Shattered images: recovery for the SCI client

Spinal cord injury (SCI) is one of the most traumatic afflictions a person can experience. The impact of the injury on body image often seems unbearable. The SCI individual faces the reality of a known body image that has been replaced by a devastating change in both appearance and function. The physiological and psychological changes created by the SCI require time for adjustment. This article proposes a four-stage process adapted from Grunbaum (1985) to help SCI clients recover from a disturbance in body image. Nursing interventions for the SCI client that facilitate restoration of a shattered body image are suggested.     

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.     

Neurologic recovery and neurologic decline after spinal cord injury

Physicians caring for patients with spinal cord injury facilitate neurologic recovery by optimizing nutrition and general health, by coordinating active exercise and functional training to enhance the underlying synapse growth, reversal of muscle atrophy, and motor learning, and by controlling interfering spasticity. SCI physicians also must monitor for neurologic decline during initial rehabilitation and later in life, diagnose promptly and accurately such decline, and orchestrate the appropriate intervention.     

Cardiopulmonary resuscitation, brain blood flow, and neurologic recovery

A review of survival rates and neurologic outcome after cardiac resuscitation indicates the importance of rapid initiation of cardiopulmonary resuscitation (CPR) and of finding ways to further improve cerebral blood flow during CPR. Mechanisms for generating blood flow to the brain during CPR and experimental strategies for enhancing cerebral viability are discussed.     

Levels of spinal cord injury and predictors of neurologic recovery

A comprehensive physical examination of the patient with acute spinal cord injury is essential in determining the initial level of injury and is the most accurate method of prognosticating neurologic recovery. Understanding neurologic recovery helps predict ultimate functional capability and needs, and helps evaluate the effectiveness of pharmacologic and therapeutic interventions.     

Predicting recovery of dextrous hand function in acute stroke

Purpose. To determine the clinical characteristics during acute stroke that predicted dextrous function in the paretic hand at 6 months post-stroke.

Method. Fifty-seven patients within 5 days post-stroke were recruited in stroke wards. Recovery of dextrous hand function, indicated by a score of ≥35 of Action Research Arm Test, was assessed weekly in the first 4 weeks then monthly till 6 months post-stroke. The seven predictor candidates evaluated included side and site of brain infarct, stroke severity, cognition, spatial neglect, two-point discrimination (2-PD), muscle tone and muscle strength of the paretic upper extremity (UE).

Results. Site of infarct, stroke severity, 2-PD and UE muscle strength had independent association with dextrous hand function at 6 months post-stroke. Stepwise multiple logistic regressions showed that the best early predictor was 2-PD in week 1 to 3 (Odds ratio [OR] ranged from 0.51–0.83) and UE muscle strength during the first 2 months post-stroke (OR ≥ 1.04). The strongest predictor was muscle strength at week 4 post-stroke, followed by combined 2-PD and muscle strength at week 2 post-stroke.

Conclusions. Muscle strength and 2-PD in the paretic UE during the first month post-stroke were the best predictors of dextrous hand function recovery at 6 months.     

Predicting recovery of upper-body dressing ability after stroke

OBJECTIVE: To identify predictors of the recovery of independent dressing ability after stroke. DESIGN: Prospective cohort study. SETTING: Rehabilitation unit at a university hospital. PARTICIPANTS: Sixty-three consecutive stroke patients were enrolled in the study. Twelve patients were not able to complete the study because they were discharged or transferred to another hospital before study completion. INTERVENTION: Fifty-one patients underwent and completed 15 days of dressing training based on the time-delay method, which included the 10 component actions of upper-body dressing and 4 cues given by therapists. MAIN OUTCOME MEASURES: The dressing item of the FIM instrument, Brunnstrom motor recovery stages, presence or absence of deep and tactile sensation, Rey-Osterrieth complex figure test, Kohs block design test, body image test, Weintraub cancellation task, and presence or absence of the visual extinction phenomenon and the motor impersistence phenomenon. RESULTS: The FIM upper-body dressing item score and the cancellation task score at the start of training were significantly better in patients who achieved independence in dressing within 15 training days than in patients who did not (P < .05). The motor impersistence phenomenon was found less frequently among patients who achieved independence in upper-body dressing than among patients who did not (P < .05). However, logistic regression analysis showed that only the FIM score for upper-body dressing on the first day of training was a significant independent predictor of dressing ability at the end of training (odds ratio, 4.33; 95% confidence interval, 1.51-12.37). The receiver operating characteristic curve indicated that a cutoff score of 3 would provide the best balance between sensitivity and specificity for the FIM upper-body dressing item. The positive predictive value of this cutoff score was .90, and the negative predictive value was .70. CONCLUSIONS: Our findings indicate that the FIM upper-body dressing score on the first day of dressing training is an independent predictor of recovery of upper-body dressing ability after stroke.     

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.     

Functional recovery and length of stay after hip fracture in patients with neurologic impairment

OBJECTIVE: To evaluate the functional recovery and the length of stay after hip fracture in patients with neurologic impairment. DESIGN: A total of 577 inpatients with hip fracture consecutively admitted to our rehabilitation hospital were included in this retrospective study. A total of 71 of 577 were affected by neurologic impairment caused by stroke with hemiplegia (n = 37), Parkinson's disease (n = 25), or other diseases (n = 9). RESULTS: Mean Barthel index was significantly lower in the patients with neurologic impairment than in the controls: 10.8 (95% confidence interval, 5.9-15.6; P < 0.001) at admission and 13.1 (95% confidence interval, 5.55-20.65; P < 0.001) at discharge. Multiple regression including eight confounding variables showed that neurologic impairment was negatively associated with the Barthel index. However, the mean increase in Barthel index through the course of rehabilitation was not affected by neurologic impairment. The length of stay was significantly higher in the patients with neurologic impairment, 3.84 days (95% confidence interval, 0.51-7.17; P < 0.05), and multiple regression showed that neurologic impairment was positively associated with the length of stay. CONCLUSIONS: After hip fracture, the presence of neurologic impairment was associated with lower Barthel index and longer length of stay, but it did not affect the increase in Barthel index due to a course of rehabilitation.     

双靶区神经环路磁刺激调控大鼠星形胶质细胞改善脊髓损伤运动功能的研究

摘要 目的：观察脊髓损伤后早期应用神经环路磁刺激治疗对星形胶质细胞活化的作用,探讨双靶区神经环路磁刺激促进脊髓损伤康复的作用机制。 方法：将36只成年雄性SD大鼠随机分成3组,Sham+SS组：假手术+假刺激组,SCI+SS组：SCI+假刺激组,SCI+NC-MS组：SCI+神经环路磁刺激组,每组12只。建立脊髓损伤大鼠模型,术后第3天SCI+NC-MS组接受真刺激,另外两组接受假刺激,每日1次,每周5次,共3周。分别在术前、术后1d、3d、7d、14d、21d采用BBB评分、斜板试验评价运动功能;治疗结束后处死大鼠并提取损伤区脊髓,HE染色观察各组损伤区脊髓的病理变化;Western Blot测定各组脊髓中胶质纤维源性酸性蛋白（GFAP）的表达。 结果：①行为学：BBB评分和斜板试验显示SCI+NC-MS组术后7d、14d、21d的运动功能显著优于SCI+SS组（P<0.001）;②HE染色显示,相对于SCI+SS组,SCI+NC-MS组的脊髓结构改善,病变程度相对减轻;③Western Blot显示,和SCI+SS组相比,SCI+NC-MS组的GFAP蛋白表达量明显降低（P<0.05）。 结论：双靶区神经环路磁刺激的早期应用可以抑制星形胶质细胞活化,减少脊髓损伤区胶质瘢痕形成,促进运动功能康复。     

失神经支配程度测试在判断面神经功能恢复中的作用

目的:探讨面神经不同失神经支配程度的病理变化对面神经功能康复的影响。方法:应用神经兴奋性测试仪测试正常人双侧面神经兴奋阈值的差值,进行重复性实验。测试面神经麻痹(facialparalysis,FP)者面神经的失神经支配程度。制作豚鼠颞骨内FP模型,应用诱发肌电图测试压榨面神经前后动作电位的反应阈值及通过瞬目反射观察面肌功能恢复时间。透射电镜观察面神经的病理改变。结果:190例FP由恢复到临床治愈,失神经支配阴性组需(33.1±21.3)d;失神经支配I度组需(63.3±12.4)d;失神经支配Ⅱ度组需(90.1±11.7)d;失神经支配III度组需(210.2±37.5)d,4组间差异有显著性意义(t=2.676～3.973,P<0.01)。压迫面神经5s组,神经兴奋性传导恢复时间和瞬目反射恢复时间都是(60.7±45.3)h;15s组神经兴奋性传导恢复时间(982.6±36.6)h,瞬目反射恢复需(46±12)d;30s组神经兴奋性传导和瞬目反射无一只恢复到正常。电镜观察5s组髓鞘板层轻度松散,15s组髓鞘板层重度松散,30s组髓鞘融解轴突破坏。结论:失神经支配程度是FP康复诊断的指标,并与髓鞘和轴突破坏程度有关。     

Hyperbaric oxygen therapy accelerates neurologic recovery after 15-minute complete global cerebral ischemia in dogs.

BACKGROUND AND METHODS: Although hyperbaric oxygen therapy is clinically used for the treatment of several types of ischemic brain injury, few basic animal studies are available that provide a rationale for this therapy for complete global brain ischemia. Therefore, we investigated the effect of hyperbaric oxygen therapy on neurologic recovery after 15-min complete global cerebral ischemia in a canine model. Complete global ischemia was induced in 19 dogs by occlusion of the ascending aorta and the caval veins. Nine dogs were randomized to treatment with hyperbaric oxygenation (3 atmospheres absolute, 100% oxygen for 1 hr) at 3, 24, and 29 hrs after ischemia under spontaneous respiration, while the other ten dogs served as the control group without hyperbaric oxygen therapy (group C). Neurologic recovery was evaluated based on the electroencephalogram (EEG) activity score (1 = normal; 5 = isoelectric) and the neurologic recovery score (100 = normal; 0 = brain death) over a 14-day postischemic period. RESULTS: The survival rates were 3/10 (30%) in the control group vs. 7/9 (78%) in the group treated with hyperbaric oxygen (p < .05). Over the 14-day postischemic period, the best (lowest) EEG scores of each dog were significantly (1.7 +/- 0.2 vs. 2.9 +/- 0.3; mean +/- SE, p < .01) lower in the hyperbaric oxygen-treated group. The best neurologic recovery scores of each dog were significantly (69 +/- 6 vs. 48 +/- 5; mean +/- SE, p < .05) higher in the treated animals. The number of dogs that recovered to a neurologic recovery score of > 65 (assessed as a slight disability) were 1/10 in the control group and 6/9 in the group treated with hyperbaric oxygen (p < .02). CONCLUSIONS: Hyperbaric oxygen therapy performed in the early postischemic period accelerated neurologic recovery and improved the survival rate in dogs after 15-mins of complete global cerebral ischemia.     

An exceptional case of complete neurologic recovery after more than 5-h cardiac arrest.

We describe a case of more than 5 h cardiac arrest in a 60-year-old patient who underwent general anesthesia for a urologic operation. Before extubation, the patient suddenly developed ventricular fibrillation, pulseless ventricular tachycardia and asystole which was immediately treated by advanced life support (ALS) measures. Thirty minutes later seizures developed and were controlled by 200 mg of thiopentone and 10 mg of diazepam. A pattern of ventricular tachycardia, coarse ventricular fibrillation and asystole lasted for nearly 120 min. Termination of resuscitation maneuvers was considered, but long-term life support was continued for 5 h. After this time, peripheral pulses, with a supraventricular tachycardia-like rhythm and regular spontaneous breathing reappeared. Seven hours later, the patient had a Glasgow Coma Scale (GCS) of 5, dilated unresponsive, absence of pupils, and a systolic arterial pressure of 100 mmHg. He was then transferred to intensive care unit (ICU). The morning after, the patient was awake, responded to simple orders, breathing spontaneously, and free from sensomotor deficit. He was, therefore, extubated. Subsequently, other episodes of transitory ST-line upper wave followed by ventricular fibrillation appeared, suggesting Prinzmetal angina. This was successfully treated by percutaneous coronary angioplasty. The first electroencephalogram recorded the day after cardiac arrest showed a mild widespread background slowing. An electroencephalogram 6 days later showed a return to alpha rhythm with only mild theta-wave abnormalities. Four weeks after the first cardiac arrest the patient was discharged. This is an exceptional experience compared with the others reported. We believe that all the efforts must not be given up when such an event occurs during anesthesia and there are optimal conditions for resuscitation maneuvers.     

Rehabilitation in spinal cord disorders. 2. Anatomy, pathogenesis, and research for neurologic recovery

This self-directed learning module highlights advances in this topic area. It is part of the chapter on rehabilitation in spinal cord disorders in the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This article contains learning objectives on the anatomy of the spine and spinal cord, pathogenesis of spinal cord trauma, mechanisms of spinal fractures and dislocations, causes of nontraumatic spinal cord disorders, and research on neurologic recovery. Advances that are covered in this section include various experimental animal models for producing spinal cord injury and new approaches to limit damage in acute injury and to promote recovery in chronic injury.