Influence of age and gender on rehabilitation outcomes in nontraumatic spinal cord injury

STUDY DESIGN: Retrospective, 3-year case series. OBJECTIVE: To investigate the relationship between gender and age and a range variables in patients with nontraumatic spinal cord injury (SCI). SETTING: Tertiary medical unit specializing in rehabilitation of patients with nontraumatic SCI. METHOD: Participants were a consecutive series of 70 adult inpatients with nontraumatic SCI undergoing initial rehabilitation. The variables of interest were demographic characteristics, clinical features, complications, mortality, length of stay (LOS), mobility, bladder and bowel continence, and Functional Independence Measure (FIM) scores. RESULTS: Men were younger than women, but the difference was not statistically significant (median 64 years vs 72.5 years, P= 0.2). There was no statistically significant relationship between age or gender and the following: American Spinal Injury Association grade, level of injury, many SCI complications, mortality, LOS, walking ability, bladder management, and fecal continence. The only SCI complication that was related to age was pressure ulcers (<65 years = 20% vs >65 years = 50%, P = 0.04). Patients discharged home were more likely to be younger (P = 0.01) and male (P = 0.03). There was a significant negative correlation between patients' age and the discharge Rasch-transformed FIM motor (Spearman's p = -0.30, P = 0.015) and cognitive (Spearman's p = -0.25, P = 0.04) subscores. There were no significant relationships between gender and FIM subscale scores. CONCLUSIONS: Gender and age do not significantly influence most aspects of rehabilitation in patients with nontraumatic SCI. Age alone should not be used as a discriminator of ability to benefit from nontraumatic SCI rehabilitation.     

Measuring pain phenomena after spinal cord injury: Development and psychometric properties of the SCI-QOL Pain Interference and Pain Behavior assessment tools

Objective: To develop modern patient-reported outcome measures that assess pain interference and pain behavior after spinal cord injury (SCI).

Design: Grounded-theory based qualitative item development; large-scale item calibration field-testing; confirmatory factor analyses; graded response model item response theory analyses; statistical linking techniques to transform scores to the Patient Reported Outcome Measurement Information System (PROMIS) metric.

Setting: Five SCI Model Systems centers and one Department of Veterans Affairs medical center in the United States.

Participants: Adults with traumatic SCI.

Interventions: N/A.

Outcome Measures: Spinal Cord Injury - Quality of Life (SCI-QOL) Pain Interference item bank, SCI-QOL Pain Interference short form, and SCI-QOL Pain Behavior scale.

Results: Seven hundred fifty-seven individuals with traumatic SCI completed 58 items addressing various aspects of pain. Items were then separated by whether they assessed pain interference or pain behavior, and poorly functioning items were removed. Confirmatory factor analyses confirmed that each set of items was unidimensional, and item response theory analyses were used to estimate slopes and thresholds for the items. Ultimately, 7 items (4 from PROMIS) comprised the Pain Behavior scale and 25 items (18 from PROMIS) comprised the Pain Interference item bank. Ten of these 25 items were selected to form the Pain Interference short form.

Conclusions: The SCI-QOL Pain Interference item bank and the SCI-QOL Pain Behavior scale demonstrated robust psychometric properties. The Pain Interference item bank is available as a computer adaptive test or short form for research and clinical applications, and scores are transformed to the PROMIS metric.     

Apolipoprotein E s4 Allele and Outcomes of Traumatic Spinal Cord Injury

Abstract

Background/Objective: To test the hypothesis that apolipoprotein E (APOE) polymorphisms are associated with outcomes after spinal cord injury (SCI).

Methods: Retrospective cohort study, from rehabilitation admission to discharge.

Participants: Convenience sample of 89 persons with cervical SCI (C3-C8) treated from 1995 through 2003. Median age was 30 years (range 14-70); 67 were male (75%) and 83 were white (93%).

Main Outcome Measures: American Spinal Injury Association (ASIA) motor and sensory scores, ASIA Impairment Scale (AIS), time from injury to rehabilitation admission, and length of stay (LOS) in rehabilitation.

Results: Subjects with an APOE s4 allele (n = 15; 17%) had significantly less motor recovery during rehabilitation than did individuals without an s4 allele (median 3.0 vs 5.5; P < 0.05) and a longer rehabilitation LOS (median 106 vs 89 days; P = 0.04), but better sensory-pinprick recovery (median 5.0 vs 2.0; P = 0.03). There were no significant differences by APOE s4 allele status in sensory-light touch recovery, likelihood of improving AIS Grade, or time from injury to rehabilitation admission.

Conclusions: APOE ε4 allele was associated with differences in neurological recovery and longer rehabilitation LOS. Genetic factors may be among the determinants of outcome after SCI and warrant further study.     

Prevalence of Spinal Cord Injury in Tehran,Iran

Abstract

Background/Objective: To determine the prevalence of traumatic spinal cord injury (SCI) in Tehran, Iran.

Methods: A population-based study was performed. In a random cluster sampling, 100 addresses were selected as the starting point of the survey for each cluster consisting of 25 households. To expand the geographic dimension of each cluster, the interviewers skipped 3 of 4 houses in gathering data for each study unit. Each person with traumatic SCI was evaluated initially by a nurse and then by a neurosurgeon by physical examination and spinal imaging at the hospital or at home.

Results: Ninety-seven percent of all surveyed agreed to participate in the study (2,425 households, or 9,006 persons). Four cases of SCI were identified. The point prevalence of SCI was 4.4 [95% CI = 1.2-11.4] per 10,000 people. Over the 5-year period from January 2003 through January 2008, the reported incidence rate of SCI was 2.2 (95% Cl = 0.27-8.00) per 10,000 people.

Conclusions: In this, the first published population-based study from Iran, the prevalence of traumatic SCI in Tehran ranged from 1.2 to 11.4 per 10,000 people. More research is required to determine the patterns and causes of SCI. Development of a nationwide SCI registry or surveillance system is fundamental to an understanding of the epidemiology, and hence the prevention, of this costly health problem.     

Predictors of Pressure Ulcer Recurrence in Veterans With Spinal Cord Injury

Background/Objective:     

Prevalence of Spinal Cord Injury in Tehran,Iran

Background/Objective:

To determine the prevalence of traumatic spinal cord injury (SCI) in Tehran, Iran.

Methods:

A population-based study was performed. In a random cluster sampling, 100 addresses were selected as the starting point of the survey for each cluster consisting of 25 households. To expand the geographic dimension of each cluster, the interviewers skipped 3 of 4 houses in gathering data for each study unit. Each person with traumatic SCI was evaluated initially by a nurse and then by a neurosurgeon by physical examination and spinal imaging at the hospital or at home.

Results:

Ninety-seven percent of all surveyed agreed to participate in the study (2,425 households, or 9,006 persons). Four cases of SCI were identified. The point prevalence of SCI was 4.4 [95% CI  =  1.2–11.4] per 10,000 people. Over the 5-year period from January 2003 through January 2008, the reported incidence rate of SCI was 2.2 (95% CI  =  0.27–8.00) per 10,000 people.

Conclusions:

In this, the first published population-based study from Iran, the prevalence of traumatic SCI in Tehran ranged from 1.2 to 11.4 per 10,000 people. More research is required to determine the patterns and causes of SCI. Development of a nationwide SCI registry or surveillance system is fundamental to an understanding of the epidemiology, and hence the prevention, of this costly health problem.     

Psychosocial Outcomes Among Youth with Spinal Cord Injury and Their Primary Caregivers

Background:

Past research has found youth with disabilities to experience poor psychosocial outcomes, but little is known about factors related to psychosocial health among youth with spinal cord injury (SCI).

Objective:

To describe psychosocial health among youth with SCI, examine relationships between psychosocial outcomes and demographic and injury-related factors, and examine relationships between aspects of psychosocial health. Youth activity, participation, quality of life (QOL), coping, anxiety and depression, and caregiver mental health were included.

Methods:

Data were collected as part of a prospective study of 420 youth with SCI ages 1-18 and their primary caregivers. Activity data were also presented from a study developing a computerized adaptive testing (CAT) platform with 226 youth with SCI ages 8-21.

Results:

Although relationships varied by factor, youth outcomes were related to youth age, sex, age at injury/injury duration, and level/extent of injury. Caregiver mental health related to child age and age at injury. Further, relationships were uncovered between aspects of psychosocial health: aspects of youth mental health were related to youth participation and QOL, youth coping was related to youth mental health, participation, and QOL, and caregiver mental health was related to child mental health and QOL.

Conclusion:

Psychosocial outcomes relate to each other and vary by child and injury-related factors and should be understood in a comprehensive, developmental context. Identifying best measures of activity and psychosocial functioning among youth with SCI and understanding factors related to their psychosocial health is critical to improving outcomes for the pediatric-onset SCI population.     

腺苷在继发性脊髓损伤中的作用及其机制

目的 通过观察大鼠脊髓损伤后内源性腺苷含量的变化,以及外源性腺苷地脊髓损伤后神经功能的影响,探讨腺苷在髓继发性损伤中的作用。方法 采用大鼠Ｔ１３脊髓腹侧压迫模型,用微透析技术每２０分钟连续收集脊髓损伤后脊髓组织细胞上液,用高效液相色谱仪紫外检测法检测细胞外液腺式的含量;伤前１４分钟蛛网膜下腔给予非特异性腺苷受体激动剂２－氯腺苷,观察伤后神经功能评分、倾斜平面临界角和组织学变化。结果 脊髓损伤后腺苷     

Trunk Function and Ischial Pressure Offloading in Individuals with Spinal Cord Injury

Objective: To determine if there is a relationship between trunk function and offloading of the ischial tuberosities in individuals with Spinal Cord Injury (SCI).

Design: Prospective cross-sectional evaluation.

Setting: Sub-acute rehabilitation hospital.

Participants: Fifteen non-ambulatory participants with complete or incomplete traumatic and non-traumatic SCI, American Spinal Injury Association Impairment Scale (AIS), Classification A-D.

Outcome Measures: Isometric trunk strength using a hand held dynamometer, the ability to reach using the multidirectional reach test and offloading times of the ischial tuberosities using a customized pressure mat.

Results: Participants who were able to engage in the multidirectional reach test were defined as “Reachers”, whereas individuals who were unable to engage in the multidirectional reach test were defined as “Non-Reachers”. Trunk strength was significantly higher in Reachers compared with Non-Reachers (P < 0.05). Offloading times over the left and right ischial tuberosities were lower in Non-Reachers when compared with Reachers, however the results were statistically significant only for offloading over the right ischial tuberosity (P < 0.05). There was no correlation between trunk strength and pressure offloading times for both groups.

Conclusions: Regardless of an individual's ability to engage in a reaching task, participants with spinal cord injury spent more time offloading the left ischial tuberosity compared with the right ischial tuberosity. The study highlights the need to identify factors that may contribute to offloading behavior in individuals with spinal cord injury who lack sufficient trunk strength.     

Prevention of Thromboembolism in Spinal Cord Injury

Abstract

Background: Prion diseases or transmissible spongiform encephalopathies (TSEs) are neurodegenerative syndromes caused by proteinaceous infectious particles (or “prions”), are fatally progressive, and affect humans and animals. Human prion disease may be familial, sporadic, or due to iatrogenic causes. The signs and symptoms include dementia, ataxia, myoclonus, dysautonomia, pyramidal and extrapyramidal tract signs, and akinesia. The incubation period of iatrogenic TSE ranges from 15 months to 30 years, and clinical presentations may be atypical.

Design: Case report.

Findings: This article presents the case study of a 39-year-old man who fell at work and subsequently complained of subjective lower extremity weakness, followed by onset of ataxia, bowel and bladder incontinence, and progressive decline in ambulation over 6 months. In the absence of a unifying diagnosis, the patient was presumed to have had a spinal cord injury (SCI). Because neuro-axis imaging studies fail ed to explain his symptoms, the patient's complaints were thought to have a large psychologic component. The patient then developed neurologic abnormalities proximal to the presumed SCI. Somatosensory evoked potentials were suggestive of a thoracic or lumbar cord myelopathy and cerebrospinal fluid analysis was suggestive of prion disease. Family members eventually revealed that the patient had had injections of growth hormones derived from cadaveric human pituitary glands as a child. Postmortem brain examination later revealed definitive Creutzfeldt-Jakob disease.     

Development and initial evaluation of the SCI-FI/AT

ObjectivesTo describe the domain structure and calibration of the Spinal Cord Injury Functional Index for samples using Assistive Technology (SCI-FI/AT) and report the initial psychometric properties of each domain.DesignCross sectional survey followed by computerized adaptive test (CAT) simulations.SettingInpatient and community settings.ParticipantsA sample of 460 adults with traumatic spinal cord injury (SCI) stratified by level of injury, completeness of injury, and time since injury.InterventionsNoneResultsConfirmatory factor analysis (CFA) and Item response theory (IRT) analyses identified 4 unidimensional SCI-FI/AT domains: Basic Mobility (41 items) Self-care (71 items), Fine Motor Function (35 items), and Ambulation (29 items). High correlations of full item banks with 10-item simulated CATs indicated high accuracy of each CAT in estimating a person''s function, and there was high measurement reliability for the simulated CAT scales compared with the full item bank. SCI-FI/AT item difficulties in the domains of Self-care, Fine Motor Function, and Ambulation were less difficult than the same items in the original SCI-FI item banks.ConclusionWith the development of the SCI-FI/AT, clinicians and investigators have available multidimensional assessment scales that evaluate function for users of AT to complement the scales available in the original SCI-FI.     

神经节苷脂有髓损伤的保护作用观察

目的：观察神经节苷脂对损伤脊髓神经组织的保护作用,并初步探讨其作用机制。方法：重度脊髓损伤大鼠随机分为对照组及神经节苷脂治疗组（n=15)。在蛛网膜下腔注射生理盐水20μl或神经节苷脂30μg。观察体重变化局部血流量、凋亡细胞原位标记、神经功能评价和定量组织学分析。结果：局部血流量2组无明显差异,治疗组存活8率、体重、神经功能评分和残余神经组织面积明显高于对照组,而TUNEL阳性细胞数量明显低于对照组。结论：神经节苷脂对损伤脊髓组织有明显保护作用,可能是通过对神经细胞凋亡的阻断来发挥作用的。     

Fever During Rehabilitation in Patients With Traumatic Spinal Cord Injury: Analysis of 392 Cases From a National Rehabilitation Hospital in Turkey

Objective:

To determine the incidence and etiology of fever and the risk factors related to fever in adults with spinal cord injury (SCI) at the rehabilitation stage.

Design/Subjects:

A retrospective examination of records of 392 consecutive adult patients with traumatic SCI who received inpatient rehabilitation program.

Setting:

A national rehabilitation center in Turkey.

Outcome Measures:

Incidence and etiology of fever, period of hospitalization (days).

Results:

A total of 187 patients (47.7%) had fever at least once during their rehabilitation program. The most common etiology was urinary tract infection. The rate of fever occurrence was significantly higher in patients with complete SCI (P  =  0.001). In patients with fever, the use of an indwelling catheter was significantly higher compared with clean intermittent catheterization and spontaneous voiding (P  =  0.001). The hospitalization period of patients with fever was significantly longer than that of patients without fever (P  =  0.006).

Conclusions:

A high rate of fever was seen in patients with SCI during rehabilitation. Fever was caused by various infections, of which urinary tract infection was the most common. Patients with motor complete injuries and those with permanent catheters constituted higher risk groups. Fever prolonged the length of rehabilitation stay and hindered active participation in the rehabilitation program.     

Perceived Quality of Care and Outcomes Following Spinal Cord Injury: Minority Status In The Context Of Multiple Predictors

Abstract

Objective: T o determine whether patients with spinal cord injury (SCI) who are members of minority groups experience a disadvantage with regard to quality of care, and investigate predictors of perceived quality of care and indicators of outcome.

Design: Correlational analysis of longitudinal data.

Sample: One hundred and forty-three individuals with SCI in the first year following injury (43.3 % tetraplegia, 56.7% paraplegia; 53.6% of total had complete injuries).

Setting: Hospital and post discharge (usually outpatient) care at 3 SCI model systems.

Main Outcome Measures: Perceived quality of acute, rehabilitative, and continuing care rated by patients according to standardformat. Objective indicators of amount of care (eg, length of stay [LOS], charges) and outcomes (eg, medical complications,Functional lndependence Measure [FIM] scores, a life satisfaction measure [the Diener Scale], and the Craig Handicap and Reporting Technique [CHART; a community participation scale]).

Results: Minorities did not report statistically significant differences in perceived quality of care or other indicators (eg, amount ofcare, medical complications, FIM gain, life satisfaction, and CHART scores) compared with other groups. Severity ofinjury affected LOS and activity outcomes. Satisfaction with medical care before the injury significantly predicted perceived quality of acute hospital care, inpatient rehabilitation, and continuing ca re (P < 0.03, 0.02, and 0.02, respectively) .

Conclusion: A number of factors may affect variations in perceived quality of care and outcomes, but ethnicity is not always the most important predictor. Asking patients about their satisfaction with previous care can assist in distinguishing satisfaction with currentcare from pre-existing biases.     

Physical Activity and Quality of Life in Adults With Spinal Cord Injury

Background/Objective: To document the relationship between level of physical activity and quality of life in persons with spinal cord injury.

Design: Cross-sectional investigation.

Participants/Methods: Men (n = 32) and women (n = 30) with complete and incomplete spinal cord lesions below C6 volunteered to participate in this study. The average length of time since the onset of disability was 9 years (range, 1.5-40 years). Using an interview-formatted survey (Quality of Well-Being Scale), a measure of quality of life was obtained for each participant. Physical activity levels were determined using the Physical Activity Scale for Individuals with Physical Disabilities.

Results: A strong positive association (r= 0.75; P < 0.05) was observed between level of physical activity and quality of life. Multiple regression analysis also showed that when level of physical activity, anatomical location of the injury, completeness of injury, and time since injury were used as explanatory variables, level of physical activity was the only significant predictor of quality of life, accounting for 56% of the total variation in quality of life.

Conclusions: Results from this study show that a significant and moderately strong positive relationship exists between level of physical activity and quality of life in adults with spinal cord injury. From a clinical perspective, these findings suggest that interventions aimed at promoting physical activity may be effective in improving quality of life in this population.     

Outcome Measures for Gait and Ambulation in the Spinal Cord Injury Population

Background:     

Outcome Measures for Gait and Ambulation in the Spinal Cord Injury Population

Background: At the 2006 National Institute on Disability and Rehabilitation Research (NIDRR) sponsored pre-conference on spinal cord injury (SCI) outcomes, several gait and ambulation measures were evaluatedfor utility in clinical practice, validity, and reliability as research measurement tools. The Conference Subcommittee on Gait and Ambulation chose to review the Walking Index for Spinal Cord Injury II (WISCIII), 50-Foot Walk Test (50FTWT), 6-Minute Walk Test (6MWT), 10-Meter Walk Test (1 OMWT), andFunctional Independence Measure-Locomotor (FIM-L).

Methods: A subcommittee of international experts evaluated each instrument for test construct,administration, population applicability, reliability, sensitivity to change, and validity. Evaluations for eachoutcome measure were compiled, distributed to the whole committee, and then further reviewed withaddition of comments and recommendations for consensus. An audience of experts voted on the validity and usefulness of each measure.

Results: WISCI II and 1 OMWT were found to be the most valid and clinically useful tests to measureimprovement in gait for patients with SCI. FIM-L had little utility and validity for research in SCI. 6MWT and50FTWT were found to be useful but in need of further validation or changes for the SCI population.

Conclusion: A combination of the 1 OMWT and WI SCI II would provide the most valid measure of improvement in gait and ambulation in as much as objective changes of speed, and functional capacity allow for interval measurement. To provide the most comprehensive battery, however, it will be importantto include a measure of endurance such as the 6MWT. Further validation and study should be devoted toWISCI II, 1 OMWT, and 6MWT as primary outcome measuresfor gait in SCI.