Spinal cord injury medicine. 3. Rehabilitation outcomes

Considerations for Contraception Following Spinal Cord Injury: A Systematic Review

Introduction

Counseling and education on women's health, specifically contraception, following spinal cord injury (SCI) is an important component of care for women with SCI. While a plethora of available contraceptive options exists, research in this area is scarce.

Objectives

This systematic review assesses the quality and quantity of research on contraception for individuals with SCI.

Methods

Literature searches of three medical databases were performed to identify articles that addressed contraception and family planning for women with SCI. Articles were then screened in a two-stage selection process and evaluated for content.

Results

Of 165 articles, 21 were identified that fit the inclusion criteria. The majority (66%) of articles were literature reviews or professional practice guidelines. Fourteen (66%) included information on short-acting hormonal oral contraception, 11 (52%) included information on long-acting reversible contraception, 15 (71%) included information on barrier methods, 6 (29%) included information on fertility awareness, 9 (43%) included information on permanent contraception, and one (5%) included information on emergency contraception.

Discussion

This systematic review demonstrates a paucity of evidence-based information on contraception tailored to women with SCI. It highlights a need for research and comprehensive guidelines on primary and emergency contraception in this population.

Spinal Cord Injury-Functional Index/Capacity: Responsiveness to Change Over Time

OBJECTIVE

To establish responsiveness of 3 Spinal Cord Injury-Functional Index/Capacity (SCI-FI/C) item banks in the first year after spinal cord injury (SCI).

DESIGN

Longitudinal patient-reported outcomes assessment replicated through secondary analysis of an independent data set.

SETTING

A total of 8 SCI Model Systems rehabilitation hospitals in the United States.

PARTICIPANTS

Study 1 participants included 184 adults with recent (≤4 months) traumatic SCI and 221 community-dwelling adults (>1 year post injury) (N=405). Study 2 participants were 418 individuals with recent SCI (≤4 months) (N=418).

INTERVENTIONS

In study 1, SCI-FI/C computer adaptive tests were presented in a standardized interview format either in person or by phone call at baseline and 6-month follow-up. Responsiveness was examined by comparing 6-month changes in SCI-FI scores within and across samples (recently injured vs community-dwelling) because only the recent injury sample was expected to exhibit change over time. Effect sizes were also computed. In study 2, the study 1 results were cross-validated in a second sample with recent SCI 1 year after baseline measurement. Study 2 also compared the SCI-FI/C measures' responsiveness to that of the Self-reported Functional Measure (SRFM) and stratified results by injury diagnosis and completeness.

MAIN OUTCOME MEASURES

The SCI-FI Basic Mobility/C, Self-care/C and Fine Motor/C item banks (study 1 and study 2); Self-reported Functional Measure SRFM (study 2 only).

RESULTS

In study 1, changes in SCI-FI/C scores between baseline and 6-month follow-up were statistically significant (P<.01) for recently injured individuals. SCI-FI Basic Mobility/C, Self-care/C, and Fine Motor/C item banks demonstrated small to medium effect sizes in the recently injured sample. In the community-dwelling sample, all SCI-FI/C effects were negligible (ie, effect size<0.08). Study 2 results were similar to study 1. As expected, SCI-FI Basic Mobility/C and Self-care/C were responsive to change for all individuals in study 2, whereas the SCI-FI Fine Motor/C was responsive only for individuals with tetraplegia and incomplete paraplegia. The SRFM demonstrated a medium effect size for responsiveness (effect size=0.65).

CONCLUSIONS

The SCI-FI Basic Mobility/C and Self-care/C banks demonstrate adequate sensitivity to change at 6 months and 1 year for all individuals with SCI, while the SCI-FI/C Fine Motor item bank is sensitive to change in individuals with tetraplegia or incomplete paraplegia. All SCI-FI/C banks demonstrate stability in a sample not expected to change. Results provide support for the use of these measures for research or clinical use.

The effects of semi-immersive virtual reality therapy on standing balance and upright mobility function in individuals with chronic incomplete spinal cord injury: A preliminary study

BACKGROUND

Individuals with chronic incomplete spinal cord injury (iSCI) commonly face persistent balance or mobility impairments. Virtual reality (VR) therapy is a useful rehabilitation approach; however, little is known about its effects in individuals with chronic iSCI.

OBJECTIVE

To investigate the effects of semi-immersive VR therapy on standing balance and upright mobility function in individuals with chronic iSCI.

METHODS

Ten subjects with chronic iSCI underwent VR therapy 30 minutes a day, 3 days a week, for 6 weeks. Limit of stability (LOS) and the Berg Balance Scale (BBS) were used to evaluate standing balance function. The Timed Up & Go (TUG) test, Activities-specific Balance Confidence (ABS) Scale, and Walking Index for Spinal Cord Injury-II (WISCI-II) were used to measure the subject's upright mobility function. Outcomes were assessed and recorded pre- and post-intervention.

RESULTS

After semi-immersive VR therapy, LOS and BBS scores were significantly increased. In addition, the TUG test results increased significantly over time, while ABC scale scores and WSCI-II levels improved significantly.

CONCLUSION

This study is the first to assess the effects of semi-immersive VR therapy for patients with chronic iSCI and limited functional abilities. These results indicated that semi-immersive VR therapy has a positive effect and is a useful intervention for standing balance and upright mobility function in patients with chronic iSCI.

Functional Outcome of Neurologic-Controlled HAL-Exoskeletal Neurorehabilitation in Chronic Spinal Cord Injury: A Pilot With One Year Treatment and Variable Treatment Frequency

STUDY DESIGN

Longitudinal prospective study.

OBJECTIVES

Whether 1-year HAL-BWSTT of chronic spinal cord injured patients can improve independent ambulated mobility further as a function of training frequency, after an initial 3-month training period.

METHODS

Eight patients with chronic SCI were enrolled. They initially received full standard physical therapy and neurorehabilitation in the acute/subacute posttrauma phase. During this trial, all patients first underwent a daily (5 per week) HAL-BWSTT for 12 weeks. Subsequently, these patients performed a 40-week HAL-BWSTT with a training session frequency of either 1 or 3 to 5 sessions per week. The patients' functional status including HAL-associated treadmill-walking time, -distance, and -speed with additional analysis of gait pattern, and their independent (without wearing the robot suit) functional mobility improvements, were assessed using the 10-Meter-Walk Test (10MWT), Timed-Up-and-Go Test (TUG) and 6-Minute-Walk Test (6MinWT) on admission, at 6 weeks, 12 weeks, and 1 year after enrollment. The data were analyzed separately for the 2 training frequency subgroups after the initial 12-week training period, which was identical in both groups.

RESULTS

During the 1-year follow-up, HAL-associated walking parameters and independent functional improvements were maintained in all the patients. This result held irrespective of the training frequency.

CONCLUSIONS

Long-term 1-year maintenance of HAL-associated treadmill walking parameters and of improved independent walking abilities after initial 12 weeks of daily HAL-BWSTT is possible and depends mainly on the patients' ambulatory status accomplished after initial training period. Subsequent regular weekly training, but not higher frequency training, seems to be sufficient to preserve the improvements accomplished.

Voluntary driven exoskeleton as a new tool for rehabilitation in chronic spinal cord injury: a pilot study

BACKGROUND CONTEXT

Treadmill training after traumatic spinal cord injury (SCI) has become an established therapy to improve walking capabilities. The hybrid assistive limb (HAL) exoskeleton has been developed to support motor function and is tailored to the patients' voluntary drive.

PURPOSE

To determine whether locomotor training with the exoskeleton HAL is safe and can increase functional mobility in chronic paraplegic patients after SCI.

DESIGN

A single case experimental A-B (pre-post) design study by repeated assessments of the same patients. The subjects performed 90 days (five times per week) of HAL exoskeleton body weight supported treadmill training with variable gait speed and body weight support.

PATIENT SAMPLE

Eight patients with chronic SCI classified by the American Spinal Injury Association (ASIA) Impairment Scale (AIS) consisting of ASIA A (zones of partial preservation [ZPP] L3-S1), n=4; ASIA B (with motor ZPP L3-S1), n=1; and ASIA C/D, n=3, who received full rehabilitation in the acute and subacute phases of SCI.

OUTCOME MEASURES

Functional measures included treadmill-associated walking distance, speed, and time, with additional analysis of functional improvements using the 10-m walk test (10MWT), timed-up and go test (TUG test), 6-minute walk test (6MWT), and the walking index for SCI II (WISCI II) score. Secondary physiologic measures including the AIS with the lower extremity motor score (LEMS), the spinal spasticity (Ashworth scale), and the lower extremity circumferences.

METHODS

Subjects performed standardized functional testing before and after the 90 days of intervention.

RESULTS

Highly significant improvements of HAL-associated walking time, distance, and speed were noticed. Furthermore, significant improvements have been especially shown in the functional abilities without the exoskeleton for over-ground walking obtained in the 6MWT, TUG test, and the 10MWT, including an increase in the WISCI II score of three patients. Muscle strength (LEMS) increased in all patients accompanied by a gain of the lower limb circumferences. A conversion in the AIS was ascertained in one patient (ASIA B to ASIA C). One patient reported a decrease of spinal spasticity.

CONCLUSIONS

Hybrid assistive limb exoskeleton training results in improved over-ground walking and leads to the assumption of a beneficial effect on ambulatory mobility. However, evaluation in larger clinical trials is required.

Epidemiology of spinal cord injuries and risk factors for complete injuries in Guangdong, China: a retrospective study

Background

Spinal cord injuries are highly disabling and deadly injuries. Currently, few studies focus on non-traumatic spinal cord injuries, and there is little information regarding the risk factors for complete injuries. This study aims to describe the demographics and the injury characteristics for both traumatic and non-traumatic spinal cord injuries and to explore the risk factors for complete spinal cord injuries.

Methods

A retrospective study was performed by reviewing the medical records of 3,832 patients with spinal cord injuries who were first admitted to the sampled hospitals in Guangdong, China. The demographics and injury characteristics of the patients were described and compared between the different groups using the chi-square test. Logistic regression was conducted to analyze the risk factors for complete spinal cord injuries.

Results

The proportion of patients increased from 7.0% to 14.0% from 2003 to 2011. The male-to-female ratio was 3.0∶1. The major cause of spinal cord injuries was traffic accidents (21.7%). Many of the injured were workers (36.2%), peasants (22.8%), and unemployed people (13.9%); these occupations accounted for 72.9% of the total sample. A multivariate logistic regression model revealed that the OR (95% CI) for male gender compared to female gender was 1.25 (1.07–1.89), the OR (95%CI) for having a spinal fracture was 1.56 (1.35–2.60), the OR (95%CI) for having a thoracic injury was 1.23 (1.10–2.00), and the OR (95%CI) for having complications was 2.47 (1.96–3.13).

Conclusion

The proportion of males was higher than the proportion of females. Workers, peasants and the unemployed comprised the high-risk occupational categories. Male gender, having a spinal fracture, having a thoracic injury, and having complications were the major risk factors for a complete injury. We recommend that preventive measures should focus on high-risk populations, such as young males.

Effect of overground training augmented by mental practice on gait velocity in chronic, incomplete spinal cord injury

OBJECTIVE

To compare the efficacy of a regimen combining mental practice (MP) with overground training (OT) with the efficacy of a regimen consisting of OT only on gait velocity and lower extremity motor outcomes in individuals with chronic (>12mo postinjury), incomplete spinal cord injury (SCI).

DESIGN

Randomized, controlled, single-blinded study.

SETTING

Outpatient rehabilitation laboratories.

PARTICIPANTS

Subjects with chronic, incomplete SCI (N=18).

INTERVENTIONS

Subjects were randomly assigned to receive (1) OT only, occurring 3d/wk for 8 weeks; or (2) OT augmented by MP (MP + OT), during which randomly assigned subjects listened to an MP audio recording directly after OT sessions.

MAIN OUTCOME MEASURES

Subjects were administered a test of gait velocity as well as the Tinetti Performance Oriented Mobility Assessment, Spinal Cord Injury Independence Measure, and Satisfaction With Life Scale on 2 occasions before intervention, 1 week after intervention, and 12 weeks after intervention.

RESULTS

A significant increase in gait velocity was exhibited across subjects at both 1 week posttherapy (P=.005) and at 12 weeks posttherapy (P=.006). However, no differences were seen in intervention response at either 1 or 12 weeks postintervention among subjects in the MP + OT group versus the OT-only group.

CONCLUSIONS

OT was associated with significant gains in gait velocity, and these gains were not augmented by further addition of MP.

Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network Locomotor Training Program

OBJECTIVE

To determine the effects of locomotor training on: (1) the International Standards for Neurological Classification of Spinal Cord Injury examination; (2) locomotion (gait speed, distance); (3) balance; and (4) functional gait speed stratifications after chronic incomplete spinal cord injury (SCI).

DESIGN

Prospective observational cohort.

SETTING

Outpatient rehabilitation centers in the NeuroRecovery Network (NRN).

PARTICIPANTS

Individuals (n=225) with American Spinal Injury Association Impairment Scale (AIS) grade C or D chronic motor incomplete SCI having completed locomotor training in the NRN.

INTERVENTION

The NRN Locomotor Training Program consists of manual-facilitated body weight-supported standing and stepping on a treadmill and overground.

MAIN OUTCOME MEASURES

AIS classification, lower extremity pin prick, light touch and motor scores, ten-meter walk and six-minute walk tests, and the Berg Balance Scale.

RESULTS

Significant gains occurred in lower extremity motor scores but not in sensory scores, and these were only weakly related to gait speed and distance. Final Berg Balance Scale scores and initial lower extremity motor scores were positively related. Although 70% of subjects showed significantly improved gait speed after locomotor training, only 8% showed AIS category conversion.

CONCLUSIONS

Locomotor training improves gait speed to levels sufficient for independent in-home or community ambulation after chronic motor incomplete SCI. Changes in lower extremity motor and sensory scores do not capture the full extent of functional recovery, nor predict responsiveness to locomotor training. Functional classification based on gait speed may provide an effective measure of treatment efficacy or functional improvement after incomplete SCI.

Locomotor training using a robotic device in patients with subacute spinal cord injury

STUDY DESIGN

Quasi experiment; single experimental group with matched historical control.

OBJECTIVES

To evaluate the effect of an additive robotic-assisted gait training (RAGT) using the Lokomat system on the neurological and functional outcomes of patients with subacute spinal cord injury (SCI).

SETTING

Department of Physical Medicine and Rehabilitation.

METHODS

A total of 28 subacute SCI patients were treated by RAGT, 2-3 times a week, 30-45 min every treatment, concomitantly with regular physiotherapy. As control, for each patient, we matched a comparable patient treated in the same department in previous years, according to age, severity of injury, level of injury and cause. The main outcomes were: the AIS (American Spinal Injury Association impairment scale) the spinal cord independence measurement (SCIM) score, the walking index for SCI II (WISCI II) and functional ambulation category scale (FAC).

RESULTS

At the end of rehabilitation, both groups showed a significant improvement in both the FAC score and the WISCI score (P<0.01) without differences between the groups. Functional abilities, according to the SCIM score, were also improved, with a significant interaction effect; the RAGT patients improve by 30±20 points, which was significantly greater gain as compared with the controls, 21±14 points (P=0.05). This improvement was mainly due to the change in the SCIM motor subscales.

CONCLUSION

RAGT is an important additional treatment to improve the functional outcome of subacute SCI patients. Larger, controlled studies are still required to determine the optimal timing and protocol design for the maximal efficacy of RAGT in SCI patients.

Outpatient spinal cord injury rehabilitation: Managing costs and funding in a changing health care environment

PURPOSE

To examine the literature describing the cost of outpatient rehabilitation for patients with spinal cord injury (SCI) as well as the effect of funding type on cost and outcome. A SCI rehabilitation planning and funding model is presented that calls for structured assessment of the client's economic environment, with follow through to promote full access to funding for rehabilitation plans.

METHOD

Literature review of specific outpatient rehabilitation intervention costs and effect of funding type, followed by development of a funding model to improve access to available funding for SCI rehabilitation.

RESULTS

There is insufficient economic data to draw conclusions about the relationship between an individual's rehabilitation needs and access to appropriate funding for outpatient rehabilitation. Consequently, health providers and payers need to adopt an approach that will improve consistency of payment decisions and access to necessary funding for rehabilitation.

CONCLUSIONS

A model for a more formal approach to: (a) Assessment of a client's economic environment; (b) use of evidence-based SCI rehabilitation; and (c) use of available financial resources should promote better access to appropriate rehabilitation following SCI.

Guidelines for the Conduction of Follow-up Studies Measuring Injury-Related Disability

BACKGROUND

Scientific knowledge on functional outcome after injury is limited. During the past decade, a variety of measures have been used at various moments in different study populations. Guidelines are needed to increase comparability between studies.

METHODS

A working group of the European Consumer Safety Association conducted a literature review of empirical studies into injury-related disability (1995-2005). We included injury from all levels of severity and selected studies using generic health status measures with both short-term and long-term follow up. The results were used as input for a consensus procedure toward the development of guidelines for defining the study populations, selecting the health status measures, selecting the timings of the assessments, and data collection procedures.

RESULTS

The group reached consensus on a common core of health status measures and assessment moments. The group advises to use a combination of EuroQol-5D and Health Utilities Mark III in all studies on injury-related disability. This combination covers all relevant health domains, is applicable in all kinds of injury populations and in widely different age ranges, provides a link with utility scores, and has several practical advantages (e.g., brevity, availability in different languages). For specific types of injury, the common core may be supplemented by injury-specific measures. The group advises a common core of assessments at 1, 2, 4, and 12 months after injury.

CONCLUSIONS

Our guidelines should be tested and may lead to improved and more consistent epidemiologic data on the incidence, severity, and duration of injury-related disability.

Assessment of sexual functions after spinal cord injury in Indian patients

This study assessed the interacting physical, psychological and social aspects of sexuality among 86 males and 14 females with spinal cord injury (SCI). Data collection involved the use of a 42-item study-specific questionnaire designed to determine different aspects of sexuality. Subjects were rated, after interview, on a scale according to an integrated index of sexual function (IISF). It was observed that patients scoring higher on this index were sexually more active and showed positive sexual adjustments. A higher incidence of complications of SCI, partner dissatisfaction, less partner co-operation, lower self-esteem and social taboos were factors responsible for less sexual activity in our patients. The present study suggests that there is a strong need for improved treatment of the medical complications of SCI, sexual counselling, literature, information and peer support in this country. We are of the opinion that the IISF can be utilized in rehabilitation settings to examine the interplay of the various complex factors in sexual rehabilitation post-SCI.

Effectiveness of automated locomotor training in patients with chronic incomplete spinal cord injury: A multicenter trial

OBJECTIVE

To determine whether automated locomotor training with a driven-gait orthosis (DGO) can increase functional mobility in people with chronic, motor incomplete spinal cord injury (SCI).

DESIGN

Repeated assessment of the same patients or single-case experimental A-B design.

SETTING

Research units of rehabilitation hospitals in Chicago; Heidelberg, Germany; and Basel and Zurich, Switzerland.

PARTICIPANTS

Twenty patients with a chronic (>2 y postinjury), motor incomplete SCI, classified by the American Spinal Injury Association (ASIA) Impairment Scale with ASIA grades C (n=9) and D (n=11) injury. Most patients (n=16) were ambulatory before locomotor training.

INTERVENTION

Locomotor training was provided using robotic-assisted, body-weight-supported treadmill training 3 to 5 times a week over 8 weeks. Single training sessions lasted up to 45 minutes of total walking time, with gait speed between .42 and .69 m/s and body-weight unloading as low as possible (mean +/- standard deviation, 37%+/-17%).

MAIN OUTCOME MEASURES

Primary outcome measures included the 10-meter walk test, the 6-minute walk test, the Timed Up & Go test, and the Walking Index for Spinal Cord Injury-II tests. Secondary measures included lower-extremity motor scores and spastic motor behaviors to assess their potential contribution to changes in locomotor function. All subjects were tested before, during, and after training.

RESULTS

Locomotor training using the DGO resulted in significant improvements in the subjects' gait velocity, endurance, and performance of functional tasks. There were no significant changes in the requirement of walking aids, orthoses, or external physical assistance. There was no correlation between improvements in walking speed or changes in muscle strength or spastic motor behaviors.

CONCLUSIONS

Intensive locomotor training on a treadmill with the assistance of a DGO results in improved overground walking.

Fibrocartilaginous embolism—an uncommon cause of spinal cord infarction: a case report and review of the literature11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

Fibrocartilaginous embolism is a rare cause of spinal cord infarction. It is postulated that an acute vertical disk herniation of the nucleus pulposus material can lead to spinal cord infarction by a retrograde embolization to the central artery. An increased intradiskal pressure resulting from axial loading of the vertebral column with a concomitant Valsalva maneuver is thought to be the initiating event for the embolus. We present a previously healthy 16-year-old boy with sudden onset of back pain and progressive paraparesis within 36 hours after lifting exercises in a squat position. His clinical presentation and neuroimaging studies were consistent with spinal cord infarction resulting from a central artery embolus at the T8 spinal cord level. Laboratory investigation showed no evidence of infectious, autoimmune, inflammatory, or neoplastic causes. Although no histologic confirmation was obtained, lack of evidence for other plausible diagnoses in the setting of his clinical presentation and in the magnetic resonance imaging findings made fibrocartilaginous embolism myelopathy the most likely diagnosis. We postulated that some cases of transverse myelitis might actually be fibrocartilaginous embolism, making it a more prevalent cause of an acute myelopathy than commonly recognized. Relevant literature and current theories regarding the pathogenesis of fibrocartilaginous embolism myelopathy are reviewed.