Kristjan T. Ragnarsson

Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury—1990–1997

OBJECTIVES To describe changes in acute and rehabilitation length of stay (LOS) for persons with traumatic spinal cord injury (SCI), describe predictors of LOS, and explore year-1 anniversary medical and social outcomes. DESIGN Longitudinal, exploratory study of patients with SCI. SETTING Eighteen Model Spinal Cord Injury Centers across the United States. SAMPLE A total of 3,904 persons discharged from the Model Systems between 1990 and 1997 who had follow-up interviews at 1 year postinjury. MAIN OUTCOME MEASURES Rehabilitation LOS; injury anniversary year-1 presence of pressure ulcers; incidence of rehospitalization; community or institutional residence; and days per week out of residence. RESULTS Acute rehabilitation LOS declined from 74 days to 60 days. Discharges to nursing homes and rehospitalizations increased between 1990 and 1997. Linear regression showed that lower admission motor Functional Independence Measure (FIM) scores, year of discharge from the Model System, method of bladder management, tetraplegia, race, education, marital status, discharge disposition, and age were related to longer LOS. At first anniversary, logistic regressions revealed that lower discharge motor FIM, injury level, and age were related to the presence of pressure ulcers, rehospitalization, residence, and time spent out of residence. Of those discharged to nursing homes, 44% returned to home by year 1, and these individuals had higher functional status and were younger. DISCUSSION High functional status is associated with shorter LOS, discharge to the community, and time spent out of residence, indicating efficiency in the system. For 44.4% of individuals one or more of the following outcomes were observed by first year anniversary: rehospitalization; residing in a skilled nursing facility; having pressure ulcers; or infrequently leaving ones residence.

Parathyroid hormone suppression in spinal cord injury patients is associated with the degree of neurologic impairment and not the level of injury

OBJECTIVE To demonstrate that after spinal cord injury (SCI) suppression of the parathyroid-vitamin D axis is associated with the degree of neurologic impairment and not the level of injury. DESIGN A retrospective analysis of clinical and biochemical data obtained from hospital records of patients with SCI compared to a control group of patients with traumatic brain injury (TBI). SETTING The inpatient rehabilitation unit of a tertiary care hospital. SUBJECTS The medical records of 82 consecutive admissions to the rehabilitation unit with a diagnosis of SCI or TBI were reviewed. Patients with SCI were classified by the American Spinal Injury Association (ASIA) impairment scale and then grouped based on the completeness and level of injury. MAIN OUTCOME MEASURE Comparisons of serum parathyroid hormone (PTH), 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D (1,25-D) were planned. Multiple comparisons were performed for total and ionized serum calcium levels, serum phosphorus levels, and 24-hour urinary calcium excretion rates to reflect changes in mineral homeostasis. Multiple comparisons were also performed for serum albumin, prolactin, thyroid function tests, and AM cortisol levels, as well as 24-hour urinary urea nitrogen and cortisol excretion rates to reflect metabolic responses to stress. RESULTS Patients with SCI had significant suppression in PTH (p < .000009) and 1,25-D (p < .02) levels with elevated phosphorus (p < 0.03) and prolactin (p < .03) levels compared to patients with TBI. Also, more patients with SCI were hypoalbuminemic (p < .003) than patients with TBI. Patients with complete SCI (ASIA A) had more suppressed PTH (p < .03) and higher urinary urea nitrogen (p < .05) levels than SCI patients with incomplete injuries (ASIA B-D). Patients with complete, but not incomplete, SCI had lower albumin levels than patients with TBI (p < .05). These differences were not found between patients with tetraplegic and paraplegic SCI. ASIA motor scores did not correlate with any of the measured parameters but when used as a covariate did abolish differences in PTH and 1,25-D among the study groups by ANOVA. CONCLUSION In patients with SCI, the degree of neurologic impairment, and not the level of injury, is associated with PTH suppression and markers of metabolic stress.

Epidemiology and Classification of Pain After Spinal Cord Injury

The prevalence of pain after spinal cord injury (SCI) is reported to be between 65% and 80%; 20% to 30% of this pain is severe. The reported variability in prevalence may be due to a number of methodological factors, which include (a) different definitions of pain after SCI, both with regard to specific pain types and abnormal sensations regarded as pain, (b) variable response rates for surveys and inadequate sampling techniques, (c) variable time from injury until pain assessment, and (d) variability in the classification schemes of pain after SCI. In this article, various classification schemes of pain after SCI are reviewed. It may be hypothesized that widespread use of a comprehensive, but easily used, classification system of pain after SCI will enhance communication between physicians, basic researchers, and clinical researchers and will allow better understanding of this clinical problem through interstudy comparisons of both epidemiological and treatment outcome data. The classification system pre...

NEUROENDOCRINE CHANGES DURING FUNCTIONAL ELECTRICAL STIMULATION

This study examined the effects of a computerized functional electrical stimulation exercise program on plasma β-endorphin-Iike immunoreactivity (BEP-ir), cortisol levels and depression parameters in spinal cord-injured individuals. Nine subjects from 1.2 to 33.5 yr postinjury with both motor and sensory complete lesions between C5 and T12 participated. It was determined that patients who sustained spinal cord-injuries <5 yr before this study had lower than normal baseline levels of BEP-ir and flattened circadian rhythms. Patients who sustained their injury >5 yr before this study had higher baseline levels of BEP-ir with some return to normal circadian rhythmicity. Baseline cortisol levels, regardless of time since injury, appeared to be dysregulated. Regular exercise with computerized functional electrical stimulation caused significantly (P < 0.05) sustained increases in BEP-ir in all patients and improved the regulation of cortisol. Furthermore, the more strenuous the exercise training, greater increases in BEP-ir levels were seen. Last, depression scores improved, which suggests a possible association between subjective mood and BEP-ir levels.

Reliability of the Bryce/Ragnarsson spinal cord injury pain taxonomy.

Abstract Background/Objective: Pain is a common secondary complication of spinal cord injury (SCI). However, the literature offers varying estimates of the numbers of persons with SCI who develop pain. The variability in these numbers is caused in part by differences in the classification of pain; there is currently no commonly accepted classification system for pain affecting persons after SCI. This study investigated the interrater reliability of the Bryce/Ragnarsson SCI pain taxonomy (BR-SCI-PT). The hypothesis was that, when used by physicians with minimal training in the BR-SCI-PT, it would have high interrater reliability for the categorization of reported pains. Methods: One hundred thirty-five vignettes, each of which described a person with SCI with one or more different etiologic subtypes of pain, were evaluated by 5 groups of up to 10 physicians with SCI subspecialization (39 respondents total). Physician classifications were compared with those made by the investigators. Results: Of 1 79 pain descriptions, 83% were categorized correctly to one of the 15 BR-SCI-PT pain types; 93% were categorized correctly with respect to level (above/at/below neurological level of injury), whereas 90% were categorized correctly as being either nociceptive or neuropathic. Subjects expressed a generally high confidence in the correctness of their classifications. Conclusions: Substantial interrater agreement was achieved in determining subtypes of pain within the BR- SCI-PT. The agreement was improved for categorizing within less restrictive categories (ie, with respect to the neurological level of injury and whether the pain was nociceptive or neuropathic).

Rehabilitation of the patient with chronic critical illness

Patients with CCI have continuing profound medical needs, poor prognosis for significant functional recovery, and a high mortality rate. Nonetheless, some survive for months or years, but unfortunately, often with functional skills and quality of life lower than need be. Careful evaluation of each patients medical condition and potential for functional improvement, early involvement of the rehabilitation team, prevention and treatment of medical conditions associated with prolonged bed rest and immobility, reduction of the emotional and financial burden of family members, and establishment of reasonable goals can increase self-sufficiency and quality of life regardless of discharge destination.

Medical rehabilitation of people with spinal cord injury during 40 years of academic physiatric practice.

ABSTRACT There are many different paths that lead to an academic physiatric career and a lifelong interest in spinal cord injury (SCI) medicine. It is unfortunate that after decades of cellular-based research in multiple laboratories, there are still no interventions available that can reverse the neurologic loss that follows SCI. In contrast, medical rehabilitation research during the last 40 yrs has led to remarkable improvements in the lives of persons with SCI as evident in their increased life expectancy, shorter hospitalizations, fewer rehospitalizations, and more effective treatments for male sexual dysfunction and fertility, as well as spasticity, heterotrophic ossification, and neuropathic pain. Application of modern technology has improved the mobility of persons with SCI with better designed wheelchairs, decreased their dependency on others, facilitated their access to information, made communication and community integration easier, and so on. Although deaths related to urinary tract complications are now rare, better methods of managing the neurogenic bladder are still needed. Furthermore, better management methods are also needed for the neurogenic bowel, SCI pain, and osteoporosis of the paralyzed limbs. Even with proper prophylaxis, deep vein thrombosis and pulmonary embolism are still common, and clinicians have paid too little attention to reducing the risk for persons with SCI of developing obesity, diabetes mellitus, and cardiovascular disease. These challenges need to be met by medical rehabilitation research, by advocating for insurance policies that support the healthcare needs of persons with SCI, and by developing comprehensive disability policies, all with the support and leadership of academic physiatrists.

Lower Limb Endurance Exercise After Spinal Cord Injury: Implications for Health and Functional Ambulation

are to reach and maintain a degree of physical fitness. It is felt that physiologically stressful exercise, i.e., 70% of age predicted maximum heart rate, for a minimum of 30-60 minutes, three to five times a week, is required to increase work capacity, maintain a high level work capacity or achieve fitness. It is fortunate, however, that there is scientific evidence that a relatively low and moderate intensity exercise such as walking, if consistently carried out, may be perfectly adequate to achieve optimal health benefits (2-4.) Spinal cord injury (SCI) is a significant health problem in the United States that usually results in extensive paralysis and reduced capacity for physical exercise. As a consequence, physical fitness is severely diminished and a series of degenerative physiological changes occur, that have negative implications for both physical fitness and health. The reported incidence of SCI varies according to the source, but recent data indicate an annual incidence of 30-32 new cases per million individuals (5). Those who sustain SCI are generally young (5) and, if they survive the acute phase, they are likely to live for many decades with a severe disability (6) particularly if they receive optimal care and maintain an active life style. While the incidence of SCI has remained stable or has even fallen slightly, its prevalence is rising due to increased life expectancy. Urinary complications are no longer a major of evaluation and management, but have been replaced by respiratory and cardiovascular conditions (5,7). So far little has been done to actively prevent these secondary complications which contribute so significantly to both morbidity and mortality. This paper will address some of

Academic physical medicine and rehabilitation departments and the future of our specialty.

Strong and healthy academic physical medicine and rehabilitation (PMR the size of externally funded research; local and national ranking based on the department’s reputation, mortality index, safety record, and discharges; and compliance with a range of regulations and requirements. Institutional leadership also may judge the health of a department by various other factors that may negatively affect the reputation of a fiscally sound academic department, including, for example, adverse publicity, poor patient care, weak academic programs, and poor internal and/or external reviews with citations. Furthermore, external factors may have a positive or negative influence on the health of any medical specialty, such as organizational changes that result from health care reform, changes in third-party payments, and new and revolutionary diagnostic and therapeutic techniques that eliminate the need for previously accepted clinical services. It also is a fact that most large academic medical centers have changing needs for space and program development, which may affect departments in a beneficial or adverse fashion. The various threats and opportunities that face academic departments demand vigilance by their leaders who must constantly identify and address each of these in a proactive fashion. Judging from the above brief and limited description of the different factors that affect the survival and health of academic departments, it should be clear that there is no status quo and never a time to rest on laurels. This article will address some of the inner operations of an academic PM&R department and examine how these may influence the future of our specialty.

Research-generated knowledge relating to spinal cord injury, traumatic brain injury, and burn injury: 1999-2004

Ragnarsson KT: Research-generated knowledge relating to spinal cord injury, traumatic brain injury, and burn injury: 1999–2004. Am J Phys Med Rehabil 2006;85:289–291.