Tiina Rekand

A 50-year follow-up of the incidence of traumatic spinal cord injuries in Western Norway

Study design:Retrospective population-based epidemiological study.Objective:To assess the prevalence and temporal trends in the incidence of traumatic spinal cord injuries (TSCI), and demographic and clinical characteristics of an unselected, geographically defined cohort in the period 1952–2001.Methods:The patients were identified from hospital records. Crude rates and age-adjusted rates were calculated for each year. The multivariate relationship between cause of injury, age at injury, decade of injury and gender was examined using a Poisson regression model.Results:Of 336 patients, 199 patients were alive on 1 January 2002, giving a total prevalence of 36.5 per 100 000 inhabitants. The average annual incidence increased from 5.9 per million in the first decade to 21.2 per million in the last. Mean age at injury was 42.9 years and the male to female ratio 4.7:1. Fall was the most common cause of injury (45.5%), followed by motor vehicle accidents (MVA) (34.2%). The incidence of MVA-related injuries increased during the observation period, especially among men <30 years. The lesion level was cervical in 52.4%, thoracic in 29.5% and lumbar/sacral in 18.2%. The lesion was clinically incomplete in 58.6% and complete in 41.4%. The incidence of fall-related injuries and the proportion of incomplete cervical lesions increased during the observation period, especially among men >60 years.Conclusions:The incidence of TSCI has increased during the past 50 years. Falls and MVA are potentially preventable causes. The increasing proportion of older patients with cervical lesions poses a challenge to the health system.

Mortality after traumatic spinal cord injury: 50 years of follow-up

Objective To study mortality and causes of death in an unselected geographically defined cohort of patients with traumatic spinal cord injury (TSCI), 1952–2001. Methods Patients were identified from hospital records. The date of death was obtained from the National Population Register, and causes of death recorded by linkage to the Norwegian Cause of Death Registry. Patient mortality was compared with mortality in the Norwegian population using standardised mortality ratios (SMR) adjusted for age and gender. Results 401 patients (70 women and 331 men) were identified. By 31 August 2008, 173 were dead. Median survival time in deceased patients was 7.4 years; 6.9 years for patients with cervical injuries and 8.2 years for patients with thoracolumbosacral injuries (TLS). TSCI patients had an increased mortality (SMR 1.85) compared with the Norwegian population. SMR did not change during the observation period. SMR was significantly higher for women than for men (2.88 vs 1.72), and higher in patients with complete TSCI compared with patients with incomplete TSCI (4.23 vs 1.25). SMR was 6.70 for patients with complete cervical injuries and 3.07 for patients with complete TLS injuries. Cause specific SMR were 1.96 for respiratory disease, and for suicide including accidental poisoning 3.70 for men and 37.59 for women. Conclusions Patients with a TSCI, and especially women, have an increased mortality despite modern treatment and care. Special attention should be paid to respiratory dysfunction and pulmonary infections, and to prevent suicide and accidental poisoning.

Post‐polio syndrome patients treated with intravenous immunoglobulin: a double‐blinded randomized controlled pilot study

Post‐polio syndrome (PPS) is characterized by new muscle weakness, atrophy, fatigue and pain developing several years after the acute polio. Some studies suggest an ongoing inflammation in the spinal cord in these patients. From this perspective, intravenous immunoglobulin (IvIg) could be a therapeutic option. We performed a double‐blinded randomized controlled pilot study with 20 patients to investigate the possible clinical effects of IvIg in PPS. Twenty patients were randomized to either IvIg 2 g/kg body weight or placebo. Primary endpoints were changes in pain, fatigue and muscle strength 3 months after treatment. Surrogate endpoints were changes in cerebrospinal fluid (CSF) cytokine levels. Secondary endpoints were pain, fatigue and isometric muscle strength after 6 months. Patients receiving IvIg reported a significant improvement in pain during the first 3 months, but no change was noted for subjective fatigue and muscle strength. CSF levels of tumour necrosis factor‐α (TNF‐α) were increased compared with patients with non‐inflammatory neurological disorders. In conclusion, in this small pilot study no effect was seen with IvIg treatment on muscle strength and fatigue, however IvIg treated PPS patients reported significantly less pain 3 months after treatment. TNF‐α was increased in the CSF from PPS patients. The results are promising, but not conclusive because of the low number of patients studied.

Clinical assessment and management of spasticity: a review

Rekand T. Clinical assessment and management of spasticity: a review. Acta Neurol Scand: 2010: 122 (Suppl. 190): 62–66.

Post-polio syndrome and total health status in a prospective hospital study.

New loss of function among patients with previous polio is frequently reported and has several causes. All patients referred to the Department of Neurology, Haukeland University Hospital, Bergen, for 13 months during 2000–2001 with diagnosis late effects of polio were examined prospectively to identify their symptoms and loss of function. Eighty‐five patients aged 47–91 years with mean of 61 years were included. The most common complaints were pain (44%), muscular weakness (27%), and fatigue (16%). Muscular weakness occurred in lower limbs in 75%, in respiratory muscles in only 5%. Walking in stairs was impaired in 72% and outdoor walking in 65%. Seventeen patients (19%) reported no loss of function.

Lifestyle and late effects after poliomyelitis. A risk factor study of two populations

Background – Patients with polio often experience new symptoms (muscle weakness, pain, fatigue and respiratory problems) many years after the acute disease. This study examined possible interactions between lifestyle factors (overweight, physical inactivity, smoking) and late polio with new symptoms.

Diagnostic coding accuracy for traumatic spinal cord injuries

Study design:Retrospective register study enhanced and verified by medical records.Objectives:To study whether electronic searches of discharge diagnosis are valid for epidemiological research of traumatic spinal cord injury (SCI), using the International Classification of Diseases (ICD).Settings:Haukeland University Hospital, Bergen, NorwayMethods:We identified all hospital admissions with discharge codes suggesting a traumatic SCI from ICD-8 to ICD-10 in the electronic database at Haukeland University Hospital, and ascertained the cases by reviewing all hospital records.Results:1080 patients had an ICD diagnostic code suggesting a traumatic SCI. Only 260 were verified when reviewing the hospital records. The ICD-10 codes had superior positive predictive values (PPV) and likelihood ratios (LR+) compared with the codes from ICD-8 and ICD-9. Combining seven codes from ICD-10 (S14.0, S14.1, S24.0, S24.1, S34.1, S34.3, T91.3) gave the highest sensitivity (0.83), specificity (0.97), PPV (0.88) and LR+ (30.23).Conclusion:Obtaining hospital discharge diagnoses solely from electronic databases overestimates the incidence of traumatic SCI. Identification of patients using ICD-10 codes is more complicated because acute traumatic SCI and traumatic SCI sequelae are listed with several codes. The latest ICD version proved to be most reliable when identifying patients with traumatic SCI. However, ICD data cannot be trusted without extensive validity checks for either research or for health planning and administration.

Spasticity following spinal cord injury.

BACKGROUND Up to 70% of patients with spinal cord injuries develop spasticity. The main aim of the paper is to provide an overview of spasticity management, primarily in patients with spinal cord injuries. METHOD The article is based on literature searches in PubMed using the keyphrases «spasticity» and «spasticity AND spinal cord injury», and own clinical experience and research. RESULTS Spasticity may be general, regional or localised. Factors such as an over-filled bladder, obstipation, acute infections, syringomyelia or bone fractures may substantially influence the degree of spasticity and must be determined. An assessment of the clinical and functional consequences for the patient is decisive before management. Active exercise, physiotherapy and peroral drugs are the simplest and cheapest options. Baclofen is the only centrally acting spasmolytic registered in Norway and is the first choice for peroral treatment. Benzodiazepines can also be used. The effect of the tablets is generally limited and there are often pronounced side effects. Local spasticity can be treated with botulinum toxin injections. The effect is time-limited and the treatment must be repeated. International guidelines recommend a combination of botulinum toxin injections and physiotherapy. In cases of regional spasticity, particularly in the lower limbs, intrathecal baclofen administered via a programmable pump may provide a continuous spasm-reducing effect. Orthopaedic surgery or neurosurgery may be an option for selected patients with intractable spasticity. INTERPRETATION Spasticity following a spinal cord injury must be assessed regularly. The treatment strategy depends on the degree of functional failure caused by the spasticity and its location.

Treatment of spasticity related to multiple sclerosis with intrathecal baclofen: a long-term follow-up.

BACKGROUND Spasticity is a frequent disabling symptom in patients with multiple sclerosis, which contributes to functional deterioration. OBJECTIVE To evaluate the long-term effect of intrathecal baclofen therapy in multiple sclerosis-related spasticity and to evaluate the side-effects of long-term therapy, and the doses of baclofen required. METHODS Fourteen patients with multiple sclerosis were followed up clinically for a mean of 62 months (range 19-137 months). Clinical evaluation was made using individual goals, modified Ashworth scale, and Kurtzke Expanded Disability Status Scale. RESULTS Spasticity, measured with the modified Ashworth score, decreased in all patients by a mean of 1 point. The score on the Expanded Disability Status Scale improved in 2 cases. Prior to implantation, 10 patients (72%) reported severe pain. After implantation 3 improved and 7 became pain-free. The daily doses needed for treatment were highly individual. The effect of intrathecal baclofen on spasticity lasted observation time. One patient experienced progressive cognitive impairment as a side-effect of baclofen. CONCLUSION Intrathecal baclofen is well-tolerated and the effect lasts for up to 12 years. A thorough continuous clinical assessment is required because the differentiation between symptoms of multiple sclerosis progression and side-effects of baclofen may be difficult. Intrathecal baclofen should be considered as an option for long-term treatment of patients with advanced spasticity. Pain control can also be achieved by optimized intrathecal baclofen treatment.

Fatigue, pain and muscle weakness are frequent after Guillain-Barré syndrome and poliomyelitis

Guillain- Barré syndrome (GBS) and poliomyelitis may cause life-long health problems. We studied fatigue, pain and muscular weakness in both conditions to define possible interactions between these symptoms and their influence on residual disability and daily functioning. We studied 50 patients with previous GBS, 89 patients with a history of poliomyelitis and a reference group of 81 people with similar sex and age and no history of poliomyelitis or GBS using the Fatigue Severity Scale, self-reported pain and muscular weakness Disability Rating Index, and Positive and Negative Affect Schedule (PANAS-X). We assessed the quality of life using the SF-36 Health Survey. The mean score on the Fatigue Severity Scale was significantly higher in the GBS and poliomyelitis patients than in the reference group. This was true also in the subgroups of mild disease, i. e., nonparalytic polio and initial Hughes score less than 3 in the GBS group. Thirty-four percent of GBS patients and 63 % of poliomyelitis patients reported pain; 13 % of GBS and 36 % of poliomyelitis patients reported residual muscle weakness. Fatigue, pain, and muscle weakness interacted in both diseases. Perceived health problems influenced all aspects of the quality of life except mental health in both diseases. Fatigue, pain, and muscle weakness are common sequelae after GBS and poliomyelitis. The symptoms interact with each other and contribute to long-term disability.ObjectiveGuillain- Barré syndrome (GBS) and poliomyelitis may cause life-long health problems. We studied fatigue, pain and muscular weakness in both conditions to define possible interactions between these symptoms and their influence on residual disability and daily functioning.MethodsWe studied 50 patients with previous GBS, 89 patients with a history of poliomyelitis and a reference group of 81 people with similar sex and age and no history of poliomyelitis or GBS using the Fatigue Severity Scale, self-reported pain and muscular weakness Disability Rating Index, and Positive and Negative Affect Schedule (PANAS-X). We assessed the quality of life using the SF-36 Health Survey.ResultsThe mean score on the Fatigue Severity Scale was significantly higher in the GBS and poliomyelitis patients than in the reference group. This was true also in the subgroups of mild disease, i. e., nonparalytic polio and initial Hughes score less than 3 in the GBS group. Thirty-four percent of GBS patients and 63 % of poliomyelitis patients reported pain; 13 % of GBS and 36 % of poliomyelitis patients reported residual muscle weakness. Fatigue, pain, and muscle weakness interacted in both diseases. Perceived health problems influenced all aspects of the quality of life except mental health in both diseases.ConclusionsFatigue, pain, and muscle weakness are common sequelae after GBS and poliomyelitis. The symptoms interact with each other and contribute to long-term disability.