Gordana Savic

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.

A multicenter international study on the spinal cord independence measure, version III: Rasch psychometric validation

Background:A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version.Objective:To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis.Design:Multicenter cohort study.Setting:Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East.Subjects:425 patients with spinal cord lesions (SCL).Interventions:SCIM III assessments by professional staff members. Rasch analysis of admission scores.Main outcome measures:SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries.Results:Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79–1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found.Conclusions:The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.

Functional Recovery Measures for Spinal Cord Injury: An Evidence-Based Review for Clinical Practice and Research

Abstract Background/Objective: The end goal of clinical care and clinical research involving spinal cord injury (SCI) is to improve the overall ability of persons living with SCI to function on a daily basis. Neurologic recovery does not always translate into functional recovery. Thus, sensitive outcome measures designed to assess functional status relevant to SCI are important to develop. Method: Evaluation of currently available SCI functional outcome measures by a multinational work group. Results: The 4 measures that fit the prespecified inclusion criteria were the Modified Barthel Index (MBI), the Functional Independence Measure (FIM), the Quadriplegia Index of Function (QIF), and the Spinal Cord Independence Measure (SCIM). The MBI and the QIF were found to have minimal evidence for validity, whereas the FIM and the SCIM were found to be reliable and valid. The MBI has little clinical utility for use in the SCI population. Likewise, the FIM applies mainly when measuring burden of care, which is not necessarily a reflection of functional recovery. The QIF is useful for measuring functional recovery but only in a subpopulation of people with SCI, and substantial validity data are still required. The SCIM is the only functional recovery outcome measure designed specifically for SCI. Conclusions: The multinational work group recommends that the latest version of the SCIM (SCIM III) continue to be refined and validated and subsequently implemented worldwide as the primary functional recovery outcome measure for SCI. The QIF may continue to be developed and validated for use as a supplemental tool for the nonambulatory tetraplegic population.

Sports, recreation and employment following spinal cord injury--a pilot study.

Study design: A pilot postal survey. Objective: To examine the levels of sporting/recreational activities, education and employment in people with spinal cord injury (SCI) and to assess if involvement in sport and recreation is associated with higher levels of education and employment. Setting: National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital, Aylesbury, UK. Methods: Forty-five subjects, who met the following criteria: SCI at level C5 or below, wheelchair dependent, aged between 18 and 50 at the time of injury, injured at least 10 years ago, admitted to the NSIC within 6 months of injury and resident in the UK, completed a 26-item postal questionnaire. Results: Among the 45 subjects 47% participated in physical activities (20% in sport; 27% in recreation), 33% were employed (29% full-time) and 18.5% had undergone further education at the time of the survey. Participation in sports as well as employment status decreased after injury (P<0.01) usually as a result of poor access to sports and work facilities. Only 4% of investigated SCI patients started to practise physical activity after the accident whilst 42% stopped. Conclusions: Levels of sporting/recreational activities and employment decreased significantly after injury. No significant correlation was found between sport/recreation involvement and education/employment status. Further investigation with a large number of participants that will enable additional analysis of subgroups, such as level of injury and functional independence, is required. Sponsorship: The study was partly funded by the British Council. Spinal Cord (2000) 38, 173–184.

Hospital readmissions in people with chronic spinal cord injury

Study design: Longitudinal observational.Objectives: To examine frequency and duration of hospital readmissions in a population based sample of people with chronic spinal cord injury (SCI) and to look at medical reasons necessitating readmissions and factors influencing them.Setting: National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK and Regional Spinal Injuries Centre, District General Hospital, Southport, UK.Methods: One-hundred-and-ninety-eight SCI patients, all injured more than 20 years ago, were interviewed on three occasions and their medical records reviewed for the period 1990–1996.Results: Between 1990 and 1996, 127 patients (64% of the sample) required hospital treatment for late medical complications, with 481 readmissions between them and the mean length of stay of 12.03 days per readmission. Only 58% of all readmissions were into specialised spinal injuries centres. Averaged over the entire sample, the readmission rate was 0.4 readmissions per person at risk per year, and the occupancy rate was 4.9 bed-days per person at risk per year. The most frequent reason for readmissions were urinary tract complications (40.5% of all readmissions) and the highest bed occupancy was for skin problems (32.2% of all bed-days). When compared with the non-hospitalised group (36% of the sample), the readmitted patients had longer duration of paralysis and lower disability and handicap scores as measured by Functional Independence Measure (FIM) and Craig Handicap Assessment & Reporting Technique (CHART). The subgroups did not differ significantly by neurological grouping or age.Conclusions: Urinary and skin complications are the two main reasons for hospital readmissions in people with chronic SCI. Risk of readmissions increases with time since injury and with disability and handicap severity. Hospital bed requirements for people with chronic SCI are greater than the amount of clinical provision currently available in specialised spinal centres. In order to meet the needs of the growing SCI population, more specialised spinal injuries care beds will be needed.

Organisation of the sympathetic skin response in spinal cord injury

Objectives: The sympathetic skin response (SSR) is a technique to assess the sympathetic cholinergic pathways, and it can be used to study the central sympathetic pathways in spinal cord injury (SCI). This study investigated the capacity of the isolated spinal cord to generate an SSR, and determined the relation between SSR, levels of spinal cord lesion, and supraspinal connections. Methods: Palmar and plantar SSR to peripheral nerve electrical stimulation (median or supraorbital nerve above the lesion, and peroneal nerve below the lesion) were recorded in 29 patients with SCI at various neurological levels and in 10 healthy control subjects. Results: In complete SCI at any neurological level, SSR was absent below the lesion. Palmar SSR to median nerve stimuli was absent in complete SCI with level of lesion above T6. Plantar SSR was absent in all patients with complete SCI at the cervical and thoracic level. In incomplete SCI, the occurrence of SSR was dependent on the preservation of supraspinal connections. For all stimulated nerves, there was no difference between recording from ipsilateral and contralateral limbs. Conclusions: No evidence was found to support the hypothesis that the spinal cord isolated from the brain stem could generate an SSR. The results indicate that supraspinal connections are necessary for the SSR, together with integrity of central sympathetic pathways of the upper thoracic segments for palmar SSR, and possibly all thoracic segments for plantar SSR.

Towards improved clinical and physiological assessments of recovery in spinal cord injury: a clinical initiative

Clinical practice and scientific research may soon lead to treatments designed to repair spinal cord injury. Repair is likely to be partial in the first trials, extending only one or two segments below the original injury. Furthermore, treatments that are becoming available are likely to be applied to the thoracic spinal cord to minimise loss of function resulting from damage to surviving connections. These provisos have prompted research into the improvement of clinical and physiological tests designed (1) to determine the level and density of a spinal cord injury, (2) to provide reliable monitoring of recovery over one or two spinal cord segments, and (3) to provide indices of function provided by thoracic spinal root innervation, presently largely ignored in assessment of spinal cord injury. This article reviews progress of the Clinical Initiative, sponsored by the International Spinal Research Trust, to advance the clinical and physiological tests of sensory, motor and autonomic function needed to achieve these aims.

Comparison of input-output patterns in the corticospinal system of normal subjects and incomplete spinal cord injured patients

Abstract We have examined input-output patterns in the corticospinal system after incomplete spinal cord injury. The amplitude of the motor evoked potential (MEP) to transcranial magnetic stimulation (TMS) was used to study the patterns of recruitment, with increasing stimulus intensity, and facilitation, with increasing voluntary contraction, in thenar muscles of 12 patients with incomplete spinal cord injuries and 13 control subjects. The patients had all suffered spinal cord injury at a segmental level rostral to C8 and T1, the segments supplying innervation of thenar muscles. The patients showed a less pronounced increase in MEP amplitude with increasing strength of TMS compared with the controls. Specifically, at a stimulus strength of 120% threshold and above, the patients showed significantly smaller MEPs relative to the maximum ulnar nerve M-wave response than the controls. The patients also showed a less steep pattern of facilitation with voluntary drive. The MEP continued to increase up to 50% maximum voluntary contraction (MVC) whereas the controls reached a plateau around 10% MVC. The results indicate that the patients show modified corticospinal recruitment and facilitation of the motoneurone pool. We speculate that the function of the adapted corticospinal system after spinal cord injury might be to regulate and modulate drive to motoneurones originating from segmental and other descending inputs. We discuss how such a modified corticospinal system might be of functional benefit to the patients.

Aging, spinal cord injury, and quality of life: structural relationships

OBJECTIVE To quantify relationships among 3 sets of factors: demographic factors, health and disability factors, and quality of life (QOL). DESIGN Part of a program of longitudinal research on aging and spinal cord injury (SCI) involving 3 populations: American, British, and Canadian. The present analysis uses data from the 1999 interval. SETTING The Canadian sample was derived from the member database of the Ontario and Manitoba divisions of the Canadian Paraplegic Association. The British sample was recruited from a national and a regional SCI center in England. The American sample was recruited through a hospital in Colorado. PARTICIPANTS A sample of 352 participants was assembled from 4 large, well-established databases. The sample included individuals who had incurred an SCI at least 20 years earlier, were admitted to rehabilitation within 1 year of injury, and were between the ages of 15 and 55 at the time of injury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES A combination of self-completed questionnaires and interviews. Data included demographics, injury-related variables, health and disability-related factors, QOL, and perceptions about aging. RESULTS Using linear structural relationships modeling, we found that QOL was affected both directly and indirectly by age, health and disability problems, and perceptions of aging. Two surprising findings were as follows: those who experienced fewer disability-related problems were more likely to report a qualitative disadvantage in aging, and the younger members of the sample were more likely to report fatigue. CONCLUSIONS Fatigue is a concern because of the relationship of fatigue with perceived temporal disadvantage in aging, health problems, and disability problems. This finding highlights the need for clinical vigilance among those just beginning to experience the effects of aging.

Responses of thenar muscles to transcranial magnetic stimulation of the motor cortex in patients with incomplete spinal cord injury

OBJECTIVE To investigate changes in electromyographic (EMG) responses to transcranial magnetic stimulation (TMS) of the motor cortex after incomplete spinal cord injury in humans. METHODS A group of 10 patients with incomplete spinal cord injury (motor level C3-C8) was compared with a group of 10 healthy control subjects. Surface EMG recordings were made from the thenar muscles. TMS was applied with a 9 cm circular stimulating coil centred over the vertex. The EMG responses to up to 50 magnetic stimuli were rectified and averaged. RESULTS Thresholds for compound motor evoked potentials (cMEPs) and suppression of voluntary contraction (SVC) elicited by TMS were higher (p<0.05) in the patient group. Latency of cMEPs was longer (p<0.05) in the patient group in both relaxed (controls 21.3 (SEM 0.5) ms; patients 27.7 (SEM 1.3) ms) and voluntarily contracted (controls 19.8 (SEM 0.5) ms; patients 27.6 (SEM 1.3) ms) muscles. The latency of SVC was longer (p<0.05) in the patients (51.8 (SEM 1.8) ms) than in the controls (33.4 (SEM 1.9) ms). The latency difference (SVC−cMEP) was longer in the patients (25.3 (SEM 2.4) ms) than in the controls (13.4 (SEM 1.6) ms). CONCLUSION The longer latency difference between cMEPs and SVC in the patients may reflect a weak or absent early component of cortical inhibition. Such a change may contribute to the restoration of useful motor function after incomplete spinal cord injury.