Statewide Investigation of Medically Attended Adverse Health Conditions of Persons With Spinal Cord Injury

Abstract

Background/Objective: To report over a 10-year period the statewide prevalence and incidence of medically attended adverse health conditions in people with new traumatic spinal cord injury (TSCI).

Design: Retrospective cohort study.

Methods: (a) Identified all new TSCI cases discharged alive from statewide acute care hospitals, 1996 to 2000, using ICD-9-CM methodology, (b) Followed cases from 1996 to 2005 to quantify medically attended health conditions documented during emergency department visits, acute care hospitalizations, and outpatient hospital visits, (c) Used the life table method to calculate the prevalence and incidence of health conditions, (d) Examined Cox proportional hazard ratio of mortality by gender controlling for age and TSCI severity.

Results: Nine hundred eighty-eight residents (257 women, 731 men) with TSCI were alive 90 days after discharge from acute care hospitalization from 1996 to 2000. Nine hundred twenty-three (251 female, 672 male) (93.4%) residents had an observed medically attended adverse health condition in the 10-year follow-up period. The most prevalent classes of diseases and disorders were (a) muscle and connective tissue, (b) renal and urinary, (c) digestive, (d) circulatory, (e) respiratory, (f) endocrine/nutritional/metabolic, and (g) infectious. Incidence of new injury was 29.0% for males and 26.9% for females. During the follow-up period, 49 women (19%) and 104 men (14%) died.

Conclusions: People with TSCI experience diverse adverse health conditions in the 10 years after initial injury. An interdisciplinary health care provider team approach to allocating resources and implementing countermeasures to prevent or limit occurrence of these conditions is vital to these patients’ continuum of care.

J Spinal Cord Med. June 2010; 33(3): 221–231     

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.     

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.     

Measuring Depression in Persons With Spinal Cord Injury: A Systematic Review

Background/Objective:     

Measuring Depression in Persons With Spinal Cord Injury: A Systematic Review

Background/Objective: Depression has been studied extensively among people with spinal cord injury (SCI). However, basic questions persist regarding the reliability and validity of depression measurement in the context of SCI. The objective of this study was to evaluate the state of knowledge of depression measurement in persons with SCI.

Methods: English-language peer-reviewed citations from MEDLINE, CINAHL, PsycINFO, ProQuest, Google Scholar, and Web of Science from 1980 to present. Two reviewers screened 377 abstracts on SCI and depression topics to identify 144 containing classifiable psychometric data. All 144 were reviewed by 6 reviewers. Twenty-four studies reporting psychometric data on 7 depression measures in SCI samples were identified, including 7 validity studies.

Results: Reliability data were limited to internal consistency and were consistently good to excellent across 19 studies. Validity data were limited to concurrent validity, construct validity, and/or clinical utility in 10 studies. Measures were comparable with respect to internal consistency, factor structure, and clinical utility. Results are limited to peer-reviewed, English literature, and studies were not judged for quality.

Conclusions: Greater attention should be paid to the psychometric evaluation of established measures. Although existing evidence may not justify universal screening, we recommend depression screening in clinical practice when patients may be seen by nonpsychology personnel. There is insufficient evidence to recommend one screening measure over another. Therefore, selection of measures will depend on clinician preferences. Psychometric studies are needed to show test-retest reliability, criterion validity, and sensitivity to change to improve depression recognition and treatment.     

Predictors of Pressure Ulcer Recurrence in Veterans With Spinal Cord Injury

Background/Objective:     

Predictors Of Pressure Ulcer Recurrence In Veterans With Spinal Cord Injury

Background/Objective: To predict recurrence of pressure ulcers (PrUs) in a high-risk populationofveterans with spinal cord injury (SCI).

Design:Cross-sectional observational design.

Participants: A convenience sample of 64 subjects from 6 Department of Veterans Affairs (VA) SCI Centers who had been admitted to the hospital for the treatment of stage III-IV pelvic PrUs and were healed at the time of discharge back to the community.

Main Outcome Measures:Primary outcome measures were pelvic PrU recurrence, defined as selfreported new skin breakdown (stage II or greater) in the pelvic area (not necessarily in the same location as previous ulcer) and time to recurrence.

Results:There were no differences between those with/without recurrences with regard to age, age at/level of injury, number of previous ulcers or surgery, rate of or time, to recurrence. Mean age was 56 years; most were white and men, lived at home, and had some college education. Mean time since SCI was 22 years; 28% had tetraplegia; mean number of prior pressure ulcers was 3; and almost one half had a previous ulcer in the same location. The strongest predictor of recurrence in a multivariate logistic regression was African American race (odds ratio = 9.3). Additional predictors included higher scores on the Charlson Co-Morbidity Index (indicating a higher burden of illness), the Salzburg PrU Risk Assessment Scales, and longer sitting time at discharge.

Conclusion:Identifying individuals at highest risk for recurrence and developing effective prevention programs are essential rehabilitation goals. We recommend that the unique findings of this exploratory study be considered preliminary until replication of these results is published.     

The Importance Of Influenza Vaccinations In Persons With Spinal Cord Injury And Disease

Abstract

Background/Objective: Spinal cord injury (SCI) impairs cardiovascular autonomic responses to exercise and, depending on the Ievei of injury, may result in hypotension and pathologic fatigue with exertion. Other clinical populations with sympathetic regulatory dysfundion, but without skeletal muscle paralysis, exhibit similar signs and symptoms. Their ability to engage in physical adivity improves with elevation of blood pressure through pharmacologic treatment: Midodrine, an oral alpha-sympathomimetic agent, has been shown to be safe and efficacious for this purpose. Use of this medication in individuals with SCI merits investigation.

Methods: Double-blind, placebo-controlled, randomized, crossover, within-subjeds protocol. Four participants with chronic,motor-complete injuries from C6 to C8 underwent 4 peak exercise tests (PXT) using a wheelchair ergometer, following administration of midodrine, 5 mg, 10 mg, and placebo, in random order. Heart rate, blood pressure, oxygen consumption (V02) , and perceived exertion were measured.

Results: Treatment with midodrine, 10 mg, was associated with elevated systolic blood pressure during peak exercise in 3 participants. Two participants showed a concurrent decrease in perceived exertion and increase in V02 . No adverse effeds of midodrine were evident.

Condusion: Midodrine enhances exercise performance in some individuals with SCI, similar to other clinical populations with cardiovascular autonomic dysfundion.     

脊髓损伤病人的运动功能评定

目的 脊髓损伤（ＳＣＩ）病人的分级多采用Ｆｒａｎｋｅｌ分级标准,我们根据２６０例ＳＣＩ病人的观察,认为对病人活动功能影响最大的最运动功能与排尿功能,且上肢与下肢评级标准不尽相同,从而对分级提出改进意见。方法 本组２６０例, 伤后观察时间达１以上者１５６例,占６０％。损伤部位：Ｃ３－４￣Ｔ１ ９０例,Ｔ ２￣１０ ３７例,Ｔ１１￣Ｌ１ １０５例,Ｌ２－３ ２８例。脊髓损伤类型：完全截瘫１６９例,不全     

Diabetes Mellitus in Individuals With Spinal Cord Injury or Disorder

Abstract

Background/Objective: To examine diabetes prevalence, care, complications, and characteristics of veterans with a spinal cord injury or disorder (SCI/D).

Methods: A national survey of veterans with an SCI/D was conducted using Behavioral Risk Factor Surveillance System (BRFSS) survey questions. Data were compared with national Centers for Disease Control and Prevention BRFSS data for veteran and nonveteran general populations.

Results: Overall prevalence of diabetes in individuals with an SCI/D was 20% (3 times higher than in the general population). Veterans with an SCI/D and veterans, in general, had a higher prevalence of diabetes across all age groups; however, those with an SCI/D who were 45 to 59 years of age had a higher prevalence than other veterans. One fourth of the persons with an SCI/D and diabetes reported that diabetes affected their eyes or that they had retinopathy (25%), and 41 % had foot sores that took more than 4 weeks to heal. More veterans, both with (63%) and without an SCI/D (60%), took a class on how to manage their diabetes than the general population (50%). Veterans with an SCI/D and diabetes were more likely to report other chronic conditions and poorer quality of life than those without diabetes.

Conclusions: Diabetes prevalence is greater among veterans with an SCI/D compared with the civilian population, but is similar to that of other veterans, although it may occur at a younger age in those with an SCI/D. Veterans with an SCI/D and diabetes reported more comorbidities, more slow-healing foot sores, and poorer quality of life than those without diabetes. Efforts to prevent diabetes and to provide early intervention in persons with SCI/D are needed.     

Fibrinogen Metabolism in Patients With Spinal Cord Injury

Abstract

Background/Objective: Deep venous thrombosis and pulmonary thromboembolism are common within weeks of spinal cord injury (SCI) but clinically uncommon in the chronically paralyzed. Fibrinogen half-life (FHL) and fibrin uptake of the legs (FUT), as indicators of an active thrombotic process, have been used to test this clinical impression.

Methods: Data from the use of autologous preparations of radioiodinated fibrinogen to determine FHL and FUT in 17 men paralyzed at cervical (6), thoracic (10), and lumbar levels (1), at ASIA grades A (15) and C (2) in 1974 to 1976 were reviewed. Group A consisted of 12 subjects 29 ± 8 years of age and paralyzed 1week to 5 months (median, 1 month). Group B consisted of 5 subjects 46 ± 17 years of age and paralyzed 24 to 96 months (median, 36 months). Group B subjects were older and paralyzed longer than Group A. Group C consisted of 4 able-bodied control subjects enrolled at the same time for FHL studies, and these subjects were 34 to 38 years of age.

Results: FHL was 61 ± 14 hours for all SCI subjects and 95 ± 23 hours for Group C (P = 0.001). Group A FHL was 59 ± 16 hours, and FUT was positive in 8 of 12 subjects. Group B FHL was 66 ±7 hours, and FUT was positive in 3 of 4 subjects (1 FUT not done; P= 0.30 and 1.0, respectively).

Conclusions: Fibrinogen metabolism was abnormal in patients with acute SCI at high risk for pulmonary thromboembolism (PE) but continued to be abnormal beyond the high risk period for PE, possibly because of the greater age of the patients in the long-term paralysis group.     

Therapists' Roles in Pressure Ulcer Management in Persons With Spinal Cord Injury

Background:

Among veterans with spinal cord injury (SCI), severe pressure ulcers (PrU) are treated by interdisciplinary rehabilitation teams in SCI units.

Method:

Cross-sectional survey administered to therapists attending a conference of the Therapy Leadership Council in SCI.

Participants:

Respondents included physical therapists (PTs; n  =  24) and occupational therapists (OTs; n  =  15).

Main Outcome Measurements:

Wound care practices as indicated by 75% or more of participants as “usual practice.”

Results:

In general, therapist involvement with wound care was initiated by physician order (eg, electrical stimulation) or postsurgery protocols. “Usual practice” after tissue healing included progressive range of motion; initial remobilization (first sitting after wound healing); progression of sitting time including assessment of skin tolerance; instruction in pressure relief maneuvers/techniques; and instruction in safe transfers. Practices in prevention of a new ulcer included education and evaluation of seating posture/positioning.

Conclusions:

Results indicate that centers may delegate responsibilities for management of ulcers differentially by discipline. A limitation was that we were unable to determine whether these centers were the same or different for OT and PT respondents. Although sample size was small and some sites had multiple respondents, the survey showed a growing role for OTs and PTs in PrU treatment. Because 75% of each discipline reported that there were usual practices, including patient education and remobilization protocols, this area requires further study to determine the clinical outcomes in terms of preventing PrUs and recurrence.     

Spinal Myoclonus After Spinal Cord Injury

Abstract

Background/Objective: In the course of examining spinal motor function in many hundreds of people with traumatic spinal cord injury, we encountered 6 individuals who developed involuntary and rhythmic contractions in muscles of their legs. Although there are many reports of unusual muscle activation patterns associated with different forms of myoclonus, we believe that certain aspects of the patterns seen with these 6 subjects have not been previously reported. These patterns share many features with those associated with a spinal central pattern generator for walking.

Methods: Subjects in this case series had a history of chronic injury to the cervical spinal cord, resulting in either complete (ASIA A; n = 4) or incomplete (ASIA D; n = 2) quadriplegia. We used multi-channel electromyography recordings of trunk and leg muscles of each subject to document muscle activation patterns associated with different postures and as influenced by a variety of sensory stimuli.

Results: Involuntary contractions spanned multiple leg muscles bilaterally, sometimes including weak abdominal contractions. Contractions were smooth and graded and were highly reproducible in rate for a given subject (contraction rates were 0.3-0.5 Hz). These movements did not resemble the brief rapid contractions (ie, "jerks") ascribed to some forms of spinal myoclonus. For all subjects, the onset of involuntary muscle contraction was dependent upon hip angle; contractions did not occur unless the hips (and knees) were extended (ie, subjects were supine). In the 4 ASIA A subjects, contractions occurred simultaneously in all muscles (agonists and antagonists) bilaterally. In sharp contrast, contractions in the 2 ASIA D subjects were reciprocal between agonists and antagonists within a limb and alternated between limbs, such that movements in these 2 subjects looked just like repetitive stepping. Finally, each of the 6 subjects had a distinct pathology of their spinal cord, nerve roots, distal trunk, or thigh; in 4 of these subjects, treatment of the pathology eliminated the involuntary movements.

Conclusion: The timing, distribution, and reliance upon hip angle suggest that these movement patterns reflect some elements of a central pattern generator for stepping. Emergence of these movements in persons with chronic spinal cord injury is extremely rare and appears to depend upon a combination of the more rostrally placed injury and a pathologic process leading to a further enhancement of excitability in the caudal spinal cord.     

Evaluation of the Effects of Compression Stockings Using Venous Plethysmography in Persons With Spinal Cord Injury

Abstract

Background/Objective: To examine the effect of graduated compression stockings (GCS) on the properties of the venous vascular system, as characterized by venous capacitance (VC) and venous outflow (VO), in the lower extremities of individuals with spinal cord injury (SCI), according to injury level.

Methods: Nine male subjects with SCI (5 with low paraplegia [LP], 4 with high paraplegia [HP]) performed 2 plethysmography tests: with and without graduated compression knee-length stockings (pressure of 21 mm/Hg). The VC, VO, and cardiovascular parameters (heart rate and blood pressure) were evaluated with and without GCS.

Results: The VC and VO were lower in patients with HP than in those with LP. For all subjects, VC was significantly lower (-14%) with GCS than without (1.77 ± 1.18 vs 1.53 ± 1.09 vol%, P < 0.01). On the contrary, VO did not differ significantly when wearing or not wearing GCS.

Conclusions: This study demonstrated that 21-mm/Hg knee-length GCS are sufficient to prevent venous distension in individuals with SCI, even those with longstanding paraplegia, by significantly decreasing venous capacitance. This intervention may help to prevent deep vein thrombosis.     

Adrenal Insufficiency in Acute Spinal Cord Injury

Abstract

Background/Objective: A 21-year-old man with a C6 American Spinal Injury Association A spinal cord injury (SCI) developed symptomatic hypotension resistant to vasopressors and volume replacement 2 weeks after injury and was diagnosed with adrenal insufficiency by cosyntropin test. Adrenal insufficiency has been documented in chronic SCI; this case shows documented adrenal insufficiency in acute SCI. Design: Case report.

Results: Secondary adrenal insufficiency complicated the medical and rehabilitative course of this patient with SCI. During 2 infectious episodes, this patient's dosage of hydrocortisone had to be doubled to control symptomatic hypotension, lethargy, diffuse weakness, and anorexia.

Conclusions: The nonspecific symptomatology of adrenal insufficiency can be easily overlooked in patients with SCI. Low basal cortisol levels may be an important clue to this disorder. Low-dose adrenocorticotropic hormone stimulation may be more sensitive than high doses for detecting subclinical adrenal insufficiency. A high index of clinical suspicion is needed for the correct diagnosis of acute and chronic adrenal insufficiency.     

Marjolin's Ulcer In Patients With Spinal Cord Injury

Abstract

Background: The term “Marjolin's ulcer” is now synonymous with malignant transformation, usually ectodermal and rarely mesenchymal, of chronic ulcers, sinus tracts, and burn scars.

Design: Literature search and personal experience with 5 patients during a 30-year period in a spinal cord injury center.

Findings: Five cases of Marjolin's ulcer diagnosed among approximately 10,000 patients indicate the rarity of the metaplasia. All cases were fatal.

Conclusions: Chronic pressure ulcers of more than 10 years' duration should be biopsied to rule out malignancy, especially with any change in the nature of the ulcer (eg, exuberant granulation and/or bleeding).     

Long-Term Survival of Persons Ventilator Dependent After Spinal Cord Injury

Abstract

Background/Objective: Identify factors related to long-term survival, and quantify their effect on mortality and life expectancy.

Setting: Model spinal cord injury systems of care across the United States.

Study Design: Survival analysis of persons with traumatic spinal cord injury who are ventilator dependent at discharge from inpatient rehabilitation and who survive at least 1 year after injury.

Methods: Logistic regression analysis on a data set of 1,986 person-years occurring among 319 individuals injured from 1973 through 2003.

Results: The key factors related to long-term survival were age, time since injury, neurologic level, and degree of completeness of injury. The life expectancies were modestly lower than previous estimates. Pneumonia and other respiratory conditions remain the leading cause of death but account for only 31 % of deaths of known causes.

Conclusions: Whereas previous research has suggested a dramatic improvement in survival over the last few decades in this population, this is only the case during the critical first few years after injury. There was no evidence for such a trend in the subsequent period.     

Shoulder Muscular Demand During Lever-Activated Vs Pushrim Wheelchair Propulsion in Persons With Spinal Cord Injury

Background/Objective:     

Shoulder Muscular Demand During Lever-Activated Vs Pushrim Wheelchair Propulsion In Persons With Spinal Cord Injury

Background/Objective: The high demand on the upper limbs during manual wheelchair (WC) use contributes to a high prevalence of shoulder pathology in people with spinal cord injury (SCI). Leveractivated (LEVER) WCs have been presented as a less demanding alternative mode of manual WC propulsion. The objective of this study was to evaluate the shoulder muscle electromyographic activity and propulsion characteristics in manual WC users with SCI propelling a standard pushrim (ST) and LEVER WC design.

Methods: Twenty men with complete injuries (ASIA A or B) and tetraplegia (C6, n = 5; C7, n = 7) or paraplegia (n = 8) secondary to SCI propelled STand LEVER WCs at 3 propulsion conditions on a stationary ergometer: self-selected free, self-selected fast, and simulated graded resistance. Average velocity, cycle distance, and cadence; median and peak electromyographic intensity; and duration of electromyography of anterior deltoid, pectoralis major, supraspinatus, and infraspinatus muscles were compared between LEVER and ST WC propulsion .

Results: Sign ificant decreases in pectoralis major and supraspinatus activity were recorded during LEVER compared with ST WC propulsion. However, anterior deltoid and infraspinatus intensities tended to increase during LEVER WC propulsion. Participants with tetraplegia had similar or greater anterior deltoid, pectoralis major, and infraspinatus activity for both ST and LEVER WC propulsion compared with the men with paraplegia.

Conclusions: Use of the LEVER WC reduced and shifted the shoulder muscular demands in individuals with paraplegia and tetraplegia. Further studies are needed to determine the impact of LEVER WC propulsion on long-term shoulder function.