Functional recovery measures for spinal cord injury: an evidence-based review for clinical practice and research

A new grading for easy and concise description of functional status after spinal cord lesions

BACKGROUND

Disability scales do not enable the transmission of concise, meaningful and daily function description for clinical purposes.

STUDY DESIGN

Cross-sectional statistical analysis of 328 patients' Spinal Cord Independence Measure (SCIM) III item scores (SIS).

OBJECTIVE

To develop a concise and clinically interpretable data-based characterization of daily task accomplishment for patients with spinal cord lesions (SCLs).

SETTING

Multi-center study at 13 spinal units in 6 countries.

METHODS

Patients were grouped into clusters characterized by smaller differences between the patients' SIS within the clusters than between their centers, using the k-medoides algorithm. The number of clusters (k) was chosen according to the percent of SIS variation they explained and the clinical distinction between them.

RESULTS

Analysis showed that k=8 SIS clusters offer a good description of the patient population. The eight functional clusters were designated as A-H, each cluster (grade) representing a combination of task accomplishments. Higher grades were usually (but not always) associated with patients implementing more difficult tasks. Throughout rehabilitation, the patients' functional grade improved and the distribution of patients with similar functional grades within the total SCIM III score deciles remained stable.

CONCLUSIONS

A new classification based on SIS clusters enables a concise description of overall functioning and task accomplishment distribution in patients with SCL. A software tool is used to identify the patients' functional grade. Findings support the stability and utility of the grades for characterizing the patients' functional status.

Age influences rehabilitative outcomes in patients with spinal cord injury (SCI)

BACKGROUND AND AIMS

To define differences in rehabilitative outcome after Spinal Cord Injury (SCI), according to age at injury.

METHODS

This is a prospective, observational, follow-up study. Completion of a questionnaire administered by a psychologist through a telephone interview to subjects discharged about 4 years previously from 22 SCI centers in Italy, who had already participated in a prospective multicenter study. A total of 403 out of 511 patients with SCI (79%), discharged between 1997 and 1999 after comprehensive rehabilitation in SCI centers, who gave their consent to a telephone interview. Main outcome measures are: number of re-admissions and medical consultations for clinical problems during follow-up (FU) period, clinical outcome related to bowel/ bladder function, family, sentimental and personal satisfaction, mobility, three-day autonomy, subjective feelings of dependency, subjective perception of quality of life.

RESULTS

The sample population was categorized into two subgroups according to severity on the Asia Spinal Injury Association (ASIA) scale by the ROC method: 276 subjects, the younger group were aged between 0 and 49 years, mean age 32 (±8 yrs), and 127 subjects in over 50 group, mean age 63 (±8 yrs). Differences in sample characteristics were found as regards cervical/dorsal lesion distribution and incompleteness of damage, more frequent in the older group. Incidence of hospital re-admissions and medical consultations, bladder autonomy, bowel autonomy and bowel continence were similar in both groups. Variables related to personal and social life, as well as life satisfaction, showed significant differences, with worse outcomes in the older group.

CONCLUSIONS

Age at injury deserves major attention, as persons not yet in geriatric age may show greater vulnerability after SCI.

Olfactory mucosal autografts and rehabilitation for chronic traumatic spinal cord injury

BACKGROUND/OBJECTIVE

Basic science advances in spinal cord injury (SCI) are leading to novel clinical approaches. The authors report a prospective, uncontrolled pilot study of the safety and outcomes of implanting olfactory mucosal autografts (OMA) in 20 patients with chronic, sensorimotor complete or motor complete SCI.

METHODS

Seven paraplegic and 13 tetraplegic subjects (17 men and 3 women; 19-37 years old) who sustained a traumatic SCI 18 to 189 months previously (mean = 49 months) were enrolled. Preoperative rehabilitation that emphasized lower extremity stepping using either overground walking training or a robotic weight-supported treadmill training was provided for 25 to 39 hours per week for a median of 4 months at 3 sites. No change in ASIA Impairment Scale (AIS) motor scores for the lower extremities or AIS grades of completeness was found. OMAs were transplanted into 1.3- to 4-cm lesions at C4-T12 neurological levels after partial scar removal. Therapy was continued postoperatively. Preoperative and postoperative assessments included AIS scores and classification, electromyography (EMG) of attempted voluntary contractions, somatosensory evoked potentials (SSEP), urodynamic studies with sphincter EMG, spinal cord magnetic resonance imaging (MRI), and otolaryngology and psychology evaluations. The Functional Independence Measure (FIM) and Walking Index for Spinal Cord Injury (WISCI) were obtained in 13 patients.

RESULTS

All patients survived and recovered olfaction. One patient was rehospitalized for aseptic meningitis. Minor adverse events occurred in 4 others. The mean duration of follow-up was 27.7 months (range = 12-45 months). By MRI, the lesion site was filled in all patients with no neoplastic overgrowth or syringomyelia. AIS grades improved in 11 of 20 patients, 6 (A --> C), 3 (B --> C), and 2 (A --> B), and declined in 1 (B --> A). Improvements included new voluntary EMG responses (15 patients) and SSEPs (4 patients). Scores improved in the FIM and WISCI (13/13 tested), and urodynamic responses improved in 5 patients.

CONCLUSION

OMA is feasible, relatively safe, and possibly beneficial in people with chronic SCI when combined with postoperative rehabilitation. Future controlled trials may need to include a lengthy and intensive rehabilitation arm as a control.

Modified Ashworth scale reliability for measurement of lower extremity spasticity among patients with SCI

STUDY DESIGN

Observational study.

OBJECTIVES

To report the intra-rater (one rater), inter-rater (two raters) and inter-session (one subject, sessions 1-5) reliability of lower extremity modified Ashworth scale (MAS) scores among patients with chronic spinal cord injury (SCI).

SETTING

Tertiary Academic Rehab Centre in Toronto, Canada.

METHODS

MAS scores of 20 subjects with chronic SCI (C5-T10 AIS A-D>12 months) were recorded for the hip abductors and adductors, knee flexors and extensors, and ankle plantar and dorsiflexors. MAS scores were assessed by two blinded raters (A and B) at the same time of day, weekly for 5 weeks using standardized test positions, a one-cycle per second metronome, with ratings recorded on the second cycle. MAS score reproducibility [intra-rater, inter-rater] were calculated using Cohen's Kappa. Intraclass correlation coefficients (ICCs) were calculated to determine inter-session (trials 1-5) reliability; Kappa values >or=0.81 and ICC values >or=0.75 were desired.

RESULTS

Intra-rater reliability was fair to almost perfect (0.2<kappa<1.0) and differed between raters. Inter-rater reliability was poor-to-moderate (kappa<0.6) for all muscle groups. Inter-session reliability for a single rater was fair-to-good (0.4<ICC<0.75) for all muscle groups.

CONCLUSIONS

MAS was not reliable as an intra-rater tool for all raters, and showed poor inter-rater and modest inter-session reliability. MAS has inadequate reliability for determining lower extremity spasticity between raters (inter-rater) or over time (inter-session). It is recommended that the rehabilitation science community seek alternative measures for quantifying spasticity.

Outcome measures in spinal cord injury: recent assessments and recommendations for future directions

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.