G Zeilig

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.

Five-year experience with the ‘Sheba’ model of comprehensive orthogeriatric care for elderly hip fracture patients

Background and purpose: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period. Method: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine. Results: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6 ± 2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3 ± 7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low. Conclusions: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies.

Hybrid functional electrical stimulation orthosis system for the upper limb : Effects on spasticity in chronic stable hemiplegia

A new hybrid functional electrical stimulation orthosis system for the upper limb has been designed to allow for ease of use in the home as a daily treatment modality, as well as offer the opportunity for function enhancement. In a pilot study, the system was used by ten patients with chronic stable hemiparesis secondary to cerebral vascular accident and head injuries. The patients were referred by their treating physicians or therapists after meeting the inclusion criteria of good general health, being greater than one year after head injury, or being ten months post-stroke, with no observed neurologic changes in the prior six weeks. Each of these patients had received prolonged physical therapy, either continuous from the initial inpatient rehabilitation treatment or on an intermittent basis over a period of years. The baseline status for factors related to increased muscle tone, i.e., passive range of motion at the wrist and elbow, posture at rest, posture immediately following activity, and spasticity were quantified before the treatment protocol with the functional electrical stimulation orthosis. Active range of motion and tests of functional use of the involved upper limb were also assessed. The patients were instructed in the protocol, trained in the use of the system, and then used the electrical orthosis at home for up to several hours per day. Follow-up assessments were at six months. A statistically significant improvement was noted in all muscle tone/spasticity parameters measured. A separate report will describe the effects on voluntary motion and functional capabilities.

SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions

Study design:A multi-center international cohort study.Objective:To evaluate the reliability and validity of the third version of the Spinal Cord Independence Measure (SCIM III), separately for patients with traumatic spinal cord lesions (SCLs).Setting:A total of 13 spinal cord units in six countries from North America, Europe and the Middle-East.Methods:SCIM III and Functional Independence Measure (FIM) were assessed for 261 patients with traumatic SCLs, on admission to rehabilitation and before discharge, by two raters. Conventional statistical measures were used to evaluate the SCIM III reliability and validity.Results:In almost all SCIM III tasks, the total agreement between the paired raters was >80%. The κ coefficients were all >0.6 and statistically significant. Pearsons coefficients of the correlations between the paired raters were >0.9, the mean differences between raters were nonsignificant and the intraclass correlation coefficients (ICCs) were ⩾0.95. Cronbachs α values for the entire SCIM III scale were 0.833–0.835. FIM and SCIM III total scores were correlated (r=0.84, P<0.001). SCIM III was more responsive to changes than FIM. In all subscales, SCIM III identified more changes in function than FIM, and in 3 of the 4 subscales, differences in responsiveness were statistically significant (P<0.02).Conclusion:The results confirm the reliability and validity of SCIM III for patients with traumatic SCLs in a number of countries.

Long-term morbidity and mortality after spinal cord injury: 50 years of follow-up.

Objective: To determine the long-term mortality rate and the types of morbidity among all people with spinal cord injuries (SCI) that occurred during the 1948 Israel War of Independence.Method: Chart review and telephone interviews for collecting demographic data, injury characteristics, marital status, physical activities, employment, morbidity and mortality.Results: Twenty individuals with SCI (19 males, one female). There was no regular follow-up during the first 20 years post injury. The most frequent morbidities were genito-urinary, cardiovascular and decubiti. Ten (50%) had died during this overall follow-up interval. The average age at death was 60 years. The cause of death was cardiovascular in six, neoplastic disease in two, pneumonia in one, and one died from an unknown cause.Conclusions: The data analysis showed that those who died participated less in physical activity and fewer were employed as compared to the survivors.

Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions.

Study design:Multicenter international cohort study.Objective:The objective of this study was to establish target values for Spinal Cord Independence Measure (SCIM) III scoring in rehabilitation for clinically complete spinal cord lesion (SCL) neurological levels.Setting:In total, 13 spinal cord units in six countries from North America, Europe and the Middle East were taken.Methods:Total SCIM III scores and gain at discharge from rehabilitation were calculated for SCL levels in 128 patients with American Spinal Injury Association Impairment Scale (AIS) grade A on admission to rehabilitation.Results:Median, quartiles, mean and s.d., values of discharge SCIM III scores and SCIM III gain for the various SCL levels are presented. Total SCIM III scores and gain were significantly correlated with the SCL level (r=0.730, r=0.579, P<0.001).Conclusions:Calculated discharge SCIM III scores can be used as target values for functional achievements at various neurological levels in patients after AIS A SCL. They are generally, but not always, inversely correlated with SCL level.

The Month of Birth and the Incidence of Multiple Sclerosis in the Israeli Population

Background: Recent studies on date of birth of multiple sclerosis (MS) patients showed a spring peak and an autumn nadir. We examined the effect of date of birth in a large group of MS patients and non-MS patients, compared to the general population in Israel. Methods: A retrospective analysis was performed in a large cohort of MS patients and patients with other neurological disorders. The date of birth, gender, and country of birth were identified for each patient. The results were compared to a national database. Results: There were 2,264 MS patients and 1,758 patients with other diagnoses. No significant peak or nadir in the date of birth was identified in either group, both in patients born in Israel or in immigrants. No difference was found compared to the national birth rate. When we controlled for the country of birth, there was no difference. Conclusion: An increased frequency of MS patients born in the months of April and May was considered as a proof of maternal influence. The results of our study show that this finding is not consistent worldwide. The month of birth was not found to be a significant factor in Israeli MS patients.

Hyperprolactinemia, galactorrhea and amenorrhea in women with a spinal cord injury

Six women with a traumatic spinal cord injury (SCI) developed hyperprolactinemia, amenorrhea and galactorrhea. Five of them had thoracic level lesions and 1 had a lumbosacral lesion. Two were postpartum and 1 was pregnant at the time of injury. Transient diabetes insipidus developed in 1 patient. Temporary administration of bromocriptine decreased prolactin levels, caused cessation of lactation and restored ovulatory cycles. The syndrome disappeared spontaneously in all 6 patients. Pituitary stalk concussion resulting from the trauma might cause this phenomenon, with the level of the cord injury playing a role. Being pregnant or early postpartum can predispose women to develop this syndrome.

'Duplicate limbs' sensation in acute traumatic quadriplegia.

A 64-year-old man sustained acute quadriplegia due to a traffic accident, while in the midst of a petit mal seizure. After recovery from the initial medical complications he developed a duplicate limb phenomenon. The patient felt that another pair of upper and lower limbs had grown from his body, parallel to the paralysed limbs. To the best of our knowledge this duplicate phenomenon in all limbs has not been described before in a traumatic quadriplegic patient. It is our impression that this phenomenon is a rare example of preoccupation with the paralytic limbs, of sensory deprivation with a (possible) unusual drug reaction.

Dermatological findings following acute traumatic spinal cord injury

Study design:Prospective study.Objective:To identify and define dermatological conditions following acute traumatic spinal cord injury (ATSCI) during inpatient rehabilitation.Setting:Spinal Cord Injury Unit, The Department of Neurological Rehabilitation, The Chaim Sheba Medical Center, Israel.Methods:During a 1-year study, all patients following ATSCI were prospectively studied for new dermatological findings during their inpatient rehabilitation. Every new dermatological finding was defined concerning its location with regard to the patients neurological level, the time from injury to appearance and the exact dermatological diagnosis.Results:During the study year, 46 ATSCI patients were hospitalized in our department, of whom were 38 (82.6%) males and eight (17.4%) females (mean age 30.2 years). A total of 21 (45.6%) patients were tetraplegic and 25 (54.3%) paraplegic. Of the patients, 28 (60.9%) had complete neurological injuries and 18 (39.1%) incomplete. In all, 14 (30.4%) patients developed a dermatological condition. There was no significant age or sex correlation to the development of these complications. There was a greater likelihood of paraplegia (48 versus 9.5%, P=0.005) and being neurologically complete (42.9 versus 11.1%, P=0.02). The dermatological findings appeared on an average of 80.3 days after the initial neurological insult. There were a total of 22 different dermatological findings: 11 (50%) were local fungal infections, two (9.1%) psoriatic lesions, two (9.1%) hyperkeratotic lesions, two (9.1%) bacterial infections (one folliculitis, one impetigo) and single cases of seborrheic dermatitis, acne, alopecia, scabies and allergic reaction. Of the findings, 14 (63.6%) were below the neurological level, including all of the fungal infections.Conclusions:Dermatological findings are common during rehabilitation of ATSCI. The clinical impact of these findings is low, but nevertheless, they are troublesome to the patient. The most common dermatological disorder was a local fungal infection below the neurological level. Paraplegic patients are more susceptible to the development of this condition. Patient and staff education regarding proper skin care may reduce these infections.