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.     

Nontraumatic spinal cord injury: an Italian survey

OBJECTIVE: To describe the demographic and clinical characteristics and the clinical course of patients with nontraumatic spinal cord injury (SCI). DESIGN: A multicenter prospective study. SETTING: Thirty-two rehabilitation centers in several Italian regions. PARTICIPANTS: Patients with nontraumatic SCI (N=330) on first admission (February 1, 1997-January 31, 1999) to rehabilitation centers. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Indicators of rehabilitation process quality were efficient bladder and bowel management. The indica-tor of neurologic recovery was improvement in American Spinal Injury Association Impairment Scale (AIS) level at discharge. The indicator of rehabilitation outcome was return home. Length of stay (LOS) was also measured as an indicator of the care process. RESULTS: Of the 330 patients, 30% exhibited an improvement in AIS classification at discharge, and 73% returned home. In multivariate analysis, a longer LOS was associated with vascular etiology, complete lesions, residence outside the district of the rehabilitation center, and presence of clinical complications. Neurologic improvement was related to incompleteness of the lesion and longer LOS. Factors predicting a return home were married status, incompleteness of lesion, clinical improvement, efficient bowel and bladder management, absence of pressure ulcers, and longer LOS. CONCLUSIONS: Patients showed long waiting times between diagnosis and initiation of rehabilitation, a good chance of improvement on the AIS, and low rates of home returns.     

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.     

Years to employment after spinal cord injury

OBJECTIVE: To identify factors related to the length of time between spinal cord injury (SCI) onset and return to work among 259 participants with SCI, all of whom have worked at some point since SCI onset. DESIGN: All data were cross-sectional and collected by survey methodology. SETTING: A midwestern university hospital and private hospital in the same metropolitan area. PARTICIPANTS: Participants were identified from outpatient records of 2 participating hospitals. They met 4 exclusion and inclusion criteria: (1) traumatic SCI; (2) 18 years of age or older; (3) a minimum of 2 years postinjury; and (4) had been employed at some time since SCI. The 259 participants' average age was 46.4 years at the time of the study, with an average of 23.5 years having passed since SCI onset. INTERVENTIONS: Not applicable. Main Outcome Measures: Years from injury onset to beginning first postinjury job, years to the first full-time postinjury job, and the Life Situation Questionnaire. RESULTS: Participants averaged 4.8 years from the time of SCI onset to their first postinjury job and 6.3 years until their first full-time postinjury job. However, these figures varied greatly depending on whether the individual returned to the preinjury job, was working as a professional at the time of injury, had a noncervical injury, and the amount of education by the time of injury. CONCLUSION: There are 2 general tracks to employment after SCI-a fast track where people return to their preinjury job or preinjury profession and a slower track that is generally associated with needs for further reeducation and training. Working to return the individual to the preinjury job or to a position related to their preinjury occupation may substantially shorten the interval to return to work. In cases where this is not possible, counselors must work with individuals to understand the timeline of return to work and identify realistic educational goals that fit both the individual's interest pattern and postinjury abilities.     

Functional outcomes and disability after nontraumatic spinal cord injury rehabilitation: Results from a retrospective study

OBJECTIVE: To describe, in a group of patients undergoing initial inpatient rehabilitation after nontraumatic spinal cord injury (SCI), the demographic characteristics, clinical features, and outcomes, with a focus on the functional status and disability. DESIGN: Retrospective data analysis, 3-year case series. SETTING: Tertiary medical unit specializing in nontraumatic SCI rehabilitation. PARTICIPANTS: Consecutive sample of 70 adult inpatient referrals with nontraumatic SCI undergoing initial inpatient rehabilitation. INTERVENTION: Chart review. MAIN OUTCOME MEASURES: Primary outcomes were demographic characteristics, clinical features, mortality, length of stay (LOS), neurologic classification, accommodation setting, support services, mobility, bladder and bowel continence, and FIM instrument scores. RESULTS: Forty-one patients (58.6%) were paraplegic incomplete, 23 (32.9%) were tetraplegic incomplete, and 6 (8.6%) were paraplegic complete. Eight patients (11.4%) died before hospital discharge. Of those who survived, 47 (75.8%) were discharged home, 11 (17.7%) were transferred to a nursing home, and 4 (6.4%) went elsewhere in the community. The geometric mean LOS was 55.8 days. Nine patients (14.5%) were discharged walking unaided, 27 (43.5%) were walking at least 10 m with a gait aid, and 26 (41.9%) were wheelchair dependent for mobility. Thirty patients (48.4%) were voiding on sensation, 7 (11.1%) used intermittent catheterization, 23 (37.2%) had an indwelling catheter, and 2 (2.8%) used reflex voiding. Eleven patients (17.7%) were fecally continent on sensation and 47 (75.8%) were fecally continent with a bowel program, 1 patient (1.6%) had a colostomy, and 3 patients (4.8%) were discharged fecally incontinent. The mean Rasch FIM motor score was 39.6 on admission and 58.7 at discharge (paired t test, t=-11.2; P<.000). CONCLUSIONS: Most nontraumatic SCI patients returned home with a good level of functioning regarding mobility, bladder, and bowel status, in comparison to other studies of patients with SCI. Patients' disability was usually significantly reduced during rehabilitation.     

Predictors of psychosocial adaptation among people with spinal cord injury or disorder

OBJECTIVE: To examine the influence of disability-related medical and psychologic variables on psychosocial adaptation to spinal cord injury or disorder (SCI/D). DESIGN: A structural equation modeling design linking 3 sets of predictive variables to an outcome measure of adaptation. SETTING: Two outpatient SCI clinics (1 veteran, 1 civilian) in Texas. PARTICIPANTS: Veterans (n=181) and civilians (n=132) with SCI/D. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The adaptation outcome was measured by 2 subscales (acknowledgment, adjustment) of the Reactions to Impairment and Disability Inventory (RIDI) and by the Quality of Life Scale. The predictive variables were measured by a demographic questionnaire, 3 subscales (intrusion, re-experiencing, hyperarousal) of the Purdue Posttraumatic Stress Disorder-Revised scale, the McMordie-Templer Death Anxiety Scale, and 3 subscales (anxiety, depression, denial) of the RIDI. RESULTS: Goodness-of-fit indices suggested that a revised model of adaptation was a moderately good fit to the data. The revised model of adaptation indicated that there were medium total effects (direct plus indirect) on psychosocial adaptation by 2 latent variables (disability severity and impact, negative affectivity) and small total effects on psychosocial adaptation by disengagement coping. The latent factor of disengagement coping had the strongest direct effect on adaptation (although not statistically significant). Disability severity and impact had medium indirect effects and negative affectivity had small indirect effects on psychosocial adaptation. All of the aforementioned effects had a negative coefficient. CONCLUSIONS: Negative emotional responses (eg, depression, anxiety) to SCI/D, disengagement-type coping (eg, disability denial, avoidance), and the severity and impact of disability were related to lower levels of adaptation to SCI/D.     

An electric stimulation cycling protocol for gait in incomplete spinal cord injury

OBJECTIVE: To determine the feasibility and impact of an outpatient, electric stimulation cycling (ESC) protocol on a patient with incomplete spinal cord injury (SCI). DESIGN: Pre-post case study. SETTING: Outpatient rehabilitation hospital. PARTICIPANT: A 24-year old man with an incomplete SCI occurring 25 months before study entry at the T12-L1 level. INTERVENTION: A 2-phase, 10-week ESC intervention occurring 3 days a week. Phase 1 provided 30-minute ESC sessions at increasing resistance with electric stimulation applied to the quadriceps and hamstrings; phase 2 required cycling independently (ie, without stimulation) at maximal effort for increasing lengths of time. MAIN OUTCOME MEASURES: Gait velocity, stride length, and step length, all collected during a 10-meter walking test, and the Walking Index of Spinal Cord Injury-II (WISCI-II). RESULTS: During phase 1, the patient quickly increased workload, session duration, and distance; during phase 2, duration that the subject was able to cycle without stimulation increased markedly. After the entire intervention, the subject exhibited diminished edema, new ability to voluntarily step, new ability to voluntarily dorsiflex the ankle and voluntarily flex the toe, and new ability to perform valued activities, such as transfers. He also exhibited increased mean gait velocity (.33 m/s), left (.11 m) and right (.07 m) stride length, left (.06 m) and right (.05 m) step length, and a 10-point WISCI-II increase. The subject was also able to discontinue use of several medications after intervention. CONCLUSIONS: SCI patients' endurance and gait deficits can possibly be effectively addressed on an outpatient basis and with minimal assistance by using this regimen.     

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

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

Effects of gender on neurologic and functional recovery after spinal cord injury

OBJECTIVE: To assess gender differences in neurologic and functional outcome measures in persons with spinal cord injury (SCI). DESIGN: Case series. SETTINGS: Model Spinal Cord Injury Systems (MSCIS) throughout the United States. PARTICIPANTS: People (N=14,433) admitted to an MSCIS within 30 days of injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Improvement in American Spinal Injury Association (ASIA) motor index score, ASIA Impairment Scale, level of injury, and FIM instrument scores after SCI. RESULTS: When examining subjects grouped by severity of injury, changes in ASIA motor index total scores, from system admission to 1-year anniversary, were significantly greater for women than men with either complete ( P =.035) or incomplete ( P =.031) injuries. Functional comparison of men and women, using the FIM motor subscale, revealed that men had higher FIM motor scores at rehabilitation discharge among those with motor-complete injuries, except for those with C1-4 and C6 neurologic levels. Women with motor-incomplete high tetraplegia (C1-4 levels) had higher discharge FIM motor scores than did similarly afflicted men. There were no significant differences in FIM motor scores among men and women with other levels of motor incomplete SCI. CONCLUSIONS: Gender differences in SCI were seen in several areas. Women may have more natural neurologic recovery than men; however, for a given level and degree of neurologic injury, men tend to do better functionally than women at time of discharge from rehabilitation. Future prospective study of the effects of estrogen on neurologic recovery and the effects of gender on functional potential are recommended.     

Health status rated with the Medical Outcomes Study 36-Item Short-Form Health Survey after spinal cord injury

OBJECTIVE: To describe the health status of Australians with spinal cord injury (SCI). DESIGN: Survey. SETTING: Australian population-based sample. PARTICIPANTS: Participants (N=305) with SCI at recruitment to a randomized trial. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) health questionnaire. RESULTS: Compared with the general population, our sample reported significantly lower scores in 6 SF-36 domains (physical function, role-physical, bodily pain, general health, social function, vitality) and the physical component summary (PCS) score, but unexpectedly higher mental component summary (MCS) scores (difference in mean MCS scores, 4.6; 95% confidence interval [CI], 2.4-6.8). Compared with people with tetraplegia, those with paraplegia had better physical function and PCS scores (difference, 21; 95% CI, 17-24; difference, 3; 95% CI, 1-5, respectively), and worse bodily pain scores (difference, 9; 95% CI, 2-15). Recent urinary infections were associated with worse general health, vitality, mental health, and MCS scores. Receiving family or external physical care was associated with worse physical function and PCS scores, but better mental health and MCS scores. Older age at injury was associated with lower bodily pain and PCS scores. CONCLUSIONS: Using the SF-36, Australians with SCI rate their physical (not mental) health status as worse than the general population.     

Pain characteristics in patients admitted to hospital with complications after spinal cord injury

OBJECTIVES: To determine characteristics of pain, the relation between pain and mood, the effect of pain on activities, and the perceived difficulty in coping with pain in patients hospitalized for treatment of complications associated with spinal cord injury (SCI). DESIGN: Cohort survey. SETTING: Hospital inpatient unit in Australia. PARTICIPANTS: Consecutive sample of patients (N=88) admitted to a hospital spinal injuries unit with complications after SCI. Two eligible patients declined to participate. INTERVENTION: Face-to-face interview with questionnaire. MAIN OUTCOME MEASURES: Pain severity, global self-rated health, mood (Kessler Mood Inventory), and interference with activities (Von Korff disability scale). RESULTS: Sixty-six (75%) of the 88 subjects experienced pain, with an average time of onset +/- standard deviation of 8.02+/-12.4 years; 27% of those with pain described it as severe or excruciating. Subjects with pain were less likely to rate their global health as excellent or very good when compared with those who did not have pain (22% vs 44%, respectively). Patients with pain had significantly greater levels of psychologic distress than did people with SCI and no pain. CONCLUSIONS: Pain is a common problem in people admitted to hospital with SCI for treatment of other complications. It has a significant impact on activities and is associated with a reduction in global self-rated health and higher levels of psychologic distress.     

A longitudinal study of depression from 1 to 5 years after spinal cord injury

Hoffman JM, Bombardier CH, Graves DE, Kalpakjian CZ, Krause JS. A longitudinal study of depression from 1 to 5 years after spinal cord injury.

Objective

To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury.

Design

Longitudinal cohort study.

Setting

SCI Model System.

Participants

Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009.

Interventions

Not applicable.

Main Outcome Measure

Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher.

Results

Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found.

Conclusion

In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population.     

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

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

Return to work after spinal cord injury in Taiwan: the contribution of functional independence

OBJECTIVE: To study the employment rate and determinants of return to work for persons with traumatic spinal cord injury (SCI) in Taiwan. DESIGN: Cross-sectional. SETTING: Taiwan community. PARTICIPANTS: One hundred sixty-nine people who had sustained traumatic SCI, had been completely rehabilitated in a university hospital between 1989 and 2002, and who were between 18 and 60 years of age at the time of interview in 2003. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A structured questionnaire was used to identify demographic and injury-related status, functional status, and pre- and postinjury work-related information. RESULTS: At the time of survey, only 47% of the participants were engaged in remunerative employment. Cox regression analysis, with time elapsed between injury and survey as the underlying time axis, showed that education and functional independence were associated with employment. Subjects with a high school education had a 2.2-fold higher chance (95% confidence interval [CI], 1.3-3.8) of returning to work than those without. Subjects with higher scores on the Barthel Index and ability to use public or private transport independently had a 2.7-fold higher chance (95% CI, 1.5-4.9) of returning to work than those unable to travel independently. Other factors significantly associated with employment included marital status, with marriage having a favorable influence; age at injury, with age below 25 years being favorable; preinjury occupation; and vocational training after injury. The importance of functional independence training in rehabilitation is stressed. CONCLUSIONS: Functional independence was a strong factor predicting return to work. Rehabilitation focused on education, vocational training, self-care ability, community mobility, and environmental modifications could improve employability after SCI.     

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.     

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.     

Health status, community integration, and economic risk factors for mortality after spinal cord injury

OBJECTIVE: To examine the association of health, community integration, and economic status with subsequent mortality and life expectancy among persons with spinal cord injury. DESIGN: Cohort study. SETTING: Model Spinal Cord Injury Systems (MSCIS) hospitals. PARTICIPANTS: A total of 5947 persons injured since 1973 who were enrolled in the National Spinal Cord Injury Database and who were still alive and received an annual evaluation from November 1995 through March 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Mortality was determined by routine follow-up supplemented by information from the Social Security Death Index. A logistic regression model based on the full set of predictor variables was developed to estimate the chance of dying in any given year. RESULTS: After adjusting for demographic characteristics and injury severity, health status indicators, measures of community integration, and economic status indicators all had relatively small but statistically significant effects (20%-70% increases) on the likelihood of dying during the next year. Inclusion of these factors may result in higher life expectancy estimates under highly favorable conditions. CONCLUSIONS: Whereas previous reports of the MSCIS data have identified the life expectancies associated with a particular set of demographic (eg, age, gender) and injury-related characteristics (level and completeness of injury; ventilator dependence), the current analysis suggests that consideration of health, economic, and psychosocial factors may make computations of life expectancy more accurate.     

Gram-negative intravascular catheter-related bacteremia in patients with spinal cord injury

Hussain R, Cevallos ME, Darouiche RO, Trautner BW. Gram-negative intravascular catheter-related bacteremia in patients with spinal cord injury.

Objective

To determine whether the prevalence of gram-negative catheter-related bloodstream infection (CRBSI) is higher in patients with spinal cord injury (SCI) than in patients without SCI.

Design

Retrospective chart review from August 1998 to August 2006.

Setting

A Veterans Affairs medical center, which serves as a tertiary care medical center to over 500 veterans with SCI and is the primary source of health care for veterans in southeast Texas.

Participants

All hospitalized patients who had an International Classification of Diseases, Ninth Revision, code for bacteremia associated with their hospital stay.

Interventions

Not applicable.

Main Outcome Measure

The proportion of CRBSI caused by gram-negative organisms in the SCI patients to the proportion of CRBSI caused by gram-negative organisms in the non-SCI patients.

Results

Eight (42%) of 19 episodes of CRBSI in the SCI were caused by a gram-negative organism as compared with 4 (11%) of 36 infections in the non-SCI group (P<.01). Factors associated with having a gram-negative organism rather than a gram-positive organism as the causative agent of CRBSI were SCI, femoral catheter site, prolonged hospitalization, decubitus ulcer, and urinary catheter.

Conclusions

In our medical center, patients with SCI who develop CRBSI are more likely to have an infection with a gram-negative organism than are patients without SCI. This knowledge may guide initial empirical therapy of suspected bloodstream infection.