI; 99 AIS C and 238 AIS D; level of injury: T10 or above; mean age= 40y; median time since injury= 1y

Treatment:  NRN Locomotor Training Program consisting of manual-facilitated BWS standing and stepping on a treadmill and overground. Sessions included 1hr of treadmill training, 30 minutes overground assessment, and 15-30 minutes of community reintegration. Sessions were 5 days per week for non ambulators, 4 days per week for ambulators with pronounced assistance, and 3 days week for independent walkers.

Outcome Measures: Berg Balance Scale, 6MWT, 10MWT.

  1. There was significant improvement on each outcome measure and significant attenuation of improvement over time.
  2. Patients varied significantly across groups defined by recovery status and American Spinal Injury Association Impairment Scale (AIS) grade at enrollment with respect to baseline performance and rates of change over time.
  3. Time since SCI was a significant determinant of the rate of recovery for all measures.
Behrman et al. 2012

USA

Prospective Cohort Study

Level 2

N=95

Population: 95 individuals- 75 males and 20 females; chronic SCI; 31 AIS C and 64 AIS D; level of injury= T11 or above; mean age= 43y; median time since injury= 1y; time since injury: <1 yr (n=47), 1-3 yrs (n=24), ³3 yrs (n=24).

Treatment: NRN Locomotor Training Program consisting of manual-facilitated BWS standing and stepping on a treadmill and overground. Sessions included 1hr of treadmill training, 30 minutes overground assessment, and 15-30 minutes of community reintegration. Sessions were 5 days per week for non ambulators, 4 days per week for ambulators with pronounced assistance, and 3 days week for independent walkers.

Outcome Measures: Berg Balance Scale, 6MWT, 10MWT

  1. Individuals classified within each of the 4 phases of the NRS were functionally discrete, as shown by significant differences in the mean values of balance, gait speed, walking endurance, and the variability of these measurements was significantly reduced by NRS classification.
  2. The magnitude of improvements in these outcomes was also significantly different among phase groups.
Fritz et al. 2011

USA

Pre-post

Level 4

N=15

Population: 15 individuals- 11 males and 4 females; incomplete chronic SCI; Lower functioning group: 10 individuals- 8 males and 2 females; mean age= 38.5y; time since injury: 6.6y; AIS lower extremity score= 24;

Higher functioning group: 5 individuals- 3 males and 2 females; mean age= 50.4y; time since injury= 5.7y; AIS lower extremity score= 44

Treatment: Participants received intensive mobility training (IMT) in activities that encouraged repetitive, task specific training of the lower extremities. IMT combines BWSTT, balance exercises, muscle strengthening, coordination and range of motion in a massed intensive therapy. Sessions were 3 hours a day for 3-5 days per week for a total of 10 weeks.

Outcome Measures:  Berg Balance Scale, Dynamic Gait Index (DGI)

  1. Individuals in the higher functioning ISCI group (BBS score ≥45 and gait speed ≥6m/s) spent more time in the intensive therapy on average than individuals in the lower functioning ISCI group.
  2. Effect sizes were comparable for changes in balance and mobility assessments between the lower and higher functioning groups, with the largest effect sizes observed for the DGI.
Musselman et al. 2009

Canada

Case Series

Level 4

N=4

Population: 4 participants- 2 males and 2 females; all AIS C; level of injury: C5-L1; mean age: 44.5y; Gender: median time since injury= 2.7y

Treatment: Initial 3 months BWSTT by all 4 patients. Patients 1, 2 received 3 months skills training, followed by 3 months BWSTT. Patients 3, 4 received the training in reverse order. Sessions were 1 hour long, 5 days a week for 3 months.

Outcome measures: Berg Balance Scale, Modified Emory Functional Ambulation Profile, 10MWT, 6MWT, Activities- specific Balance Confidence Scale.

  1. Overall improvements in walking speed met or exceeded the minimal clinically important difference for individuals with iSCI (> or = 0.05 m/s), particularly during the skill training phase (skill training: median=0.09 m/s, IQR=0.13; BWSTT: median=0.01 m/s, IQR=0.07).
  2. Walking endurance, obstacle clearance, and stair climbing also improved with both types of intervention. Three of the 4 patients had retained their gains at follow-up (retention of walking speed: median=92%, IQR=63%).
  3. The findings suggest that skill training was effective in this small group of individuals.

Table 2: Sitting Balance

By | | No Comments

Author Year; Country
Score
Research Design
Total Sample Size

Methods Outcomes

Sitting Balance-Acute

Harvey et al. 2011

Australia/Bangledesh

RCT

PEDro=8

N=32

Population: 32 individuals- 30 males and 2 females; chronic SCI; motor level T1 – L1; 29 AIS A, 2 AIS B, 1 AIS C; age range= 24-31y; years post injury= 8-17 weeks

Treatment: In the control group, individuals received 6 weeks standard in patient rehabilitation. In the experimental group, participants received 6 weeks standard in patient rehabilitation + 3 additional 30-minute sessions/wk of 84 task specific exercises with 3 levels of difficulty (252 exercises) in unsupported sitting.

Outcome Measures: Maximal Lean Test (Maximal Balance Range), Maximal Sideward Reach Test.

  1. The mean between-group differences for the Maximal Lean Test, Maximal Sideward Reach Test and the Performance Item of the COPM were –20 mm, 5% arm length, and 0.5 points respectively.
Sitting Balance-Chronic (>1 year SCI)
 

 

 

 

Boswell-Ruys et al. 2010

Australia

RCT

PEDro=8

N=30

 

 

Population: 30 participants- 25 males and 5 females; 25 AIS A, 15 AIS B; level of injury: T1-12; mean age=45y; mean years post injury= 14.5y

Treatment: Participants in the experimental group receieved 1hr of 84 task specific exercises with 3 grades of difficulty in an unsupported sitting 3 times a week for 6 weeks. The control group did not receive any intervention.

Outcome Measures: Primary measures were: Upper Body Sway Test, Maximal Balance Range Test; Secondary measures were: Alternating Reach test (supported and unsupported), Seated Reach Test 45°to right, Coordinated Stability Test (Version A), Upper Body Sway Test (lateral and antero-posterior components).

  1. The between-group mean difference for the maximal balance range was 64mm.

Kim et al. 2010

Korea

Prospective Controlled Trial

Level 2

N=12

Population: 12 individuals- 9 males and 3 females; 11 AIS A, 1 AIS B; level of injury: T6-12. mean age= 40.86y

 

Treatment: The control group received conventional PT. The experimental group received conventional PT and goal-oriented training on a rocker board. The patients sat on a stable surface with their legs straight on the floor. Reach forwarrd, left and right, were all measured. Sessions were 5 sets of 10 reps 5 times a week for 4 weeks.

 

Outcome Measures: Modified Functional Reach Test, sway area and sway velocity using the Balance Performance Monitor

  1. There was an increase in the MFRT distance in the experimental group.
  2. The experimental group showed a decrease in sway area with both opened and closed eyes after training.
  3. The experimental group showed a significant difference before and after training compared to the control, as shown by MFRT distance and swaying area.

Bjerkefors et al. 2006

Sweden

Pre-post

Level 4

N=10

Population: 10 individuals- 7 males and 3 females; 7 AIS A, 2 AIS B, 1 AIS C; level of injury between T3-12; mean age= 37.6 ± 12y; median years post-injury= 11.5y

Treatment: Participants paddled a modified kayak ergometer for 60 minutes 3 times a week for 10 weeks.

Outcome Measures: sit and reach tests

  1. Sit and reach tests significantly increased from 3.5cm at baseline to 5.8cm at the end of 10 weeks.

Bjerkefors et al. 2007

Sweden

Pre-post

Level 4

N=10

Population: 10 individuals- 7 males and 3 females; 7 AIS A, 2 AIS B, 1 AIS C; level of injury between T3-12; mean age= 37.6 ± 12y; median years post-injury= 11.5y

 

Treatment: Participants paddled a modified kayak ergometer for 60 minutes 3 times a week for 10 weeks.

 

Outcome Measures:anterior-posterior (A/P), medio-lateral (M/L) angular and linear and twisting (TW) displacements on support surface translations – forward (FWD), backward (BWD) and lateral (LAT); Kinematic Responses include: I-onset of acceleration (unpredictable), II-constant velocity, III-deceleration (predictable), IV-end of deceleration

  1. A/P angular and linear and TW angular during LAT translations for all kinematic responses were significantly decreased except II for A/P angular
  2. M/L angular displacements during LAT translations-significant decrease for kinematic response IV.
  3. M/L linear displacement during LAT translations-no significant effects for all kinematic responses.

Grigorenko et al. 2004

Sweden

Pre-post

Level 4

N=24

Population: Experimental group: 12 individuals- 9 males and 3 females; chronic SCI; 6 AIS A, 5 AIS B, 1 AIS C; level of injury: T2-11; mean age=40y; median years post-injury= 17y;

Control group: 12 able bodied participants who did not train

 

Treatment: Participants were involved in 2-3 modified kayak sessions on open water per week for 8 weeks.

 

Outcome Measures: sitting quietly on a force plate-standard deviation (SD), median velocity, median frequency

  1. Small effects in all 3 variables except on the median frequency in the sagittal plane (opposite to becoming normal)
  2. Before training and comparing to the control group, all variables differed.
  3. Small effects on balance variables-no significant effect.

 

Housing and Attendant Care Systematic Reviews Table 1

By | | No Comments
 

Author Year; Country
Score
Research Design
Total Sample Size

Methods

Outcome

Barclay et al. 2014

Australia

Systematic Review

Reviewed articles from 2001 to 2013.

N= 23

Level of evidence: Critical Review Form was used to evaluate studies

Type of studies: 5 qualitative, 17 quantitative (cross sectional surveys or questionnaires, no intervention studies), 1 mixed method

AMSTAR= 6

Methods: Literature search for published English quantitative, qualitative and mixed method studies related to evidence on social and community participation following SCI in addition to factors (i.e. personal & environmental) that influence participation.

Databases: OVID MEDLINE, AMED, CINAHL, PLUS, PSYCHINFO

Studies published from 2001 to 2013

  1. Factors identified as facilitating participation include having adequate personal care assistance, having appropriate social support, having adequate specialized equipment and appropriate occupational therapy input.
  2. Barriers identified that impeded participation include inability to access appropriate transportation, inaccessibility of natural and built environments, issues with healthcare services and rehabilitation providers.

 

Dwyer and Mulligan, 2015

New Zealand

Systematic Review

Reviewed articles since 2000

N=7

Level of evidence: The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of methodology

Type of study: 5 qualitative, 2 mixed method

AMSTAR= 6

Methods: Literature search for published English qualitative studies in peer-reviewed journals to determine what individuals with SCI perceive to be the barriers or facilitators to community reintegration.

 

Databases: Ovid Medline, CINAHL, AMED, Cochrane Database of Systematic Reviews and PEDro

  1. The accessibility of the environment (i.e., housing, community, transport, health professionals, assistive devices), re-establishing self, support and connections were strong facilitators for community reintegration.
  2. Barriers for community reintegration include lack of social support from family and friends, inaccessibility of housing and transportation, feelings of isolation or decreased sense of belonging, not being psychologically prepared for returning home, and lack of personal control over the environment.
  3. Contextual influences from environmental and personal factors (as opposed to factors related to body structure or function or activity level) predominated as both facilitators and barriers to community reintegration.

Table 5: Cellular Therapies

By | | No Comments
Author Year
Country
Research Design

Total Sample Size
Methods Outcome
Vaquero et al., 2018a
Spain
Pre-Post
N=6
Population: Mean age: 39 yr; Gender: Males=6; Injury etiology: SCI-trauma=6; Mean time since injury: 13.7 yr; Level of severity: AISA-A=3, AISA-B=2, AISA-D=1; Lesion location: D5=2, D3=1, D4=1, D8=1, L1=1.
Intervention: Cell therapy medicament (NC1, PEI number 12-141), developed by the Spanish Agency of Medicament and Health Products. The solution was injected into the syrinx over the course of one month.
Outcome Measures: Alteration to genome of expanded cells, ASIA, SCI Functional Rating Scale of the International Association of Neurorestoratology (IANR-SCIFRS), Visual Analog Scale (VAS), Penn and modified Ashworth scale (MAS), Geffner scale, and neurogenic bowel dysfunction scale (NBD).
  1. No genome alterations were detected during the cell expansion process.
  2. Pin prick scores on the ASIA measure improved (p=0.06), this effect was only observed at 6 mo follow-up.
  3. Scores on the IANR-SCIFRS (spinal cord function) increased at 3 mo follow-up (p=0.06), and 6 mo follow-up (p=0.06).
  4. There were no significant differences in VAS score post-injection (p=0.25), although patients self-reported a decrease in neuropathic pain.
  5. There were no significant differences in levels of spasticity or spasms experienced by patients post-injection (MAS, p=0.50).
  6. The Geffner scale (bladder dysfunction) showed no significant differences post-injection (p=0.25).
  7. The NBD scale showed no significant differences post-injection (p=0.12), although four patients observed an improvement.

Work and Employment Table 1: Systematic Review and Meta-Analysis

By | | No Comments

Author

Country

Review

AMSTAR Rating

Study Size

Study Details

Outcomes

Trenaman et al. 2014

Canada

Systematic Review

AMSTAR= 8

N=14

Population: 14 studies were included in the review that investigated interventions among people with SCI and where employment was an outcome.

Methods: An electronic search of Medline/PubMed, EMBASE, Cochrane database, CINAHL, PsycINFO, Social Science Abstracts and Social Work Abstract databases was performed on 31 December 2013. Exclusion criteria include (i) reviews, (ii) studies not published in English and (iii) non-peer reviewed publications.

Outcome measures: employment status, workplace support, rate of return to work, labour market outcomes, time to productive activities, time to employment

  1. 14 studies met the inclusion criteria: 2 RCTs and 12 observational studies
  2. The strongest evidence finds that supported employment can improve employment outcomes among individuals with SCI.
  3. The use of service dogs has also been shown to improve employment outcomes.
  4. The remaining 12 studies are observational and predominantly focus on vocational rehabilitation programs.
  5. There is a lack of high-quality intervention research that targets employment outcomes in individuals with SCI.

Trenaman et al. 2015

Canada/Switzerland

Systematic Review

AMSTAR=8

N=39

Population: 39 studies were included that investigated factors associated with employment outcomes following SCI.

Methods: Studies published from 1952-2014 were identified through an electronic search of MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, Social Science Abstracts and Social Work databases.

Exclusion criteria included: (1) reviews (2) studies not published in English (3) studies not controlling for potential confounders through a regression analysis, or (4) studies not providing an effect measure in the form of OR, RR, or HR. Data were categorized based on the International Classification of Functioning, Disability and Health framework, with each domain sub-categorized by modifiability.

Outcome measures: employment, domains: body structures & function, activity & participation, environmental facilitators, barriers, personal factors

  1. 39 studies met the inclusion criteria.
  2. 20 modifiable and 12 non-modifiable factors have been investigated in the context of employment following SCI.
  3. Education, vocational rehabilitation, functional independence, social support, and financial disincentives were modifiable factors that have been consistently and independently associated with employment outcomes.
  4. Future research should focus on determining which factors have the greatest effect on employment outcomes, in addition to developing and evaluating interventions targeted at these factors.

Roels et al. 2016

Netherlands

Systematic Review

AMSTAR= 10

N=15

Population: 15 studies were included that studied interventions enhancing employment in people with SCI and reported on effects of interventions on employment rate and duration. Three studies were RCTs. One RCT was of high quality. One RCT was of moderate quality and one was of low quality according to the Grade approach of assessing the quality of evidence.

1 RCT including 201 patients; average years post injury = 12.4y

Methods: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, PsycINFO and SPORTDISCUS databases were searched. Randomized controlled trials (RCTs) and non-randomized studies (NRSs) describing a hospital- or a community-based intervention aiming at employment in a SCI population were selected.

Outcome Measures: Employment rate and duration were primary outcomes. Quality appraisal was done using the SIGN methodology, and the quality of evidence was graded using the Grade approach.

  1. The majority of the studies, 11 out of 15 (73%), were case reports or case series.
  2. Only 1 RCT was of high quality (Ottomanelli et al. 2012), including 201 patients describing an intervention over 1 and 2 years. In this study, the employment rate was 26% after 1 year and 31% after 2 years for competitive work, compared with 10% in the treatment as usual-intervention site (TAU-IS) control group and 2% in the treatment as usual observational site (TAU-OS) after 1 and 2 years.
  3. This RCT showed evidence that a vocational rehabilitation programme based on the principles of supported employment integrated in a multidisciplinary team enhances employment for SCI people.
  4. Other studies were of low quality and describe higher employment rates from 36 to 100%.

Kent & Dorstyn, 2014

Australia

Meta-Analysis

AMSTAR = 10

N = 14

Population: 9,868 participants with SCI; average age = 38.0 ± 9.4yo; time since injury = 11.7 ± 6.6y

Methods: A meta-analysis was conducted to examine and quantify differences in psychological functioning and employment status among adults with an acquired SCI. Fourteen observational studies (N=9,868 participants) were identified from an electronic database search. Standardized mean difference scores between employed and unemployed groups were calculated using Cohen’s d effect sizes. Additionally, 95% confidence intervals, fail-safe Ns, percentage overlap scores and heterogeneity statistics were used to determine the significance of d.

Outcome measures: Cohen’s d effect sizes tests for psychological measures (feelings, QoL, life satisfaction, thoughts & beliefs)

  1. Moderate to large and positive weighted effects were noted across three broad psychological constructs (that could be considered clinically important to employment): affective experience or feelings (dw=3.16), quality of life (dw=1.06) and life satisfaction (dw=0.70). (d=0.2, 0.5 and 0.8 equates to small, medium and large effects, respectively).
  2. The psychological domain of life satisfaction had positive effect sizes with employment ranging from 0.37 to 0.85 (a statistically homogeneous finding).
  3. Higher effect sizes were associated with studies that comprised a greater proportion of males (r=0.56, P=0.04); this finding should be interpreted with caution due to the likelihood of a Type I error (false-positive association) due to the relatively small number of mean effect sizes (n=14) contributing to this finding.

Table 25: Summary Table re: Issues affecting Sexual Satisfaction and/or Activity

By | | No Comments

Issues perceived to affect sexual satisfaction and/or sexual activity

Positive or Negative Impact

Reported in men/women or both

Studies supporting

Age (<18 years or >30 years old)

(-)

Women

Kreuter et al. 1994; Westgren et al. 1997; Ferreiro-Velasco et al. 2005

Time since injury

(+)

Both, Men

Black et al. 1998; Tepper et al. 2001; Anderson et al. 2007; Lombardi et al. 2008; Pakpour et al. 2016; Choi et al. 2015

Severity of injury

(-)

Both, Men

Mona et al. 2000; Anderson et al. 2007; Kreuter et al. 2008; Sale et al. 2012; Pakpour et al. 2016

Bladder management problems (incontinence/UTIs)

(-)

Both, Men

White et al. 1993; Richards et al. 1997; Jackson & Wadley 1999; Benevento & Sipski 2002; Blok & Holstege 1999; Anderson et al. 2007; Kreuter et al. 2008; BieringSorensen et al. 2012; Sale et al. 2012; Moreno et al. 1995; Bozan et al. 2015; Otero-Villaverde et al. 2015

Spasticity

(-)

Both, Women

Jackson & Wadley 1999; Anderson et al. 2007; BieringSorensen et al. 2012, OteroVillaverde et al. 2015

Fecal incontinence

(-)

Both, Women

Charlifue et al. 1992; White et al. 1993; Richards et al. 1997; Kreuter et al. 2008; BieringSorensen et al. 2012; Bozan et al. 2015

Autonomic dysreflexia/Blood pressure

(-)

Women

Charlifue et al. 1992; Jackson & Wadley 1999; Anderson et al. 2007

Pressure ulcers and pain

(-)

Both, Women

Biering-Sorensen et al. 2012; Otero-Villaverde et al. 2015

Sexual self esteem

(+)

Both

Mona et al. 2000

Making a female partner pregnant

(+)

Biering-Sorensen et al. 2012

Altered body image

(-)

Both, Women

Bozan et al. 2015; Smith et al. 2015; Bailey et al. 2015; Merghati-Khoei et al. 2017; Richards et al. 1997; Elkland & Lawrie 2004; Reitz et al. 2004; Kreuter et al. 2008

Altered genital sensation

(-)

Women<, Men/p>

Richards et al. 1997; Anderson et al. 2007; Kreuter et al. 2008, Miranda et al. 2016; OteroVillaverde et al. 2015; Akman et al. 2015

Sexual desire

(+)

Both, Men

Phelps et al. 2001; Reitz et al. 2004; Miranda et al. 2016

Lack of a partner

(-)

Women

Jackson & Wadley, 1999; Kreuter et al. 2008; Otero-Villaverde et al. 2015

Quality of intimate relationship/relationship satisfaction

(+)

Both/Men

Jackson & Wadley 1999; Phelps et al. 2001; Reitz et al. 2004, Lombardi et al. 2008; Smith et al. 2015

Repertoire of sexual behaviour

(+)

Men, Women

Richards et al. 1997; Phelps et al. 2001

Partner as caregiver

(-)

Women

Kreuter et al. 1996; Black et al. 1998; Pentland et al. 2002

Perceived partner satisfaction

(+)

Men, Women

Phelps et al. 2001; Ekland & Lawrie 2004; Miranda et al. 2016

Partner’s understanding of sexual needs

(+)

Kreuter et al. 1996

Level of social and vocational activity; outgoing personality; acceptance of the disability**

(+)

Kreuter 2000

Inadequate vaginal lubrication

(-)

Women

Charlifue et al. 1992; Jackson & Wadley 1999; Anderson et al. 2007

Ability to move

(+)

Both

Reitz et al. 2004; Anderson et al. 20à7; Kreuter et al. 2008; Bozan et al. 2015

Mental well-being

(+)

Both, Men

Reitz et al. 2004; Kreuter et al. 2008, Smith et al. 2015, Pakpour et al. 2016

Sexual education and counselling

(+)

Women, Men, BOth

White et al. 1993; Westgren et al. 1997; Hess et al. 2007; Valtonen et al. 2006; New et al. 2016; Akman et al. 2015

Peer support

(+)

Women, Both

Richards et al. 1997; Fisher et al. 2002; Pentland et al. 2002; Ekland & Lawrie 2004

Sexual arousal

(-)

Men

Cardoso et al. 2008; Miranda et al. 2016

Orgasm intensity

(-)

Men

Cardoso et al. 2008; Miranda et al. 2016

 

**correlates positively with partner availability thereby indirectly related to sexual satisfaction Discussion Research shows that sexual function is important to people after SCI. A systematic

Table 24: Other Studies on Sexual Health

By | | No Comments

Author Year
Country
Research Design
Total Sample Size

Methods

Outcome

Cobo Cuenca et al. 2014

Spain

Case Control

Level 3

N=165 (85 SCI)

Population: 165 men with sexual dysfunction SD: Group A 85 with SCI (mean age= 35.61±8.13 years) and Group B 80 without SCI (mean age=46.31±10.69 years); duration of lesion 26.45±8.72 years; neurological level of injury 16 cervical, 46 thoracic, and 23 lumbar; 59 AIS A and 26 AIS B/C/D
Treatment: None.
Outcome Measures:The Sexual Health Evaluation Scale, the Fugl-Meyer Life Satisfaction Questionnaire scale (LISAT8), the Hospital Anxiety and Depression Scale, the Evaluation of the Sexual Health Scale, and the Rosenberg’s Self-esteem Scale.

  1. In the SCI group, 89.3% (76) showed erectile dysfunction and 75.2% (64) reported anejaculation.
  2. In the non-SCI group, 96.8% (75) showed erectile dysfunction and 58.7% (47) had disorders of sexual desire.
  3. All of the participants reported a high general QOL and a high satisfaction with their QOL but their satisfaction with their sexual lives was only at the acceptable level.
  4. Social QOL was significantly higher in the SCI group than the non-SCI group.
  5. The QOL, self-esteem, and anxiety and depression levels are significantly correlated.
  6. Sexuality and employment status are the areas where men with spinal cord injuries report less satisfaction.

Miranda et al. 2016

Brazil

Cross-sectional Study

Level 5

N=7=295

Population: 295 men (mean age 40.7±14.5 years) with SCI for more than 1 year (median time since SCI= 3.6 years; range= 1.6-7.0 years).
Treatment:None.
Outcome Measures:Performance in various domains of sexual function was evaluated using the Male Sexual Quotient (MSQ) questionnaire and Sexual Health Inventory for Men (SHIM) questionnaires.

  1. The prevalence of sexual dysfunction was as follows: decreased sexual desire (28.8%), lack of confidence for partner seduction (38.3%), dissatisfaction with sexual foreplay (48.8%), frustration with partner’s sexual satisfaction (54.6%), inability to obtain an erection (71.0%), difficulty maintaining erection (67.8%), lack of full erections (64.4%), problems with ejaculatory control (89.4%), inability to achieve orgasm (74.5%), and overall sexual intercourse dissatisfaction (51.1%).
  2. Only 70 men (23.7%) had an MSQ score >60, which represents highly or partially satisfied individuals; only 71 individuals (24.1%) had good erectile function or mild dysfunction based on the SHIM questionnaire (SHIM >17).
  3. The Pearson correlation coefficient revealed a strong correlation between the MSQ and the SHIM (r=.826; 95% CI, .779 -.864).

Sunilkumar et al. 2015

India

Qualitative Study

Level 5

N=7

Population: 7 men living with SCI/paraplegia.
Treatment:None.
Outcome Measures: Semi-structured and open-ended interviews regarding participant perspective of living with SCI in India.

  1. 7 themes emerged through qualitative methods: 1) recalling an active sexual life, 2) disconnection with sexual identity, 3) incongruence between a sense of physical and emotional capability, 4) isolation of spouse or sexual partner, 5) social readjustment of spouse, 6) perceived physical barriers to improved sexual functioning, and 7) coping and attempting ways of sexual integration.
  2. All patients were sexually active prior to injury and all desired a healthy and active sexual life. A huge gap existed between sexual desire and physical capability, and quality of life (physiological, social, existential, emotional) has been compromised for both patient and family, causing anxiety, distress, and sadness.
  3. There is a significant burden of added responsibility placed on the participants’ spouses in that she must find a way of coping and attempting ways of sexual reintegration.

Otero-Villaverde et al. 2015

Spain

Observational Study

Level 5

N=32

Population: 32 women (mean age=29.8 years, range 13.9-59 years); most common cause of SCI trauma (72%); degree of disability 44% AIS A, 19% AIS B, 9% AIS C, and 28% AIS D.
Treatment:None.
Outcome Measures: Spinal Cord Independence Measure (SCIM) version III.

  1. The only factors that we found to be related to sexual activity were not having a stable partner (P=0.017) and a lack of sensation in the genital area (P=0.039).
  2. When comparing the group of women who were sexually active with those who were not, variables such as age, neurological level, time since the SCI, ASIA or Spinal Cord Independence Measure score, urinary incontinence, chronic pain and spasticity were not related to sexual activity.
  3. The median score on the SCIM scale was 68.7. 80% of the women maintained a stable relationship at the time of the SCI, and 9 of these (37.5%) subsequently lost their partner.

Pakpour et al. 2016

Iran

Observational Study

Cross-sectional study

Level 5

N=93

Population: 93 men with SCI (mean age=37.8 years, age range=19-63 years, mean post-injury time=4.6 years).
Treatment:None.
Outcome Measures: Levels of anxiety and depressive mood were assessed using the Hospital Anxiety and Depression Scale. Religious coping strategies were measured using the 14-Items Brief Coping Questionnaire. Erectile function was measured using the International Index of Erectile Function (IIEF).

  1. SCI patients reported more positive religious coping than negative religious coping and higher levels of anxiety than depressive mood.
  2. Multivariate regression analyses indicated that age, education, the American Spinal Injury Association impairment scale, anxiety, positive religious coping, negative religious coping and the duration of injury were all independent factors influencing erectile function in SCI patients.

Akman et al. 2015

Turkey

Observational Study

Level 5

N=47

Population: 47 men with spinal cord injuries (age range = 20-62 years, mean age = 35.2 years, mean time since injury=6.3±4.0 years) who were out of the spinal shock period and had their injury for more than 6 months.
Treatment:None.
Outcome Measures:Social status, sexual activities, abilities, sexual education after injury, and erectile function evaluated by the International Index of Erectile Function-5 (IIEF-5) questionnaire.

  1. 28 patients had lesions located above T10, 15 had lesions between T11 and L2, and 4 had lesions at the cauda equina.
  2. Mean IIEF-5 score of group was 5.3 + 4.1.
  3. 61.7% of patients reported sexual activity and 93.6% reported some degree of erection.
  4. 87.3% of men in this study had moderate to severe erectile dysfunction.

 

Sexual Satisfaction and Activity Systematic Reviews

By | | No Comments

Author, Year; Country
Dates included in the review
Total sample size
Level of evidence
Type of study
Score

Methods

Outcome

Sunilkumar et al. 2015

India

Systematic Review

N=19

Methods: Search key words and phrases: SCI and sexuality, paraplegia and sexuality, paraplegia and sexual functioning, Indian males and SCI, Indian males and paraplegia and sexual attitudes, and males and SCI and sexual functioning. Inclusion criteria included: English language, Indian male population with sexuality issues, all age groups history of a SCI with resultant paraplegia. The search yielded 457 articles but only 19 were specifically related to male views on sexuality.
Databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Applied Social Sciences Index and Abstracts (ASSIA), and Google Scholar.

  1. 6 areas related to the topic of sexual functioning, SCI, and paraplegia were identified: sexual stigmatization, physiological barriers to sexual satisfaction, clinical aspects of sexual functioning, biomedical approaches to sexual dysfunction, partner satisfaction, and lack of accessibility to sexual education.
  2. TSCI and sexual functioning affects a large segment of the male Indian population, yet most current research focuses on quantitative measurement with the emphasis on ejaculatory dysfunction, orgasm impairment, incontinence, and other physiological dysfunction.

 

Table 22: Body Image and Acceptance

By | | No Comments

Author, Year; Country
Research Design
Total Sample Size

Methods

Outcome

Bailey et al. 2015

Canada

Observational/Qualitative

Level 6

N=9

Population: 9 individuals (5 females & 4 males, age range= 21-63 years), type of injury C3-T7 (AIS A-D, complete & incomplete SCI), years post injury 4-36 years.
Treatment: None.
Outcome Measures:Interview consisting of open-ended questions to determine participants’ overall body image, how participants themselves defined body image, positive body image, and negative body image.

  1. The following main categories were found: body acceptance, body appreciation and gratitude, social support, functional gains, independence, media literacy, broadly conceptualizing beauty, inner positivity influencing outer demeanour, finding others who have a positive body image, unconditional acceptance from others, religion/spirituality, listening to and taking care of the body, managing secondary complications, minimizing pain, and respect.
  2. Unique characteristics (i.e., resilience, functional gains, and independence) were also reported demonstrating the importance of exploring positive body image in diverse groups.

Merghati-Khoei et al. 2017

Iran

Qualitative Study

Level 5

N=53

Population: 53 individuals with SCI; 41 men (mean age 24.4 ± 5.7 years) and 12 women (mean age 29.5 ± 8.3 years); duration of SCI for men (46.0 ±41.6 months) and for women (97.3 ± 99.6 months).
Treatment: None.
Outcome Measures: Semi-structured Interview to understand how people with SCI understand marriage.

  1. “Attractiveness,” “able body for breadwinning,” “sexually active,” and “reproduction” were dominant concepts (‘outer’ scenarios) for how Iranian adults with SCI understood marriage.
  2. The participants’ inner scenarios (beliefs) revealed that marriage would be welcomed if a potential partner accepted them as a “whole person” regardless of their SCI condition. Adults with SCI do not ignore or reject marriage, however it was a lower life priority due to major health concerns that they had internalized.

Smith et al. 2015

USA

Cross-sectional Study

Level 5

N=218

Population: 218 individuals consisting of 120 males and 98 females (mean age=58, 7years); 38% had SCI.
Treatment: None.
Outcome Measures: Patient Reported Outcomes Measurement Information System’s (PROMIS) sexual function item bank measuring sexual function, sexual satisfaction, and use of aids for sexual activity; PROMIS Pain Interference – Short Form; Patient Health Questionnaire-9 (PHQ-9); Mobility was measured with the 6-point Gross Motor Function Classification System.

  1. Consistent with studies of able-bodied adults, sexual function was the strongest predictor of satisfaction.
  2. Depression also predicted sexual satisfaction for women.
  3. Use of aids for sexual activity varied by disability type and was generally associated with better function.
  4. Lowest levels of sexual satisfaction were reported by men with SCI.
  5. Depression may negatively impact sexual satisfaction in women, beyond contributions of sexual dysfunction, and effective use of sexual aids may improve function in this population.

Bozan et al. 2015

Turkey

Observational

Level 5

N=50

Population: 50 individuals- 29 male and 21 female patients; 10 had tetraplegia and 40 had paraplegia.
Treatment: None.
Outcome Measures: Participants were asked to rate how significant each dysfunction (walking disorder, urinary incontinence, fecal incontinence, and sexual dysfunction) was in their view.

  1. 50% of male participants and 36% of female participants had urinary incontinence.
  2. 46% of males and 32% of females had fecal incontinence.
  3. All participants had at least impaired walking, with complete inability to walk in a certain proportion of patients.
  4. 22% of males and 24% of female patients required walking-aids for walking. All male patients and 16 female patients reported sexual dysfunction.
  5. Male patients regarded inability to walk as the most significant dysfunction, followed by sexual dysfunction, absence of voluntary defecation, and absence of voluntary urination.
  6. In females, inability to walk and absence of voluntary urination were placed equal level of importance, followed by the loss of voluntary defecation. Interestingly, no female patients included sexual dysfunction in the ranking.
  7. The observed gender difference in the perceived significance of dysfunction because of SCI may be due to anatomical, cultural and social factors.

 

Table 21: Systematic Reviews on Sexual Behaviour

By | | No Comments

Author Year
Country
Dates included in the review
Total Sample Size
Type of study
Score

Methods

Databases

Outcome

Cramp et al. 2014

Canada

Systematic Review

N=40

Methods:The first search used the following search terms ‘‘spinal cord injury, women, and sexuality”. Articles were included if they were published in 1990 or more recently, had a term related to sexuality or sexual function in the title, were written in English, and were available in full text. Forty articles were accepted and are included in this review.
Databases:PubMed.

  1. A woman’s relationships, sexual desires, frequency of participation in sexual activities, the types of sexual activities she participates in, stimulation and arousal, orgasm and sexual satisfaction, as well as psychological influences on image and esteem have all been shown to be affected by SCI.
  2. Spinal cord injury and its related consequences have a greater effect on the marital status of women than men and the marriage rate is considerably lower for women with SCI than for men with SCI.
  3. Women’s sexual desire and the frequency of sexual activity has been found to decrease after SCI.
  4. The ability for a woman with SCI to become sexually aroused and to experience orgasm seems to occur less frequently after injury, but also seems to depend on the lesion level and completeness and on the type of stimulation that is used to induce the response.
  5. Women with SCI will typically experience a decrease in sexual satisfaction after injury.
  6. Having an active and satisfying sexual life after injury is associated with improved quality of life.
  7. After SCI, two types of neurogenic bladder exist, those being overactive and hypotonic bladders.

 

top