James Middleton

Psychological morbidity and spinal cord injury: a systematic review

Study Design:A systematic review of the literature concerning the nature of the psychological morbidity in people with spinal cord injury (SCI).Objectives:SCI is believed to place the individual at a high risk of psychological morbidity. The objective of this paper was to examine systematically the prevalence of negative psychological states in people with SCI, as well as to explore mediating and contextual factors.Methods:Search engines such as Medline and PsycInfo were systematically searched using specific key words, such as SCI, depression, anxiety and so on. Only studies that fulfilled certain criteria such as the use of valid measures in assessing psychological morbidity were used in the review process.Results:The systematic review revealed that clarification is still needed concerning the psychological consequences of people with SCI. However, findings suggest that approximately 30% of people with SCI are at risk of having a depressive disorder although in rehabilitation, and approximately 27% are at risk of having raised depressive symptoms when living in the community. The review also established that people with SCI have higher comparative risks of anxiety disorder, elevated levels of anxiety, feelings of helplessness and poor quality of life (QOL).Conclusion:People with SCI have an increased risk of suffering debilitating levels of psychological morbidity. Future research needs to clarify the extent and nature of psychological morbidity following SCI by conducting prospective and comprehensive research in large heterogeneous samples of people with SCI during the rehabilitation phase and following reintegration into the community.

Causes of death after spinal cord injury

Study design: Mortality review was undertaken of patients who suffered traumatic spinal cord injury (SCI) between 1955 and 1994 inclusive.Objectives: The study objective was to provide evidence of reasons for the observed reduction in long-term life expectancy for the SCI population.Setting: Patients were those who had most, if not all, of their inpatient and outpatient care at Royal North Shore Hospital, Spinal Injuries Unit, Sydney, New South Wales, Australia.Methods: Data on causes of death for 195 patients fitting the inclusion criteria were analysed by actuarial methods using ICD9CM classifications.Results: The incidence of death in the spinal cord injured, from septicaemia, pneumonia and influenza, diseases of the urinary uystem and suicide, are significantly higher than in the general population. The findings confirm variations in potentially treatable causes of death depending on neurological impairment, attained age and duration since injury. Unlike septicaemia and pneumonia, which have shown a significant reduction since 1980, the death rate for suicide alone has risen.Conclusion: This analysis identified complications which affect mortality and morbidity in patients suffering from the effects of SCI.

Neuropathic pain and primary somatosensory cortex reorganization following spinal cord injury.

Abstract The most obvious impairments associated with spinal cord injury (SCI) are loss of sensation and motor control. However, many subjects with SCI also develop persistent neuropathic pain below the injury which is often severe, debilitating and refractory to treatment. The underlying mechanisms of persistent neuropathic SCI pain remain poorly understood. Reports in amputees describing phantom limb pain demonstrate a positive correlation between pain intensity and the amount of primary somatosensory cortex (S1) reorganization. Of note, this S1 reorganization has also been shown to reverse with pain reduction. It is unknown whether a similar association between S1 reorganization and pain intensity exists in subjects with SCI. The aim of this investigation was to determine whether the degree of S1 reorganization following SCI correlated with on‐going neuropathic pain intensity. In 20 complete SCI subjects (10 with neuropathic pain, 10 without neuropathic pain) and 21 control subjects without SCI, the somatosensory cortex was mapped using functional magnetic resonance imaging during light brushing of the right little finger, thumb and lip. S1 reorganization was demonstrated in SCI subjects with the little finger activation point moving medially towards the S1 region that would normally innervate the legs. The amount of S1 reorganization in subjects with SCI significantly correlated with on‐going pain intensity levels. This study provides evidence of a link between the degree of cortical reorganization and the intensity of persistent neuropathic pain following SCI. Strategies aimed at reversing somatosensory cortical reorganization may have therapeutic potential in central neuropathic pain.

Mortality following spinal cord injury

This study analyzed the mortality in 1453 spinal cord injured patients admitted early after injury to a specialised Spinal Injuries Unit within a University teaching hospital over a 40-year period. The cohort comprised 55.3% patients with cervical lesions and 44.7% patients with thoracic/lumbar lesions. Those patients who died within 18 months of the spinal injury (132) were excluded from the final analysis. Standardised Mortality Ratios, survival rates and life expectancy ratios were calculated for specific ranges of current attained age and duration since injury with reference to level and degree of spinal cord injury. The projected mean life expectancy of spinal cord injured people compared to that of the whole population was then estimated to approach 70% of normal for individuals with complete tetraplegia and 84% of normal for complete paraplegia (Frankel grade A). Patients with an incomplete lesion and motor functional capabilities (Frankel grade D) are projected to have a life expectancy of at least 92% of the normal population.

A proposed algorithm for the management of pain following spinal cord injury

Study design:Review.Objectives:To review published articles on the assessment, diagnosis and treatment of pain following spinal cord injury (SCI) and to synthesise evidence from these materials to formulate and propose a systematic approach to management.Methods:Relevant articles regarding the treatment of pain were identified from electronic databases using the search terms ((‘spinal cord injury’ or ‘spinal cord injuries’) and ‘pain’) and both (‘treatment’) and (‘randomised controlled trials’). Relevant articles were also identified through citations in indexed journal publications and book chapters on this topic.Results:Review of the literature indicates that there are a large variety of treatments used in the management of pain following SCI with a small number supported by strong evidence for effectiveness. A treatment algorithm is proposed based on identification of underlying pain contributors and application of appropriate treatment.Conclusion:Although there are relatively few studies clearly indicating efficacy in this population, an algorithm for the management of pain following SCI might assist to maximise our effectiveness in the treatment of this condition. It is recognised that choice of treatment is also determined by factors such as medication availability, cost and side effects as well as the preferences and characteristics of the person being treated. Nevertheless, an algorithm is proposed as a way to synthesise our current level of knowledge, identify gaps for further study and aid in the management of this difficult problem.

Patterns of morbidity and rehospitalisation following spinal cord injury

Study design: Longitudinal, descriptive design.Objectives: The aim of this study was to investigate the frequency, cause and duration of rehospitalisations in individuals with spinal cord injury (SCI) living in the community.Setting: Australian spinal cord injury unit in collaboration with State Health Department.Methods: A data set was created by linking records from the NSW Department of Health Inpatient Statistics Collection between 1989–1990 and 1999–2000 with data from the Royal North Shore Hospital (RNSH) Spinal Cord Injuries Database using probabilistic record linkage techniques. Records excluded were nontraumatic injuries, age <16 years, spinal column injury without neurological deficit, full recovery (ASIA Grade E) and index admission not at RNSH. Descriptive statistics and time to readmission using survival analysis, stratified by ASIA impairment grade, were calculated.Results: Over the 10-year period, 253 persons (58.6%) required one or more spinal-related readmissions, accounting for 977 rehospitalisations and 15,127 bed-days (average length of stay (ALOS) 15.5 days; median 5 days). The most frequent causes for rehospitalisation were genitourinary (24.1% of readmissions), gastrointestinal (11.0%), further rehabilitation (11.0%), skin-related (8.9%), musculoskeletal (8.6%) and psychiatric disorders (6.8%). Pressure sores accounted for only 6.6% of all readmissions, however, contributed a disproportionate number of bed-days (27.9%), with an ALOS of 65.9 (median 49) days and over 50% of readmissions (33 out of 64) occurred in only nine individuals aged under 30 years. Age, level and completeness of neurological impairment, all influenced differential rates of readmission depending on the type of complication. Overall rehospitalisation rates were high in the first 4 years after initial treatment episode, averaging 0.64 readmissions (12.6 bed-days) per person at risk in the first year and fluctuating between 0.52 and 0.61 readmissions (5.1–8.3 bed-days) per person at risk per year between the second to fourth years, before trending downwards to reach 0.35 readmissions (2.0 bed-days) as 10th year approaches. Time to readmission was influenced by degree of impairment, with significantly fewer people readmitted for ASIA D (43.2%) versus ASIA A, B and C (55.2–67.0%) impairments (P<0.0001). The mean duration to first readmission was 46 months overall, however, differed significantly between persons with ASIA A–C impairments (26–36 months) and ASIA D impairment (60 months).Conclusion: Identifying rates, causes and patterns of morbidity is important for future resource allocation and targeting preventative measures. For instance, the late complication of pressure sores in a small subgroup of young males, consuming disproportionately large resources, warrants further research to better understand the complex psychosocial and environmental factors involved and to develop effective countermeasures.

Electroencephalographic slowing and reduced reactivity in neuropathic pain following spinal cord injury.

Study Design:Brain wave activity in people with paraplegia, with and without neuropathic pain, was compared to brain wave activity in matched able-bodied controls.Objectives:To investigate whether spinal cord injury with neuropathic pain is associated with a slowing of brain wave activity.Setting:Australia.Methods:Electroencephalographic (EEG) data were collected in the eyes open (EO) and eyes closed (EC) states from 16 participants with paraplegia (eight with neuropathic pain and eight without pain) and matched able-bodied controls. Common EEG artefacts were removed using independent component analysis (ICA). Peak frequency in the θ–α band and EEG power in the δ, θ, α and β frequency bands were compared between groups.Results:The results show significant slowing of the EEG in people with neuropathic pain, consistent with the presence of thalamocortical dysrhythmia (TCD). Furthermore, people with neuropathic spinal cord injury (SCI) pain had significantly reduced EEG spectral reactivity in response to increased or decreased sensory input flowing into the thalamocortical network, as modulated by the eyes open and eyes closed states.Conclusion:The results provide further evidence for alterations in brain electric activity that may underlie the development of neuropathic pain following SCI.

Benefits of FES gait in a spinal cord injured population.

Study design:Review.Objectives:This review article investigated the objective evidence of benefits derived from functional electrical stimulation (FES)-assisted gait for people with spinal cord injury (SCI). Both FES and gait have been proposed to promote not only augmented health and fitness, but specific ambulatory outcomes for individuals with neurological disabilities. However, due to small sample sizes and the lack of functionality of the intervention, it has not been widely used in clinical practice. This review assessed whether there is sufficient evidence to encourage a more widespread deployment of FES gait within the rehabilitation community.Methods:Hand searches and online data collection were performed in Medline and Science Direct. Specific search terms used included SCI/paralysis/paraplegia and tetraplegia with electrical stimulation/FES, gait and walking.Results:The searches generated 532 papers. Of these papers, 496 were excluded and 36 papers were included in the review. Many reported benefits were not carefully investigated, and small sample sizes or different methodologies resulted in insufficient evidence to draw definitive conclusions.Conclusions:FES gait can enhance gait, muscle strength and cardiorespiratory fitness for people with SCI. However, these benefits are dependent on the nature of the injury and further research is required to generalize these results to the widespread population of SCI individuals. Proof of the functionality and further evidence of the benefits of FES gait will assist in FES gait gaining clinical acceptance.

Life expectancy after spinal cord injury: a 50-year study.

Study design:Cohort of incident cases from 1955 to 2006.Objectives:To analyse acute and long-term mortality, estimate life expectancy and identify survival patterns of individuals experiencing traumatic spinal cord injury (SCI).Setting:Specialised SCI unit in Australia.Methods:Data for patients with traumatic SCI admitted to a spinal unit in Sydney, Australia between January 1955 and June 2006 were collated and deaths confirmed. Cumulative survival probability was estimated using life-table techniques and mortality rates were calculated from the number of deaths and aggregate years of exposure. Standardised mortality ratios (SMRs) were estimated from the ratio of observed to expected number of deaths. Life expectancy was then estimated using adjusted attained age-specific mortality rates.Results:From 2014 persons, 88 persons with tetraplegia (8.2%) and 38 persons with paraplegia (4.1%) died within 12 months of injury, most often with complete C1–4 tetraplegia. Among first-year survivors, overall 40-year survival rates were 47 and 62% for persons with tetraplegia and paraplegia, respectively. The most significant increases in mortality were seen in those with tetraplegia and American Spinal Injury Association Impairment Scale (AIS) grades A–C lesions, with SMRs between 5.4 and 9.0 for people ⩽50 years, reducing with advancing attained age. Estimated life expectancies from 25 to 65 years ranged between 69–64%, 74–65%, 88–91% and 97–96% for C1–4 AIS A–C, C5–8 A–C, T1–S5 A–C and all AIS D lesions, respectively.Conclusion:Survival related strongly to extent of neurological impairment. Future research should focus on identifying contextual factors, personal or environmental, that may contribute to the reduced life expectancy after SCI.

Spinal-injured neuropathic bladder antisepsis (SINBA) trial

Objective:To determine whether Methenamine Hippurate (MH) or cranberry tablets prevent urinary tract infections (UTI) in people with neuropathic bladder following spinal cord injury (SCI).Study design:Double-blind factorial-design randomized controlled trial (RCT) with 2 year recruitment period from November 2000 and 6 month follow-up.Setting:In total, 543 eligible predominantly community dwelling patients were invited to participate in the study, of whom 305 (56%) agreed.Methods:Eligible participants were people with SCI with neurogenic bladder and stable bladder management. All regimens were indistinguishable in appearance and taste. The dose of MH used was 1 g twice-daily. The dose of cranberry used was 800 mg twice-daily. The main outcome measure was the time to occurrence of a symptomatic UTI.Results:Multivariate analysis revealed that patients randomized to MH did not have a significantly longer UTI-free period compared to placebo (HR 0.96, 95% CI: 0.68–1.35, P=0.75). Patients randomized to cranberry likewise did not have significantly longer UTI-free period compared to placebo (HR 0.93, 95% CI: 0.67–1.31, P=0.70).Conclusion:There is no benefit in the prevention of UTI from the addition of MH or cranberry tablets to the usual regimen of patients with neuropathic bladder following SCI.