Worklife After Traumatic Spinal Cord Injury

Abstract

Objective: To develop predictive models to estimate worklife expectancy after spinal cord injury (SCI).

Design: Inception cohort study.

Setting: Model SCI Care Systems throughout the United States.

Participants: 20,143 persons enrolled in the National Spinal Cord Injury Statistical Centerdatabase since 1973.

Intervention: Not applicable.

Main Outcome Measure: Postinjury employment rates and worklife expectancy.

Results: Using logistic regression, we found a greater likelihood of being employed in any given year to be significantly associated with younger age, white race, higher education level, being married, having a nonviolent cause of injury, paraplegia, ASIA D injury, longer time postinjury, being employed at injury and during the previous postinjury year, higher general population employment rate, lower level of Social Security Disability Insurance benefits, and calendar years after the passage of the Americans with Disabilities Act.

Conclusions: The likelihood of postinjury employment varies substantially among persons with SCI. Given favorable patient characteristics, worklife should be considerably higher than previous estimates.     

Aging After Spinal Cord Injury: A 30-Year Longitudinal Study

Abstract

Background/Objective: This longitudinal study investigated changes in life satisfaction, general health, activities, and adjustment over 3 decades among individuals with spinal cord injury (SCI).

Participants: The cohort of participants was identified from outpatient records of a large Midwestern United States university hospital. In 1973, 256 individuals completed an initial survey. There were 5 subsequent follow-up surveys, with the most recent being in 2002. Seventy-eight participants completed materials on all 6 occasions.

Methods: The Life Situation Questionnaire was used to identify changes over the 30-year period in 6 areas of life satisfaction, self-rated adjustment (current and predicted), employment status, activities, and medical treatments.

Analyses: These analyses used data from 3 points in time, separated by approximately 15-year intervals. One-way analysis of variance with repeated measures was used to identify changes in outcomes between 1973, 1988, and 2002 for all continuous variables.

Results: We found a mixed pattern of changes over the 30 years, with increases noted during the first 15- year period in sitting tolerance, educational and employment outcomes, satisfaction with employment, and adjustment. Although these changes tended to remain stable during the last 15 years, subtle declines were suggested in some areas, with clear declines noted in terms of diminished sitting tolerance, an increase in the number of physician visits, and decreased satisfaction with social life and sex life.

Conclusions: The results suggest that many positive changes occur within the first 2 decades after SCI, followed by a period of stability in some life areas, but decline with aging in some participation and health-related aspects of life.     

Spinal Myoclonus After Spinal Cord Injury

Abstract

Background/Objective: In the course of examining spinal motor function in many hundreds of people with traumatic spinal cord injury, we encountered 6 individuals who developed involuntary and rhythmic contractions in muscles of their legs. Although there are many reports of unusual muscle activation patterns associated with different forms of myoclonus, we believe that certain aspects of the patterns seen with these 6 subjects have not been previously reported. These patterns share many features with those associated with a spinal central pattern generator for walking.

Methods: Subjects in this case series had a history of chronic injury to the cervical spinal cord, resulting in either complete (ASIA A; n = 4) or incomplete (ASIA D; n = 2) quadriplegia. We used multi-channel electromyography recordings of trunk and leg muscles of each subject to document muscle activation patterns associated with different postures and as influenced by a variety of sensory stimuli.

Results: Involuntary contractions spanned multiple leg muscles bilaterally, sometimes including weak abdominal contractions. Contractions were smooth and graded and were highly reproducible in rate for a given subject (contraction rates were 0.3-0.5 Hz). These movements did not resemble the brief rapid contractions (ie, "jerks") ascribed to some forms of spinal myoclonus. For all subjects, the onset of involuntary muscle contraction was dependent upon hip angle; contractions did not occur unless the hips (and knees) were extended (ie, subjects were supine). In the 4 ASIA A subjects, contractions occurred simultaneously in all muscles (agonists and antagonists) bilaterally. In sharp contrast, contractions in the 2 ASIA D subjects were reciprocal between agonists and antagonists within a limb and alternated between limbs, such that movements in these 2 subjects looked just like repetitive stepping. Finally, each of the 6 subjects had a distinct pathology of their spinal cord, nerve roots, distal trunk, or thigh; in 4 of these subjects, treatment of the pathology eliminated the involuntary movements.

Conclusion: The timing, distribution, and reliance upon hip angle suggest that these movement patterns reflect some elements of a central pattern generator for stepping. Emergence of these movements in persons with chronic spinal cord injury is extremely rare and appears to depend upon a combination of the more rostrally placed injury and a pathologic process leading to a further enhancement of excitability in the caudal spinal cord.     

Adrenal Insufficiency in Acute Spinal Cord Injury

Abstract

Background/Objective: A 21-year-old man with a C6 American Spinal Injury Association A spinal cord injury (SCI) developed symptomatic hypotension resistant to vasopressors and volume replacement 2 weeks after injury and was diagnosed with adrenal insufficiency by cosyntropin test. Adrenal insufficiency has been documented in chronic SCI; this case shows documented adrenal insufficiency in acute SCI. Design: Case report.

Results: Secondary adrenal insufficiency complicated the medical and rehabilitative course of this patient with SCI. During 2 infectious episodes, this patient's dosage of hydrocortisone had to be doubled to control symptomatic hypotension, lethargy, diffuse weakness, and anorexia.

Conclusions: The nonspecific symptomatology of adrenal insufficiency can be easily overlooked in patients with SCI. Low basal cortisol levels may be an important clue to this disorder. Low-dose adrenocorticotropic hormone stimulation may be more sensitive than high doses for detecting subclinical adrenal insufficiency. A high index of clinical suspicion is needed for the correct diagnosis of acute and chronic adrenal insufficiency.     

Incidence,Etiology, and Risk Factors for Fever Following Acute Spinal Cord Injury

Abstract

Objective: To identify the incidence, etiology, and risk factors for fevers in individuals with traumatic spinal cord injury (SCI).

Design: A retrospective review of the medical records of consecutive adult traumatic SCI patients over a 2- year period was performed.

Setting: The study was performed at a tertiary care, Level I trauma center.

Participants: Consecutive adult traumatic SCI admissions to acute care (n = 48) and rehabilitation (n = 40) were included in the study.

Main Outcome Measures: Incidence, etiology, mean maximum temperature elevation, and duration of fevers (temperature >99.9 F) were measured.

Results: The incidence of fever was 60.4% and 50% (acute care and rehabilitation, respectively). Total number of fevers was 58 and 66, acute and rehabilitation, respectively. Respiratory and urinary tract were the most common identifiable fever etiologies. Unidentified fever etiologies were numerous in both the acute and rehabilitation groups, representing 66% and 56% of cases, respectively. Significant differences (P < 0.05) were found between identified vs unidentified fever etiology groups for mean maximal temperature (102.5°F vs 101.1°F on acute and 101.5°F vs 100.7°F on rehabilitation), duration of fever (10.3 days vs 2.2 on acute and 2.8 days vs 1.3 on rehabilitation), fevers above 101.4°F (75% vs 29% on acute and 40% vs 8% on rehabilitation), cause of injury (gunshot wound on acute care) and completeness of injury (American Spinal Injury Association classification A on rehabilitation).

Conclusions: This study suggests that fevers occur commonly in patients with SCI, with respiratory and genitourinary system etiologies most commonly identified. Unidentified etiologies were common and were associated with lower temperature elevation and shorter fever duration. Injury etiology and completeness of injury may comprise additional risk factors. These factors should be taken into account when initiating cost- efficient fever workup in individuals with SCI.     

Serum Leptin Levels Following Acute Experimental Spinal Cord Injury

Background/Objective:

Spinal cord injury influences many hormones that are known to be involved in the modulation of neurotrophic, neurogenic, and neuroprotective events. Recent studies showed that leptin could be neuroprotective, enhancing neuronal survival in vitro and in vivo. The objective of this study was to evaluate the pattern of the serum leptin levels in rats during acute traumatic SCI.

Methods:

Forty male Sprague-Dawley rats were divided randomly into 4 groups. In the control group, neither laminectomy nor SCI was performed; only laminectomy was performed without SCI in the sham group. In the cervical and thoracic spinal trauma groups, laminectomies were performed following the same trauma procedure. Blood samples were drawn 2, 6, 12, and 24 hours after the procedures and assayed immediately.

Results:

In the first 2 hours, levels of leptin were similar in control and sham-operated groups and higher in neurotrauma groups (P < 0.05). At the sixth hour, leptin levels increased in the sham-operated group, decreased in the neurotrauma groups (P < 0.05), and did not change in the control group (P > 0.05). At the 12th hour, the levels of leptin increased in all groups (P > 0.05). At the 24th hour, they decreased in the control, sham-operated, and cervical groups (P < 0.05); levels did not change in the thoracic group (P > 0.05). The decrease was higher in the control group than in the other groups (P < 0.05).

Conclusions:

Activation of endogenous leptin secretion started immediately after the SCI. The level of neurologic lesion (either cervical or thoracic regions) affected the levels of serum leptin differently, but with the exception of the first 12-hour period, this difference did not reach a statistically significant level.     

Prevention of Thromboembolism in Spinal Cord Injury

Abstract

Background: Prion diseases or transmissible spongiform encephalopathies (TSEs) are neurodegenerative syndromes caused by proteinaceous infectious particles (or “prions”), are fatally progressive, and affect humans and animals. Human prion disease may be familial, sporadic, or due to iatrogenic causes. The signs and symptoms include dementia, ataxia, myoclonus, dysautonomia, pyramidal and extrapyramidal tract signs, and akinesia. The incubation period of iatrogenic TSE ranges from 15 months to 30 years, and clinical presentations may be atypical.

Design: Case report.

Findings: This article presents the case study of a 39-year-old man who fell at work and subsequently complained of subjective lower extremity weakness, followed by onset of ataxia, bowel and bladder incontinence, and progressive decline in ambulation over 6 months. In the absence of a unifying diagnosis, the patient was presumed to have had a spinal cord injury (SCI). Because neuro-axis imaging studies fail ed to explain his symptoms, the patient's complaints were thought to have a large psychologic component. The patient then developed neurologic abnormalities proximal to the presumed SCI. Somatosensory evoked potentials were suggestive of a thoracic or lumbar cord myelopathy and cerebrospinal fluid analysis was suggestive of prion disease. Family members eventually revealed that the patient had had injections of growth hormones derived from cadaveric human pituitary glands as a child. Postmortem brain examination later revealed definitive Creutzfeldt-Jakob disease.     

Trunk Function and Ischial Pressure Offloading in Individuals with Spinal Cord Injury

Objective: To determine if there is a relationship between trunk function and offloading of the ischial tuberosities in individuals with Spinal Cord Injury (SCI).

Design: Prospective cross-sectional evaluation.

Setting: Sub-acute rehabilitation hospital.

Participants: Fifteen non-ambulatory participants with complete or incomplete traumatic and non-traumatic SCI, American Spinal Injury Association Impairment Scale (AIS), Classification A-D.

Outcome Measures: Isometric trunk strength using a hand held dynamometer, the ability to reach using the multidirectional reach test and offloading times of the ischial tuberosities using a customized pressure mat.

Results: Participants who were able to engage in the multidirectional reach test were defined as “Reachers”, whereas individuals who were unable to engage in the multidirectional reach test were defined as “Non-Reachers”. Trunk strength was significantly higher in Reachers compared with Non-Reachers (P < 0.05). Offloading times over the left and right ischial tuberosities were lower in Non-Reachers when compared with Reachers, however the results were statistically significant only for offloading over the right ischial tuberosity (P < 0.05). There was no correlation between trunk strength and pressure offloading times for both groups.

Conclusions: Regardless of an individual's ability to engage in a reaching task, participants with spinal cord injury spent more time offloading the left ischial tuberosity compared with the right ischial tuberosity. The study highlights the need to identify factors that may contribute to offloading behavior in individuals with spinal cord injury who lack sufficient trunk strength.     

Measuring Depression in Persons With Spinal Cord Injury: A Systematic Review

Background/Objective:     

Measuring Depression in Persons With Spinal Cord Injury: A Systematic Review

Background/Objective: Depression has been studied extensively among people with spinal cord injury (SCI). However, basic questions persist regarding the reliability and validity of depression measurement in the context of SCI. The objective of this study was to evaluate the state of knowledge of depression measurement in persons with SCI.

Methods: English-language peer-reviewed citations from MEDLINE, CINAHL, PsycINFO, ProQuest, Google Scholar, and Web of Science from 1980 to present. Two reviewers screened 377 abstracts on SCI and depression topics to identify 144 containing classifiable psychometric data. All 144 were reviewed by 6 reviewers. Twenty-four studies reporting psychometric data on 7 depression measures in SCI samples were identified, including 7 validity studies.

Results: Reliability data were limited to internal consistency and were consistently good to excellent across 19 studies. Validity data were limited to concurrent validity, construct validity, and/or clinical utility in 10 studies. Measures were comparable with respect to internal consistency, factor structure, and clinical utility. Results are limited to peer-reviewed, English literature, and studies were not judged for quality.

Conclusions: Greater attention should be paid to the psychometric evaluation of established measures. Although existing evidence may not justify universal screening, we recommend depression screening in clinical practice when patients may be seen by nonpsychology personnel. There is insufficient evidence to recommend one screening measure over another. Therefore, selection of measures will depend on clinician preferences. Psychometric studies are needed to show test-retest reliability, criterion validity, and sensitivity to change to improve depression recognition and treatment.     

脊髓损伤病人的运动功能评定

目的 脊髓损伤（ＳＣＩ）病人的分级多采用Ｆｒａｎｋｅｌ分级标准,我们根据２６０例ＳＣＩ病人的观察,认为对病人活动功能影响最大的最运动功能与排尿功能,且上肢与下肢评级标准不尽相同,从而对分级提出改进意见。方法 本组２６０例, 伤后观察时间达１以上者１５６例,占６０％。损伤部位：Ｃ３－４￣Ｔ１ ９０例,Ｔ ２￣１０ ３７例,Ｔ１１￣Ｌ１ １０５例,Ｌ２－３ ２８例。脊髓损伤类型：完全截瘫１６９例,不全     

Treatment Of Major Depression In Individuals With Spinal Cord Injury

Abstract

Objective: This study evaluated the effects of treating major depression in individuals with spinal cord injury (SCI), focusing on the degree of improvement and correlated changes that could be expected in 6 months of treatment.

Design: Apretreatment–posttreatment designwas used. Random assignment to a nontreatment group could not be implemented ethically. Therefore, this study compared participants who declined treatment to persons who accepted treatment over a 24–month period.

Setting and Participants: Participants were outpatients of a large urban rehabilitation center in southern California. Twenty–eight participants who accepted treatment were assigned to a treatment group; 15 individuals who declined treatment were assigned to a nontreatment group. The age of the participants ranged from 20 to 7 4 years. Varying Ieveis of SCI dysfunction were represented. lnterventio1,1s: A 6–month combination of psychotherapy and antidepressant medication.

Outcome Measures: Adepression inventory, a community activities checklist, and a life satisfaction scale.

Results: A significant (P < 0.001) 57% reduction in depressive symptoms occurred in the treatment group, whereas there was no significant change in the nontreatment group. At theend of 6 months, 30% of participantshad no depression, 42%had minor depression, and 297% still had major depression, butto a lesser degree.Community activities increased significantly over the treatment period, as did life satisfaction.

Conclusion: The results suggest that depression is treatable in this population, although 6 months may not be sufficient to reach maximum benefit in all cases. This study further identified obstacles that limited the ability to randomize participants into treatment arms and made it difficult to deliver services to all those in need. Complications related to SCI, such as difficulties in transportation, likely restriet the ability to implement needed services to many individuals with SCI.     

Assessment Of Behavior In Animal Models Of Spinal Cord Injury

Abstract

Summary: There has been a significant increase in the amount of research directed at understanding pathologic and behavioral consequences of spinal cord injury (SCI), and attempts to promote recovery offunction. Several different approaches can be used to induce SCI; each has particular strengths and weaknesses. Ultimately, behavior is an extremely relevant outcome measure for determining the functional consequences of the initial injury, spontaneous recovery of function, and the efficacy of therapeutic interventions that are developed. Behavioral assessment can encompass a wide range of tests, and the appropriateness of each measure must be considered in determining the merit of each study. This review provides a brief overview and discussion of techniques used to induce SCI and assess behavior. The appropriate use and interpretation of these methods is critical for proper study design, interpretation of experimental results, and extrapolation to clinical relevance.     

Spinal Cord Injuries in Children and Adolescents: A Review

Abstract

This introductory review provides an overview of pediatric-onset spinal cord injury, emphasizing unique clinical and epidemiologic features, pathophysiology, medical and musculoskeletal complications, and psychosocial and management issues. Developmental factors influence the approach to bowel and bladder programs, mobility, patient education, and management of complications. Rehabilitation goals must be set for each developmental stage, with the final goal being that of a satisfying and productive adult life.     

Factors Related to Obstacle Crossing in Independent Ambulatory Patients With Spinal Cord Injury

Abstract

Background/Objectives: To evaluate factors related to the ability of ambulatory patients with spinal cord injury (SCI) to walk over small obstacles.

Study Design: Cross-sectional study.

Methods: Thirty-four patients with SCI (ASIA impairment scale [AIS] D) who were able to walk independently at least 10 m with or without walking devices were recruited for the study. Participants were required to walk over small obstacles (1,4, and 8 cm in height or width; total of 6 conditions). A “fail” was recorded when either the lower limbs or the walking device contacted the obstacle. Multiple logistic regression models were applied to determine the effects of walking devices (presence or absence), SCI levels (tetraparesis or paraparesis), and SCI stages (acute or chronic) on the ability of obstacle crossing.

Results: Fifteen participants (44%) failed to adequately clear the foot or walking device over obstacles in at least one condition (range 1–3 conditions). After adjusting for covariates, the chance of failure on obstacle crossing was greatly increased with the use of walking devices (odds ratio = 8.50; 95% CI = 0.85?75.03)

Conclusions: Gait safety in independent ambulatory participants with SCI remains threatened. Participants who walked with walking devices encountered a greater chance of failing to walk over obstacles as a result of inefficiently moving the foot or walking device over small obstacles. Thus, instead of training in an empty/ quiet room, rehabilitation procedures should incorporate contextual conditions that patients encounter at home and in the community in order to minimize risk of injury and prepare patients to be more independent after discharge.     

Bacteremia in the Spinal Cord Injury Population

Abstract

Positive blood cultures were found in 41 patients on the Spinal Cord Injury Service at the Milwaukee VAMC during the period of July, 1980 to December, 1985 giving an incidence of bacteremia of 1.3%. Mortality rate was 17%. Most common pathogens were E. Coli, Proteus mirabilis, Serratia marcescens and Staphylococcus aureus. A review of 29 available charts revealed genitourinary and respiratory tracts as the most common sources of infection (72.4% and 10.3% respectively). Other sources of infection were skin, postoperative, intravenous catheter site and cellulitis. Initial febrile response was seen in 93.1% of patients with 48.1% having temperature greater than 38.3°C. Hypotension (blood pressure less than 90/50 mm Hg) was noted in five out of the 29 (17.1%) patients. Clinical diagnosis of disseminated intravascular coagulation was made in two out of the 29 (6.9%) patients. Underlying risk factors were poor nutrition, respirator dependency, indwelling Foley catheters and manipulative procedures. Incidence and mortality rates are similar to the non-SCI population as reported elsewhere. The risk factors are different; therefore preventive management is extremely important.     

腺苷在继发性脊髓损伤中的作用及其机制

目的 通过观察大鼠脊髓损伤后内源性腺苷含量的变化,以及外源性腺苷地脊髓损伤后神经功能的影响,探讨腺苷在髓继发性损伤中的作用。方法 采用大鼠Ｔ１３脊髓腹侧压迫模型,用微透析技术每２０分钟连续收集脊髓损伤后脊髓组织细胞上液,用高效液相色谱仪紫外检测法检测细胞外液腺式的含量;伤前１４分钟蛛网膜下腔给予非特异性腺苷受体激动剂２－氯腺苷,观察伤后神经功能评分、倾斜平面临界角和组织学变化。结果 脊髓损伤后腺苷     

脊髓损伤基因治疗的研究进展

目的：探讨脊髓损伤基因治疗的最新研究进展。方法;综述了脊髓损伤基因治疗相关的神经营养素家庭的应用,移植细胞的选择,研究现状,存在的问题等。结果：ＮＧＦｓ在干预脊髓损伤后的病理反应和促进工矿企业 能恢复有潜在的治疗作用。雪旺细胞不仅可作为ＳＣＩ基因治疗的移植载体,其本身也可促进中枢神经的再生,髓鞘的重建和部分神经功能的恢复。     

Effects of Exercise Training and Inspiratory Muscle Training in Spinal Cord Injury: A Systematic Review

Objective: To provide a systematic review of the studies assessing exercise training and inspiratory muscle training (IMT) in individuals for the improved respiratory function of patients with spinal cord injury (SCI).

Methods: Thirteen studies (5 exercise training, 8 IMT) were identified. Articles were scored for their methodological quality using the Physiotherapy Evidence Database scores and Downs and Black tools for randomized and nonrandomized studies, respectively. Conclusions were based on the most rigorously executed studies using Sackett's levels of evidence.

Results: Study comparison was compromised by diverse research designs; small sample sizes; and heterogeneity of studied populations, protocols, and outcome measures. Based on current literature, there is level 2 evidence supporting exercise training as an intervention to improve respiratory strength andendurance and level 4 evidence to support exercise training as an intervention that might improve restingand exercising respiratory function in people with SCI. There is level 4 evidence to support IMT as anintervention that might decrease dyspnea and improve respiratory function in people with SCI.

Conclusions: There are insufficient data to strongly support the use of exercise training or IMT for improved respiratory function in people with SCI. There is some evidence of efficacy of both regimens; however, the evidenceis not of the best possible quality.