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The Spinal Cord Independence Measure (SCIM) version III: Reliability and validity in a multi-center international study

Purpose. To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in a multi-center cohort study. Method. Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries from three continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission to rehabilitation and before discharge. Results. Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statistically significant (P < 0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclass correlation coefficients were above 0.94. Cronbachs α was above 0.7. The coefficient of Pearson correlation between FIM and SCIM III was 0.790 (P < 0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration and sphincter management and Mobility indoors and outdoors. Conclusions. The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitations of the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can be safely used for clinical and research trials, including international multi-center studies.

Return to work following spinal cord injury: a review

Purpose. To review literature on return to work (RTW) and employment in persons with spinal cord injury (SCI), and present employment rates, factors influencing employment, and interventions aimed at helping people with SCI to obtain and sustain productive work. Methods. A systematic review for 2000 – 2006 was carried out in PubMed/Medline, AMED, (ISI) Web of Science, EMBASE, CINAHL, PsycInfo and Sociological abstracts database. The keywords ‘spinal cord injuries’, ‘spinal cord disorder’, ‘spinal cord lesion’ or ‘spinal cord disease’ were cross-indexed with ‘employment’, ‘return to work’, ‘occupation’ or ‘vocational’. Results. Out of approximately 270 hits, 110 references were used, plus 13 more found elsewhere. Among individuals with SCI working at the time of injury 21 – 67% returned to work after injury. RTW was higher in persons injured at a younger age, had less severe injuries and higher functional independence. Employment rate improved with time after SCI. Persons with SCI employed ranged from 11.5% to 74%. Individuals who sustained SCI during childhood or adolescence had higher adult employment rates. Most common reported barriers to employment were problems with transportation, health and physical limitations, lack of work experience, education or training, physical or architectural barriers, discrimination by employers, and loss of benefits. Individuals with SCI discontinue working at younger age. Conclusions. This review confirmed low employment rates after SCI. Future research should explore interventions aimed at helping people with SCI to obtain and sustain productive work.

Bone fracture during electrical stimulation of the quadriceps in a spinal cord injured subject

We report a fracture through the lateral femoral condyle of a paraplegic subject caused by electrical stimulation (ES). The subject was a 50-year-old man who 4 years earlier had sustained a complete spinal cord injury (SCI) at level T6. The fracture occurred during ES-induced measurement of maximal isometric torque of the quadriceps with the knee flexed at an angle of 90 degrees. ES was delivered through surface electrodes with biphasic square wave pulses from a constant current stimulator. The torque was calculated to be 93Nm, corresponding to 20.8kg at the ankle. The regional bone mineral density of the entire lower extremities was .83g/cm2, corresponding to 60% of sex- and age-matched able-bodied reference values. Several factors are suspected to have contributed to the fracture: maximal ES in combination with a muscle spasm, severe osteoporosis, increased muscular strength induced by regular ES cycling (twice a week), and testing position with the knee locked in 90 degrees flexion. The risk of fracture as well as various precautions are discussed and should be taken into consideration in future studies.

Suicide in a spinal cord injured population: Its relation to functional status☆☆☆★

OBJECTIVEnTo determine the relation between functional status and risk of suicide among individuals with spinal cord injury (SCI).nnnDESIGNnA follow-up study of all individuals who survived a traumatic SCI during the period from 1953 through 1990.nnnSETTINGnAn SCI center in eastern Denmark.nnnSUBJECTSnA total of 888 individuals with SCI, including 236 who died, 23 of whom committed suicide.nnnMAIN OUTCOME MEASURESnStandardized Mortality Ratios (SMRs) of suicides among individuals with SCI.nnnRESULTSnA 100% follow-up was established January 1, 1993. The total suicide rate among individuals with SCI was nearly five times higher than expected in the general population and lower for men than for women. The suicide rate doubled from an early inclusion period (1953-1971) to a later period (1972-1990). An unexpected finding was that the suicide rate in the group of marginally disabled persons was nearly twice as high as the group of functionally complete tetraplegic individuals.nnnCONCLUSIONnGiven the high frequency of suicide, there is a need for increased awareness by rehabilitation staff and general practitioners regarding depression and psychological adjustment difficulties. Such conditions should be given special attention during rehabilitation and follow-up, especially among women with SCI and the marginally disabled.

Mesenchymal stem cells improve locomotor recovery in traumatic spinal cord injury: systematic review with meta-analyses of rat models.

Traumatic spinal cord injury (SCI) is a devastating event with huge personal and societal costs. A limited number of treatments exist to ameliorate the progressive secondary damage that rapidly follows the primary mechanical impact. Mesenchymal stem or stromal cells (MSCs) have anti-inflammatory and neuroprotective effects and may thus reduce secondary damage after administration. We performed a systematic review with quantitative syntheses to assess the evidence of MSCs versus controls for locomotor recovery in rat models of traumatic SCI, and identified 83 eligible controlled studies comprising a total of 1,568 rats. Between-study heterogeneity was large. Fifty-three studies (64%) were reported as randomised, but only four reported adequate methodologies for randomisation. Forty-eight studies (58%) reported the use of a blinded outcome assessment. A random-effects meta-analysis yielded a difference in behavioural Basso-Beattie-Bresnahan (BBB) locomotor score means of 3.9 (95% confidence interval [CI] 3.2 to 4.7; P<0.001) in favour of MSCs. Trial sequential analysis confirmed the findings of the meta-analyses with the upper monitoring boundary for benefit being crossed by the cumulative Z-curve before reaching the diversity-adjusted required information size. Only time from intervention to last follow-up remained statistically significant after adjustment using multivariate random-effects meta-regression modelling. Lack of other demonstrable explanatory variables could be due to insufficient meta-analytic study power. MSCs would seem to demonstrate a substantial beneficial effect on locomotor recovery in a widely-used animal model of traumatic SCI. However, the animal results should be interpreted with caution concerning the internal and external validity of the studies in relation to the design of future clinical trials.

Urological Situation Five Years after Spinal Cord Injury

OBJECTIVEnTo evaluate bladder emptying methods and urinary tract problems five years after spinal cord injury (SCI).nnnMATERIAL AND METHODSnNeurological level, method of bladder emptying and urological investigations were retrieved from the records for all 165 patients admitted to our Centre for Spinal Cord Injured with a traumatic SCI sustained from 1984 to 1988.nnnRESULTSnA total of 77 patients with completed 5-year control were included in the final analyses. We found that 64% had suprasacral bladder dysfunction, while 23% had infrasacral bladder dysfunction. Plasma-creatinine was normal, both at the initial examination and the 5-year control. From the time in the SCI centre to the 5-year control a trend towards less intermittent catheterization and more use of abdominal pressure was observed. During the follow-up period nine patients (12%) experienced urinary calculi. Six bladder- stones were removed endoscopically. Five had kidney stones; three were left untreated, one was removed by extracorporeal shock wave lithotripsy and one by open surgery. Four patients (5%) had renograms with functional distribution outside the limits 40-60%. Three patients had bladder neck incision performed, one had a sacral anterior root stimulator implanted and one had a continent Kock reservoir. No sphincterotomies were performed. Fifty-one had received medicine to facilitate bladder emptying. Eighty-one percent had been treated for at least one urinary tract infection (UTI), 22% had 2-3 UTI/year, and 12% 4 or more UTI/year. Twelve percent had been on prophylactic low-dose antibiotics.nnnCONCLUSIONnThe final outcome regarding urological complications is satisfactory even with our conservative handling of the SCI individuals.

Validation of the walking index for spinal cord injury in a US and European clinical population

Objective:To demonstrate the prospective construct validity of the walking index for spinal cord injury (WISCI) in US/European clinical population.Design:Prospective Cohort in Denmark, Germany, Italy and the USA.Participants/Method:Participants with acute complete/incomplete (ASIA Impairment Scale (AIS) A, B, C and D) traumatic spinal cord injuries were enrolled from four centers. Lower extremity motor scores (LEMS), WISCI level and Locomotor Functional Independence Measure (LFIM) levels were assessed with change in ambulatory status. WISCI progression was assessed for monotonic direction of improvement (MDI). LEMS were correlated to WISCI/LFIM. Use of walking aids/braces were analyzed.Results:One hundred and seventy participants were enrolled and 20 excluded. Of the 150 participants (USA 112/150; Europe 38/150) (AIS A=59, B=19, C=32, D=40), LEMS and WISCI assessments were performed initially and at final assessment (3–12 months post injury) or until maximum WISCI score of 20. Eighty-five percent of motor complete (66/78) and 10% (7/72) of motor incomplete participants showed no progression (73/150). Of the remaining participants (77/150) who improved, 81% (62/77) showed MDI. However, the deviation from MDI occurred only at one time-point in 10/15 participants. LEMS correlated with WISCI at initial and final assessment (0.47 and 0.91 P<0.001). Parallel bar use differed between the US and Europe possibly due to patterns of care. Use of braces also differed.Conclusion:The results support the hierarchical ranking of the WISCI scale and the correlation of WISCI levels to impairment (LEMS) in a clinical setting of four nations. Differences in practice between the US and Europe need consideration in design of trials.

Urinary calculi following traumatic spinal cord injury

Objective. To investigate the time aspect of the development of renal and bladder calculi in individuals with traumatic spinal cord injury (SCI) and a possible relation between the development of calculi and the bladder-emptying method. Material and methods. The study comprised a retrospective data collection from medical records and a questionnaire follow-up at least 10 years after the SCI. Results. A total of 236 individuals with SCI (82% male, 18% female; 47% tetraplegic, 53% paraplegic) who were injured between 1956 and 1990 participated in the study and the response rate was 84.6%. The mean age at the time of follow-up was 50.5 years (range 28–84 years). The mean duration from the time of SCI was 24.1 years (range 10–45 years). During follow-up 47 participants (20%) had at least one episode of renal calculi and 32 (14%) had at least one episode of bladder calculi. The risk of first renal and bladder calculus was highest within the first 6 months post-injury. The cumulative proportion of calculi-free participants 45 years post-injury was 62% for renal calculi and 85% for bladder calculi. For participants who did not develop renal calculi within the first 2 years post-injury, the risk of having a renal calculus within the next 43 years was 34%. For bladder calculi the corresponding risk of having a bladder calculus within the next 43 years was 5%. No significant differences were found regarding the bladder-emptying method and either renal or bladder calculi, only a non-significant trend that more participants with bladder calculi used indwelling catheters. Participants with renal or bladder calculi were not statistically significantly different from the remainder of the study group regarding gender, para- or tetraplegia or Frankel classification. Conclusions. The risk of developing renal and bladder calculi was higher in the SCI population compared to the normal population. Bladder calculi primarily occur early post-injury and renal calculi appear both early post-injury and years later. Therefore, it is important to follow individuals with SCI regularly by means of urological investigations from the time of the injury until death.

Ambulation in adults with myelomeningocele. Is it possible to predict the level of ambulation in early life

ObjectiveThe objective of this study was to evaluate the prediction of ambulation in adults with myelomeningocele from muscle strength testing and ambulation in early life.Materials and methodsFifty-two myelomeningocele (MMC) individuals at the age 18–37xa0years at follow-up were studied. Information on muscle strength and ambulatory function in early life was retrieved from medical records. The motor levels determined by the muscle strength were used to predict ambulatory function later in life. At follow-up, a clinical examination was performed.ResultsOf 20 MMC individuals assessed with muscle strength within the first year of life, 7 achieved the predicted ambulatory function, 6 had a better, and 7 a poorer function. Of 32 individuals with known muscle strength at the age of 5–8xa0years, 10 had function as predicted, 5 a better ambulatory function, and 17 had a poorer ambulation in adult life than predicted. Good strength in quadriceps muscles gave significant better prospect for adult walking. Of the 52 participants, 41 retained their ambulation status from 5–8xa0years of age.ConclusionFor MMC individuals with motor levels L3–L5, adult ambulatory function cannot be determined from muscle strength in early life, while it to some extend can be predicted for motor levels at or above L2 and at or below S1. The majority of the participants who at the age 5–8xa0years were community walkers without walking aid kept that function.

Residual urine after intermittent catheterization in females using two different catheters

Objective. To evaluate the ability of a new 7-cm long female catheter (SpeediCath Compact®; Coloplast A/S, Humlebæk, Denmark) to drain the urinary bladder compared to standard-length female catheters. Material and methods. This was a prospective, single-blind, randomized, crossover study. Twenty-four female intermittent catheter users with neurogenic bladder dysfunction took part. Each test person catheterized three times with the test catheter on one day and three times with a standard-length female catheter on another day. The residual urine (RU) volume in the bladder after catheterization was measured by means of ultrasound. Furthermore, participants were asked to evaluate the length and handling of the test catheter during insertion, and to rate their overall satisfaction with the test catheter. Results. There was no difference between the catheters in terms of volume of RU. One test person could not use the SpeediCath Compact catheter. Twenty-three participants found handling the SpeediCath Compact very easy or easy and rated their overall satisfaction with it as either very satisfying or satisfying. Conclusion. In most females, the SpeediCath Compact catheter is at least as efficient at emptying the bladder as more conventional female catheters.