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Study design:Prospective cohort study.Objective:To assess functional hindrance due to spasticity during inpatient rehabilitation and 1 year thereafter in individuals with spinal cord injury (SCI) and to determine factors that influence the hindrance.Setting:Eight specialized rehabilitation centres in the Netherlands.Methods:A total of 203 patients with recent SCI rated the hindrance they perceived due to spasticity in daily living at the start of active rehabilitation (t1), 3 months later (t2), at discharge (t3) and 1 year after discharge (t4). Hindrance was dichotomized into absent or negligible and present. Multilevel regression analyses were performed to determine the course of functional hindrance due to spasticity and its associations with possible determinants-namely, age, gender, cause, lesion level, motor completeness, spasticity and anti-spasticity medication.Results:The percentage of individuals that indicated functional hindrance due to spasticity ranged from 54 to 62% over time and did not change significantly over time (Δt3t1 odds ratio (OR)=0.85, P=0.44; Δt3t2 OR=1.20, P=0.41; Δt3t4 OR=0.91, P=0.67). The percentage of individuals who experienced a lot of hindrance due to spasticity during specific activities ranged from 4 to 27%. The odds for experiencing functional hindrance due to spasticity were significantly higher for individuals with tetraplegia (OR=2.17, P=0.0001), more severe spasticity (OR=5.51, P<0.0001) and for those using anti-spasticity medication (OR=4.18, P<0.0001).Conclusion:Functional hindrance due to spasticity occurred in the majority of persons with SCI and did not change significantly during inpatient rehabilitation and 1 year thereafter. Factors that influence hindrance were determined. [ABSTRACT FROM AUTHOR]

Study design:Longitudinal.Objective:To investigate the relative importance of personality traits, emotional distress and pain as predictors of functional health status in patients with spinal cord injury (SCI) or multiple traumas (MTs).Setting:Sunnaas Rehabilitation Hospital, Norway.Methods:Data were obtained from SCI and MT patients at admission (n=101) and at discharge (n=87) from rehabilitation, as well as 4 years post injury (n=75). The primary outcome measure was the sickness impact profile (SIP). Personality traits, that is, dispositional optimism and positive/negative affectivity, were measured using the Life Orientation Test-Revised and the Positive Affect and Negative Affect Schedule, respectively.Results:Using hierarchical regression analysis, dispositional optimism and pain emerged as the most robust predictors of functional health status. Generally, these two variables accounted for a substantial part of the variance (that is, 20-40%) in the SIP scales. Significant correlations between pain and anxiety/depression were found in all phases of the study, and at follow-up depression level appeared as an independent predictor of functional health.Conclusion:The substantial predictive power, in terms of explained variance, of dispositional optimism, pain and depression/anxiety, indicates that these variables may be of practical-clinical importance in a rehabilitation setting. Specifically, patients characterized by low optimism, combined with presence of pain and depression/anxiety, may constitute a high-risk group for disability and reduced quality of life. On the other hand, high optimism should be regarded as a resilience characteristic, protecting the individual against long-term sequelae of severe physical injury. [ABSTRACT FROM AUTHOR]

Study design:Retrospective, observational study, with consecutive sampling.Objectives:To document the frequency and time frames for the achievement of independence in mobility skills for people undergoing rehabilitation following spinal cord injury (SCI).Setting:The South Australian Spinal Cord Injury Service, Hampstead Rehabilitation Centre, Adelaide, Australia.Methods:Retrospective data collection from a purpose-designed form. The achievement of independence in nine functional mobility skills, and time lines for this, were documented for people with a new SCI undergoing rehabilitation. Data from 152 participants were analyzed.Results:Of the nine mobility-based goals evaluated, the one most likely to be achieved was sitting on the edge of the bed and the least likely was gait. Time taken to achieve the skills varied from 4 to 10 weeks on average and reflected the degree of difficulty.Conclusion:The frequency and time frames to achieve independence in mobility skills documented in this study will be useful when goal setting in a post-acute SCI rehabilitation setting. [ABSTRACT FROM AUTHOR]

Study design:Case series from a prospectively acquired database and phone survey.Objectives:To assess the efficacy of upper limb reanimation (ULR) protocols on acquisition of intermittent self-catheterization (ISC) in C5-C7 ASIA tetraplegic patients.Setting:University Hospital, Paris, France.Methods:A prospectively acquired database of 152 tetraplegic patients followed in ULR consultation between 1997 and 2008 in a rehabilitation unit was studied. A total of 20 patients met the inclusion criteria, which mainly were traumatic C5-C7 tetraplegic adult patients who were unable to perform ISC, and who benefited from ULR with the objectives of improving hand abilities and of ISC acquisition, through urethral orifice for males or via a continent urinary stoma for females. The main outcome measure was ISC acquisition (ISC+) proportion. Population characteristics and secondary outcome measures: ISC+/ISC− patients were compared regarding epidemiological and surgical data, key-grip strength, patient global improvement score, activities of daily living and quality of life (PGI-I, Wuolle questionnaire, verbal rating scale).Results:ISC+ was 75%. It depended on key-grip strength (P<0.05) and led to a statistically significant improvement of urinary status compared with ISC− patients (P<0.01). ULR improved patients' abilities and QoL in both ISC+ and ISC− patients.Conclusion:ULR protocols allow ISC in most C5-C7 tetraplegic patients. Multidisciplinary care with surgeons and PRM physicians improves patients' vital and functional prognosis by changing their urological-management method. [ABSTRACT FROM AUTHOR]

Study design:A cross-sectional descriptive study was undertaken.Objectives:The overall objective was to explore the potential usefulness of clinicians' and patients' impressions of change in motor performance for clinical trials. Specifically, the aim was to compare clinicians' and patients' impressions of change in motor performance with standardized outcome measures in people with spinal cord injury (SCI).Setting:Spinal injury units, Sydney, Australia.Methods:Thirty people undergoing rehabilitation after recent SCI were recruited. They were assessed on two occasions separated by between 1 and 5 months. On both occasions, patients were assessed sitting unsupported (n=25), transferring (n=23) and walking (n=12) using standardized outcome measures. On the second occasion, patients rated their impressions of change in each of the three motor tasks since their initial assessment. A 15-point scale was used. In addition, patients were videoed performing the three motor tasks on the two occasions. Two clinicians with SCI experience independently viewed the pairs of videos and rated their impressions of change using the same 15-point scale. Clinicians' and patients' impressions of change were compared with each other and to the standardized objective measures.Results:Clinicians' and patients' impressions of change were greater than change measured with standardized objective measures for all three motor tasks (P<0.01). In addition, patients' impressions of change were greater than clinicians' impressions of change for transferring, but comparable for unsupported sitting and walking.Conclusion:Clinicians' and patients' impressions of change in motor performance may have potential for evaluating treatment effectiveness in clinical trials. [ABSTRACT FROM AUTHOR]

Study design:Cross-sectional, mail-back questionnaire study.Objectives:To describe women's experiences of sexual functioning and sex life after spinal cord injury (SCI).Setting:Sweden, Denmark, Norway, Finland, and Iceland.Methods:All community-living SCI women treated at spinal cord centres in Sweden, Denmark, Norway, Finland, and Iceland meeting inclusion criteria (n=963) were mailed the study-specific SCI Women Questionnaire. Out of the 532 respondents, 392 reported having had sex after injury and were thus included in the study. The included women had a mean age of 42 years (range 18-68) and a mean time since injury of 11 years (range 2-54).Results:The SCI women reported that the injury caused many changes in their sex life and affected many aspects of their sexuality negatively. Some changes were of a physical nature (for example, decreased, lost, or changed sensation; difficulties to achieve orgasm; bladder or bowel problems; and difficulties to move and position oneself) whereas other changes were of a psychological nature (for example, feeling unattractive or less attractive, having less self-confidence, and difficulties to meet or find a partner).Conclusion:Successful SCI rehabilitation requires a holistic approach, taking into account the patient's physical, psychological, and interpersonal circumstances. Given that many women with SCI remain sexually active but often experience less satisfaction after injury, it is important that rehabilitation efforts address this aspect of the patient's life. Our results elucidating strategies applied by women with SCI to compensate for loss of genital sensation and cope with physiological impairment during sexual activity may serve to help professionals in developing rehabilitation programmes for women with SCI. [ABSTRACT FROM AUTHOR]

Study design:Retrospective analysis of civilians with spinal cord injuries (SCIs) due to terror explosions.Objectives:To analyze and describe the clinical characteristics and rehabilitation outcomes of civilians with SCI due to explosions admitted for in-patient rehabilitation from 2000-2004.Setting:SCI rehabilitation service, Tel Hashomer, Israel.Methods:Retrospective chart review. Civilians with SCI due to terror-related gunshot wounds (GSWs) served as a control group.Results:Eleven civilians with SCI caused by penetrating atypical foreign objects (PAFOs) and eight with GSWs were identified. The male-to-female ratio was approximately 2:1. Foreign objects were present within the spinal canal in seven patients, causing bone injury without canal penetration in three, and one patient had both bone injury and canal penetration. The most common level of injury was thoracic. Seven had complete motor SCI. Three individuals improved in American Spinal Injury Association status: one individual improved from B to C (cervical); one from C to D (thoracic); and the third from D to E (lumbar). Despite the similar acute hospital length of stay and functional independence measure (FIM) scores on admission, the PAFO group had a shorter rehabilitation length of stay with higher FIM scores and higher FIM efficiency at discharge.Conclusions:Although the pathophysiology of PAFO blast injuries is similar to the high-velocity GSWs or the high-energy military munition injuries, better rehabilitation outcomes were seen, with slightly higher FIM efficiency and efficacy at discharge. This result is likely to be caused by less neurological tissue damage at impact. [ABSTRACT FROM AUTHOR]

Study design: Longitudinal, multiple wave panel design. Objectives: To investigate the degree to which current thinking in terms of early appraisals and coping predicts adjustment and quality of life outcomes after spinal cord injury, and to what degree social and demographic variables are involved. Setting: Data were analysed from 266 patients recruited as part of an ongoing study from specialist units in selected British, Swiss, German and Irish spinal centres. Method:Questionnaire booklets were administered as soon as possible after injury onset and after 12 weeks to patients with newly acquired spinal cord injuries. Individuals included had sustained their injury between the ages of 16 and 83. Results: Significant improvements in outcome measures were found across the data set within the first 12 weeks after spinal cord injury and changes observed in the appraisals and coping strategies employed. Significant differences were found between participating centres on both outcome measures and in the coping and appraisal processes used. Coping and appraisal processes at 6 weeks after injury were found to contribute significantly to the variation in psychological well-being at 12 weeks after injury. Conclusion: This study shows the process of adjustment to spinal cord injury to begin in the early stages of rehabilitation, and initial appraisals are important to how an individual will cope with their injury and to their psychological well-being. Support is also given to the importance of psychological factors to functional outcomes. [ABSTRACT FROM AUTHOR]

Study design: A repeated measures, non-randomised controlled trial. Objective:To examine the effectiveness of individualised cognitive behaviour therapy (CBT) on the psychological adjustment of patients undergoing rehabilitation for newly acquired spinal cord injury. Setting:South Australian Spinal Cord Injury Service, Hampstead Rehabilitation Centre, South Australia, Australia. Methods:Eleven participants received individual CBT as part of their spinal rehabilitation. Self-reported levels of depression, anxiety and stress were assessed before the intervention, at week 12 of rehabilitation and at 3 months post-discharge, using the depression, anxiety and stress scales (DASS-21). Functional independence was also assessed, using the Functional Independence Measure (FIM). Responses were compared with 13 participants, closely matched on demographic and injury variables, who received standard psychological care (that is, assessment and monitoring only). Results:Depression scores for treatment participants showed a significant time effect, with worsening symptoms reported at three-month follow-up, after CBT was discontinued. In contrast, the DASS-21 scores of standard care participants remained at subclinical levels throughout the study. Clinical improvements in symptoms of anxiety and stress were also reported by the treatment group as inpatient therapy progressed. Conclusion:Targeted, individualised psychological treatment contributed to short-term, meaningful improvements in emotional outcomes for individuals reporting psychological morbidity after recent spinal injury. The results also highlight the need for ongoing access to specialised, psychological services post-discharge. Replication of these results with a larger sample is required before definitive conclusions can be drawn. [ABSTRACT FROM AUTHOR]

Study design:Longitudinal study.Objectives:To examine the relationship between and predictors of quality of life (QOL) at 3 and 15 months post-rehabilitation discharge using the Disability Creation Process model as an explanatory framework.Setting:Vancouver, Canada.Methods:A consecutive sample of individuals with spinal cord injury (SCI) was enrolled in the study. Data were collected using the Quality of Life Index (QLI) and a variety of personal, participation and environmental instruments. On admission, 197 subjects were recruited, but dropouts and missing values led to the final inclusion of 93 cases in multiple regression models used to identify predictors of QOL at 3 and 15 months post-rehabilitation discharge.Results:Mean QLI group scores did not differ between 3 and 15 months (P=0.85). Regression models accounted for 64% of variance in QLI total scores at 3 months and 70% of variance at 15 months. The main predictors of QOL at 3 months were health competence and mood state. The main predictors of QOL at 15 months were QOL level at 3 months, health competence and family support. At both time points, personal factors explained most of the variance, whereas participation and environmental factors were less significant.Conclusion:Given that health competence, mood state and some environmental factors may be amenable to modification, this study suggests interventions to mediate these variables might improve subjective QOL after SCI. [ABSTRACT FROM AUTHOR]

Study design:Prospective, observational study.Objectives:To determine the proportion of patients with non-traumatic spinal cord injury (NTSCI) who regain the ability to walk and to describe walking outcomes with reference to three commonly used clinical measures of walking capacity.Setting:Spinal Rehabilitation Unit specializing in NTSCI, Melbourne, Australia.Methods:Demographic, clinical and mobility data collected from a consecutive cohort of patients admitted to the spinal rehabilitation unit between March 2006 and December 2007. Main outcome measures were the Timed Up And Go (TUG), the 10-m walk test (10 mWT) and the 6-min walk test (6MWT). Logistic regression analysis was conducted to explore predictors of walking ability after NTSCI.Results:Of 62 patients, 30 (48%) regained some capacity to walk during inpatient rehabilitation. Initial ASIA grade was the strongest predictor of walking. Twenty-seven patients regained the ability to perform functional tests (TUG, 10 mWT and 6MWT) of walking at ∼2 months after injury. Their performance at discharge remained low compared with normal scores but were similar to those measured in some studies of subjects with traumatic spinal cord injury (TSCI).Conclusion:Three simple clinical tests of walking suggest that half of all NTSCI patients are able to walk at discharge from inpatient rehabilitation. Their gait speed, however, remained impaired and not compatible with safe and efficient community walking. [ABSTRACT FROM AUTHOR]

Study design:An experimental, cross-sectional study.Objective:To investigate effects of external information or external cues on gait performance in independent ambulatory incomplete spinal cord injury (iSCI) patients (American Spinal Injury Association C or D, and functional independence measure walking scores=5–7).Setting:A university hospital, Thailand.Method:Gait performance was assessed in 29 patients with iSCI under four conditions including self-determined fastest walking speed, and fastest walking with the use of visual, auditory and visuotemporal cues. Average gait speed, stride length, cadence and percent step symmetry of these conditions were compared.Results:The use of external cues facilitated subjects to walk faster with a greater stride length, cadence and percent step symmetry than their own determination. The visuotemporal cue assisted subjects to increase their walking speed by 0.17 m s−1. The visual cue helped subjects to walk with a significantly greater stride length than the self-determined fastest pace condition (P<0.05). However, the visual cue made subjects walk with the lowest cadence and significantly lower than the visuotemporal cue condition (P<0.05).Conclusion:External information helped subjects to reorganize movement characteristics and perform a more efficient spatiotemporal gait pattern. The findings imply a significant role of external information on gait performance in patients with iSCI. [ABSTRACT FROM AUTHOR]

Study design:Intra-rater reliability study, cross-sectional design.Objectives:To report on the intra-rater agreement of the anorectal examinations and classification of injury severity in children with spinal cord injury (SCI).Setting:Two, non-profit children's hospitals specializing in pediatric SCI.Methods:180 subjects had at least two trials of the anorectal examinations as defined by the International Standards for Neurological Classification of Spinal Cord Injury. Intraclass correlation coefficients (ICC) and 95% confidence intervals (CI) were used to evaluate the agreement. ICC>0.90=high agreement; ICC between 0.75–0.89=moderate agreement; ICC<0.75=poor agreement.Results:When evaluated for the entire sample, agreement was moderate-high for anal sensation and contraction and injury classification. When evaluated as a function of age at examination and type of injury, agreement for anal sensation was poor for subjects with tetraplegia in the 12–15-year age group (ICC=0.56) and 16–21-year age group (ICC=0.70) and for subjects with paraplegia in the 6–11-year age group (ICC=0.69). Agreement for anal contraction was moderate for subjects with tetraplegia in the 16–21-year age group (ICC=0.81) and subjects with paraplegia in the 12–15-year age group (ICC=0.78) and poor for subjects with paraplegia in the 6–11-year age group (ICC=0.67). Agreement for injury classification was poor for subjects with tetraplegia in the 12–15-year group (ICC=0.56) and 16–21-year group (ICC=0.74) and paraplegia in the 6–11-year group (ICC=0.11) and 12–15-year group (ICC=0.63). Anorectal responses had high agreement in subjects with tetraplegia in the 6–11-year group and moderate to high agreement in subjects with paraplegia in the 16–21-year group.Conclusion:The data do not fully support the use of anorectal examination in children. Further work is warranted to establish the validity of anorectal examination. [ABSTRACT FROM AUTHOR]

Study design:Case series, consecutive sample.Objective:To investigate the rehabilitation outcomes of patients with spinal cord injury (SCI) suffering from preexisting mental health disorders (MHD).Setting:National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital, UK.Method:Twenty-eight newly injured SCI patients: 14 with preexisting MHD and a matched cohort of 14 patients without MHD who were admitted between 2000 and 2006. All patients were involved in a multidisciplinary Goal Planning and Needs Assessment Rehabilitation Programme. Rehabilitation outcomes were measured using the Needs Assessment Checklist (NAC), which has been specifically designed for use with people with SCI. It is a reliable and valid clinical assessment tool, which provides a means to assess and facilitate the delivery of an individually tailored rehabilitation programme.Results:No significant difference was found between the MHD and non-MHD groups for rehabilitation outcomes. The MHD group showed higher achieved independence scores in psychology for the first needs assessment. Overall, both groups were found to make significant improvements in their level of independence for all nine areas of need between the first and second NAC administration.Conclusion:Results suggest that rehabilitation can be tailored to meet the individual needs of patients with SCI having MHD; however, further research comparing these outcomes with other rehabilitation approaches is required. The function of timely psychological support for MHD patients on admission to the NSIC has been suggested as a potential explanation for rehabilitation performance. Most importantly, rehabilitation outcomes of patients with MHD have not been found to differ significantly compared with those without MHD.Spinal Cord (2009) 47, 290–294; doi:10.1038/sc.2008.116; published online 16 September 2008 [ABSTRACT FROM AUTHOR]

Study design:Prospective cross-sectional study.Objective:To study epidemiology, complication, neurological and functional outcome in non-traumatic spinal cord lesions (NTSCL) after inpatient rehabilitation.Setting:Neurological rehabilitation unit of a tertiary research hospital.Methods:Sixty-four patients (M/F=28:36) with NTSCL admitted from June 2005 to January 2008 for multidisciplinary rehabilitation. Epidemiology, medical complications during stay in rehabilitation, admission and discharge—Barthel Index (BI) and American Spinal Injury Association (ASIA) impairment scale for functional and neurological recovery, respectively, were recorded and analyzed.Results:NTSCL constituted 60% (64 of 106) of the total SCL patients admitted for rehabilitation during the same period. Female patients outnumbered males (56.25%) in the study. Mean age, duration of illness and duration of stay in rehabilitation were 30.64±13.67 years (6–57), 7.09±9.15 months (1–48) and 55.75±40.91 days (14–193), respectively. The ratio of paraplegia and quadriplegia was 2:1. Forty-four patients (68.75%) had incomplete cord lesion according to the ASIA impairment scale. Spinal tumors (26.6%) were found to be the most common etiology, followed by Pott's spine (25%) and transverse myelitis (22%). Urinary tract infection was found to be the most common complication (50%), followed by spasticity (35.93%) and urinary incontinence (31.25%). The mean BI scores showed significant (P=0.000) functional recovery during rehabilitation using paired Student's t-test. The ASIA impairment scale showed significant neurological recovery (P=0.001) using the Wilcoxon non-parametric test.Conclusions:NTSCL constitute a significant proportion of overall SCL. Female population, paraplegia and incomplete cord lesions are more common among NTSCL in this study. Patients with NTSCL recover significantly both neurologically and functionally with rehabilitation intervention.Spinal Cord (2009) 47, 307–311; doi:10.1038/sc.2008.123; published online 21 October 2008 [ABSTRACT FROM AUTHOR]

Study design:Multi-centre prospective descriptive study.Objective:To establish a profile of the population affected with traumatic and non-traumatic spinal cord injury (SCI) admitted to rehabilitation centres in the Netherlands and Flanders (Belgium) and to describe determinants of length of stay (LOS) and functional outcome.Setting:Eleven rehabilitation centres in the Netherlands and Flanders.Patients:A total of 919 patients with traumatic and non-traumatic SCI on first admission to rehabilitation centres between 2002 and 2007.Methods:Information about LOS, functional outcome and personal and injury characteristics was derived from a joint data set developed for this project.Results:A total of 54.7% of patients with SCI had a non-traumatic lesion. The group of patients with non-traumatic SCI showed a more even gender distribution, a more advanced age and less severe lesion characteristics than the group of patients with traumatic SCI. Linear regression models explained 32% of the variance of LOS and 42% of the variance of functional outcome. Functional status on admission was the strongest determinant of LOS and completeness of the lesion was the strongest determinant of functional outcome. Aetiology (traumatic versus non-traumatic) was a weak independent determinant of LOS but was not an independent determinant of functional outcome.Conclusion:Patients with non-traumatic SCI formed a majority in the Dutch and Flemish SCI population. Although the characteristics of patients with traumatic and non-traumatic SCI clearly differed, rehabilitation of patients with non-traumatic SCI appears at least as efficient as rehabilitation of patients with traumatic SCI.Spinal Cord (2009) 47, 339–344; doi:10.1038/sc.2008.127; published online 11 November 2008 [ABSTRACT FROM AUTHOR]

Study design:Systematic review.Objectives:To provide a quantitative analysis of all randomized controlled trials designed to determine the effectiveness of physical interventions for people with spinal cord injury (SCI).Setting:Sydney, Australia.Methods:A search was conducted for randomized controlled trials involving physical interventions for people with SCI. Two reviewers independently rated methodological quality using the PEDro scale and extracted key findings from the trials.Results:Four thousand five hundred and forty three abstracts were identified of which 31 trials met the inclusion criteria. Trials examined the effectiveness of fitness and strength training (n=7), gait training (n=5), hand therapy (n=3), stretch (n=4), acupuncture (n=3), hand splinting (n=2) and other related therapies (n=7). Six trials reported a between-group mean difference with a clearly important treatment effect on at least one outcome measure. These trials supported the use of fitness, strength and gait training as well as acupuncture.Conclusion:There is initial evidence supporting the effectiveness of some physical interventions for people with SCI. However, there is a pressing need for high-quality trials to determine the effectiveness of all physical interventions commonly administered in clinical practice.Spinal Cord (2009) 47, 184–195; doi:10.1038/sc.2008.100; published online 26 August 2008 [ABSTRACT FROM AUTHOR]

Background:Pressure ulcers (PUs) are a common complication following a spinal-cord injury (SCI). Good prevention requires identifying the individuals at risk for developing PUs. Risk assessment scales used nowadays were designed on pathophysiological concepts and are not SCI-specific. Recently, an epidemiological approach to PU risk factors has been proposed to design an SCI-specific assessment tool. The first results seem quite disappointing, probably becuase of the level of evidence of the risk factors used.Objective:To determine PU risk factors correlated to the patients with SCI, medical care management during the acute as well as in the rehabilitation and chronic stages. This first part focuses on identifying the risk factors during the acute and rehabilitation stages.Materials and methods:Systematic review of the literature.Results:Six studies met our inclusion criteria. The risk factors during the acute stage of an SCI are essentially linked to care management and treatment modalities. There is insufficient evidence to make a recommendation on medical risk factors, except for low blood pressure on admission to the Emergency Room, with a moderate level of evidence. Regarding the rehabilitation stage, no study was deemed relevant.Discussion and conclusions:Additional observational studies are needed, for both the acute and rehabilitation stages, to improve this level of evidence. However, this systematic review unveiled the need for a carefully assessed t care management and the related practices, especially during the acute stage of an SCI.Spinal Cord (2009) 47, 99–107; doi:10.1038/sc.2008.107; published online 2 September 2008 [ABSTRACT FROM AUTHOR]

Study design:Retrospective study.Objectives:To determine the potential impact of rehabilitation care on associated symptoms and functional improvements of paraplegic patients with metastatic spinal cord compression.Setting:CMN Propara, Montpellier (France).Measures:Demographics, Functional Independence Measure (FIM), Frankel Modified Score and Visual Analog Scale (VAS) for pain, intercurrent adverse medical events and neurological outcome, duration of stay, survival time, rehospitalization in a non-Spinal Cord Injury unit, number of contracts defining the patients rehabilitation goals, number of contracts defining the patients duration of stay within the rehabilitation center.Results:We reviewed the charts of 26 patients. The initial neurological profile was paraplegia or paraparesis for 24 patients and quadriparesis for 2 patients. Regarding functional improvements: four patients demonstrated a poor functional evolution, five patients showed no functional improvements or very slight improvements and all the other patients showed an increase in their overall functional aptitudes. At the end of the stay, 14 patients were urinary independent. Our study reports 52 rehospitalizations in an another unit and 101 outpatient visits during their rehabilitation stay in a physical medicine and rehabilitation (PM&R) center. For the 14 patients who were deceased at the time of data collection, the median survival rate post-paraplegia was 12.7 months. A total of 12 of the 14 patients spent more than a third of their remaining survival time in a rehabilitation center.Discussion:Compared to the patients' life expectancy, their stay in a rehabilitation center is too long and prevents them from spending time with family and loved ones. The occurrence rate of the associated symptoms is high because of both cancer-related disorders and neurological disorders caused by the spinal cord lesion. PM&R professionals are faced with patients affected by chronic pain and fatigue as well as frequent rehospitalizations, short stays and outpatient stays, in the primary oncology unit. This study focuses on the need to privilege the patients' comfort over their functional rehabilitation.Spinal Cord (2009) 47, 115–121; doi:10.1038/sc.2008.75; published online 10 June 2008 [ABSTRACT FROM AUTHOR]

Design:Prospective double-blind study.Objective:Manual emptying of rectal contents is necessary for patients with spinal cord injury to prevent bowel obstruction; however, this maneuver induces a rise in blood pressure (BP) and autonomic dysreflexia (AD). The purpose of this prospective double-blind study was to investigate whether topical anorectal anesthesia attenuates the BP rise and AD during bowel manipulation in patients with cervical spinal cord injury (CSCI).Setting:Kibikogen Rehabilitation Center for Employment Injuries.Methods:The study subjects were 25 consecutive clinically stable patients with CSCI. Each subject received a complete bowel program involving manual removal of stool in lateral recumbency, after topical application of lidocaine or placebo jelly to the anorectal area. Systolic and diastolic BP, heart rate and symptoms of AD were recorded before, during and after bowel manipulation.Results:Systolic BP was significantly lower during the lidocaine arm of the study compared with placebo at insertion of rectal medication, digital stimulation, beginning of stool flow, manual removal of stool, end of stool flow and at 5-min after emptying. The mean maximal increase in systolic BP during lidocaine treatment (33.2±14.6 mm Hg) was less than during placebo (50.2±19.5 mm Hg, P<0.001).Conclusion:On the basis of our findings, we recommend induction of lidocaine jelly immediately before rectal manipulation in patients with CSCI to minimize the incidence and severity of AD.Spinal Cord (2009) 47, 144–148; doi:10.1038/sc.2008.86; published online 15 July 2008 [ABSTRACT FROM AUTHOR]

Study design:Assessor-blinded within-subject randomized controlled trial.Objective:To determine the effects of 6 months of regular passive movements on ankle joint mobility in people with spinal cord injury.Setting:Community, Australia.Methods:A total of 20 people with tetraplegia living in the community had one ankle randomized to a control group and the other to an experimental group. Carers administered passive movements to participants' experimental ankles for 10 min, 10 times a week for 6 months. The control ankles were left untreated. The primary outcome was passive ankle dorsiflexion range of motion.Results:Adherence was high (mean adherence rate of 96%). Ankle dorsiflexion range of motion decreased by a mean (s.d.) of 2° (4) in control ankles and increased by 2° (4) in experimental ankles. The mean (95% confidence interval, CI) effect on ankle dorsiflexion range of motion was 4° (95% CI, 2–6°).Conclusion:Regular passive movements have small effects on ankle joint mobility. It is unclear if these effects are clinically worthwhile.Spinal Cord (2009) 47, 62–66; doi:10.1038/sc.2008.71; published online 24 June 2008 [ABSTRACT FROM AUTHOR]

Study design:Cross-sectional; questionnaire.Objective:To compare the differences in life satisfaction, quality, value and meaning of life, and mood between Chinese and British people with tetraplegia after the completion of rehabilitation. This study was undertaken at the China Rehabilitation Research Centre, Beijing, China and the National Spinal Injuries Centre, Stoke Mandeville Hospital, United Kingdom.Method:Self-report questionnaires were completed by 44 people with tetraplegia; 22 from China and 22 from the United Kingdom. The results of life satisfaction, quality, value and meaning of life, anxiety and depression were analysed.Results:The British group were significantly more satisfied than the Chinese group with their vocational situation, their financial situation and their family life. The British group was more positive than the Chinese group towards the value they placed on their life and had lower mood scores. No significant differences were identified between the two groups in life as a whole, self-care, leisure situation, sexual life, partnership relations, contact with friends, meaning of life and quality of life.Conclusion:To improve the value placed on life by people with tetraplegia in China, a future emphasis of rehabilitation should include addressing vocational, financial and family-life issues.Spinal Cord (2009) 47, 82–86; doi:10.1038/sc.2008.83; published online 24 June 2008 [ABSTRACT FROM AUTHOR]

Objectives:To review the measurement properties of outcome measures of function or mobility currently used in the context of spinal cord injury (SCI).Methods:A keyword search of multiple databases to identify original papers. Papers were reviewed where they had included an evaluation, of people with SCI, of the psychometric properties of an outcome measure, which included functional or mobility domains.Information was extracted concerning item generation, ease and intended method of use and scale properties, in particular: reliability, validity and responsiveness. Conclusions were reached concerning the psychometric properties of each instrument.Results:Eight outcome measures were identified (plus adapted versions). Five had originally been developed specifically for evaluating patients with SCI (chiefly reflecting clinicians’ perspectives), the remaining three had not. The psychometric properties of the instruments varied, with some mixed/contradictory evidence likely relating to differing study sample sizes, characteristics and variable quality. Instruments also varied in stated purpose or emphasis.Conclusion:In addition to weighing evidence concerning measurement properties, users need to consider the stated purpose and item content of instruments in relation to their specific aims. With regard to the former, while reviewed instruments had some flaws, the Spinal cord Independence Measure (revised version III), Quadriplegia Index of Function (Short-form), Needs Assessment Checklist and SIP68 appeared the best, despite limited evidence of their responsiveness.Spinal Cord (2008) 46, 768–780; doi:10.1038/sc.2008.50; published online 3 June 2008 [ABSTRACT FROM AUTHOR]

Study design:Register study.Objectives:To design and implement a validation process to check the completeness of the Hospital Discharge Register (HDR) held by the Swedish National Board of Health and Welfare.Setting:Sweden.Methods:An accurate traumatic spinal cord injury prevalence group (n=495) was acquired from the Swedish Spinalis Clinic. A register control was performed on the group by raising three questions to check the validity of the HDR: Is an inpatient stay registered in association with the injury date? Is the reported first length of stay plausible, given the level and extent of injury? Are all the anticipated care and/or rehabilitation providers represented in the HDR?Results:For 62% (of 413 cases) the first registered hospitalization date correlated with the injury date. For the other 38%, hospitalization was reported to start between 2 and 8651 days after injury. Considering the level and extent of injury, individuals were reported to have unrealistically short initial hospitalization. The prevalence group visited 42 different hospitals and 47 clinics. Five rehabilitation clinics, though, were not reported.Conclusions:The HDR is a valuable source when conducting epidemiological and health services research. However, using the register without any validation process could, as detected in the investigated diagnosis group, lead to a severe underestimation of the inpatient usage. The study showed that systematic errors could be detected by means of extensive knowledge of the diagnosis group.Spinal Cord (2008) 46, 748–752; doi:10.1038/sc.2008.42; published online 13 May 2008 [ABSTRACT FROM AUTHOR]

Study design:A prospective intervention of functional electrical stimulation leg cycle ergometry (FES-LCE) of four women with spinal cord injury (SCI).Objective:To evaluate the effect of FES-LCE training on arterial compliance in individuals with chronic SCI of traumatic origin.Setting:Tertiary rehabilitation center in Canada.Methods:Large and small artery compliance were measured at the radial artery before and after a 3-month training program using FES-LCE.Results:There was no significant change in large artery compliance after FES-LCE (16.0±4.2 to 16.8±6.1 ml mm Hg−1 × 10, P=NS). There was a marked (63%) increase in small artery compliance after the FES training program (4.2±1.8 to 6.9±3.2 ml mm Hg−1 × 100, P<0.05).Conclusion:It appears that FES-LCE is effective in improving small artery compliance in females with SCI.Spinal Cord (2008) 46, 722–726; doi:10.1038/sc.2008.34; published online 15 April 2008 [ABSTRACT FROM AUTHOR]

Study design:Review.Objectives:Identify and describe the body of literature pertaining to non-pharmacological management of orthostatic hypotension (OH) during the early rehabilitation of persons with a spinal cord injury (SCI).Setting:Sunnaas Rehabilitation Hospital, Oslo, Norway.Methods:Search strategy: a comprehensive search of electronic databases and cited references was undertaken. Selection criteria: case studies, parallel group trials and crossover designs using random or quasi-random assignments were considered. Participants with any level or degree of completeness of SCI and any time elapsed since injury were included. Interventions must have measured at least systolic blood pressure (BP), and have induced orthostatic stress in a controlled manner and have attempted to control OH during an orthostatic challenge. Data collection and analysis: studies were selected, assessed and described qualitatively. Meta-analysis was deemed inappropriate.Results:Four distinct non-pharmacological interventions for OH were identified: application of compression and pressure to the abdominal region and/or legs, upper body exercise, functional electrical stimulation (FES) applied to the legs and biofeedback. Methodological quality varied dramatically between studies. Compression/pressure, upper body exercise and biofeedback therapies have proven inconclusive in their ability to control OH. During orthostatic challenge, FES consistently attenuates the fall in BP; however, its clinical application is less well established.Conclusions:The clinical usefulness of compression/pressure, upper body exercise and biofeedback for treating OH has not been proven. FES of the legs holds the most promise.Spinal Cord (2008) 46, 652–659; doi:10.1038/sc.2008.48; published online 10 June 2008 [ABSTRACT FROM AUTHOR]

Study design:Cross-sectional and longitudinal direct observation of a constrained consensus-building process in nine consumer panels and three rehabilitation professional panels.Objectives:To illustrate differences among consumer and clinician preferences for the restoration of walking function based on severity of injury, time of injury and age of the individual.Setting:Regional Spinal Cord Center in Philadelphia, USA.Methods:Twelve panels (consumer and clinical) came to independent consensus using the features–resource trade-off game. The procedure involves trading imagined levels of independence (resources) across different functional items (features) at different stages of recovery.Results:Walking is given priority early in the game by eight out of nine consumer panels and by two out of three professional panels. The exception consumer panel (ISCI<50) moved walking later in the game, whereas the exception professional panel (rehRx) moved wheelchair early but walking much delayed. Bowel and Bladder was given primary importance in all panels.Conclusions:Walking is a high priority for recovery among consumers with spinal cord injury irrespective of severity of injury, time of injury and age at time of injury. Among professional staff, walking is also of high priority except in rehabilitation professionals.Spinal Cord (2008) 46, 500–506; doi:10.1038/sj.sc.3102172; published online 22 January 2008 [ABSTRACT FROM AUTHOR]

Study design:A multicenter prospective cohort study.Objective:To determine the longitudinal relationship between physical capacity and lipid profile in persons with spinal cord injury (SCI) during and 1 year after rehabilitation.Setting:Eight Dutch rehabilitation centers with a specialized SCI unit.Methods:A total of 206 subjects with SCI (78 with tetraplegia) participated. The longitudinal relationship between lipid profiles (total cholesterol (TC), high- (HDL) and low-density lipoprotein (LDL) and triglycerides (TG) and physical capacity (peak power output (POpeak), peak oxygen uptake (VO2peak), and muscle strength) was investigated during inpatient SCI rehabilitation (start, 3 months later, discharge) and 1 year after discharge. A correction was made for the possible confounding variables age, body mass index, gender, time since injury, lesion level and completeness.Results:HDL and the ratios LDL/HDL and TC/HDL showed a significant and favorable relationship with VO2peak, POpeak and muscle strength. TG was positively related to POpeak and muscle strength.Conclusions:More favorable lipid profiles were seen in people with a higher physical capacity after correction for personal and lesion characteristics. Therefore, improving the physical capacity by being active during daily life or in sport may further improve the lipid profile and thus reduce the risk for coronary heart disease.Spinal Cord (2008) 46, 344–351; doi:10.1038/sj.sc.3102147; published online 20 November 2007 [ABSTRACT FROM AUTHOR]

Repair of the injured spinal cord by regeneration therapy remains an elusive goal. In contrast, progress in medical care and rehabilitation has resulted in improved health and function of persons with spinal cord injury (SCI). In the absence of a cure, raising the level of achievable function in mobility and self-care will first and foremost depend on creative use of the rapidly advancing technology that has been so widely applied in our society. Building on achievements in microelectronics, microprocessing and neuroscience, rehabilitation medicine scientists have succeeded in developing functional electrical stimulation (FES) systems that enable certain individuals with SCI to use their paralyzed hands, arms, trunk, legs and diaphragm for functional purposes and gain a degree of control over bladder and bowel evacuation. This review presents an overview of the progress made, describes the current challenges and suggests ways to improve further FES systems and make these more widely available.Spinal Cord (2008) 46, 255–274; doi:10.1038/sj.sc.3102091; published online 11 September 2007 [ABSTRACT FROM AUTHOR]

Study design:Retrospective chart review.Objectives:To determine the prevalence of fatigue in an outpatient spinal cord injury population and to examine the clinical variables contributing to that fatigue.Setting:GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada.Methods:Medical charts of 76 individuals admitted to the GF Strong Outpatient SCI Program between December 2004 and December 2005 were reviewed. Data collected included information on clinical characteristics, demographics and Fatigue Severity Scale (FSS) scores. Multivariable analysis was completed to determine the independent association between these variables and fatigue severity.Results:A total of 57% (95% confidence interval (CI)=45–67%) of the sample were found to have fatigue severe enough to interfere with function. People that were admitted for medical reasons; had pain, spasticity, incomplete injuries, and/or were on more that one medication with a known side effect of fatigue had significantly higher FSS scores. Multivariable analysis indicated incomplete injury was the only statistically significant predictor of a higher FSS scores; pain approached significance (P=0.07, CI=−0.09, 2.06). Together these variables account for 18% of the variance in FSS scores in this sample.Conclusion:Fatigue among individuals with spinal cord injury who are seeking outpatient rehabilitation is very common. The severity of fatigue was greater for individuals with incomplete lesions. Pain was also a potentially important covariate of fatigue. Further research is required to determine what else contributes to fatigue severity beyond these clinical variables as only minimal variance was accounted for in our model.Spinal Cord (2008) 46, 21–25; doi:10.1038/sj.sc.3102053; published online 3 April 2007 [ABSTRACT FROM AUTHOR]

Study Design:Retrospective data analysis.Objectives:To determine prevalence of orthostatic hypotension (OH) in patients with spinal cord injury (SCI) during the acute rehabilitation period.Setting:Quaternary care spinal unit, Vancouver General Hospital, British Columbia, CanadaMethods:Eighty-nine patients with acute SCI stratified by neurological level (cervical, 55 (62%); upper thoracic, 12 (13%); lower thoracic, 22 (25%)), and graded by American Spinal Injury Association standards. Non-invasive measurement of systolic and diastolic blood pressure and heart rate were made at baseline and 3 min following an orthostatic challenge test administered during the first month after SCI.Results:Patients with cervical or upper thoracic motor complete SCI more frequently experienced OH (P<0.01). OH persisted during the first month following SCI in 74% of cervical and only 20% of upper thoracic motor complete SCI patients.Conclusion:Patients with cervical and upper thoracic motor complete SCI are more likely to experience persistent OH than those with lower level or motor incomplete SCI during the first month of rehabilitation.Spinal Cord (2008) 46, 65–69; doi:10.1038/sj.sc.3102064; published online 10 April 2007 [ABSTRACT FROM AUTHOR]

Study design:Clinical controlled trial.Objectives:To evaluate the effectiveness of an occupational therapy (OT) program combined with neuromotor rehabilitation, by assessing the degree of functional independence reached by patients with spinal cord injuries at first hospitalization.Settings:Subjects selected from the Spinal Cord Unit of the Rehabilitation Institute of Montecatone (Imola, Italy).Participants:Thirty-six male patients below age 60, with complete paraplegia (ASIA-A) in thoracic-lumbar level, at first hospitalization.Methods:Patients were divided into experimental and control groups. Subjects in the experimental group underwent neuromotor rehabilitation coupled with an OT program, whereas those in the control group followed neuromotor rehabilitation only. Increase in functional independence at discharge was evaluated by the Valutazione Funzionale Mielolesi (VFM) assessment scale.Results:Patients in the experimental group showed a significant increase in the total VFM score, and in domains concerning transfers and wheelchair use. A significant improvement was observed in unmarried patients as compared to married ones.Conclusion:An OT service within a Spinal Cord Unit allows us to achieve a higher level of functional independence.Spinal Cord (2008) 46, 78–81; doi:10.1038/sj.sc.3102072; published online 24 April 2007 [ABSTRACT FROM AUTHOR]

Study Design:Qualitative study.Objectives:To develop the knowledge base regarding women's experiences of spinal cord injury (SCI) rehabilitation.Setting:United Kingdom.Methods:Qualitative interviews with 10 women from four regional SCI rehabilitation centres were transcribed verbatim and analysed according to grounded theory.Results:The central psychosocial problem identified for women during SCI rehabilitation was vulnerability. Vulnerability was amplified by lack of privacy within the rehabilitation centre, by negative staff interactions (associated with perceived lack of control and lack of respect) and by women's minority status in the rehabilitation setting, which at times left women feeling marginalized and inferior. Vulnerability was contained by: negotiating privacy and space; receiving support and encouragement from staff, other patients and family; and by adopting a positive attitude.Conclusion:The SCI rehabilitation environment and interactions within it have the potential to influence significantly, either positively or negatively, women's feelings and behaviours as they begin to negotiate a revised identity as a disabled person. There is a need for further research to be carried out in this area in order that women's needs and concerns can be better understood and clinical practice developed accordingly.Spinal Cord (2007) 45, 758–764; doi:10.1038/sj.sc.3102111; published online 4 September 2007 [ABSTRACT FROM AUTHOR]

Study Design:Review of how spinal neurons can modulate the consequences of functional electrical stimulation (FES) in an animal model.Methods:Spinal effects of FES are examined in male Sprague–Dawley rats transected at the second thoracic vertebra. The rats are exposed to FES training 24–48 h after surgery. Experimental manipulations of stimulation parameters, combined with physiological and pharmacological procedures, are used to examine the potential role of spinal neurons.Results:The isolated spinal cord is inherently capable of learning the response–outcome relations imposed in FES training contingencies. Adaptive behavioral modifications are observed when an outcome (electrical stimulation) is contingent on a behavioral response. In contrast, a lack of correlation between the response and outcome in training produces a learning deficit in the spinal cord, rendering it incapable of adaptive learning for up to 48 h. The N-methyl-D-aspartic acid receptor appears to mediate both the adaptive plasticity and loss of plasticity, seen in this spinal model.Conclusion:The behavioral effects observed with FES therapies are not simply due to the direct (motor) consequences of stimulation elicited by the activation of efferent motor neurons and/or selected muscles. FES training has the capacity to shape inherent spinal circuits and to produce a long-lasting behavioral modification. Further understanding of the spinal mechanisms underlying adaptive behavioral modification will be integral for establishing functional neural connections in a regenerating spinal system.Spinal Cord (2007) 45, 702–712; doi:10.1038/sj.sc.3102096; published online 14 August 2007 [ABSTRACT FROM AUTHOR]

Study design:Retrospective, descriptive study.Objective:To determine if patients with metastatic spinal cord compression (MSCC) make significant functional gains through rehabilitation. To study survival and predictors of survival in MSCC. To explore predictive factors for high or low functional gains in MSCC.Setting:Inpatient neuro-oncology rehabilitation ward, Henderson General Hospital, Hamilton, Canada.Methods:Clinical records were examined for 63 inpatients with MSCC. Demographics, treatment of MSCC, length of rehabilitation, admission, and discharge Functional Independence Measure (FIM) scores, Tokuhashi score and survival data were collected. Statistical analyses included nonparametric comparisons, Kaplan–Meier analyses, Cox regression, and exploratory logistic regression.Results:FIM score improved from 83 to 102 (P<0.0001). Estimated median survival from time of rehabilitation was 10.0 months. Kaplan–Meier analysis showed longer survival in patients with high Tokuhashi scores (9–15) compared to low scores (0–8) (P<0.005); and high FIM change (>13) compared to low FIM change (13) (P<0.02). Cox regression revealed that high FIM gain and high Tokuhashi score were prognostic factors. Logistic regression showed Tokuhashi score (odds ratio (OR)=1.30, 95% confidence interval (CI)=1.04–1.62) and length of rehabilitation (OR=1.04, 95% confidence interval (CI)=1.01–1.07) were associated with high FIM gain.Conclusions:Rehabilitation improves functional outcomes in MSCC. Patients who had a high Tokuhashi score and achieved high functional gains after rehabilitation had longer survival. Tokuhashi score and length of rehabilitation were associated with high FIM gain. The Tokuhashi score can help identify patients with good prognosis and potential for improvement during rehabilitation.Spinal Cord (2007) 45, 671–677; doi:10.1038/sj.sc.3102024; published online 16 January 2007 [ABSTRACT FROM AUTHOR]

Study design:Retrospective register study.Objective:To investigate the predictive value of the following parameters for the development of neuropathic pain after non-traumatic spinal cord lesion: that is age at onset of spinal cord disease, gender, completeness of lesion, level of lesion, and aetiology.Setting:A unit for patients with post-acute traumatic and non-traumatic spinal cord lesions in the greater area of Stockholm, Sweden.Method:All patients with non-traumatic spinal cord lesions visiting the unit between 1995 and 2000 were classified according to the following: that is neuropathic pain at or below lesion level according to IASP criteria, age at time of the onset of the spinal cord symptoms, injury level, complete/incomplete injury, and aetiology. Results were analysed with χ2 – analysis and logistic regression.Results:In total, 38% had neuropathic pain, 15% had pain predominantly at the level of lesion, and 23% predominantly below the level of lesion. Of those with pain, 67% reported that the pain affected daily life. Women reported neuropathic pain below the level of lesion more often (40%) than men (13%). The prevalence was particularly high (64%) for patients with malignant spinal cord diseases. Neither age at onset of the spinal cord symptoms, nor complete/incomplete injury nor injury level had significant influence on the prevalence.Conclusion:Neuropathic pain is common among patients with acquired non-traumatic spinal cord lesions regardless of aetiology, often causing severe problems in daily life.Spinal Cord (2007) 45, 609–615; doi:10.1038/sj.sc.3102000; published online 12 December 2006 [ABSTRACT FROM AUTHOR]

Study design:Intra-rater reliability study, cross-sectional design.Objectives:To determine reliability of the International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) motor and sensory exam in children.Setting:Nonprofit pediatric hospital.Methods:In all, 74 subjects had two trials of the motor and sensory exams. Intraclass correlation coefficients (ICC), 95% confidence intervals (CI) were generated for total motor (TM), pin prick (PP) and light touch (LT) scores for the entire sample, four age groups, severity and type of injury. Coefficients >0.90=high reliability; 0.75–0.90=moderate reliability and <0.75=inadequate reliability.Results:Children 0.90 except for TM in complete injuries (0.808).Conclusion:The ISCSCI exams may have poor utility in children under 4 years. While reliability values for the motor and sensory exams met or exceeded recommended values, wide CI suggest poor precision of the motor exam in children under 15 years of age and sensory exams in children under 5 years.Sponsorship:This study was supported by the Shriners Hospitals for Children, Philadelphia Hospital.Spinal Cord (2007) 45, 452–459; doi:10.1038/sj.sc.3101987; published online 3 October 2006 [ABSTRACT FROM AUTHOR]

Study Design:Cross-sectional study with repeated measurements.Objectives:To examine the patient's perspective of the impact of spinal cord injury (SCI) on physical, cognitive, emotional function, and quality of life (QOL).Setting:Australia.Methods:A sample of 63 patients with SCI, 32 of whom had recent injuries, and 31 with established injuries were administered the Ruff Neurobehavioral Inventory to examine patients’ subjective evaluation of pre- and post-injury functioning. Current happiness levels were also evaluated using the Subjective Happiness Scale. A follow up assessment was performed 6 months later to examine changes over time.Results:A significant difference was found between perception of pre- and postmorbid function on composite Cognitive (t=5.99, df=62, P<0.001), Physical (t=11.56, df=62, P<0.001), and QOL (t=7.16, df=62, P<0.001) scales and on several of the Emotional subscales including anxiety, paranoia and suspicion, and substance abuse (P<0.001). A series of hierarchical regression analyses indicate that post-SCI pain was a significant predictor of: cognitive (R 2=0.20, P<0.001); emotional (R 2=0.13, P<0.004); and of QOL (R 2=0.22, P<0.001) functioning. With the exception of a decrease in happiness (P<0.01), there were no significant changes in any measures over the 6 month time period.Conclusions:There are significant changes in patients’ perceptions of physical and cognitive functioning, and of QOL before and after SCI and some aspects of emotional functioning. Pain has a significant adverse effect on functioning. Happiness decreased slightly in the 6 months between surveys.Spinal Cord (2007) 45, 429–436; doi:10.1038/sj.sc.3102022; published online 16 January 2007 [ABSTRACT FROM AUTHOR]

Study design:Retrospective analysis of in-patient stay and prospective follow-up.Objectives:To study neurological and functional outcomes after traumatic central cord syndrome (TCCS).Setting:Regional Spinal Unit of Florence, Italy.Methods:In total, 82 patients, admitted for acute rehabilitation to our Centre (1996–2002) with a diagnosis of TCCS entered the study. Data on admission and discharge were collected for assessments performed at 18 months of injury or later. Data included: cause of injury, gender, type of vertebral lesion, treatment, time of hospitalisation (LoS), ASIA/ISCOS Impairment Scale, neurological examination, functional independence measure (FIM) on admission and discharge. Additional measures included the walking index for spinal cord injuries (WISCI), bladder management, FIM, spasticity on discharge/follow-up and neuropathic pain at follow-up. Correlations were performed on outcome measures in relation to age, treatment, LoS, spasticity and neuropathic pain.Results:Average age was 52 (16–82) years. Causes included falls (47%), road traffic accidents (36%) and sport (7%). Of patients, 45% were treated surgically and 55% conservatively. LoS was 120 days (24–390), but less for those treated without surgery. Patients under 65 years had better outcomes with less neuropathic pain. Neurological and functional recovery was observed on discharge from rehabilitation, which continued in the period following discharge. Spasticity was equally present in all age groups. No difference in outcome was found as a result of spine surgery.Conclusions:Patients with TCCS are older than other spinal cord injured patients, but often show improvement after discharge. Improvement in subjects under 65 years was significantly better than for those over 65 years.Spinal Cord (2007) 45, 292–297. doi:10.1038/sj.sc.3101944; published online 13 June 2006 [ABSTRACT FROM AUTHOR]

Study design:Meta-synthesis of qualitative research.Objectives:To identify, compare and synthesize published qualitative evidence concerning the experience of rehabilitation following spinal cord injury (SCI).Methods:Published articles were identified from the Medline, CINAHL and Sociological abstracts databases, a hand search through selected journals published since 1990, and from reference lists. These were assessed for their relevance to the focus of interest and appraised for rigour. The key themes that emerged from the data were summarized, compared and synthesized.Results:The search located 64 papers and four books, of which eight papers (describing seven studies) met the review criteria for relevance and rigour. Thematic comparison and synthesis resulted in the identification of seven concepts that encapsulate the important dimensions of rehabilitation from participants' perspectives: (1) the importance of specific staff qualities; (2) the need for a vision of future life possibilities; (3) the importance of peers; (4) the relevance of programme content; (5) the institutional context of rehabilitation; (6) the importance of reconnecting the past to the future; (7) the importance of meeting the needs of the real world.Conclusions:If rehabilitation services are to be evidence-based, relevant and effective in meeting the needs of people with SCI they must be informed by the perspectives of people with SCI. The findings of this review suggest that the most important dimension of rehabilitation for people with SCI is the calibre and vision of the rehabilitation staff.Sponsorship:N/A.Spinal Cord (2007) 45, 260–274. doi:10.1038/sj.sc.3102034; published online 20 February 2007 [ABSTRACT FROM AUTHOR]

Study design:Postal survey.Objective:To describe the health behaviour of persons with spinal cord injury (SCI) living in the community and the relationships between health behaviour, respondent/injury characteristics, and health-related variables: the presence and number of secondary impairments, readmissions in rehabilitation centre and hospital, and perceived health.Setting:Members of the Dutch Association of Patients with SCI.Methods:The frequency of health behaviours, that delay or prevent secondary impairments, was assessed by means of a 22-item, self-report questionnaire. The questionnaire was also focused on 13 secondary impairments.Results:The frequency of engaging in health behaviour varied considerably between the respondents. Variance was observed between and within the health behaviours measured. The respondents did not frequently engage in pressure relief methods when sitting/driving in their wheelchair. Almost no statistical differences were observed between health behaviour of subgroups of respondents based on respondent/injury characteristics. However, the total health behaviour scores increased significantly with increasing age and pressure sore prevention was significantly more applied in persons with a complete lesion. Health behaviour was significantly more applied in respondents who had one or more secondary impairments.Conclusion:As secondary impairments are prevalent among persons with SCI and education on a healthy lifestyle is a core component of every rehabilitation programme, it is of great importance to rigorously test the efficacy of health behaviours promoted during rehabilitation. Therefore, longitudinal research is recommended.Spinal Cord (2007) 45, 243–249. doi:10.1038/sj.sc.3101967; published online 12 September 2006 [ABSTRACT FROM AUTHOR]

Study design:Spinal reflex excitability study in sensory–motor incomplete spinal cord-injured (SCI) and spinal intact subjects.Objectives:To investigate the effects of plantar cutaneous afferent excitation on the soleus H-reflex and flexion reflex in both subject groups while seated.Setting:Rehabilitation Institute of Chicago and City University of New York, USA.Methods:The flexion reflex in SCI subjects was elicited by non-nociceptive stimulation of the sural nerve. In normal subjects, it was also elicited via innocuous medial arch foot stimulation. In both cases, reflex responses were recorded from the ipsilateral tibialis anterior muscle. Soleus H-reflexes were elicited and recorded via conventional methods. Both reflexes were conditioned by plantar cutaneous afferent stimulation at conditioning test intervals ranging from 3 to 90 ms.Results:Excitation of plantar cutaneous afferents resulted in facilitation of the soleus H-reflex and late flexion reflex in SCI subjects. In normal subjects, the soleus H-reflex was depressed while the late flexion reflex was absent. The early flexion reflex was irregularly observed in SCI patients, while in normal subjects a bimodal reflex modulation pattern was observed.Conclusion:The effects of plantar cutaneous afferents change following a lesion to the spinal cord leading to exaggerated activity in both flexors and extensors. This suggests impaired modulation of the spinal inhibitory mechanisms involved in the reflex modulation. Our findings should be considered in programs aimed to restore sensorimotor function and promote recovery in these patients.Sponsorship:NIH, NICHD, Grant no. 1R03HD043951-01 and PSC CUNY Research Award no. 67051-0036.Spinal Cord (2007) 45, 69–77. doi:10.1038/sj.sc.3101917; published online 14 March 2006 [ABSTRACT FROM AUTHOR]

Objective:To analyse cross-culture validity of the Functional Independence Measure (FIM™) in patients with a spinal cord injury using a modern psychometric approach.Settings:A total of 19 rehabilitation facilities from four countries in Europe.Participants:A total of 647 patients at admission, median age 46 years, 69% male.Methods:Data from the FIM™, collected on inpatient admission, was fitted to the Rasch model. A detailed analysis of scoring functions of the seven categories of the FIM™ items was undertaken before to testing fit to the model. Categories were rescored where necessary. Fit to the model was assessed initially within country, and then in the pooled data. Analysis of differential item functioning (DIF) was undertaken in the pooled data for each of the FIM™ motor and social cognitive scales, respectively. Final fit to the model was tested for breach of local independence by principle components analysis (PCA).Results:The present scoring system for the FIM™ motor and cognitive scales, that is a seven category scale, was found to be invalid, necessitating extensive rescoring. Following this, DIF was found in a number of items within the motor scale, requiring a complex solution of splitting items by country to allow for the valid pooling of data. Five country-specific items could not be retained within this solution. The FIM cognitive scale fitted the Rasch model after rescoring, but there was a substantial ceiling effect.Conclusions:Data from the FIM™ motor scale for patients with spinal cord injury should not be pooled in its raw form, or compared from country to country. Only after fit to the Rasch model and necessary adjustments could such a comparison be made, but with a loss of clinical important items. The FIM cognitive scale works well following rescoring, and data may be pooled, but many patients were at the maximum score.Spinal Cord (2006) 44, 746–752. doi:10.1038/sj.sc.3101895; published online 3 January 2006 [ABSTRACT FROM AUTHOR]

Study design:A multicenter prospective cohort study.Objective:To compare the demographic data of the included population with other studied spinal cord injury (SCI) populations in the international literature.Setting:Eight Dutch rehabilitation centers with a specialized SCI unit.Methods:A total of 205 individuals with SCI participated in this study. Information about personal, lesion and rehabilitation characteristics were collected at the beginning of active rehabilitation by means of a questionnaire.Results:The research group mainly consisted of men (74%), of individuals with a paraplegia (59%), and had a complete lesion (68%). The SCI was mainly caused by a trauma (75%), principally due to a traffic accident (42%). The length of clinical rehabilitation varied between 2 months and more than a year, which seemed to be dependent on the lesion characteristics and related comorbidity.Conclusions:The personal and lesion characteristics of the subjects of the multi-center study were comparable to data of other studies, although fewer older subjects and subjects with an incomplete lesion were included due to the inclusion criteria ‘age’ and ‘wheelchair-dependent’. The length of stay in rehabilitation centers in The Netherlands was longer compared to Denmark but much longer than in eg Australia and the USA.Spinal Cord (2006) 44, 668–675. doi:10.1038/sj.sc.3101906; published online 7 February 2006 [ABSTRACT FROM AUTHOR]

Study design:Direct observation of a constrained consensus-building process in three culturally independent five-person panels of rehabilitation professionals from the US, Italy and Canada.Objectives:To illustrate cultural differences in belief among rehabilitation professionals about the relative importance of alternative functional goals during spinal cord injury (SCI) rehabilitation.Setting:Spinal Cord Injury Units in Philadelphia-USA, Rome-Italy and Vancouver-Canada.Methods:Each of the three panels came to independent consensus about recovery priorities in SCI utilizing the features resource trade-off game. The procedure involves trading imagined levels of independence (resources) across different functional items (features) assuming different stages of recovery.Results:Sphincter management was of primary importance to all three groups. The Italian and Canadian rehabilitation professionals, however, showed preference for walking over wheelchair mobility at lower stages of assumed recovery, whereas the US professionals set wheelchair independence at a higher priority than walking.Conclusions:These preliminary results suggest cross-cultural recovery priority differences among SCI rehabilitation professionals. These dissimilarities in preference may reflect disparities in values, cultural expectations and health care policies.Spinal Cord (2006) 44, 567–575. doi:10.1038/sj.sc.3101876; published online 29 November 2005 [ABSTRACT FROM AUTHOR]

Objective:The objective of this paper is to outline the proposed development process for the ICF Core Sets for Spinal Cord Injury (SCI) and to invite clinical and consumer experts to actively participate in this process. ICF Core Sets are selections of categories of the International Classification of Functioning, Disability and Health (ICF) that are relevant to persons with a specific condition or in a specific setting.Method:The project is a cooperation between the ICF Research Branch of the World Health Organization (WHO) Collaboration Centre of the Family of International Classifications (DIMDI, Germany), the Classification, Assessment and Terminology (CAT) team and the Disability and Rehabilitation (DAR) team at WHO, the International Spinal Cord Society (ISCoS) and International Society for Physical and Rehabilitation Medicine (ISPRM) and partner institutions across the world. The project will consist of four worldwide studies to be conducted from 2006 to 2007 with a proposed ICF Core Set Consensus Conference to be held in 2007. ICF categories relevant for SCI are to be identified by means of (I) an empirical study, (II) a systematic review of outcomes and measures used in SCI research (III) an expert survey and (IV) focus groups and semistructured interviews with persons with SCI. Consensus about items that have to be part of a Comprehensive and of a Brief ICF Core Set for SCI will be reached in a final ICF Core Set Consensus Conference. Subsequent field testing will be necessary to validate this first version of ICF Core Sets for SCI.Invitation for participation:The development of ICF Core Sets is an inclusive and open process. Anyone who wishes to actively participate in this process is invited to contact the project coordinator (Monika.Scheuringer@med.uni-muenchen.de or http://www.icf-research-branch.org/research/spinalcord-injuries.htm). Individuals, institutions and associations can be formally associated as partners of the project.Spinal Cord (2006) 44, 541–546. doi:10.1038/sj.sc.3101918 [ABSTRACT FROM AUTHOR]

Study design:Repeated-measures design.Objectives:To assess the validity and responsiveness of five additional mobility and locomotor (5-AML) items when used in conjunction with the Functional Independence Measure (FIM) for assessing the mobility and locomotor function of individuals with spinal cord injury (SCI).Setting:Specialised acute spinal and rehabilitation units in Sydney, Australia.Methods:A previously published scale comprising five key mobility and locomotor skills was further refined. The five items included a bed mobility and vertical (floor-to-chair) transfer item and three wheelchair propulsion items (pushing 200 m over flat ground, pushing up a ramp and negotiating a kerb). A total of 43 eligible patients with SCI (ASIA A–C impairment) admitted consecutively to two acute SCI units in Sydney between 1999 and 2002 were recruited, with four being lost to follow-up. Locomotor and mobility outcomes were measured at regular intervals for up to 6 months with the FIM and the 5-AML. Construct validity of the 5-AML was assessed by testing ability of items to discriminate between different impairment groups (tetraplegia and paraplegia). Item responsiveness was assessed by analysing ability to detect changes in mobility and locomotor function over time. Factor analysis techniques were used to test the hypothesis that the 5-AML, when used in conjunction with the FIM, provides a more sensitive measure of mobility and locomotor function than the FIM alone.Results:The 5-AML items were shown to be valid and responsive, measuring aspects of ‘real world’ mobility and locomotor function not reflected by the FIM. The bed mobility item was highly responsive to change over time for the tetraplegic group, but quickly reached a ceiling in the paraplegic group. The vertical (floor-to-chair) transfer item showed greater responsiveness over time and less ceiling effect for the paraplegic group than any of the FIM locomotor or mobility items. The three wheelchair propulsion items better discriminated between people with tetraplegia and paraplegia, and were more sensitive to changes in locomotor ability over the 6-month period than FIM locomotor items. Results of a preliminary factor analysis indicated that the 5-AML items measure different aspects of mobility and locomotor function than the FIM.Conclusion:The 5-AML items, when used in conjunction with the FIM, provides better delineation of function between people with tetraplegia and paraplegia and provides a more responsive measure of change in function over time than the FIM alone.Spinal Cord (2006) 44, 495–504. doi:10.1038/sj.sc.3101872; published online 6 December 2005 [ABSTRACT FROM AUTHOR]

Study design:Case series, and repeated assessments of the same individuals.Objective:To demonstrate the feasibility and efficacy of a multiweek intervention on walking function in people with chronic, incomplete spinal cord injuries.Setting:Rehabilitation hospital for spinal cord injury (SCI) in Toronto, Canada.Methods:A convenience sample of five subjects with chronic, incomplete SCI trained for 12–18 weeks using a new multichannel neuroprosthesis for walking. The following outcome measures were recorded throughout the training period: walking speed, step frequency and average stride length based on a 2-min walk test. Also identified were which walking aids and orthoses subjects preferred to use, and whether they employed a step-to or step-through gait strategy. Follow-up measurements of three subjects were made up to 10 weeks after treatment.Results:All subjects demonstrated significant improvements in walking function over the training period. Four of the subjects achieved significantly increased walking speeds, which were due to increases in both stride length and step frequency. The fifth subject experienced a significant reduction in preferred assistive devices. Follow-up measurements revealed that two subjects walked slightly slower several weeks after treatment, but they still walked significantly faster than at the start of treatment.Conclusion:The gait training regimen was effective for improving voluntary walking function in a population for whom significant functional changes are not expected. This application of functional electrical therapy is viable for rehabilitation of gait in incomplete SCI.Spinal Cord (2006) 44, 357–361. doi:10.1038/sj.sc.3101864; published online 25 October 2005 [ABSTRACT FROM AUTHOR]

Study design:Prospective cohort study.Objectives:To study upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using subjects with a spinal cord injury (SCI) and its relation with lesion characteristics, muscle strength and functional outcome.Setting:Eight rehabilitation centers with an SCI unit in the Netherlands.Methods:Using a questionnaire, number, frequency and seriousness of musculoskeletal pain complaints of the upper extremity were measured. A pain score for the wrist, elbow and shoulder joints was calculated by multiplying the seriousness by the frequency of pain complaints. An overall score was obtained by adding the scores of the three joints of both upper extremities. Muscle strength was determined by manual muscle testing. The motor score of the functional independence measure provided a functional outcome. All outcomes were obtained at four test occasions during and 1 year after rehabilitation.Results:Upper extremity pain and shoulder pain decreased over time (30%) during the latter part of in-patient rehabilitation (P<0.001). Subjects with tetraplegia (TP) showed more musculoskeletal pain than subjects with paraplegia (PP) (P<0.001). Upper extremity pain and shoulder pain were significantly inversely related to functional outcome (P<0.001). Muscle strength was significantly inversely related to shoulder pain (P<0.001). Musculoskeletal pain at the beginning of rehabilitation and BMI were strong predictors for pain 1 year after in-patient rehabilitation (P<0.001).Conclusions:Subjects with TP are at a higher risk for upper extremity musculoskeletal pain and for shoulder pain than subjects with PP. Higher muscle strength and higher functional outcome are related to fewer upper extremity complaints.Spinal Cord (2006) 44, 152–159. doi:10.1038/sj.sc.3101826; published online 6 September 2005 [ABSTRACT FROM AUTHOR]

Study design:Cross-sectional or psychotherapy, questionnaire.Objectives:To examine the community needs of people with spinal cord injury (SCI) across four European countries and to identify areas of unmet needs. It is intended that this information will be of use to rehabilitation professionals in fostering greater social participation among SCI individuals.Setting:United Kingdom, Germany, Austria and Switzerland.Methods:Self-report questionnaires were sent to 1000 people with SCI resident in the community in the UK, Germany, Austria and Switzerland. Questionnaires measured current needs, community integration, mood, appraisals, coping strategies, functional independence and perceived manageability.Results:Occupation, sexual activity and pain relief were areas indicative of highest community needs in all four countries. Most participants were psychologically well adjusted and socially integrated into the community. Well-addressed needs were skin management, wheelchair needs and accommodation. Some differences that occurred in certain areas across the four countries were found.Conclusion:This study has highlighted that the main areas of unmet needs for a European community sample of people with SCI includes levels of occupation, sexual activity and pain relief. The findings will be of interest to those involved in rehabilitation of newly as well as long-term injured people and demonstrate the need to consistently readdress such issues as part of a person's long-term rehabilitation in order to achieve and maximise effective social participation.Spinal Cord (2006) 44, 95–105. doi:10.1038/sj.sc.3101787; published online 30 August 2005 [ABSTRACT FROM AUTHOR]