国际脊髓损伤数据集:疼痛基础数据集

慢性疼痛足降低脊髓损伤患者生活质量的最常见原因之一。目前仍缺乏统一的收集疼痛数据的标准方法。采用统一的办法收集脊髓损伤患行的疼痛信息将有利于疼痛产生机制的研究及治疗结果的比较。本文旨在通过设立疼痛基础数据集来对脊髓损伤患者疼痛信息的收集和报告标准化。文中对数据集的变量进行了详细说明,并通过3个训练案例解释如何填写基础数据集表。     

Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis

OBJECTIVES: To examine the frequency and reasons for rehospitalization in persons with acute traumatic spinal cord injury (SCI) during follow-up years and to examine the association between rehospitalization and demographics, neurologic category, payer sources, length of stay (LOS), discharge motor FIM instrument score, and discharge residence. DESIGN: Survey design with analysis of cross-sectional data. SETTING: Model Spinal Cord Injury Systems (MSCIS) centers. PARTICIPANTS: Data for 8668 persons with SCI from 16 MSCIS centers entered in the National Spinal Cord Injury Statistical Center database between 1995 and 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: MSCIS Forms I and II were used to identify the annual incidence, medical complications, and etiologies of rehospitalizations reported at 1-, 5-, 10-, 15-, and 20-year follow-ups. RESULTS: The leading cause of rehospitalization was diseases of the genitourinary system, including urinary tract infections (UTIs). Diseases of the respiratory system tended to be more likely in patients with tetraplegia (C1-8 American Spinal Injury Association [ASIA] grades A, B, C); whereas patients with paraplegia (T1-S5 ASIA grades A, B, C) were more likely to be rehospitalized for pressure ulcers. The rate of rehospitalization was significantly higher at year 1, 5, and 20 for those who were discharged to a skilled nursing facility after acute rehabilitation. Lower motor score using the FIM was predictive of rehospitalization (P=.000). The average LOS per rehospitalization at the year-5 follow-up was approximately 12 days, which is lower than in past MSCIS reports. CONCLUSIONS: Despite improvements in SCI medical management, rehospitalization rates remain high, with an increased incidence in conditions associated with the genitourinary system (including UTIs), respiratory complications (including pneumonia), and diseases of the skin (including pressure ulcers). Acutely injured patients need close follow-up to reduce morbidity and rehospitalizations.     

Postural control during stance in paraplegia: effects of medially linked versus unlinked knee-ankle-foot orthoses

OBJECTIVE: To investigate the effect of medially linking knee-ankle-foot orthoses (KAFOs) on postural stability and sway during (1) quiet standing and (2) functional activities for persons with spinal cord injury (SCI). DESIGN: A randomized, mixed design, with the factors being activity (quiet standing and two function-mimicking tasks), SCI (present or not), and type of orthosis used in SCI group (linked or unlinked KAFO). PARTICIPANTS: Nine men with T5 to T12 paraplegia, 8 of whom had complete lesions and 1 with some sacral sparing (American Spinal Injury Association grade B) without proprioception, matched to 9 able-bodied men. MAIN OUTCOME MEASURES: Mean amplitude of sway and sway path in anteroposterior and mediolateral directions, derived from center of pressure measurements on a force platform. RESULTS: All men with SCI were able to stand unsupported and perform function-mimicking activities in medially linked KAFOs; however, when wearing unlinked KAFOs only 5 could maintain balance during quiet stance and 3 could maintain balance during activity. Significant differences were found between linked and unlinked KAFOs; side-to-side mean amplitude of sway was less and sway path was greater for SCI subjects when they wore the linked KAFOs. CONCLUSION: Medial linkage of bilateral KAFOs provides an effective strategy to improve stability and increase postural control for persons with SCI, facilitating performance of functional activities during standing without upper limb support.     

Cognitions,Coping, and Social Environment Predict Adjustment to Pain in Spinal Cord Injury

The current study examined the utility of a biopsychosocial model of chronic pain, and the associations between specific pain-related beliefs, coping, and social support and both mental health and pain interference, in persons with Spinal Cord Injury (SCI) and pain. A total of 157 patients completed surveys assessing physical and psychological functioning, as well as psychosocial, demographic, and injury-related variables. Greater catastrophizing and pain-related beliefs (eg, the belief that pain signals damage) were related with increased pain interference and poorer mental health, while coping styles (eg, resting, asking for assistance) were related only with pain interference. Alternatively, greater perceived social support was related with better mental health. The findings are consistent with a biopsychosocial model, implicating the need to consider the impact of process and clinical variables on adjustment to chronic pain in persons with SCI.PerspectiveThis article identifies several psychosocial variables, including coping, catastrophizing, pain-related beliefs, and social support that are related to adjustment in persons with SCI and pain. These results have implications for interventions designed to treat pain interference in persons with SCI.     

Recent demographic and injury trends in people served by the Model Spinal Cord Injury Care Systems

OBJECTIVE: To identify trends in the demographic and injury data of persons with spinal cord injury (SCI). DESIGN: Consecutive case series. SETTINGS: Model Spinal Cord Injury Care Systems throughout the United States. PATIENTS: A total of 25,054 persons admitted to a Model Spinal Cord Injury Care System within 365 days of injury between 1973 and 1998. RESULTS: Many trends and changes have been noted in the clinical features of patients who have been admitted to the Model SCI Care Systems. Average age at time of injury is rising; persons older than 60 comprise 11.5% of all persons enrolled in the National Database during the 1994-1998 period. Although the overall male-to-female ratio is greater than 4:1, the proportion of males has decreased significantly in recent years. Violence-related injuries have increased dramatically from 13.9% in 1973-1977 to 21.8% in 1994-1998. Since 1973, the proportions of injuries resulting from vehicular crashes and sports declined while injuries from falls increased. Injury continues to occur most commonly in the summer. When age, race, and gender are considered, violence is a more common cause of injury among individuals who are younger, male, or African American. Complete injuries were more common among younger individuals and among men than among older adults and women. CONCLUSION: Trends in the national database provide valuable data for tracking groups at risk for traumatic SCI.     

Medical procedures, complications, and outcomes for patients with spinal cord injury: A multicenter investigation comparing African Americans and whites

OBJECTIVE: To examine the role of race on rehabilitation outcomes for a matched sample of patients with spinal cord injury (SCI). DESIGN: African Americans and whites with SCI were matched based on age group, level and completeness of injury, and sponsor of care to retrospectively analyze the impact of race. SETTING: Eighteen medical centers in the federally sponsored Model Spinal Cord Injury Systems project. PARTICIPANTS: A total of 628 adults with SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Medical procedures and complications; American Spinal Injury Association motor index, and FIMT instrument scores at admission and discharge; and discharge dispositions. RESULTS: Analysis revealed race-related differences in spinal surgeries, laparotomies, traction during acute care, and method of bladder management at discharge. In most cases, these were explained by cause of injury rather than direct affects of race. No differences were found with regard to medical complications functional outcomes, or discharge disposition. CONCLUSIONS: Although differences exist in the medical procedures given to African Americans and whites with SCI, they are generally accounted for by cause of injury rather than the direct affects of race.     

Early versus delayed inpatient spinal cord injury rehabilitation: an Italian study

OBJECTIVE: To examine what effect the injury-to-rehabilitation interval has on the outcome of spinal cord injury (SCI) rehabilitation. DESIGN: Retrospective study. SETTING: Spinal unit of a large rehabilitation hospital. PARTICIPANTS: Consecutive admissions were divided into groups according to age, sex, and American Spinal Injury Association impairment grade and neurologic level of injury. The patients were matched for these variables and divided into groups according to the interval from injury to admission into acute rehabilitation. This approach resulted in 150 patients with SCI grouped into 50 comparison subgroupings. Interventions Three comparison groups-short (<30 d), medium (31-60 d), and long (>60 d) time to admission (TTA)-were evaluated for rehabilitation outcomes. MAIN OUTCOME MEASURES: Barthel Index, Rivermead Mobility Index, Walking Index for Spinal Cord Injury, and motor scores at admission and discharge were examined. The changes and efficiencies were evaluated. RESULTS: The 3 groups were comparable for all medical and demographic characteristics as well as neurologic recovery. The 3 subgroups differed significantly in activity of daily living outcomes, with the short TTA group exhibiting higher Barthel Index raw discharge scores, score increases, and score efficiencies. CONCLUSIONS: Early rehabilitation seems to be a relevant prognostic factor of functional outcome. Rehabilitation intervention in patients with SCI should begin as soon as possible, in a specialized setting, because delay may adversely affect functional recovery.     

Function-limiting dysesthetic pain syndrome among traumatic spinal cord injury patients: a cross-sectional study

Diffuse burning dysesthetic sensations distal to the level of spinal injury are the most common and disabling painful sequelae of traumatic spinal cord injury (SCI). In a cross-sectional study of 19 SCI patients, clinical characteristics and results of 3 validated pain measurement instruments (McGill Pain Questionnaire, Sternbach Pain Intensity and Zung Pain and Distress Scale) were used to develop a profile of function-limiting dysesthetic pain syndrome (DPS). Compared to a cohort of 147 patients admitted to the Midwest Regional Spinal Cord Injury Care System during the time period of the study, subjects were more likely to have paraplegia, incomplete sensory myelopathy, gunshot wounds to the spine and non-surgical spinal stabilization. Most patients described the pain as 'cutting,' 'burning,' 'piercing,' 'radiating' and 'tight.' The majority of patients located the pain internally and in the lower extremities. Values obtained from 6 McGill Pain Questionnaire subscales, 2 Sternbach Pain Intensity ratings and the Zung Pain and Distress index equalled or exceeded those reported for other pain syndromes. Use of these validated pain measures resulted in a systematic comprehensive assessment of function-limiting DPS following SCI.     

Activity and participation after spinal cord injury: state-of-the-art report

The importance of activities and community participation for persons with spinal cord injury (SCI) has been recognized for decades and yet theoretical and empirical advances have been limited. This report summarizes the recommendations for researchers on the topic of measuring activity and participation among persons with SCI formulated by the Spinal Cord Injury workgroup at the State-of-the-Art Conference on Outcome Measures in Rehabilitation held in January 2010. Activity and participation were defined as independent constructs ideally measured in reference to personal values and environmental influences. Measures of activity, participation, and factors influencing activity and participation are reviewed and critiqued. Gaps in available measures are described, measures in development are discussed, and suggestions for future research are made.     

Gender and minority differences in the pain experience of people with spinal cord injury

OBJECTIVES: To examine gender and minority differences in the prevalence and severity of pain in people with traumatic-onset spinal cord injury (SCI) during follow-up, and to determine the relation of those differences to demographic characteristics, etiology of injury, and level and extent of the lesion. DESIGN: Survey and analysis of cross-sectional data using case-control methodology and multiple regression methods. SETTING: Model Spinal Cord Injury Systems (MSCIS). PARTICIPANTS: A total of 7379 individuals with traumatic-onset SCI from 16 MSCIS entered in the National Spinal Cord Injury Statistical Center database between 1998 and 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prevalence and severity of pain as reported in follow-up surveys. RESULTS: Pain prevalence remained fairly stable over time, ranging from 81% at 1 year postinjury to 82.7% at 25 years. Pain was no more common in women than in men, nor did pain severity scores differ significantly. However, pain prevalence was significantly lower among nonwhites, although they tended to report a higher average pain severity score when pain was present. Also, people with SCI who were employed when injured, who had more than a high school education, and who were not tetraplegic reported a higher prevalence of pain. Pain interfered with work more often for women and nonwhites during some, but not all, follow-up years, and for those who were not employed at the time of interview, for those whose SCI was caused by violence, for those with paraplegia, and for those with incomplete SCI. CONCLUSIONS: Pain is a common and significant problem for the majority of people with SCI. It may interfere less frequently with work over time, which suggests that an adaptive process may be occurring. Gender differences in the pain experience did not emerge, but nonwhites tended to have a lower prevalence of pain. If pain was present, nonwhites tended to report more severe pain than did whites. Further research is needed to delineate the possible psychosocial and biomedical causes of these findings.     

Aging with spinal cord injury: changes in selected health indices and life satisfaction

OBJECTIVES: To document the impact of age, age at injury, years postinjury, and injury severity on changes over time in selected physical and psychosocial outcomes of people aging with spinal cord injury (SCI), and to identify the best predictors of these outcomes. DESIGN: Retrospective cross-sectional and longitudinal examination of people with SCI. SETTING: Follow-up of people who received initial rehabilitation in a regional Model Spinal Cord Injury System. PARTICIPANTS: People who meet the inclusion criteria for the National Spinal Cord Injury Database were studied at 5, 10, 15, 20, and 25 years postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Number of pressure ulcers, number of times rehospitalized, number of days rehospitalized, perceived health status, satisfaction with life, and pain during the most recent follow-up year. RESULTS: The number of days rehospitalized and frequency of rehospitalizations decreased and the number of pressure ulcers increased as time passed. For the variables of pressure ulcers, poor perceived health, the perception of pain and lower life satisfaction, the best predictor of each outcome was the previous existence or poor rating of that same outcome. CONCLUSIONS: Common complications of SCI often herald the recurrence of those same complications at a later point in time, highlighting the importance of early intervention to prevent future health and psychosocial difficulties.     

脊髓损伤患者盆底表面肌电与肠功能的相关性研究

目的探讨脊髓损伤(SCI)患者盆底表面肌电(sEMG)值与国际SCI 数据集肠功能基础数据集问卷调查指标的相关性,为SCI 患者水疗项目的选择提供依据。方法根据美国脊柱损伤协会(ASIA)2006 年颁发的SCI 神经学分类国际标准,将180 例残损分级为A级、B级、C级和D级的SCI 受试者分别分成A组、B组、C组和D组。应用标准的Glazer 盆底sEMG评估方案及设备,对患者进行肛门括约肌sEMG值的测定,同时进行国际SCI 数据集肠功能基础数据集——数据表的问卷调查。结果Glazer 评估中各个收缩阶段的盆底sEMG检测值与SCI 肠功能问卷调查中的便意、主要排便方法、平均排便时间、便失禁的次数、需要外用衬垫或塞子5 项指标之间存在相关性(P<0.05),各个收缩阶段的盆底sEMG 检测值也与SCI 残损分级之间存在相关性(P<0.01)。结论Glazer 盆底sEMG评估与国际SCI 数据集肠功能基础数据集的问卷调查对SCI 患者水疗项目的选择具有一定的参考意义。     

Prevalence and Impact of Neuropathic and Nonneuropathic Pain in Chronic Spinal Cord Injury

ObjectiveTo compare prevalence, intensity ratings, and interference ratings of neuropathic pain (NeuP) and nociceptive pain in people with chronic spinal cord injury (SCI)DesignCross-sectional survey.SettingSix SCI Model System centers in the United States.ParticipantsConvenience sample of 391 individuals (N=391) with traumatic SCI, 18 years or older, 81% male, 57% White.InterventionsNot applicable.Main Outcome MeasuresSurvey based on the International Spinal Cord Injury Pain Basic Data Set and the Spinal Cord Injury Pain Instrument, including 0-10 numeric ratings of pain intensity and pain interference with daily activities, mood, and sleepResultsA total of 80% of those surveyed reported having at least 1 pain problem; 58% reported 2 or more pain problems; 56% had probable NeuP; and 49% had non-NeuP. When comparing ratings for all pains (n=354 for NeuP, n=290 for non-NeuP) across participants, probable NeuPs were significantly more intense (6.9 vs 5.7) and interfered more with activities (5.2 vs 3.7), mood (4.9 vs 3.2), and sleep (5.4 vs 3.6) than non-NeuPs (all P<.001). However, when comparing ratings for probable NeuPs and non-NeuPs within participants, for the subgroup of 94 participants with both pain types, only ratings for sleep interference were found to be significantly different between the pain types. Additionally, we found significantly greater prevalence of NeuP and non-NeuP for women compared with men and of NeuP for those with paraplegia compared with those with tetraplegia.ConclusionsIndependent assessment of the pain conditions experienced by an individual with SCI is useful in understanding the differential effect that pain type has on quality of life. This is particularly important regarding sleep interference and should be kept in mind when determining treatment strategies for meeting patient-centered outcome goals.     

Poster 17: Is length of stay associated with spinal cord injury functional outcome at discharge from acute rehabilitation?

Objective: To determine whether rehabilitation length of stay (LOS) is associated with discharge motor function for persons with spinal cord injury (SCI). Design: Longitudinal. Setting: Spinal Cord Injury Model Systems center. Participants: 920 persons with traumatic, complete SCI enrolled in the Spinal Cord Injury National Database, with levels of injury (LOI) at C5, C6, C7, and T1-5; and inpatient rehabilitation discharge dates between 1989 and 1992 (“early”) and 1999 and 2002 (“late”). Interventions: Not applicable. Main Outcome Measures: FIM™ instrument at rehabilitation discharge. Results: For all LOI groups, the late group had a LOS shorter than the early group, with the largest difference in the C7 group: 107 days (early) versus 59 days (late). FIM motor scores at rehabilitation discharge also differed significantly for the C5, C7, and T1-5 LOI groups. For each of these LOIs, the late group was discharged with lower FIM motor scores; the largest difference was again noted for the C7 group, which had FIM motor scores of 51.9 (early) versus 40.7 (late). Conclusions: Decreased inpatient rehabilitation LOS was associated with decreased function at rehabilitation discharge. Persons with C7-level SCI were the most affected group; this group had the largest decrease in LOS and motor FIM score.     

A Concordance Table to Convert FIM Basic Mobility and Self-Care Scale Scores to SCI-FI/AT Scores

ObjectiveTo estimate Spinal Cord Injury Functional Index Assistive Technology (SCI-FI/AT) scores from FIM motor items.DesignSecondary data analysis.SettingFourteen Spinal Cord Injury Model Systems (SCIMS) programs.ParticipantsPersons with traumatic spinal cord injury (SCI) discharged from inpatient rehabilitation at 14 SCIMS programs (N=1237).InterventionsNot applicable.Main Outcome MeasuresFIM motor items were matched to SCI-FI/AT domains and summary scores for each measure were developed. The kernel-based method was employed to develop a concordance table to estimate SCI-FI/AT domain summary scores from content-matched FIM motor item summary scores. We conducted analyses to compare agreement between actual SCI-FI/AT summary scores (actual SCI-FI/AT_S) and estimated SCI-FI/AT summary scores (est-SCI-FI/AT_S) for the total sample and for participants with different SCI injury categories.ResultsNine FIM items matched SCI-FI/AT basic mobility and self-care domain content. Pearson correlations for actual and est-SCI-FI/AT_S scores (0.79) were adequate for using concordance linking methods. Intraclass correlation coefficient values (0.79; 95% confidence interval, 0.77-0.81) indicated moderate reliability. t tests revealed no significant differences between actual and est-SCI-FI/AT_S scores in the total sample. For almost 60% of the sample, actual and est-SCI-FI/AT_S score differences were <5 points (half of a SD). Greater differences between actual and est-SCI-FI/AT_S scores were noted for persons with tetraplegia American Spinal Injury Association Impairment Scales (AISs) A, B, and C.ConclusionsDespite differences between the FIM and SCI-FI/AT assessments, we developed a concordance table to estimate self-care and basic mobility SCI-FI/AT scores from content-matched FIM motor item scores. This concordance table allows researchers to merge FIM data with SCI-FI/AT data to analyze SCI functional outcomes at the group level. However, owing to greater differences between actual and estimated scores, the concordance table should be used with caution to interpret scores for those with cervical-level injuries AISs A, B, C.     

The CONECSI trial: results of a randomized controlled trial of a multidisciplinary cognitive behavioral program for coping with chronic neuropathic pain after spinal cord injury

Many people with spinal cord injury (SCI) rate chronic neuropathic pain as one of the most difficult problems to manage. The aim of the CONECSI (COping with NEuropathiC Spinal cord Injury pain) trial was to evaluate a multidisciplinary cognitive behavioral treatment program for persons with chronic neuropathic pain after SCI. The intervention consisted of educational, cognitive, and behavioral elements. A total of 61 people were randomized to either the intervention group or the waiting list control group in 4 Dutch rehabilitation centers. Primary outcomes were pain intensity and pain-related disability (Chronic Pain Grade questionnaire), and secondary outcomes were mood (Hospital Anxiety and Depression Scale), participation in activities (Utrecht Activities List), and life satisfaction (Life Satisfaction Questionnaire). Measurements were performed at baseline, and at 3, and 6 months follow-up. The primary statistical technique was random coefficient analysis. The analyses showed significant changes over time on both primary (t1-t2), and 2 out of 4 secondary outcomes (both t1-t2 and t1-t3). Significant intervention effects (Time * Group interactions) were found for anxiety and participation in activities, but not for the primary outcomes. Subsequent paired t tests showed significant changes in the intervention group that were not seen in the control group: decrease of pain intensity, pain-related disability, anxiety, and increase of participation in activities. This study implies that a multidisciplinary cognitive behavioral program might have beneficial effects on people with chronic neuropathic SCI pain.     

A database of self-reported secondary medical problems among VA spinal cord injury patients: its role in clinical care and management

An interactive data management (IDM) system for the Spinal Cord Injury (SCI) Service was developed to collect self-reported patient data related to secondary medical complications and to provide feedback to the SCI rehabilitation team. The long-term objective is to improve clinical care through a process of staff review of current rehabilitation programs in the areas of prevalence, prevention, and management. Based on data from the first 99 SCI patients visiting the clinic and hospital after the installation of the IDM system, SCI patients reported high rates of current problems with spasticity (53 percent), pain (44 percent), and pressure ulcers (38 percent). Respiratory (12 percent) and bowel (14 percent) problems were less common current problems. The SCI staff questioned the reportedly high spasticity rates. They thought that the patients' answers might have indicated simply the occurrence of spasticity, rather than the more important issue of severe spasticity that interferes with daily activities. The staff suggested several additional spasticity questions to add to the study. In other areas, only a small percentage of patients wanted to talk with a therapist about prevention of pressure ulcers. Patients who had urinary problems consistently reported five urinary signs (e.g., cloudy urine). The clinical staff found these data informative and stated that they should continue to be collected.     

Gender-related differences in acute rehabilitation lengths of stay, charges, and functional outcomes for a matched sample with spinal cord injury: a multicenter investigation

OBJECTIVE: To examine the effects of gender on length of stay (LOS), treatment costs, and outcomes by using a matched sample of patients with spinal cord injury (SCI). DESIGN: A 2 x (15 x 3) mixed, block design was used retrospectively to analyze the impact of gender on subjects matched for age, American Spinal Injury Association (ASIA) motor impairment classification, and level of neurologic injury. SETTING: Twenty medical centers in the federally sponsored Spinal Cord Injury Model Systems project. PARTICIPANTS: One thousand seventy-four adult patients with SCI admitted between 1988 and 1998 were assessed at acute-care admission, inpatient rehabilitation admission, and inpatient rehabilitation discharge. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: ASIA motor index and FIM instrument admission, discharge, and efficiency scores; rehabilitation LOS and medical care charges; and discharge disposition. RESULTS: Analysis revealed no gender-related differences in FIM motor scores on admission and discharge. No differences in FIM motor efficiencies or daily change were observed. No significant differences were found for ASIA motor scores on acute-care admission and rehabilitation discharge. No differences in acute rehabilitation LOS and charges were observed. No gender-related differences were seen in the likelihood of discharge to an institutional setting. CONCLUSION: Gender was not a significant factor in functional outcome of SCI patients after acute rehabilitation.     

Long-term consequences of spinal cord injury on social participation: the occurrence of handicap situations

Purpose : Handicap situations in daily life of persons with Spinal Cord Injury (SCI) is rarely evaluated in spite of their impact on long-term health. The purpose of the present study was to identify the occurrence of potential handicap situations in individuals with SCI and to determine the potential associations between the level of social participation and some characteristics of the person. Methods : Four hundred and eighty-two individuals completed a mailed questionnaire that comprised the 'assessment of life habits', a tool developed to assess social participation in persons with disabilities. Results : Significant disruptions were particularly observed in home maintenance, participation in recreational and physical activities as well as in productive activities and the achievement of sexual relations. However, many individuals successfully achieved various social roles despite the presence of disabilities. No indications of a potential impact of premature ageing on the accomplishment of life habits were observed. Conclusions : The severity of injury seems to significantly increase the occurrence of handicap situations as the individuals with tetraplegia reported carrying out their life habits with much more difficulty or requiring more assistance than those with a less severe impairment.