Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the national spinal cord injury database

Marino RJ, Burns S, Graves DE, Leiby BE, Kirshblum S, Lammertse DP. Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the National Spinal Cord Injury Database.

Objective

To present upper- (UEMS) and lower-extremity motor score (LEMS) recovery, American Spinal Injury Association Impairment Scale (AIS) change, and motor level change in persons with traumatic tetraplegia from the Spinal Cord Injury Model Systems (SCIMS).

Design

Longitudinal cohort; follow-up to 1 year.

Setting

U.S. SCIMS.

Participants

Subjects (N=1436; age>15y) with tetraplegia with at least 2 examinations, the first within 7 days of injury. Subjects were 80% men injured by vehicular collisions (44%), falls (30%), sports (12%), and violence (11%).

Interventions

Not applicable.

Main Outcome Measures

Change in AIS, UEMS, LEMS, and motor levels.

Results

From a baseline of 7 days or less, 22% of subjects with AIS grade A converted to AIS grade B or better by rehabilitation discharge; and 30%, by 1 year, with 8% to AIS grade C and 7.1% to grade D. Conversion from complete to motor incomplete was not related to timing of the initial examination (P=.54) or initial neurologic level (P=.96). For AIS grade B, 34% remained motor complete, 30% became AIS grade C, and 37% became grade D by 1 year. Although 82.5% of those with AIS grade C improved to AIS grades D and E, mean 1-year UEMS score was only 35 points. UEMS scores in patients with AIS grade A increased a mean of 9 to 11 points, except for C1 to C3 and C8 to T1 motor levels (gain, 2–3 points). Motor level was unchanged or ascended in 35% and improved 1 level in 42%, 2 levels in 14%, and more than 2 levels in 9%. Motor zone of partial preservation of 2 segments or more was associated with gain of 2 or more motor levels, with a relative risk of 5.0 (95% confidence interval, 3.2–7.8; P<.001).

Conclusions

More patients with cervical complete spinal cord injury may be converting to AIS grade D compared with earlier reports. Motor level recovery in those with AIS grade A and UEMS recovery in those with AIS grade C injuries are potential outcomes for acute clinical trials.     

Psychosocial subgroups in persons with spinal cord injuries and chronic pain

Widerström-Noga EG, Felix ER, Cruz-Almeida Y, Turk DC. Psychosocial subgroups in persons with spinal cord injuries and chronic pain.

Objectives

To define adaptational subgroups in people with chronic pain and spinal cord injury (SCI), and to compare these subgroups with respect to demographic factors, level of injury, functional independence, pain disability, depressed mood, social support, and life satisfaction.

Design

Interviews.

Setting

Veterans Affairs medical center and The Miami Project to Cure Paralysis.

Participants

Persons with SCI and chronic pain (N=190).

Interventions

Not applicable.

Main Outcome Measure

The Multidimensional Pain Inventory, SCI version.

Results

Cluster analysis revealed 3 subgroups: (1) dysfunctional (34.6% of all participants), characterized by higher pain severity, life interference, and affective distress scores, and lower levels of life control and activities scores; (2) interpersonally supported (33.0% of participants), characterized by moderately high pain severity, and higher life control, support from significant others, distracting responses, solicitous responses, and activities scores; and (3) adaptive copers (32.4% of participants), characterized by lower pain severity, life interference, affective distress, support from significant others, distracting responses, solicitous responses, activities and higher life control scores. Compared with the dysfunctional subgroup, the interpersonally supported subgroup reported significantly greater social support and life satisfaction and less pain disability and emotional distress, despite moderately high pain severity.

Conclusion

Three subgroups, independent of sex, pain duration, and functional status, were identified. Although severe pain significantly decreases life satisfaction after SCI, its impact is moderated by perceived social support.     

The impact of sacral sensory sparing in motor complete spinal cord injury

Kirshblum S, Botticello A, Lammertse DP, Marino RJ, Chiodo AE, Jha A. The impact of sacral sensory sparing in motor complete spinal cord injury.

Objective

To determine the effect of sensory sparing in motor complete persons with spinal cord injury (SCI) on completion of rehabilitation on neurologic, functional, and social outcomes reported at 1 year.

Design

Secondary analysis of longitudinal data collected by using prospective survey-based methods.

Setting

Data submitted to the National SCI Statistical Center Database.

Participants

Of persons (N=4106) enrolled in the model system with a motor complete injury (American Spinal Injury Association Impairment Scale [AIS] grade A or B) at the time of discharge between 1997 and 2007, a total of 2331 (56.8%) completed a 1-year follow-up interview (Form II) and 1284 (31.3%) had complete data for neurologic (eg, AIS grade, injury level) variables at 1 year.

Interventions

Not applicable.

Main Outcome Measures

AIS grade (A vs B) at 1 year, bladder management, hospitalizations, perceived health status, motor FIM items, Satisfaction With Life Scale, depressive symptoms, and social participation.

Results

Compared with persons with AIS grade A at discharge, persons with AIS grade B were less likely to require indwelling catheterization and be hospitalized and more likely to perceive better health, report greater functional independence (ie, self-care, sphincter control, mobility, locomotion), and report social participation in the first year postinjury. A greater portion of individuals with AIS grade B at discharge had improved neurologic recovery at 1 year postinjury than those with AIS grade A. Significant AIS group differences in 1-year outcomes related to physical health were maintained after excluding persons who improved to motor incomplete status for only bladder management and change in perceived health status. This recognition of differences between persons with motor complete injuries (AIS grade A vs B) has important ramifications for the field of SCI rehabilitation and research.     

Interrater reliability of the international standards for neurological classification of spinal cord injury in youths with chronic spinal cord injury

Mulcahey MJ, Gaughan JP, Chafetz RS, Vogel LC, Samdani AF, Betz RR. Interrater reliability of the International Standards for Neurological Classification of Spinal Cord Injury in youths with chronic spinal cord injury.

Objectives

To evaluate the interrater reliability of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) in children with chronic spinal cord injury (SCI), and to define the lower age limit at which the examinations have clinical utility.

Design

Repeated measures, multicenter reliability study.

Setting

Two U.S. pediatric specialty hospitals with recognized SCI programs.

Participants

Children (N=236) with chronic SCI.

Interventions

Subjects underwent 4 examinations by 2 raters: sensory tests (pin prick [PP] and light touch [LT]), a motor test, and a test of anal sensation (AS) and anal contraction (AC).

Main Outcome Measures

A 2-way general linear model analysis of variance was used for analysis. Intraclass correlation coefficients (ICCs) and 95% confidence intervals were calculated for PP, LT, motor, AS, and AC.

Results

No child younger than 6 years completed the examination. When examined as a function of age, interrater reliability for motor, PP, LT, AS, and AC was moderate (ICC=.89) to high (ICC=.99). There was poor reliability for AS (ICC=.49) in subjects with complete injuries but moderate reliability for all other variables. There was moderate to high reliability for classification of type (tetraplegia/paraplegia) and severity (complete/incomplete) of injury across age groups.

Conclusions

The ISNCSCI does not have utility for children younger than 6 years. For children older than 6 years, interrater reliability of PP, LT, and motor examinations is high.     

Cell telephone ownership and social integration in persons with spinal cord injury

Roach MJ, Harrington A, Powell H, Nemunaitis G. Cell telephone ownership and social integration in persons with spinal cord injury.

Objectives

To describe the prevalence and demographic characteristics associated with cell telephone ownership and to investigate whether cell telephone ownership has a positive relationship with social integration.

Design

Cross-sectional.

Setting

Spinal Cord Injury (SCI) Model Systems.

Participants

Participants (N=7696) with traumatic SCI who were entered into the National SCI Database and completed a follow-up interview from April 2004 through April 2009.

Interventions

None.

Main Outcome Measures

Cell telephone ownership; Craig Handicap Assessment Reporting Technique Social Integration subscale.

Results

A total of 73% of participants owned a cell telephone. Persons who were younger, employed, achieved education beyond grade school, and had computer and e-mail access were more likely to own cell telephones. Not owning a cell telephone decreased the likelihood of belonging to the high-social-integration group compared with the low-integration group (odds ratio, .509; 95% confidence interval, .396–.654). Persons with low or medium social integration scores were less likely to own a cell telephone than those who had high social integration scores.

Conclusion

In this study, most participants owned a cell telephone, although 27% did not compared with 13% nonowners in the general population. Owning a cell telephone increased the likelihood of being more socially integrated compared with non–cell telephone ownership.     

The relationship between quality of life and change in mobility 1 year postinjury in individuals with spinal cord injury

Riggins MS, Kankipati P, Oyster ML, Cooper RA, Boninger ML. The relationship between quality of life and change in mobility 1 year postinjury in individuals with spinal cord injury.

Objective

To examine quality-of-life (QOL) factors and change in mobility in individuals with traumatic spinal cord injury (SCI) 1 year after injury.

Design

Retrospective case study of National SCI Database data.

Setting

SCI Model Systems (SCIMS) sites (N=18).

Participants

Subjects (N=1826; age >18y) who presented to an SCIMS site after traumatic SCI between June 2004 and July 2009 and returned for 1-year follow-up. All subjects had FIM mobility data for both assessments.

Interventions

Not applicable.

Main Outcome Measures

Assessment of impairment based on Lower-Extremity Motor Score. Assessment of QOL based on Craig Handicap Assessment and Reporting Technique, Patient Health Questionnaire, Satisfaction With Life Scale, Self-perceived Health Status, and pain severity scores.

Results

Of the sample, 55 individuals transitioned from walking to wheelchair use within 1 year of discharge. This group had the highest number of individuals from minority groups (52.8%) and the lowest employment rate (7.3%). Compared with individuals who transitioned from wheelchair use to walking or maintained wheelchair use or ambulation, the walking-to-wheelchair transition group had significantly lower QOL scores (P<.01), including higher depression (P<.01) and higher pain severity (P<.001).

Conclusions

Individuals with SCI who transitioned from walking at discharge to wheelchair use within 1 year had low QOL factors, including high pain and depression scores. Rehabilitation professionals should consider encouraging marginal ambulators to work toward functional independence from a wheelchair, rather than primary ambulation during acute inpatient rehabilitation.     

Arm crank ergometry and shoulder pain in persons with spinal cord injury

Dyson-Hudson TA, Sisto SA, Bond Q, Emmons R, Kirshblum SC. Arm crank ergometry and shoulder pain in persons with spinal cord injury.

Objective

To determine whether a primary fitness program utilizing arm crank ergometry would cause increased shoulder pain in persons with spinal cord injury (SCI).

Design

Cohort study.

Setting

Clinical research center.

Participants

People (N=23) with chronic SCI (>1y) who were participating in a weight loss study to compare the effectiveness of diet only (1000kcal/d for 12wk) versus diet with arm crank ergometry (1000kcal/d and arm crank ergometry 3 times a week for 12wk).

Intervention

Arm crank ergometry.

Main Outcome Measure

Changes in shoulder pain intensity using the Wheelchair User’s Shoulder Pain Index (WUSPI).

Results

After adjusting for baseline scores, there was no significant difference between the 2 groups on postintervention WUSPI scores (F_1,20=.85, P=.37, partial η²=.04). The strength of the relationship between group assignment (diet only vs diet and arm crank ergometry) and final WUSPI score was weak, as assessed by a partial η², with group assignment accounting for 4% of the variance on the WUSPI. The adjusted means were lower in the diet and arm crank ergometry group (mean, 7.84) than in the diet only group (mean, 12.22); however, these differences did not appear to be clinically significant.

Conclusions

A primary fitness program using arm crank ergometry does not increase shoulder pain in people with SCI who use wheelchairs. Further investigation with a larger group and what constitutes clinically significant changes on the WUSPI is warranted to confirm our results.     

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.     

Trajectories in the course of life satisfaction after spinal cord injury: identification and predictors

van Leeuwen CM, Post MW, Hoekstra T, van der Woude LH, de Groot S, Snoek GJ, Mulder DG, Lindeman E. Trajectories in the course of life satisfaction after spinal cord injury: identification and predictors.

Objective

To identify different life satisfaction trajectories in the period between the start of active spinal cord injury (SCI) rehabilitation and 5 years after discharge, and to find predictors for distinguishing between trajectories. The hypotheses were that different life satisfaction trajectories would be identified and that demographic, lesion, physical, and social characteristics would be predictors of life satisfaction trajectory membership.

Design

Multicenter prospective cohort study with measurements at the start of active rehabilitation, after 3 months, at discharge, and 1, 2, and 5 years after discharge.

Setting

Eight Dutch rehabilitation centers with specialized SCI units.

Participants

Persons (N=225) with recently acquired SCI between the ages of 18 and 65 years were included, and data from 206 persons were analyzed.

Interventions

Not applicable.

Main Outcome Measures

Life satisfaction was measured as the sum score of “current life satisfaction” and “current life satisfaction compared with life satisfaction before SCI” (range, 2–13).

Results

Five life satisfaction trajectories were identified by using latent class growth mixture modeling: (1) low median scores (3–5) at all time points (27%), (2) intermediate scores (6–7) at all time points (31%), (3) high scores (8–10.5) at all time points (17%), (4) improvements from 3 to 9 (23%), and (5) deterioration from 9 to 4 (2%). Logistic regression showed that predictors of the low versus high life satisfaction trajectory were functional independence and pain. Predictors of the low life satisfaction versus the recovery trajectory were sex and functional independence. These predictors explained only a small part of the total variance.

Conclusions

Life satisfaction in people with SCI follows distinct trajectories. Monitoring life satisfaction at the start of active rehabilitation and 3 months later might allow identification of persons at risk for poor long-term adjustment.     

Patterns, predictors, and associated benefits of driving a modified vehicle after spinal cord injury: findings from the National Spinal Cord Injury Model Systems

Norweg A, Jette AM, Houlihan B, Ni P, Boninger ML. Patterns, predictors, and associated benefits of driving a modified vehicle after spinal cord injury: findings from the National Spinal Cord Injury Model Systems.

Objectives

To investigate the patterns, predictors, and benefits associated with driving a modified vehicle for people with spinal cord injuries (SCIs).

Design

Cross-sectional retrospective survey design.

Settings

Sixteen Model SCI Systems (MSCISs) throughout the United States.

Participants

People (N=3726) post-SCI from the National MSCIS Database.

Interventions

Not applicable.

Main Outcome Measures

Driving, employment, and community reintegration post-SCI.

Results

The study found that 36.5% of the sample drove a modified vehicle after SCI. Significant predictors of driving a modified vehicle post-SCI included married at injury, younger age at injury, associate's degree or higher before injury, paraplegia, a longer time since the injury, non-Hispanic race, white race, male sex, and using a wheelchair for more than 40 hours a week after the injury (accounting for 37% of the variance). Higher activity of daily living independence (in total motor function) at hospital discharge also increased the odds of driving. Driving increased the odds of being employed at follow-up by almost 2 times compared with not driving postinjury (odds ratio, 1.85). Drivers tended to have higher community reintegration scores, especially for community mobility and total community reintegration. Driving was also associated with small health-related quality-of-life gains, including less depression and pain interference and better life satisfaction, general health status, and transportation availability scores.

Conclusions

The associated benefits of driving and the relatively low percentage of drivers post-SCI in the sample provide evidence for the need to increase rehabilitation and assistive technology services and resources in the United States devoted to facilitating driving after SCI.     

Recovery of Sensory and Supraspinal Control of Leg Movement in People With Chronic Paraplegia: A Case Series

Objective

To report on unexpected findings in 4 patients with chronic paraplegia who underwent the laparoscopic implantation of neuroprosthesis procedure in the pelvic lumbosacral nerves.

Design

Observational case series.

Setting

Tertiary referral unit specialized in advanced gynecological surgery and neuropelveology.

Participants

Three patients with incomplete American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade B (n=2) and AIS grade C (n=1) spinal cord injury (SCI) and 1 patient with flaccid complete chronic SCI (AIS grade A) (n=1).

Intervention

Functional electrical stimulation (FES)-assisted locomotor training and continuous low-frequency pelvic-lumbosacral neuromodulation.

Main Outcome Measures

Change in ASIA Lower Extremity Motor Scores, ASIA sensory scores for light touch and pinprick sensation, and Walking Index for Spinal Cord Injury scores.

Results

All 4 patients developed progressive recovery of some sensory and voluntary motor functions below the lesions. Three are currently capable of voluntary weight-bearing standing and walking a few meters with a walker without FES. The first patient with the longest follow-up is even capable of electrically assisted standing/walking with 2 crutches without braces or assistance for a distance of about 900 meters, and of weight-bearing standing and walking for 30 meters with a walker without stimulation.

Conclusions

We report unexpected sensory and locomotor recovery in 4 people with paraplegia with SCI. Our findings suggest that FES-assisted locomotor training with continuous low-frequency pelvic nerve stimulation in patients with SCI may induce changes that affect the central pattern generator and allow supra- and infraspinal inputs to engage residual spinal pathways.     

The effect of a series of repetitive transcranial magnetic stimulations of the motor cortex on central pain after spinal cord injury

Defrin R, Grunhaus L, Zamir D, Zeilig G. The effect of a series of repetitive transcranial magnetic stimulations of the motor cortex on central pain after spinal cord injury.

Objective

To study the analgesic effect of repetitive transcranial magnetic stimulation (rTMS) of the motor cortex on central pain in patients with chronic spinal cord injury (SCI).

Design

Double-blind randomized controlled trial. Mean follow-up period was 4.5 weeks.

Setting

General hospital.

Participants

Twelve paraplegic patients due to thoracic SCI suffering chronic central pain (11 completed the study) who were randomly selected from a list of eligible patients.

Intervention

Real or sham 10 daily motor rTMS treatments (500 trains at 5Hz for 10s; total of 500 pulses at intensity of 115% of motor threshold) using figure-of-8 coil over the vertex.

Main Outcome Measures

Chronic pain intensity (visual analog scale [VAS], McGill Pain Questionnaire [MPQ]), pain threshold, and level of depression (Beck Depression Inventory).

Results

Both real and sham TMS induced a similar, significant reduction in VAS scores (P<.001) immediately after each of the 10 treatment sessions and in VAS and MPQ scores after the end of the treatment series. However, only real rTMS conferred a significant increase in heat-pain threshold (4°C, P<.05) by the end of the series. Most important, the reduction in MPQ scores in the real rTMS group continued during the follow-up period. Depression scores were equally reduced in both groups but similar to pain relief, depression continued to improve at follow-up in the real rTMS group.

Conclusions

Whereas the pain alleviation induced by a single rTMS treatment is probably due to placebo, patients with SCI may benefit from a series of rTMS treatments.     

Income and risk of mortality after spinal cord injury

Krause JS, Saunders LL, DeVivo MJ. Income and risk of mortality after spinal cord injury.

Objective

To evaluate the association of household income and formal education with risk of mortality after spinal cord injury (SCI).

Design

Cohort study.

Setting

Twenty hospitals designated as Model SCI Systems of care in the United States.

Participants

Adults (N=8027) with traumatic SCI, seen in one of the Model SCI Systems, who had at least 1 follow-up assessment between 1995 and 2006. All participants were at least 1 year postinjury at the time of assessment. There were 57,957 person-years and 1036 deaths. The follow-up period started with the first assessment between 1995 and 2006 and went until either the date of death or March 2009.

Interventions

Not applicable.

Main Outcome Measures

Mortality status was determined by routine follow-up supplemented by using the Social Security Death Index. A logistic regression model was developed to estimate the chance of dying in any given year.

Results

Educational status and income were significantly predictive of mortality after adjusting for age, sex, race, and severity of injury. Compared with those with household income of $75,000 or greater, the odds of mortality was greater for those who had income between $25,000 and $75,000 (1.61) and still higher for those with less than $25,000 a year (2.41). Life expectancy differed more as a function of household income than the economic subscale of the Craig Handicap Assessment and Reporting Technique.

Conclusion

There was a clear gradation in survival based on familial income (high, middle, low), not just an effect of the lowest income.     

Bcl-2 in suppressing neuronal apoptosis after spinal cord injury

BACKGROUND:

Apoptosis plays an important role in central neural diseases and trauma. B-cell lymphoma/Leukemia-2 (Bcl-2) can inhibit apoptosis in a wide variety of cells including neurons. In this experiment, by studying Bcl-2 over-expression transgenic (TG) mice subjected to spinal cord injury (SCI), we investigated whether Bcl-2 could reduce posttraumatic neuronal apoptosis, reduce the range of damage, and improve the behavioral functional recovery after contusive SCI.

METHODS:

Nine Bcl-2 TG mice and nine control mice were subjected to SCI of moderate severity at T10, with the use of weight dropping (WD) method (impact force 2.5×3.0 g/cm). At times up to 1 day, 7 days and 14 days after SCI, functional deficits were evaluated with Basso, Beattie, and Bresnahan (BBB) scales, and apoptosis of neurons was investigated by using the TUNEL method. Another three control mice only underwent lamina opening, but were not subjected to SCI, to provide blank comparison.

RESULTS:

The mean functional scores for the control mice (5.05 ±0.35) were lower than those for the Bcl-2 TG mice (5.45 ±0.15), although the unpaired T-test revealed no significant difference (P=0.67). On the other hand, the number of TUNEL positive neurons and integrated option density (IOD) scores for the Bcl-2 TG mice were both significantly lower than those for the control mice (P<0.05).

CONCLUSIONS:

This experiment suggests that overexpression of Bcl-2 may suppress neuronal apoptosis after SCI. Bcl-2 may be an important factor within the central nervous system that can relieve the damage after trauma.KEY WORDS: Spinal cord injury, Bcl-2, Apoptosis of neurons, Weight dropping, Transgenic mouse     

Medical and psychosocial complications associated with method of bladder management after traumatic spinal cord injury

Cameron AP, Wallner LP, Forchheimer MB, Clemens JQ, Dunn RL, Rodriguez G, Chen D, Horton J III, Tate DG. Medical and psychosocial complications associated with method of bladder management after traumatic spinal cord injury.

Objectives

To determine the relationships between bladder management method and medical complications (renal calculi or decubitus ulcers), number of hospital days, and psychosocial factors. We hypothesized that indwelling catheterization would be associated with more complications, more hospitalizations, and worse psychosocial outcomes compared with other bladder management methods.

Design

Inception cohort study.

Setting

Model spinal cord injury (SCI) centers funded by the National Institute on Disability and Rehabilitation Research from 1973 to 2005.

Participants

Persons with new traumatic SCI (N=24,762) enrolled in the National SCI Database entire data set forms I and II. Patients were stratified according to the bladder management method recorded at each time of data collection into 1 of 4 groups as follows: indwelling catheterization, spontaneous voiding, condom catheterization, and intermittent catheterization. Those who reported no management method or errors in reporting were excluded (n=1564).

Interventions

Not applicable.

Main Outcome Measures

Medical complications, including pressure ulcer number and grade of worst ulcer, kidney stones, and hospitalizations, as well as psychosocial factors (satisfaction with life, perceived health status, societal participation), were stratified by bladder management method. Results were adjusted for level and completeness of neurologic injury and other confounding and modifying factors.

Results

Compared with other forms of bladder management, use of an indwelling catheter was associated with more pressure ulcers and longer and more hospitalizations for all causes and urology-specific causes. Indwelling catheter use was associated with the lowest levels of participation, but similar satisfaction with life and perceived health status.

Conclusions

Indwelling catheterization was associated with more medical complications and lower levels of participation than other bladder management methods, but more research is required to ascertain the causality of these complications.     

Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury

Behrman AL, Ardolino E, VanHiel LR, Kern M, Atkinson D, Lorenz DJ, Harkema SJ. Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury.ObjectiveTo develop a scale (Neuromuscular Recovery Scale [NRS]) for classification of functional motor recovery after spinal cord injury (SCI) based on preinjury movement patterns that would reduce variability of the populations' level of function within each class, because assessment of functional improvement after SCI is problematic as a result of high variability of the populations' level of function and the insensitivity to change within the available outcome measures.DesignProspective observational cohort with longitudinal follow-up.SettingSeven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).ParticipantsIndividuals (N=95) with American Spinal Injury Association Impairment Scale (AIS) grade C or AIS grade D having received at least 20 locomotor training treatment sessions in the NRN.InterventionsIntensive locomotor training including stepping on a treadmill with partial body weight support and manual facilitation and translation of skills into home and community activities.Main Outcome MeasuresBerg Balance Scale, six-minute walk test, and ten-meter walk test.ResultsIndividuals classified within each of the 4 phases of the NRS were functionally discrete, as shown by significant differences in the mean values of balance, gait speed, and walking endurance, and the variability of these measurements was significantly reduced by NRS classification. The magnitude of improvements in these outcomes was also significantly different among phase groups.ConclusionsAssessment with the NRS provides a classification for functional motor recovery without compensation, which reduces variability in performance and improvements for individuals with injuries classified as AIS grades C and D.     

Computer and internet use by persons after traumatic spinal cord injury

Goodman N, Jette AM, Houlihan B, Williams S. Computer and internet use by persons after traumatic spinal cord injury.

Objective

To determine whether computer and internet use by persons post spinal cord injury (SCI) is sufficiently prevalent and broad-based to consider using this technology as a long-term treatment modality for patients who have sustained SCI.

Design

A multicenter cohort study.

Setting

Twenty-six past and current U.S. regional Model Spinal Cord Injury Systems.

Participants

Patients with traumatic SCI (N=2926) with follow-up interviews between 2004 and 2006, conducted at 1 or 5 years postinjury.

Interventions

Not applicable.

Results

Results revealed that 69.2% of participants with SCI used a computer; 94.2% of computer users accessed the internet. Among computer users, 19.1% used assistive devices for computer access. Of the internet users, 68.6% went online 5 to 7 days a week. The most frequent use for internet was e-mail (90.5%) and shopping sites (65.8%), followed by health sites (61.1%). We found no statistically significant difference in computer use by sex or level of neurologic injury, and no difference in internet use by level of neurologic injury. Computer and internet access differed significantly by age, with use decreasing as age group increased. The highest computer and internet access rates were seen among participants injured before the age of 18. Computer and internet use varied by race: 76% of white compared with 46% of black subjects were computer users (P<.001), and 95.3% of white respondents who used computers used the internet, compared with 87.6% of black respondents (P<.001). Internet use increased with education level (P<.001): eighty-six percent of participants who did not graduate from high school or receive a degree used the internet, while over 97% of those with a college or associate's degree did.

Conclusions

While the internet holds considerable potential as a long-term treatment modality after SCI, limited access to the internet by those who are black, those injured after age 18, and those with less education does reduce its usefulness in the short term for these subgroups.     

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.