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.     

Spinal Epidural Abscess: A 5-Year Case-Controlled Review of Neurologic Outcomes After Rehabilitation

Koo DW, Townson AF, Dvorak MF, Fisher CG. Spinal epidural abscess: a 5-year case-controlled review of neurologic outcomes after rehabilitation.

Objective

To describe the neurologic outcomes of 29 spinal epidural abscess (SEA) patients after rehabilitation compared with a case-controlled traumatic spinal cord injury (TSCI) cohort.

Design

Five-year retrospective chart review.

Setting

University-affiliated surgical spine unit and inpatient rehabilitation program.

Participants

Patients (n=29; 19 men, 10 women) requiring inpatient rehabilitation after SEA and TSCI case controls (n=29) matched by level of injury, American Spinal Injury Association (ASIA) Impairment Scale (AIS), ASIA motor score (AMS), sex, and age.

Main Outcome Measure

The primary outcome was a change in AMS from acute admission to discharge from inpatient rehabilitation.

Results

Despite having lower admission motor scores, there was a significant trend toward greater neurologic recovery in the SEA group (P=.047). In contrast to what is known regarding recovery from complete TSCI, this study shows potential for dramatic recovery in SEA subjects presenting with AIS grade A deficit with a 73% conversion rate to incomplete status; out of 11 SEA subjects with initial AIS grade A, 2 improved to AIS grade B, 1 to AIS grade C, and 5 to AIS grade D.

Conclusions

This study shows the potential for a significant improvement in neurologic deficits related to SEA. Based on the results of our study, it is clearly inappropriate to generalize recovery patterns seen in the TSCI patient population to SEA-associated myelopathy because the latter appears to have more favorable outcomes.     

Characterizing Natural Recovery of People With Initial Motor Complete Tetraplegia

ObjectiveTo determine the differences in neurologic recovery in persons with initial cervical American Spinal Cord Injury Association Impairment Scale (AIS) grades A and B over time.DesignRetrospective analysis of data from people with traumatic cervical spinal cord injury (SCI) enrolled in the National Spinal Cord Injury Model Systems (SCIMS) database from 2011-2019.SettingSCIMS centers.ParticipantsIndividuals (N=187) with traumatic cervical (C1-C7 motor level) SCI admitted with initial AIS grade A and B injuries within 30 days of injury, age 16 years or older, upper extremity motor score (UEMS) ≤20 on both sides, and complete neurologic data at admission and follow-up between 6 months and 2 years.InterventionsNot applicable.Main Outcome MeasuresConversion in AIS grades, UEMS and lower extremity motor scores (LEMS), and sensory scores.ResultsMean time to initial and follow-up examinations were 16.1±7.3 days and 377.5±93.4 days, respectively. Conversion from an initial cervical AIS grades A and B to motor incomplete status was 13.4% and 50.0%, respectively. The mean UEMS change for people with initial AIS grades A and B did not differ (7.8±6.5 and 8.8±6.1; P=.307), but people with AIS grade B experienced significantly higher means of LEMS change (2.3±7.4 and 8.8±13.9 (P≤.001). The increased rate of conversion to motor incomplete status from initial AIS grade B appears to be the primary driving factor of increased overall motor recovery. Individuals with initial AIS grade B had greater improvement in sensory scores.ConclusionsWhile UEMS recovery is similar in persons with initial AIS grades A and B, the rate of conversion to motor incomplete status, LEMS, and sensory recovery are significantly different. This information is important for clinical as well as research considerations.     

Racial and Ethnic Disparities in Functioning at Discharge and Follow-Up Among Patients With Motor Complete Spinal Cord Injury

Objective

To examine racial and ethnic differences in self-care and mobility outcomes for persons with a motor complete, traumatic spinal cord injury (SCI) at discharge and 1-year follow-up.

Design

Retrospective cohort study.

Setting

Sixteen rehabilitation centers contributing to the Spinal Cord Injury Model Systems (SCIMS) database.

Participants

Adults with traumatic, motor complete SCI (N=1766; American Spinal Injury Association Impairment Scale grade A or B) enrolled in the SCIMS between 2000 and 2011. Selected cases had complete self-reported data on race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic) and motor FIM scores assessed at inpatient rehabilitation admission, discharge, and 1-year follow-up.

Interventions

Not applicable.

Main Outcome Measures

Functional outcomes were measured by FIM self-care and mobility scores on a 1 to 7 FIM scale, at discharge and 1-year follow-up.

Results

Multiple regression models stratified by neurologic category and adjusted for sociodemographic and injury characteristics assessed racial and ethnic group differences in FIM self-care and mobility change scores at discharge and 1-year follow-up. At discharge, non-Hispanic black participants with tetraplegia and paraplegia had significantly poorer gains in FIM self-care and mobility scores relative to non-Hispanic white and Hispanic participants. At 1-year follow-up, similar FIM self-care and mobility change scores were found across racial and ethnic groups within each neurologic category.

Conclusions

Non-Hispanic white and Hispanic participants had comparatively more improvement in self-care and mobility during inpatient rehabilitation compared with non-Hispanic black participants. At 1-year follow-up, no differences in self-care and mobility outcomes were observed across racial and ethnic groups. Additional research is needed to identify potential modifiable factors that may contribute to racially and ethnically different patterns of functional outcomes observed during inpatient rehabilitation.     

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.     

Neurologic recovery after traumatic spinal cord injury: data from the Model Spinal Cord Injury Systems

OBJECTIVE: To present data on neurologic recovery gathered by the Model Spinal Cord Injury (SCI) Systems over a 10-year period. DESIGN: Case series. SETTING: Twenty-one Model SCI Systems. PATIENTS: A total of 3,585 individuals with traumatic SCI admitted between January 1, 1988 and December 31, 1997. MAIN OUTCOME MEASURES: Neurologic impairment category; Frankel grade; American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade; motor score. RESULTS: SCI caused by violence is more likely than SCI from nonviolent etiologies to result in a complete injury. Changes in severity of injury were similar using the older Frankel scale and the newer ASIA Impairment Scale. Individuals who were motor-complete with extended zones of sensory preservation but without sacral sparing were less likely to convert to motor-incomplete status than those with sacral sparing (13.3% vs 53.6%; p < .001). Motor score improvements at 1 year were related to severity of injury, with greater increases for better AIS grades except grade D, because of ceiling effects. Individuals with AIS grade B injuries have a mixed prognosis. CONCLUSION: Neurologic recovery after SCI is influenced by etiology and severity of injury. Multicenter studies on prognostic features such as preserved pin sensation in grade B injuries may identify subgroups with similar recovery patterns. Identification of such groups would facilitate clinical trials for neurologic recovery in acute SCI.     

Functional motor preservation below the level of injury in subjects with American Spinal Injury Association Impairment Scale grade A spinal cord injuries

Zariffa J, Curt A, for the EMSCI Study Group, Steeves JD. Functional motor preservation below the level of injury in subjects with American Spinal Injury Association Impairment Scale grade A spinal cord injuries.ObjectiveTo assess how frequently subjects with spinal cord injuries (SCIs) classified as American Spinal Injury Association Impairment Scale (AIS) grade A have substantial preserved motor function below the neurologic level of injury, despite having no preserved sensory or motor function at the S4-5 spinal cord segment.DesignAnalysis of the European Multicenter Study about Spinal Cord Injury database to determine how frequently subjects assessed as AIS A would have been AIS D based on motor scores alone (ie, had scores of ≥3 in at least half of the International Standards for Neurological Classification of Spinal Cord Injury [ISNCSCI] key muscles below the neurologic level of injury, despite having no sacral sparing).SettingEighteen European centers.ParticipantsIndividuals with traumatic SCI at any level (total of 2557 assessments).InterventionsNot applicable.Main Outcome MeasureISNCSCI assessments.ResultsOver the first year after SCI (with assessments at approximately 1, 4, 12, 24, and 48wk) and for all rostrocaudal levels of injury, only 3.2% of AIS A assessments were found to meet the AIS D motor score criteria. The percentage was highest for lumbar (16.3%) and lower thoracic (4.4%) SCI. No trends were observed across time points.ConclusionsThese results suggest that the low frequency of individuals with an AIS A classification and high levels of motor function are not a significant concern in subject recruitment for clinical trials, unless the level of SCI is within the lumbar cord.     

Weight matters: physical and psychosocial well being of persons with spinal cord injury in relation to body mass index

Chen Y, Cao Y, Allen V, Richards JS. Weight matters: physical and psychosocial well being of persons with spinal cord injury in relation to body mass index.

Objective

To examine the relationship of body mass index (BMI) with multiple health indices among persons with spinal cord injury (SCI).

Design

Multicenter cross-sectional study.

Setting

A total of 16 SCI Model Systems throughout the United States.

Participants

A total of 1107 men and 274 women (N=1381), mean age ± SD, 43.1±14.6 years (tetraplegia, 56.9%; complete injuries, 50.2%; mean years since injury ± SD, 7.8±8.6), who received follow-up in 2006 to 2009, were classified into 1 of the 4 BMI categories—underweight, normal, overweight, and obese—based on self-reported height and measured weight.

Interventions

Not applicable.

Main Outcome Measures

Rehospitalization, pain, self-perceived health, FIM, Craig Handicap Assessment and Reporting Technique, Patient Health Questionnaire-9 (PHQ-9), and the Diener's Satisfaction With Life Scale (SWLS).

Results

The prevalence of underweight, overweight, and obesity was 7.5%, 31.4%, and 22.1%, respectively, which varied by age, sex, marital status, education, and neurologic impairment. For those with tetraplegia and functional motor-complete injuries, rehospitalization occurred more frequently among obese persons, while days rehospitalized were the longest among underweight persons. Pain was more severe in those classified as obese. Community mobility was lower in the underweight, overweight, and obese groups than in those with normal weight. There was no significant association between BMI and self-perceived health, FIM, PHQ-9, and SWLS beyond the effect of neurologic impairment.

Conclusions

Prevention and intervention directed at those significantly overweight or underweight deserve consideration as priorities in the continuity of care for persons with SCI. Efforts should be targeted particularly to those at higher risk, including persons with more severe injuries, who are less educated, and who are living alone.     

Measuring fatigue in persons with spinal cord injury

Anton HA, Miller WC, Townson AF. Measuring fatigue in persons with spinal cord injury.

Objective

To evaluate the psychometric properties of the Fatigue Severity Scale (FSS) in persons with spinal cord injury (SCI).

Design

A 2-week methodologic study was conducted to assess the internal consistency, reliability, and construct validity of the FSS.

Setting

A tertiary spinal cord rehabilitation facility.

Participants

Forty-eight community-living subjects at least 1 year post-SCI with American Spinal Injury Association (ASIA) grade A or B SCI and no medical conditions causing fatigue. The sample was predominantly male (n=31 [65%]) with tetraplegia (n=26 [54%]) and ASIA grade A injuries (n=30 [63%]). The average duration since injury was 14.9 years.

Interventions

Not applicable.

Main Outcome Measures

The ASIA Impairment Scale, the FSS, a visual analog scale for fatigue (VAS-F), the vitality scale of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and the Center for Epidemiologic Studies Depression Scale (CES-D).

Results

Mean FSS score ± standard deviation at baseline was 4.4±1.4, with 54% (n=26) scoring greater than 4. The internal consistency of the FSS was excellent (Cronbach α=.89). Two-week test-retest reliability was adequate (intraclass correlation coefficient, .84; 95% confidence interval, .74-.90). The magnitude of the relationship was as hypothesized for the VAS-F (r=.67) and CES-D (r=.58) and lower than hypothesized for the vitality subscore (r=−.48) of the SF-36.

Conclusions

The FSS has acceptable reliability with regard to internal consistency, test-retest reliability, and validity in persons with motor complete SCI.     

PREVALENCE OF DISCOMPLETE SENSORIMOTOR SPINAL CORD INJURY AS EVIDENCED BY NEUROPHYSIOLOGICAL METHODS: A CROSS-SECTIONAL STUDY

ObjectivesTo assess the prevalence of residual trans-lesion connectivity in persons with chronic clinically complete spinal cord injury (discompleteness) by neurophysiological methods.ParticipantsA total of 23 adults with chronic sensorimotor complete spinal cord injury, identified through regional registries the regional spinal cord registry of Östergötland, Sweden.MethodsDiagnosis of clinically complete spinal cord injury was verified by standardized neurological examination. Then, a neurophysiological examination was performed, comprising electroneurography, electromyography, sympathetic skin response and evoked potentials (sensory, laser and motor). Based on this assessment, a composite outcome measure, indicating either strong, possible or no evidence of discomplete spinal cord injury, was formed.ResultsStrong neurophysiological evidence of discomplete spinal cord injury was found in 17% (4/23) of participants. If also accepting “possible evidence”, the discomplete group comprised 39% (9/23). The remaining 61% showed no neurophysiological evidence of discompleteness. However, if also counting reports of subjective sensation elicited during neurophysiological testing in the absence of objective findings, 52% (12/23) showed indication of discomplete spinal cord injury.CONCLUSIONEvidence of discomplete spinal cord injury can be demonstrated using standard neurophysiological techniques in a substantial subset of individuals with clinically complete spinal cord injury. This study adds to the evidence base indicating the potential of various modes of cross-lesional sensorimotor functional restoration in some cases of chronic clinically complete spinal cord injury.LAY ABSTRACTSpinal cord injuries are usually classed as complete or incomplete. A complete injury implies that no residual function exists below the neurological level of injury. This status is determined by standardized neurological examination and is thought to correlate with spinal cord function in each individual with spinal cord injuries. However, studies have indicated that, in some people with complete spinal cord injury, there may be residual function that is not detected by such testing. The aim of the current study was to examine whether residual function, which is not detected by such testing, exists, and, if so, how common it is among people with complete spinal cord injuries (based on clinical testing) in a chronic stage (>2 years since injury). A battery of neurophysiological tests was used. Signs of “subclinical” residual function were found in 17–39% of 23 participants. This finding may lead to improvements in rehabilitative outcomes for people with complete spinal cord injury.Key words: somatosensory evoked potentials, motor evoked potentials, electromyography, sympathetic skin response, laser evoked potentials, spinal cord injury, complete, discomplete

Spinal cord injury (SCI) causes sensorimotor deficits at and below the neurological level of injury (NLI), including paralysis and altered or lost sensory function. Autonomic functions are usually also impaired to some extent, affecting respiratory, circulatory, bladder, bowel and sexual functions (1). In addition, complications such as excessive spasticity and neuropathic pain are common (2, 3) and associated with decreased quality of life (4). There is no known unambiguous correlation between the degree of neurological deficits and the presence of such complications.Currently, no methods are available in clinical routine practice for repairing SCI. However, as the concept of neuroplasticity has gained acceptance (5, 6), interest in exploring therapeutic neuro-modulation has increased.SCI is classified as complete or incomplete, using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) (7), which is based entirely on clinical sensorimotor examination. Based on the clinical assessment, SCI is sub-classified into 5 levels of varying residual infra-lesion neurological function; American Spinal Injury Association Impairment Scale (AIS) A–E (where A is complete functional transection, and E is complete restitution of infra-lesional sensory and voluntary motor function). In some individuals with SCI of grade AIS A, there exists a “zone of partial preservation” (ZPP), defined as the most caudal segment with some sensory function, determined by pin-prick and light touch testing below NLI, without sacral preservation of sensory and voluntary motor function (7, 8).A high prevalence (30–78%) of residual anatomical continuity was noted in post-mortem studies on clinically complete traumatic SCI (9, 10). It is likely that such anatomical continuity corresponds to a functional but subclinical neurological connectivity across the injury site in some cases. However, other pathways for such connectivity have also been proposed, e.g. the sympathetic trunk and/or the vagus nerve (11–14).For residual subclinical trans-lesion connectivity, the term discomplete spinal cord injury (dSCI) was proposed (15). Various methods for detection of this phenomenon have since been used, and both motor and sensory discompleteness have been proposed.For assessment of motor dSCI, electromyography (EMG) was the first method used (16). EMG recordings below the NLI can also be combined with transcranial magnetic stimulation (TMS) of the brain motor cortex (17, 18) to find signs of subclinical trans-lesion motor conduction.Sensory dSCI has been studied using somatosensoryevoked potentials (SEP, 17–19), consisting of somatosensory peripheral stimulation (typically electrical nerve stimulation) under simultaneous registration of activity in the somatosensory cortex, using scalp electrodes. Functional magnetic resonance imaging (fMRI) appears to have a higher sensitivity for detecting remaining sensory connectivity in patients with clinically complete SCI (25–54% (19–21)), compared with SEP (13–25% (22, 23)):In one study (23), 8/12 (67%) people with SCI and neuropathic pain perceived a change in perception below the NLI using adjuvant-enhanced thermal stimulation, compared with 0/12 (0%) for the group without neuropathic pain. Thus, a correlation was postulated between sensory dSCI and neuropathic pain after SCI.In summary, evidence for the concept of dSCI has accumulated. However, most of these studies have been small, and methods and quality of control conditions have varied. The current study aimed to determine the prevalence of motor and/or sensory dSCI among persons with chronic clinically complete SCI, by strict application of current clinical diagnostic criteria, and use of multiple, standardized neurophysiological methods.     

Health Conditions: Effect on Function,Health-Related Quality of Life,and Life Satisfaction After Traumatic Spinal Cord Injury. A Prospective Observational Registry Cohort Study

Objective

To analyze relations among injury, demographic, and environmental factors on function, health-related quality of life (HRQoL), and life satisfaction in individuals with traumatic spinal cord injury (SCI).

Effect of different sympathetic stimuli-autonomic dysreflexia and head-up tilt-on leg vascular resistance in spinal cord injury

Groothuis JT, Rongen GA, Geurts AC, Smits P, Hopman MT. Effect of different sympathetic stimuli–autonomic dysreflexia and head-up tilt–on leg vascular resistance in spinal cord injury.

Objective

To compare the effect of different sympathetic stimuli, that is, exaggerated sympathetic activity and orthostatic challenges, on the increase in leg vascular resistance in persons with spinal cord injury (SCI) without and controls with supraspinal sympathetic control.

Design

Case-control intervention study.

Setting

Physiology research laboratory.

Participants

Persons with SCI (N=9; motor and sensory complete spinal cord lesion above the sixth thoracic spinal segment) and able-bodied controls (N=9).

Interventions

In persons with SCI, exaggerated sympathetic activity was evoked by autonomic dysreflexia, and in controls, by using a cold pressor test (CPT). A 30° head-up tilt (HUT) was performed in both groups.

Main Outcome Measure

Leg blood flow was measured by using venous occlusion plethysmography during the different sympathetic stimuli. Leg vascular resistance was calculated as the arterial-venous pressure gradient divided by blood flow.

Results

In persons with SCI, leg vascular resistance significantly increased during autonomic dysreflexia and 30° HUT (25±20 and 24±13 arbitrary units [AU], respectively), with no difference (P=.87) between stimuli. In controls, leg vascular resistance significantly increased during CPT and 30° HUT (15±13 and 29±12AU, respectively) with no difference (P=.03) between stimuli. There were no differences (P=.22) in increase in leg vascular resistance during the different sympathetic stimuli between persons with SCI and controls.

Conclusions

The increase in leg vascular resistance during autonomic dysreflexia in persons with SCI is not different from that during 30° HUT, which might be caused by a limited vasoconstrictor reserve. Despite the lack of supraspinal sympathetic control in persons with SCI, the increase in leg vascular resistance during exaggerated sympathetic activity was not different from controls.     

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.     

Obesity and inpatient rehabilitation outcomes for patients with a traumatic spinal cord injury

Stenson KW, Deutsch A, Heinemann AW, Chen D. Obesity and inpatient rehabilitation outcomes for patients with a traumatic spinal cord injury.

Objective

To examine the effect of obesity on change in FIM self-care and mobility ratings and community discharge for patients with traumatic spinal cord injury (SCI).

Design

Retrospective cohort study analyzing National Model Systems SCI Database data.

Setting

Fourteen Model Systems SCI programs.

Participants

Patients (N=1524) with a new traumatic SCI discharged from Model Systems rehabilitation centers between October 2006 and October 2009.

Interventions

None.

Main Outcome Measures

Change in FIM self-care and mobility ratings, discharge destination. Separate analyses were conducted by neurologic category: paraplegia incomplete, paraplegia complete, tetraplegia incomplete, and tetraplegia complete.

Results

Of all patients with traumatic SCI, approximately 25% were obese at admission. Patients who were obese were more likely to be married and slightly older than nonobese patients. In patients with paraplegia incomplete, obese patients had lower FIM self-care (−1.9; 95% confidence interval [CI], −3.4 to −.4) and mobility score gains (−1.5; 95% CI, −2.9 to −.1) than normal-weight patients. For patients with paraplegia complete, obese patients had significantly lower self-care (−2.2; 95% CI, −3.5 to −.8) and mobility score gains (−2.7; 95% CI, −3.9 to −1.5). For patients with tetraplegia incomplete and tetraplegia complete, FIM self-care and mobility ratings for obese patients were not significantly different from ratings for normal-weight patients. Within each neurologic category, the percentage of patients discharged to the community was not significantly different for nonobese and obese patients.

Conclusions

Obesity appears to be a barrier to meeting self-care and mobility functional goals for patients with paraplegia in inpatient SCI rehabilitation.     

Late neurologic recovery after traumatic spinal cord injury

OBJECTIVE: To present Model Spinal Cord Injury System (MSCIS) data on late neurologic recovery after 1 year after spinal cord injury (SCI). DESIGN: Longitudinal study of neurologic status as determined by annual evaluations at 1 and 5 years postinjury. SETTING: MSCIS centers contributing data on people with traumatic SCI to the National Spinal Cord Injury Statistical Center database. PARTICIPANTS: People with traumatic SCI (N=987) admitted to an MSCIS between 1988 and 1997 with 1- and 5-year follow-up examinations. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: American Spinal Injury Association (ASIA) Impairment Scale (AIS) classification, motor index scores (MIS), motor level, and neurologic level of injury (NLI), measured and compared for changes over time. RESULTS: The majority of subjects (94.4%) who had a neurologically complete injury at 1 year remained complete at 5 years postinjury, with 3.5% improving to AIS grade B, and up to 1.05% each improving to AIS grades C and D. There was a statistically significant change noted for MIS. There were no significant changes for the motor level and NLI over 4 years; however, approximately 20% of subjects improved their motor level and NLI. People with complete and incomplete injuries had similar improvements in motor level, but subjects with an incomplete injury had a greater chance of improvement in NLI and MIS. CONCLUSIONS: There was a small degree of neurologic recovery (between 1 and 5 y postinjury) after a traumatic SCI. Late conversion, between 1 and 5 years, from a neurologically complete to an incomplete injury occurred in 5.6% of cases, but in only up to 2.1% was there a conversion from motor complete to motor incomplete status. Limitations of this study included changes in the ASIA classification during the study and in the intra- and interrater reliability typically seen in longitudinal studies of the ASIA standards. Functional changes were not studied. Knowledge of the degree of late recovery may help in analyzing newer interventions to enhance recovery.     

Relationship between quality of life and self-efficacy in persons with spinal cord injuries

Middleton J, Tran Y, Craig A. Relationship between quality of life and self-efficacy in persons with spinal cord injuries.

Objective

To study the interaction between quality of life in people with spinal cord injury (SCI) and expectations of daily living (self-efficacy) and pain.

Design

Cross-sectional study with multiple independent measures.

Setting

Home survey.

Participants

Included 106 persons with SCI of 12 months or more in duration who were living in the community and had enrolled from past admission lists in a rehabilitation unit.

Intervention

Participants received no treatments as part of the study but were asked to complete 2 questionnaires by postal survey in their postrehabilitation stage.

Main Outcome Measures

The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the Moorong Self-Efficacy Scale.

Results

Persons with SCI were found to have lowered quality of life (QOL) compared with the Australian general population. Low self-efficacy and pain intensity were found to reduce QOL across all SF-36 domains even further. Factors such as completeness of lesion, sex, age at time of injury, and time since injury were not associated with reduced QOL. Tetraplegia was associated with lower QOL in physical functioning and greater limitation due to bodily pain. A combination of low self-efficacy and pain intensity was associated with an increased reduction in QOL compared with reductions seen for these factors by themselves.

Conclusions

Rehabilitation strategies may need to concentrate on improving QOL by targeting factors like low self-efficacy.     

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.     

Cut point determination in the measurement of pain and its relationship to psychosocial and functional measures after traumatic spinal cord injury: a retrospective model spinal cord injury system analysis

Forchheimer MB, Richards JS, Chiodo AE, Bryce TN, Dyson-Hudson TA. Cut point determination in the measurement of pain and its relationship to psychosocial and functional measures after traumatic spinal cord injury: a retrospective Model Spinal Cord Injury System analysis.

Objective

To evaluate potential pain cutoff scores reflecting mild, moderate, and severe pain in the spinal cord injury (SCI) population and determine the relationship between the derived cutoff scores and both psychosocial and functional outcome measures.

Design

Retrospective analysis.

Setting

SCI Model Systems.

Participants

Persons (N=6096; age >18y) with traumatic SCI (American Spinal Injury Association Impairment Scale [AIS] grades A–D; injured in 1973–2008).

Interventions

Not applicable.

Main Outcome Measures

Numeric rating scale (NRS) of pain severity (11 points), NRS of pain interference (5 points), Satisfaction With Life Scale, Patient Health Questionnaire-9, Craig Handicap Assessment and Reporting Technique Short-Form (CHART-SF), motor component of the FIM (M-FIM), and employment.

Results

The best set of pain severity cutoff points are 1 to 3, 4 to 6, and 7 to 10. This was validated by randomly assigning sample members to 2 groups and replicating. There were significant differences in all outcomes as a function of pain severity grouping, although they explained little of the variance in M-FIM and CHART-SF Physical Independence scale scores. Neurologic status differed significantly between pain groups, with incongruence between pain severity and interference in people in the AIS grade D group, who reported the greatest pain interference and least pain severity.

Conclusion

Pain severity can be categorized into groups that reflect pain interference. These groupings differentiate psychosocial well-being better than activity limitations. They do not provide a comprehensive pain assessment, for which pain type, location, and interference are likely to be necessary.     

Mechanical ventilation, health, and quality of life following spinal cord injury

Charlifue S, Apple D, Burns SP, Chen D, Cuthbert JP, Donovan WH, Lammertse DP, Meade MA, Pretz CR. Mechanical ventilation, health, and quality of life following spinal cord injury.

Objective

To examine differences in perceived quality of life (QOL) at 1 year postinjury between people with tetraplegia who required mechanical ventilation assistance at discharge from rehabilitation and those who did not.

Design

Prospective cross-sectional examination of people with spinal cord injury (SCI) drawn from the SCI Model Systems National Database.

Setting

Community.

Participants

People with tetraplegia (N=1635) who sustained traumatic SCI between January 1, 1994, and September 30, 2008, who completed a 1-year follow-up interview, including 79 people who required at least some use of a ventilator at discharge from rehabilitation.

Interventions

Not applicable.

Main Outcome Measures

Satisfaction With Life Scale (SWLS); Craig Handicap Assessment and Reporting Technique (CHART)-Short Form Physical Independence, Mobility, Social Integration, and Occupation subscales; Patient Health Questionnaire-9 (PHQ-9), Medical Outcomes Study 36-Item Short-Form Health Survey self-perceived health status.

Results

Significant differences were found between the ventilator-user (VU) group and non–ventilator-user (NVU) group for cause of trauma, proportion with complete injury, neurologic impairment level, and number of rehospitalizations. The NVU group had significantly higher SWLS and CHART Social Integration scores than the VU group after controlling for selected covariates. The NVU group also had more positive perceived health status compared with a year previously and a lower incidence of depression assessed by using the PHQ-9 than the VU group. There were no significant differences between groups for perceived current health status.

Conclusions

People in this study who did not require mechanical ventilation at discharge from rehabilitation post-SCI reported generally better health and improved QOL compared with those who required ventilator assistance at 1 year postinjury. Nonetheless, the literature suggests that perceptions of QOL improve as people live in the community for longer periods.