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Background Most epidemiologic reports focus on lower extremity amputation (LEA) caused specifically by diabetes mellitus. However, narrowing scope disregards the impact of other causes and types of limb amputation (LA) diminishing the true incidence and societal burden. We explored the rates of LEA and upper extremity amputation (UEA) by level of amputation, sex and age over 14 years in Saskatchewan, Canada. Methods We calculated the differential impact of amputation type (LEA or UEA) and level (major or minor) of LA using retrospective linked hospital discharge data and demographic characteristics of all LA performed in Saskatchewan and resident population between 2006 and 2019. Rates were calculated from total yearly cases per yearly Saskatchewan resident population. Joinpoint regression was employed to quantify annual percentage change (APC) and average annual percent change (AAPC). Negative binomial regression was performed to determine if LA rates differed over time based on sex and age. Results Incidence of LEA (31.86 ± 2.85 per 100,000) predominated over UEA (5.84 ± 0.49 per 100,000) over the 14-year study period. The overall LEA rate did not change over the study period (AAPC -0.5 [95% CI − 3.8 to 3.0]) but fluctuations were identified. From 2008 to 2017 LEA rates increased (APC 3.15 [95% CI 1.1 to 5.2]) countered by two statistically insignificant periods of decline (2006–2008 and 2017–2019). From 2006 to 2019 the rate of minor LEA steadily increased (AAPC 3.9 [95% CI 2.4 to 5.4]) while major LEA decreased (AAPC -0.6 [95% CI − 2.1 to 5.4]). Fluctuations in the overall LEA rate nearly corresponded with fluctuations in major LEA with one period of rising rates from 2010 to 2017 (APC 4.2 [95% CI 0.9 to 7.6]) countered by two periods of decline 2006–2010 (APC -11.14 [95% CI − 16.4 to − 5.6]) and 2017–2019 (APC -19.49 [95% CI − 33.5 to − 2.5]). Overall UEA and minor UEA rates remained stable from 2006 to 2019 with too few major UEA performed for in-depth analysis. Males were twice as likely to undergo LA than females (RR = 2.2 [95% CI 1.99–2.51]) with no change in rate over the study period. Persons aged 50–74 years and 75+ years were respectively 5.9 (RR = 5.92 [95% Cl 5.39–6.51]) and 10.6 (RR = 10.58 [95% Cl 9.26–12.08]) times more likely to undergo LA than those aged 0–49 years. LA rate increased with increasing age over the study period. Conclusion The rise in the rate of minor LEA with simultaneous decline in the rate of major LEA concomitant with the rise in age of patients experiencing LA may reflect a paradigm shift in the management of diseases that lead to LEA. Further, this shift may alter demand for orthotic versus prosthetic intervention. A more granular look into the data is warranted to determine if performing minor LA diminishes the need for major LA.

Background Understanding trends in limb amputation (LA) can provide insight into the prevention and optimization of health care delivery. We examine the influence of primary (first report) and subsequent (multiple reports) limb amputation on the overall (all reports) rate of limb amputation in Saskatchewan considering amputation level. Methods Hospital discharged data associated with LA from 2006 to 2019 and population estimates in Saskatchewan were used. LA cases were grouped based on overall, primary, and subsequent LA and further divided by level into major (through/above the ankle/wrist) and minor (below the ankle/wrist). Incidence rates were calculated using LA cases as the numerator and resident population as the denominator. Joinpoint and negative binomial were used to analyze the trends. In addition, the top three amputation predisposing factors (APF) were described by LA groups. Results The rate of overall LA and primary LA remained stable (AAPC − 0.9 [95% CI − 3.9 to 2.3]) and (AAPC −1.9 [95% CI −4.2 to 0.4]) respectively, while the rate of subsequent LA increased 3.2% (AAPC 3.2 [95% CI 3.1 to 9.9]) over the 14-year study period. The rate of overall major LA declined 4.6% (AAPC − 4.6 [95% CI −7.3 to −1.7]) and was largely driven by the 5.9% decline in the rate of primary major LA (AAPC − 5.9 [95% CI − 11.3 to –0.2]). Subsequent major LA remained stable over the study period (AAPC −0.4 [95% CI − 6.8 to 6.5]). In contrast, the overall rate of minor LA increased 2.0% (AAPC 2.0 [95% CI 1.0 to 2.9]) over the study period which was largely driven by a 9.6% increase in the rate of subsequent minor LA (AAPC 9.6 [95% CI 4.9 to 14.4]). Primary minor LA rates remained stable over the study period (AAPC 0.6 [95% CI − 0.2 to 1.5]). The study cohorts were 1.3-fold greater risk of minor LA than major LA. Diabetes mellitus (DM) was the leading APF representing 72.8% of the cohort followed by peripheral vascular disease (PVD) and trauma with 17.1 and 10.1% respectively. Most (86.7%) of subsequent LA were performed on people with DM. Conclusions Overall LA rates remained stable over the study period with declining rates of major LA countered by rising rates of minor LA. Minor LA exceeded major LA with the largest rate increase identified in subsequent minor LA. Diabetes was the greatest APF for all LA groups. This rising rate of more frequent and repeated minor LA may reflect changing intervention strategies implemented to maintain limb function. The importance of long-term surveillance to understand rates of major and minor LA considering primary and subsequent intervention is an important step to evaluate and initiate prevention and limb loss management programs.

Background The Spinal Cord Injury and You (SCI&U) intervention aims to improve self-management skills for persons living with SCI using a web-based, peer health-coaching model. This study assessed feasibility of a future definitive trial of SCI&U, specifically feasibility of recruitment and retention, program usability and quality, effect size estimates for self-management outcomes and rehospitalisation rates (i.e. health-related quality of life). Methods A two-group, randomised, controlled, pilot trial with prospective recruitment, concealed group allocation, blinded outcome evaluation and waitlist control was conducted. We aimed to recruit 60 adult participants living in the community at least 6 months post-injury who could speak and read English and had a family physician. The intervention included up to 14 1-h online client-coach videoconferencing sessions, goal setting, action planning and a sortable resource library. Data were collected at baseline, 2, 6 and 12 months post-randomisation. SCI&U was offered to waitlist participants at 12 months. Results Trial methodology and procedures were feasible. Recruitment and retention targets were achieved. Individuals were randomised to intervention ( n  = 31) and waitlist control ( n  = 34). Mean time since SCI was 25.6 years (intervention) and 20.2 years (control). Timeline for completion of online sessions was extended from 2 months to 6 months. Outcome data were gathered for 86% (6 months) and 89% (12 months) of participants. Program usability and quality were highly rated on the Mobile App Rating Scale. Difference in Skill and Technique Acquisition subscale between intervention and control was 0.56 (95%CI -0.41, 1.52) at 6 months and 0.72 (95%CI -0.28, 1.72) at 12 months. Other Health Education Impact Questionnaire subscales had large effect sizes: self-monitoring and insight 1.51 (95% CI 0.39, 2.69); emotional distress -1.40 (95%CI -3.04, 0.23). In 12 months post-recruitment, 5 intervention and 4 control participants spent median 11 (95% CI 3-19) and 24 (95% CI 5-95) nights in hospital, respectively. Conclusions Trial methodology and procedures were feasible. The SCI&U intervention was acceptable to participants and positively impacted an individual’s ability to self-manage. A definitive trial is warranted to build on these findings, particularly in those with recently acquired SCI. Future recruitment efforts will focus on inpatient rehabilitation hospitals to recruit individuals < 5 years post-injury. Trial registration ClinicalTrials.gov, NCT04474171, retrospectively registered 07/13/2020; https://clinicaltrials.gov/study/NCT04474171#study-record-dates .

Return to living at home is an important patient-reported outcome following traumatic spinal cord injury (tSCI). Specialized inpatient rehabilitation assists such patients in maximizing function and independence. Our project aim was to describe those patients receiving specialized rehabilitation after tSCI in Canada, and to determine if such rehabilitation improved the likelihood of returning home. This cohort study utilized data from the Rick Hansen Spinal Cord Injury Registry (RHSCIR) to identify patients with tSCI discharged from 1 of 18 participating acute specialized spine facilities between 2011 and 2015 to either 1 of 13 participating specialized rehabilitation facilities, or to another discharge destination. To determine if specialized rehabilitation affected likelihood of returning home, multiple logistic regressions and propensity score matchings were performed to account for age at injury, gender, neurological severity and level, acute length of stay (LOS), and region of residence. The χ2 test was used to compare rate of return home between matched groups. Of the 1599 patients included, 71% received specialized rehabilitation. Receiving specialized rehabilitation was a significant and strong predictor of return to home after controlling for covariates (adjusted odds ratio = 3.1; 95% confidence interval [CI], 1.6–5.9). The rate of return to home was significantly higher in the matched rehabilitation group than the no rehabilitation group (98% vs. 87%, p = 0.0004). For the matched patients, an extra 11 patients returned home for every 100 patients receiving specialized rehabilitation. However, effect of age on returning home requires further investigation. Improving access to specialized rehabilitation could potentially reduce discharges to nursing homes or other non-home destinations.

Survivors of traumatic spinal cord injury (tSCI) have intense healthcare needs during acute and rehabilitation care and often through the rest of life. To prepare for a growing and aging population, simulation modeling was used to forecast the change in healthcare financial resources and long-term patient outcomes between 2012 and 2032. The model was developed with data from acute and rehabilitation care facilities across Canada participating in the Access to Care and Timing project. Future population and tSCI incidence for 2012 and 2032 were predicted with data from Statistics Canada and the Canadian Institute for Health Information. The projected tSCI incidence for 2012 was validated with actual data from the Rick Hansen SCI Registry of the participating facilities. Using a medium growth scenario, in 2032, the projected median age of persons with tSCI is 57 and persons 61 and older will account for 46% of injuries. Admissions to acute and rehabilitation facilities in 2032 were projected to increase by 31% and 25%, respectively. Because of the demographic shift to an older population, an increase in total population life expectancy with tSCI of 13% was observed despite a 22% increase in total life years lost to tSCI between 2012 and 2032. Care cost increased 54%, and rest of life cost increased 37% in 2032, translating to an additional CAD $16.4 million. With the demographics and management of tSCI changing with an aging population, accurate projections for the increased demand on resources will be critical for decision makers when planning the delivery of healthcare after tSCI.

Specialized centers of care for persons sustaining a traumatic spinal cord injury (tSCI) have been established in many countries, but the ideal system of care has not been defined. The objective of this study was to describe care delivery, with a focus on structures and services, for persons with tSCI in Canada. A survey was sent to 26 facilities (12 acute, 11 rehabilitation, and three integrated) from eight provinces participating in the Access to Care and Timing project. The survey included questions about: 1) care provision; 2) structural attributes and; 3) service availability. Survey completion rate was 100%. Data sources used to complete the survey were the Rick Hansen Spinal Cord Injury Registry, other hospital databases, clinical protocols, and subject matter experts. Acute and rehabilitation care provided by integrated facilities were described separately, resulting in data from 15 acute and 14 rehabilitation facilities. The number of admissions for tSCI over a 12-month period between 2009–2011 ranged from 17 to 104 (median 39), and 11 to 96 (median 32), for acute and rehabilitation facilities, respectively. Grouping of patients was reported by 8/15 acute and 10/14 rehabilitation facilities. Criteria for admission to the inpatient rehabilitation facilities varied among facilities (25 different criteria reported). Results from the survey revealed similarities in the basic structure and the provision of general services, but also some differences in the degree of specialization of care for persons with tSCI. Continued work on the impact of specialized care for both the patient and healthcare system is needed.

Background: Although the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam is considered a best practice, its clinical use is inconsistent. Few studies have thoroughly documented ISNCSCI use across the spinal cord injury (SCI) care continuum. This study aims to compare exam use in people with traumatic (tSCI) and nontraumatic spinal cord injury (NtSCI) across Canadian acute and rehabilitation facilities. Methods: We used the Rick Hansen Spinal Cord Injury Registry 2015-2022 database to review all participants with tSCI and NtSCI. The 5 cohorts were (A) tSCI-acute-admission (n = 4461); (B) tSCI-rehabilitation-admission (n = 2673); (C) tSCI-rehabilitation- discharge (n = 2316), (D) NtSCI-rehabilitation-admission (n = 728); and (E) NtSCI-rehabilitation-discharge (n = 619). Assessment of ISNCSCI use included exam performed (yes or no), timing (≤ or > 72 hours of admission/discharge), completeness (partial: missing ≥ 1 ISNCSCI items; full: having all ISNCSCI items), and presence or absence of individual exam items. Descriptive statistics were used to characterize ISNCSCI use across all cohorts. Results: Across all cohorts, the frequencies for Yes-Exam-Performed were A 81%, B 79%, C 54%, D 89%, and E 36%. Of these, most exams were performed within ≤ 72 hours of admission or discharge (A 83%, B 78%, C 59%, D 72%, and E 72%). Of the exams performed within ≤ 72 hours, overall, 41% were partially complete (A 55%, B 37%, C 44%, D 25%, and E 42%). Notably, the frequency of partial exams was lower at admission than at discharge for people with tSCI (37% v. 44%) and NTSCI (25% v. 42%). When reviewing the presence or absence of individual items from partial exams, the rectal components (voluntary anal contraction and deep anal pressure) had the highest rate of absence (44%), and the motor scores had the highest rate of presence (92%). Conclusion: We thoroughly detailed ISNCSCI exam use throughout the care continuum and identified vast differences in exam use and completeness at different time points in care. Further work is needed to determine barriers to completion at these different time points and establish consensus on the ISNCSCI elements considered clinically important to collect, given these variations and the implications for clinical care.

summary A group of 15 patients with amputee-related diagnoses were given a satisfaction survey after telemedicine assessment. Most of the videoconferencing sessions used an IP connection at 768 kbit/s. The patients were seen at four sites. The average connection time was less than 5min and the average time for a session was approximately 40min. Thirteen questions required scaled responses (poor, fair, good, excellent) and two required yes/no answers. The 13 categories broadly related to satisfaction with the telemedicine service and the quality of specialist care. In all categories, 97% of the responses fell in the good to excellent range. Concerns were raised about ease of access to local telemedicine sites, connection waiting times and lack of familiarity with telemedicine technology. The study showed that telemedicine was acceptable to patients with amputations and provided a reliable assessment of the amputee.