Pain during in-patient rehabilitation after traumatic spinal cord injury

In this prospective study, we surveyed the pain experience of 40 participants during the in-patient rehabilitation period following traumatic spinal cord injury (SCI). Twenty-eight patients (70% of the study population) had musculoskeletal (MS) pain or neuropathic (NP) pain. Pain responded positively to physical therapy and analgesics. A numerical pain scale decreased from a mean of 6.36+/-1.7 on admission to 3.2+/-1.94 on discharge (P<0.001). Paraplegic patients were more likely to have MS pain (P=0.001) and NP pain (P=0.046). There was no relationship between completeness of injury, or spinal surgery, and type of pain encountered. There was also no significant difference in the modified Barthel index between patients with and without pain on admission and discharge. We conclude that pain is a common experience in SCI patients and that it can be reduced significantly by the end of in-patient rehabilitation.

Outcome of patients with cervical spondylotic myelopathy seen at a rehabilitation centre

A retrospective study was conducted on 21 patients with cervical spondylotic myelopathy to study the clinical characteristics of these patients and the influence of surgery and rehabilitation on their outcome. All the patients were 50 years and above, with a mean age of 63.6 years. The most common presenting feature was weakness of all the limbs. Neckache was not a prominent finding. Although only 2 patients complained of bladder disturbance, 6 other patients were found to have bladder dysfunction after urodynamic assessment. Clinical outcome after surgery was 50% improved, 28% unchanged and 22% worsened. Fifty percent of the patients with voiding problems recovered after bladder training. Rehabilitation was significant in assisting in the recovery of patients after surgery. One patient had a disabling stroke 4 days after cervical surgery while another died of urinary tract infection while undergoing rehabilitation.

Speech disorders in closed head injury patients

Head injuries vary in type and degree of severity and clinicians agree that most individuals who suffer head injury have cognitive, speech injury, behavioural and sensory motor problems immediately after and during their rehabilitative phase.

METHOD

The hospital courses of thirty-one closed head injury (CHI) patients admitted to our Rehabilitation Department from January 1990 to April 1991 were studied with particular reference to their speech disorders.

RESULTS

Severity of the initial brain injury, best measured by length of coma using the Glasgow Coma Scale (GCS) was the most significant predictor of outcome, defined by the Glasgow Outcome Scale (GOS). Eighty-one percent of our patients were unconscious immediately following their injury. Upon admission into our neurosurgical department, thirty-nine percent were comatose with a Glasgow Coma Scale score of eight or less. Fifty-two percent had a score of twelve or more and the rest were in between. Twenty-six percent had skull fractures, while seventy-four percent had one or more extracranial injuries. Neurologically eighty-one percent of our patients had either a left or right hemiplegia/paresis. In the assessment of speech, thirty percent were aphasic, twenty-five percent had motor speech disorders, thirty-two percent had mixed speech deficits and thirteen percent did not have any significant speech problems. Average stay in the Rehabilitation Department was ten weeks.

CONCLUSION

Although most patients showed an overall trend of speech improvement across time, the severely injured (Glasgow Coma Scale less than eight) continued to manifest permanent residual deficits especially those with expressive, mixed or global aphasia. The mild to moderately injured (Glasgow Coma Scale more than eight) seem to have anomia and word retrieval difficulty with little receptive language impairment, and these persisted months after discharge.

Bladder training in patients with spinal cord injury

Immediately following severe injury to the spinal cord or conus medullaris, there is a stage of flaccid paralysis of the bladder. The smooth muscle of the detrusor and rectum is affected. Drainage of the bladder is very important in the early care of such patients. From August 1989 to August 1990, 55 spinal cord injury patients were studied on admission to our department. The current bladder training method used for these patients is presented. A patient was deemed to have been successfully bladder trained when catheter-free, continent, and able to consistently maintain a residual volume of 100 mL or less with the aid of tapping and compression. On discharge 45 patients (82%) were successfully bladder trained, 8 (15%) employed a regimen of clean intermittent self-catheterization, and 2 went home/institutional care with an indwelling catheter. The material presented is applicable to any type of neurogenic bladder dysfunction.

Urinary tract infection in acute spinal cord injury

Preservation of renal function and prevention of recurrent urinary tract infections is the ultimate goal of any method of neurogenic bladder management in spinal cord injury patients. METHOD--The hospital courses of fifty such patients admitted to our Rehabilitation Department from August 1989 to August 1990 were studied according to age, gender, spinal cord injury level, method of bladder drainage on admission and upon discharge, type of urinary tract infections and results of bladder management were documented. RESULTS--Forty-five men and ten women were studied. Mean age of males was forty and females, forty-two. The commonest cause of injury was road traffic accident followed by accidents at work place. Fifty-three percent had cervical cord injuries, thirteen percent thoracolumbar and sixteen percent lumbo sacral injuries. Seventy-eight percent had an indwelling foley catheter upon admission. Upon discharge eighty-two percent of spinal cord injury patients were able to void with/without tapping and compression. There were a total of one hundred and forty-three urinary tract infections in our study group. All positive urine cultures had greater than or equal to 100,000 CFU/ml. The commonest organisms causing urinary tract infection were Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Proteus mirabilis. CONCLUSION--For bacteria to produce disease in the urinary tract, they must gain access and colonise the uroepithelium, induce inflammation and tissue damage. The indwelling catheter provides a direct access to the uroepithelium, making bacteriuria and subsequent infection inevitable. Impaired voiding and sensation in spinal cord injury patients provides an excellent reservoir for the multiplication of bacteria, tissue invasion and recurrent urinary tract infection. Hence current methods of neurogenic bladder management have to focus on attaining a catheter-free status as soon as possible; relevant antibiotic therapy and careful attention to individual urinary tract problems to reduce morbidity and improve on spinal cord injury patient's future. Although spinal cord injury patients are described, the material covered is applicable to any type of neurogenic bladder dysfunction.

Pyuria: index of infection in patients with spinal cord injuries

Little is known about the significance of pyuria in patients with spinal cord injuries. The progress in hospital of 55 such patients was studied. They were divided into 2 groups according to the method of bladder drainage on admission. Group A comprised 43 patients with indwelling catheters. Group B comprised 12 patients who were able to void with tapping, with/without compression and on intermittent catheterisation. The results showed that group A had a mean pyuria level of 185 WBC/HPF on admission. The incidence of urinary tract infection was 4 per patient during hospitalisation and the mean duration of bladder training was 82 days. Group B had a mean pyuria level of 32 WBC/HPF on admission. The incidence of urinary tract infection was 1 per patient during hospitalisation and the mean duration of bladder training was 40 days. The difference between groups A and B for all 3 parameters was statistically significant. These results suggest that patients with spinal cord injuries and indwelling catheters have a higher pyuria level and an increased risk of significant morbidity secondary to urinary tract infection, especially at the pyuria level of 100 WBC/HPF. A low pyuria level of less than or equal to 30 WBC/HPF was associated with a nil or low incidence of bacteriuria and urinary tract infection in our patients.