Test-retest reliability of the Donovan spinal cord injury pain classification scheme

STUDY DESIGN: Videotape rating by independent viewers. OBJECTIVE: To determine the test-retest reliability of the Donovan spinal cord injury (SCI) pain classification scheme. SETTING: Rehabilitation Centre, Alabama, USA. METHODS: A total of 28 individuals with SCI reported 60 pain sites. A structured interview and physical exam were used to illicit information to classify each pain site according to the Donovan criteria. All structured interviews and exams were videotaped. Three independent raters viewed the videotapes on two occasions, separated by a 3-month interval, and classified each pain site using the Donovan pain classification scheme. RESULTS: Considering all three raters together, 78% of the pain sites were consistently classified from one period to the next. Within each rater, consistent classification ranged from 67 to 83%. However, inter-rater agreement for the classification of each pain site into the various types of pain was low for both periods (about 50-60%). CONCLUSIONS: Pain classification within each rater generally showed adequate test-retest reliability when using the Donovan SCI pain classification scheme. However, reliability estimates of agreement across raters highlight the ongoing need to exam and improve the psychometric characteristics of the various pain classification schemes.     

Shoulder pain in chronic spinal cord injury, Part I: Epidemiology, etiology, and pathomechanics

STUDY DESIGN: Review of the literature. BACKGROUND/OBJECTIVE: Shoulder pain is extremely common in individuals with chronic spinal cord injury (SCI) and is a source of morbidity and functional loss. The purpose of this review is to outline the present knowledge of the epidemiology, etiology, and pathomechanics of musculoskeletal shoulder pain in individuals with chronic SCI. METHODS: Review of the literature using PubMed/MEDLINE, EMBASE, and bibliographies of selected articles. RESULTS: Shoulder pain is more common in individuals with tetraplegia and complete injuries and may occur more frequently in women. Musculoskeletal conditions, primarily injuries to the rotator cuff, are most common. Risk factors include the duration of injury, older age, higher body mass index, the use of a manual wheelchair, poor seated posture, decreased flexibility, and muscle imbalances in the rotator cuff and scapular stabilizing muscles. CONCLUSION: With a better understanding of the epidemiology, etiology, and basic pathomechanics of shoulder pain in SCI, physicians are in a better position to evaluate, treat, and prevent these disorders.     

International differences in ageing and spinal cord injury

DESIGN: The present study is part of a programme of longitudinal research on ageing and spinal cord injury involving three populations - American, British and Canadian. The design was multivariate. OBJECTIVE: To identify international differences in outcomes associated with ageing and spinal cord injury. SETTING: A sample of 352 participants was assembled from five large, well-established databases. The Canadian sample was derived from the member database of the Canadian Paraplegic Association (Ontario and Manitoba divisions). The British sample was recruited from Southport Hospital's Northwest Regional Spinal Injuries Centre and Stoke-Mandeville Hospital's National Spinal Injuries Centre. The American sample has been recruited through Craig Hospital in Denver, Colorado. METHODS: The sample included individuals who had incurred a spinal cord injury at least 20 years previously; were admitted to rehabilitation within 1 year of injury; were between age 15 and 55 at the time of injury. Data were collected using a combination of self-completed questionnaires and interviews. Data included medical information, general health, hospitalisations, and changes in bladder and bowel management, equipment, pain, spasticity, the need for assistance, and other health issues. RESULTS: Clear international differences existed between the three samples in the three different countries. After controlling for sampling differences (ie, differences in age, level of lesion, duration of disability, etc.), the following differences were seen: (1) American participants had a better psychological profile and fewer health and disability-related problems; (2) British participants had less joint pain and less likelihood of perceiving they were ageing more quickly; (3) Canadians had more health and disability-related complications (particularly bowel, pain and fatigue problems). CONCLUSION: These differences are discussed in terms of socio-political, health care system and cultural factors that might be used to explain them, and to generate hypotheses for future research.     

Pain intensity, pain interference and characteristics of spinal cord injury

STUDY DESIGN: Postal survey. OBJECTIVES: To examine if the intensity of pain in persons with spinal cord injury (SCI) varied as a function of pain site, and to identify the patient and SCI characteristics associated with pain location, pain intensity and pain interference in a sample of persons with SCI. SETTING: Community sample, United States. METHODS: A postal survey including measures of pain intensity, pain interference, other pain, demographic and medical characteristics was completed by 238 adults with SCI. RESULTS: Average pain intensity was moderate and pain was common across the body. Demographic and medical variables, including SCI level, were generally not associated with pain prevalence, intensity and interference. However, persons with higher level injuries were more likely to report upper extremity pain than persons with paraplegic injuries. The lower body was the location of the highest pain ratings. CONCLUSION: Persons with SCI tend to experience high pain intensity over multiple body locations. Lower body pain was as common as upper extremity pain, but tended to be more intense.     

_ 2009 review and revisions of the international standards for the neurological classification of spinal cord injury

The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) were recently reviewed by the ASIA's Education and Standards Committees, in collaboration with the International Spinal Cord Society's Education Committee. Available educational materials for the ISNCSCI were also reviewed. The last citable reference for the ISNCSCI's methodology is the ISNCSCI Reference Manual, published in 2003 by ASIA. The Standards Committee recommended that the numerous items that were revised should be published and a precedent established for a routine published review of the ISNCSCI. The Standards Committee also noted that, although the 2008 reprint pocket booklet is current, the reference manual should be revised after proposals to modify/revise the ASIA Impairment Scale (AIS as modified from Frankel) are considered. In addition, the Standards Committee adopted a process for thorough and transparent review of requests to revise the ISNCSCI.     

脊髓损伤后膀胱尿流动力学检查及分类

目的：检测脊髓损伤患者膀胱功能并分类。探讨并发症与膀胱功能的关系。方法：采用尿流动力学四导程测压仪对３６例脊髓损伤患者进行下尿路功能分组检测。结果：各组患者因脊髓损伤节段及程度的不同，会有不同的尿流动力学表现及不同的膀胱功能，而且有相应的并发症发生，这之间有一定的规律及内在联系，并据此将膀胱分为三类。结论：根据尿流动力学表现对脊髓损伤后膀胱进行分类，对临床有一定的指导意义。     

Chronic pain after spinal cord injury: a survey of practice in UK spinal injury units

OBJECTIVE: To determine current practice regarding assessment and management of patients with chronic pain after spinal cord injury (SCI) in the UK. METHODS: A postal questionnaire sent to the medical directors of the 12 spinal injury units in the UK. RESULTS: A response was received from nine of the 12 units. Chronic pain was felt to be a significant problem amongst patients with SCI, with inconsistent opinion between respondents regarding prevalence, aetiology and classification of chronic pain after spinal cord injury. Only one unit had established protocols for the investigation and management of pain, and most units felt that guidelines would be useful. Most felt that there was a need for further information on the subject. CONCLUSION: Our survey has demonstrated the uncertainty that exists amongst specialists dealing with pain after SCI, and emphasised the need for more research into the problem.     

Adults with pediatric-onset spinal cord injury: part 2: musculoskeletal and neurological complications

OBJECTIVE: To determine the prevalence of musculoskeletal and neurological complications of adults with pediatric-onset spinal cord injuries (SCI), and their association with demographic, impairment, and functional limitation factors. METHOD: Structured interview including standardized measures. PARTICIPANTS: Individuals who sustained SCI at < or = age 18 years and were > or = age 24 years at interview. OUTCOME MEASURES: Prevalence of musculoskeletal and neurological complications: fractures during the past 3 years; scoliosis; heterotopic ossification; hip dislocation or contractures; ankle contractures or pain; shoulder pain; elbow contractures or pain; pain at other sites; neurological deterioration; syringomyelia; and spasticity since injury. RESULTS: The 216 individuals who were interviewed had mean age at injury of 14 years and mean age at follow-up of 29 years. Most common complications were pain at any site (69%), spasticity (57%), shoulder pain (48%), scoliosis (40%), hip contractures (23%), and back pain (22%). There were no statistically significant associations between gender and the complications. Whites were more likely than nonwhites to experience pain. Younger age at injury was significantly associated with scoliosis and hip subluxation, and older age at injury was associated with ankle pain and spasticity. Older age at follow-up and longer duration of injury were both associated with elbow and shoulder pain, fractures, and neurological deterioration. Longer injury duration was also associated with hip subluxation and scoliosis. Ankle pain, elbow contractures, and spasticity were more common in those with tetraplegia, and hip contractures were associated with paraplegia. American Spinal Injury Association motor scores were significantly lower in those with elbow contractures and spasticity, and significantly higher in those with hip contractures and neurological deterioration. CONCLUSION: Musculoskeletal and neurological complications are common sequelae among adults with pediatric-onset SCI. Demographic, impairment, and functional limitation factors are associated with these complications and can identify at-risk individuals.     

Shoulder pain and functional disability in spinal cord injury patients

Sixty spinal cord injured patients were examined to determine the incidence of nontraumatic shoulder pain and associated functional disability during the first 18 months after spinal cord injury (SCI). Seventy-eight percent of quadriplegics and 35% of paraplegics had pain in the first six months. When reexamined six to 18 months after SCI, 33% of the quadriplegics and 35% of the paraplegics continued to have pain. The functional disability resulting from shoulder pain was not a significant problem for the paraplegics; however, 84% of the quadriplegics having pain had either moderate or severe functional disability during the first six months after SCI, and this impairment persisted in patients with shoulder spasticity at follow-up evaluation between six and 18 months postinjury.     

The relationship between pain and mood following spinal cord injury

Objectives: To explore the relationship between pain and mood during spinal cord injury rehabilitation, and to discuss clinical implications to optimize rehabilitation outcomes.

Design: Repeated measures, retrospective cohort study.

Setting: Tertiary care, spinal cord injury rehabilitation center.

Participants: Patients (N?=?509) who completed both Needs Assessment Checklist (NAC) 1 and NAC2 between February 2008 and February 2015.

Interventions: Not applicable.

Outcome measure: Pain ratings (0–10) and mood scores (0–24) were obtained from the Needs Assessment Checklist (NAC). NAC1 is completed within 4 weeks post-mobilization and NAC2 upon the patient moving to the pre-discharge ward.

Results: There were statistically significant improvements in both pain and mood from NAC1 to NAC2. There were significant correlations between pain and mood at both NAC1 and NAC2 (a decrease in pain was associated with an improvement in mood). Individuals who reported that pain interfered with their rehabilitation had higher pain scores and lower mood scores at both NAC1 and NAC2.

Conclusions: Pain and mood evidently interact following spinal cord injury, and the nature of this relationship is complex. The current study provides some support for the bidirectional causality hypothesis, suggesting that pain and mood exert an effect upon each other. It is important to address pain and psychological issues early and together in the post-injury phase to optimize rehabilitation outcomes.     

抑制脊髓损伤后疼痛的分子和细胞策略

即使外科手术管理、物理治疗和药理学干预新药有效性的持续改进.仍然有许多脊髓损伤病人继续遭受难以治疗的神经性疼痛.目前分子和细胞水平基础研究尝试对脊髓损伤后疼痛的治疗策略,明显扩展了治疗临床疼痛的潜力,其中分子策略包括病毒介导基因转移、离子通道控制、反义寡核苷酸和短干扰RNA镇痛,细胞策略包括嗜铬细胞系、永生化神经细胞系、含"基因开关"嗜铬细胞系、前体细胞系镇痛等.随着表达载体调控系统的有效开发和疼痛机制研究的不断深入,将为建立可靠安全的镇痛分子和细胞库打下基础,相关分子和细胞策略有望为脊髓损伤后疼痛病人带来福音.     

Sustained spinal cord compression: part I: time-dependent effect on long-term pathophysiology

BACKGROUND: The objective of this study is to determine whether there is a relationship between the duration of sustained spinal cord compression and the extent of spinal cord injury and the capacity for functional recovery after decompression. METHODS: Sixteen dogs underwent sustained spinal cord compression for thirty or 180 minutes. The cords were compressed with use of a loading device with a hydraulic piston. A pressure transducer was attached to the surface of the piston, which transmitted real-time spinal cord interface pressures to a data-acquisition system. Somatosensory evoked potentials were monitored during a sixty-minute recovery period as well as at twenty-eight days after the injury. Functional motor recovery was judged throughout a twenty-six-day period after the injury with use of a battery of motor tasks. The volume of the lesion and damage to the tissue were assessed with both magnetic resonance imaging and histological analysis. RESULTS: Sustained spinal cord compression was associated with a gradual decline in interface pressure. Despite this, there was continuous decline in the amplitude of the somatosensory evoked potentials, which did not return until the cord was decompressed. Within one hour after the decompression, the dogs in the thirty-minute-compression group had recovery of somatosensory evoked potentials, but no animal had such recovery in the 180-minute group. Recovery of the somatosensory evoked potentials in the thirty-minute group was sustained over the twenty-eight days after the injury. Motor tests demonstrated rapid recovery of hindlimb motor function in the thirty-minute group, but there was considerable impairment in the 180-minute group. Within two weeks after the injury, balance, cadence, stair-climbing, and the ability to walk up an inclined plane were significantly better in the thirty-minute group than in the 180-minute group. The longer duration of compression produced lesions of significantly greater volume, which corresponded to the long-term functional outcome. CONCLUSIONS: The relatively rapid viscoelastic relaxation of the spinal cord during the early phase of sustained cord compression suggests that there are mechanisms of secondary injury that are linked to tissue displacement. Longer periods of displacement allow propagation of the secondary injury process, resulting in a lack of recovery of somatosensory evoked potentials, limited functional recovery, and more extensive tissue damage.     

Comparing 4- and 6-week post-flap protocols in patients with spinal cord injury

Objective: For patients with spinal cord injury (SCI) who undergo flap surgery to treat pressure injuries (PIs), the optimal duration of post-operative bedrest to promote healing and successful remobilization to sitting is unknown. At the study center, the minimum duration of post-operative bedrest was changed from 4 to 6 weeks. The purpose of this study is to compare outcomes of patients who underwent flap surgery using bedrest protocols of different duration.Design: This was a retrospective review of all flap procedures completed at VA Puget Sound Health Care System from 1997 to 2016 to treat PIs in patients with SCI. Surgeries were excluded if they were not a flap (i.e. primary skin closure or graft), involved a non-pelvic region, or were a same-hospitalization revision of a prior surgery. The primary outcome of this investigation was the number of days between surgery and the first time the patient mobilized to sitting out of bed for 2 h with an intact surgical incision.Methods: 190 patients received a total of 286 flap surgeries from 1994 to 2016. A chart review of each case was completed to determine the planned duration of bedrest (4- vs 6-weeks), first date of successful mobilization out of bed for 2 h, length of stay post-surgery, and occurrence of complications such as dehiscence or need for operative revisions.Results: Among 286 primary surgeries, 171 surgeries used the 4-week protocol and 115 used the 6-week protocol. When compared to the 4-week protocol, patients treated with the 6-week protocol were slightly older, more likely to have a diagnosis of diabetes, and less likely to be current smokers. Healing was never achieved after 4 surgeries in the 4-week group and 2 surgeries in the 6-week group. With the analysis restricted to a single surgery per subject who achieved healing (109 treated with 4-week protocol and 75 with 6-week protocol), there was a significant difference in days until 2-h sitting: median 54 days for the 4-week protocol compared to 60 days for the 6-week protocol (p = 0.041). Up to about 60 days post-operatively, the 4-week protocol produced a greater proportion remobilized to sitting, and thereafter the proportion of patients successfully remobilized did not differ between protocols.Conclusions: The 6-week protocol was not associated with improved remobilization outcomes (reduced rates of dehiscence or surgical revisions), and the 4-week protocol resulted in a significantly shorter time to remobilization to sitting for 2 h as well as a shorter length of stay. We did not identify any subgroup of patients that benefited from the longer protocol.     

脊髓,圆锥与马尾损伤分类：附106例胸腰段脊柱与脊髓损伤分析

本文将１０６例胸１０到腰４的脊柱脊髓损伤的病例进行神经损伤的分类：Ｉ型：完全性脊髓损伤；Ⅱ型：完全性脊髓－圆锥损伤；Ⅲ型：不完全性圆锥马尾损伤；Ⅳ型：完全性圆锥损伤，合并部分马尾损伤：Ⅴ型：完全性圆锥马尾损伤；Ⅵ型：单纯圆锥损伤；Ⅶ型：部分马尾损伤．文章论述了每一型损伤的诊断标准，讨论了分类的意义，神经损伤与膀眈功能分级的关系；提出了以感觉、运动及膀胱功能为指标的截瘫量化功能评价的格式．     

Adults with pediatric-onset spinal cord injury: part 1: prevalence of medical complications

OBJECTIVE: To determine the prevalence of medical complications of adults with pediatric-onset spinal cord injury (SCI) and their association with demographic, impairment, and functional limitation factors. METHOD: Structured interview including standardized measures. PARTICIPANTS: Individuals who sustained spinal cord injuries at age 18 years or younger and were 24 years of age or older at interview. OUTCOME MEASURES: Prevalence of medical complications: Urinary tract infections (UTI) requiring intravenous antibiotics or hospitalization (severe UTI), pressure ulcers, hemorrhoids and rectal bleeding, chronic medical conditions, and hospitalizations in the past 3 years. Urinary stones, orchitis or epididymitis, pneumonia, ventilatory assistance, thromboembolism, and latex allergy since injury. Current experience with UTI, bladder and bowel incontinence, bowel program length, constipation or diarrhea, dysreflexia, and hyperhidrosis. RESULTS: Two hundred sixteen individuals were interviewed, with a mean age of injury of 14 years and a mean age at follow-up of 29 years. Most commonly experienced complications were UTI (74%), bowel incontinence (63%), pressure ulcers (44%), autonomic dysreflexia (42%), and respiratory complications (33%). Pressure ulcers were more common in men and latex allergy more common in women. Age at injury was not associated with any of the complications. Older age at interview was associated with orchitis or epididymitis, bowel incontinence, respiratory complications, thromboembolism, and chronic medical conditions; longer duration of injury was associated with these same complications, except for bowel incontinence. Greater neurologic impairment was related to UTI, severe UTI, stones, bowel incontinence, respiratory complications, autonomic dysreflexia, hyperhidrosis, latex allergy, and pressure ulcers. With the exception of latex allergy and UTI, Functional Independence Measure (FIM) scores were associated with the same factors as neurologic impairment. CONCLUSIONS: Medical complications are common sequelae for adults with pediatric-onset SCI. Demographic, impairment, and functional limitation factors are associated with these complications and can be used to identify at-risk individuals.