Richard Levi

Quality of life and traumatic spinal cord injury

OBJECTIVE To determine associations between major outcome variables after traumatic spinal cord injury (SCI) and quality of life (QL). SUBJECTS Of a total population of 353 SCI patients, 320 participated, 261 men and 59 women living in the greater Stockholm area: 124 were tetraplegic, 176 were paraplegic, and 20 had no classified level. Mean age was 42 years (range, 17 to 78). METHOD The Swedish SF-36 Health Survey was used to assess QL. The SF-36 is a self-administered questionnaire containing 36 items, divided into 8 multi-item dimensions, covering physical function, physical and emotional role function, social function, bodily pain, mental health, vitality and overall evaluation of health. Neurologic, general medical, and psychosocial variables were obtained from the Stockholm Spinal Cord Injury Study (SSCIS) data base. QL indices were analyzed for the SCI group as a whole, as well as for subgroups. Descriptors for subgroups were demographic variables, presence or absence of common medical problems, and subjective evaluation of the degree of impact of the medical problem on well-being/daily activities. RESULTS QL in individuals with SCI was significantly lower in all subscales as compared with a normative population. No difference in QL was seen in subgroups according to extent of lesion, with the exception of physical functioning. Several medical complications such as neurogenic pain, spasticity, and neurogenic bladder and bowel problems were associated with lower QL scores. SUMMARY QL, as defined by SF-36, is better in persons injured many years ago, as compared with those recently injured, suggesting an adaptive process operating over a long period. The presence of complicating medical problems, such as severe pain, problematic spasticity, and incontinence, seem to have more negative effects on QL than the extent of SCI as such.

The Stockholm spinal cord injury study: 1. Medical problems in a regional SCI population

Out of a regional traumatic spinal cord injury population consisting of 379 individuals, 353 (93.1%) participated in the present study. Subjects were individually interviewed using semi-structured protocols. In addition, previous medical records were available for over 96% of subjects, and were used in all these cases to minimise recall bias. Cause of injury, prevalence of present medical symptoms and occurrence of medical complications in the post-acute, post-discharge phase were recorded. Neurological classification was verified by physical examination according to ASIA/IMSOP standards. Many subjects had experienced complications since discharge from initial hospitalisation, especially urinary tract infections, decubitus ulcers, urolithiasis, and neurological deterioration. Prevalence of medical symptoms was also high. More than 41% of subjects with spastic paralysis reported excessive spasticity to be associated with additional functional impairment and/or pain. Almost two-thirds of subjects reported significant pain, with a predominance of neurogenic-type pain. Bladder and bowel dysfunction were each rated by nearly 41% of subjects as a moderate to severe life problem. As expected, sexual dysfunction was also commonly reported. Prevalence of reported symptoms by general systems review was high, particularly fatigue, constipation, ankle oedema, joint and muscle problems, and disturbed sleep. However, lack of adequate normative data precludes comparison with the general population. The frequent occurrence of reported medical problems and complications support advocacy of comprehensive, life-long care for SCI patients. The commonly reported problems of neurogenic pain and neurological deterioration, in particular, require more attention, as these symptoms are not seldom ominous, either by virtue of their impact on quality of life, or because of underlying pathology.

Spasticity after traumatic spinal cord injury: Nature, severity, and location

OBJECTIVE To assess spasticity in a prevalence population of persons with traumatic spinal cord injury (SCI), and determine the degree of correspondence between self-reported spasticity and investigator-elicited spasticity using the modified Ashworth scale. DESIGN Survey of a near total (88%) prevalence population. SETTING Outpatient clinic of a university hospital. PATIENTS A total of 354 individuals with SCI. MAIN OUTCOME MEASURES The survey includes self-reported symptoms, neurologic examination (American Spinal Injury Association [ASIA] classification), physical therapy examination, range of motion (ROM), and complications. RESULTS Presence of problematic spasticity was significantly correlated with cervical incomplete (ASIA B-D) injury. Reports of beneficial effects of spasticity were significantly less common in women. Self-reported problematic spasticity was significantly correlated with extensor spasticity. Spasticity was elicitable by movement provocation in 60% of the patients reporting spasticity. Significant correlations were found between elicitable spasticity and limited ROM. CONCLUSION Flexion, extension, and abduction movements performed with the patient placed in a standardized supine test position are suitable both for test of ROM and degree of spasticity. Spasticity was not elicitable by movement provocation on physical examination in 40% of the patients who reported spasticity, thus indicating that the patients self-report is an important complement to the clinical assessment. A significant association between spasticity and contractures (reduced ROM) was seen.

The Stockholm Spinal Cord Injury Study : 2. Associations between clinical patient characteristics and post-acute medical problems.

The Stockholm Spinal Cord Injury Study (SSCIS) is an extensive evaluation of a sample of 353 subjects with traumatic SCI, constituting 93% of the known regional prevalence population with this diagnosis. In a previous analysis of this group, symptoms such as pain, incontinence, sexual dysfunction and neurological deterioration, as well as secondary complications such as decubitus ulcers, urinary tract infections, spinal deformity and fractures, were found to be common. In the present report, we investigate associations between a few commonly used patient characteristics, ie gender, age at injury, duration of injury and extent of neurological compromise, and the occurrence of such problems, to assess differences in vulnerability in SCI subgroups. Results generally indicate an increased vulnerability in subjects with extensive neurological deficits, as well as a cumulation of complications with the increasing duration of injury. However, some exceptions are found, possibly indicating differences in temporal patterns of the occurrence of various complications, as well as certain gender-, age-, and lesion-associated variations in vulnerability. Symptoms directly related to the spinal cord lesion, eg neurogenic pain and neurological deterioration, seem to present rather soon post-injury. Males are more prone to experience excessive spasticity and sexual problems. Females experience more fractures and spinal deformity. Younger age at injury is associated with more spinal deformity but less severe pain problems. Higher age at injury is not found to be associated with more medical problems, with the exception of neurogenic pain, among post-acute, post-discharge survivors. The latter finding does not, however, preclude more such problems in the acute stage, since the present study neither addresses the pre-discharge period, nor includes information about mortality. Finally, the ASIA/IMSOP Impairment Scale Grade E-rated subjects were found to report problems to an extent that underlines the restricted sensorimotor sense in which this rating reflects recovery.

Effects of functional electrical stimulation training for six months on body composition and spasticity in motor complete tetraplegic spinal cord-injured individuals

The effect of functional electrical stimulation (FES) training on body composition, assessed by computed tomography, and the effect of spasticity, assessed by both objective and subjective measures, are evaluated. Fifteen motor-complete spinal-cord-injured men participated in the study. Eight of the 15 subjects undertook FES cycling 3 times weekly for 6 months. Whole body computed tomography scans evaluated changes in body composition. Simultaneous Modified Ashworth Scale and electromyography (EMG) measurements, resistive torque (Kin-Com) and EMG measurements, and self-ratings with Visual Analogue Scale during four consecutive days were used to evaluate changes in spasticity. Lower extremity muscle volume increased by an average of 1300 cm3 (p < 0.001) in the training group compared to the control group, who experienced no change. Otherwise no changes in body composition were seen. Significant correlations (Spearman) were found between individual EMG activity recordings and movement-provoked Modified Ashworth Scale ratings in 26% of the test situations, irrespective of group and time. The objective and subjective evaluation of movement-provoked passive (viscoelastic) and active (spasticity-related) resistance remained unchanged.

Simultaneous Ashworth measurements and electromyographic recordings in tetraplegic patients

OBJECTIVE A recent prevalence study of 353 spinal cord injured (SCI) individuals in the greater Stockholm area showed problematic spasticity in 30% of this population. To treat spasticity, the evaluation becomes crucial. The modified Ashworth scale (MAS) is the clinically most-used scale to grade degree of spasticity. This study evaluated whether the MAS correlated with electromyographic (EMG) recordings of muscle activity. STUDY DESIGN This cross-sectional study was performed at an outpatient clinic that has the responsibility to do a standardized, yearly follow-up of all SCI patients in the greater Stockholm area. Thirty-eight SCI individuals met the inclusion criteria; 15 of the 38 were randomly selected for the study. They were all motor-complete tetraplegic men; mean age was 33 years and mean time since injury was 9 years. Spasticity evaluation was performed by flexing and extending the knees during simultaneous EMG recordings and MAS assessment of the thigh muscle activity. RESULTS Eighty percent of the individual EMG recordings correlated significantly with the corresponding Ashworth measurements. The spastic resistance, as measured both clinically and electromyographically, was stronger and lasted longer during extension than flexion movements. Spearman coefficients for correlation of quantitative spasticity measures with MAS grades were calculated. EMG and clinical measures of spasticity were more closely correlated for flexion movements. Among EMG parameters, duration of movement-associated electrical activity invariably correlated significantly with the MAS grades (p < .05). Furthermore, Ashworth measurements of movement-associated spasticity showed a positive correlation with the EMG parameters mean, peak, and start to peak of electrical activity. Each increasing grade on the MAS corresponded to increasing myoelectric activity levels for each movement. CONCLUSION EMG parameters were significantly positively correlated with simultaneous MAS measurements of the spastic muscle contraction. The Ashworth scale may therefore accurately reflect the movement-provoked spasticity in motor-complete tetraplegic patients.

Pain in a Swedish spinal cord injury population

Objective: To describe pain and associated variables in a prevalence group of persons with a sustained spinal cord injury (SCI) in the Swedish capital and its surroundings. Setting: Spinalis SCI Unit (outpatient clinic), Stockholm, Sweden. Design: Assessment over a 12-month period in a yearly health control. Subjects: Four hundred and fifty-six SCI patients. Results: Two hundred and ninety-one out of 456 SCI patients (63.7%) suffered from pain, and in 45.7% of these it was classified as being neurogenic. Aching pain was the most used descriptor (38.5%). The onset of pain was commonly within three months (73.5%). In 70.4% of patients pain occurred below the level of the lesion. Most patients identified pain as coming from one (55.0%) or two (28.2%) body regions. Rating of the general pain intensity on a visual analogue scale (VAS) was 46 out of 100 and rating of the worst pain intensity was 78 out of 100. Ninety-four out of 276 patients (32.3%) considered that their quality of life was significantly affected by pain. Conclusion: Pain was most common in patients with incomplete lesions (ASIA impairment grade D) and there was a correlation between pain and higher mean age at injury and between pain and female gender.

INCReASed CARdIoVASCuLAR dISeASe RISK IN SwedISH PeRSoNS wITH PARAPLegIA: THe SToCKHoLM SPINAL CoRd INJuRy STudy

OBJECTIVE Comparison of prevalence of cardiovascular disease risks in persons with chronic traumatic paraplegia with those in the general population. DESIGN Cross-sectional comparative study. SUBJECTS A total of 135 individuals, age range 18-79 years, with chronic (> or = 1 year) traumatic paraplegia. METHODS The prevalences of diabetes mellitus, dyslipidaemia, hypertension, overweight, and smoking, were assessed in the study population and were compared with an age- and gender-matched sample of the general population in the region under study. History of myocardial infarction and medication for dyslipidaemia, hypertension, and diabetes mellitus were also recorded. chi2 tests were used to compare the paraplegic cohort with the general population sample. RESULTS Significantly more persons with paraplegia reported a history of myocardial infarction (5.9%) than those in the comparison group (0.7%). The prevalences of diabetes mellitus (5.9%), dyslipidaemia (11.1%), and hypertension (14.1%) were also significantly higher in the paraplegic group, as were drug treatment for these disorders. CONCLUSION Persons with paraplegia report increased prevalences of diabetes mellitus, hypertension, and dyslipidaemia, in particular, compared with the general population. Population-based screening and therapeutic counter-measures for these conditions may therefore be particularly indicated for this patient group.

Incidence of traumatic spinal cord injury in Thessaloniki, Greece and Stockholm, Sweden: A prospective population-based study

Study design:Prospective population-based open-ended study. This paper is part of the Stockholm–Thessaloniki Acute Traumatic Spinal Cord Injury Study.Objectives:To calculate incidence and evaluate the epidemiological profile of the incident population with traumatic spinal cord injury (TSCI).Settings:The greater Thessaloniki region in Greece and the greater Stockholm region in Sweden.Methods:TSCI individuals, older than 15 years of age, who had survived the first 7 days post-trauma, were identified through an active surveillance system. The forms of the Nordic Spinal Cord Injury Registry were used.Results:87 individuals were injured in the greater Thessaloniki and 49 in the greater Stockholm region. Annual crude incidence was 33.6 per million for Thessaloniki and 19.5 per million for the Stockholm region. The leading causes of injury for the Thessaloniki region were transportation accidents (51%) and falls (37%), and those for the Stockholm region were falls (47%) and transportation accidents (23%). A significantly larger number of individuals of the Thessaloniki group were injured in transportation accidents. There was no significant difference between regions with regard to the type of resulting impairment.Conclusions:Incidence of TSCI was considerably higher in the Thessaloniki region as compared with that in the Stockholm region, probably chiefly reflecting differences in preventative measures with regard to driving.

Pediatric spinal cord injury in Sweden: incidence, etiology and outcome

Study design: Retrospective descriptive study.Objectives: To assess incidence, causes and early outcome of traumatic spinal cord injury (SCI) among children in Sweden, thereby identifying high-risk groups and situations as a basis for preventative measures and improved care.Methods: Data from population registers, County Habilitation Centers as well as from informal sources were used to estimate the incidence of SCI in Sweden during the years 1985–1996 among children aged 0–15 years. Contacts with the treating hospitals, reviews of medical records and/or personal interviews were used to verify primary data. In total, 92 children were thus identified.Results: The incidence was found to be 4.6/million children/year (95% CI 3.6–5.5). When excluding prehospital fatalities, the incidence was 2.4 (95% CI 1.8–3.1). The main cause of injury among fatalities was traffic accidents. Associated injuries occurred in 41% of the children. Among survivors (10–15 years), sports-related injuries (43%) were as common a cause as traffic accidents (39%). The survivors were treated in 18 different hospitals.Conclusion: Pediatric SCI in Sweden is rare, presumably because of effective primary prevention. Preventative measures should be further differentiated for each age group of children in accordance with their differing risk profiles. In contrast to the effective preventative measures that have been implemented in Sweden, care of these patients is still too fractionated and decentralized for sufficient specialization to emerge.