Spinal cord injury and co-occurring traumatic brain injury: assessment and incidence

Macciocchi S, Seel RT, Thompson N, Byams R, Bowman B. Spinal cord injury and co-occurring traumatic brain injury: assessment and incidence.

Objectives

To examine prospectively the incidence and severity of co-occurring traumatic brain injury (TBI) in persons with traumatic spinal cord injury (SCI) and to describe a TBI assessment process for SCI rehabilitation professionals.

Design

A prospective, cohort design to collect and analyze clinical variables relevant for diagnosing co-occurring TBI.

Setting

An urban, single-center National Institute of Disability and Rehabilitation Research Model Spinal Cord Injury System in the Southeastern United States.

Participants

People (N=198) who met inclusion criteria and provided consent within an 18-month recruitment window.

Interventions

Not applicable.

Main Outcome Measure

FIM cognitive scale.

Results

Based on participants' presence and duration of posttraumatic amnesia, initial Glasgow Coma Scale total score, and presence of cerebral lesion documented by neuroimaging, 60% of our traumatic SCI sample also sustained a TBI (n=118). Most co-occurring TBIs were mild (34%). Co-occurring mild complicated (10%), moderate (6%), and severe TBI (10%) were less common but still occurred in a significant percentage (26%) of persons with traumatic SCI. Persons with traumatic SCI who were injured in motor vehicle collisions and falls were more likely to sustain a co-occurring TBI. Cervical level traumatic SCI was associated with greater rates of TBI but not more severe injuries. Tree analyses established a practical algorithm for classifying TBI severity associated with traumatic SCI. Analysis of variance established criterion validity for the algorithm's TBI severity classifications.

Conclusions

Findings from our prospective study provide strong support that TBI is a common co-occurring injury with traumatic SCI. Incomplete acute care medical record documentation of TBI in the traumatic SCI population remains a considerable issue, and there is a significant need to educate emergency department and acute care personnel on the TBI clinical data needs of acute rehabilitation providers. A systematic algorithm for reviewing acute care medical records can yield valid estimates of TBI severity in the traumatic SCI population.     

A Multivariate Examination of Temporal Changes in Berg Balance Scale Items for Patients With ASIA Impairment Scale C and D Spinal Cord Injuries

Datta S, Lorenz DJ, Morrison S, Ardolino E, Harkema SJ. A multivariate examination of temporal changes in Berg Balance Scale items for patients with ASIA Impairment Scale C and D spinal cord injuries.

Objective

To provide a multivariate examination of the Berg Balance Scale (BBS) in patients with spinal cord injury (SCI) as a first step in developing a balance tool for the SCI population.

Design

Observational cohort.

Setting

The NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for patients with SCI.

Participants

Patients (N=97) with American Spinal Injury Association Impairment Scale C or D SCI who were enrolled in the NRN between March 1, 2005, and June 12, 2007.

Interventions

All enrolled patients received 3 to 5 locomotor training sessions a week, according to NRN protocol, and were periodically evaluated for progress on functional outcome measurements.

Main Outcome Measures

Scores on the items of the BBS, six-minute walk test distances, ten-meter walk test speeds, and scores on the SCI Functional Ambulation Index. Temporal rates of change of the BBS items were examined with a principal components and correlation analysis.

Results

The first principal component accounted for nearly half of the overall variability in the BBS, correlated well with rates of change in functional mobility measures, and had good stability in its composition as verified by a resampling analysis. Further analysis showed that the composition of the first principal component varied with the patient's level of recovery.

Conclusions

The BBS captures a significant amount of information about balance recovery in persons with SCI and may be a good foundation for a balance tool. However, the utility of BBS items may be dependent on a patient's level of recovery. A dynamic balance instrument for the SCI population may be needed.     

Clinical correlates of elevated serum concentrations of cytokines and autoantibodies in patients with spinal cord injury

Davies AL, Hayes KC, Dekaban GA. Clinical correlates of elevated serum concentrations of cytokines and autoantibodies in patients with spinal cord injury.

Objective

To determine the serum cytokine profiles of patients with spinal cord injury (SCI) and varying clinical presentations relative to healthy, able-bodied, age-matched control subjects.

Design

Cross-sectional study.

Setting

Clinical research unit.

Participants

People with SCI (N=56) and different clinical presentations, and healthy, able-bodied, age-matched control subjects (N=35).

Interventions

Not applicable.

Main Outcome Measures

Serum levels of the proinflammatory cytokines interleukin (IL) 1β, IL-6, tumor necrosis factor alpha (TNF-α), the anti-inflammatory cytokines IL-4 and IL-10, the regulatory cytokine IL-2, the IL-1 receptor antagonist (IL-1RA), and autoantibodies against myelin-associated glycoprotein and GM₁ ganglioside (anti-GM₁) immunoglobulin (IgG and IgM), as determined by enzyme-linked immunosorbent assay. The relationship between elevated serum cytokine levels and clinical variables was also studied.

Results

SCI subjects exhibited serum concentrations of IL-6, TNF-α, IL-1RA, and anti-GM₁ (IgG) that were greater (P<.05) than control group values. Elevated cytokine concentrations were not associated with high white blood cell counts, level of injury, or American Spinal Injury Association classification; they were evident in SCI subjects who were asymptomatic for medical complications, but were further elevated in subjects with pain, urinary tract infection (UTI), and pressure ulcers.

Conclusions

Elevated levels of circulating proinflammatory cytokines and autoantibodies are present in the serum of SCI subjects without medical complications, and are further elevated in SCI subjects with neuropathic pain, UTI, or pressure ulcers, relative to healthy, able-bodied control subjects. These findings may be indicative of a protective autoimmunity, simply a consequence of occult or evident infection, or evidence of cytokine dysregulation that may contribute to an immune-mediated impairment of axonal conduction.     

Impact of associated conditions resulting from spinal cord injury on health status and quality of life in people with traumatic central cord syndrome

Noonan VK, Kopec JA, Zhang H, Dvorak MF. Impact of associated conditions resulting from spinal cord injury on health status and quality of life in people with traumatic central cord syndrome.

Objective

To determine the effect of associated spinal cord injury (SCI) conditions on the health status and quality of life (QOL) in people with traumatic central cord syndrome.

Design

Cross-sectional design.

Setting

Community-based.

Participants

Subjects (N=70) with traumatic central cord syndrome who were a minimum of 2 years postinjury.

Interventions

Not applicable.

Main Outcome Measures

Presence of associated SCI conditions (neuropathic pain, spasticity, bowel, bladder, and/or sexual dysfunction, decreased motor function); health status (36-Item Short-Form Health Survey [SF-36], symptom satisfaction); and QOL.

Results

The SF-36 physical component score (PCS) was lower in subjects who reported problems with bowel, bladder, and/or sexual function (−6.9; 95% confidence interval [CI], −11.6 to −2.2). The PCS was decreased in subjects with a lower motor score and this relationship was negatively affected by spasticity and being less educated. The SF-36 mental component score was negatively affected by neuropathic pain and a lower motor score. Neuropathic pain and a lower motor score were both associated with subjects being dissatisfied with their symptoms. Subjects who had a higher motor score were more likely to have a higher QOL (odds ratio, 1.7; 95% CI, 1.1 to 2.7).

Conclusions

The associated SCI conditions bowel, bladder, and/or sexual dysfunction, neuropathic pain, decreased motor function, and spasticity negatively affect the health status of persons with traumatic central cord syndrome. Diminished motor recovery was the only associated SCI condition to impact QOL. By developing a conceptual model and adjusting for confounders, an estimate for each associated SCI condition's effect on patient outcomes was obtained. Our results indicate the importance of treating or ameliorating associated SCI conditions in order to maximize physical and mental functioning.     

Effects of Multijoint Spastic Reflexes of the Legs During Assisted Bilateral Hip Oscillations in Human Spinal Cord Injury

Onushko T, Hyngstrom A, Schmit BD. Effects of multijoint spastic reflexes of the legs during assisted bilateral hip oscillations in human spinal cord injury.

Objective

To investigate the timing and magnitude of muscle activation during an active-assist bilateral hip motor task in human spinal cord injury (SCI).

Design

A single test session using a novel robotic system to alternately flex and extend the hips from 40° of hip flexion to 10° of hip extension at 1 of 3 frequencies (.25, .50, .75Hz). Subjects were asked either to actively assist the movements or to remain relaxed during the imposed oscillations.

Setting

All data were collected in a research laboratory.

Participants

Ten subjects with motor incomplete (American Spinal Injury Association grade C or D) SCI and 10 individuals without neurologic injury participated in this study.

Interventions

Not applicable.

Main Outcome Measures

Electromyograms and joint torques were recorded from the lower extremities of SCI subjects and compared with electromyograms and joint torque patterns recorded from 10 neurologically healthy individuals completing the same tasks.

Results

In trials involving active assistance of the imposed hip oscillations, SCI subjects produced muscle activation patterns that were phased differently from muscle activity of neurologically intact subjects. SCI subjects generated peak torque at the end ranges of movement (ie, 40° hip flexion, 10° extension), whereas control subjects generated the greatest torque midway through the movements. Moreover, the phasing of active-assist hip torque in SCI subjects was similar to the phasing of reflexive hip torques produced during the unassisted condition (ie, SCI subjects instructed to relax), while control subjects produced no reflexive torques during unassisted trials.

Conclusions

The differences in the timing of muscle activity during the active-assist task in controls and SCI subjects highlights problems in generating appropriately timed muscle activity during ongoing movements. The similarity in muscle activity patterns for the active-assist and unassisted trials in SCI subjects further suggests that reflex feedback from hip afferents contributes substantially to muscle activation during active-assist movements. These findings demonstrate the disruptions in reflex regulation of movement in people with incomplete SCI and suggest that spastic reflexes might disrupt motor control.     

Changes and determinants of life satisfaction after spinal cord injury: a cohort study in the Netherlands

van Koppenhagen CF, Post MW, van der Woude LH, de Witte LP, van Asbeck FW, de Groot S, van den Heuvel W, Lindeman E. Changes and determinants of life satisfaction after spinal cord injury: a cohort study in The Netherlands.

Objective

To determine the impact of spinal cord injury (SCI) on life satisfaction of persons with SCI 1 year after discharge of inpatient rehabilitation.

Design

A cohort study. Life satisfaction before SCI was retrospectively measured at the start of active rehabilitation. One year after discharge from inpatient rehabilitation, current life satisfaction was measured.

Setting

Eight rehabilitation centers in The Netherlands.

Participants

Persons (N=147) aged 18 to 65 and wheelchair-dependent at least for long distances.

Interventions

Not applicable.

Main Outcome Measure

The Life Satisfaction Questionnaire.

Results

Mean satisfaction with life ± SD as a whole was 5.3±0 before SCI and 4.3±1.3 one year after inpatient rehabilitation. Sexual life, self-care, and vocational situation showed the largest impact of SCI (P<.05), whereas the social relationships domains appeared to be the least affected. Decrease of life satisfaction after SCI was larger when using the retrospective ratings than when using general population scores. Significant determinants of life satisfaction after SCI were high lesion level (β=.31, P<.05), pain (β=.19, P<.05), and secondary impairments (β=.22, P<.05).

Conclusions

Life satisfaction decreased in persons with SCI. Level of lesion and suffering secondary impairments or pain were associated with low life satisfaction 1 year after discharge from inpatient rehabilitation.     

Dual Energy X-Ray Absorptiometry of the Distal Femur May Be More Reliable than the Proximal Tibia in Spinal Cord Injury

Morse LR, Lazzari AA, Battaglino R, Stolzmann KL, Matthess KR, Gagnon DR, Davis SA, Garshick E. Dual energy x-ray absorptiometry of the distal femur may be more reliable than the proximal tibia in spinal cord injury.

Objective

To evaluate the precision of dual energy x-ray absorptiometry scanning at 2 skeletal sites at the knee (proximal femur and distal tibia) in people with SCI.

Design

Cross-sectional.

Setting

Veterans Affairs Medical Center.

Participants

Subjects (N=20) with chronic SCI.

Interventions

Not applicable.

Main Outcome Measures

Precision as determined by root mean square coefficient of variation (RMS-CV) and root mean square standard deviation (RMS-SD).

Results

At the distal femur the root RMS-CV was 3.01% and the RMS-SD was 0.025g/cm². At the proximal tibia the RMS-CV was 5.91% and the RMS-SD was 0.030g/cm².

Conclusions

Precision at the distal femur is greater than at the proximal tibia and we recommend it as the preferred site for the longitudinal assessment of bone mineral density at the knee in chronic SCI.     

The effect of medial patellar taping on pain, strength and neuromuscular recruitment in subjects with and without patellofemoral pain

Objectives

Patellar taping is used by clinicians to reduce pain, increase strength and enhance neuromuscular recruitment in patients with patellofemoral pain. This study explored the effect of medial patellar taping on these parameters in physically active subjects with and without patellofemoral pain.

Study design

A placebo-controlled clinical trial with randomised interventions.

Setting

Sport Science Institute of South Africa.

Participants

Fifteen subjects with patellofemoral pain (experimental group) and 20 subjects without patellofemoral pain (healthy cohort).

Methods

Pain perception, quadriceps force output and electromyographic (EMG) data were collected during maximal quadriceps strength testing and submaximal step testing for each intervention.

Intervention

Subjects were tested during three different knee taping conditions: (1) no tape; (2) placebo tape; and (3) medial tape, in a randomised order.

Main outcome measures

Visual analogue scale (VAS), isokinetic and isometric force output, and EMG analysis.

Results

Medial patellar tape did not result in a significant reduction in pain during the step testing (step-up) in the group with patellofemoral pain (no tape condition: mean VAS 1.0, 95% confidence interval 0.30-1.70; taped condition: mean VAS 1.07, 95% confidence interval 0.22-1.91) or an increase in quadriceps force output. However, there was a significant decrease in EMG activity of the vastus medialis oblique in both groups during the closed chain step test (e.g. group with patellofemoral pain, no tape condition: mean 77%, 95% confidence interval 62-92%; taped condition: mean 64%, 95% confidence interval 53-75%, P < 0.05).

Conclusion

Although taping did not reduce pain in the patellofemoral pain group, it did enhance the efficiency of the vastus medialus oblique. Future studies should determine whether there are clinical benefits to these findings.     

Paraplegia after aortic aneurysm repair versus traumatic spinal cord injury: functional outcome, complications, and therapy intensity of inpatient rehabilitation

Yokoyama O, Sakuma F, Itoh R, Sashika H. Paraplegia after aortic aneurysm repair versus traumatic spinal cord injury: functional outcome, complications, and therapy intensity of inpatient rehabilitation.

Objective

To compare outcomes, complications, and therapy intensity of inpatient rehabilitation in patients with paraplegia caused by spinal cord injury associated with aortic aneurysm repair (SCI-AA) versus patients with traumatic spinal cord injury (SCI).

Design

Case-controlled study.

Setting

SCI unit in a rehabilitation center.

Participants

Seventeen patients with SCI-AA and 17 patients with traumatic SCI.

Intervention

Standard rehabilitation therapy for SCI.

Main Outcome Measures

Length of stay (LOS) in acute and rehabilitation hospitals; FIM instrument scores; FIM change; FIM efficiency; complications; therapy intensity; and ambulatory state and return to community at discharge.

Results

No significant differences were noted in acute and rehabilitation LOS and admission FIM scores. Discharge FIM scores, FIM change, and FIM efficiencies were significantly lower in the SCI-AA group, which had many complications related to AA and SCI. Intensity of rehabilitation sports therapy in the SCI-AA group was significantly lower than that of the traumatic SCI group, but total therapy intensity did not differ significantly. Both had similar rates of return to ambulatory state and discharge to the community.

Conclusions

SCI-AA patients had many complications that interfered with rehabilitation therapy, and could not achieve functional gains comparable to those with traumatic SCI. However, both groups achieved comparable success with return to ambulatory state and discharge to the community.     

Cognitive and Behavioral Impairment in Traumatic Brain Injury Related to Outcome and Return to Work

Benedictus MR, Spikman JM, van der Naalt J. Cognitive and behavioral impairment in traumatic brain injury related to outcome and return to work.

Objective

To evaluate the cognitive and behavioral disturbances related to return to work (RTW) in patients with traumatic brain injury (TBI) with the application of a differentiated outcome scale.

Design

Longitudinal cohort study.

Setting

Level I trauma center.

Participants

Adults (N=434) with TBI of various severity.

Interventions

Not applicable.

Main Outcome Measures

Extended Glasgow Outcome Scale (GOS-E), Differentiated Outcome Scale (DOS), and RTW.

Results

Patients encountered problems in the physical (40%), cognitive (62%), behavioral (55%), and social domains (49%) of the DOS, with higher frequency related to severity of injury. Even those with mild TBI experienced cognitive (43%) and behavioral problems (33%). Patients with good recovery (58%) according to the GOS-E experienced problems in 1 or more domains of the DOS. Half the patients were able to resume previous vocational activities completely, although 1 in 3 experienced cognitive or behavioral problems. Using multivariate logistic regression analysis, the cognitive (odds ratio [OR], 10.548; confidence interval [CI], 5.99-18.67), behavioral (OR, 2.648; CI, 1.63-4.29), and physical domains (OR, 2.763; CI, 1.60-4.78) were significant (P<.01) predictors of RTW. For subcategories of TBI, the cognitive domain was predictive for RTW in those with moderate and severe TBI, whereas both the cognitive and behavioral domains were predictive for RTW in those with mild TBI.

Conclusions

With application of a more detailed outcome scale, cognitive and behavioral impairments interfering with RTW were present in a substantial part of patients with TBI in the chronic phase after injury. More research is needed exploring the cognitive and behavioral outcome in different categories of injury severity separately.     

Expiratory Muscle Training in Spinal Cord Injury: A Randomized Controlled Trial

Roth EJ, Stenson KW, Powley S, Oken J, Primack S, Nussbaum SB, Berkowitz M. Expiratory muscle training in spinal cord injury: a randomized controlled trial.

Objective

To assess the effectiveness of expiratory muscle training on the pulmonary function of spinal cord injured patients.

Design

Randomized controlled trial.

Setting

Acute inpatient rehabilitation hospital.

Participants

Patients (N=29, 22 men and 7 women) with recent traumatic, motor complete, spinal cord injury (SCI) at or above level T1 consecutively admitted to an SCI rehabilitation service. Subjects were randomized to either resistance training (n=16) or sham training (n=13).

Interventions

The subjects completed either sham training or expiratory muscle resistive training with maximal expiratory force using a small handheld device, which is a tube with an aperture at the distal end, for 10 repetitions twice a day 5 days a week for a total of 6 weeks.

Main Outcome Measures

Pulmonary function tests were measured before and after the training program and included forced vital capacity (FVC); forced expiratory volume in 1 second (FEV1); maximum expiratory pressure (MEP), which is often referred to as forced expiratory pressure; maximum inspiratory pressure (MIP), which is often referred to as negative inspiratory force; inspiratory capacity (IC); expiratory reserve volume (ERV); total lung capacity (TLC); functional residual capacity (FRC); and residual volume (RV).

Results

FVC, FEV1, and ERV improved in both groups. Although exit values of MEP were improved in both groups compared with entry values, this increase was statistically significant only in the resistance training group. No significant improvements occurred in IC, TLC, FRC, or RV from entry to exit. MIP improved in both groups, but this increase was statistically significant only in the resistance training group. There was also a significant between-group difference in MEP exit values (98cmH₂O for the resistance training group and 59cmH₂O for the sham training group, t=3.45, P=.002). Multivariate analyses failed to reveal significant effects of treatment for any of the pulmonary function tests.

Conclusions

The resistance training group had significantly greater exit MEP values than the sham training group in univariate analysis only. However, improvements in pulmonary function were noted in both the resistance training and sham training groups. Although multivariate analysis failed to reveal a significant difference between groups, these findings offer some indication that expiratory training may benefit people with SCI.     

‘My brain couldn’t move from planning a birth to planning a funeral’: A qualitative study of parents’ experiences of decisions after ending a pregnancy for fetal abnormality

Background

With increasing technology for screening and diagnostic testing for fetal abnormality in pregnancy, many more pregnant women and couples are faced with the decision to terminate a pregnancy often after receiving diagnostic test results in the second or third trimester of pregnancy. Whilst there is extensive research on people's experience of diagnostic testing and decision-making, there has been less research on people's experiences of decisions they face immediately following their termination.

Objectives

To describe the experiences of (often unanticipated) decisions that people face in the immediate aftermath of ending a pregnancy following diagnosis of serious fetal abnormality.

Design

Secondary analysis of narrative qualitative interview data.

Settings

Participants were recruited throughout the United Kingdom (UK) and interviewed between 2004 and 2006.

Participants

38 individual mothers, 10 individual fathers and 10 couples who ended a pregnancy following diagnosis of fetal abnormality.

Results

Parents who had experienced the ending of a pregnancy following diagnosis of fetal abnormality described their experiences, and often distress, of facing painful decisions consequent upon their decision to terminate the pregnancy. What was striking from their accounts was their sense of being unprepared for these decisions. Often they suggested that they had received no information or forewarning of the ‘choices’ they would have to make, although information designed specifically for people in this situation is available in the UK.

Conclusions

Many of the decisions that people face in the immediate aftermath of a termination for fetal abnormality are upsetting, and in some circumstances more so because they are not anticipated. Often parents report not receiving information which could be helpful until after these decisions have been made. Health professionals face difficult choices about what issues to raise with patients at this sensitive time, and the optimum time to inform patients of the extra decisions they will face. More research is needed on whether these decisions subsequent to a termination for fetal abnormality have long term implications for people's mental health and their ability to come to terms with their loss.     

Intrarater test-retest reliability of hip range of motion and hip muscle strength measurements in persons with hip osteoarthritis

Pua YH, Wrigley TW, Cowan SM, Bennell KL. Intrarater test-retest reliability of hip range of motion and hip muscle strength measurements in persons with hip osteoarthritis.

Objective

To examine the relative and absolute intrarater test-retest reliability of muscle strength and range of motion (ROM) measurements of the hip performed in people with hip osteoarthritis.

Design

Repeated measures.

Setting

Human movement laboratory of a university.

Participants

Participants (N=22; 10 men, 12 women; age range, 50-84y) with hip osteoarthritis.

Interventions

On 2 separate occasions, at least 1 week apart, isometric torque measurements were obtained from the hip rotators, flexors, abductors, and extensors. Passive ROMs in hip rotation, flexion, abduction, and extension were also determined.

Main Outcome Measures

Relative reliability was estimated using the intraclass correlation coefficient, model 2,2 (ICC_2,2). Absolute reliability was estimated using the coefficient of variation (CV) and the standard error (SE) of measurement.

Results

For measurements of muscle strength, ICC_2,2 ranged from .84 to .97, and the CV ranged from 8% to 15.7%. Hip extensors and internal and external rotators showed high ICC_2,2 (>.96) and low CV (<9.8%); hip abductors showed the lowest ICC_2,2 (.84) and the highest CV (15.7%). For ROM measurements, ICC_2,2 ranged from .86 to .97 and SE ranged from 3.1° to 4.7°. Hip flexion ROM showed the highest ICC_2,2 (.97) and an SE of 3.5°; hip extension ROM showed the lowest ICC_2,2 (.86) and the highest SE (4.7°).

Conclusions

Strength and ROM testing of the hip in people with hip osteoarthritis can be performed with good to excellent reliability.     

The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation

Miller CA, Forrester GA, Lewis JS. The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation.

Objective

To investigate whether the lag signs were valid tools in diagnosing full-thickness tears of the rotator cuff.

Design

A same-subject, correlation, double-blinded design was used. The results of the external rotation lag sign, drop sign, and internal rotation lag sign were compared with the criterion standard of diagnostic ultrasound to establish their accuracy.

Setting

A regional orthopedic hospital.

Participants

Consecutive subjects (N=37), 21 women and 16 men, with shoulder pain referred to a consultant orthopedic surgeon specializing in shoulder conditions were recruited for this investigation.

Interventions

Not applicable.

Main Outcome Measures

Sensitivity, specificity, and positive and negative likelihood ratios of the lag signs when using ultrasound as the reference test.

Results

The specificities of the drop sign and internal rotation lag sign were 77% and 84%, respectively, which, together with low positive likelihood ratios 3.2 (95% confidence interval [CI], 1.5-6.7) and 6.2 (95% CI, 1.9-12.0), indicate that a positive result was poor at recognizing the presence of full-thickness tears. The drop sign had a sensitivity of 73% with a negative likelihood ratio of .34 (95% CI, 0.2-0.8), suggesting that a negative test was fair at ruling out the presence of full-thickness tears. The sensitivity of the internal rotation lag sign (100%) supported by the negative likelihood ratio of 0 (95% CI, 0.0-2.5) suggests that a negative test will effectively rule out the presence of full-thickness tears of the subscapularis. A positive external rotation lag sign is the clinical test most likely to indicate that full-thickness tears of the supraspinatus and infraspinatus are present (specificity, 94%). However, the external rotation lag sign did demonstrate a low sensitivity score of 46% and negative likelihood ratio of .57 (95% CI, 0.4-0.9), which means that a negative test will not rule out the presence of full-thickness tears.

Conclusions

The findings of this investigation suggest that a clinical diagnosis of a full-thickness tear of the rotator cuff cannot be conclusively reached using one or more of the lag signs.     

Longitudinal Changes in Physical Capacity Over 20 Years in Athletes With Spinal Cord Injury

Shiba S, Okawa H, Uenishi H, Koike Y, Yamauchi K, Asayama K, Nakamura T, Tajima F. Longitudinal changes in physical capacity over 20 years in athletes with spinal cord injury.

Objective

To investigate the longitudinal changes in physical capacity over 20 years in athletes with spinal cord injury (SCI).

Design

Longitudinal study (20-y follow-up).

Setting

Laboratory setting.

Participants

Persons with SCI (N=7).

Interventions

Not applicable.

Main Outcome Measures

Maximum oxygen consumption V?o₂max) measured in 1986-1988 and in 2006.

Results

Subjects with SCI maintained stable V?o₂max in 2006. Six of the 7 continued various wheelchair sports activities, while 1 person quit sports activities 1 year after the baseline study. The latter person showed reduced V?o₂max by 53%, while 2 persons who continued strenuous wheelchair sports activities showed increased V?o₂max by 43% and 45% after 20 years.

Conclusion

The results indicated that physical capacity reflected the level of sports activity in subjects with SCI who maintained sports activities.     

Predictors of disrupted social participation in myotonic dystrophy type 1

Gagnon C, Mathieu J, Jean S, Laberge L, Perron M, Veillette S, Richer L, Noreau L. Predictors of disrupted social participation in myotonic dystrophy type 1.

Objective

To identify personal and environmental predictors of the most disrupted participation domains in people with myotonic dystrophy type 1 (DM1).

Design

Cross-sectional study.

Setting

Outpatient neuromuscular clinic.

Participants

Adults (n=200; 121 women), age 18 years or older (mean age, 47y), with a confirmed diagnosis of DM1 were selected from the registry of a neuromuscular clinic (N=416). Fifty-two participants had the mild phenotype and 148 the adult phenotype.

Interventions

Not applicable.

Main Outcome Measures

Social participation in mobility, housing, employment, and recreation was assessed with the Life Habits Measure. Disrupted participation was based on whether help was needed in performing most life habits because of incapacities or environmental barriers. Environmental factors were assessed by using the Measure of the Quality of the Environment. Personal factors were assessed with standardized instruments including the Berg Balance Scale, the Krupp Fatigue Severity Scale, and manual muscle testing.

Results

A large proportion of participants (45%-61%) reported disrupted participation in all 4 domains. Lower-extremity strength (odd ratios [OR], 15.0-5.5; P<.050) and higher fatigue (OR, 6.0-2.6; P<.05) were present in participants with disrupted participation. With regard to environmental factors, family support (OR, 3.6-2.5; P<.05) and public services (OR, 2.8-2.2; P<.05) were perceived as barriers for participants with disrupted participation in most domains.

Conclusions

This study identified personal and environmental factors that may influence the trajectory toward disrupted participation in individuals with DM1. Fatigue, strength, family support, and public services were found to be independent predictors of disrupted participation.     

Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury

Brose SW, Boninger ML, Fullerton B, McCann T, Collinger JL, Impink BG, Dyson-Hudson TA. Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury.

Objectives

To investigate the presence of ultrasound (US) abnormalities in manual wheelchair users with spinal cord injury (SCI) using a quantitative Ultrasound Shoulder Pathology Rating Scale (USPRS). To investigate physical examination (PE) findings using a quantitative Physical Examination of the Shoulder Scale (PESS), and to obtain data about pain and other subject characteristics such as age, years with SCI, and weight.

Design

Case series.

Setting

National Veterans' Wheelchair Games 2005 and 2006.

Participants

Volunteer sample of manual wheelchair users with SCI participating in the National Veterans' Wheelchair Games.

Interventions

Not applicable.

Main Outcome Measures

Presence of relationships between US findings, PE findings, pain, and subject characteristics.

Results

The USPRS correlated with age, duration of SCI, and weight (all P<.01), and showed a positive trend with the total Wheelchair User's Shoulder Pain Index (WUSPI) score (r=.258, P=.073). Several US findings related to presence of PE findings for specific structures. The PESS score correlated with the WUSPI (r=.679, P<.001) and duration of SCI (P<.05). The presence of untreated shoulder pain that curtailed activity was noted in 24.5% of subjects, and this was related to increased WUSPI scores (P=.002).

Conclusions

PE and US abnormalities are common in manual wheelchair users with SCI. The USPRS and PESS demonstrated evidence for external validity and hold promise as research tools. Untreated shoulder pain is common in manual wheelchair users with SCI, and further investigation of this pain is indicated.