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.     

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.     

A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge

van den Berg-Emons RJ, Bussmann JB, Haisma JA, Sluis TA, van der Woude LH, Bergen MP, Stam HJ. A prospective study on physical activity levels after spinal cord injury during inpatient rehabilitation and the year after discharge.

Objectives

To assess the change over time in the physical activity level after a spinal cord injury (SCI), to explore its determinants, and to compare the physical activity level 1 year after discharge from the rehabilitation center with the level in able-bodied persons.

Design

Prospective cohort study. Measurements were obtained at the start of active rehabilitation, 3 months later, at discharge, 2 months after discharge, and 1 year after discharge.

Setting

Rehabilitation center in The Netherlands and the participant's home.

Participants

Persons (n=40) with SCI.

Interventions

Not applicable.

Main Outcome Measures

The physical activity level, as indicated by the duration of dynamic activities (ie, wheelchair driving, walking, cycling, noncyclic movement) per day, and the intensity of everyday activity; both were measured with an accelerometry-based activity monitor during 2 consecutive weekdays.

Results

Random coefficient analyses showed that the duration of dynamic activities and the intensity of everyday activity increased during inpatient rehabilitation at rates of 41% and 19%, respectively (P<.01). Shortly after discharge, there was a strong decline (33%; P<.001) in the duration of dynamic activities. One year after discharge, this decline was restored to the discharge level but was low in comparison with levels in able-bodied persons. The level of lesion and completeness of lesion were determinants of the change in the physical activity level after discharge.

Conclusions

The physical activity level increased during inpatient rehabilitation, but this increase did not continue after discharge, and the level 1 year after discharge was distinctly lower than the level in able-bodied persons. Subpopulations had a different change over time in the physical activity level after discharge.     

脊髓损伤患者与健康人步行时躯干肌肌肉利用率的对照研究

目的观察和比较脊髓损伤患者与健康人步行时躯干肌的肌肉利用率（MUR）。 方法选取20例T11完全性脊髓损伤患者（病例组）及健康志愿者（对照组）,每组10例,采用表面电极和同步摄像技术对2组受试者步行时躯干肌表面肌群（胸大肌、腹直肌、腹外斜肌、斜方肌、背阔肌、竖脊肌）的肌电活动情况进行测试和分析,以最大用力收缩的百分比表示MUR。用独立样本t检验分析比较组间MUR的差异,用单因素方差分析比较组内MUR的差异。 结果①站立相时,病例组胸大肌、腹外斜肌和竖脊肌的MUR分别为（24.93±17.22）%、（30.38±13.92）%和（15.54±5.02）%,均大于对照组［(7.54±3.84)%、(10.48±6.02)%及(10.85±4.61)%］,且组间差异有统计学意义（P<0.05）。迈步相时,病例组腹外斜肌和竖脊肌的MUR［（29.11±24.62）%和（19.57±11.15）%］大于对照组［（8.20±4.23）%和（8.54±3.95）%］,组间差异亦有统计学意义（P<0.05）。②站立相时,病例组组内比较,腹外斜肌的MUR大于其它肌肉（胸大肌除外）,而胸大肌的MUR［（24.93±17.22）%］大于斜方肌［（10.88±9.28）%］,差异均有统计学意义（P<0.05）;对照组组内比较,各肌肉的MUR差异无统计学意义（P>0.05）。迈步相时,病例组内比较,腹外斜肌的MUR大于斜方肌（P<0.05）;对照组内斜方肌的MUR［（13.09±9.17）%］大于胸大肌［（7.90±4.06）%］和腹直肌［（5.76±4.21）%］,背阔肌的MUR［（11.06±6.52）%］大于腹直肌［（5.76±4.21）%］,且差异均有统计学意义（P<0.05）。 结论T11完全性脊髓损伤患者步行时胸大肌、腹外斜肌及竖脊肌的肌肉利用率高于健康人,可为优化步行训练方案提供参考。     

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.     

Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury

Weeks DL, Greer CL, Bray BS, Schwartz CR, White JR Jr. Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury.

Objective

To study whether outcomes in patients who have undergone inpatient rehabilitation for stroke, traumatic brain injury (TBI), or traumatic spinal cord injury (TSCI) differ based on antidepressant medication (ADM) use.

Design

Retrospective cohort study of 867 electronic medical records of patients receiving inpatient rehabilitation for stroke, TBI, or TSCI. Four cohorts were formed within each rehabilitation condition: patients with no history of ADM use and no indication of history of depression; patients with no history of ADM use but with a secondary diagnostic code for a depressive illness; patients with a history of ADM use prior to and during inpatient rehabilitation; and patients who began ADM therapy in inpatient rehabilitation.

Setting

Freestanding inpatient rehabilitation facility (IRF).

Participants

Patients diagnosed with stroke (n=625), TBI (n=175), and TSCI (n=67).

Interventions

Not applicable.

Main Outcome Measures

FIM, rehabilitation length of stay (LOS), deviation between actual LOS and expected LOS, and functional gain per day.

Results

In each impairment condition, patients initiating ADM therapy in inpatient rehabilitation had longer LOS than patients in the same impairment condition on ADM at IRF admission, and had significantly longer LOS than patients with no history of ADM use and no diagnosis of depression (P<.05). LOS for patients initiating ADM therapy as inpatients even exceeded LOS for patients without ADM history, but who had a diagnosis for a depressive disorder. Deviation in LOS was significantly larger in the stroke and TBI groups initiating ADM in IRF than their counterparts with no history of ADM use, illustrating that the group initiating ADM therapy in rehabilitation significantly exceeded expected LOS. Increased LOS did not translate into functional gains, and in fact, functional gain per day was lower in the group initiating ADM therapy in IRF.

Conclusions

Explanations for unexpectedly long LOS in patients initiating ADM in inpatient rehabilitation focus on the potential for ADM to inhibit therapy-driven remodeling of the nervous system when initiated close in time to nervous system injury, or the possibility that untreated sequelae (eg, depressive symptoms or fatigue) were limiting progress in therapy, which triggered ADM treatment.     

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.     

Changes in physical capacity during and after inpatient rehabilitation in subjects with a spinal cord injury

OBJECTIVE: To assess changes in physical capacity and its determinants in persons with a spinal cord injury. DESIGN: Prospective cohort study. Measurements at the start of active rehabilitation (t1), 3 months later (t2), at discharge (t3), and 1 year after discharge (t4). SETTING: Eight rehabilitation centers in The Netherlands. PARTICIPANTS: A total of 186 subjects at t1 and 123 subjects at t4. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Peak aerobic power output (POpeak), peak oxygen uptake (V(O2)peak), muscle strength of the upper extremity (manual muscle test, handheld dynamometry), and respiratory function (forced expiratory flow per second, forced vital capacity). RESULTS: Random coefficient analysis demonstrated that the POpeak, V(O2)peak, strength, and respiratory function improved during inpatient rehabilitation, and that V(O2)peak, strength, and respiratory function continued to improve after discharge. Age, sex, and level and completeness of lesion were determinants of the change in components of physical capacity. CONCLUSIONS: Physical capacity improves during inpatient rehabilitation, and some components continue to improve after discharge. Subpopulations have a different level of (change in) physical capacity. The components of physical capacity are related; intervention studies are needed to confirm whether training 1 component could improve another component.     

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.     

The assessment of walking capacity using the walking index for spinal cord injury: self-selected versus maximal levels

OBJECTIVES: To assess (1) the frequency and magnitude of differences between self-selected and maximal walking capacity following spinal cord injury (SCI) by using the Walking Index for Spinal Cord Injury (WISCI) and (2) how these levels differ in efficiency and velocity. DESIGN: Prospective cohort. SETTING: Academic medical center. PARTICIPANTS: Fifty people with chronic incomplete SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subjects ambulated at the level used in the community (self-selected WISCI) and the highest level possible (maximal WISCI). Velocity (in m/s), Physiological Cost Index (PCI), and Total Heart Beat Index (THBI) were calculated. Differences were compared using the paired t test (parametric) or Wilcoxon signed-rank test (nonparametric). RESULTS: For 36 subjects, maximal WISCI was higher than self-selected WISCI; 21 subjects showed an increase of 3 levels or more. Ambulatory velocity was higher for self-selected WISCI compared with maximal WISCI (.68 m/s vs .56 m/s, P<.001). PCI and THBI at self-selected WISCI were lower than at maximal WISCI (PCI, 0.99 beats/m vs 1.48 beats/m, P<.001; THBI, 3.39 beats/m vs 4.75 beats/m, P<.001). CONCLUSIONS: Many people with chronic SCI are capable of ambulating at multiple levels. For these people, ambulation at self-selected WISCI was more efficient as evidenced by greater velocity and decreased PCI and THBI. The findings have implications for assessing walking capacity within the context of clinical trials.     

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.     

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.     

Prospective analysis of lipid profiles in persons with a spinal cord injury during and 1 year after inpatient rehabilitation

de Groot S, Dallmeijer AJ, Post MW, Angenot EL, van den Berg-Emons RJ, van der Woude LH. Prospective analysis of lipid profiles in persons with a spinal cord injury during and 1 year after inpatient rehabilitation.

Objectives

To investigate the course of lipid profiles during and 1 year after inpatient rehabilitation of persons with spinal cord injury, and to determine which personal, lesion, and lifestyle characteristics influence the changes in lipid profiles over time and among subjects.

Design

Multilevel regression analysis of measurement points during and after rehabilitation.

Setting

Eight rehabilitation centers in The Netherlands.

Participants

People with complete and incomplete paraplegia and tetraplegia (N=180).

Interventions

Not applicable.

Main Outcome Measures

Total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), and the TC/HDL ratio.

Results

We found a significant decrease in TG and TC/HDL during inpatient rehabilitation and a significant increase in HDL during and after inpatient rehabilitation. TC and LDL, however, showed unfavorable increases after clinical discharge. The changes in HDL and LDL over time differed between lesion groups. An increase in the body mass index (BMI) led to an unfavorable change in all lipid profiles. Older participants showed higher TC, LDL, and HDL concentrations. Women and participants who consumed some alcohol, or who were more active 1 year after discharge, had more favorable HDL levels.

Conclusions

Lipid profiles improved during inpatient rehabilitation but deteriorated somewhat after clinical discharge. Controlling one’s BMI seems important in diminishing the risk for unfavorable lipid profiles.     

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.     

Subject- and injury-related factors influencing the course of manual wheelchair skill performance during initial inpatient rehabilitation of persons with spinal cord injury

OBJECTIVES: To study changes in wheelchair skills in subjects with spinal cord injury (SCI) during rehabilitation; to determine whether changes in wheelchair skill performance are related to the subject, lesion characteristics, secondary complications, and upper extremity pain; and to investigate if wheelchair skill performance at discharge can be predicted from these features. DESIGN: Longitudinal. Subjects performed the Wheelchair Circuit 3 times during rehabilitation: at admission (t1), 3 months later (t2), and at discharge (t3). SETTING: Eight rehabilitation centers in the Netherlands. PARTICIPANTS: One hundred twenty-one subjects with SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Wheelchair Circuit consists of 8 wheelchair skills and results in 3 test scores: ability, performance time, and physical strain. RESULTS: All the scores of the Wheelchair Circuit improved significantly between t1 and t2, and between t2 and t3. The scores were related to age and lesion level, whereas changes in scores were related to age, sex, lesion level, and secondary complications. The variables age, body mass index, sex, lesion level, motor completeness, and secondary complications contributed significantly to the prediction of the scores at t3. CONCLUSIONS: Wheelchair skill performance improved during rehabilitation. Personal and lesion characteristics are most important for improving wheelchair skill performance and predicting wheelchair skill performance.     

Prognostic value of pinprick preservation in motor complete, sensory incomplete spinal cord injury

OBJECTIVE: To assess sacral and lower-extremity pinprick preservation as prognostic indicators for ambulation in motor complete, sensory incomplete spinal cord injury (SCI). DESIGN: Retrospective analysis. SETTING: Twenty-eight tertiary care centers in the United States and Canada. PARTICIPANTS: Subjects (N=131; mean age, 31.6y) with motor complete, sensory incomplete SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Ambulation at 26 and 52 weeks postinjury (modified Benzel scale). RESULTS: A higher percentage of subjects with sacral pinprick preservation at baseline were ambulating at 26 (39.4% vs 28.3%) and 52 weeks (53.6% vs 41.5%). This finding did not reach statistical significance. The presence of sacral pinprick preservation at 4 weeks postinjury was significant for predicting ambulation at 52 weeks postinjury (36.0% vs 4.4%, P =.011) and approached significance at 26 weeks (15.2% vs 0.0%, P =.056). Significant differences in ambulation rates were also observed between subjects, based on the presence of baseline lower-extremity pinprick preservation (>/=50% of lower-extremity L2-S1 dermatomes) at both 26 (50.0% vs 28.8%, P =.048) and 52 weeks (66.7% vs 40.3%, P =.023) after injury. CONCLUSIONS: Baseline lower-extremity pinprick preservation and sacral pinprick preservation at 4 weeks postinjury are associated with an improved prognosis for ambulation.     

Effects of a simple functional electric system and/or a hinged ankle-foot orthosis on walking in persons with incomplete spinal cord injury

OBJECTIVES: To compare the effect of functional electric stimulation (FES) with that of a hinged ankle-foot orthosis (AFO) for assisting foot clearance, gait speed, and endurance and to determine whether there is added benefit in using FES in conjunction with the hinged AFO in persons with incomplete spinal cord injury (SCI). DESIGN: Within-subject comparison of walking under 4 conditions: AFO, FES, AFO and FES, and no orthosis. A plastic hinged AFO was used for all AFO conditions. SETTING: Tertiary rehabilitation center. PARTICIPANTS: Nineteen subjects with incomplete SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The self-selected gait speed, 6-minute walk distance, and foot clearance values were compared between conditions. RESULTS: Gait speed increased with FES ( P <.05) and with the AFO ( P =.06). Six-minute walk distance also increased with the AFO ( P <.05). No difference was found between the 2 forms of orthoses in either gait speed or endurance. The greatest increase in gait speed and endurance from the no-orthosis condition occurred with the combined AFO and FES condition. Foot clearance improved with FES but not with AFO. Subjects whose gait speed increased with FES had weaker hip flexors, knee flexors, and ankle dorsiflexors than those who did not benefit from FES. CONCLUSIONS: Both FES and the hinged AFO promote walking and FES is only superior to the AFO in increasing foot-clearance values. The hinged AFO and FES together may offer advantages over either device alone.     

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.