Background Stroke now represents the condition with the highest need for physical rehabilitation worldwide, with only low or moderate-level evidence testing telerehabilitation compared to in-person care. We compared functional ambulation in subacute patients with stroke following telerehabilitation and matched in-person controls with no biopsychosocial differences at baseline. Methods We conducted a matched case-control study to compare functional ambulation between individuals with stroke following telerehabilitation and in-person rehabilitation, assessed using the Functional Ambulation Categories (FAC) and the Functional Independence Measure™ (FIM). Results The telerehabilitation group (n = 38) achieved significantly higher FAC gains (1.5 (1.3) vs 1.0 (1.0)) than the in-person rehabilitation group, with no differences in ambulation efficiency, in individuals: admitted to rehabilitation within 60 days after stroke onset; aged 49.8 (±11.4) years at admission; 55.3% female sex; moderate stroke severity; 42.1% with ‘good’ motor FIM at baseline; mostly living with sentimental partner (73.7%); with 21.1% holding an university education degree. Conclusions The groups showed no significant differences in ambulation efficiency, though the telerehabilitation group achieved higher FAC gains. Our results suggest that home telerehabilitation can be considered a good alternative to in-person rehabilitation when addressing ambulation in patients with moderate stroke severity and whose home situation mostly includes a cohabiting partner.

Objectives: To (1) compare baseline clinical and demographic characteristics of postacute stroke inpatients who were diagnosed with first-time urinary tract infection (UTI) versus inpatients who were not; (2) compare rehabilitation outcomes between both groups; and (3) examine associations between time to UTI event and risk factors. Design: Retrospective observational cohort study. Setting: Institution for inpatient neurologic rehabilitation. Participants: Inpatients (n=1683) admitted within 3 months poststroke to a rehabilitation facility between 2005 and 2023. Interventions: Not applicable. Main Outcome Measures: Functional independence measure (FIM), functional ambulation categories (FACs) at admission. Cox proportional hazard models analyzed the association between UTI event timing and risk factors. Results: Of the (n=1683) included patients, 196 (11.6%) experienced a UTI. In 32.1% of cases, the UTI occurred during the first week after admission to rehabilitation and 47.9% of UTIs occurred during the first 2 weeks. The median (interquartile range) time to UTI was 16 (5-37) days since admission. Most common germs were Escherichia coli (40.5%), Klebsiella pneumoniae (23.7%), and Pseudomonas aeruginosa (6.4%). Patients who acquired a UTI had older age, higher stroke severity, higher proportion of dysphagia, hypertension, neglect, bilateral affectation, atrial fibrillation, hemiplegia, lower levels of functional independence, and lower FAC. We identified no differences in gender, type of stroke (ischemic or hemorrhagic), time to admission, aphasia, diabetes, dyslipidemia, chronic obstructive pulmonary disease, dominant side affected, and educational level between both groups. Patients with UTI presented significantly poorer rehabilitation outcomes including lower discharge FIM and FAC, larger length of stay, lower FIM efficiency, and decreased FIM effectiveness. Multivariable Cox proportional hazards identified hypertension HR=1.60 (1.13-2.27), admission FIM HR=0.98 (0.97-0.99), admission body mass index HR=0.96 (0.93-0.99), and admitted with catheter HR=1.80 (1.22-2.64) as significant predictors of time to first UTI event (Concordance-index=0.754). Conclusions: UTIs identification, characterization, and predictive factors can support postacute stroke mitigation strategies to minimize UTI-related complications and optimize rehabilitation outcomes. Archives of Physical Medicine and Rehabilitation 2025;106:729-37 (c) 2024 by the American Congress of Rehabilitation Medicine.

Background Over half of spinal cord injuries result in tetraplegia, profoundly impairing daily activities (ADLs).Objective To evaluate biceps-to-triceps (B-T) and deltoids-to-triceps (D-T) tendon transfers, comparing their impacts on elbow extension strength and ADL independence.Methods Retrospective review of tendon transfers performed between 2003 and 2023 at a neurorehabilitation center. Post-surgery muscle strength was assessed using the Medical Research Council (MRC) scale and ADL independence with the motor Functional Independence Measure (mFIM). We used ANOVA to identify post-surgery associations between MRC achieved scores and performance in ADLs.Results A total of 34 individuals (42 arms) underwent B-T or D-T surgeries, predominantly at C5 level (66.7%) with 69.0% classified as AIS A. Post-surgery, 81% of B-T and 76.2% of D-T achieved antigravity elbow extension (MRC 3-4), with mean MRC scores of 3.2 for both groups. The B-T group, older at surgery (39.9 vs. 27.8 years) and with shorter time since injury to surgery (2.3 vs. 5.0 years), showed significant post-surgery improvements in Self-care, Transfers, Locomotion, and total mFIM. In contrast, significant associations between MRC scores and mFIM outcomes in D-T transfers involved Self-care, Sphincter control, Transfers, and total mFIM.Conclusions MRC scores and ADLs were positively impacted by rehabilitation tendon transfers.

IntroductionThe ABLE Exoskeleton has been tested to be safe and feasible for persons with spinal cord injury (SCI) to complete basic skills in clinical settings but has not been tested for use in home and community environments. A user-centered design process was employed to test the feasibility of the current ABLE Exoskeleton (designed for clinical use) for persons with SCI to perform the basic and advanced skills required for home and community environments, to gain crucial feedback for the development of a novel personal-use exoskeleton.MethodsIn this prospective pretest-posttest quasi-experimental study across two SCI centers (Germany, Spain), in-and outpatients with SCI were included into a 22-session training and assessment protocol, utilizing the ABLE Exoskeleton. Feasibility and usability measures [level of assistance (LoA) for basic and advanced skills, donning/doffing-time and LoA] were recorded together with safety outcomes, and participant and therapist satisfaction with the device.Results10 participants (44.4 ± 24 years), with SCI from C5 to T11, (American Spinal Injury Association Impairment Scale A–D) completed the study. In 209 sessions, six device-related adverse events (pain and skin lesions) were reported. Average total time for don and doff was 10:23 ± 3:30 min. Eight participants were able to complete don and doff with minimal assistance or less. Independence to carry out all skills in the device increased significantly for all participants (p < 0.05). Participants with chronic SCI required a significantly (p < 0.05) lower LoA for six of the nine advanced skills than those in the sub-acute phase.DiscussionThis study shows that the ABLE Exoskeleton is safe, feasible and usable for people with SCI in respect to independent donning, doffing and performance of basic and advanced exoskeleton skills. The supervised exoskeleton use in the clinical environment was a highly valuable approach for identifying the challenging tasks and the necessary technological developments that need to be carried out for a personal-use exoskeleton, including a more independent sit-to-stand transition, faster speed of transitions between states and a richer display on the remote control for the user.Clinical trial registrationhttps://clinicaltrials.gov/study/NCT05643313.

Existing literature on pediatric traumatic spinal cord injury (PTSCI) demonstrates large variations in characteristics, incidence, time-periods and etiology, worldwide. Epidemiological studies addressing injuries to the total spine, conducted in Southern European regions are remarkably scarce; therefore we aimed to investigate long-term trends analyzing etiology, fracture location and type, single or multiple fractures, associated lesions and neurological status in Catalonia, Spain. We conducted a retrospective observational study. We analyzed post-acute patients after PTSCI, aged 0–17, admitted with neurological deficits between 1986 and 2022 to a specialized hospital in Catalonia. Neurological deficits were assessed using the American Spinal Injury Association Impairment Scale (AIS). Two hundred and forty nine children were included, 174 (69.9

Background In-hospital falls are frequent post-stroke medical complications and will remain of concern because it may not be possible to prevent all of them. We aimed to i) compare admission clinical and sociodemographic characteristics between fallers and non-fallers ii) determine falls characteristics iii) compare length of stay (LOS), discharge functional independence, ambulation and destination between fallers and non-fallers. Methods A matched case-control study, comparing individuals (n=302) who fell during inpatient post-acute rehabilitation, matched (on time to admission, age and motor Functional Independence Measure (mFIM)) to individuals (n=302) who didn´t fall, admitted within 3 months post-injury to a center between 2008 and 2023. Ambulation was assessed using the Functional Ambulation Category (FAC). Results Mean age at admission was 50±8 years. No baseline differences were seen between groups in the proportion of patients with aphasia, diabetes, dyslipidemia, hypertension, neglect, atrial fibrillation, dysphagia, dominant side affected, medication for depression, FAC assessment, body mass index and educational level.A first-fall in the first week was experienced by 22.2% and in the first three weeks by 54.3%. Most falls occurred at the patients’ room (75.1%) mostly due to distractions (55.3%) and transferring without help (32.4%) with 18% occurring in the bathroom, fallers were alone in 68.6% of the cases.Fallers had an 8-day longer mean LOS compared to non-fallers, yet there were no differences in discharge mFIM or FAC scores. While non-fallers had a higher proportion of poor mFIM outcomes (28.5% vs. 17.9%) and no ambulation (20.7% vs. 12.4%), fallers showed greater mFIM gains (26 vs. 22 points). Discharge destinations were similar across both groups. Conclusions Despite no baseline differences, fallers experienced longer stays with comparable independence and ambulation scores at discharge. Most falls occurred in patients' rooms during unsupervised activities. Preventive recommendations have been provided to address these risks and enhance patient safety.

BACKGROUND:Telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and health outcomes in patients with spinal cord injury (SCI). The clinical effectiveness of teleSCI is not known. OBJECTIVES:To compare independence in activities of daily living and mobility capacity in patients following teleSCI and matched controls undergoing traditional rehabilitation. DESIGN:Matched case-control study. SETTING:TeleSCI occurring in home setting (cases) versus traditional rehabilitation on inpatient unit (controls). PARTICIPANTS:Forty-two consecutive patients with SCI followed with teleSCI were compared to 42 historical rehabilitation inpatients (controls) matched for age, time since injury to rehabilitation admission, level of injury (paraplegia/tetraplegia), complete or incomplete injury, and etiology (traumatic/nontraumatic). The teleSCI group (n = 42) was also compared to the complete cohort of historical controls (n = 613). INTERVENTIONS:The teleSCI group followed home-based telerehabilitation (3.5 h/day, 5 days/week, 67 days average duration) and historical controls followed in-person rehabilitation. MAIN OUTCOME MEASURE(S):The Functional Independence Measure (FIM), the Spinal Cord Independence Measure (SCIM) and the Walking Index for Spinal Cord Injury (WISCI). We formally compared gains, efficiency and effectiveness. International Standards for Neurological Classification of Spinal Cord Injury and the American Spinal Injury Association Impairment Scale (AIS) were used. RESULTS:The teleSCI group (57.1% nontraumatic, 71.4% paraplegia, 73.8% incomplete, 52.4% AIS grade D) showed no significant differences compared with historical controls in AIS grades, neurological levels, duration, gains, efficiency and effectiveness in FIM, SCIM, or WISCI, although the teleSCI cohort had significantly higher admission FIM scores compared with the complete cohort of historical controls. CONCLUSIONS:TeleSCI may provide similar improvements in mobility and functional outcomes as traditional rehabilitation in medically stable patients (predominantly with paraplegia and motor incomplete SCI) when provided with appropriate support and equipment.

BACKGROUND AND PURPOSE:Aquatic therapy (AT), though potentially effective, lacks studies on clinical efficacy in patients with spinal cord injury (SCI). A recent study analyzing interviews with rehabilitation professionals on its clinical application reported that the scarce evidence of AT benefits was one of the actual barriers to its successful integration into clinical practice. We seek to provide evidence by comparing independence in activities of daily living (ADLs) and functional ambulation capacity in patients following rehabilitation which included AT and matched controls who followed rehabilitation without AT (non-AT). METHODS:Functional Independence Measure (FIM), Spinal Cord Independence Measure (SCIM-III), Walking Index for Spinal Cord Injury (WISCI-II) and its minimal clinically important difference (WISCI-II/MCID) were assessed. The AT group followed the Halliwick concept. We performed nonparametric nearest-neighbor k:1 matching for age, time since injury to admission, FIM at admission, level of injury (paraplegia/tetraplegia), completeness and cause of injury (traumatic, non-traumatic). The rehabilitation program comprised four daily hours of intensive treatment from the multidisciplinary team. Both groups received the same total number of rehabilitation hours at the same specialized clinical center and were admitted to follow inpatient rehabilitation within 2 months after injury. RESULTS:A total of 29 patients with SCI who followed AT (admitted between 2017 and 2023) were compared to historical matches selected from 551 inpatients with SCI (admitted between 2014 and 2023). For k = 1, the groups showed no significant differences in gains, efficiency, or effectiveness in FIM and SCIM-III; significant differences were observed in WISCI-II gain (p = 0.018) and WISCI-II efficiency (p = 0.046) in favor of the AT group; the proportion of patients achieving WISCI-II/MCID was significantly higher for the AT group (75.9% vs. 48.3%) (p = 0.030). These results were confirmed for k = 2. CONCLUSION:The AT group performed similarly in independence for performing ADLs and significantly better in ambulation than the matched historical controls.

BACKGROUND: Most studies focus on the risk factors associated with the development of pressure ulcers (PUs) during acute phase or community care for individuals with spinal cord injury (SCI). OBJECTIVES: This study aimed to i) compare clinical and demographic characteristics of inpatients after SCI with PUs acquired during rehabilitation vs inpatients without PUs and ii) evaluate an existing PU risk assessment tool iii) identify first PU predictors. METHODS: Individuals (n = 1,135) admitted between 2008 and 2022 to a rehabilitation institution within 60 days after SCI were included. Admission Functional Independence Measure (FIM), American Spinal Injury Association Impairment Scale (AIS) and mEntal state, Mobility, Incontinence, Nutrition, Activity (EMINA) were assessed. Kaplan-Meier curves and Cox proportional hazards models were fitted. RESULTS: Overall incidence of PUs was 8.9%. Of these, 40.6% occurred in the first 30 days, 47.5% were sacral, 66.3% were Stage II. Patients with PUs were older, mostly with traumatic injuries (67.3%), AIS A (54.5%), lower FIM motor (mFIM) score and mechanical ventilation. We identified specific mFIM items to increase EMINA specificity. Adjusted Cox model yielded sex (male), age at injury, AIS grade, mFIM and diabetes as PUs predictors (C-Index = 0.749). CONCLUSION: Inpatients can benefit from combined assessments (EMINA + mFIM) and clinical features scarcely addressed in previous studies to prevent PUs.

Objectives To (1) determine fall characteristics (eg, cause, location, witnesses) of inpatients with spinal cord injury (SCI) and whether they were different for ambulatory persons vs wheelchair users; (2) visualize the total number of daily falls per clock-hour for different inpatients' features (eg, cause of injury, age); (3) compare clinical and demographic characteristics of inpatients who experienced a first fall event vs inpatients who did not experience such event; and (4) identify first fall event predictors. Design Retrospective observational cohort study. Setting Institution for inpatient neurologic rehabilitation. Participants Persons with SCI (N=1294) admitted to a rehabilitation facility between 2005 and 2022. Interventions Not applicable. Main Outcome Measures Functional independence measure (FIM), Hospital Anxiety and Depression Scale (HADS), American Spinal Injury Association Impairment Scale (AIS), and Spinal Cord Independence Measure (SCIM) at admission. Kaplan-Meier survival curves and Cox proportional hazards models were used. Results A total of 502 fall events were experienced by 369 ambulatory inpatients (19.8%) and wheelchair users (80.2%) in 63.9% of cases being alone, with cause, situation, and location significantly different in both groups. Clock-hour visualizations revealed an absolute peak at 12 AM (complete or incomplete injuries, with paraplegia or tetraplegia) but a relative peak at 9 AM mainly including incomplete patients with paraplegia. Of the (n=1294) included patients, 16.8% experienced at least 1 fall. Fallen patients reported higher levels of HADS depression, lower total SCIM, and longer time since injury to admission, with no differences in age, sex, educational level, FIM (quasi-significant), and AIS grade. Multivariable Cox proportional hazards identified time since injury to admission and AIS grade D as significant predictors of first fall event. Conclusions Falls identification, characterization, and clock-hour visualization can support decisions for mitigation strategies specifically addressed to inpatients with SCI. Fall predictors were identified as a first step for future research.

Background Robotic lower-limb exoskeletons have the potential to provide additional clinical benefits for persons with spinal cord injury (SCI). However, high variability between protocols does not allow the comparison of study results on safety and feasibility between different exoskeletons. We therefore incorporated key aspects from previous studies into our study protocol and accordingly conducted a multicentre study investigating the safety, feasibility and usability of the ABLE Exoskeleton in clinical settings. Methods In this prospective pretest-posttest quasi-experimental study across two SCI centres in Germany and Spain, in- and outpatients with SCI were recruited into a 12-session training and assessment protocol, utilising the ABLE Exoskeleton. A follow-up visit after 4 weeks was included to assess after-training outcomes. Safety outcomes (device-related adverse events (AEs), number of drop-outs), feasibility and usability measures (level of assistance, donning/doffing-time) were recorded at every session together with changes in gait parameters and function. Patient-reported outcome measures including the rate of perceived exertion (RPE) and the psychosocial impact of the device were performed. Satisfaction with the device was evaluated in both participants and therapists. Results All 24 participants (45 ± 12 years), with mainly subacute SCI (< 1 year after injury) from C5 to L3, (ASIA Impairment Scale A to D) completed the follow-up. In 242 training sessions, 8 device-related AEs (pain and skin lesions) were reported. Total time for don and doff was 6:50 ± 2:50 min. Improvements in level of assistance and gait parameters (time, steps, distance and speed, p < 0.05) were observed in all participants. Walking function and RPE improved in participants able to complete walking tests with (n = 9) and without (n = 6) the device at study start (p < 0.05). A positive psychosocial impact of the exoskeleton was reported and the satisfaction with the device was good, with best ratings in safety (participants), weight (therapists), durability and dimensions (both). Conclusions Our study results prove the feasibility of safe gait training with the ABLE Exoskeleton in hospital settings for persons with SCI, with improved clinical outcomes after training. Our study protocol allowed for consistent comparison of the results with other exoskeleton trials and can serve as a future framework towards the standardisation of early clinical evaluations. Trial Registration https://trialsearch.who.int/ , DRKS00023503, retrospectively registered on November 18, 2020.

OBJECTIVES:To compare independence in activities of daily living (ADLs) in post-acute patients with stroke following tele-rehabilitation and matched in-person controls.MATERIALS AND METHODS:Matched case-control study. A total of 35 consecutive patients with stroke who followed tele-rehabilitation were compared to 35 historical in-person patients (controls) matched for age, functional independence at admission and time since injury to rehabilitation admission (<60 days). The tele-rehabilitation group was also compared to the complete cohort of historical controls (n=990). Independence in ADLs was assessed using the Functional Independence Measure (FIM) and the Barthel Index (BI). We formally compared FIM and BI gains calculated as discharge score - admission scores, efficiency measured as gains / length of stay and effectiveness defined as (discharge score-admission score)/ (maximum score-admission score). We analyzed the minimal clinically important difference (MCID) for FIM and BI.RESULTS:The groups showed no significant differences in type of stroke (ischemic or hemorrhagic), location, severity, age at injury, length of stay, body mass index, diabetes, dyslipidemia, hypertension, aphasia, neglect, affected side of the body, dominance or educational level. The groups showed no significant differences in gains, efficiency nor effectiveness either using FIM or Barthel Index. We identified significant differences in two specific BI items (feeding and transfer) in favor of the in-person group. No differences were observed in the proportion of patients who achieved MCID.CONCLUSIONS:No significant differences were seen between total ADL scores for tele-rehabilitation and in-person rehabilitation. Future research studies should analyze a combined rehabilitation approach that utilizes both models.

Background: Cognitively impaired neurological rehabilitation inpatients are at an increased risk for falls; yet, little is known regarding fall risk of different groups, such as stroke versus traumatic brain injury. Objectives: To determine if rehabilitation patients' fall characteristics differ for patients with stroke versus patients with traumatic brain injury. Methods: This retrospective observational cohort study evaluates inpatients with stroke or traumatic brain injury admitted to a rehabilitation center in Barcelona, Spain, between 2005 and 2021. We assessed independence in daily activities with the Functional Independence Measure. We compared fallen versus nonfallen patients' features and examined the association between time to first fall and risk using Cox proportional hazards models. Results: A total of 1,269 fall events were experienced by 898 different patients with traumatic brain injury (n = 313; 34.9%) and stroke (n = 585; 65.1%). A higher proportion of falls for patients with stroke occurred while performing rehabilitation activities (20.2%–9.8%), whereas falls were significantly higher for patients with traumatic brain injury during the night shift. Fall timing revealed completely different behaviors (stroke vs. traumatic brain injury), for example, an absolute peak at 6 a.m. due to young male traumatic patients. Nonfallen patients (n = 1,363; 78.2%) were younger, with higher independence in daily activities scores, and having a larger time since injury to admission; all three were significant fall predictors. Conclusions: Patients with traumatic brain injury and stroke showed different fall behaviors. Knowledge of fall patterns and characteristics in the inpatient rehabilitation setting can help design management protocols to mitigate their risk.

BACKGROUND: Predicting the ability to walk after traumatic spinal cord injury is of utmost importance in the clinical setting. Nevertheless, only a small fraction of predictive models are evaluated on their performance by other authors using external data. The Dutch Clinical Prediction Rule for long-term walking ability was developed and validated using neurological assessments performed within 15 days postinjury. However, in reality, this assessment is most often performed between 11 and 55 days. When considering a longer time from injury to neurological assessments, the Dutch Clinical Prediction Rule has only been externally validated for patients after non–traumatic spinal cord injury. OBJECTIVE: We aimed to validate the Dutch Clinical Prediction Rule with neurological assessment performed within 3–90 days after traumatic spinal cord injury, using (a) the Dutch Clinical Prediction Rule logistic regression coefficients (Equation 1); (b) the Dutch Clinical Prediction Rule weighted coefficients (Equation 2); and (c) the reestimated (using a Spanish population) weighted coefficients (Equation 3). METHODS: We conducted a retrospective (STROBE-compliant) study involving 298 adults with traumatic spinal cord injury admitted to a hospital between 2010 and 2019 in Spain. The Spinal Cord Independence Measure item-12 was used for walking assessment. RESULTS: Using Equation 1, the model yielded 86.2% overall classification accuracy, 94.5% sensitivity, and 83.4% specificity (area under the curve [AUC] = 0.939, 95% confidence interval [CI]: 0.915–0.965; p < .001). Using Equation 2 yielded 86.2% overall classification accuracy, 93.2% sensitivity, and 83.9% specificity (AUC = 0.9392, 95% CI: 0.914–0.964; p < .001). Using Equation 3 yielded 86.9% overall classification accuracy, 68.9% sensitivity, and 92.8% specificity (AUC = 0.939, 95% CI: 0.914–0.964; p < .001). CONCLUSIONS: This study validates the Dutch Clinical Prediction Rule in a Spanish traumatic spinal cord injury population with assessments performed up to 90 days postinjury with similar performance, using the original coefficients and including a reestimation of the coefficients.

Context/objective Compare community integration, quality of life, anxiety and depression of people with chronic spinal cord injury (SCI) living in the community before the outbreak of coronavirus SARS-CoV-2 disease (COVID-19) and during it. Design Prospective observational cohort study. Setting In-person follow-up visits (before COVID-19 outbreak) to a rehabilitation hospital in Spain and on-line during COVID-19. Participants Community dwelling adults (>= 18 years) with chronic SCI. Outcome measures Hospital Anxiety and Depression Scale (HADS), Community Integration Questionnaire (CIQ) and World Health Organization Quality of Life (WHOQOL-BREF) were compared using the Wilcoxon ranked test or paired t-test when appropriate. Results One hundred and seventy five people with SCI assessed on-line between June 2020 and November 2020 were compared to their own assessments before COVID-19. Participants reported significantly decreased Social Integration during COVID-19 compared to pre-pandemic scores (P = 0.037), with a small effect size (d = -0.15). Depression (measured using HADS) was significantly higher than before COVID-19 (P < 0.001) with a moderate effect size (d = -0.29). No significant differences were found in any of the 4 WHOQOL-BREF dimensions (Physical, Psychological, Social and Environmental). Nevertheless, when all participants were stratified in two groups according to their age at on-line assessment, the younger group (19-54 years, N = 85) scored lower during COVID-19 than before, in WHOQOL-BREF Physical (P = 0.004), (d = -0.30) and Psychological dimensions (P = 0.007) (d = -0.29). The older group (55-88 years, N = 0) reported no significant differences in any dimension. Conclusions COVID-19 impacted HADS' depression and CIQ's social integration. Participants younger than 55 years were impacted in WHOQOL-BREF's physical and psychological dimensions, meanwhile participants older than 55, were not.