Navigating an unfamiliar world - Parents' experiences of having a child with post COVID-19

BACKGROUND

Post COVID-19 diagnosis in children has been difficult as there has been a lack of knowledge within the healthcare system, leading to uncertainty concerning how these children should be assessed and treated. To understand the aspects of how parents experience seeking care for their child with an array of symptoms and how the child's symptoms affect their everyday life and family situation, we need to listen to the parents' stories about having a child living with post COVID-19.

PURPOSE

To describe parents' experiences of seeking professional care for their child with post COVID-19 symptoms and what kinds of impacts there are on their children's daily life.

DESIGN AND METHODS

A qualitative study with an inductive and exploratory approach including seventeen parents of children with post COVID-19. Face-to-face interviews were conducted between October 2022 and March 2023 and analyzed with thematic analysis.

RESULTS

The findings describe how the parents' constant struggle for their child and how the child's symptoms affect their daily life and their family situation in three themes: Navigating the unknown, Navigating life with post COVID-19, and Navigating between fear and hope for an uncertain future.

CONCLUSIONS

This study corroborates the parents' struggle for acceptance of the children's problems in the health system.

PRACTICE IMPLICATIONS

It is important that health care focuses on the everyday world and the problems that the child and parents express to understand the family's perspective and the problems that arise in everyday life.

Oculomotor screening and neuro-visual rehabilitation following pediatric brain tumor resection

Visual difficulties are common after brain tumors, despite a lack of visual complaints at diagnosis. These include difficulties with eye movements, visual coordination, vergence, accommodation, and photophobia, in addition to more obvious problems such as visual field defects.This case report presents the results of a thorough neuro-visual evaluation in a boy with sequelae after a brain tumor including intermittent double vision that was not explained by routine visual examination. Subjective complaints included poor reading perseverance, intermittent blurred and double vision, headache around the eyes when performing near activities, less efficient eye movement behavior in reading tasks, and increased sensitivity to visual motion. The patient participated in a multidisciplinary visual rehabilitation program that included reading glasses with prism compensation and tinted glasses, as well as training with the aim of improving eye teaming, near vision functions, and perseverance in eye movements.The patient responded quickly to the vision therapy program, with positive changes after just four weeks. Repeated neuro-visual evaluations over eight months showed remarkable improvements that were stable over time. This encouraging case report supports the notion that neuro-visual evaluation and rehabilitation should be included in the follow-up of patients after brain tumors.

Test-Retest Reliability of Kinematic and Temporal Outcome Measures for Clinical Gait and Stair Walking Tests, Based on Wearable Inertial Sensors

It is important to assess gait function in neurological disorders. A common outcome measure from clinical walking tests is average speed, which is reliable but does not capture important kinematical and temporal aspects of gait function. An extended gait analysis must be time efficient and reliable to be included in the clinical routine. The aim of this study was to add an inertial sensor system to a gait test battery and analyze the test-retest reliability of kinematic and temporal outcome measures. Measurements and analyses were performed in the hospital environment by physiotherapists using customized software. In total, 22 healthy persons performed comfortable gait, fast gait, and stair walking, with 12 inertial sensors attached to the feet, shank, thigh, pelvis, thorax, and arms. Each person participated in 2 test sessions, with about 3-6 days between the sessions. Kinematics were calculated based on a sensor fusion algorithm. Sagittal peak angles, sagittal range of motion, and stride frequency were derived. Intraclass-correlation coefficients were determined to analyze the test-retest reliability, which was good to excellent for comfortable and fast gait, with exceptions for hip, knee, and ankle peak angles during fast gait, which showed moderate reliability, and fast gait stride frequency, which showed poor reliability. In stair walking, all outcome measures except shoulder extension showed good to excellent reliability. Inertial sensors have the potential to improve the clinical evaluation of gait function in neurological patients, but this must be verified in patient groups.

Pediatric spinal cord injury rehabilitation: A protocol for an international multicenter project (SINpedSCI)

PURPOSE

Children and adolescents (<18 years old) who sustain a spinal cord injury (SCI) should ideally be managed in specialized rehabilitation services. This project aims to describe the organization of pediatric SCI in ten rehabilitation units in seven countries and to qualitatively explore psychosocial aspects of adolescents living with SCI.

METHODS

A multicenter cross-sectional project is planned, using quantitative (web survey) and qualitative (interview) methods in ten rehabilitation units from Norway, Sweden, United States, Israel, PR China, Russia and Palestine. Individual interviews will be conducted with ≥20 adolescents aged 13-17 years at least 6 months' post rehabilitation.

RESULTS

Units involved will be described and compared, according to funding, attachment to an acute SCI unit, catchment area, number of beds, admittance and discharge procedures, availability of services, staff/patient ratio, content and intensity of rehabilitation programs, length of stay, measurement methods, follow-up services, health promotion services, and pediatric SCI prevention acts. The semi-structured interview guide will include experiences from acute care and primary rehabilitation, daily life, school, contact with friends, leisure time activities, peers, physical and psychological health, and the adolescents' plans for the future.

CONCLUSION

Based on the present protocol, this project is likely to provide new insight and knowledge on pediatric SCI rehabilitation and increase the understanding of pediatric SCI in adolescents and their families internationally.

A Systematic Review of the Scientific Literature for Rehabilitation/Habilitation Among Individuals With Pediatric-Onset Spinal Cord Injury

Objectives

To conduct a systematic review to examine the scientific literature for rehabilitation/habilitation among individuals with pediatric-onset spinal cord injury (SCI).

Methods

A literature search of multiple databases (i.e., PubMed/MEDLINE, CINAHL, EMBASE, PsychINFO) was conducted and was filtered to include studies involving humans, published as full-length articles up to December 2020, and in English. Included studies met the following inclusion criteria: (1) ≥50% of the study sample had experienced a traumatic, acquired, nonprogressive spinal cord injury (SCI) or a nontraumatic, acquired, noncongenital SCI; (2) SCI onset occurred at ≤21 years of age; and (3) sample was assessed for a rehabilitation/habilitation-related topic. Studies were assigned a level of evidence using an adapted Sackett scale modified down to five levels. Data extracted from each study included author(s), year of publication, country of origin, study design, subject characteristics, rehabilitation/habilitation topic area, intervention (if applicable), and outcome measures.

Results

One hundred seventy-six studies were included for review (1974-2020) with the majority originating from the United States (81.3%). Most studies were noninterventional observational studies (n = 100; 56.8%) or noninterventional case report studies (n = 5; 2.8%). Sample sizes ranged from 1 to 3172 with a median of 26 (interquartile range [IQR], 116.5). Rehabilitation/habilitation topics were categorized by the International Classification of Functioning, Disability and Health (ICF); most studies evaluated ICF Body Function. There were 69 unique clinical health outcome measures reported.

Conclusion

The evidence for rehabilitation/habilitation of pediatric-onset SCI is extremely limited; nearly all studies (98%) are level 4-5 evidence. Future studies across several domains should be conducted with novel approaches to research design to alleviate issues related to sample sizes and heterogeneity.

Patients' experiences of self-administered electrotherapy for spasticity in stroke and cerebral palsy: A qualitative study

OBJECTIVE

To explore patients' experiences of a self-administered electrotherapy treatment for muscle spasticity in cerebral palsy and stroke; the Exopulse Mollii Suit®.

DESIGN

Qualitative design with an inductive approach Subjects: Fifteen patients with spasticity due to stroke or cerebral palsy, participating in a previous randomized controlled trial (RCT) evaluating the treatment concept.  Methods: Information letters were sent to all potential participants (n = 27) in the previous study. Semi-structured interviews (21-57 min) were carried out with all subjects who volunteered (n = 15), administered by an experienced interviewer who was not involved in the previous study. Transcribed interviews were subject to content analysis.  Results: The 5 categories that emerged from the content analysis were "New method gives hope", experiences related to "Using the assistive technology", "Outcome from training with the assistive technology", "The assistive technology" and "Taking part in the study". Respondents felt hopeful when included in the previous study, motivated when experiencing a treatment effect, and disappointed when not.  Conclusion: The qualitative approach used in this study elicited complementary information that was not evident from the previous RCT. This included statements regarding increased mobility, reduced spasticity, reduced use of medication, and problems related to using the treatment concept.

Complications of intrathecal drug delivery therapy (ITDD): A retrospective study of 231 implantations between 1999 and 2014

OBJECTIVE

Determination of types and frequencies of complications related to ITDD therapy, and assessment of possible risk factors for such complications.

METHODS

Retrospective study (1999-2014) including all ITDD-implantations at one regional center in Sweden. Descriptors comprised: sex; age; medical condition; body weight index; preoperative ASA-grade; presence of indwelling urinary catheters, feeding tubes, and/or daily urinary or anal incontinence; primary or re-implantation; type of pump and catheter; drug delivered; weekday of surgery; surgical procedure time; surgeon; experience of surgeon; surgical theater; and type of antibiotic prophylaxis. All deaths during the study period were assessed as regards possible relation to ITDD. Data were analyzed with SPSS 25, using Chi2 test for correlations between descriptors and complications.

RESULTS

231 ITDD pump implantations/re-implantations occurred in 159 patients. Seventy-eight (34%) instances of complications were found: 33 catheter-associated; 6 pump-associated; and 29 infection-associated, where 16 were surgical site infections. A higher infection rate occurred in pump re-implantations, as compared to primary implantations (p = 0.002), and in patients with traumatic spinal cord injury (TSCI) as compared to other diagnoses (p = 0.02). Cloxacillin as antibiotic prophylaxis correlated with a higher infection risk (p = 0.005) relative to other antibiotic prophylaxis. Prolonged surgical procedure time in re-implantations correlated positively with increased catheter-associated complications (p = 0.006).

CONCLUSION

Complications in ITDD therapy were common, comprising catheter-, infection-, and pump-associated mishaps. A comprehensive system of care needs to be present for managing complications. Future studies may show less complications due to improved protocols and equipment.

Dosing Patterns In Treatment of Disabling Spasticity With Intrathecal Baclofen

PURPOSE

The aim of this study was to describe and analyze dosing patterns for patients with ITB treatment over time and to identify possible subgroups demonstrating diversity in patterns.

DESIGN

A retrospective design.

METHODS

For 81 patients from six different hospitals, baclofen doses from the first 2 years of treatment were identified using medical records. Line graphs of each patient's doses were analyzed and grouped based on similarities in dosing pattern.

FINDINGS

The analyses of the dosing patterns resulted in four different subgroups classified as stable, slow increase, rapid increase, and fluctuating.

CONCLUSION

The results highlight the clinical challenge of predicting dose development over time.

CLINICAL RELEVANCE TO REHABILITATION NURSING

This study provides rehabilitation healthcare professionals with a better understanding of intrathecal baclofen dose development. Illustrations of the four subgroups can be used as an educational tool for patients, family, and caregivers.

A review and evaluation of patient-reported outcome measures for spasticity in persons with spinal cord damage: Recommendations from the Ability Network - an international initiative

Context: Patient-reported outcome measures (PROMs) are valuable for capturing the impact of spasticity on health-related quality of life (HRQoL) in persons with spinal cord damage (SCD) and evaluating the efficacy of interventions. Objective: To provide practical guidance for measuring HRQoL in persons with spasticity following SCD. Methods: Literature reviews identified measures of HRQoL and caregiver burden, utilized in studies addressing spasticity in SCD. Identified measures were evaluated for clinical relevance and practicality for use in clinical practice and research. The PRISM, SCI-SET, EQ-5D and SF-36 instruments were mapped to the International Classification of Functioning, Disability and Health (ICF). The PRISM and SCI-SET were evaluated using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Results: Two spasticity-specific, five generic, and four preference-based measures were identified. ICF mapping and the COSMIN checklist supported the use of the PRISM and SCI-SET in SCD. The SF-36 is considered the most useful generic measure; disability-adapted versions may be more acceptable but further studies on psychometric properties are required. The SF-36 can be converted to a preference-based measure (SF-6D), or alternatively the EQ-5D can be used. While no measures specific to caregivers of people with SCD were identified, the Caregiver Burden Scale and the Zarit Burden Interview are considered suitable. Conclusion: Recommended measures include the PRISM and SCI-SET (condition-specific), SF-36 (generic), and Caregiver Burden Scale and Zarit Burden Interview (caregiver burden). Consideration should be given to using condition-specific and generic measures in combination; the PRISM or SCI-SET combined with SF-36 is recommended.

Impact of spasticity on functioning in spinal cord injury: an application of graphical modelling

OBJECTIVE

To identify the impact of moderate-to-severe spasticity on functioning in people living with spinal cord injury.

DESIGN

Secondary analysis of cross-sectional survey data using graphical modelling.

SUBJECTS

Individuals (n = 1,436) with spinal cord injury aged over 16 years with reported spasticity problems.

METHODS

Spasticity and 13 other impairments in body functions were assessed using the spinal cord injury Secondary Conditions Scale. Impairments in mental functions were assessed using the Mental Health subscale of the 36-item Short Form (SF-36). Independence in activities was measured with the Spinal Cord Injury Independence Measure Self-Report. Restrictions in participation were measured with the Utrecht Scale for Evaluation Rehabilitation - Participation.

RESULTS

Fifty-one percent of participants reported moderate-to-severe spasticity. Graphical modelling showed that Chronic pain, Contractures, Tiredness, Doing housework, and Respiratory functions were associated with spasticity and were the top 5 potential targets for interventions to improve the experience of spasticity. The associations and intervention targets were dependent on the level and completeness of the lesion.

CONCLUSION

This is the first application of graphical modelling in studying spasticity in people living with spinal cord injury. The results can be used as a basis for studies aiming to optimize rehabilitation interventions in people with moderate-to-severe spasticity.

Inequalities in pharmacologic treatment of spasticity in Sweden - health economic consequences of closing the treatment gap

BACKGROUND

The Swedish Healthcare Act states that patients should have equal access to healthcare. This study addresses at how this translates to pharmacological treatment of adult spasticity, including injections with botulinum toxin A (BoNT-A) and pumps for intrathecal baclofen (ITB). To address potential economic incentives for treatment differences, the results are also set into a health economic perspective. Thus, the current study provides a detailed and comprehensive overview for informed decision- and policymaking.

METHODS

Botulinum toxin use was retrieved from sales data. Clinical practice regarding mean BoNT-A treatment dose and proportion used for spasticity indication were validated in five county councils, while the number of ITB pumps were mapped for all county councils. Published costs and quality of life data was used for estimating required responder rates for cost-balance or cost-effectiveness.

RESULTS

The proportion of patients treated with BoNT-A varied between 5.8% and 13.6% across healthcare regions, with a mean of 9.2% on a national level. The reported number of ITB pumps per 100,000 inhabitants varied between 3.6 and 14.1 across healthcare regions, with a national mean of 6/100,000. The estimated incremental cost for reaching treatment equity was EUR 1,976,773 per year for BoNT-A and EUR 3,326,692 for ITB pumps. Based on expected cost-savings, responder rates ranging between 4% and 15% cancelled out the incremental cost for BoNT-A. Assuming no cost-savings, responder rates of 14% or 36% was required for cost-effectiveness.

CONCLUSIONS

There is a marked variation in pharmacologic treatment of adult spasticity in Sweden. Overall, the results indicate an underuse of treatment and need for harmonisation of clinical practice. Furthermore, the incremental cost for reaching treatment equity is likely to be offset by spasticity-associated cost-savings.

Experiences from intrathecal baclofen treatment based on medical records and patient- and proxy-reported outcome: a multicentre study

PURPOSE

To investigate patient satisfaction with intrathecal baclofen treatment, complications from the treatment, and the impact of general expectations on treatment outcome in relation to satisfaction.

METHODS

A multicentre study with cross-sectional design. Data were collected through questionnaires and patient records. Patients were recruited from six outpatient intrathecal baclofen clinics in Sweden. Eighty-three patients who had been treated with intrathecal baclofen for 1-4 years were included. For patients unable to communicate, data were collected through a proxy. The Patient Global Impression of Change was used to measure patients' general satisfaction with change from intrathecal baclofen treatment. The Life Orientation Test - revised, was used to measure general expectations/optimism.

RESULTS

General satisfaction with intrathecal baclofen treatment was high; 51/77 patients reported "much improved" or "very much improved." There was no relationship between the two main outcomes (general satisfaction and general expectations/optimism) (r_s = 0.12, p = 0.382). The two groups; those who could and those who could not communicate, did differ regarding personal characteristics and should be evaluated as such.

CONCLUSIONS

Most patients/proxies reported a high level of satisfaction with intrathecal baclofen treatment. The reported satisfaction with intrathecal baclofen treatment was not dependent on general expectations. Implications for Rehabilitation Patients with intrathecal baclofen treatment report low levels of health and quality of life at the same time as they are highly satisfied with their treatment. Intrathecal baclofen should be equally offered to both optimistic and less optimistic patients. Patients who are able to/not able to communicate, differs in characteristics and should be informed and followed up in different ways in daily clinical practice.

Evaluation of a self-administered transcutaneous electrical stimulation concept for the treatment of spasticity: a randomized placebo-controlled trial

BACKGROUND

Spasticity is a common consequence of injury to the central nervous system negatively affecting patient's everyday activities. Treatment mainly consists of training and different drugs, often with side effects. There is a need for treatment options that can be performed by the patient in their home environment.

AIM

The objective of this study was to assess the effectiveness of an assistive technology (AT), Mollii®, a garment with integrated electrodes for multifocal transcutaneous electrical stimulation intended for self-treatment of spasticity, in study participants with spasticity due to stroke or CP.

DESIGN

The study was a randomized, controlled, double-blind study with a cross-over design.

SETTING

Participants were recruited from two rehabilitation clinics. Treatments were performed in participants' homes and all follow-ups were performed in the two rehabilitation clinics.

POPULATION

Thirty-one participants were included in the study and 27 completed the study. Four participants discontinued the study. Two declined participation before baseline and two withdrew due to problems handling the garment.

METHODS

Participants used the AT with and without electrical stimulation (active/non-active period) for six weeks each, followed by six weeks without treatment. Goal Attainment Scaling (GAS), change in mobility, arm-hand ability, spasticity and pain were measured at baseline and after 6, 12 and 18 weeks.

RESULTS

Fifteen of the 27 participants fulfilled the treatment protocol in terms of recommended use. Deviations were frequent. No statistically significant differences in outcome were found between the active and the non-active treatment periods. During the active period, an improvement was seen in the 10-meter comfortable gait test, time and steps. An improvement was seen in both the active and non-active periods for the GAS.

CONCLUSIONS

Compliance was low, partly due to deviations related to the garment, complicating the interpretation of the results. Further research should focus on identifying the target population and concomitant rehabilitation strategies.

CLINICAL REHABILITATION IMPACT

The evaluated concept of multifocal transcutaneous electrical stimulation (TES) represents an interesting addition to the existing repertoire of treatments to alleviate muscle spasticity. The evaluated concept allows TES to be self-administered by the patient in the home environment. A more elaborate design of training activities directly related to patient's own rehabilitation goals is recommended and may increase the value of the evaluated concept.

Efficacy and safety of oral baclofen in the management of spasticity: A rationale for intrathecal baclofen

Oral baclofen has long been a mainstay in the management of spasticity. This review looks at the clinical evidence for the efficacy and safety of oral baclofen in patients with spasticity of any origin or severity, to determine whether there is a rationale for the use of intrathecal baclofen. Results suggest that oral baclofen may be effective in many patients with spasticity, regardless of the underlying disease or severity, and that it is at least comparable with other antispasmodic agents. However, adverse effects, such as muscle weakness, nausea, somnolence and paraesthesia, are common with oral baclofen, affecting between 25% and 75% of patients, and limiting its usefulness. Intrathecal baclofen may be an effective alternative as the drug is delivered directly into the cerebrospinal fluid, thus bypassing the blood-brain barrier and thereby optimizing the efficacy of baclofen while minimizing drug-related side-effects. Intrathecal baclofen is a viable option in patients who experience intolerable side-effects or who fail to respond to the maximum recommended dose of oral baclofen.

Changes in body composition after spasticity treatment with intrathecal baclofen

OBJECTIVE

To assess changes in body composition, body weight and resting metabolic rate in patients who received intrathecal baclofen therapy for spasticity.

DESIGN

Prospective, longitudinal, quasi-experimental, with a pre/post design.

PATIENTS

Twelve patients with spasticity, fulfilling study criteria, and due for pump implantation for intrathecal baclofen therapy, completed the study.

METHODS

Data were obtained before, 6 months and 12 months after commencement of intrathecal baclofen therapy as regards body composition (by skinfold calliper), body weight, and resting metabolic rate (by resting oxygen consumption). Spasticity was assessed according to the Modified Ashworth Scale (MAS) and Penn Spasm Frequency Scale (PSFS).

RESULTS

A reduction in spasticity according to MAS occurred. Mean fat body mass increased and mean lean body mass decreased. Mean body weight showed a non-significant increase and resting metabolic rate a non-significant decrease.

CONCLUSION

This explorative study indicates that unfavourable changes in body composition might occur after intrathecal baclofen therapy. Since obesity and increased fat body mass contribute to an increased cardiovascular risk, these findings may indicate a need for initiation of countermeasures, e.g. increased physical activity and/or dietary measures, in conjunction with intrathecal baclofen therapy. Further studies, including larger study samples and control groups, are needed to corroborate these findings.

Regional disparities in botulinum toxin A (BoNT-A) therapy for spasticity in Sweden: budgetary consequences of closing the estimated treatment gap

OBJECTIVES

As no national treatment guidelines for spasticity have been issued in Sweden, different regional treatment practices may potentially occur. This study examines botulinum toxin A (BoNT-A) treatment for spasticity on a regional level in Sweden and presents budgetary consequences of closing the estimated treatment gap.

MATERIALS AND METHODS

Prevalence of spasticity in Sweden was estimated from published data. Regional sales data for BoNT-A were acquired from IMS Health. A set proportion of hospital BoNT-A use was assumed to represent treatment of spasticity. Total intervention cost of BoNT-A treatment was gathered from healthcare regional tariffs, while costs associated with spasticity were derived from publications on multiple sclerosis and stroke.

RESULTS

Results show that the regional variation in treatment of spasticity with BoNT-A is large, with approximately every fourth patient being treated in Southern healthcare region compared to every tenth in the Stockholm-Gotland or Western healthcare regions. The incremental cost of filling the reported treatment gap was also assessed and was estimated at around 9.4 million EUR. However, for the incremental cost to be offset by savings in spasticity-related costs, only a small proportion of treatment responders (defined as patients transitioning to a lower severity grade of spasticity) was required (12%).

CONCLUSIONS

The study revealed apparent regional disparities of BoNT-A treatment for spasticity in Sweden. The results further suggest that the incremental cost of eliminating the treatment gap has a high probability of being offset by savings in direct costs, even at a low proportion of the patients reaching clinical improvement.

OnabotulinumtoxinA Improves Pain in Patients With Post-Stroke Spasticity: Findings From a Randomized, Double-Blind, Placebo-Controlled Trial

CONTEXT

Patients with post-stroke spasticity (PSS) commonly experience pain in affected limbs, which may impact quality of life.

OBJECTIVES

To assess onabotulinumtoxinA for pain in patients with PSS from the BOTOX(®) Economic Spasticity Trial, a multicenter, randomized, double-blind, placebo-controlled trial.

METHODS

Patients with PSS (N = 273) were randomized to 22- to 34-week double-blind treatment with onabotulinumtoxinA + standard care (SC) or placebo injection + SC and were eligible to receive open-label onabotulinumtoxinA up to 52 weeks. Assessments included change from baseline on the 11-point pain numeric rating scale, proportion of patients with baseline pain ≥4 achieving ≥30% and ≥50% improvement in pain, and pain interference with work at Week 12, end of double-blind treatment, and Week 52.

RESULTS

At baseline, most patients (74.3%) experienced pain and 47.4% had pain ≥4 (pain subgroup). Mean pain reduction from baseline at Week 12 was significantly greater with onabotulinumtoxinA + SC (-0.77, 95% CI -1.14 to -0.40) than placebo + SC (-0.13, 95% CI -0.51 to 0.24; P < 0.05). Higher proportions of patients in the pain subgroup achieved ≥30% and ≥50% reductions in pain at Week 12 with onabotulinumtoxinA + SC (53.7% and 37.0%, respectively) compared with placebo (28.8% and 18.6%, respectively; P < 0.05). Reductions in pain were sustained through Week 52. Compared with placebo + SC, onabotulinumtoxinA consistently reduced pain interference with work.

CONCLUSION

This is the first randomized, placebo-controlled trial demonstrating statistically significant and clinically meaningful reductions in pain and pain interference with work with onabotulinumtoxinA in patients with PSS.

Optimizing the Management of Disabling Spasticity Following Spinal Cord Damage: The Ability Network-An International Initiative

Optimizing the treatment of disabling spasticity in persons with spinal cord damage is hampered by a lack of consensus regarding the use of acceptable definitions of spasticity and disabling spasticity, and the relative absence of decision tools such as clinical guidelines and concise algorithms to support decision-making within the broader clinical community. Many people with spinal cord damage are managed outside specialist centers, and variations in practice result in unequal access to best practice despite equal need. In order to address these issues, the Ability Network-an international panel of clinical experts-was initiated to develop management algorithms to guide and standardize the assessment, treatment, and evaluation of outcomes of persons with spinal cord damage and disabling spasticity. To achieve this, consensus was sought on common definitions through facilitated, in-person meetings. To guide patient selection, an in-depth review of the available tools was performed and expert consensus sought to develop an appropriate instrument. Literature reviews are guiding the selection and development of tools to evaluate treatment outcomes (body functions, activity, participation, quality of life) as perceived by people with spinal cord damage and disabling spasticity, and their caregivers and clinicians. Using this approach, the Ability Network aims to facilitate treatment decisions that take into account the following: the impact of disabling spasticity on health status, patient preferences, treatment goals, tolerance for adverse events, and in cases of totally dependent persons, caregiver burden.

A new way of assessing arm function in activity using kinematic Exposure Variation Analysis and portable inertial sensors--A validity study

Portable motion systems based on inertial motion sensors are promising methods, with the advantage compared to optoelectronic cameras of not being confined to a laboratory setting. A challenge is to develop relevant outcome measures for clinical use. The aim of this study was to characterize elbow and shoulder motion during functional tasks, using portable motion sensors and a modified Exposure Variation Analysis (EVA) and evaluate system accuracy with optoelectronic cameras. Ten healthy volunteers and one participant with sequel after stroke performed standardised functional arm tasks. Motion was registered simultaneously with a custom developed motion sensor system, including gyroscopes and accelerometers, and an optoelectronic camera system. The EVA was applied on elbow and shoulder joints, and angular and angular velocity EVA plots was calculated. The EVA showed characteristic patterns for each arm task in the healthy controls and a distinct difference between the affected and unaffected arm in the participant with sequel after stroke. The accuracy of the portable system was high with a systematic error ranging between -1.2° and 2.0°. The error was direction specific due to a drift component along the gravity vector. Portable motion sensor systems have high potential as clinical tools for evaluation of arm function. EVA effectively illustrates joint angle and joint angle velocity patterns that may capture deficiencies in arm function and movement quality. Next step will be to manage system drift by including magnetometers, to further develop clinically relevant outcome variables and apply this for relevant patient groups.

Functional goal achievement in post-stroke spasticity patients: the BOTOX® Economic Spasticity Trial (BEST)

OBJECTIVE

Evaluate changes in active and passive function with onabotulinumtoxinA + standard of care within goal-oriented rehabilitation programmes in adults with focal post-stroke spasticity.

METHODS

Prospective, 24-week double-blind study with an open-label extension. Subjects were randomized to onabotulinumtoxinA + standard of care or placebo + standard of care, at baseline and at 12 weeks, if judged appropriate, with follow-up to 52 weeks. The primary endpoint was the number of patients achieving their principal active functional goal at 24 weeks (or 10 weeks after an optional second injection). Secondary endpoints included achievement of a different active or a passive goal at this timepoint.

RESULTS

The intent-to-treat population comprised 273 patients. The proportion of patients achieving their principal active functional goal and secondary active functional goal with onabotulinumtoxinA + standard of care was not statistically different from placebo + standard of care. Significantly more patients achieved their secondary passive goal with onabotulinumtoxinA + standard of care (60.0%) vs. placebo + standard of care (38.6%) (odds ratio, 2.46; 95% confidence interval, 1.18-5.14) as well as higher Goal Attainment Scaling levels for upper limb and ankle flexor subgroups.

CONCLUSIONS

Addition of onabotulinumtoxinA to standard of care as part of goal-oriented rehabilitation in post-stroke spasticity patients significantly increased passive goal achievement and was associated with higher levels of active function.

Practical considerations for goal attainment scaling during rehabilitation following acquired brain injury

OBJECTIVE

Goal attainment scaling represents a unique approach to identifying and quantifying individualized, meaningful treatment outcomes, and its use in the rehabilitation medicine setting is increasing. The aim of this paper is to discuss the available literature for goal attainment scaling in patients with acquired brain injury, in terms of its advantages, disadvantages and practical application, including examples of goal setting and scaling.

Bacteriuria in spinal cord injured patients with neurogenic bladder dysfunction

The occurrence of bacteriuria in spinal cord injured patients with neurogenic bladder dysfunction who used clean intermittent catheterisation to empty their bladders was studied in order to examine cut-off concentration breakpoints for significant bacteriuria in this group of patients using procedures of the European Urinanalysis Guideline. 344 samples were cultured, yielding 285 isolates. Coagulase-negative staphylococci (27%), Enterococci (25%), Klebsiella spp (19%), and Escherichia coli (12%) were the most common findings. Bacteria grew at concentrations of 10(5)-10(8) cfu/L, but only a few at 10(4) cfu/L. It is concluded that low bacterial concentrations in the urine (10(5) cfu/L) of patients with neurogenic bladder dysfunction who are on intermittent catheterisation might be as significant for bladder contamination with bacteria as a high bacterial concentration and can possibly be responsible for bladder infections.

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.

Gender related differences in pain in spinal cord injured individuals

STUDY DESIGN

Out of a population of 456 patients with spinal cord injuries (SCI), 130 having pain were selected after matching, based on gender, age, American Spinal Injury Association (ASIA) impairment grade and level of lesion.

OBJECTIVE

To investigate whether gender differences with regard to pain perception and prevalence exist in a population of patients following spinal cord injury.

SETTING

Spinalis SCI Unit (out-patient clinic), Stockholm, Sweden.

METHOD

130 patients suffering from pain were assessed over a 12-month period in a yearly health control.

RESULTS

SCI women had a higher prevalence of nociceptive pain than men and their use of analgesics was greater. However, no differences between the sexes could be seen regarding pain and localization, onset, distribution, factors affecting pain, number of painful body regions, pain descriptors, ratings of pain intensities or in pain and life satisfaction.

CONCLUSION

This study showed that SCI men and women describe their pain very similarly. However, SCI women had a higher prevalence of nociceptive pain than men and their use of opiates and non-steroid anti-inflammatory drugs (NSAIDs) was greater.

Obliteration of a posttraumatic spinal cord cyst with solid human embryonic spinal cord grafts: first clinical attempt

Cystic lesions of the spinal cord (syringomyelia) may occur after spinal cord injury. Posttraumatic syringomyelia may result in a myelopathy causing symptoms of sensory and motor loss, as well as worsening spasticity, pain, hyperhidrosis, and autonomic dysreflexia. Shunting of the cyst cavity along with untethering of the scarred spinal cord is widely accepted as the treatment of choice. However, the long-term stabilization of the progressive myelopathy caused by a posttraumatic cyst is suboptimal because of arachnoidal rescarring, shunt tube blockage, and cyst reexpansion. A new neurosurgical strategy to overcome the complication of cyst reexpansion was designed. Experimental studies have shown the successful use of embryonic spinal cord grafts, including human grafts, to obliterate induced spinal cord cavities in rats. The authors report the first use of solid human embryonic spinal cord grafts to successfully obliterate 6 cm of a large cyst cavity in a patient becoming myelopathic from a posttraumatic cyst. The grafts are well visualized by MRI to the 7-month postoperative follow-up and cyst obliteration is seen in the region where the grafts were placed.

[Central nervous pain in patients with spinal cord injury. Medical and surgical treatment]

About 50% of patients with spinal cord injury suffer from persistent central neurogenic pain. The authors review the case of a patient with traumatic paraplegia who developed persistent central neurogenic pain. The pain was described as burning in the buttock area, icing in the rectum area and as lancinating pain to the lower extremities. The combination of amitryptilin and morphine had a slight, short-term effect, but the pain did not respond to treatment with simple analgetica, dextropropoxyphen or ketobemidone, neither administered alone nor in combination with tricyclic antidepressants, carbamazepine or baclophen. Transcutanous nerve stimulation and acupuncture had no effect. The patient was operated on by means of the computer-assisted dorsal root entry zone (DREZ)-microcoagulation technique 2.5 years after the trauma. This technique is described in brief. The prevalence and classification of neurogenic pain, and possible medical and surgical treatment, are also discussed.

Obstructive effect of a closed 12F urethral catheter during the emptying phase of cystometry in patients with a spinal reflex bladder

In spinal cord injured patients with a reflex urinary bladder urodynamic evaluation of the detrusor pressure during the emptying phase is important, but the methods are not yet standardised. The aim of this study was to examine whether the detrusor pressure is significantly affected by the presence of a catheter in the urethra. In seven patients with a spinal reflex bladder, the maximum detrusor pressure and the duration of detrusor contractions in cystometry with a suprapubic technique were compared with the corresponding measurements when a closed 12F catheter was added to mimic a transurethral cystometric technique. Four cystometries were performed with about 10 min intervals and the mean values from two cytometries without the urethral catheter were compared with the mean values from two cystometries with the catheter. After addition of the urethral catheter there was an increase of the mean maximum detrusor pressure form 8.4 to 10.5 kPa (P = 0.009). The mean duration of the detrusor contraction increased from 122 to 191 s (P = 0.031) and the mean time during which the detrusor pressure exceeded 4 kPa, in each contraction, increased from 60 to 150 s (P = 0.009). The average flow rate, calculated as the voided volume divided by the duration of a contraction, decreased from 1.4 to 0.6 ml s-1 (P = 0.009).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of nifedipine on cystometry-induced elevation of blood pressure in patients with a reflex urinary bladder after a high level spinal cord injury

In 10 patients with a reflex urinary bladder after a cervical or high thoracic spinal cord injury, the effect of nifedipine on the cystometry-induced elevation of blood pressure was studied. The blood pressure was measured every 30 s in four consecutive cystometries before and after administration of 10 mg nifedipine sublingually. In each patient there was a decrease in the maximum systolic and diastolic blood pressure after the administration of nifedipine. In the whole group the mean maximum systolic pressure decreased significantly from 147 mmHg (range 119-165, SD 14) to 118 mmHg (range 99-145, SD 14). The mean maximum diastolic pressure decreased from 110 mmHg (range 96-124, SD 10) to 83 mmHg (range 71-99, SD 10). The effect of nifedipine was significant in each of the four cystometries that were performed. The decrease in blood pressure was due to both a significant decrease of the baseline pressure and a significant decrease of the blood pressure reaction during cystometry. Nifedipine may be useful in order to prevent dangerous blood pressure reactions, e.g. during cystoscopy and other diagnostic or therapeutic procedures in spinal cord injured patients with autonomic dysreflexia.

Blood pressure response to detrusor pressure elevation in patients with a reflex urinary bladder after a cervical or high thoracic spinal cord injury

In 12 patients with a reflex urinary bladder after a cervical or high thoracic spinal cord injury, blood pressure was measured every 30 s during cystometry. Four consecutive cystometries were performed by means of suprapubical catheters and 50 ml/min filling rate. The aim was to improve the methodological basis for cystometrical studies of paroxysmal hypertension and its treatment. In each cystometry there was an elevation of the systolic (20-60 mmHg) and the diastolic (15-55 mmHg) blood pressure. The maximum blood pressure always occurred during the emptying phase and always in close relation to the peak of the detrusor pressure. The amplitude of the blood pressure response varied intraindividually, but did not change in any particular direction during the series of cystometries. Thus, a cystometrical method which stimulates the detrusor in a physiological way is sufficient to give the typical uninhibited blood pressure reaction in most patients with a reflex bladder and a spinal reflex vasomotor function after a high level spinal cord injury. The blood pressure reaction obtained with this method is probably representative for the daily reaction during physiological reflex emptying of the bladder. To describe the maximum blood pressure reaction, it has to be measured during a well defined emptying phase and close to the occurrence of the maximum detrusor pressure. Since repetition of cystometry did not change the blood pressure response, this cystometrical method is useful for evaluation of pharmacological intervention.