Research Interests:
Research Interests: Nursing, Surgery, Medicine, Paraplegia, Complication, and 15 moreHumans, Pulmonary Embolism, Male, Anticoagulants, Clinical Sciences, Middle Aged, Inferior Vena Cava, Warfarin, Public health systems and services research, Thrombosis, X ray Computed Tomography, Spinal Cord Injuries, Spinal fractures, Venous Thrombosis, and Fatal outcome
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Background A substantial proportion of individuals with spinal cord injury (SCI) experience depression, which has been negatively associated with recovery and community participation after injury. Despite significant barriers to seeking... more
Background A substantial proportion of individuals with spinal cord injury (SCI) experience depression, which has been negatively associated with recovery and community participation after injury. Despite significant barriers to seeking and receiving in-person mental health care, little research has focused on the efficacy of telepsychology among individuals with SCI. Objectives To describe the design and implementation of an ongoing single-center, randomized controlled, video-based cognitive behavioral therapy (CBT) intervention among individuals with SCI. Methods Participants within 1 year of SCI will be randomized 1:1 to intervention or usual care in a 24-week study. Intervention participants will engage in 10 sessions of CBT over 12 weeks with a licensed clinical psychologist, using iPads via Apple FaceTime. Primary outcomes are depressive symptomatology, anxiety, and life satisfaction (as measured by the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 and Satisfa...
Research Interests:
Research Interests:
Research Interests:
INTRODUCTION One of the most important predictors of clean intermittent catheterization (CIC) adoption after spinal cord injury (SCI) is upper extremity (UE) motor function at discharge from rehabilitation. It is not clear however if... more
INTRODUCTION One of the most important predictors of clean intermittent catheterization (CIC) adoption after spinal cord injury (SCI) is upper extremity (UE) motor function at discharge from rehabilitation. It is not clear however if post-discharge improvements in UE motor function affect future bladder management decisions. METHODS We assessed persons with cervical SCI in the National Spinal Cord Injury Dataset for the years 2000-2016 who underwent motor examination at discharge from rehabilitation and again at 1-year follow-up. Individuals were stratified based on a previously described algorithm which categorizes the ability to independently perform CIC based upon UE motor scores. Improvements in the predicted ability to self-catheterize over the first year after rehabilitation discharge were evaluated in relation to bladder management. RESULTS Despite 15% of our SCI cohort improving from "less than able to independently catheterize" to "able to independently catheterize", more patients in the overall cohort dropped out of CIC (175/643 = 27.2%) than adopted CIC (68/548 = 12.4%) (P < .001). We found that in those initially categorized as "less than able to independently catheterize" at the time of rehabilitation discharge, CIC adoption was not significantly different at 1-year follow-up whether or not there was motor improvement to "able to independently catheterize" (12.7% vs 9.2% respectively, P = 0.665). Between these two groups, CIC dropout was also equivalent (34.3% vs 30.0% respectively, P = 0.559). CONCLUSIONS In the first year after rehabilitation, more overall SCI patients transition away from CIC than convert to CIC. Significant improvements in UE motor function during the first year after rehabilitation discharge do not appear to affect bladder management decisions.
Research Interests:
Purpose: In many individuals with spinal cord injury a return of volitional bladder voiding is considered more important than regaining motor function. Recently a predictive model using only composite bilateral lower extremity motor... more
Purpose: In many individuals with spinal cord injury a return of volitional bladder voiding is considered more important than regaining motor function. Recently a predictive model using only composite bilateral lower extremity motor scores for levels L2‐S1 (range 0 to 50) was proposed by the EMSCI (European Multicenter Study about Spinal Cord Injury) group. The model showed exceptional predictive power with an AUC of 0.912. We sought to further validate the EMSCI model in a national spinal cord injury cohort. Materials and Methods: We created models of volitional voiding using the United States NSCID (National Spinal Cord Injury Database) for 2007 to 2016. In addition to testing lower extremity motor scores, we evaluated other patient variables that we hypothesized might affect volitional voiding. Results: Volitional voiding was present in 1,333 of the cohort of 4,327 individuals (30.8%) at 1‐year followup. While younger age, female gender, increased sacral sparing, improved AIS (American Spinal Injury Association Impairment Scale) classification and a more caudal sensory level predicted volitional voiding, lower extremity motor scores were most predictive (AUC 0.919). Adding the other patient characteristics did little to improve model performance (full model AUC 0.932). Further analysis of the predictive power of lower extremity motor scores suggested that while the AUC appeared to decrease in persons who were most likely to void volitionally, the performance of the predictive model remained outstanding with a combined AIS C and D AUC of 0.792. Conclusions: Our study verifies the validity of the EMSCI predictive model of volitional voiding after spinal cord injury. The differing performance of lower extremity motor scores in various AIS classifications should be noted.
Research Interests:
Research Interests:
Research Interests:
Research Interests: Helicobacter pylori, Medicine, Humans, Female, Male, and 15 moreClinical Sciences, Aged, Middle Aged, Adult, Coronary Artery Disease, Cerebrovascular Accident, Cerebrovascular Disorders, Peptic Ulcer Disease, Enzyme Linked Immunosorbent Assay, Gastric Carcinoma, H Pylori, Gastrointestinal bleeding, Brain injuries, mass Screening, and Paediatrics and reproductive medicine
Research Interests:
Background: While clean intermittent catheterization (CIC) is the gold standard for bladder management after spinal cord injury (SCI), many individuals with SCI, for reasons not fully understood, choose alternative bladder management. We... more
Background: While clean intermittent catheterization (CIC) is the gold standard for bladder management after spinal cord injury (SCI), many individuals with SCI, for reasons not fully understood, choose alternative bladder management. We hypothesized that CIC is associated with an increased time burden in individuals with SCI. Objectives: To investigate the time required to perform neurogenic bladder management in individuals with SCI. Methods: An electronic nonvalidated questionnaire was designed to determine the self-reported time spent performing bladder management. It was sent to participants in the Neurogenic Bladder Research Group SCI Registry, a national quality of life study of individuals with SCI. Results: Eighty-seven individuals responded to the survey. CIC was the most common bladder management (76%). Men and women performing independent CIC had similar average times with each catheterization episode (8.8 vs. 8.5 minutes, p = .864) as did women with a catheterizable sto...
Research Interests:
Changes in bladder function are a common occurrence in individuals afflicted with progressive neurologic disease. The alterations in urinary function, either alone, or in conjunction with nongenitourinary systems can lead not only to a... more
Changes in bladder function are a common occurrence in individuals afflicted with progressive neurologic disease. The alterations in urinary function, either alone, or in conjunction with nongenitourinary systems can lead not only to a decrease in quality of life, but also significant morbidity. Unfortunately, while the basic genitourinary dysfunction expected to occur with progressive neurologic diseases is available in textbooks, the optimal bladder management strategy and appropriate follow-up of those afflicted with progressive neurologic diseases is often difficult to ascertain. This chapter focuses on how losses of functional independence, altered nutritional states, bowel dysfunction, and genitourinary infections affect care.
Research Interests:
Research Interests:
Retrospective analysis. In patients with spinal cord injury, limitations in upper extremity (UE) motor function are cited as a reason for the lack of adherence to clean intermittent catheterization (CIC). By examining the UE function in... more
Retrospective analysis. In patients with spinal cord injury, limitations in upper extremity (UE) motor function are cited as a reason for the lack of adherence to clean intermittent catheterization (CIC). By examining the UE function in spinal cord injury (SCI) patients, we aim to provide insight into why CIC 'dropout' occurs and determine a more appropriate target percentage for CIC in this patient population. United States centers participating in National Spinal Cord Injury Database (NSCID). We assessed discharge data from the 2006 to 2012 NSCID. Neurologic motor scores for C5 to C8 (involved in UE movement) were transformed into a binary variable consisting of the ability ('strong') or the inability ('weak') to achieve active motion against resistance. We generated an algorithm based on expert opinion and published literature to categorize a person's ability to perform CIC by the UE function alone. Of the 4481 patients evaluated, 77.3% were unable to ...
Research Interests:
Research Interests:
Research Interests:
Research Interests:
ABSTRACT TITLE: Low Vitamin D Levels in Persons with Spinal Cord Injury and Increased Incidence of Venous Thromboembolic Events During Acute Inpatient and Rehabilitation Stay. AUTHORS (FIRST NAME, LAST NAME): Molly A. Timmerman1, James... more
ABSTRACT TITLE: Low Vitamin D Levels in Persons with Spinal Cord Injury and Increased Incidence of Venous Thromboembolic Events During Acute Inpatient and Rehabilitation Stay. AUTHORS (FIRST NAME, LAST NAME): Molly A. Timmerman1, James Crew2, Kazuko Shem1, Min Kim2, Stephanie A. Kolakowsky‐Hayner1, Jerry A. Wright1 INSTITUTIONS (ALL): 1. Physical Medicine and Rehabilitation, Stanford University, Redwood City, CA, United States. 2. Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA, United States. PRESENTATION TYPE: Abstract CURRENT CATEGORY: General Rehabilitation (Neuromuscular Medicine, Pediatric Rehabilitation, Medical Rehabilitation) ABSTRACT BODY: Objective (Abstract Only): To determine if low serum 25‐hydroxyvitamin D level is associated with an increased incidence of venous thrombotic events (VTE) in spinal cord injury (SCI) patients during their acute hospital or rehab stay. Design (Abstract Only): Retrospective cohort study. Setting (Required for Abstracts and Case Reports): Academic Medical Center Participants (Abstracts Only): Two hundred and five persons admitted consecutively to acute rehabilitation at Santa Clara Valley Medical Center (SCVMC) with a diagnosis of SCI from December 2009 to June 2012. Interventions (Abstracts Only): The following demographic data was collected: age, gender, race, and admission date. Additional information regarding injury was obtained including: level of injury (paraplegia versus tetraplegia), motor completeness of injury (motor complete versus motor incomplete), and etiology of injury (traumatic versus non‐traumatic). Serum 25‐hydroxyvitamin D (VitD‐ 25OH) levels and presence of VTE (deep vein thrombosis or pulmonary embolism) during acute hospital or rehab stay was also recorded. Main Outcome Measures (Abstracts Only): We looked at incidence of vitamin D deficiency in our patient population. Chi‐square analysis was used to determine significant associations with regard to demographic variables, injury characteristics, and vitamin D deficiency. Specific to our hypothesis, we looked at whether low vitamin D levels had a significant association with VTE. P values of &lt;0.05 were regarded significant. Results (Abstract or Case Report) or Clinical Course (Case Reports Only): We found 83% of persons with SCI admitted to acute inpatient rehabilitation have low levels of vitamin D. Patients who had low vitamin D levels had three and a half times the incidence of developing VTE (p=.036) Discussion (Case Reports Only): Vitamin D is biosynthesized in the skin from 7‐dehydrocholesterol or obtained through nutrition. It is modified in the liver and kidneys to form the active metabolite 1,25‐dihydroxyvitamin D3 (calcitriol). Recent in vivo and in vitro evidence suggests that calcitriol exerts an effect on coagulation by binding to nuclear vitamin D receptors (VDR) present in blood and subendothelial tissues and exerting anticoagulant effects by upregulating the expression of the anticoagulant glycoprotein, thrombomodulin (TM), and downregulating the expression of a critical coagulation factor, tissue factor (TF) in monocytic cells. Conclusions (Required for Abstracts and Case Reports): This study is the first to demonstrate an association between low vitamin D levels in persons with SCI in acute inpatient rehabilitation and VTE.
Research Interests:
Study design Uncontrolled clinical pilot study. Objectives To assess usage, perceived impact, and satisfaction with a telemedicine program among individuals with spinal cord injury (tele-SCI). Setting Community-based. Methods Participants... more
Study design Uncontrolled clinical pilot study. Objectives To assess usage, perceived impact, and satisfaction with a telemedicine program among individuals with spinal cord injury (tele-SCI). Setting Community-based. Methods Participants (N = 83) were recruited from acute SCI inpatient rehabilitation and outpatient SCI care at a community hospital to participate in a 6-month tele-SCI intervention administered by SCI subspecialty board-certified physiatrists via iPad FaceTime. In addition to monthly follow up interview calls, psychosocial and Quality of Life (QoL) measures were collected at baseline and post-intervention. A program satisfaction survey was also collected post-intervention. Results Seventy-five percent of participants engaged in tele-SCI visits (Median [IQR]: 2.5 [2.0, 4.0]) for a total of 198 tele-SCI visits. Bladder and bowel concerns were the leading topics discussed during tele-SCI visits, followed by neurological, pain, and functional concerns. Tele-SCI users res...
Research Interests:
To characterize domains of life stressors encountered by individuals with acute spinal cord injury (SCI) and change in psychological distress in the context of tele-cognitive behavioral therapy (tele-CBT). A within-arm (tele-CBT) mixed... more
To characterize domains of life stressors encountered by individuals with acute spinal cord injury (SCI) and change in psychological distress in the context of tele-cognitive behavioral therapy (tele-CBT). A within-arm (tele-CBT) mixed methods analysis in an ongoing randomized controlled trial to assess the efficacy of CBT telepsychology intervention on depressive symptomology, secondary symptoms (anxiety), and quality of life (QoL). Community setting. Fifteen individuals (Demographics: mean injury age=47.93years [SD=20.17], 53.3% male, 26.7% White;Injury Characteristics: time since injury mean=67.97days [SD=53.36], 66.7% traumatic etiology, 46.7% tetraplegia, 33.3% complete SCI) with acute SCI. The intervention group received 10 tele-CBT sessions over 12 weeks via Apple's FaceTime application with a licensed psychologist specializing in treating individuals with SCI. Session adhered to the basic structure outlined in Wenzel et al. (2011)1 and the study psychologist used individualized behavioral and/or cognitive strategies. Domains of life stressors qualitatively coded from CBT therapy notes. Patient Health Questionnaire-9 (PHQ-9)2 and Generalized Anxiety Disorder-7 (GAD-7)3 measured each session. Findings are preliminary as the study is ongoing. Participants attended an average of 9.8 CBT sessions. Thirty life stressors typically associated with psychological distress were identified from participants' CBT notes. The most frequently concerns were pain (73.3%), relationship issues (66.7%), sleep problems (60.0%), other non-SCI medical concerns (46.7%), COVID-19 (46.7%), UTIs (40.0%), perceived burden (26.7%), fatigue (26.7%), and returning to work (26.7%). At the first CBT session, the average PHQ-9 and GAD-7 total scores were 7.00 (SD= 3.72) and 5.80 (SD= 4.42). Over the course of therapy, symptoms of depression and anxiety decreased (PHQ-9:B=-0.346, SE=0.051, p<.001;GAD-7:B=-0.232, SE=0.109, p<.05). Individuals with acute SCI experience a diverse range of challenges that may impact mood.4–6 Although the majority of concerns and life stressors endorsed were medical, a substantial number were related to relationships, perceived burden, and resumption of functional roles.5 Tele-CBT provided by an SCI specialist may be an effective intervention to support adjustment and bolster against life stressors after acute SCI. The authors have no disclosures to report.
Research Interests:
Research Interests:
Research Interests:
INTRODUCTION Recently, it has been observed that early infections after SCI are associated with decreased long-term motor and sensory recovery. We investigate the effects of early infection after SCI on long-term bladder function. METHODS... more
INTRODUCTION Recently, it has been observed that early infections after SCI are associated with decreased long-term motor and sensory recovery. We investigate the effects of early infection after SCI on long-term bladder function. METHODS We assessed data for the years 1995 to 2006 using the National Spinal Cord Injury Database. Postoperative wound infections and pneumonia were used to classify infections during the acute inpatient and rehabilitation periods. The effect of early infections on volitional voiding status at 1-year follow-up was assessed. Age, sex, and neurologic status at rehabilitation discharge (Level of Injury, American Spinal Injury Association Impairment scale (AIS) and bilateral lower extremity motor (LEM) scores) were included in multivariate logistic regression modeling to control for confounding. RESULTS Of the 3561 persons studied, 1233 (34.6%) had an early infection. Those with an infection during early recovery were less likely to void than their non-infected counterparts if in the AIS A (0.3% vs 1.9%, p=0.010), AIS B (3.8% vs 10.5%, p=0.018) and AIS C (29.1% vs 37.3%, p=0.071) classification, while those with less complete injuries (AIS D) did not appear to be affected (62.6% vs 65.4%, p=0.456). Similar findings were found when stratifying by LEM scores and persisted on multivariate analysis, where early infection decreased the odds of volitional voiding at 1-year follow-up (OR=0.79, p=0.042). CONCLUSION Infections during the early recovery period may modify volitional voiding at 1-year follow-up by 20% or more. Future investigations to confirm our findings and potentially evaluate mitigation strategies are warranted.
Research Interests:
INTRODUCTION Carpal tunnel syndrome (CTS) is the most common nerve entrapment syndrome worldwide. There are limited studies on the effectiveness of carpal ligament stretching on symptomatic and electrophysiologic outcomes. PURPOSE OF THE... more
INTRODUCTION Carpal tunnel syndrome (CTS) is the most common nerve entrapment syndrome worldwide. There are limited studies on the effectiveness of carpal ligament stretching on symptomatic and electrophysiologic outcomes. PURPOSE OF THE STUDY The purpose of this study was to evaluate the effect of self-myofascial stretching of the carpal ligament on symptom outcomes and nerve conduction findings in persons with CTS. STUDY DESIGN This is a prospective, double-blinded, randomized, placebo-controlled trial. METHODS Eighty-three participants diagnosed with median mononeuropathy across the wrist by nerve conduction study were randomized 1:1 to sham treatment or self-carpal ligament stretching. Participants were instructed to perform the self-treatment four times a day for six weeks. Seventeen participants in the sham treatment group and 19 participants in the carpal ligament stretching group completed the study. Pre- and post-treatment outcome measures included subjective complaints, strength, nerve conduction findings, and functional scores. RESULTS Groups were balanced on age, sex, hand dominance, symptom duration, length of treatment, presence of nocturnal symptoms, and compliance with treatment. Even though the ANOVA analyses were inconclusive about group differences, explorative post hoc analyses revealed significant improvements in numbness (P = .011, Cohen's d = .53), tingling (P = .007, Cohen's d = .60), pinch strength (P = .007, Cohen's d = -.58), and symptom severity scale (P = .007, Cohen's d = .69) for the treatment group only. CONCLUSIONS The myofascial stretching of the carpal ligament showed statistically significant symptom improvement in persons with CTS. Larger comparative studies that include other modalities such as splinting should be performed to confirm the effectiveness of this treatment option.
Research Interests:
Objectives: To identify and describe the types and time course of dysphagia following cervical spinal cord injury (SCI). Methods: This was a prospective cohort study conducted in an SCI inpatient rehabilitation unit. Seventy-six... more
Objectives: To identify and describe the types and time course of dysphagia following cervical spinal cord injury (SCI). Methods: This was a prospective cohort study conducted in an SCI inpatient rehabilitation unit. Seventy-six individuals with SCI were enrolled. Inclusion criteria were age 18 years or older, admitted into SCI inpatient rehabilitation unit, and medically stable for participation in bedside swallow evaluation (BSE) and videofluoroscopic swallow study (VFSS). All participants first underwent a BSE, of whom 33 completed a VFSS. A follow-up BSE was conducted on individuals who tested positive on the initial BSE and continued to show signs of dysphagia. Diagnosis and type of dysphagia as well risk factors were collected. Results: Twenty-three out of 76 individuals with cervical SCI were diagnosed with dysphagia using the BSE. All participants with positive BSE and VFSS had pharyngeal dysfunction. For participants with a positive initial BSE and persisting dysphagia ( n ...
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
The aim of this study was to identify the factors associated with dysphagia in individuals with high tetraplegia. The Santa Clara Valley Medical Center (SCVMC) has a high tetraplegia program utilizing experienced Speech Pathologists in... more
The aim of this study was to identify the factors associated with dysphagia in individuals with high tetraplegia. The Santa Clara Valley Medical Center (SCVMC) has a high tetraplegia program utilizing experienced Speech Pathologists in the early evaluation of dysphagia and in appropriate intervention in individuals with high tetraplegia. The factors associated with dysphagia were ASIA impairment level, intubation, mechanical ventilation, and pulmonary infections. The earlier individuals were admitted to SCVMC, the less likely they were to have pulmonary complications, which may be a result of early screening by the SCVMC Speech Pathology Department for dysphagia.