History, implementation, and current status of the National Spinal Cord Injury Database

Emergency evacuation readiness of full-time wheelchair users with spinal cord injury

OBJECTIVES

To determine the percentage of full-time wheelchair users with spinal cord injuries who felt they could evacuate from various locations, and the percentage who have a plan for evacuation. Study results will help clinicians and emergency officials understand needs related to evacuation preparedness.

DESIGN

Convenience sample survey.

SETTING

Six Spinal Cord Injury Model System centers, part of the national database funded through the Department of Education, National Institute on Disability and Rehabilitation Research.

PARTICIPANTS

People (N=487) with spinal cord injuries who use a wheelchair more than 40 hours a week.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The percentage of wheelchair users who felt they would be able to safely evacuate, had a plan for safe evacuation, or reported a need for assistive technology and human assistance to evacuate from various locations in the event of an emergency.

RESULTS

The highest percentage of participants felt they would be able to safely evacuate and had a plan for work evacuation. The lowest percentage of participants reported they could evacuate from their city/town in the event of an emergency and had a plan to evacuate their city/town in the event of a natural disaster. A large difference exists between the percentage of participants who felt they could evacuate and those who have a plan for evacuation.

CONCLUSIONS

A large discrepancy exists between the perception that one can evacuate and actually having a plan. The perception that one can evacuate without a plan or the use of assistive technology is an area of concern that must be further addressed by educators. Education must emphasize the need to have a defined evacuation plan and effective utilization of assistive technology.

Current research outcomes from the spinal cord injury model systems

This article serves as an introduction to this issue of the Archives of Physical Medicine and Rehabilitation that is devoted to current research findings of the Spinal Cord Injury Model Systems (SCIMS) program. The SCIMS program began in 1970, with funding from the National Institute on Disability and Rehabilitation Research in the U.S. Department of Education, to demonstrate a comprehensive care system for spinal cord injury (SCI) and also to conduct research to improve the health and quality of life of persons with SCI. Over the last 20 years, similar collaborative efforts for the dissemination of SCIMS research outcomes have produced conference proceedings in 1990, a book in 1995, and dedicated journal issues in 1999 and 2004. The collection of 24 articles in this issue shows the depth and breadth of work being carried out by the SCIMS investigators, from descriptive epidemiology to a randomized controlled trial, from neurologic recovery to community reintegration, and from health services utilization to assistive technology for mobility. Herein, we provide a brief overview of the SCIMS program, highlight the research initiatives currently underway, and describe the important findings of the original research articles contained in this issue.

Do communities matter after rehabilitation? The effect of socioeconomic and urban stratification on well-being after spinal cord injury

OBJECTIVE

To assess the influence of community-level socioeconomic status (SES) and urban composition on well-being after spinal cord injury (SCI) rehabilitation.

DESIGN

Retrospective analysis of cross-sectional survey data.

SETTING

Two participating centers in the SCI Model Systems (SCIMS) program.

PARTICIPANTS

Persons (N=1454) with traumatic SCI from New Jersey and Alabama enrolled in the SCIMS database in 2000 to 2009.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Dichotomous measures of perceived health (ill vs good health), life satisfaction (dissatisfied vs satisfied), and depressive symptoms (presence of a syndrome vs not) to assess well-being.

RESULTS

Multilevel logistic regression was used to model community effects on each indicator of well-being. The likelihood of ill health and dissatisfaction with life in people with SCI, but not depressive symptoms, varied across communities. Community SES was related inversely to the odds of reporting ill health. However, the odds for dissatisfaction were higher in persons with SCI living in high SES and urban communities. Associations between community predictors and dissatisfaction with life were sustained after controlling for individual differences in injury severity, SES, and demographics, whereas individual SES was a stronger predictor of ill health than community SES.

CONCLUSION

This research suggests that community stratification influences the likelihood for diminished well-being for persons with SCI after rehabilitation. Understanding the contribution of communities in long-term outcomes after SCI rehabilitation is needed to inform future interventions aimed at preventing disability in this population.

Future directions for spinal cord injury research: recent developments and model systems contributions

The authors look forward and discuss future directions in spinal cord injury (SCI) from a perspective of biomedical, psychosocial and technologic research. This discussion is based both on recent developments from various fields of knowledge and, more specifically, on SCI Model Systems' research contributions to medical rehabilitation. Biomedical research, as described here, includes (1) the process of moving from the "bench to bedside" and harnessing knowledge from basic science to produce new clinical treatment options for SCI during the life span; (2) the rapid proliferation of clinical trials aimed at neurologic recovery; (3) the growth of new technologies to restore and improve function; and (4) the challenges of developing relevant outcome measures to evaluate efficacy and effectiveness of interventions. Recent progress in psychosocial research has contributed significantly to understanding of the many factors associated with disability during the life course, the importance of quality of life issues, and the value of activity, participation, and the environment in promoting successful rehabilitation outcomes following SCI. Technology and bioengineering advances are discussed in relation to access to high-quality technology; restoration and replacement of movement; and technology to enhance rehabilitation outcomes.

Weight matters: physical and psychosocial well being of persons with spinal cord injury in relation to body mass index

OBJECTIVE

To examine the relationship of body mass index (BMI) with multiple health indices among persons with spinal cord injury (SCI).

DESIGN

Multicenter cross-sectional study.

SETTING

A total of 16 SCI Model Systems throughout the United States.

PARTICIPANTS

A total of 1107 men and 274 women (N=1381), mean age ± SD, 43.1±14.6 years (tetraplegia, 56.9%; complete injuries, 50.2%; mean years since injury ± SD, 7.8±8.6), who received follow-up in 2006 to 2009, were classified into 1 of the 4 BMI categories-underweight, normal, overweight, and obese-based on self-reported height and measured weight.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rehospitalization, pain, self-perceived health, FIM, Craig Handicap Assessment and Reporting Technique, Patient Health Questionnaire-9 (PHQ-9), and the Diener's Satisfaction With Life Scale (SWLS).

RESULTS

The prevalence of underweight, overweight, and obesity was 7.5%, 31.4%, and 22.1%, respectively, which varied by age, sex, marital status, education, and neurologic impairment. For those with tetraplegia and functional motor-complete injuries, rehospitalization occurred more frequently among obese persons, while days rehospitalized were the longest among underweight persons. Pain was more severe in those classified as obese. Community mobility was lower in the underweight, overweight, and obese groups than in those with normal weight. There was no significant association between BMI and self-perceived health, FIM, PHQ-9, and SWLS beyond the effect of neurologic impairment.

CONCLUSIONS

Prevention and intervention directed at those significantly overweight or underweight deserve consideration as priorities in the continuity of care for persons with SCI. Efforts should be targeted particularly to those at higher risk, including persons with more severe injuries, who are less educated, and who are living alone.

Spinal Cord Injuries and Disabilities: A Review

La lesión medular es una entidad neurológica causante de importantes procesos de discapacidad. Su incidencia en el país puede estar cercana a los mayores estimativos mundiales debido a las condiciones actuales de violencia. El aumento de la expectativa de vida de esta población —gracias a los avances tecnológicos y científicos en prevención, atención y manejo de complicaciones— lleva a la necesidad de proveer servicios de rehabilitación integrales que trasciendan los aspectos funcionales y permitan la inclusión social. Para este propósito es necesario un abordaje integral de la situación, que en el ámbito de la evaluación debe incluir no sólo la estimación de la condición de salud, sino todo lo relacionado con el funcionamiento de las personas en su vida diaria. La clasificación internacional del funcionamiento, la discapacidad y la salud, brinda un marco conceptual para abordar la discapacidad y el funcionamiento humano relacionado con la salud desde un enfoque biopsicosocial que articula las dimensiones corporal, individual y social de las personas y su relación con los factores del ambiente. Este enfoque de abordaje, plasmado en el instrumento de evaluación denominado WHO-DAS II, se considera un referente importante para evaluar la discapacidad asociada a la lesión medular.

Evaluating the quality of acute rehabilitation care for patients with spinal cord injury: an extended Donabedian model

OBJECTIVE

In this study, the researchers examined the quality of rehabilitation care for patients with spinal cord injury (SCI), using an extension of Donabedian's structure, process, outcome model that included environmental and patient characteristic.

METHODS

Cluster analysis, univariate variance analysis, and multilevel analysis were used to examine the quality of care for patients with SCI (N = 1974) enrolled in SCI Model Systems between 2000 and 2004.

RESULTS

Patients were classified into low-, intermediate-, and high-functioning groups on the basis of admission functional status profiles as measured by the Functional Independence Measure (FIM). Patient profiles and therapy received were found to be related to outcomes measured by FIM gain. Care structure measured by patient volume was found to be negatively associated with outcomes, but facility-level therapist-bed ratios were not related to FIM gain. Medicare Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) interacted with patient profiles influencing FIM gain.

CONCLUSION

The results from this study indicated a clear disconnection between the number of therapists and the amount of therapy delivered. This would suggest that potential inefficiency of therapy delivery due to the deployment and allocation of therapy services could be addressed by further consideration of patient profiles that reflect their specific needs and characteristics.

Epidemiological trends of spine and spinal cord injuries in the largest Canadian adult trauma center from 1986 to 2006

Object

In this study the author documents the epidemiology of spine and spinal cord injuries (SCIs) over 2 decades at the largest Level I adult trauma center in Canada. He describes the current state of spine injuries (SIs), their changing patterns over the years, and the relative distribution of different demographic factors in a defined group of trauma patients.

Methods

Data on all trauma patients admitted to Sunnybrook Health Sciences Centre between 1986 and 2006 were collected from the Sunnybrook Trauma Registry Database. Aggregate data on SIs and SCIs, including demographic information, etiology, severity of injuries (injury severity score [ISS]), and associated injuries, were recorded. The data were analyzed in a main category of spinal fracture and/or dislocation with or without SI and in two subgroups of patients with SIs, one encompassing all forms of SCIs and the other including only complete SCIs (CSCIs). Collected data were evaluated using univariate techniques to depict the trend of variables over the years. The number of deaths per year and the length of stay (LOS) were used as crude measures of outcome. Several multivariate analysis techniques, including Poisson regression, were used to model the frequency of death and LOS as functions of various trauma variables.

Results

There were 12,192 trauma patients in the study period with 23.2% having SIs, 5.4% having SCIs, and 3% having CSCIs. The SCIs constituted 23.3% of all SIs. The respective characteristics of the SI, SCI, and CSCI groups were as follows: median age 36, 33, and 30 years; median LOS 18, 27, and 29 days; median ISS 29, 30, and 34; female sex ratio 34, 24, and 23%; and case fatality rate 16.7, 16.6, and 21%. Seventy-nine percent of patients had associated head injuries; conversely, 24% of patients with head injuries had SIs. The mean admission age of patients increased by ~ 10 years over the study period, from the early 30s to the early 40s. The relative incidence of SIs remained stable at ~ 23%, but the incidence of SCIs decreased ~ 40% over time to 4.5%. Motor vehicle accidents remained the principal etiology of trauma, although falling and violence became more frequent contributors of SIs. The average annual ISS remained stable over time, but the LOS was reduced by 50% in both the SI and SCI groups. Age, ISS, and SCIs were associated with a longer LOS. The case fatality rate remained relatively unchanged over time. Poisson analysis suggested that the presence of an SCI does not change the case fatality rate.

Conclusions

Data in this analysis will provide useful information to guide future studies on changing SI patterns, possible etiologies, and efficient resource allocation for the management of these diseases.

Out-patient rehabilitation programme for spinal cord injured patients: Evaluation of the results on motor FIM score

PURPOSE

The aim of this study was to evaluate an out-patient attention programme based on a short in-patient phase followed by an out-patient interdisciplinary rehabilitation programme.

METHODS

A prospective quasi-experimental before-and-after study was carried out; a phase 2 trial. The study population consisted of 42 patients who met the inclusion criteria. The Functional Independence Measurement (FIM) was the main outcome, and the American Spinal Injury Association (ASIA) motor scores and morbidity the secondary ones. The intervention was a two-phase goal-based interdisciplinary programme which consisted of a hospital and an ambulatory phase. After an evaluation upon admission to hospital, follow-up was carried out 1, 3, 6, 12 and 18 months later.

RESULTS

Initially, 208 patients were evaluated and only 42 completed the study. The in-patient phase was short (average: 13.5 days) and the out-patient phase lasted 18 months. Motor FIM scores progressively increased from 25/91 up to 69/91 (p < 0.01). Some 25% of the patients had pressure sores at 1 month, and 11.9% still had them after 18 months. Pain was the most frequent complication, in 80% of patients by the third month. Urinary and fecal continence improved during follow-up (74% at 18 months and 81.1% at 12 months, respectively).

CONCLUSIONS

Good functional evolution of SCI patients and low morbidity can be obtained with a low-cost out-patient rehabilitation programme. Such a programme must emphasize patient and family education concerning self-care and possible SCI complications.

Sir Ludwig Guttmann Lecture: Trends in spinal cord injury rehabilitation outcomes from model systems in the United States: 1973–2006

STUDY DESIGN

Consecutive case series with 5-year follow-up.

OBJECTIVE

To evaluate the spinal cord injury (SCI) model systems program in the United States by documenting improvements in treatment outcomes over time.

SETTING

SCI model systems throughout the United States.

METHODS

Initial data were collected on 24 332 patients injured between 1973 and 2006. Follow-up data were collected on 9225 of these patients 5 years post-injury. All data were grouped by calendar year. Descriptive statistics included means and percentages. Multiple linear or logistic regression was used to assess outcome trends after adjusting for demographics and injury severity.

RESULTS

Acute care and rehabilitation lengths of stay declined dramatically over time (P<0.01). Mean functional independence measure motor score at discharge and gain during rehabilitation decreased, whereas gain per day increased (P<0.01). The probability of neurologic improvement from admission to discharge increased. Odds of medical complications decreased during in-patient treatment, but increased post-discharge (P<0.05). Rehospitalizations declined over time (P<0.01). Community integration improved. First year mortality rates improved, but longer term mortality rates showed no improvement since 1982.

CONCLUSIONS

Steady improvements have occurred for many treatment outcomes. Newer and more effective methods of prevention and treatment need to be developed to target those outcomes that have not improved and remain suboptimal.

Long-term survival after childhood spinal cord injury

OBJECTIVE

To determine whether persons who incur a spinal cord injury as children are at increased risk of mortality compared with persons injured as adults given comparable current age, sex, and injury severity.

METHODS

A total of 25,340 persons admitted to the National Spinal Cord Injury Statistical Center database or the National Shriners Spinal Cord Injury database who were not ventilator dependent and who survived more than 2 years after injury were included in this study. These persons contributed 274,020 person-years of data, with 3844 deaths, over the 1973-2004 study period. Data were analyzed using pooled repeated observations analysis of person-years. For each person-year the outcome variable was survival/mortality, and the explanatory variables included current age, sex, race, cause of injury, severity of injury, and age at injury (the focus of the current analysis).

RESULTS

Other factors being equal, persons who were less than 16 years of age at time of injury had a 31% (95% CI = 3%-65%) increase in the annual odds of dying compared with persons injured at older ages (P= 0.013). This increased risk did not vary significantly by current age, sex, race, injury severity, or era of injury (P > 0.05).

CONCLUSION

Life expectancy for persons injured as children appears to be slightly lower than that of otherwise comparably injured persons who suffered their injuries as adults. Nonetheless, persons who are injured young can enjoy relatively long life expectancies, ranging from approximately 83% of normal life expectancy for persons with minimal deficit incomplete injuries to approximately 50% of normal in high-cervical-level injuries without ventilator dependence.

Donald Munro Lecture. Spinal cord injury--past, present, and future

This special report traces the path of spinal cord injury (SCI) from ancient times through the present and provides an optimistic overview of promising clinical trials and avenues of basic research. The spinal cord injuries of Lord Admiral Sir Horatio Nelson, President James A. Garfield, and General George Patton provide an interesting perspective on the evolution of the standard of care for SCI. The author details the contributions of a wide spectrum of professionals in the United States, Europe, and Australia, as well as the roles of various government and professional organizations, legislation, and overall advances in surgery, anesthesia, trauma care, imaging, pharmacology, and infection control, in the advancement of care for the individual with SCI.

REVIEW OF TREATMENT TRIALS IN HUMANSPINAL CORD INJURY

OBJECTIVE

To provide a comprehensive review of the treatment trials in the field of spinal cord injury, emphasizing what has been learned about the effectiveness of the agents and strategies tested and the quality of the methodology. The review aims to provide useful information for the improvement of future trials. The review audience includes practitioners, researchers, and consumers.

METHODS

All publications describing organized trials since the 1960s were analyzed in detail, emphasizing randomized, prospective controlled trials and published Phase I and II trials. Trials were categorized into neuroprotection, surgery, regeneration, and rehabilitation trials. Special attention was paid to design, outcome measures, and case selection.

RESULTS

There are 10 randomized prospective control trials in the acute phase that have provided much useful information. Current neurological grading systems are greatly improved, but still have significant shortcomings, and independent, trained, and blinded examiners are mandatory. Other trial designs should be considered, especially those using adaptive randomization. Only methylprednisolone and thyrotropin-releasing hormone have been shown to be effective, but the results of the former are controversial, and studies involving the latter involved too few patients. None of the surgical trials has proven effectiveness. Currently, a multitude of cell-based Phase I trials in several countries are attracting large numbers of patients, but such treatments are unproven in effectiveness and may cause harm. Only a small number are being conducted in a randomized or blinded format. Several consortia have committed to a promise to improve the conduct of trials.

CONCLUSION

A large number of trials in the field of spinal cord injury have been conducted, but with few proven gains for patients. This review reveals several shortcomings in trial design and makes several recommendations for improvement.

International Spinal Cord Injury Core Data Set

STUDY DESIGN

Survey of expert opinion, feedback, and development of final consensus.

OBJECTIVE

Present the background, purpose, development process, and results for the International Spinal Cord Injury (SCI) Core Data Set.

SETTING

International.

METHODS

A committee of experts was established to select and define data elements to be included in an International SCI Core Data Set. A draft core data set was developed and disseminated to appropriate organisations for comment. All suggested revisions were considered, and a final version of the core data set was disseminated again for approval and adoption.

RESULTS

The core data set consists of 24 variables, including basic demographic characteristics, dates of admission and discharge from initial acute and rehabilitation care, cause of injury, place of discharge, presence of vertebral fractures and associated injuries, occurrence of spinal surgery, and measures of neurological and ventilator status.

CONCLUSION

Collection of the core data set should be a basic ingredient of all future studies of SCI to facilitate accurate description of patient populations and comparison of results across published studies from around the world.

Outcomes of outpatient visits for acute respiratory illness in veterans with spinal cord injuries and disorders

OBJECTIVE

Respiratory complications are a leading cause of death in persons with spinal cord injuries and disorders (SCI&D). We examined same-day and 60-day hospitalizations and 60-day mortality after acute respiratory illness (ARI) outpatient visits.

DESIGN

A longitudinal study was conducted of 8775 ARI visits in the Veterans Health Administration (VA) (October. 1997-September 2002) by persons with SCI&D. ARIs included upper respiratory infections (URI), acute bronchitis, pneumonia, and influenza (P&I).

RESULTS

URIs accounted for almost half of all (49%) visits. A total of 14.9% of patients with ARIs were hospitalized the same day; 30.8% were hospitalized within 60 days. Predictors of hospitalization included diagnosis of either P&I or acute bronchitis, comorbid illness, level of injury, age, and VA SCI center visit. Overall 60-day mortality was 2.9% but was 7.9% for pneumonia. Mortality was related to diagnosis (P&I: odds ratio [OR] = 9.80, 95% confidence interval [CI]: 6.27-13.33; acute bronchitis: OR = 2.00, 95% CI: 1.08-2.93), age (65+: OR = 3.96, 95% CI: 2.23-5.70), and comorbid conditions (OR = 1.94, 95% CI: 1.43-2.46).

CONCLUSIONS

P&I and acute bronchitis were associated with increased VA hospitalization and mortality rates. The case fatality rate for pneumonia is higher for SCI&D than the general population. Level of injury predicted hospitalization but not death. Efforts to improve prevention and treatment of ARIs in persons with SCI&D are needed.

Trends in life expectancy after spinal cord injury

OBJECTIVE

To investigate whether there have been improvements in survival after spinal cord injury (SCI) over time, both in the critical first 2 years after injury and in the longer term.

DESIGN

Pooled repeated observations analysis of person-years. For each person-year, the outcome variable is survival and mortality, and the explanatory variables include age, level and grade of injury, and calendar year (the main focus of the analyses). The method can be viewed as a generalization of proportional hazards regression.

SETTING

Model spinal cord injury systems and hospital SCI units across the United States.

PARTICIPANTS

Persons (N=30,822) admitted to a Spinal Cord Injury Model Systems facility a minimum of 1 day after injury. Only persons over 10 years of age and known not to be ventilator dependent were included. These persons contributed 323,618 person-years of data, with 4980 deaths, over the 1973 to 2004 study period.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Survival.

RESULTS

Other factors being equal, over the last 3 decades there has been a 40% decline in mortality during the critical first 2 years after injury. However, the decline in mortality over time in the post-2-year period is small and not statistically significant.

CONCLUSIONS

The absence of a substantial decline in mortality after the first 2 years postinjury is contrary to widely held impressions. Nevertheless, the finding is based on a large database and sensitive analytic methods and is consistent with previous research. Improvements in critical care medicine after spinal cord injury may explain the marked decline in short-term mortality. In contrast, although there have no doubt been improvements in long-term rehabilitative care, their effect in enhancing the life span of persons with SCI appears to have been overstated.

Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI

OBJECTIVE

To compare the efficacy of step training with body weight support on a treadmill (BWSTT) with over-ground practice to the efficacy of a defined over-ground mobility therapy (CONT) in patients with incomplete spinal cord injury (SCI) admitted for inpatient rehabilitation.

METHODS

A total of 146 subjects from six regional centers within 8 weeks of SCI were entered in a single-blinded, multicenter, randomized clinical trial (MRCT). Subjects were graded on the American Spinal Injury Association Impairment Scale (ASIA) as B, C, or D with levels from C5 to L3 and had a Functional Independence Measure for locomotion (FIM-L) score < 4. They received 12 weeks of equal time of BWSTT or CONT. Primary outcomes were FIM-L for ASIA B and C subjects and walking speed for ASIA C and D subjects 6 months after SCI.

RESULTS

No significant differences were found at entry between treatment groups or at 6 months for FIM-L (n = 108) or walking speed and distance (n = 72). In the upper motor neuron (UMN) subjects, 35% of ASIA B, 92% of ASIA C, and all ASIA D subjects walked independently. Velocities for UMN ASIA C and D subjects were not significantly different for BWSTT (1.1 +/- 0.6 m/s, n = 30) and CONT (1.1 +/- 0.7, n = 25) groups.

CONCLUSIONS

The physical therapy strategies of body weight support on a treadmill and defined overground mobility therapy did not produce different outcomes. This finding was partly due to the unexpectedly high percentage of American Spinal Injury Association C subjects who achieved functional walking speeds, irrespective of treatment. The results provide new insight into disability after incomplete spinal cord injury and affirm the importance of the multicenter, randomized clinical trial to test rehabilitation strategies.

Worklife after traumatic spinal cord injury

OBJECTIVE

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

DESIGN

Inception cohort study.

SETTING

Model SCI Care Systems throughout the United States.

PARTICIPANTS

20,143 persons enrolled in the National Spinal Cord Injury Statistical Center database since 1973.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURE

Postinjury employment rates and worklife expectancy.

RESULTS

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

CONCLUSIONS

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

Long-term survival of persons ventilator dependent after spinal cord injury

BACKGROUND/OBJECTIVE

Identify factors related to long-term survival, and quantify their effect on mortality and life expectancy.

SETTING

Model spinal cord injury systems of care across the United States.

STUDY DESIGN

Survival analysis of persons with traumatic spinal cord injury who are ventilator dependent at discharge from inpatient rehabilitation and who survive at least 1 year after injury.

METHODS

Logistic regression analysis on a data set of 1,986 person-years occurring among 319 individuals injured from 1973 through 2003.

RESULTS

The key factors related to long-term survival were age, time since injury, neurologic level, and degree of completeness of injury. The life expectancies were modestly lower than previous estimates. Pneumonia and other respiratory conditions remain the leading cause of death but account for only 31% of deaths of known causes.

CONCLUSIONS

Whereas previous research has suggested a dramatic improvement in survival over the last few decades in this population, this is only the case during the critical first few years after injury. There was no evidence for such a trend in the subsequent period.

Pressure ulcer prevalence in people with spinal cord injury: age-period-duration effects

OBJECTIVE

To examine age-period-duration patterns of the prevalence of pressure ulcers in community-residing people with spinal cord injury (SCI).

DESIGN

Multicenter cohort study.

SETTING

Nine Model Spinal Cord Injury Systems throughout the United States.

PARTICIPANTS

People with SCI (N=3361) injured between 1986 and 1995 and followed up thereafter on a yearly basis through 2002.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Physician-confirmed pressure ulcers of stage II or greater at the follow-up visits.

RESULTS

The multivariable generalized estimating equations model showed a significant trend toward increasing pressure ulcer prevalence in the recent years (1994-2002 vs 1984-1993: odds ratio=1.4; 95% confidence interval, 1.2-1.6) not explained by aging, years since injury, or demographic and clinical factors. The risk of pressure ulcers appeared to be steady during the first 10 years and increased 15 years postinjury. Pressure ulcers were more common among the elderly, men, African Americans, singles, subjects with education less than high school, unemployed, subjects with complete injury, and subjects with history of pressure ulcers, rehospitalization, nursing home stay, and other medical conditions. Injury cause and level had no significant effect.

CONCLUSIONS

These results highlight the need for research into factors that contribute to the increasing pressure ulcer prevalence.

Epidemiology of spinal cord injury in children and adolescents

OBJECTIVE

To describe the unique aspects of the epidemiology of pediatric-onset spinal cord injury (SCI).

METHODS

The characteristics of persons with SCI enrolled in either the Shriners Hospitals for Children SCI database or the National SCI Statistical Center database from 1973 through 2002 were evaluated based on age at time of injury (0-5 years, 6-12 years, 13-15 years, 16-21 years, and 22 years and older).

RESULTS

Males comprised a consistently decreasing proportion of new cases of SCI, ranging from 83% among persons between 16 and 21 years of age to only 51% among those aged 0 to 5 years. Among children and adolescents (under the age of 22), the proportion of SCI due to motor vehicle crashes was higher than in adults (22+ years). Sports, violence, and medical or surgical complications also accounted for a significantly greater proportion of SCI in teenagers (13-21 years) than in adults. Violence has become the leading cause of SCI among African American and Hispanic teenage males (13-21 years), whereas vehicular crashes are more common among African American and Hispanic men of older ages (22 years of age and above). Approximately one third of new cases of SCI in the youngest two age groups (0-5 years, 6-12 years) had cervical injuries compared with almost one half in the older age groups (age 13 and above). SCI was much more likely to be neurologically complete in younger persons (69% age 0-5 years vs 51% age > or = 16 years).

CONCLUSION

The pediatric-onset SCI population is heterogeneous and exhibits distinct epidemiologic characteristics both within the different pediatric age groups and with the adult-onset SCI population.

Cluster Analysis and Chronic Pain: An Empirical Classification of Pain Subgroups in a Spinal Cord Injury Sample

OBJECTIVE

To demonstrate the presence of homogeneous spinal cord injury (SCI) pain subgroups.

DESIGN

Prospective longitudinal design.

PARTICIPANTS

Persons with traumatic onset SCI (n = 1,334) with self-reported pain, pain interference, and depression.

OUTCOME MEASURES

Pain (Verbal Analogue Scale); Pain Interference (item from Short Form 12); Depression (Brief Patient Health Questionnaire).

RESULTS

Multivariate clustering indicated four SCI pain subgroups: (1) Low Pain (low pain intensity, pain interference, and depression); (2) Positive Adaptation to Pain (high pain intensity, low pain interference and depression); (3) Minimal Distress (high pain intensity, high pain interference, and low depression); and (4) Chronic Pain Syndrome (high pain intensity, pain interference, and depression).

CONCLUSIONS

Homogeneous SCI pain subgroups may be important for clinicians to consider in treatment planning and research.

Patterns of alcohol and substance use and abuse in persons with spinal cord injury: risk factors and correlates

OBJECTIVE

To investigate patterns of alcohol consumption and abuse and substance use among persons with spinal cord injury (SCI), relating these patterns to demographic and injury-related characteristics, as well as to key medical and psychosocial outcomes.

DESIGN

Retrospective cross-sectional.

PARTICIPANTS

Subjects with traumatic SCI (N=3041) with dates of injury between June 6, 1975, and June 23, 2002, who were interviewed between November 2000 and March 2003.

SETTING

Sixteen Model Spinal Cord Injury Systems participating in this collaborative study during the 2000-2005 grant cycle.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Alcohol consumption, substance use, CAGE questionnaire, Satisfaction With Life Scale, Craig Handicap Assessment Reporting Technique, and pain. Data were analyzed using chi-square tests, analysis of variance, analysis of covariance, and logistic regression models.

RESULTS

Fourteen percent of the subjects were classified as likely to have an alcohol abuse issue, based on the CAGE, and 11% reported using illegal drugs or prescription medications for nonmedical reasons. Demographic and injury characteristics were associated with alcohol consumption patterns, abuse, and substance use. At-risk drinkers and substance users tended to be younger, single, male, and less educated. Those who were CAGE positive and substance users reported more pain and lower satisfaction with life. Persons who drank without indication of problem drinking had superior occupation outcomes. Pressure ulcers were associated with substance use.

CONCLUSIONS

Alcohol abuse and substance use were related to a number of adverse outcomes. The specific role of drinking with increased work activity deserves further exploration.

Race, employment, and spinal cord injury

OBJECTIVES

To examine issues of employment and race for persons with spinal cord injury (SCI), by assessing the type of work that was being done before and after injury and by placing this in the context of patterns for the general population.

DESIGN

Retrospective, cross-sectional analysis.

SETTING

Centers funded as part of the federally sponsored Model Spinal Cord Injury Systems (MSCIS) Project.

PARTICIPANTS

Two samples: 5925 African Americans and whites with SCI who are part of the MSCIS and a subset of 577 people with SCI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographic information, occupational status, employment rate, job census codes, Craig Hospital Assessment and Reporting Technique-Short Form, and Satisfaction With Life Scale.

RESULTS

Racial disparities were found in employment rates before injury and at 1, 5, 10, 15, and 20 years after SCI. Differences were also found in the types of jobs that were held before SCI with patterns for participants similar to those of African Americans and whites in the general population. No differences were found in the types of jobs held by African Americans and whites with SCI at 1 year after injury. After injury, African Americans had lower economic self-sufficiency scores, regardless of employment status, and lower social integration scores among those who were not employed.

CONCLUSIONS

Racial disparities found in employment patterns among persons with SCI mirrored patterns among the general population.

Health status, community integration, and economic risk factors for mortality after spinal cord injury

OBJECTIVE

To examine the association of health, community integration, and economic status with subsequent mortality and life expectancy among persons with spinal cord injury.

DESIGN

Cohort study.

SETTING

Model Spinal Cord Injury Systems (MSCIS) hospitals.

PARTICIPANTS

A total of 5947 persons injured since 1973 who were enrolled in the National Spinal Cord Injury Database and who were still alive and received an annual evaluation from November 1995 through March 2002.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Mortality was determined by routine follow-up supplemented by information from the Social Security Death Index. A logistic regression model based on the full set of predictor variables was developed to estimate the chance of dying in any given year.

RESULTS

After adjusting for demographic characteristics and injury severity, health status indicators, measures of community integration, and economic status indicators all had relatively small but statistically significant effects (20%-70% increases) on the likelihood of dying during the next year. Inclusion of these factors may result in higher life expectancy estimates under highly favorable conditions.

CONCLUSIONS

Whereas previous reports of the MSCIS data have identified the life expectancies associated with a particular set of demographic (eg, age, gender) and injury-related characteristics (level and completeness of injury; ventilator dependence), the current analysis suggests that consideration of health, economic, and psychosocial factors may make computations of life expectancy more accurate.

A demographic profile of new traumatic spinal cord injuries: Change and stability over 30 years

OBJECTIVE

To evaluate epidemiologic trends in new spinal cord injuries (SCIs) in the United States over 3 decades.

DESIGN

Consecutive case series.

SETTING

Model Spinal Cord Injury Systems (MSCIS) facilities.

PARTICIPANTS

Persons (N=30,532) admitted to MSCIS facilities within 365 days of injury between 1973 and 2003, and enrolled in the National Spinal Cord Injury Database.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Data were collected at MSCIS admission and rehabilitation discharge. Variables included age, gender, race and ethnic group, year of injury, and level and extent of injury. Specific etiologies were grouped as motor vehicle collisions (MVCs), violence, falls, sports, and other. Demographic and injury severity trends were analyzed by year of injury groupings according to decades (1973-1979, 1980-1989, 1990-1999, 2000-2003.) Chi-square tests assessed statistical significance. One-way analysis of variance compared mean ages.

RESULTS

The male/female ratio remained fairly stable at 4:1, but the percentage of women increased slightly over time, especially from MVC etiologies ( P <.001). Over time, the mean age at injury increased significantly ( P <.001); it was 37.7+/-17.5 years in 2000-2003. The majority of cases were white (66.1%). Tetraplegia (54.1%) and complete injuries (55.6%) occurred more than paraplegia and incomplete injuries, respectively. MVCs (45.6%) remained the most common etiology; falls (19.6%) held the second position over violence (17.8%), except for the 1990-1999 period when the positions were reversed. Significantly increasing percentages of new injuries were seen for SCI due to automobile, motorcycle, bicycle, and all-terrain vehicle crashes, blunt object attacks, snow skiing, and medical and surgical mishaps.

CONCLUSIONS

Many previously seen SCI demographic trends continued into the 2000 decade.

Demographic and socioeconomic factors associated with disparity in wheelchair customizability among people with traumatic spinal cord injury

OBJECTIVES

To determine if a standard of care for wheelchair provision exists within the participating centers and if there is disparity in wheelchair customizability among the study sample.

DESIGN

Convenience sample survey.

SETTING

Thirteen Model Spinal Cord Injury Systems that provide comprehensive rehabilitation for people with traumatic spinal cord injury (SCI) and that are part of the national database funded through the US Department of Education.

PARTICIPANTS

A total of 412 people with SCI who use wheelchairs over 40 hours a week.

INTERVENTION

Survey information was obtained from subjects via telephone and in-person interviews and from the national database. Collected information included age, race, education, level of injury, and wheelchair funding source.

MAIN OUTCOME MEASURES

Number and type (manual or power) of wheelchairs. Wheelchair customizability as defined by design features (eg, adjustable axle position, programmable controls).

RESULTS

Ninety-seven percent of manual wheelchair users and 54% of power wheelchair users had customizable wheelchairs. No power wheelchair user received a wheelchair without programmable controls. Minorities with low socioeconomic backgrounds (low income, Medicaid/Medicare recipients, less educated) were more likely to have standard manual and standard programmable power wheelchairs. Older subjects were also more likely to have standard programmable power wheelchairs.

CONCLUSIONS

The standard of care for manual wheelchair users with SCI is a lightweight and customizable wheelchair. The standard of care for power wheelchairs users has programmable controls. Unfortunately, socioeconomically disadvantaged people were less likely to receive customizable wheelchairs.

Metric properties of the ASIA motor score: Subscales improve correlation with functional activities11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To apply item response theory (IRT) methods to neurologic and functional scales to determine the value of using American Spinal Injury Association (ASIA) motor subscores and ability estimates, rather than total ASIA motor scores, to predict motor FIM instrument scores.

DESIGN

Secondary analysis of prospectively collected data.

SETTING

Model Spinal Cord Injury Systems centers.

PARTICIPANTS

People with traumatic spinal cord injury (SCI) (N=4338) discharged from inpatient rehabilitation between January 1, 1994, and March 31, 2003.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Total discharge motor FIM scores, FIM subscale scores, and IRT-derived ability estimates of motor FIM scores.

RESULTS

Use of separate ASIA upper-extremity and lower-extremity motor scores improved prediction of motor FIM scores over that of total ASIA motor score (R(2) for motor FIM score, .71 vs .59). Use of IRT-based ability estimates derived by applying a 2-parameter graded response model to the raw scores, however, did not improve prediction of motor FIM scores above that of the ASIA motor subscale scores.

CONCLUSIONS

Consistent with the metric properties of the ASIA motor score, and with recent models of disablement, impairment in SCI is more accurately characterized by using separate ASIA upper- and lower-extremity motor scores than by using a single motor score. Use of subscores for impairment should improve prediction of functional abilities and enhance more complex models of disability.

Gender and minority differences in the pain experience of people with spinal cord injury11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated

OBJECTIVES

To examine gender and minority differences in the prevalence and severity of pain in people with traumatic-onset spinal cord injury (SCI) during follow-up, and to determine the relation of those differences to demographic characteristics, etiology of injury, and level and extent of the lesion.

DESIGN

Survey and analysis of cross-sectional data using case-control methodology and multiple regression methods.

SETTING

Model Spinal Cord Injury Systems (MSCIS).

PARTICIPANTS

A total of 7379 individuals with traumatic-onset SCI from 16 MSCIS entered in the National Spinal Cord Injury Statistical Center database between 1998 and 2002.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prevalence and severity of pain as reported in follow-up surveys.

RESULTS

Pain prevalence remained fairly stable over time, ranging from 81% at 1 year postinjury to 82.7% at 25 years. Pain was no more common in women than in men, nor did pain severity scores differ significantly. However, pain prevalence was significantly lower among nonwhites, although they tended to report a higher average pain severity score when pain was present. Also, people with SCI who were employed when injured, who had more than a high school education, and who were not tetraplegic reported a higher prevalence of pain. Pain interfered with work more often for women and nonwhites during some, but not all, follow-up years, and for those who were not employed at the time of interview, for those whose SCI was caused by violence, for those with paraplegia, and for those with incomplete SCI.

CONCLUSIONS

Pain is a common and significant problem for the majority of people with SCI. It may interfere less frequently with work over time, which suggests that an adaptive process may be occurring. Gender differences in the pain experience did not emerge, but nonwhites tended to have a lower prevalence of pain. If pain was present, nonwhites tended to report more severe pain than did whites. Further research is needed to delineate the possible psychosocial and biomedical causes of these findings.

An Italian survey of traumatic spinal cord injury. The Gruppo Italiano Studio Epidemiologico Mielolesioni study11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVE

To describe the etiology, clinical presentation, complications, outcome indicators, and links between emergency and acute intervention and rehabilitation of patients with traumatic spinal cord injury (SCI).

DESIGN

Multicenter prospective study involving patients with SCI discharged, after rehabilitative care, between February 1, 1997, and January 31, 1999.

SETTING

Thirty-two Italian hospitals involved in SCI rehabilitation.

PARTICIPANTS

Six hundred eighty-four patients with traumatic SCI on their first admission to a rehabilitation center.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Neurologic improvement (NI), bladder autonomy, feelings of dependency, and destination were evaluated on discharge. Pressure ulcers on admission, time from injury to admission, and length of stay (LOS) were considered as indirect measures of the effectiveness of the health system.

RESULTS

Traumatic etiology had a male-to-female ratio of 4:1 (548:136). Collision on the road was the main cause of traumatic injury (53.8%). Mean time from injury to admission was 36.8 days; 126 patients (18%) were admitted within the first week after injury. Mean LOS was 135.5 days. In 184 patients (26.9%), a pressure ulcer was present on admission. On discharge, NI was recorded in 179 patients (26.2%), whereas 446 (65%) and 418 (61%) had bladder and bowel autonomy, respectively, and 560 (81.9%) returned home. In the multivariate analysis, independent variables predicting poor outcome (NI, feelings of dependency, sphincter autonomy, discharge to home, LOS) were related both to the lesion (completeness, cervical involvement) and to the indicators of health service organization (time from injury to admission, complications on admission and during stay).

CONCLUSIONS

Our focus on the etiology of traumatic SCI showed that efforts should be made to prevent collisions on the road. Our study also highlights problems in the comprehensive management of patients with SCI in Italy. Better organization could help reduce the time from injury to admission, the number of complications on admission, and LOS, and it could help improve rehabilitation outcome.

Methods for a randomized trial of weight-supported treadmill training versus conventional training for walking during inpatient rehabilitation after incomplete traumatic spinal cord injury

The authors describe the rationale and methodology for the first prospective, multicenter, randomized clinical trial (RCT) of a task-oriented walking intervention for subjects during early rehabilitation for an acute traumatic spinal cord injury (SCI). The experimental strategy, body weight-supported treadmill training (BWSTT), allows physical therapists to systematically train patients to walk on a treadmill at increasing speeds typical of community ambulation with increasing weight hearing. The therapists provide verbal and tactile cues to facilitate the kinematic, kinetic, and temporal features of walking. Subjects were randomly assigned to a conventional therapy program for mobility versus the same intensity and duration of a combination of BWSTT and over-ground locomotor retraining. Subjects had an incomplete SCI (American Spinal Injury Association grades B, C, and D) from C-4 to T-10 (upper motoneuron group) or from T-11 to L-3 (lower motoneuron group). Within 8 weeks of a SCI, 146 subjects were entered for 12 weeks of intervention. The 2 single-blinded primary outcome measures are the level of independence for ambulation and, for those who are able to walk, the maximal speed for walking 50 feet, tested 6 and 12 months after randomization. The trial's methodology offers a model for the feasibility of translating neuroscientific experiments into a RCT to develop evidence-based rehabilitation practices.

Pediatric spinal cord injury in Sweden: incidence, etiology and outcome

STUDY DESIGN

Retrospective descriptive study.

OBJECTIVES

To assess incidence, causes and early outcome of traumatic spinal cord injury (SCI) among children in Sweden, thereby identifying high-risk groups and situations as a basis for preventative measures and improved care.

METHODS

Data from population registers, County Habilitation Centers as well as from informal sources were used to estimate the incidence of SCI in Sweden during the years 1985-1996 among children aged 0-15 years. Contacts with the treating hospitals, reviews of medical records and/or personal interviews were used to verify primary data. In total, 92 children were thus identified.

RESULTS

The incidence was found to be 4.6/million children/year (95% CI 3.6-5.5). When excluding prehospital fatalities, the incidence was 2.4 (95% CI 1.8-3.1). The main cause of injury among fatalities was traffic accidents. Associated injuries occurred in 41% of the children. Among survivors (10-15 years), sports-related injuries (43%) were as common a cause as traffic accidents (39%). The survivors were treated in 18 different hospitals.

CONCLUSION

Pediatric SCI in Sweden is rare, presumably because of effective primary prevention. Preventative measures should be further differentiated for each age group of children in accordance with their differing risk profiles. In contrast to the effective preventative measures that have been implemented in Sweden, care of these patients is still too fractionated and decentralized for sufficient specialization to emerge.

Predictors of personal care assistance for people with spinal cord injury

OBJECTIVE

To assess the predictors of personal care assistance (PCA) use in people with spinal cord injury (SCI).

DESIGN

Cross-sectional.

SETTING

Follow-up of individuals crossing their 1st, 5th, 10th, 15th, 20th, or 25th anniversary of injury who underwent their initial rehabilitation at a Spinal Cord Injury Model Systems center.

PARTICIPANTS

A total of 2154 participants (2547 records) who met the inclusion criteria for the National Spinal Cord Injury Database and had valid values for the main outcome measures.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily hours of paid, unpaid, and occasional PCA services.

RESULTS

Differences in an interval version of the motor portion of the FIM trade mark instrument accounted for 26.3% of the variance in total PCA hours, Model Systems differences accounted for 9.3%, and no other predictor accounted for more than 2.1% of the variance.

CONCLUSION

Activities of daily living functioning, as measured by the motor portion of the FIM, was the strongest predictor of PCA use among people with SCI.

Measurements and recovery patterns in a multicenter study of acute spinal cord injury

STUDY DESIGN

Post hoc, secondary analysis of data from 1992 to 1998 in the trial of Sygen in acute spinal cord injury.

OBJECTIVES

Quasi-epidemiologic understanding of measurement tools and of recovery patterns. No drug efficacy results.

SUMMARY OF BACKGROUND DATA

Many authors have studied individual scales for measuring the severity of spinal cord injury.

METHODS

Emphasis on descriptive, rather than inferential, statistics: consistent with secondary analysis.

RESULTS

Of the 760 patients, 43 died within 365 days. The rate was higher for complete injuries (7.1% vs. 3.2%, P = 0.017). Marked recovery at 26 weeks was more frequent in those with better baseline American Spinal Injury Association (ASIA) Impairment Scale (AIS) scores, but was not different for methylprednisolone within versus after 3 hours. Light touch scores improved at each visit, more so in those with higher scores at baseline. Bladder control similarly improved. Motor and sensory scores exhibited departures from assumptions underlying normal-theory statistical techniques: t test and analysis of variance. Furthermore, they were mixtures of differing distributions from different study strata, so that overall conclusions depend on the mixture of patients seen.

CONCLUSIONS

The prognosis of these patients with spinal cord injury seen at 28 centers in North America during the mid-1990s appears better than was often assumed earlier. The general patterns are similar across different measurement scales, although there are intriguing differences. The patterns in different strata are different in specifics, and complete injuries do less well. Pooling data from different strata may result in probability distributions that depart from normal-theory assumptions and give misleading results depending on recruitment patterns.

Recruitment and early treatment in a multicenter study of acute spinal cord injury

STUDY DESIGN

Post hoc secondary analysis of data from 1992 to 1998 in the trial of Sygen in Acute Spinal Cord Injury.

OBJECTIVES

Quasi-epidemiologic understanding of injury and treatment patterns and of recruitment in an SCI trial. No drug efficacy results.

SUMMARY OF BACKGROUND DATA

The most recent large epidemiologic study was the National SCI Database by Stover and colleagues around 1980.

METHODS

Emphasis on descriptive, rather than inferential, statistics: consistent with secondary analysis.

RESULTS

The study involved 760 patients at 28 centers in North America. Cervical injuries were more common than thoracic, and complete injuries were more common than incomplete injuries. Recruitment in the complete cervical stratum was 332, but the incomplete thoracic strata had only 31 patients combined. Vital signs at arrival and on randomization show fair stability. Clock times show more injuries on weekends and nights but suggest immediate attention was given. Elapsed times to treatment (especially EMT and Medevac arrival) are short. The rate of direct admission to tertiary centers, traction weight, and time to surgery vary among centers. Inpatient rehabilitation appeared driven by insurance in addition to severity.

CONCLUSIONS

The imbalances in favor of cervical and of complete injuries would make it hard for studies to attain results for SCI in general. The vital signs and time patterns suggest local protocol-driven stabilization to prevent secondary physiologic injury early after SCI. Some features of care vary among centers, but the sparseness of prospective data in specific injury and treatment categories suggests that treatment guidelines have limited empirical support and should be made cautiously.

Epidemiology of extraspinal fractures associated with acute spinal cord injury

STUDY DESIGN

A descriptive study of concurrent extraspinal fractures collected prospectively during initial hospital care.

OBJECTIVES

To examine the frequency and related characteristics of concurrent extraspinal fractures among patients with a new onset of spinal cord injury (SCI).

SETTING

Model SCI care systems throughout the United States.

METHODS

A consecutive sample of 5711 subjects admitted to the National SCI Database between 1986-1995 was recruited to estimate the incidence of extraspinal fractures associated with acute SCI, stratified by anatomic sites, demographics, and injury related characteristics.

RESULTS

Of 5711 subjects, 1585 (28%) patients had extraspinal fractures; 580 (37%) patients had more than one fracture site. The most common region of fractures was chest, followed by lower extremity, upper extremity, head, others, and pelvis. The overall incidence rate was higher for women than men, for whites than non-whites, for paraplegics than tetraplegics, and for those injured in motor vehicle crashes than others. Compared with patients having single fracture, those who had multiple fractures were likely to be white, paraplegic, and injured in motor vehicle crashes. There was no age difference in the incidence of concurrent fractures, single or multiple.

CONCLUSIONS

Extraspinal fractures are not uncommon at the same time as SCI. The fracture occurrence varies by gender, race, injury level, and etiology of injury. The knowledge of these associated factors will aid in early recognition of fractures, preventing complications, and facilitating rapid mobilization and rehabilitation outcomes among persons with SCI.

Bladder stone incidence in persons with spinal cord injury: determinants and trends, 1973-1996

OBJECTIVES

To examine the current trend in the incidence of an initial bladder stone and the potential contributing factors among persons with spinal cord injury.

METHODS

A longitudinal cohort of 1336 patients with spinal cord injury who were injured between 1973 and 1996 and followed up on a yearly basis up to 1999 in a single institution was used to estimate bladder stone incidence. Multivariable analysis was performed to identify risk factors for an initial bladder stone.

RESULTS

During the study period, 229 incident bladder stone cases were documented. It is estimated that for those injured in 1973 to 1979, 1980 to 1984, 1985 to 1989, and 1990 to 1996, the 5-year cumulative incidence rate of an initial bladder stone was 29%, 23%, 14%, and 8%, respectively (P <0.0001). This decreasing trend was consistent for various demographic and clinical characteristics. During the first year after injury only, the bladder stone risk increased with decreasing age (P <0.0001) and was greater for whites. A neurologically complete lesion was associated with an increased bladder stone risk in later years (P = 0.008). Males and persons with indwelling and intermittent catheters had a higher risk during all the years after the injury.

CONCLUSIONS

With improvement in urologic rehabilitation, bladder stone incidence has declined during the past several decades. The study results, however, suggest that new strategic interventions may be required to further prevent stone occurrence in individuals with spinal cord injury and a complete neurologic lesion who are using indwelling catheterization, because these patients are still at a relatively higher risk.

Development of computer-based environment for simulating the voluntary upper-limb movements of persons with disability

Upper-limb orthotic systems have been designed for restoring the upper-limb functions of individuals with disabilities resulting from spinal cord injury (SCI), stroke and muscular dystrophy. These systems employ either functional electrical stimulation or external power. It is proposed that, instead of time-consuming and complicated monitoring using sensors and motion analysis, a software simulator with both angular displacement and acceleration parameters can facilitate the design of a control strategy for an orthosis. Reaching movements of three cervical SCI subjects are used to verify the simulator. A motion analysis system is used to measure the range of motion and joint angles during hand reaching. Results indicate that quaternion and spline curve techniques are suitable for interpolation of the hand reaching movements. The information needed for good simulation only compress the shoulder and elbow joint angles in a few key postures. Stimulated acceleration signals on the upper-arm segment have a high correlation coefficient (> 0.9) and a small root mean squared error (< 0.11 g) with a real bi-axial accelerometer.

A model of outcomes research: spinal cord injury

OBJECTIVE

To use spinal cord injury (SCI) care and research as a paradigm to illustrate how the principles and practices of outcomes research have been and can be applied to the sequelae of a specific disability.

DATA SOURCES

Review of data sources and literature pertaining to outcomes of SCI.

STUDY SELECTION

English language literature, health status and health services research agencies, academic and governmental research, and surveillance settings.

DATA EXTRACTION

A critical review of measures that have been and may be used to measure the outcomes of SCI. Special attention was paid to data sources; the need for methodologic accommodations: the research balance between generic and condition-specific methods; and the measurement outcomes that are highly relevant to people with SCIs.

DATA SYNTHESIS

There is a substantial research record related to the natural history, rehabilitation, survival, and long-term social reintegration of people with SCI, but relatively less addressing widely used generic health outcomes.

CONCLUSION

Contemporary outcomes research is relevant to people with SCI and those who provide treatment. One area of special attention is the occurrence of secondary conditions. To a large extent, SCI outcomes research can use conventional methods and generic instruments. There also is a need to modify research methods and to refine and apply some measures specific to people with SCI.

Model Spinal Cord Injury System trends, and implications for the future

In the 25 years since the federally designated Model Spinal Cord Injury Systems program was started, many changes have occurred. The systems have increased in number and location and have changed in composition. Data are available on approximately 19,000 acutely injured traumatic spinal cord injured individuals, with more than 117,000 total records. This volume of data allows analysis of many trends affecting the care of people with spinal cord injuries. The time span covered by the database allows comparison of various time periods, including the most recent decade--during which managed care has emerged as a dominant force in health care evolution. This article summarizes these trends, based on information in the articles in this special issue devoted to the Model Spinal Cord Injury Systems. Finally, this article offers an analysis of future implications for SCI care in general and the federally designated Model Spinal Cord Injury Systems program in particular.