Long-term survival in spinal cord injury: a fifty year investigation

The longitudinal relationship between lipid profile and physical capacity in persons with a recent spinal cord injury

STUDY DESIGN

A multicenter prospective cohort study.

OBJECTIVE

To determine the longitudinal relationship between physical capacity and lipid profile in persons with spinal cord injury (SCI) during and 1 year after rehabilitation.

SETTING

Eight Dutch rehabilitation centers with a specialized SCI unit.

METHODS

A total of 206 subjects with SCI (78 with tetraplegia) participated. The longitudinal relationship between lipid profiles (total cholesterol (TC), high- (HDL) and low-density lipoprotein (LDL) and triglycerides (TG) and physical capacity (peak power output (POpeak), peak oxygen uptake (VO2peak), and muscle strength) was investigated during inpatient SCI rehabilitation (start, 3 months later, discharge) and 1 year after discharge. A correction was made for the possible confounding variables age, body mass index, gender, time since injury, lesion level and completeness.

RESULTS

HDL and the ratios LDL/HDL and TC/HDL showed a significant and favorable relationship with VO2peak, POpeak and muscle strength. TG was positively related to POpeak and muscle strength.

CONCLUSIONS

More favorable lipid profiles were seen in people with a higher physical capacity after correction for personal and lesion characteristics. Therefore, improving the physical capacity by being active during daily life or in sport may further improve the lipid profile and thus reduce the risk for coronary heart disease.

Effect of spinal cord injury on the respiratory system: basic research and current clinical treatment options

Spinal cord injury (SCI) often leads to an impairment of the respiratory system. The more rostral the level of injury, the more likely the injury will affect ventilation. In fact, respiratory insufficiency is the number one cause of mortality and morbidity after SCI. This review highlights the progress that has been made in basic and clinical research, while noting the gaps in our knowledge. Basic research has focused on a hemisection injury model to examine methods aimed at improving respiratory function after SCI, but contusion injury models have also been used. Increasing synaptic plasticity, strengthening spared axonal pathways, and the disinhibition of phrenic motor neurons all result in the activation of a latent respiratory motor pathway that restores function to a previously paralyzed hemidiaphragm in animal models. Human clinical studies have revealed that respiratory function is negatively impacted by SCI. Respiratory muscle training regimens may improve inspiratory function after SCI, but more thorough and carefully designed studies are needed to adequately address this issue. Phrenic nerve and diaphragm pacing are options available to wean patients from standard mechanical ventilation. The techniques aimed at improving respiratory function in humans with SCI have both pros and cons, but having more options available to the clinician allows for more individualized treatment, resulting in better patient care. Despite significant progress in both basic and clinical research, there is still a significant gap in our understanding of the effect of SCI on the respiratory system.

Open-heart operations in patients with a spinal cord injury

BACKGROUND

The objective of our study was to evaluate the outcomes of open-heart surgery in patients with a spinal cord injury.

METHODS

A retrospective analysis of all patients (n = 8) with a spinal cord injury who underwent open-heart operations in a single institution from April 1994 to November 2006 was conducted.

RESULTS

All patients had a permanent spinal cord injury with levels ranging from T3 to L2 with a mean age of 62 years (range, 47-72). Seven coronary artery bypass operations and 2 aortic valve replacements were performed. The mean cardiac ejection fraction was 44% (range, 20-60). Seventy-five percent of the patients were extubated within 24 hours of the operation. A decubitus ulcer occurred in only 1 patient. The acute hospital stay averaged 14 days (range, 6-36). One patient died from multiorgan failure on postoperative day 13 giving an in-hospital 30-day mortality of 12.5%. The 5-year survival was 75% with a mean follow-up of 67 months (range, .5-129).

CONCLUSIONS

Open-heart operations in patients with a spinal cord injury can be performed safely with acceptable early and late outcomes.

Long-term mortality following injury in working-age adults: a systematic review

Priorities for prevention activities and planning for services depend on comprehensive knowledge of the distribution of the injury-related burden in the community. The aim of this systematic review was to quantify the effect of being injured, compared with not being injured, on long-term mortality in working age adults. Cohort studies were selected that were population-based, measured mortality post-discharge from inpatient treatment, included a non-injured comparison group and related to working-age adults. Data synthesis was in tabular and text form with a meta-analysis not being possible because of the heterogeneity between studies. Eleven studies met the inclusion criteria. All studies found an overall positive association between injury and increased mortality. While the greatest excess mortality was evident during the initial period post-injury, increased mortality was shown in some studies to persist for up to 40 years after injury. Due to the limited number of injury types studied and heterogeneity between studies, there is insufficient published evidence on which to calculate population estimates of long-term mortality, where injury is a component cause. The review does suggest there is considerable excess mortality following injury that is not accounted for in current methods of quantifying injury burden, and is not used to assess quality and effectiveness of trauma care.

[Urinary tract infection and neurogenic bladder]

One of the main complications of spinal cord injury is neurogenic bladder when the bladder fails to empty spontaneously. Urinary tract infection is the leading cause of morbidity and the second cause of mortality in these subjects. Patient education and personalized medical follow-up must ensure adapted management depending on the risk factors and the voiding mode. The risk of urinary tract infection can be decreased by perfect neurological control of detrusor activity combined with a method of drainage: intermittent self-catheterization. Despite these measures, many patients experience recurrent symptomatic urinary tract infections. Repeated antibiotic therapy increases the risk of selection of multiresistant bacteria without reducing either the incidence or the severity of symptomatic urinary tract infections. Asymptomatic bacteriuria is very frequent in patients treated by intermittent catheterization and does not justify antibiotic therapy, as antiseptics and urinary alkalinizers or acidifiers have been shown to be effective. "Antibiocycle" strategies could have a beneficial role by significantly decreasing the number of infections and hospitalizations with no major ecological risks, by using molecules that are well tolerated orally with a low selection pressure. All febrile urinary tract infections require rapid investigation and an urgent urological and infectious diseases opinion (abscess, severe sepsis, resistance). The SPILF-AFU 2002 consensus conference provided answers to major questions concerning the definition, treatment and prevention of nosocomial urinary tract infection, especially in a context of neurogenic bladder.

Reliability of the clinical outcome variables scale when administered via telephone to assess mobility in people with spinal cord injury

OBJECTIVE

To examine the equivalence reliability and test-retest reliability of the Clinical Outcome Variables Scale (COVS) when administered via telephone (TCOVS) to people with spinal cord injury (SCI).

DESIGN

Equivalence (telephone administration vs in-person) and test-retest reliability study.

SETTING

Assessments conducted in participants' home environment.

PARTICIPANTS

Equivalence reliability was examined in a convenience sample of 37 people with a diagnosis of traumatic SCI who had been discharged from the Queensland Spinal Injuries Unit to the community. In a separate group of participants, test-retest reliability of COVS when administered via telephone was examined in 43 people with SCI who were randomly selected from the Queensland Spinal Cord Injuries Service records.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Reliability was assessed at the subscale and composite score level using intraclass correlation coefficients (ICC(2,1)) and Bland-Altman limits of agreement.

RESULTS

Reliability was good for TCOVS and COVS for the composite score (ICC=.98), mobility subscale (ICC=.97), and ambulation subscale (ICC=.99). Reliability was also good for TCOVS test and retest assessments for the composite score (ICC=1), mobility subscale (ICC=1), and ambulation subscale (ICC=1). For all comparisons, most data points were within the 95% limits of agreement and the width of limits of agreement were considered to be clinically acceptable.

CONCLUSIONS

The study findings confirm the equivalence and test-retest reliability of the TCOVS in an SCI population when administered by trained raters.

Reliability and validity of the six-minute arm test for the evaluation of cardiovascular fitness in people with spinal cord injury

OBJECTIVES

To design a submaximal arm ergometry test (six-minute arm test [6-MAT]), for persons with spinal cord injury (SCI) and to determine the test-retest reliability and concurrent validity of this test.

DESIGN

Prospective, exploratory, methodologic study. To determine test-retest reliability, subjects completed the 6-MAT on 2 days, separated by 1 week. Validity was determined by comparing 6-MAT results with peak oxygen consumption (VO2peak).

SETTING

Tertiary rehabilitation center.

PARTICIPANTS

Thirty subjects with SCI (mean age, 36.3y; 83% male).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Subjects were evaluated on the 6-MAT and a VO2peak test.

RESULTS

All subjects were able to complete the 6-MAT. Test-retest reliability of steady-state oxygen consumption (VO2) and heart rate during the 6-MAT were excellent (intraclass correlation coefficient [ICC], .81; 95% confidence interval [CI], .58-.92; ICC=.90; 95% CI, .75-.96, respectively). The correlation between VO2peak and 6-MAT VO2 was excellent (r=.92) and the correlations between VO2peak and 6-MAT heart rate (r=.63) and VO2peak and 6-MAT power output (r=.73) were good.

CONCLUSIONS

This study showed that the 6-MAT has acceptable values for test-retest reliability and validity. The 6-MAT should be further tested for responsiveness to enhance its use as a clinical tool.

Chapitre A - Troubles vésico-sphinctériens et traumatismes médullaires

The life expectancy of spinal cord injury patients has increased considerably over recent years due to improved management based on a better understanding of the pathophysiology of the abnormalities induced by spinal cord injury. The objective of treatment of spinal cord injury patients is to prevent the various complications, but also allow patients to regain maximum independence in order to facilitate their social rehabilitation. This result can only be obtained and maintained by multidisciplinary management in a network including urologists, as, although urinary complications have considerably decreased (they no longer represent the leading cause of mortality), they still constitute a frequent presenting complaint or reason for rehospitalization in this population.

Chapitre C - Cancer de vessie et vessie neurologique

In 2006, the risk of developing bladder tumour remains an important aspect of the management and surveillance of spinal cord injury patients. Based on a review of the literature, the authors show that these patients present a particularly high risk of squamous cell carcinoma of the bladder Risk factors remain controversial, but the duration of neurogenic bladder and the voiding mode appear to be the main risk factors. The authors discuss the optimal diagnostic modalities in this setting and the particular case of bladder augmentation.

Estimated prevalence of obstructive sleep apnea-hypopnea syndrome after cervical cord injury

OBJECTIVES

To estimate the prevalence of obstructive sleep apnea-hypopnea syndrome (OSAHS) in patients with cervical cord injury and to identify predictive factors.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation center.

PARTICIPANTS

Forty-one adults with cervical cord injury of more than 6 months in duration.

INTERVENTIONS

Medical history, physical exam, and full in home overnight polysomnography were undertaken. Data were collected on characteristics of spinal cord injury, current medication, sleeping habits, daytime sleepiness, body mass index (BMI), and neck circumference.

MAIN OUTCOME MEASURE

Presence or absence of OSAHS as defined by the American Academy of Sleep Medicine criteria (1999).

RESULTS

Twenty-two (53%) patients (95% confidence interval [CI], 38.4%-68.9%) had OSAHS. Daytime sleepiness (odds ratio [OR], 41.1; 95% CI, 2.3-739.7; P=.02), BMI of 30 kg/m2 or higher (OR=17.2; 95% CI, 1.4-206.4; P=.03), and 3 or more awakenings during sleep (OR=34; 95% CI, 1.6-744.8; P=.03) were the best predictive factors of OSAHS obtained by a forward stepwise multiple logistic regression.

CONCLUSIONS

The estimated prevalence of OSAHS is high after cervical cord injury. OSAHS should be suspected, especially in patients with daytime sleepiness, obesity, and frequent awakenings during sleep.

Kidney disease as a predictor of mortality in chronic spinal cord injury

BACKGROUND

The purpose of this study is to assess the predictive value of proteinuria and creatinine clearance (CrCl) in relation to mortality in patients with spinal cord injury.

METHODS

Computerized medical records covering 6 to 11 years were reviewed in 2004 to determine all-cause mortality. Long-term survival was assessed by means of Kaplan-Meier analysis. Multiple and stepwise Cox proportional hazards models were used to identify risk factors for mortality. The dependent variable was duration of survival in months. Potential predictors included proteinuria, CrCl, age, duration and type of injury, type of bladder management, ethnicity, diabetes mellitus, hypertension, coronary artery disease, hematocrit, serum albumin level, and serum cholesterol level.

RESULTS

With the Cox model, proteinuria with protein of 500 mg/d or greater (hazard ratio [HR], 2.98), CrCl less than 60 mL/min (<1.00 mL/s; HR, 3.89), or both (HR, 7.86) were associated independently with increased mortality. When added individually to the base Cox model, bladder catheter use (HR, 1.70) and age (HR, 1.05) also were independently predictive of time to death. Patients with preserved CrCl (>or=60 mL/min) and no proteinuria (protein < 500 mg/d) had a significantly greater duration of survival compared with patients with proteinuria (protein >or= 500 mg/d), decreased CrCl (<60 mL/min), or both (median survival, 120, 86, 87, and 47 months, respectively; P < 0.0001). There was no significant difference in survival in patients with proteinuria (protein >or= 500 mg/d) and preserved CrCl (>or=60 mL/min) compared with those with no proteinuria (protein < 500 mg/d) and decreased CrCl (<60 mL/min; P = 0.90). However, those with both proteinuria and decreased CrCl had significantly worse survival compared with those with only 1 condition (P < 0.01). Kidney disease was associated with an increase in both cardiovascular and noncardiovascular mortality.

CONCLUSION

The presence of either proteinuria with protein of 500 mg/d or greater or CrCl less than 60 mL/min is associated independently with increased mortality in the chronic spinal cord injury population. The presence of both conditions further increases this risk.

The neurogenic bladder in multiple sclerosis: review of the literature and proposal of management guidelines

Vesicourethral dysfunction is very frequent in multiple sclerosis (MS) and has functional consequences for patients' quality of life and also an organic impact following complications of the neurogenic bladder on the upper urinary tract. While the functional impact and its management are well documented in the literature, the organic impact remains underestimated and there are no consensual practical guidelines for the screening and prevention of MS neurogenic bladder complications. The aim of this review of the literature, focused on identifying the risk factors of urinary tract complications in MS, is to put forward well informed considerations to help in the definition of practical guidelines for the follow-up of the neurogenic bladder in MS in order to improve its prevention and patient management. Four main risk factors have been identified for upper urinary tract damage: the duration of MS, the presence of an indwelling catheter, high-amplitude neurogenic detrusor contractions and permanent high detrusor pressure. Detrusor-sphincter dyssynergia, age over 50 and male sex may form three additional risk factors. Recommendations for long-term urological follow-up, taking into account these specific risks are constructed according to the procedures recommended by the French Health Authorities.

Kinetic therapy beds are associated with more complications in patients with thoracolumbar spinal column injuries

BACKGROUND AND PURPOSE

Traumatic spine injuries are an important cause of morbidity and mortality. Kinetic therapy (KT) beds were designed to minimize skin breakdown and enhance clearance of pulmonary secretions by rotating the patient from side to side. However, little evidence exists to suggest that fewer complications occur in patients with thoracolumbar spine injuries (TLSIs) treated preoperatively with a KT bed. We investigated the effect of KT bed use on infectious complications and respiratory failure in patients requiring surgery for TLSIs.

METHODS

We queried the trauma registry of a Level 1 trauma center for patients who had surgery for a TLSI from January 1, 1994, through June 30, 2001, and performed a retrospective medical record review. Patients were divided into two groups according to whether they were treated with a KT bed preoperatively. Patient data included age, injury severity score (ISS), admission Glasgow Coma Scale score (GCS), time to surgery, narcotics administered in total and during the first 24 h after injury, the lowest recorded systolic blood pressure, and acute resuscitation volume requirement. Outcome data included infectious complications, neurologic deficits, respiratory failure, hospital length of stay (LOS), and number of days of ventilator support. Infectious complications included pneumonia, urinary tract infections, and surgical site infections.

RESULTS

Patients treated with a KT bed and patients treated with a conventional bed were similar in age, ISS, admission GCS, time to surgery, total narcotics administered, lowest recorded systolic blood pressure, and resuscitation requirement during the first 24 h. However, patients with neurologic deficits were more frequently treated with a KT bed. Infectious complications were more common in patients receiving KT bed therapy than among those on conventional beds. The incidence of respiratory failure, the number of days of ventilator support, and hospital LOS also were significantly higher in patients treated with KT beds. The variables most predictive of infectious complications were the number of days of ventilator support, the amount of fluid administered during the first 24 h, and KT bed therapy (r2 = 0.459).

CONCLUSIONS

Patients with TLSIs treated with a KT bed had a higher incidence of infectious complications and respiratory failure and more days of ventilator support than patients treated with a conventional bed despite similar ISS and time to surgical repair. The longer hospital LOS in patients treated with a KT bed may be secondary to the higher incidence of infectious complications and respiratory failure and the greater number of days of ventilator support.

Long-term follow-up study of intraurethral stents in spinal cord injured patients with detrusor-sphincter dyssynergia

STUDY DESIGN

Retrospective study.

OBJECTIVES

To assess in the long-term clinical and urodynamic results of intraurethral stents in a group of patients with spinal cord injury.

SETTING

Spinal Cord Injury Unit, Juan Canalejo Hospital, A Coruña, Spain.

METHODS

Forty-seven consecutive male patients were studied from 1993 to 2002. All of them suffered from hyperreflexia with detrusor-sphincter dyssynergia (DSD) owing to spinal cord injury, and were treated by means of the placement of an intraurethral stent at the external sphincter.

RESULTS

After surgery, significant decreases in all the parameters studied were observed. The number of patients with symptoms of urinary tract infection decreased by 25% (P<0.031). Post-void residual urine volume experienced an average decrease of 224.3 cm(3) (P=0.001). Episodes of dysreflexia decreased from 35.1 to 16.2% (P=0.039). The urodynamic study showed an average reduction of 44.36 cm H(2)O in the maximum detrusor pressure (P<0.0001). Complications in the upper urinary tract descended from 46.8 to 23.4% after placing the stent (P=0.013). The most frequent stent complication was displacement, followed by stenosis, lithiasis and intraprosthetic calcification. In all, 8.5% required the stent removal.

CONCLUSIONS

Intraurethral stent is a good choice for the long-term management of DSD in spinal cord-injured patients, even in those who had been previously submitted to prior sphincterotomy. It has the advantage of being a potentially reversible procedure, so patients prefer it to more invasive therapies such as sphincterotomy.

Effect of spinal cord injury on the respiratory system: basic research and current clinical treatment options

Spinal cord injury (SCI) often leads to an impairment of the respiratory system. The more rostral the level of injury, the more likely the injury will affect ventilation. In fact, respiratory insufficiency is the number one cause of mortality and morbidity after SCI. This review highlights the progress that has been made in basic and clinical research, while noting the gaps in our knowledge. Basic research has focused on a hemisection injury model to examine methods aimed at improving respiratory function after SCI, but contusion injury models have also been used. Increasing synaptic plasticity, strengthening spared axonal pathways, and the disinhibition of phrenic motor neurons all result in the activation of a latent respiratory motor pathway that restores function to a previously paralyzed hemidiaphragm in animal models. Human clinical studies have revealed that respiratory function is negatively impacted by SCI. Respiratory muscle training regimens may improve inspiratory function after SCI, but more thorough and carefully designed studies are needed to adequately address this issue. Phrenic nerve and diaphragm pacing are options available to wean patients from standard mechanical ventilation. The techniques aimed at improving respiratory function in humans with SCI have both pros and cons, but having more options available to the clinician allows for more individualized treatment, resulting in better patient care. Despite significant progress in both basic and clinical research, there is still a significant gap in our understanding of the effect of SCI on the respiratory system.

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.

Management of detrusor-external sphincter dyssynergia

Detrusor-external sphincter dyssynergia (DSD) is a debilitating problem in patients with spinal cord injury. DSD carries a high risk of complications, and even life expectancy can be affected. The mainstay of treatment is the use of antimuscarinic medication and catheterization, but in those for whom this is not possible external sphincterotomy has been the traditional management route. External sphincterotomy, however, is associated with significant risks, including hemorrhage, erectile dysfunction and the need for repeat procedures, and over the last decade alternatives have been investigated, such as urethral stents and botulinum toxin injection. We present a review of DSD, including the current management strategies and prospects for future treatment.

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.

Developing core sets for persons with spinal cord injuries based on the International Classification of Functioning, Disability and Health as a way to specify functioning

OBJECTIVE

The objective of this paper is to outline the proposed development process for the ICF Core Sets for Spinal Cord Injury (SCI) and to invite clinical and consumer experts to actively participate in this process. ICF Core Sets are selections of categories of the International Classification of Functioning, Disability and Health (ICF) that are relevant to persons with a specific condition or in a specific setting.

METHOD

The project is a cooperation between the ICF Research Branch of the World Health Organization (WHO) Collaboration Centre of the Family of International Classifications (DIMDI, Germany), the Classification, Assessment and Terminology (CAT) team and the Disability and Rehabilitation (DAR) team at WHO, the International Spinal Cord Society (ISCoS) and International Society for Physical and Rehabilitation Medicine (ISPRM) and partner institutions across the world. The project will consist of four worldwide studies to be conducted from 2006 to 2007 with a proposed ICF Core Set Consensus Conference to be held in 2007. ICF categories relevant for SCI are to be identified by means of (I) an empirical study, (II) a systematic review of outcomes and measures used in SCI research (III) an expert survey and (IV) focus groups and semistructured interviews with persons with SCI. Consensus about items that have to be part of a Comprehensive and of a Brief ICF Core Set for SCI will be reached in a final ICF Core Set Consensus Conference. Subsequent field testing will be necessary to validate this first version of ICF Core Sets for SCI.

INVITATION FOR PARTICIPATION

The development of ICF Core Sets is an inclusive and open process. Anyone who wishes to actively participate in this process is invited to contact the project coordinator (Monika.Scheuringer@med.uni-muenchen.de or http://www.icf-research-branch.org/research/spinalcord-injuries.htm). Individuals, institutions and associations can be formally associated as partners of the project.

Pharmacotherapy for Neurogenic Detrusor Overactivity

Chancellor MB, Anderson RU, Boone TB: Pharmacotherapy for neurogenic detrusor overactivity. Am J Phys Med Rehabil 2006;85:536-545. Patients with neurogenic detrusor overactivity are a heterogeneous group with voiding dysfunction secondary to neurologic injury or disease. The neurogenic detrusor overactivity syndrome, which may include urinary frequency, urgency, and incontinence, frequently contributes to a loss of independence, or even institutionalization. Urodynamic assessment provides the best method of quantifying and classifying neurogenic detrusor overactivity dysfunction in patients with primary diagnoses as diverse as Parkinson's disease, cerebral palsy, multiple sclerosis, spinal cord injury, and spina bifida. For many patients, management of urinary symptoms includes pharmacotherapy with an anticholinergic agent. Several novel approaches to managing neurogenic detrusor overactivity, including intravesical instillation of anticholinergic agents, vanilloids, and neurotoxins, are being investigated. For most patients, however, flexible dosing with an anticholinergic agent, with clean intermittent catheterization when indicated, has been shown to reduce the risks of urologic complications, improve levels of continence, and enhance patient quality of life in both children and adults.

Changing face of spine trauma care in North America

STUDY DESIGN

An evidence-based review and summary of literature from multiple disciplines involved in spine trauma.

OBJECTIVES

To outline epidemiologic, clinical, and research issues influencing spine trauma in a longitudinal perspective. In addition, to provide guidance to clinicians and researchers to ensure that philosophies pertaining to the betterment of spine trauma care are understood and supported.

SUMMARY OF BACKGROUND DATA

Epidemiologic data have provided insight into future demands the elderly patient with spine injury will place on the health care system. Regional trauma programs have emerged with further specialization resulting in regionalized spine trauma care. Evidence-based guidelines have streamlined imaging, and biomaterial advancements have facilitated the stabilization of the spinal column and decompression of the spinal cord. Promising experimental therapies promoting axonal regeneration and neuroprotective agents are beginning clinical trials, generating cautious optimism that effective therapies for spinal cord injuries will emerge. The unsustainable economics of increasing technology and patient expectations will make economic evaluation critical.

METHODS

Evidence-based review of current literature and expert opinion.

CONCLUSIONS

Multicenter spine trauma registries with patient-reported outcomes will allow many questions around spine trauma to be answered using the highest levels of evidence. This process in synergy with technical and biologic developments should ensure progress toward optimal care of the spine trauma patient. Future challenges will be to treat the breadth and magnitude of the discoveries within the fiscal restraints of the health care system and ensure its affordability for society.

Methylprednisolone treatment in acute spinal cord injury: the myth challenged through a structured analysis of published literature

BACKGROUND CONTEXT

Methylprednisolone has evolved during the 1990s, through the results obtained from the National Acute Spinal Cord Injury Studies NASCIS II and III, as a standard treatment in acute spinal injury.

PURPOSE

To evaluate the scientific basic for the use of methylprednisolone in acute spinal cord injury.

STUDY DESIGN

Systematic review of the accumulated literature.

METHODS

Critical evaluation of the data obtained in the NASCIS II and III studies plus other accumulated literature.

RESULTS

Analyses have been made on subgroups of the study populations, and the results were based on statistical artefacts. Furthermore, improved functional recovery shown by these studies was not clinically significant.

CONCLUSION

There is insufficient evidence to support the use of methylprednisolone as a standard treatment in acute spinal cord injury.

Respiratory muscle training in persons with spinal cord injury: a systematic review

The purpose of this paper was to review the effectiveness of respiratory muscle training (RMT) on respiratory muscle strength and endurance, pulmonary function, quality of life, respiratory complications and exercise performance in persons with spinal cord injury. A MEDLINE (National Library of Medicine, Bethesda, MD, USA) database was used for selection of the literature (from 1980 to November 2004), and relevant references from peer-reviewed articles were retrieved as well. Studies investigating the effects of RMT (i.e. resistive breathing weight lifting or normocapnic hyperpnea) in persons with spinal cord injury were selected. Two independent reviewers investigated controlled studies for methodological quality by using a modification of the framework for methodological quality. Methodological quality ranged between 15 and 29 (maximal feasible score=40). Twenty-three papers were retrieved and six controlled trials were kept for further analysis. A meta-analysis and calculation of effect-size of each individual study and weighted summary effect-size was intended. However, unreported data and heterogeneity in outcome variables did not allow performing a meta-analysis. From the systematic review it is concluded that RMT tended to improve expiratory muscle strength, vital capacity and residual volume. Insufficient data was available to make conclusions concerning the effects on inspiratory muscle strength, respiratory muscle endurance, quality of life, exercise performance and respiratory complications.

Spinal cord stimulation: a new method to produce an effective cough in patients with spinal cord injury

Patients with spinal cord injury have an increased risk of developing respiratory tract infections as the result of expiratory muscle paralysis and consequent inability to cough. We have developed a method by which the expiratory muscles can be activated via lower thoracic and upper lumbar spinal cord stimulation to produce an effective cough mechanism. In a tetraplegic patient who required frequent (8.57+/-2.3 times per week [mean+/-SEM]) caregiver assistance to facilitate airway clearance and expectoration of secretions, three epidural electrodes were applied in the T9, T11, and L1 spinal cord regions. During stimulation at the T9 and L1 levels, airway pressures were 90 and 82 cm H2O, respectively. Peak expiratory flow rates were 6.4 L/s and 5.0 L/s; respectively. During combined (T9+L1) stimulation, airway pressure and expiratory flow rate increased to 132 cm H2O and 7.4 L/s, respectively. Addition of the third lead did not result in further increases in pressure generation. These values are characteristic of those observed with a normal subject. Because the patient is able to trigger the device independently, he no longer requires caregiver support for airway management. If confirmed in additional patients, spinal cord stimulation may be a useful method to restore an effective cough mechanism in patients with spinal cord injury.

Improving the global management of the neurogenic bladder patient: part I. The complexity of patients

BACKGROUND

The management of urinary incontinence in patients with neurological disease is complex. Physicians face a multitude of challenges related to progression of the primary condition, the presence of a diversity of other related and unrelated symptoms, the safety, efficacy and tolerability issues associated with multiple therapies being required and the changing need for collaboration with other specialities.

SCOPE

Current guidelines produced by the urological communities, as well as the disease-focused organizations, aim to standardize care in their specific group of patients. A passive approach to implementation, however, means that guidelines produced are all too frequently not readily available to, read by or followed by the wider audience. In addition, each speciality has its own guidelines and a different view of the primary focus of care in neurological patients, which may lead to variations in recommendations and, subsequently, in clinical practice. A review of current urological and disease specific guidelines was made to evaluate differences between the published guidance between the specialities and within urology itself.

CONCLUSIONS

Although availability of effective therapies remains a cornerstone of neurogenic bladder treatment, consideration must also be given to the non-pharmacological and surgical issues related to the global management of this population. Improved cross-speciality interactions and development of patient-specific treatment and follow-up plans, which are in keeping with the current guidelines of each speciality involved, may serve to enhance physicians' understanding of the importance of effective urinary incontinence treatment as well as the overall management of the patient.

Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey?

STUDY DESIGN

Literature survey.

OBJECTIVES

To provide an overview of the literature data on incidence, prevalence and epidemiology of spinal cord injury (SCI) worldwide and to study their evolution since 1977.

SETTING

University Antwerp.

METHODS

The literature from 1995 onwards was searched on Pubmed. To include evolutionary data, we incorporated the results of three older studies.

RESULTS

Two studies gave prevalence of SCI, and 17 incidence of SCI. The published data on prevalence of SCI was insufficient to consider the range of 223-755 per million inhabitants to be representative for a worldwide estimate. Reported incidence of SCI lies between 10.4 and 83 per million inhabitants per year. One-third of patients with SCI are reported to be tetraplegic and 50% of patients with SCI to have a complete lesion. The mean age of patients sustaining their injury at is reported as 33 years old, and the sex distribution (men/women) as 3.8/1.

CONCLUSION

There is a need for improved registration of SCI, and publication of the findings in many parts of the world. This survey pleads for uniformity in methodology. The data show that the reported incidence and prevalence have not changed substantially over the past 30 years. Data from Northern America and Europe show higher figures for incidence, but prevalence figures have remained the same. Epidemiology of SCI seems to have changed during the last decades with a higher percentage of tetraplegia and of complete lesions. If such evolution is present worldwide, how it could eventually be prevented needs to be studied.

SPONSORSHIP

Not applicable.

The Real Predictors of Disposition in Patients with Spinal Cord Injuries

OBJECTIVES

A primary goal of health care providers for managing patients with spinal cord injury (SCI) is to discharge them to a rehabilitation facility (RF) to allow for maximal functional recovery. This study was undertaken to analyze hospital mortality and disposition of patients with SCI with a specific focus on evaluating the effect of payor source on discharge to a RF. Our hypothesis was that commercial insurance (CI) would be the greatest influence of hospital disposition.

METHODS

All patients under 60 years of age with SCI over a 7-year period were identified from the trauma registry; and grouped according to payor source: No insurance (NI), Government insurance (GI), No Commercial insurance (NCI) (NCI = NI + GI), and CI.

RESULTS

A total of 492 patients with SCI were identified with a mean age of 33, an ISS of 29, and a hospital mortality of 7.7%. Independent predictors of mortality were cervical SCI and blood transfusions. Patients who were discharged to a RF had higher ISS and %CI with lower functional independent measurement scores compared with patients who were not discharged to a RF. Logistic regression analysis demonstrated that the predictors of disposition to a RF were CI (p < 0.001) and ISS (p = 0.002).

CONCLUSION

The presence of CI was an independent predictor of disposition to a RF for patients with SCI. Lack of commercial insurance clearly compromises recovery and rehabilitation of patients with SCI and predicts outcome more clearly than any other parameter. Additional funding for patients without CI is necessary to afford all with an equal opportunity for maximal functional recovery.

Spinal cord injury alters cardiac electrophysiology and increases the susceptibility to ventricular arrhythmias

The autonomic nervous system modulates cardiac electrophysiology and abnormalities of autonomic function are known to increase the risk of ventricular arrhythmias. The abnormal and unstable autonomic control of the cardiovascular system following spinal cord injury also is well known. For example, individuals with mid-thoracic spinal cord injury have elevated resting heart rates, increased blood pressure variability, episodic bouts of life-threatening hypertension as part of a condition termed autonomic dysreflexia, and elevated sympathetic activity above the level of the lesion. Furthermore, cardiovascular morbidity and mortality are high in individuals with spinal cord injuries due to a relatively sedentary lifestyle and higher prevalence of other cardiovascular risk factors, including obesity and diabetes. Therefore, spinal cord injury may alter cardiac electrophysiology and increase the risk for ventricular arrhythmias. In this chapter, we discuss how the autonomic changes associated with cord injury can influence cardiac electrophysiology and the susceptibility to ventricular arrhythmias.

Control of urinary bladder function with devices: successes and failures

The management of urinary tract dysfunction is crucial for the health and well-being of people with spinal cord injury. Devices, specifically catheters, play an important role in the daily regime of bladder management for most people with spinal cord injury. However, the high incidence of complications associated with the use of catheters, and the fact that the spinal segments involved in lower urinary tract control remain intact in most cord-injured people, continue to motivate research into devices that could harness the nervous system to provide greater control over lower urinary tract function. Mechanical devices discussed in this review include catheters, artificial urethral sphincters, urethral stents and intraurethral pumps. Additionally, many attempts to restore control of the lower urinary tract with electrical stimulation have been made. Stimulation sites have included: inside the bladder, bladder wall, thigh, pelvic floor, dorsal penile nerve, pelvic nerve, tibial nerve, sacral roots, sacral nerves and spinal cord. Catheters and sacral root stimulators are two techniques whose efficacy is well established. Some approaches have proven less successful and others are still in the development stage. Modifications to sacral root stimulation including posterior root stimulation, anodal blockade and high-frequency blockade as well as new techniques including intraspinal microstimulation, urethral afferent stimulation and injectable microstimulators are also discussed. No single device has yet restored the control and function of the lower urinary tract to the pre-injury state, but new techniques are bringing this possibility closer to reality.

Spinal activation of serotonin 1A receptors enhances latent respiratory activity after spinal cord injury

BACKGROUND/OBJECTIVE

Hemisection of the cervical spinal cord results in paralysis of the ipsilateral hemidiaphragm. Removal of sensory feedback through cervical dorsal rhizotomy activates latent respiratory motor pathways and restores hemidiaphragm function. Because systemic administration of serotonin 1A receptor (5HT1A) agonists reversed the altered breathing patterns after spinal cord injury (SCI), we predicted that 5HT1A receptor activation after SCI (C2) would activate latent crossed motor pathways. Furthermore, because 5HT1 A receptors are heavily localized to dorsal horn neurons, we predicted that spinal administration of 5HT1A agonists should also activate latent motor pathways.

METHODS

Hemisection of the C2 spinal cord was performed 24 to 48 hours, 1 week, or 16 weeks before experimentation. Bilateral phrenic nerve activity was recorded in anesthetized, vagotomized, paralyzed Sprague-Dawley rats, and 8-OH-DPAT (5HT1A agonist) was applied to the dorsal aspect of the cervical spinal cord (C3-C7) or injected systemically.

RESULTS

Systemic administration of 8-OH-DPAT led to a significant increase in phrenic frequency and amplitude, whereas direct application to the spinal cord increased phrenic amplitude alone. Both systemic and spinal administration of 8-OH-DPAT consistently activated latent crossed phrenic activity. 8-OH-DPAT induced a greater respiratory response in spinal injured rats compared with controls.

CONCLUSION

The increase in crossed phrenic output after application of 8-OH-DPAT to the spinal cord suggests that dorsal horn inputs, respiratory and/or nonrespiratory, may inhibit phrenic motor output, especially after SCI. These findings support the idea that the administration of 5HT1A agonists may be a beneficial therapy in enhancing respiratory neural output in patients with SCI.

Physical disability and obesity

Nearly 20% of US citizens are disabled. Epidemiologic studies have shown that people with physical disabilities have a 1.2- to 3.9-fold increase in obesity prevalence. Obesity is becoming a serious problem in disabled individuals. The mechanisms by which obesity occurs in people with physical disabilities is not clear, but pathophysiological changes of body composition and energy metabolism, physical inactivity, and muscle atrophy all favor the development of obesity. Health professionals should identify disabled patients at risk and provide early prevention guidance. Research is needed to help generate detailed clinical guidelines to promote weight control among people with physical disabilities.

Spinal cord injury-induced changes in breathing are not due to supraspinal plasticity in turtles (Pseudemys scripta)

After occurrence of spinal cord injury, it is not known whether the respiratory rhythm generator undergoes plasticity to compensate for respiratory insufficiency. To test this hypothesis, respiratory variables were measured in adult semiaquatic turtles using a pneumotachograph attached to a breathing chamber on a water-filled tank. Turtles breathed room air (2 h) before being challenged with two consecutive 2-h bouts of hypercapnia (2 and 6% CO2or 4 and 8% CO2). Turtles were spinalized at dorsal segments D8–D10so that only pectoral girdle movement was used for breathing. Measurements were repeated at 4 and 8 wk postinjury. For turtles breathing room air, breathing frequency, tidal volume, and ventilation were not altered by spinalization; single-breath (singlet) frequency increased sevenfold. Spinalized turtles breathing 6–8% CO2had lower ventilation due to decreased frequency and tidal volume, episodic breathing (breaths/episode) was reduced, and singlet breathing was increased sevenfold. Respiratory variables in sham-operated turtles were unaltered by surgery. Isolated brain stems from control, spinalized, and sham turtles produced similar respiratory motor output and responded the same to increased bath pH. Thus spinalized turtles compensated for pelvic girdle loss while breathing room air but were unable to compensate during hypercapnic challenges. Because isolated brain stems from control and spinalized turtles had similar respiratory motor output and chemosensitivity, breathing changes in spinalized turtles in vivo were probably not due to plasticity within the respiratory rhythm generator. Instead, caudal spinal cord damage probably disrupts spinobulbar pathways that are necessary for normal breathing.

Validity of the detection of wheelchair propulsion as measured with an Activity Monitor in patients with spinal cord injury

STUDY DESIGN

Validation study.

OBJECTIVES

An accelerometry-based Activity Monitor (AM) has proven to be a valid instrument to quantify mobility-related activities (lying, sitting, standing, walking, cycling, general (noncyclic) movement). The aim of this study was to assess whether, additional to other activities, wheelchair propulsion (hand-rim wheelchair propulsion and handbiking) can be validly detected by the AM in patients with spinal cord injury (SCI).

SETTING

Rehabilitation center.

METHODS

In all, 10 patients with SCI (aged 19-63 years; five patients with poor triceps strength and five patients with good triceps strength) participated. Patients performed a series of representative daily life activities (involving wheelchair propulsion and nonwheelchair propulsion activities), according to a standard protocol, in a seminatural setting. Continuous registrations of signals from body-fixed accelerometers were made and the AM output (after automatic analysis) was compared with visual analysis of simultaneously made video recordings (reference method). Validity scores (agreement, sensitivity, specificity) between the output of the AM and the video analysis were calculated.

RESULTS

Agreement, sensitivity and specificity for the detection of wheelchair propulsion were overall 92 (range, 87-96)%, 87 (76-99)% and 92 (85-98)%, respectively. Sensitivity was smaller in patients with poor triceps strength compared to patients with good triceps strength; 81 (76-89)% and 95 (89-99)%, respectively (P<0.01). Mean overestimation in duration of wheelchair propulsion by the AM was 3.9% (P<0.05).

CONCLUSION

Besides already validated other activities, wheelchair propulsion (hand-rim wheelchair propulsion and handbiking) can be validly detected by the AM in patients with SCI, both with good and poor triceps strength. Therefore, the AM offers the possibility to obtain objective and detailed information on all major mobility-related activities performed by patients with SCI.

SPONSORSHIP

Stichting Rotterdams Kinderrevalidatie Fonds Adriaanstichting.

A prospective assessment of mortality in chronic spinal cord injury

STUDY DESIGN

Prospective mortality study.

OBJECTIVE

To assess the relationship between comorbid medical conditions and other health-related factors to mortality in chronic spinal cord injury (SCI).

SETTING

Boston, MA, USA.

METHODS

Between 1994 and 2000, 361 males >/=1 year after injury completed a respiratory health questionnaire and underwent pulmonary function testing. Cause-specific mortality was assessed over a median of 55.6 months (range 0.33-74.4 months) through 12/31/2000 using the National Death Index.

RESULTS

At entry, mean (+/-SD) age was 50.6+/-15.0 years (range 23-87) and years since injury was 17.5+/-12.8 years (range 1.0-56.5). Mortality was elevated (observed/expected deaths=37/25.1; SMR=1.47; 95% CI=1.04-2.03) compared to US rates. Risk factors for death were diabetes (RR=2.62; 95% CI=1.19-5.77), heart disease (RR=3.66; 95% CI=1.77-7.78), reduced pulmonary function, and smoking. The most common underlying and contributing causes of death were diseases of the circulatory system (ICD-9 390-459) in 40%, and of the respiratory system in 24% (ICD-9 460-519).

CONCLUSIONS

These results suggest that much of the excess mortality in chronic SCI is related to potentially treatable factors. Recognition and treatment of cardiovascular disease, diabetes, and lung disease, together with smoking cessation may substantially reduce mortality in chronic SCI.

The effects of gender on clinical and neurological outcomes after acute cervical spinal cord injury

The potential clinical relevance of gender on clinical and neurological outcome after spinal cord injury (SCI) has received little attention. In order to address this issue, we examined all consecutive cases of acute traumatic cervical SCI admitted to our institution from 1998 to 2000. There were 38 males (ages 17-89 years, mean of 51.6) and 17 females (ages 18-84 years, mean of 63.2). Both groups were comparable regarding level (C1 to C7) and severity of SCI (ASIA A to D) at admission. Age differences between the groups approached significance (p = 0.057), and thus this factor was treated as a covariate in the analysis. Co-morbidities were as frequent in men (86.8%) as in women (76.5%). The therapeutic approaches, length-of-stay in the acute care unit, mortality, and discharge disposition were similar in men and women. During hospitalization, 44.7% of men and 52.9% of women developed post-SCI secondary complications without any significant gender-related differences. Both groups showed a similar incidence of infections, cardiovascular complications, thromboembolism, and pressure sores. Univariate analysis revealed a trend for higher incidence of psychiatric complications (p = 0.054) and deep venous thrombosis (p = 0.092) in women, which was confirmed by multivariate analysis. Neurological outcome was not correlated with gender. A similar number of males and females (42.1%, 47.1%) showed evidence of neurological recovery as revealed by an improvement in ASIA scores. Moreover, 18.4% of males and 29.4% of females recovered to ASIA E status. Our data suggest a shift in the demographics of acute SCI with an increasing incidence in elderly women. Although neurological outcomes were not significantly related to gender, we observed a trend for higher rates of reactive depression and deep venous thrombosis in women. These issues may be of key clinical importance in developing improved management protocols for SCI so as to maximize functional recovery and quality-of-life.

Adenosinergic mechanisms underlying recovery of diaphragm motor function following upper cervical spinal cord injury: potential therapeutic implications

OBJECTIVES

In adult rats, a latent respiratory motor pathway can be pharmacologically activated with 1,3-dimethylxanthine (theophylline) to restore respiratory-related activity to a hemidiaphragm paralysed by an ipsilateral upper cervical (C2) spinal cord hemisection. The purpose of this review is to describe mechanisms that underlie theophylline-induced recovery of respiratory-related function following C2 hemisection and to underscore the therapeutic potential of theophylline therapy in spinal cord injured patients with respiratory deficits.

METHODS

Theophylline mediates recovery of respiratory-related activity via antagonism of central adenosine A(1) receptors. When administered chronically, the drug restores and maintains recovered function. Since theophylline is an adenosine receptor antagonist with affinity for both the adenosine A(1) and A(2) receptors, we assessed the relative contributions of each receptor to functional recovery. While A(1) receptor antagonism plays a predominant role, activation of the A(2) receptors by specific agonists subserves the A(1) receptor-mediated actions. That is, when an adenosine A(2) receptor agonist is administered first, it primes the system such that subsequent administration of the A(1) antagonist induces a greater degree of recovered respiratory activity than when the antagonist alone is administered.

RESULTS

Chronic oral administration of theophylline in C2 hemisected animals demonstrates that even when animals have been weaned from the drug, theophylline-induced recovered respiratory actions persist. This suggests that in clinical application, it may not be necessary to maintain patients on long-term theophylline. We have shown that recovery of respiratory-related activity in the ipsilateral phrenic nerve can occur spontaneously 3-4 months after C2 hemisection. Theophylline administration after this post-injury period obliterates/negates the recovery function. This indicates strongly that there is therapeutic window (more acutely after injury) for the initiation of theophylline therapy. We have also demonstrated that peripheral (carotid bodies) adenosine A(1) receptors can be selectively activated to modulate theophylline-induced CNS actions. Blocking central adenosine receptors while simultaneously activating peripheral adenosine receptors minimizes the potential of respiratory muscle fatigue with theophylline.

DISCUSSION

The significance of the current findings lies in the potential clinical application of theophylline therapy in spinal cord injured patients with respiratory deficits. The ultimate goal of theophylline therapy is to wean ventilator-dependent patients off ventilatory support. Thus far, our animal studies suggest that the onset of theophylline therapy must be soon after injury.

Prevalence of spinal cord injury in Australia

STUDY DESIGN

Cohort study, based on cases of spinal cord injury (SCI) that occurred between 1986 and 1997 (n=2959).

OBJECTIVES

To estimate prevalence historically, currently and into the future.

SETTING

Australia.

METHODS

Prevalence was estimated on the basis of (1) historical data concerning survival and the relationship between the incidence of fatalities and SCI, (2) information on SCI incidence and survival 1986-1997, and (3) forecasts of incidence and population growth from 1997 to 2021 and consideration of survival.

RESULTS

It was estimated that the prevalence of SCI in Australia was in the range 8096-9614 cases by 1985. By 1997, this had increased to nearly 10,000 and the prevalence rate was more than 681 per million of population. By 2021, this could increase to nearly 12,000 if age-specific SCI incidence rates continued at average values evident over the period 1986-1997 and national population projections applied. In addition, there would be more elderly SCI cases due to the ageing of the national population. The prevalent population could be reduced to less than 7000 if the incidence rate was reduced by -3% p.a.

CONCLUSION

The prevalence of SCI in Australia has increased and it will continue to increase unless measures are taken to control incidence. The case mix will change due to the ageing of the population, and treatment services will need to be prepared for a larger and more elderly prevalent population. It was suggested that consideration should be given to a national health and welfare goal to reduce the SCI incidence rate by -3% p.a., focusing in particular on the prevention of transport crashes and falls.

Etiology and outcomes of veterans with spinal cord injury and disorders hospitalized with community-acquired pneumonia

OBJECTIVE

To determine whether documentation of a causative organism for community-acquired pneumonia (CAP) is associated with outcomes, including mortality and length of stay (LOS), in hospitalized veterans with spinal cord injuries and disorders (SCI&D).

DESIGN

Retrospective cohort study.

SETTING

Patients with SCI&D admitted with CAP to any Veterans Affairs medical center between September 1998 and October 2000.

PARTICIPANTS

Hospital administrative data on 260 patients with SCI&D and a CAP diagnosis.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

All-cause, 30-day mortality and hospital LOS.

RESULTS

An organism was documented by International Classification of Diseases, 9th Revision , discharge codes in 24% of cases. Streptococcus pneumoniae and Pseudomonas aeruginosa accounted for 32% and 21%, respectively, of the identified bacterial pathogens. The overall mortality rate was 8.5%. No significant association was found between etiologic diagnosis of CAP and 30-day mortality. Lower mortality was associated with treatment at a designated SCI center (relative risk=.35; confidence interval, .12-.99). Pathogen-based CAP diagnosis was significantly associated with longer LOS (adjusted r 2 =.023, P =.024).

CONCLUSIONS

There was no association between etiologic diagnosis of CAP and 30-day mortality among people with SCI&D. Documentation of CAP etiology was associated with the variance in LOS. Pneumococcal vaccination and antibiotic therapy with antipseudomonal activity may be particularly prudent in these patients given the high frequency of these pathogens among SCI&D patients with CAP.

Endogenous recovery of injured spinal cord: longitudinal in vivo magnetic resonance imaging

Pathological changes were followed longitudinally with in vivo magnetic resonance imaging (MRI) and behavioral studies in experimental spinal cord injury (SCI). MRI-observed pathology was correlated with histology. On MRI, the cavitated regions of the injured cord were gradually filled with viable tissue between two and 8 weeks postinjury, and a concomitant improvement was observed in the neurobehavioral scores. By weeks 3-6, on MRI, the gray matter (GM) returned in the segments caudal, but not rostral, to the injury site. The corresponding histological sections revealed motor neurons as well as other nuclei in the gray matter immediately caudal to the epicenter, but not at the site of injury, suggesting neuronal recovery in perilesioned areas. The neuronal and neurological recovery appeared to occur about the same time as neovasculature that was reported on the contrast-enhanced MRI, suggesting a role for angiogenesis in recovery from SCI. The role of angiogenesis in neuronal recovery is further supported by the immunohistochemical observation of greater bromodeoxyuridine uptake by blood vessels near the lesion site compared with uninjured cords.

Aging with spinal cord injury

The years after SCI may be associated with acceleration of the aging process because of diminished physiologic reserves and increased demands on functioning body systems. Clinicians with expertise in the treatment and prevention of SCI-specific secondary complications need to collaborate with gerontologists and primary care specialists and need to invest in the training of future physicians to ensure a continuum of accessible, cost-effective, and high-quality care that meets the changing needs of the SCI population. Managed care payers often do not adequately cover long-term disability needs to prevent secondary SCI-specific complications. In this era of increasing accountability, evidence-based clinical practice guidelines are needed to document scientific evidence and professional consensus to effectively diagnose, treat, and manage clinical conditions; to reduce unnecessary testing and procedures; and to improve patient outcomes. Longitudinal research is needed to minimize cohort effects that contribute to misinterpretation of cross-sectional findings as representative of long-term changes in health and functioning. However, longitudinal studies confound chronologic age, time since injury, and environmental change. Thus, time-sequential research, which controls for such confounding effects, is essential, as is research on the effects of gender,culture, and ethnicity. If we consider how much progress has been made over the past 50 years with respect to SCI mortality related to infectious disease, we can expect to achieve even greater progress against the effects of aging in the next 50 years. Recent developments in molecular biology regarding growth and neuro-trophic factors are bringing us closer to the goal of repairing the damaged spinal cord. The challenge remains for rehabilitation professionals to provide the most comprehensive and holistic approach to long-term follow-up, with an emphasis on health promotion and disease prevention, to postpone functional decline and enhance QOL.

Hormone replacement therapy in women with spinal cord injury – a survey with literature review

STUDY DESIGN

Postal questionnaire survey.

OBJECTIVE

To examine the current use of hormone replacement therapy (HRT) in a sample of menopausal women with spinal cord injury (SCI).

SETTING

National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital, Aylesbury, UK.

METHOD

A postal questionnaire was sent to 94 women from the NSIC patient database who met the study inclusion criteria (wheelchair dependent, aged 49 years and above, last seen or heard from within the last 3 years).

RESULTS

A total of 59 valid questionnaires were analysed. At the time of the survey, 50 women were menopausal and 11 of them were using HRT, six for menopausal symptoms and five for osteoporosis prevention. Another 11 had used HRT, eight for menopausal symptoms and three for osteoporosis prevention, but had discontinued it. The main reasons for stopping HRT were side effects. Of the 28 women who had never been on HRT, 20 had either enquired about it, or had been offered HRT, but decided against it. Of the nine women who were still premenopausal at the time of the survey, four would consider using HRT.

CONCLUSIONS

Results show that 44% of the menopausal women in our sample have used HRT at some point and 22% still do, mostly for treatment of menopausal symptoms and for osteoporosis prevention. In view of the latest literature findings in able-bodied women, use of HRT for osteoporosis prevention in women with SCI may have to be reconsidered.

Aging with a spinal cord injury: factors associated with the need for more help with activities of daily living

OBJECTIVES

To determine (1) the frequency of the need for more help with activities of daily living (ADLs), (2) the frequency of medical complications, and (3) the association between medical, injury-related, and sociodemographic factors and the need for more help with ADLs among those aging with spinal cord injury (SCI).

DESIGN

Cross-sectional survey.

SETTING

General community, international.

PARTICIPANTS

Volunteers (N=352) with SCI for more than 20 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The need for more help with ADLs.

RESULTS

The need for more help with ADLs during the last 3 years was reported by 32.1% of participants. At least 1 medical complication was reported by 85%. Constipation (47.9%), diarrhea/bowel accidents (41.8%), and pressure ulcers (38.7%) were common. Constipation, pressure ulcers, female gender, and years postinjury were associated with needing more help with ADLs. Constipation and pressure ulcers were associated with a 97% and a 76% increase, respectively, in the likelihood of needing more help with ADLs during a 3-year time period. Female gender was associated with a 96% increased odds of needing more help with ADLs. There was a 42% increased odds of needing more help with ADLs per decade after SCI.

CONCLUSIONS

People aging with SCI are vulnerable to medical complications, and additional help is required to function. Knowledge of the effect of these factors, particularly the tetrad of constipation, pressure ulcers, female gender, and number of years postinjury, should increase awareness that more help with ADLs may be needed over time.

Factor analysis of the metabolic syndrome in spinal cord-injured men

Disturbances of carbohydrate and lipid metabolism in men with spinal cord injury are common, but poorly defined. Clustering of recognized risk factors for obesity and disorders of carbohydrate and lipid metabolism are characteristic of the metabolic syndrome. The purpose of this study was to investigate the presence of metabolic syndrome using modifications of the World Health Organization (WHO) definition and including total physical activity levels (minutes/week), in a group of active males with spinal cord injury who were carefully matched for age, height, and weight with active able-bodied males. Factor analysis is used widely to explore factors of the metabolic syndrome. This technique was used in this study of 20 spinal cord-injured (SCI) men and 20 able-bodied controls, matched for age, height, and weight. Three-factor models, each reflecting a different aspect of the metabolic syndrome, were identified for both study groups. The average communality score for the SCI group was 0.8 and 0.7 for the control group. For the SCI group, factor 1 reflected an interaction between adiposity measures, physical activity, and postload insulin and glucose, factor 2 was reflective of dyslipidemia, while factor 3 revealed an interaction between fasting levels of insulin and glucose. In the control group, factor 1 reflected an association between the adiposity measures and physical activity, factor 2 was reflective of postload glycemic control, with factor 3 reflecting an interaction between fasting insulin and dyslipidemia. By summation of the total variance of each factor, the 3-factor models explained 80% and 69% of the variance in the original 9 variables examined in the SCI and control groups, respectively. In summary, while the WHO definition for the metabolic syndrome appears suitable for use in identifying the incidence of this syndrome in SCI men, some modification of anthropometric and lipid measures may be required.