Amie B. Jackson

Long-term medical complications after traumatic spinal cord injury: A regional model systems analysis

OBJECTIVE To analyze the incidence, risk factors, and trends of long-term secondary medical complications in individuals with traumatic spinal cord injury. DESIGN Data were reviewed from the National SCI Statistical Center on annual evaluations performed at 1, 2, 5, 10, 15, and 20 years after injury on patients injured between 1973 and 1998. SETTING Multicenter Regional SCI Model Systems. MAIN OUTCOME MEASURES Secondary medical complications at annual follow-up years, including pneumonia/atelectasis, autonomic dysreflexia, deep venous thrombosis, pulmonary embolism, pressure ulcers, fractures, and renal calculi. RESULTS Pressure ulcers were the most frequent secondary medical complications in all years, and individuals at significant (p < .05) risk included those with complete injuries (years 1, 2, 5, 10), younger age (year 2), concomitant pneumonia/atelectasis (year 1, 2, 5), and violent injury (years 1, 2, 5, 10). The incidence of pneumonia/atelectasis was 3.4% between rehabilitation discharge and year-1 follow-up with those most significantly at risk being older than 60 years (years 1, 2, 5, 10) and tetraplegia-complete (years 1, 2). One-year incidence of deep venous thrombosis was 2.1% with a significant decline seen at year 2 (1.2%), and individuals most significantly (p < .001) at risk were those with complete injuries (year 1). The incidence of calculi (kidney and/or ureter) was 1.5% at 1-year follow-up and 1.9% at 5 years and was more frequent in patients with complete tetraplegia. Intermittent catheterization was the most common method of bladder management among patients with paraplegia but became less common at later postinjury visits. CONCLUSIONS Pressure ulcers, autonomic dysreflexia, and pneumonia/atelectasis were the most common long-term secondary medical complications found at annual follow-ups. Risk factors included complete injury, tetraplegia, older age, concomitant illness, and violent injury.

Incidence of respiratory complications following Spinal Cord Injury

From 1985 to 1990 five Model Regional Spinal Cord Injury (SCI) Care Systems participated in a collaborative effort to prospectively document the occurrence of adult respiratory distress syndrome (ARDS), aspiration, atelectasis, bronchitis, bronchospasm, lung abscess, pleural effusion, pneumonia, pneumo/hemothorax, pulmonary edema, pulmonary thromboembolism, tracheitis, upper respiratory infection, and ventilatory failure in patients admitted within 48 hours of SCI with a level of C1-T12 and Frankel Grade A, B, or C. The mean, standard deviation and range was calculated for the time of onset and duration of each complication. Of the 261 patients who entered the study, 175 (67%) experience 544 respiratory complications with atelectasis being the most common (36.4%) followed by pneumonia (31.4%) and ventilatory failure (22.6%). These complications occurred on the average of 17.7 days, 24.5 days and 4.5 days postinjury and lasted 12.8 days, 15.5 days, and 35.9 days, respectively. Twenty-two percent, 47%, and 31% had injury levels at C1-4, C5-8, T1-12, respectively with the majority being Frankel Grade A (78%). Eighty-four percent of C1-4, 60% of the C5-8, and 65% of the T1-12 had respiratory complications. Statistical analysis revealed complications to be significantly greater (p < .05) and of longer duration (p < .05) for the C1-4 group. Ventilatory failure and aspiration were the earliest to occur (at 4.5 days) for all SCI patients. Surprisingly, however, complications overall occurred significantly sooner (p < .05) in the T1-12 group. In conclusion, patients who sustain SCI have a high incidence of respiratory complications; however, some occur earlier and more frequently depending on the level of injury.

A multicenter study of women's self-reported reproductive health after spinal cord injury

OBJECTIVE Little attention has been given to womens reproductive health issues in the disabled population. This study documents the unique reproductive health conditions, complications, and behaviors in women with spinal cord injury (SCI). SUBJECTS A total of 472 women at least 18 years of age who were at least 1 year post-SCI. Their average age at injury was 32 years. DESIGN An extensive questionnaire regarding gynecologic, sexual, obstetric, and menopausal health issues was developed and piloted. The questionnaire was then administered by a trained woman health care clinician to women who agreed to participate in the study. SETTING Private outpatient clinics at 10 regional model SCI systems of care. RESULTS Women reported similar gynecologic problems in both preinjury and postinjury time periods. Exceptions were urinary tract infections and vaginal yeast infections. Sexually transmitted infections appear to be less common after injury, but the difference was not statistically significant. The number of hysterectomies was similar both before and after injury, but reasons differed greatly. Women with SCI were less likely to have routine mammograms. They reported similar preventive practices such as performing self-breast examinations and obtaining Papanicolaou smears. Almost 14% of women with SCI became pregnant after injury (101 pregnancies). Complications from pregnancy, labor, and delivery were reported to be more frequent in their postinjury than in their preinjury obstetric experiences. They tended to have babies of lower birth weight and with more complications at time of delivery. Of the sample, 87% reported having sexual intercourse before injury, with only 67% having intercourse after injury. Years postinjury and level of injury were predictive of intercourse; extent of injury was not. Experience of orgasms and methods of contraception varied among the two groups. There were significant complaints of dysreflexia and bladder incontinence with sexual function. Menopause after injury was reported by 14.6% of the women. Postinjury menopausal symptoms were of low frequency, but more than those reported by women who had undergone menopause before injury. Only 19% of women who had menopause after SCI were placed on hormone replacement therapy. Almost one third of the women who had menopause after injury reported new bone fractures. CONCLUSION This study illustrates the unique reproductive health concerns of women with SCI. Many pregnancy, labor, and delivery experiences in these women are different. Sexual activity and function have several disability-related consequences and the effects of menopause are still unknown, but may be more problematic than for able-bodied women.

Overview Of The National Spinal Cord Injury Statistical Center Database

Abstract Objective: An evaluation of the history, design, and status of the database of the National Spinal Cord Injury Statistical Center (NSCISC) was undertaken to identify its continued relevance. Research Design: A systematic review was conducted of goals, content, and quality control procedures, as well as its suitability and public availability for conducting future epidemiologic and health services research. Results: The NSCISC database contains information on approximately 29,000 persons injured since 1973 and treated at any regional model spinal cord injury system within 1year of injury. The NSCISC database is structured longitudinally with data collected at discharge, 1year after injury, 5 years after injury, and every 5 years thereafter. The database includes information on demographics, injury seventy, medical complications, surgical procedures, types and amounts of therapy, length of stay, charges, and both short-term and long-term treatment outcomes. Strengths include large sample size, use of valid and reliable measures, geographic and patient diversity, comprehensiveness, availability of long-term prospective follow-up information, good case identification, and rigorous quality control procedures. Limitations include lack of population basis, inclusion of only model system patients, losses to follow-up, and other missing data. Recent content additions include detailed information on each treatment phase, depression, substance abuse, environmental barriers to community integration, and patient identifying information. A process exists for researchers to gain access to the data. Conclusions: The database remains a valuable resource. Future plans include linkage to other databases to enhance research capability, a published research compendium, and development of a users guide to facilitate database usage.

Outcome measures for gait and ambulation in the spinal cord injury population.

Abstract Background: At the 2006 National Institute on Disability and Rehabilitation Research (NIDRR) sponsored pre-conference on spinal cord injury (SCI) outcomes, several gait and ambulation measures were evaluatedfor utility in clinical practice, validity, and reliability as research measurement tools. The Conference Subcommittee on Gait and Ambulation chose to review the Walking Index for Spinal Cord Injury II (WISCIII), 50-Foot Walk Test (50FTWT), 6-Minute Walk Test (6MWT), 10-Meter Walk Test (1 OMWT), andFunctional Independence Measure-Locomotor (FIM-L). Methods: A subcommittee of international experts evaluated each instrument for test construct,administration, population applicability, reliability, sensitivity to change, and validity. Evaluations for eachoutcome measure were compiled, distributed to the whole committee, and then further reviewed withaddition of comments and recommendations for consensus. An audience of experts voted on the validity and usefulness of each measure. Results: WISCI II and 1 OMWT were found to be the most valid and clinically useful tests to measureimprovement in gait for patients with SCI. FIM-L had little utility and validity for research in SCI. 6MWT and50FTWT were found to be useful but in need of further validation or changes for the SCI population. Conclusion: A combination of the 1 OMWT and WI SCI II would provide the most valid measure of improvement in gait and ambulation in as much as objective changes of speed, and functional capacity allow for interval measurement. To provide the most comprehensive battery, however, it will be importantto include a measure of endurance such as the 6MWT. Further validation and study should be devoted toWISCI II, 1 OMWT, and 6MWT as primary outcome measuresfor gait in SCI.

Reproductive Health Care for Women with Spina Bifida

Women with spina bifida have unique health care concerns and as the life expectancy of this population increases, they are transitioning from adolescence to womanhood and entering their reproductive years with little information about what to expect. Likewise, their health care providers do not have the benefit of evidence-based research that comprehensively addresses the issues these women may face related to reproduction or aging. Few studies have focused on the effects that spina bifida may have on these womens reproductive systems, nor has attention been paid to the effects that possible reproductive endocrine changes may have on their disability. Needless to say, concerns about sexuality, sexual function, and pregnancy are just as important to these women as they are to their able-bodied counterparts.

Measurement of sexual functioning after spinal cord injury: preferred instruments.

Abstract Background/Objective: To determine the utility of certain instruments to assess sexuality and fertility after SCI, an expert panel identified key areas to study and evaluated available instruments. These were rated according to certain predefined criteria. Methods: The authors divided sexual issues into male and female sexual function, male reproductive function, and female reproductive function. The instruments that have been used most frequently to measure these aspects of sexual function over the past 5 years were identified by expert consensus. Finally, these instruments were subjected to a critical review. Results: The Female Sexual Function Index (FSFI), measurement of vaginal pulse amplitude (VPA), the International Index of Erectile Function (IIEF), and the measurement of ejaculatory function and semen quality were considered appropriate measures to assess sexual responses and reproductive function after SCI. There were no measures identified to assess female reproductive function. Conclusions: For clinical trials aiming to improve sexual function after SCI, the FSFI or the IIEF is currently preferred. Although VPA is an appropriate means to assess female sexual responses, it is only useful for laboratory studies and is too invasive for use in clinical trials. For assessment of male fertility potential, assessment of ejaculatory capacity and semen analysis are recommended.

Body mass index underestimates adiposity in women with spinal cord injury

To assess the relationship between body mass index (BMI) and adiposity as well as the influence of injury level on this relationship in 24 women with spinal cord injury (SCI) and 23 able‐bodied (AB) women with similar age, race, and BMI.

Invited Review Shoulder Pain In Chronic Spinal Cord Injury, Part 1: Epidemiology, Etiology, And Pathomechanics

Abstract Background/Objectives: Few studies have adequately examined the unique issues of womenwith spina bifida as they enter their reproductive years. Most studies are anecdotal, retrospective case studies that contribute little to our understanding of the physiologicaleffects of the disability on the reproductive system and, conversely, the effects of thereproductive endocrine changes on the womans disability. The purpose of this article wastoreview previously published reports on the reproductive issues facing female adolescentsand women and to ascertain the current knowledge so that future research needs can be established. Methods: Multiple MEDLINE searches were performed for publications from 1957 through the present pertaining to females/women with spina bifida and/or disabilities. Papers werethen chosen if information was provided on menarche, menstruation and sexual maturation,gynecologic issues, sexual function, birth control, pregnancy outcomes, and menopause. These were then reviewed and classified according to the level of evidence (as defined by Ball et al). Results: More than 150 titles and abstracts were reviewed for inclusion. Of these, 75 papers met the guidelines for the subject content. Studies were stratified by level of evidence and included 1 study at level 3,71 studies at level 4,and 3 studies at level 5. Conclusion: Little research has examined the reproductive issues of women with spina bifida and women with other neurologic disabilities. Future controlled prospective research studies are needed to examine issues related to puberty and sexual and gynecologic issues throughout the life span and pregnancy in these populations.

Development of international standards to document sexual and reproductive functions after spinal cord injury: Preliminary report

Clinicians need standard terminology to communicate effectively about remaining autonomic function in persons after spinal cord injury. This article illustrates the development of standard nomenclature that describes the impact of injury on sexual functioning. A standard anatomic diagnosis and a secondary means of describing the presence of male and female sexual dysfunction, genital arousal, and orgasmic function are discussed.