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Study Design: Retrospective anonymized cohort study., Objectives: To study X-ray images of video urodynamics (VUD) in patients with spinal cord injury (SCI)., Setting: Single-center study., Methods: X-ray images during VUD were categorized. Relation with the American Spinal Injury Association Impairment Scale (AIS), time since and level of SCI, cystometric data, method of bladder management, findings of flexible cystoscopy, and renal ultrasound were evaluated. Changes over time were studied., Results: In 231 consecutive patients, VUD was done at a mean of 8.5 years after SCI. X3-ray bladder appearance was categorized as normal/standard, tonic, or flaccid. In 19 patients, specific findings were seen: diverticula, cystocele, vesicoureteral reflux. X-ray images differed by maximum cystometric capacity, presence of neurogenic detrusor overactivity, and maximum detrusor pressure during detrusor overactivity, but not by bladder compliance. There was no difference in the categories found in different levels and completeness of SCI. In the 23 patients able to void no pathology was seen on urethral images. Renal ultrasound was normal in >99%. In 86 patients, repeated testing after 72 ± 143 weeks showed changed findings in 30%. Cystoscopy showed significantly more local pathologies., Conclusion: Complications in the lower urinary tract were seen on imaging only in a limited number of our cohort. As our findings represent a real-life example of the actual yield of VUD in patients with neurogenic bladder due to SCI treated following the international guidelines, further multicentre evaluation is needed to determine when imaging should be used or not., (© 2022. The Author(s), under exclusive licence to International Spinal Cord Society.)

Study Design: Cross-sectional construct validation study., Objectives: To test the construct validity of the Leisure Time Physical Activity Questionnaire for People with Spinal Cord Injury (LTPAQ-SCI) by examining associations between the scale responses and cardiorespiratory fitness (CRF) in a sample of adults living with spinal cord injury (SCI)., Setting: Three university-based laboratories in Canada., Methods: Participants were 39 adults (74% male; M age: 42 ± 11 years) with SCI who completed the LTPAQ-SCI and a graded exercise test to volitional exhaustion using an arm-crank ergometer. One-tailed Pearson's correlation coefficients were computed to examine the association between the LTPAQ-SCI measures of mild-, moderate-, heavy-intensity and total minutes per week of LTPA and CRF (peak volume of oxygen consumption [V̇O 2peak ] and peak power output [PO peak ])., Results: Minutes per week of mild-, moderate- and heavy-intensity LTPA and total LTPA were all positively correlated with V̇O 2peak . The correlation between minutes per week of mild intensity LTPA and V̇O 2peak was small-medium (r = 0.231, p = 0.079) while all other correlations were medium-large (rs ranged from 0.276 to 0.443, ps < 0.05). Correlations between the LTPAQ-SCI variables and PO peak were also positive but small (rs ranged from 0.087 to 0.193, ps > 0.05), except for a medium-sized correlation between heavy-intensity LTPA and PO peak (r = 0.294, p = 0.035)., Conclusions: People with SCI who report higher levels of LTPA on the LTPAQ-SCI also demonstrate greater levels of CRF, with stronger associations between moderate- and heavy-intensity LTPA and CRF than between mild-intensity LTPA and CRF. These results provide further support for the construct validity of the LTPAQ-SCI as a measure of LTPA among people with SCI.

Study Design: Retrospective chart review., Objectives: To compare the proportion of fallers and the patient level and fall characteristics among inpatients who had experienced at least one fall in a spinal cord injury (SCI), an acquired brain injury (ABI), and a neuromusculoskeletal disease (NMS) rehabilitation program., Setting: Tertiary rehabilitation hospital., Subjects: Inpatients who had experienced at least one fall during rehabilitation., Methods: Patient and fall level variables were extracted from electronic medical records over a 5-year period (January 1, 2011 to January 1, 2016): hospital program, age, sex, Functional Independence Measure (FIM) scores, length of stay, number of medications, as well as fall date, time, location, cause, harm, fall risk assessment data, and whether the fall was witnessed. The impact of hospital program on fall was examined using bivariate and multivariable analysis., Results: Two hundred and thirty-seven (16%) inpatients experienced at least one fall during the study period. Inpatients with SCI had the highest proportion of fallers (20%) and fell later after admission than inpatients in the other programs. Patients with ABI were more likely to sustain moderate-to-severe physical harm from falls. Taking >5 medications at time of fall and being earlier in one's rehabilitation course were associated with increased fall rate among fallers., Conclusions: Although the type of program was not a significant predictor of fall rate in the multivariable analysis, there were some important differences among the rehabilitation programs on patient and fall level characteristics. These results may be useful when developing and timing fall prevention interventions for inpatient rehabilitation.

Study Design: Prospective cross-sectional study OBJECTIVES: The objective of this study was to assess associations between white matter changes and functional motor markers including grip strength and prehension in the upper limb., Setting: Single Center Imaging Study, in Vancouver Canada., Methods: Diffusion tensor imaging produced FA (Fractional Anisotropy) maps of the brain for participants with SCI (n = 7) and controls (n = 6). These FA maps were analyzed using tract-based spatial statistics. Correlations between the FA values (of the genu of the corpus callosum, the left superior longitudinal fasciculus and the right anterior thalamic radiation) of the SCI group and functional outcomes (grip strength, Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP)) were assessed., Results: Significant differences (p < 0.05) were found between the FA values of the controls and the SCI group in two white matter clusters, with lower values in the SCI group. Strong correlations were found between the FA values of the identified clusters and the age of SCI participant, and the right GRASSP Quantitative Prehension and right total GRASSP score., Conclusions: This preliminary data suggests that decreased FA in the genu of the corpus callosum may be a biomarker for functional motor ability of the upper limb with higher FA indicating better ability. Further research needs to be done to determine if other white matter tracts are also associated with strength and use of the hand following SCI., Sponsorship: The International Collaboration on Repair Discoveries (operating grant) and Canada Research Chair Program (for JJE) provided support for this research.

Study Design: Retrospective observational., Objectives: To compare objective (neurological examination) and subjective (patients perception) recovery in patients with spinal cord injury (SCI) who chose to undergo cell transplantation therapies (CTT) outside of clinical trials abroad., Setting: Physical Medicine and Rehabilitation Hospital, Kuwait., Methods: Nine patients with SCI who had undergone CTT outside Kuwait were identified and their neurological pre-transplantation evaluation according the International Standards for Neurological Classification of SCI (ISNCSCI) was collected from hospital records. Post transplantation ISNCSCI examination was conducted during follow-up visits and scores were completed between pre and post CTT. In addition to the ISNCSCI evaluation, change in disability status, and patient's perception of improvement after stem cell transplantation were examined., Results: Overall, 8 males and 1 female with chronic SCI underwent CTT (42 ± 38.2 months post SCI) in various centers (China, Egypt, Germany, India, and Iran). On follow-up post CTT assessment (89.2 ± 36 months post SCI), 55.5% of individuals reported perceived improvement as follows: increased deep tissue sensation below the injury (100%) or increase in bladder sensation (11.1%). Objective examination after CTT revealed that none of the examined individuals demonstrated improvement in their motor scores or neurological level of SCI., Conclusion: We were not able to objectively document clinically useful improvements in sensorimotor, autonomic, or functional status in individuals after CTT.

Objective: To describe the changes made to the international spinal cord injury (SCI) skin and thermoregulation function basic data set in version 1.1., Setting: International., Methods: An international working group reviewed suggested changes to the international SCI skin and thermoregulation function basic data set version 1.0. These changes were discussed and the agreed changes were made. Subsequently, the recommended adjustments were circulated for review to the International Spinal Cord Society (ISCoS) Executive and Scientific Committees, the American Spinal Injury Association (ASIA) Board, around 40 national and international societies, and to interested individuals who had signed up wishing to have the opportunity to review. In addition, the suggested changes were displayed at the ISCoS and ASIA websites for at least a month for possible comments., Results: The recommendation 'largest diameter, including undermining' is changed to: 'Largest undermining', and a description of how to measure this is inserted. The 'smallest opening diameter' is changed to: 'Width' as the maximum dimension perpendicular to the length axis. In the literature, there is a tendency to replace 'grades' or 'stages' with 'categories'; therefore, the word 'category' is used instead of 'grade' or 'stage'., Conclusions: Impracticable measurements have been adjusted and new terminology adopted. All are to be found on ISCoS website: http://www.iscos.org.uk/international-sci-skin-and-thermoregulation-function-data-sets.

Study Design: Retrospective chart review., Objectives: To establish the frequency and severity of autonomic dysreflexia (AD) during urodynamics among individuals with chronic spinal cord injury (SCI) and to investigate the possible effect of the number of years since SCI on the severity of AD., Setting: SCI outpatient clinic., Methods: A retrospective chart review was undertaken of individuals with SCI who were seen at an outpatient clinic and could potentially develop an episode of AD (T6 and above). Data regarding age, gender, urodynamic examination, lower urinary tract function, cardiovascular parameters and SCI were collected. In addition, information on signs and symptoms of AD were retrieved., Results: A total of 76 individuals with SCI were examined with blood pressure (BP) monitoring. The majority had cervical SCI (79%). The mean age was 47.8±13.9 years. The median duration after SCI was 51.5 months. During urodynamics, a total of 48 (63.2%) individuals showed an increase in systolic BP>20 mm Hg, meeting the criteria for AD. Indicators for higher incidences of AD were cervical SCI, being >2 years after SCI, the presence of detrusor sphincter dyssynergia (DSD) and low bladder compliance. AD was more severe in individuals with complete (American Spinal Cord Association (ASIA) impairment scale (AIS) A) injuries, worse with greater time after SCI., Conclusion: Individuals with cervical SCI, DSD, poor bladder compliance or >2 years after SCI were associated with a higher possibility of developing AD during urodynamics. Furthermore, AD was more severe in complete (AIS A) individuals and was exacerbated with time after injury.

Study Design: Longitudinal observational study., Objective: To quantify the amount of upper- and lower-extremity movement repetitions (that is, voluntary movements as part of a functional task or specific motion) occurring during inpatient spinal cord injury (SCI), physical (PT) and occupational therapy (OT), and examine changes over the inpatient rehabilitation stay., Setting: Two stand-alone inpatient SCI rehabilitation centers., Methods: Participants: A total of 103 patients were recruited through consecutive admissions to SCI rehabilitation., Interventions: Trained assistants observed therapy sessions and obtained clinical outcome measures in the second week following admission and in the second to last week before discharge., Main Outcome Measures: PT and OT time, upper- and lower-extremity repetitions and changes in these outcomes over the course of rehabilitation stay., Results: We observed 561 PT and 347 OT sessions. Therapeutic time comprised two-thirds of total therapy time. Summed over PT and OT, the median upper-extremity repetitions in patients with paraplegia were 7 repetitions and in patients with tetraplegia, 42 repetitions. Lower-extremity repetitions and steps primarily occurred in ambulatory patients and amounted to 218 and 115, respectively (summed over PT and OT sessions at discharge). Wilcoxon-signed rank tests revealed that most repetition variables did not change significantly over the inpatient rehabilitation stay. In contrast, clinical outcomes for the arm and leg improved over this time period., Conclusions: Repetitions of upper- and lower-extremity movements are markedly low during PT and OT sessions. Despite improvements in clinical outcomes, there was no significant increase in movement repetitions over the course of inpatient rehabilitation stay., Competing Interests: The authors declare that there are no competing financial interests in relation to the work described.

Study Design: Single-group pre-/post-test with 3- and 6-month follow-ups., Objectives: To test the effects of the 'ABCs of AD' educational module on immediate and longer-term changes in paramedics' knowledge and beliefs about using the autonomic dysreflexia clinical practice guidelines (AD-CPGs)., Setting: Canada., Methods: A total of 119 paramedics completed an AD knowledge test and measures of attitudes, perceived control, self-efficacy, social pressure from patients and health-care professionals, and intentions to use the AD-CPGs before and 1 week, 3 months and 6 months after viewing 'ABCs of AD'., Results: There were significant improvements in AD knowledge, attitudes and social pressure from patients to use the AD-CPGs from baseline to 1 week, 3 months and 6 months post viewing (all P<0.001). Self-efficacy and intentions increased 1 week post viewing (P<0.001), but returned to baseline levels at 3 and 6 months (P>0.05). There was no change in perceived control or social pressure from health-care professionals. AD knowledge and beliefs explained 50-61% of the variance in intentions to use the AD-CPGs. Attitudes, social pressure from patients and perceived behavioural control were significant unique predictors of intentions at all time points (P<0.05); AD knowledge was a significant predictor at 6 months only (P=0.048). No other predictors were significant., Conclusion: 'ABCs of AD' has immediate and sustained effects on paramedics' knowledge of attitudes toward and perceived pressure from patients to use the AD-CPGs. Updates to paramedic patient care guidelines and standards are needed to increase paramedics' perceived control and self-efficacy to implement the guidelines, and their intentions to use the AD-CPGs., Sponsorship: Canadian Institutes of Health Research (2011-CIHR- 260877).

Study Design: Interactive workshops with a presurvey-postsurvey., Objectives: To describe a series of workshops held at international meetings to inform the spinal cord injury (SCI) community about the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) and to obtain feedback on both the workshop and the ISAFSCI assessment., Setting: Three international conferences of SCI practitioners in Toronto, Las Vegas and Vancouver held between 2012 and 2013., Methods: The workshops included an overview of the ISAFSCI, sharing experiences using it in clinical practice and interactive cases illustrating how to complete the scoring. A presurvey-postsurvey was administered to obtain feedback on the workshops and the ISAFSCI assessment., Results: One hundred and fourteen participants completed the workshop surveys and 96% (109/114) completed both presurvey and postsurvey. Prior to the workshop, 41% (47/114) of those who had completed the survey reported assessing autonomic function in their practice, and of those, 53% (25/47) reported using the ISAFSCI. After the workshop, 74% (84/114) of participants reported that the case studies were helpful, and 57% (65/114) reported that they wanted to start or continue to use the ISAFSCI in their clinical practice. Suggestions for improving the ISAFSCI included providing further areas to consider when performing the assessment, addressing ambiguity of terms and reporting foreseeable implementation challenges., Conclusion: Results from this workshop suggest that more work is needed to inform the SCI community on the ISAFSCI assessment and to further clarify its language. Results from this study will inform future revisions to the ISAFSCI.

Study Design: Cost-effectiveness analysisObjective:To establish a model to investigate the cost effectiveness for people with spinal cord injury (SCI), from a lifetime perspective, for the usage of two different single-use catheter designs: hydrophilic-coated (HC) and uncoated (UC). The model includes the long-term sequelae of impaired renal function and urinary tract infection (UTI)., Setting: Analysis based on a UK perspective., Methods: A probabilistic Markov decision model was constructed, to compare lifetime costs and quality-adjusted life years, taking renal and UTI health states into consideration, as well as other catheter-related events. UTI event rates for the primary data set were based on data from hospital settings to ensure controlled and accurate reporting. A sensitivity analysis was applied to evaluate best- and worst-case scenarios., Results: The model predicts that a 36-year-old SCI patient with chronic urinary retention will live an additional 1.4 years if using HC catheters compared with UC catheters, at an incremental cost of £2100. Moreover, the lifetime number of UTI events will be reduced by 16%. All best- and worst-case estimates were within the UK threshold of being cost effective., Conclusion: The use of HC catheters for intermittent catheterisation in SCI patients is highly cost effective. The outcome is consistent irrespective of whether UTI data are collected in hospital or community settings.

Study Design: Retrospective chart analysis., Objectives: To investigate the use of the International Autonomic Standards (IAS, 2009 edition) for classification of remaining autonomic function following spinal cord injury (SCI) over a 1-year period in a rehabilitation center, to determine clinical adherence to use of the IAS, and to examine the most common autonomic dysfunctions, as determined by using the IAS., Setting: Tertiary rehabilitation hospital., Methods: A retrospective study was conducted on the use of the IAS at admission and discharge over a 1-year period on patients admitted to an in-patient SCI unit in a tertiary rehabilitation center. We examined the consistency of the form completion, as well as the completion of separate components of the forms. Finally, we examined the prevalence of each autonomic impairment., Results: A total of 70 patients were admitted to the unit. The clinical adherence to the IAS was lower than the International Standards for Neurological Classification of SCI (ISNCSCI) at both admission (63% and 93%, respectively) and discharge (39% and 78%, respectively). Blood pressure dysfunction was most common among the general autonomic function disorders. However, urinary, bowel and sexual dysfunctions were present in almost all individuals with acute SCI., Conclusion: The IAS is in the initial stages of being incorporated into routine admission and discharge clinical examinations of individuals with SCI. The current results suggest that the clinical adherence to the IAS is low; however, it is expected that increased education, experience, and accumulating evidence for the IAS will improve its use.

Study Design: This is a systematic review., Objective: The objective of this study was to review the literature on iatrogenic urological triggers of autonomic dysreflexia (AD)., Setting: This study was conducted in an international setting., Methods: A systematic review was conducted from PubMed search using AD/ autonomic hyperreflexia and spinal cord injury (SCI). Studies selected for review involved iatrogenic urological triggers of AD in individuals with SCI, including original articles, previous practice guidelines, case reports and literature reviews. Studies that did not report AD or blood pressure (BP) assessments during urological procedures were excluded., Results: Forty studies were included for analysis and categorized into four groups: (1) urodynamics and cystometry; (2) cystoscopy and transurethral litholapaxy; (3) extracorporeal shock-wave lithotripsy (ESWL); and (4) other procedures. During urodynamics, the incidence of AD ranged from 36.7% to 77.8%. The symptomatic rate ranged from 50% to 65%, with AD symptoms seen predominantly in cervical SCI patients. The studies imply no consensus regarding the relationship between AD, neurogenic detrusor overactivity and detrusor sphincter dyssynergia. Without anesthesia, the majority of individuals develop AD during cystoscopy, transurethral litholapaxy and ESWL. The effectiveness of different anesthesia methods relies on blocking the nociceptive signals from the lower urinary tract (LUT) below the level of the neurological lesion. Other iatrogenic urological triggers were commonly associated with bladder filling., Conclusion: The LUT triggers of episodes of AD are often associated with iatrogenic urological procedures. AD was more prevalent in cervical SCI than in thoracic SCI. To detect this potential life-threatening complication following cervical and high thoracic SCI, routine BP monitoring during urological procedures is highly recommended.

Study Design: Despite significant progress in bladder management, urinary tract infections (UTIs) are still common among individuals with spinal cord injury (SCI), and could negatively impact their health and quality of life. However, there are no data available on bladder management and frequency of UTIs among elite athletes with SCI., Methods: Athletes were assessed during the London 2012 Paralympic Games and 2013 Paracycling World Championships. Athletes completed the standard form of the International Standards to Document remaining Autonomic Functions after SCI, along with the standardized Autonomic Function Questionnaire., Results: A total of 61 (age=35.5±7.7 years (mean±s.d.); time since injury=16.0±7.6 years) elite athletes from 15 countries with traumatic SCI and who used clean intermittent catheterization were included in this study. The majority (75%) were from developed nations. Athletes catheterized on average 6±2 times per day. We found that individuals who reused catheters experienced more frequent UTIs (P<0.001). We also demonstrated that 83% of individuals from developed nations never reused a single-use catheter, whereas only 27% of individuals from developing nations used a new catheter each time (P<0.001). We also noted a twofold increase in the frequency of UTIs in individuals from developing nations (P=0.027)., Conclusions: This study demonstrates that catheter reuse is intimately linked to UTI frequency and provides novel insight on bladder function and management in elite athletes with SCI. Reasons for catheter reuse may be due to a lack of health education and/or a lack of bladder-management resources. (Support: Craig Neilsen Foundation, ICORD, IPC).

Objectives: Spinal cord injury (SCI) often results in severe dysfunction of the autonomic nervous system. C1-C8 SCI affects the supraspinal control to the heart, T1-T5 SCI affects the spinal sympathetic outflow to the heart, and T6-T12 SCI leaves sympathetic control to the heart intact. Heart rate variability (HRV) analysis can serve as a surrogate measure of autonomic regulation. The aim of this study was to investigate changes in HRV patterns and alterations in patients with acute traumatic SCI., Methods: As soon as possible after SCI patients who met the inclusion criteria had 24 h Holter monitoring of their cardiac rhythm, additional Holter monitoring were performed 1, 2, 3 and 4 weeks after SCI., Results: Fifty SCI patients were included. A significant increase in standard deviation of the average normal-to-normal (SDANN) sinus intervals was seen in the first month after injury (P=0.008). The increase was only significant in C1-T5 incomplete patients and in patients who did not experience one or more episodes of cardiac arrest. Significant lower values of Low Frequency Power, Total Power and the Low Frequency over High Frequency ratio were seen in the C1-T5 SCI patients compared with T6-T12 SCI patients., Conclusions: The rise in SDANN in the incomplete C1-T5 patients could be due to spontaneous functional recovery caused by synaptic plasticity or remodelling of damaged axons. That the autonomic nervous system function differs between C1-C8, T1-T5 and T6-T12 patients suggest that the sympathovagal balance in both the C1-C8 and T1-T5 SCI patients has yet to be reached.

Study Design: Interventional training session., Objective: To investigate the effect and satisfaction with didactic training using printed text of a submodule of www.elearnSCI.org for nurse students and to assess the answers of each question., Setting: A Peking University teaching hospital., Methods: Twenty-eight nurse students in two groups (14 in each) were involved. Only group A received a translated print-out of the slides from the 'Nursing management' submodule in www.elearnSCI.org for 1-h self-study before the class. At the beginning of class, both groups were tested using the self assessment questions. Then, a lecture according to the content of this submodule was carried out and afterwards both groups answered the self assessment questions again. Finally, both groups filled in a training course satisfaction questionnaire., Results: At the beginning of the class, the mean score (max 9) of the self assessment in group A was 7.1 ± 1.1, which was significantly higher than that in group B (4.9 ± 1.7, P = 0.001). After the lecture, the mean score of the self assessment in group A had insignificantly increased to 7.4 ± 1.3, whereas in group B it increased significantly to 6.9 ± 0.8 (P < 0.001). The mean score (max 50) of the training course satisfaction questionnaire was 42.8 ± 5.2. Sixty-four percentage of the students indicated that they were very satisfied (overall score ⩾ 42) with the training and no students were unsatisfied (overall score < 30)., Conclusion: Self-study and lecture presentation are effective methods for training the content of www.elearnSCI.org to nurse students. The training satisfaction of this submodule within the www.elearnSCI.org is favorable.

Study Design: Randomized, controlled clinical trial., Objectives: Bladder and bowel management may cause serious autonomic dysreflexia (AD) in subjects with high spinal cord injury (SCI). We aimed at investigating autonomic responses to digital rectal evacuation (DE), transanal irrigation (TAI) with 500 ml and filling cystometry (FC) in SCI., Setting: Aarhus University Hospital, Denmark., Methods: Eight subjects with SCI (AIS A) at or above T6 (high SCI) and a previous history of AD were compared with three subjects with SCI (AIS A) between T10 and L2 (low SCI). In randomized order, DE, TAI and FC were performed. AD was defined as an acute rise in systolic blood pressure (sBP) of ⩾30 mm Hg above baseline. Blood levels of norepinephrine and epinephrine were determined before and shortly after the procedures., Results: During all three procedures, AD occurred in all patients with high SCI but not in those with low SCI. In high SCI subjects, DE increased median sBP from 127 (range: 86-154) to 188 (range: 140-206) mm Hg (P<0.02), TAI from 126 (range: 91-146) to 163 (range: 130-188) mm Hg (P<0.02) and FC from 125 (range: 106-149) to 200 (range: 179-220) mm Hg (P<0.01). The sBP increase was lower during TAI than during DE (P<0.05) or FC (P<0.02). In high SCI subjects, the blood levels of norepinephrine, but not those of epinephrine, increased significantly during all three stimuli (all P<0.05)., Conclusion: Bowel and bladder management caused AD in high SCI. The response is less severe during TAI than during FC or DE.

Study Design: Within-subject repeated measures., Objectives: To determine the intra- and inter-tester reliability of aortic pulse wave velocity (aPWV) measurements collected using applanation tonometry in individuals with spinal cord injury (SCI)., Setting: Inpatient Rehabilitation Centre and outpatient Clinic in Vancouver, BC, Canada., Methods: Fifteen men and three women with traumatic SCI (age: 46±16 years; C3-L1; American Spinal Injury Association Impairment Scale A-D; 2-284 months post injury) participated in two testing sessions separated by an average of 2 days. During each testing session, aPWV measurements were collected in the supine position following 10 min of rest. Arterial blood pressure waveforms were collected simultaneously by two trained raters at the carotid and femoral arterial sites using applanation tonometry. Heart rate was continuously measured using a single-lead electrocardiogram, whereas brachial blood pressures were measured at 5-min intervals using an automated device., Results: Intra- and inter-tester aPWV measurements demonstrated almost perfect reliability with intraclass correlation coefficients of 0.91 and 0.98 (P<0.001), and coefficients of variation of 5.9% and 3.4%, respectively. The smallest detectable differences (SDDs) for intra- and inter-tester measurements were 0.9 m s(-1) and 0.6 m s(-1), respectively. There were no significant differences in heart rate or blood pressure between intra- and inter-testing sessions., Conclusion: Applanation tonometry measurements of aPWV are reliable in individuals with SCI. In addition, the SDDs were smaller than a clinically relevant value, suggesting that this measurement is suitable for repeated measures study designs in SCI.

Study Design: Retrospective chart review., Objective: To compare autonomic dysreflexia (AD) severity during urodynamics and cystoscopy in individuals with spinal cord injury (SCI)., Setting: Outpatient urological clinic., Methods: Demographic and clinical data were collected from charts of individuals with SCI who had blood pressure (BP) monitoring during urological procedures. Cardiovascular parameters were collected at baseline and during the various stages of two examinations., Results: A total of 21 SCI individuals (mean age 49.4 years) who underwent both procedures developed episodes of AD. The majority of individuals had cervical SCI (85.7%). The median duration of injury was 183 months (ranging from 3 to 530 months). There was statistically more of an increase (P=0.039) in systolic BP during cystoscopy (67.1±33.8 mm Hg) in comparison with urodynamics (51.8±21.8 mm Hg). The BP response during episodes of AD was more pronounced in individuals with more than 2 years post SCI than with less than 2 years post SCI during both urodynamics and cystoscopy (P=0.047 and P=0.010, respectively)., Conclusion: Even though cystoscopy filled the bladder to lesser volumes than did urodynamics (150 ml vs 500 ml), during cystoscopy the individuals developed greater changes in systolic BP, indicating that stimulation of the urethra/prostate/internal sphincter region probably is a more potent stimulus of AD than just the filling of the bladder. The severity of AD also increased with time post SCI during both procedures. Considering the high incidence of silent episodes of AD during the urological procedures, it is recommended that monitoring of cardiovascular parameters during these procedures be routinely performed.

Study Design: Interventional training sessions., Objectives: To examine the effectiveness of training medical students in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)., Setting: A Peking University teaching hospital., Methods: A total of 46 medical students were involved in the study. First, they had a 2-h self-study session with the ISNCSCI booklet, followed by a 10-item questionnaire. The booklet was allowed for use as a reference during this assessment. Two days later, the questionnaire was repeated without the use of reference. Students then had a session with case discussion, followed by a final questionnaire., Results: After the initial self-study session, the mean score (max. 10) on the questionnaire was 7.67 ± 1.49. Two days later, the mean score of the second test was 7.96 ± 1.15. All key points of the ISNCSCI were supplemented during the second session with case presentations. The mean score of the final test increased significantly to 9.61 ± 0.88 (P<0.01) in comparison with the previous tests. The overall correct response rates by students in determining sensory level, motor level and American Spinal Injury Association Impairment Scale of the training case were 89.1%, 84.8% and 91.3%, respectively., Conclusion: The training effectiveness of ISNCSCI through self-study is reliable. The correct answers to key points could remain for at least 2 days without the need to use a reference. However, some specialized knowledge could not be transmitted without more detailed discussions and case presentations. Utilization of cases is a valuable method in training ISNCSCI and can improve the overall training effectiveness.

Study Design: A case report., Objectives: To present a case of postpartum hypogalactia in a woman with Brown-Séquard-plus syndrome (BSPS)., Setting: Outpatient spinal cord injury (SCI) clinic., Case Report: A 33-year-old woman with C4 AIS D tetraplegia (American Spinal Injury Association Impairment Scale) was followed at the outpatient SCI clinic for the past 5 years. Her right side presents with increased tone, increased spasticity and decreased sensitivity to light touch. Conversely, her left side presents with minimal changes in tone and no motor function deficits, but decreased sensitivity to pinprick and temperature sensation. These findings are consistent with BSPS. After inpatient rehabilitation, she was engaged, married, and 8 months ago delivered a healthy child. After an uncomplicated delivery, breastfeeding was attempted, but a significant lack of lactation was noted the first month postpartum from the right breast. Despite the implementation of measures to increase lactation, the lack of lactation from the right breast persisted, and required initiation of formula feeding. The right breast in this case lost not only sensory proprioception, but also autonomic control, which could contribute to this instance of asymmetric lactation., Conclusion: In addition to motor and sensory dysfunctions following SCI, autonomic dysfunctions are commonly seen in individuals with these devastating injuries. The lactation on the right side, which had interrupted descending spinal autonomic pathways, was decreased by approximately 83%. This case provides us with interesting information regarding attention that clinicians should be paying when discussing the breastfeeding options for women with SCI.

Study Design: Review article., Objectives: To provide an overview of free radical biology, particularly with respect to muscle physiology, as well as the potential effects of muscle morphological changes, physical capacity and nutritional status on oxidative stress in people with chronic spinal cord injury (SCI). The potential implications of these factors for determining the optimal dosage of rehabilitation training interventions in people with chronic SCI will also be presented., Setting: Vancouver, BC, Canada., Methods: Literature review., Results: Not applicable., Conclusion: There has been a great deal of focus on rehabilitation exercise interventions providing intensive practice of movements to enhance functional recovery and physical capacity following SCI. However, there is still much to be understood about the appropriate dosage of training parameters (e.g. frequency, duration). It has been known for several decades that exercise increases free radical production, leading to oxidative stress. To date, there has been little consideration of the potential interaction of oxidative stress with training parameters on functional outcomes in chronic SCI. Furthermore, individuals with chronic SCI face many secondary consequences of their injury, such as muscle atrophy, change in muscle fiber type, general deconditioning and nutritional status, that are known to influence free radical production and antioxidant capacity. Better understanding of the potential confounding effects of oxidative stress associated with exercise will improve our ability to determine the optimal 'dose' of rehabilitation training to maximize functional recovery following SCI.

Study Design: An investigation on large and small artery compliance in 36 able-bodied persons and persons with spinal cord injury (SCI)., Objective: To evaluate the effect of various training states (endurance-trained vs untrained) on arterial compliance in individuals with chronic SCI of traumatic origin and in able-bodied individuals (matched for age, sex, height, and weight)., Setting: Tertiary rehabilitation center in Canada., Methods: Large and small artery compliance were measured at the radial artery and physical activity was assessed via questionnaire., Results: There was no significant difference in large artery compliance between groups. Small artery compliance was reduced markedly (5.8±3.1 ml mm Hg(-1) × 100) in untrained persons with SCI, in comparison to all other groups. Small artery compliance of endurance-trained individuals with SCI was slightly (4%) higher than that observed in the untrained able-bodied individuals (8.6±1.5 vs. 8.2±1.4 ml mm Hg(-1) × 100, respectively). Endurance-trained, able-bodied persons had greater small artery compliance (10.6±2.3 ml mm Hg(-1) × 100) in comparison to the all other groups., Conclusion: Endurance training is related to increased small artery compliance in able-bodied individuals and persons with SCI (who are matched for age, sex, height and weight). Endurance training may attenuate the decline in small artery compliance seen with SCI.

Objective: To develop a web-based educational resource for health professionals responsible for the management of spinal cord injury (SCI). The resource:www.elearnSCI.org is comprised of seven learning modules, each subdivided into various submodules. Six of the seven modules address the educational needs of all disciplines involved in comprehensive SCI management. The seventh module addresses prevention of SCI. Each submodule includes an overview, activities, self-assessment questions and references., Development of the Resource: Three hundred and thirty-two experts from The International Spinal Cord Society (ISCoS) and various affiliated societies from 36 countries were involved in developing the resource through 28 subcommittees. The content of each submodule was reviewed and approved by the Education and Scientific Committees of ISCoS and finally by an Editorial Committee of 23 experts., Key Features: The content of the learning modules is relevant to students and to new as well as experienced SCI healthcare professionals. The content is applicable globally, has received consumer input and is available at no cost. The material is presented on a website underpinned by a sophisticated content-management system, which allows easy maintenance and ready update of all the content. The resource conforms to key principles of e-learning, including appropriateness of curriculum, engagement of learners, innovative approaches, effective learning, ease of use, inclusion, assessment, coherence, consistency, transparency, cost effectiveness and feedback., Conclusion: www.elearnSCI.org provides a cost effective way of training healthcare professionals that goes beyond the textbook and traditional face-to-face teaching.

Background: During the past 20 years, significant advances in patient care have resulted in individuals with spinal cord injury (SCI) living longer than before. As lifespan increases, cardiovascular complications are emerging as the leading cause of mortality in this population, and individuals with SCI develop cardiovascular disease at younger ages than their able-bodied counterparts. To address this increasing clinical challenge, several recent studies investigated the central cardiovascular adaptations that occur following SCI. However, a somewhat less recognized component of cardiovascular dysfunction in this population is the peripheral vascular adaptations that also occur as a result of SCI., Study Design: Literature review., Objective: To present a comprehensive overview of changes in arterial structure and function, which occur after SCI., Setting: Canada., Methods: A systematic literature review was conducted to extract studies that incorporated measures of arterial structure or function after SCI in animals or humans., Results: Individuals with SCI exhibit vascular dysfunction below the lesion that is characterized by a reduction in conduit artery diameter and blood flow, increased shear rate and leg vascular resistance, and adrenoceptor hyper-responsiveness. There is also recent alarming evidence for central arterial stiffening in individuals with SCI., Conclusion: Although physical deconditioning is the primary candidate responsible for the maladaptive remodeling of the peripheral vasculature after SCI, there is emerging evidence that blood pressure oscillations, such as those occurring in the large majority of individuals with SCI, also exacerbates vascular dysfunction in this population.

Background: Although motor and sensory deficits following spinal cord injury (SCI) are well known, there are still contrasting reports on how SCI affects baseline cardiovascular (CV) parameters and other autonomic functions., Study Design: Meta-analysis is performed., Objectives: To examine the effect of injury level on supine and seated CV function in individuals with SCI., Methods: A total of 98 studies representing 1968 individuals were retrieved for analysis. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were abstracted from the studies and compared between four groups according to the neurological lesion level, cervical (C) SCI (C4-C8), high-thoracic (HT) SCI (T1-T6), low-thoracic lumbar (LTL) SCI (below T6) and able-bodied (AB) controls., Results: In the supine position, SBP, DBP and HR were lower in C compared with HT, LTL and AB (all P<0.04). In the seated position, SBP and DBP were significantly lower in C compared with LTL and AB (all P<0.003) and HR was significantly lower in C compared with LTL only (P=0.01). A final finding was that C exhibited a lower resting SBP in the seated compared with the supine position (P<0.001)., Conclusion: Individuals with SCI exhibit a lesion-dependent impairment in resting CV function, whereby those with the highest injury had the greatest degree of CV dysfunction. A further finding was that individuals with a C injury exhibited a lower resting SBP in the seated vs supine position. Thus, clinicians and researchers should consider lesion level and body position when measuring and interpreting CV parameters in individuals with SCI.

Objectives: To create an international spinal cord injury (SCI) skin and thermoregulation basic data set within the framework of the International SCI Data Sets., Setting: An international working group., Methods: The draft of the data set was developed by a working group comprising members appointed by the American Spinal Injury Association (ASIA), the International Spinal Cord Society (ISCoS) and a representative of the Executive Committee of the International SCI Standards and Data Sets. The final version of the data set was developed after review and comments by members of the Executive Committee of the International SCI Standards and Data Sets, the ISCoS Scientific Committee, ASIA Board, relevant and interested international organizations and societies, individual persons with specific interest and the ISCoS Council. To make the data set uniform, each variable and each response category within each variable have been specifically defined to promote the collection and reporting of comparable minimal data., Results: Variables included in the present data set are: date of data collection, thermoregulation history after SCI, including hyperthermia or hypothermia (noninfectious or infectious), as well as the history of hyperhidrosis or hypohidrosis above or below level of lesion. Body temperature and the time of measurement are included. Details regarding the presence of any pressure ulcer and stage, location and size of the ulcer(s), date of appearance of the ulcer(s) and whether surgical treatment has been performed are included. The history of any pressure ulcer during the last 12 months is also noted.

Objectives: To develop the International Spinal Cord Injury (SCI) Pulmonary Function Basic Data Set within the framework of the International SCI Data Sets in order to facilitate consistent collection and reporting of basic bronchopulmonary findings in the SCI population., Setting: International., Methods: The SCI Pulmonary Function Data Set was developed by an international working group. The initial data set document was revised on the basis of suggestions from members of the Executive Committee of the International SCI Standards and Data Sets, the International Spinal Cord Society (ISCoS) Executive and Scientific Committees, American Spinal Injury Association (ASIA) Board, other interested organizations and societies and individual reviewers. In addition, the data set was posted for 2 months on ISCoS and ASIA websites for comments., Results: The final International SCI Pulmonary Function Data Set contains questions on the pulmonary conditions diagnosed before spinal cord lesion,if available, to be obtained only once; smoking history; pulmonary complications and conditions after the spinal cord lesion, which may be collected at any time. These data include information on pneumonia, asthma, chronic obstructive pulmonary disease and sleep apnea. Current utilization of ventilator assistance including mechanical ventilation, diaphragmatic pacing, phrenic nerve stimulation and Bi-level positive airway pressure can be reported, as well as results from pulmonary function testing includes: forced vital capacity, forced expiratory volume in one second and peak expiratory flow. The complete instructions for data collection and the data sheet itself are freely available on the website of ISCoS (http://www.iscos.org.uk).

Objective: To develop the International Spinal Cord Injury (SCI) Endocrine and Metabolic Function Basic Data Set within the framework of the International SCI Data Sets that would facilitate consistent collection and reporting of basic endocrine and metabolic findings in the SCI population., Setting: International., Methods: The International SCI Endocrine and Metabolic Function Data Set was developed by a working group. The initial data set document was revised on the basis of suggestions from members of the Executive Committee of the International SCI Standards and Data Sets, the International Spinal Cord Society (ISCoS) Executive and Scientific Committees, American Spinal Injury Association (ASIA) Board, other interested organizations and societies, and individual reviewers. In addition, the data set was posted for 2 months on ISCoS and ASIA websites for comments., Results: The final International SCI Endocrine and Metabolic Function Data Set contains questions on the endocrine and metabolic conditions diagnosed before and after spinal cord lesion. If available, information collected before injury is to be obtained only once, whereas information after injury may be collected at any time. These data include information on diabetes mellitus, lipid disorders, osteoporosis, thyroid disease, adrenal disease, gonadal disease and pituitary disease. The question of gonadal status includes stage of sexual development and that for females also includes menopausal status. Data will be collected for body mass index and for the fasting serum lipid profile. The complete instructions for data collection and the data sheet itself are freely available on the websites of ISCoS (http://www.iscos.org.uk) and ASIA (http://www.asia-spinalinjury.org).

Objective: When someone suffers a spinal cord injury (SCI) many organs, including those of the cardiovascular (CV) system, cease to be controlled by the autonomic nervous system (ANS). Response to physical activity fails to meet the needs of the body and typically results in low blood pressure (BP), and in turn, reduced endurance and performance. This study examines the effect of SCI on the ANS of elite athletes and possible effect on their CV functions and ultimately their performance. The study also provides input on evidence of boosting and the current classification system. Finally, authors are exploring a possibility for future research in assessing whether consideration of ANS function would strengthen current Paralympic classification systems., Study Design: MEDLINE, SportDiscus, Embase databases and the official Paralympic website were reviewed. In total, 60 manuscripts and five website documents were reviewed., Result: Athletes with high-level SCI affecting the ANS have limited ability to regulate their heart rate and BP in response to exercise. According to current Paralympic classification systems, these athletes are grouped with competitors who have similar motor control but intact ANS, thereby potentially putting them at a disadvantage within their own classification category. High-level SCI athletes with ANS dysfunction are also the only athletes who experience episodes of autonomic dysreflexia (AD). Whereas AD is a state of uninhibited sympathetic discharge, it is called 'boosting' when intentionally induced during competition. Boosting has been shown to improve sporting performance but can also cause serious complications due to extreme rises in BP. Therefore, boosting has been banned by the International Paralympic Committee (IPC). Despite this ban some elite high-level SCI athletes continue to boost. The IPC recognizes that the current classification systems are not the gold standard and further work is needed to create a more evidence-based classification., Conclusions: Further research is needed to determine if the inclusion of ANS parameters contributes to strengthen classifications systems in Paralympic sports. This includes the development of a simple, valid and reliable bedside assessment of autonomic function that can be used to reliably compare athletes with or without ANS dysfunction thereby enabling further research into the isolated effect of ANS dysfunction on sporting performance. Researchers who are studying individuals with SCI, and who have CV parameters as their outcomes, should ensure a homogenous study group by the presence or absence of ANS function in addition to level of lesion so as to eliminate the potential for confounding variables that lead to inaccurate interpretation of results.

Study Design: A case report of a Guillain-Barré syndrome (GBS) variant presenting in a patient with a high cervical spinal cord injury (SCI)., Objectives: To illustrate a clinical presentation of GBS in an individual with chronic SCI., Setting: Vancouver General Hospital, Vancouver, BC, Canada., Methods/results: A 31-year-old man with chronic C2 AIS B (American Spinal Injury Association Impairment Scale) SCI and diaphragmatic pacing presented with respiratory failure with sepsis. His sepsis resolved with antibiotic therapy, but he continued to have autonomic instability and was unable to be weaned off his ventilator. Concurrently he developed flaccidity and facial diplegia. Investigations including nerve conduction studies and cerebrospinal fluid analysis prompted a diagnosis of acute motor-sensory axonal neuropathy, a variant of Guillian-Barré syndrome. Owing to ongoing autonomic instability, he was treated with intravenous immunoglobulin. His autonomic dysfunction resolved and he regained some facial muscle function, but 6 months post injury he remained dysphagic and required 24-h ventilator support., Conclusion: Careful neurological reassessment prompted the diagnosis of acute polyradiculoneuropathy following respiratory sepsis as the root cause of diaphragmatic pacer failure and autonomic instability.

Objective: To provide recommendations regarding translation and reliability testing of International Spinal Cord Injury (SCI) Data Sets., Setting: The Executive Committee for the International SCI Standards and Data Sets., Recommendations: Translations of any specific International SCI Data Set can be accomplished by translation from the English version into the target language, and be followed by a back-translation into English, to confirm that the original meaning has been preserved. Another approach is to have the initial translation performed by translators who have knowledge of SCI, and afterwards controlled by other person(s) with the same kind of knowledge. The translation process includes both language translation and cultural adaptation, and therefore shall not be made word for word, but will strive to include conceptual equivalence. At a minimum, the inter-rater reliability should be tested by no less than two independent observers, and preferably in multiple countries. Translations must include information on the name, role and background of everyone involved in the translation process, and shall be dated and noted with a version number., Conclusion: By following the proposed guidelines, translated data sets should assure comparability of data acquisition across countries and cultures. If the translation process identifies irregularities or misrepresentation in either the original English version or the target language, the working group for the particular International SCI Data Set shall revise the data set accordingly, which may include re-wording of the original English version in order to accomplish a compromise in the content of the data set.

Introduction: Similarities between the clinical presentation of individuals living with spinal cord injury (SCI) and astronauts are remarkable, and may be of great interest to clinicians and scientists alike., Objectives: The primary purpose of this review is to outline the manner in which cardiovascular, musculoskeletal, renal, immune and sensory motor systems are affected by microgravity and SCI., Methods: A comprehensive review of the literature was conducted (using PubMed) to evaluate the hallmark symptoms seen after spaceflight and SCI. This literature was then examined critically to determine symptoms common to both populations., Results: Both SCI and prolonged microgravity exposure are associated with marked deteriorations in various physiological functions. Atrophy in muscle and bone, cardiovascular disturbances, and alterations in renal, immune and sensory motor systems are conditions commonly observed not only in individuals with SCI, but also in those who experience prolonged gravity unloading., Conclusion: The preponderance of data indicates that similar physiological changes occur in both SCI and prolonged space flight. These findings have important implications for future research in SCI and prolonged space flight.

Study Design: Randomized-controlled trials (RCTs), prospective cohort, case-control, pre-post studies, and case reports that assessed pharmacological and non-pharmacological intervention for the management of the neurogenic bowel after spinal cord injury (SCI) were included., Objective: To systematically review the evidence for the management of neurogenic bowel in individuals with SCI., Setting: Literature searches were conducted for relevant articles, as well as practice guidelines, using numerous electronic databases. Manual searches of retrieved articles from 1950 to July 2009 were also conducted to identify literature., Methods: Two independent reviewers evaluated each study's quality, using Physiotherapy Evidence Database scale for RCTs and Downs and Black scale for all other studies. The results were tabulated and levels of evidence assigned., Results: A total of 2956 studies were found as a result of the literature search. On review of the titles and abstracts, 57 studies met the inclusion criteria. Multifaceted programs are the first approach to neurogenic bowel and are supported by lower levels of evidence. Of the non-pharmacological (conservative and non-surgical) interventions, transanal irrigation is a promising treatment to reduce constipation and fecal incontinence. When conservative management is not effective, pharmacological interventions (for example prokinetic agents) are supported by strong evidence for the treatment of chronic constipation. When conservative and pharmacological treatments are not effective, surgical interventions may be considered and are supported by lower levels of evidence in reducing complications., Conclusions: Often, more than one procedure is necessary to develop an effective bowel routine. Evidence is low for non-pharmacological approaches and high for pharmacological interventions.

Study Design: A case report of silent myocardial ischemia in a man with C5 AIS A (American Spinal Injury Association Impairment Scale) tetraplegia during an episode of autonomic dysreflexia (AD)., Objective: The aim of this study was to show a clinical presentation of myocardial ischemia in individuals with spinal cord injury (SCI)., Case Report: A 45-year-old man with chronic C5 complete SCI presented with an episode of uncontrolled AD. He denied any symptoms of typical myocardial ischemia. Despite initiation of the AD management protocol, his blood pressure remained elevated. Additional testing revealed an unexpected horizontal ST depression in the lateral leads with a significant elevation of troponins. A follow-up cardiac angiography and MIBI cardiac perfusion scan revealed normal left ventricular contractility and no evidence of coronary artery occlusion., Conclusions: In individuals with SCI, the loss of sensory input from the myocardium to supraspinal structures predisposes them to asymptomatic myocardial ischemia. Furthermore, during an episode of AD, a significant increase in visceral sympathetic activity with coronary artery constriction can result in myocardial ischemia, even in the absence of coronary artery disease.

Objective: To create an International Spinal Cord Injury (SCI) Cardiovascular Function Basic Data Set within the framework of the International SCI Data Sets., Setting: An international working group., Methods: The draft of the data set was developed by a working group comprising members appointed by the American Spinal Injury Association (ASIA), the International Spinal Cord Society (ISCoS) and a representative of the executive committee of the International SCI Standards and Data Sets. The final version of the data set was developed after review by members of the executive committee of the International SCI Standards and Data Sets, the ISCoS scientific committee, ASIA board, relevant and interested international organizations and societies, individual persons with specific interest and the ISCoS Council. To make the data set uniform, each variable and each response category within each variable have been specifically defined in a way that is designed to promote the collection and reporting of comparable minimal data., Results: The variables included in the International SCI Cardiovascular Function Basic Data Set include the following items: date of data collection, cardiovascular history before the spinal cord lesion, events related to cardiovascular function after the spinal cord lesion, cardiovascular function after the spinal cord lesion, medications affecting cardiovascular function on the day of examination; and objective measures of cardiovascular functions, including time of examination, position of examination, pulse and blood pressure. The complete instructions for data collection and the data sheet itself are freely available on the websites of both ISCoS (http://www.iscos.org.uk) and ASIA (http://www.asia-spinalinjury.org).

Study Design: Review by the spinal cord outcomes partnership endeavor (SCOPE), which is a broad-based international consortium of scientists and clinical researchers representing academic institutions, industry, government agencies, not-for-profit organizations and foundations., Objectives: Assessment of current and evolving tools for evaluating human spinal cord injury (SCI) outcomes for both clinical diagnosis and clinical research studies., Methods: a framework for the appraisal of evidence of metric properties was used to examine outcome tools or tests for accuracy, sensitivity, reliability and validity for human SCI., Results: Imaging, neurological, functional, autonomic, sexual health, bladder/bowel, pain and psychosocial tools were evaluated. Several specific tools for human SCI studies have or are being developed to allow the more accurate determination for a clinically meaningful benefit (improvement in functional outcome or quality of life) being achieved as a result of a therapeutic intervention., Conclusion: Significant progress has been made, but further validation studies are required to identify the most appropriate tools for specific targets in a human SCI study or clinical trial.

Study Design: A case report of a patient with spinal cord injury with autonomic dysreflexia and associated acute neurogenic pulmonary edema., Objective: To further describe autonomic dysreflexia as a potential cause of acute neurogenic pulmonary edema; specifically in a population with spinal cord injury., Setting: James A Haley Veterans Hospital, Tampa, FL, USA., Methods: A patient with a prior history of C5 AIS (ASIA impairment scale) B spinal cord injury was admitted for bowel preparation before a screening colonoscopy. During the 2-day bowel preparation, the patient developed severe autonomic dysreflexia. Due to persistent hypertension and acute onset respiratory failure, he required transfer to the intensive care setting., Results: Following a complicated course, the patient expired without a definitive cause of death. Autopsy findings showed gross and microscopic evidence of pulmonary edema., Conclusions: To date, the association between autonomic dysreflexia and acute neurogenic pulmonary edema is not described in the spinal cord or rehabilitation literature. The purpose of this case report is to further describe the overlooked and/or under reported incidence of acute neurogenic pulmonary edema associated with episodes of dysreflexia in a population with spinal cord injury.

Study Design: Self-report survey., Objective: To ascertain physiatrists' opinions and current practice patterns for bone health management after spinal cord injury (SCI)., Participants: Physiatrists who work in teaching rehabilitation centers in Canada., Methods: A 4-page 17-question survey (available in French and English) was sent to working physiatrists in all major Canadian SCI rehabilitation centers., Results: We had an 85% response rate (22 responses). Physiatrists reported that they should be managing bone health issues after SCI in conjunction with family physicians, and most respondents assess and treat for bone health after SCI. However, just over one-third of the physiatrists reported that the current treatment options are not effective for low bone mass; there was more support for pharmacological treatments than there was for rehabilitation modalities., Conclusion: Bone health after SCI is an important health concern that is being managed by physiatrists; however, more discussion and research is needed to ascertain the effectiveness of assessment and treatment options for low bone mass.

Study Design: Literature review., Objectives: To present a comprehensive overview of autonomic assessment in experimental spinal cord injury (SCI)., Methods: A systematic literature review was conducted using PubMed to extract studies that incorporated functional motor, sensory or autonomic assessment after experimental SCI., Results: While the total number of studies assessing functional outcomes of experimental SCI increased dramatically over the past 27 years, studies with motor outcomes dramatically outnumber those with autonomic outcomes. Within the areas of autonomic dysfunction (cardiovascular, respiratory, gastrointestinal, lower urinary tract, sexual function and thermoregulation), not all aspects have been characterized to the same extent. Studies focusing on bladder and cardiovascular function greatly outnumber those on sexual function, gastrointestinal function and thermoregulation. This review addresses the disparity between well-established motor-sensory testing presently used in experimental animals and the lack of standardized autonomic testing following experimental SCI. Throughout the review, we provide information on the correlation between existing experimental and clinically used autonomic tests. Finally, the review contains a comprehensive set of tables and illustrations to guide the reader through the complexity of autonomic assessment and dysfunctions observed following SCI., Conclusions: A wide variety of techniques exist to evaluate autonomic function in experimental animals with SCI. The incorporation of autonomic assessment as outcome measures in experiments testing treatments or interventions for SCI should be considered a high, clinically relevant priority.

Study Design: Experts opinions consensus., Objective: To develop a common strategy to document remaining autonomic neurologic function following spinal cord injury (SCI)., Background and Rationale: The impact of a specific SCI on a person's neurologic function is generally described through use of the International Standards for the Neurological Classification of SCI. These standards document the remaining motor and sensory function that a person may have; however, they do not provide information about the status of a person's autonomic function., Methods: Based on this deficiency, the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) commissioned a group of international experts to develop a common strategy to document the remaining autonomic neurologic function., Results: Four subgroups were commissioned: bladder, bowel, sexual function and general autonomic function. On-line communication was followed by numerous face to face meetings. The information was then presented in a summary format at a course on Measurement in Spinal Cord Injury, held on June 24, 2006. Subsequent to this it was revised online by the committee members, posted on the websites of both ASIA and ISCoS for comment and re-revised through webcasts. Topics include an overview of autonomic anatomy, classification of cardiovascular, respiratory, sudomotor and thermoregulatory function, bladder, bowel and sexual function., Conclusion: This document describes a new system to document the impact of SCI on autonomic function. Based upon current knowledge of the neuroanatomy of autonomic function this paper provides a framework with which to communicate the effects of specific spinal cord injuries on cardiovascular, broncho-pulmonary, sudomotor, bladder, bowel and sexual function.

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) x 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) x 100, P<0.05)., Conclusion: It appears that FES-LCE is effective in improving small artery compliance in females with SCI.

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, Canada., Methods: 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.