Eimear Smith

A study of bone mineral density in adults with disability.

OBJECTIVES To examine prevalence of low bone mineral density (BMD) among adults with disability, using World Health Organization diagnostic categories. DESIGN Cross-sectional study. SETTING National Rehabilitation Hospital, Dublin, Ireland. PARTICIPANTS Patients (N=255; 178 men, 77 women) who were disabled for at least 3 months because of acquired brain injury, spinal cord injury, other neurologic condition, or lower-limb amputation. INTERVENTIONS None. MAIN OUTCOME MEASURES Laboratory investigations including intact parathyroid hormone, 25-hydroxyvitamin D (25-OHD), and sex hormones; and BMD of lumbar spine and at least 1 hip, measured by dual-energy x-ray absorptiometry and expressed as T scores and z scores. RESULTS Mean age +/- SD of participants was 48.7+/-15.6 years. Vitamin D deficiency, 25-OHD level 50 nmol/L or less, occurred in 154 (62.9%); insufficiency, a level between 51 and 72 nmol/L, occurred in 36 (14.7%). Based on T scores, 108 participants (42.4%) had osteopenia, and 60 (23.5%) had osteoporosis. A z score of -1 or less but more than -2 occurred in 76 (29.8%); a further 52 (20.4%) had a z score of -2 or less. On multiple linear regression analysis, ambulatory status and duration of disability were independent predictors of BMD at neck of femur (beta=.152, P=.007; beta=-.191, P=.001, respectively) and total proximal femur (beta=.170, P=.001; beta=-.216, P<.001, respectively). CONCLUSIONS Osteopenia and osteoporosis are very common in adults with disability participating in rehabilitation, compared with the general young adult population. Duration since onset of disability and mobility status are independent predictors of BMD at the hip. Bone health monitoring should form part of the long-term follow-up in adults with newly acquired disabilities.

International Retrospective Comparison of Inpatient Rehabilitation for Patients With Spinal Cord Dysfunction Epidemiology and Clinical Outcomes

OBJECTIVE To describe and compare epidemiologic characteristics of patients with spinal cord dysfunction admitted to spinal rehabilitation units (SRUs) in 9 countries (Australia, Canada, Italy, India, Ireland, The Netherlands, Switzerland, United Kingdom, and United States). DESIGN Retrospective multicenter open-cohort case series. SETTING SRUs. PARTICIPANTS Patients (N=956) with initial onset of spinal cord dysfunction consecutively admitted between January 1, 2008, and December 31, 2010. Median age on admission was 59 years (interquartile range [IQR], 46-70), and 60.8% of patients were men. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Demographic characteristics (eg, age, sex), time frame over which clinical symptoms of spinal cord dysfunction developed, etiology, length of stay in hospital, level of lesion and American Spinal Injury Association Impairment Scale (AIS) grade, discharge destination, and inpatient mortality. RESULTS The time frame of onset of spinal cord dysfunction symptoms was as follows: ≤1 day (28.5%); ≤1 week (13.8%); >1 week but ≤1 month (10.5%), and >1 month (47.2%). Most common etiologies were degenerative conditions (30.8%), malignant tumors (16.2%), ischemia (10.9%), benign tumors (8.7%), and bacterial infections (7.1%). Most patients (72.3%) had paraplegia. The AIS grade on SRU admission was grade A in 14%, grade B in 6.5%, grade C in 24%, grade D in 52.4%, grade E in 0.2%, and missing in 2.9%. AIS grade significantly improved by discharge (z=-10.1, P<.0001). Median length of stay in the SRU was 46.5 days (IQR, 17-89.5). Most (80.5%) patients were discharged home. Differences between countries were found for most variables. CONCLUSIONS This international study of spinal cord dysfunction showed substantial variation of etiology, demographic, and clinical characteristics across countries. Further research, including multiple centers per country, are needed to separate country effects from center effects.

International Retrospective Comparison of Inpatient Rehabilitation for Patients With Spinal Cord Dysfunction: Differences According to Etiology

OBJECTIVES To describe and compare epidemiologic characteristics and clinical outcomes of patients with nontraumatic spinal cord dysfunction according to etiology. DESIGN Retrospective, multicenter open-cohort case series. SETTING Spinal rehabilitation units (SRUs) in 9 countries. PARTICIPANTS Patients (N=956; men, 60.8%; median age, 59.0y [interquartile range, 46-70.0y]; paraplegia, n=691 [72.3%]) with initial onset of spinal cord dysfunction consecutively admitted between January 1, 2008, and December 31, 2010. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Etiology of spinal cord dysfunction, demographic characteristics, length of stay (LOS) in rehabilitation, pattern of spinal cord dysfunction onset, discharge destination, level of spinal cord damage, and the American Spinal Injury Association Impairment Scale (AIS) grade on admission and discharge. RESULTS The most common etiologies were degenerative (30.8%), malignant tumors (16.2%), infections (12.8%), ischemia (10.9%), benign tumors (8.7%), other vascular (8.5%), and other conditions (12.1%). There were major differences in epidemiologic characteristics and clinical outcomes of patients with different etiologies of spinal cord dysfunction. Paraplegia was more common in patients with a malignant tumor and vascular etiologies, while tetraplegia was more common in those with a degenerative etiology, a benign tumor, and infections. Patients with a malignant tumor tended to have the shortest LOS in the SRU, while those with a vascular etiology tended to have the longest. Except for patients with a malignant tumor, all patient groups had a significant change in their AIS grade between admission and discharge. CONCLUSIONS This international study of spinal cord dysfunction showed substantial variation between the different etiologies regarding demographic and clinical characteristics, including changes in AIS between admission and discharge.

Bone Mineral Density in Adults Disabled Through Acquired Neurological Conditions: A Review

This article is a review of the changes in bone mineral density (BMD), which occur in a number of acquired neurological conditions resulting in disability. For each of spinal cord injury, stroke, multiple sclerosis, Parkinsons disease, and traumatic brain injury, the following aspects are discussed, where information is available: prevalence of low BMD according to World Health Organization diagnostic categories and recommended diagnostic method, prevalence based on other diagnostic tools, comparison of BMD with a control population, rate of decline of BMD following onset of the neurological condition, factors influencing decline; mechanism of bone loss, and fracture rates. The common risk factors of immobilization and vitamin D deficiency would appear to cross all disability groups, with the most rapid phase of bone loss occurring in the acute and subacute phases of each condition.

Treatments for Osteoporosis in People With a Disability

The morbidity from osteoporotic fractures for people with a disability is considerable because of the increased risk of medical complications, loss of independence and mobility, and prolonged hospitalization. The frequency with which low bone mineral density occurs in people with a disability is now well recognized, and professionals have a greater awareness of the need to investigate bone mineral density levels with a view to preventing fragility fractures. After patients with osteoporosis are identified, the challenge is to treat them appropriately. This article reviews the physical and pharmacologic measures that have been researched in the prevention and treatment of low bone mineral density in people with a disability.

Epidemiology of Traumatic Spinal Cord Injury in Ireland, 2010–2015

Background: The International Spinal Cord Society and World Health Organisation recommend the collection of epidemiological data on traumatic spinal cord injury (TSCI). A 1-year prospective study is ongoing in Ireland. While the results of this study are awaited, it was concluded from a feasibility exercise that a complete retrospective dataset, 2010–2015, could be obtained and would be useful for service planning. Methods: All patients with TSCI discharged from the national SCI acute and rehabilitation centres were included. Data was collected on gender, age, aetiology, level of injury, American Spinal Injuries Association impairment scale, length of rehabilitation admission and discharge destination. Population denominators were national census figures 2006 and 2011, rolled forward. Results: The incidence of TSCI remained constant throughout the study period, 11.5–13.3 per million per year. The mean age of injury onset was 48.9 (SD 19.8) years. Males accounted for 71.5%. The most common injury level/AIS was incomplete tetraplegia, accounting for 43.2% of all TSCI. Leading aetiology was falls, accounting for 53.3% of injuries. Patients with incomplete tetraplegia were older than those with all other injuries (p < 0.001). Conclusions: The epidemiological trends identified are similar to those prevalent elsewhere in the developed world. More incomplete tetraplegia among an older patient population necessitates a review of how acute care and rehabilitation services are delivered.

Epidemiology of Pediatric Traumatic and Acquired Nontraumatic Spinal Cord Injury in Ireland

Objective: To examine the epidemiology of pediatric traumatic (TSCI) and acquired nontraumatic spinal cord injury (NTSCI) in Ireland. There are few studies reporting pediatric TSCI incidence and fewer of pediatric NTSCI incidence, although there are several case reports. As there is a single specialist rehabilitation facility for these children, complete population-level data can be obtained. Method: Retrospective review of prospectively gathered data in the Patient Administration System of the National Rehabilitation Hospital of patients age 15 years or younger at the time of SCI onset. Information was retrieved on gender, age, etiology, level of injury/AIS. Population denominator was census results from 1996, 2002, 2006, and 2011, rolled forward. Results: Since 2000, 22 children have sustained TSCI and 26 have sustained NTSCI. Median (IQR) age at TSCI onset was 6.3 (4.4) years, and at NTSCI onset it was 7.3 (8.1) years. Most common TSCI etiology was transportation (n = 10; 45.5%), followed by surgical complications (n = 8; 36.4%); most common injury type was complete paraplegia (n = 12; 54.5%) followed by incomplete paraplegia (n = 5; 22.7%). Most common NTSCI etiology was transverse myelitis (n = 11; 42.3%) followed by vascular (n = 5; 20%); most common injury type was incomplete paraplegia (n = 17; 65.4%) followed by incomplete tetraplegia (n = 6; 24%). Incidence of TSCI ranged from 0 to 3.1 per million per year; incidence of NTSCI ranged from 0 to 6.5 per million per year. Conclusion: Incidence of SCI in Ireland seems similar to or slightly lower than other developed countries. Injury patterns are also similar, considering variations in reporting methods.