Venous thromboembolism and anticoagulation in spinal cord lesion rehabilitation inpatients: A 10-year retrospective study.

BACKGROUND: Venous thromboembolism (VTE) is a concern following the onset of spinal cord lesions (SCL). OBJECTIVES: To assess the current efficacy and risks of anticoagulation after SCL and consider changes in thromboprophylaxis. METHODS: This retrospective cohort study included individuals admitted to inpatient rehabilitation within 3 months of SCL onset. Main outcome measures were the incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, thrombocytopenia, or death, which occurred within 1 year of the SCL onset. RESULTS: VTE occurred in 37 of the 685 patients included in the study (5.4%, 95% CI 3.7-7.1%, 2.8% PE), and in 16 of 526 patients who received prophylactic anticoagulation at rehabilitation (3%, 95% CI 1.6-4.5%, 1.1% PE, with at least 1 fatality). Of these 526, 1.3% developed clinically significant bleeding and 0.8% thrombocytopenia. Prophylactic anticoagulation, most commonly 40 mg/day, continued until a median period of 6.4 weeks after SCL onset (25% -75% percentiles 5.8-9.7), but in 29.7%, VTE occurred more than 3 months after SCL onset. CONCLUSION: The VTE prophylaxis used for the present cohort contributed to a considerable but limited reduction of VTE incidence. The authors recommend conducting a prospective study to assess the efficacy and safety of an updated preventive anticoagulation regimen.

A multi-center international study on the spinal cord independence measure, version IV: Rasch psychometric validation.

CONTEXT: The Spinal Cord Independence Measure is a comprehensive functional rating scale for individuals with spinal cord lesion (SCL). OBJECTIVE: To validate the scores of the three subscales of SCIM IV, the fourth version of SCIM, using advanced statistical methods. STUDY DESIGN: Multi-center cohort study. SETTING: Nineteen SCL units in 11 countries. METHODS: SCIM developers created SCIM IV following comments by experts, included more accurate definitions of scoring criteria in the SCIM IV form, and adjusted it to assess specific conditions or situations that the third version, SCIM III, does not address. Professional staff members assessed 648 SCL inpatients, using SCIM IV and SCIM III, at admission to rehabilitation, and at discharge. The authors examined the validity and reliability of SCIM IV subscale scores using Rasch analysis. RESULTS: The study included inpatients aged 16-87 years old. SCIM IV subscale scores fit the Rasch model. All item infit and most item outfit mean-square indices were below 1.4; statistically distinct strata of abilities were 2.6-6; most categories were properly ordered; item hierarchy was stable across most clinical subgroups and countries. In a few items, however, we found misfit or category threshold disordering. We found SCIM III and SCIM IV Rasch properties to be comparable. CONCLUSIONS: Rasch analysis suggests that the scores of each SCIM IV subscale are reliable and valid. This reinforces the justification for using SCIM IV in clinical practice and research.

Responses to stimuli in the 'snoezelen' room in unresponsive wakefulness or in minimally responsive state.

BACKGROUND: Sensory stimulation in Snoezelen room increased responsiveness after brain injury and dementia. OBJECTIVE: To explore the physiological and clinical effects of Snoezelen stimulation in persons with unresponsive wakefulness syndrome or minimally conscious state (UWS or MCS). DESIGN: A comparative prospective observational cohort study. METHODS: Ten patients with UWS and 25 in MCS were exposed to consecutive stimuli involving the 5 senses in a Snoezelen room. Heart rate (HR) and cerebral blood flow velocity (CBFV), and scores of the Loewenstein communication scale (LCS) were obtained before and during or after the stimuli. RESULTS: The stimuli increased HR values and decreased left hemisphere CBFV values in patients with MCS (p < 0.05). Stimulation increased LCS scores (from 28.48 ± 6.55 to 31.13 ± 7.14; p < 0.001) in patients with MCS, but not in the UWS group. LCS gain correlated with HR and right hemisphere CBFV gains in patients with MCS (r = 0.439 and 0.636 respectively, p < 0.05). CONCLUSIONS: Snoezelen stimulation induced immediate improvement in communication and physiological changes in patients with MSC, and had a minor physiological effect in patients with UWS. If additional studies support these findings, it will be possible to suggest that Snoezelen stimulation can affect arousal, and possibly improve functioning.

Satisfaction scores can be used to assess the quality of care and service in spinal rehabilitation.

STUDY DESIGN: Cohort comparative study. OBJECTIVE: Evaluate the suitability of satisfaction scores for the assessment of quality of care and service in spinal rehabilitation. SETTING: Spinal rehabilitation department. METHODS: Fifty-two inpatients participated anonymously in a large satisfaction survey, in 2017. A questionnaire containing the same questions was completed by 96 other inpatients, whose personal details were known, admitted to the same department between 2017 and 2019. Differences in satisfaction scores were compared between the two groups, between years, and between identified patients with differences in perceived progress and satisfaction with progress, using Mann-Whitney tests. In the identified patients, the association between satisfaction and patient demographic, neurological, and functional characteristics was evaluated using Pearson correlations. Analysis of variance and t test assessed the effect of comorbidities on satisfaction. T test assessed gender differences between groups. The effect of associated factors on satisfaction was examined using a stepwise linear regression. RESULTS: The total satisfaction score was 86.05 ± 16.99 for the anonymous group and 88.75 ± 12.45 for the identified patients (p > 0.05). The only patient characteristics that were associated with satisfaction were years of education, the perception of progress during rehabilitation, and the satisfaction with progress (p < 0.02). Their contribution to the total satisfaction variance, however, was relatively small (R2 = 0.211). CONCLUSIONS: The small effect of patient characteristics on total satisfaction indicates that satisfaction scores can be used to assess the quality of care and service in spinal rehabilitation. This and the similarity in findings between the groups supports the validity of the questionnaires.

Ability Realization Improves During Inpatient Rehabilitation for Guillain-Barré Syndrome.

OBJECTIVE: The aim of the study was to investigate improvement in ability realization and additional long-term outcomes, during and after inpatient rehabilitation for Guillain-Barré syndrome. DESIGN: This is a retrospective, longitudinal cohort study, in which outcomes were examined using validated scales, for 47 inpatients with Guillain-Barré syndrome. RESULTS: Scores improved from 65 on the American Spinal Injury Association Motor Score and 50 on the Spinal Cord Independence Measure, at admission to inpatient rehabilitation, to 81 and 80 at discharge, and to 92 and 95 at the end of 7.5 yrs, on average, at the follow-up ( P = 0.001). The mean Spinal Cord Independence Measure/American Spinal Injury Association Motor Score ratio, which reflects the ability realization, increased during rehabilitation from 50/65 to 80/81 ( P = 0.001), and tended to increase further at follow-up to 95/92 ( P = 0.228). At follow-up, pain did not correlate, and fatigue showed a weak correlation with the American Spinal Injury Association Motor Score, Spinal Cord Independence Measure, and the Adult Subjective Assessment of Participation ( r = -0.363, P = 0.012; r = -0.362, P = 0.012; r = -0.392, P = 0.006). CONCLUSIONS: Ability realization improved during inpatient rehabilitation for Guillain-Barré syndrome and remained high after discharge, suggesting a likely contribution of rehabilitation to the functional outcome, beyond the contribution of neurological recovery. Despite residual fatigue and pain, there was only minor or no effect on daily function or participation.

Reliability Validity and Responsiveness of the Spinal Cord Independence Measure 4th Version in a Multicultural Setup.

OBJECTIVE: To examine the fourth version of the Spinal Cord Independence Measure for reliability and validity. DESIGN: Partly blinded comparison with the criterion standard Spinal Cord Independence Measure III, and between examiners and examinations. SETTING: A multicultural cohort from 19 spinal cord injury units in 11 countries. PARTICIPANTS: A total of 648 patients with spinal cord injury. INTERVENTION: Assessment with Spinal Cord Independence Measure (SCIM IV) and Spinal Cord Independence Measure (SCIM III) on admission to inpatient rehabilitation and before discharge. MAIN OUTCOME MEASURES: SCIM IV interrater reliability, internal consistency, correlation with and difference from SCIM III, and responsiveness. RESULTS: Total agreement between examiners was above 80% on most SCIM IV tasks. All Kappa coefficients were above 0.70 and statistically significant (P<.001). Pearson's coefficients of the correlation between the examiners were above 0.90, and intraclass correlation coefficients were above 0.90. Cronbach's alpha was above 0.96 for the entire SCIM IV, above 0.66 for the subscales, and usually decreased when an item was eliminated. Reliability values were lower for the subscale of respiration and sphincter management, and on admission than at discharge. SCIM IV and SCIM III mean values were very close, and the coefficients of Pearson correlation between them were 0.91-0.96 (P<.001). The responsiveness of SCIM IV was not significantly different from that of SCIM III in most of the comparisons. CONCLUSIONS: The validity, reliability, and responsiveness of SCIM IV, which was adjusted to assess specific patient conditions or situations that SCIM III does not address, and which includes more accurate definitions of certain scoring criteria, are very good and quite similar to those of SCIM III. SCIM IV can be used for clinical and research trials, including international multi-center studies, and its group scores can be compared with those of SCIM III.

Consciousness recovery after various periods in vegetative state.

BACKGROUND: Recent studies suggest that late recovery from vegetative state (VS) is more prevalent today than previously thought. This study examined the decline in the rate of recovery from VS with time after admission to rehabilitation, and established a new time frame, in which the odds of recovery from VS remain substantial. METHODS: Data of 206 patients with VS after traumatic and non-traumatic brain injuries (TBI and NTBI), who were treated at the Loewenstein Rehabilitation Hospital (LRH), in Raanana, Israel, between 2003 and 2015, and described in a previous publication, were further analysed. Rate of recovery from VS was monitored at several time points after admission to intensive care and consciousness rehabilitation (ICCR). RESULTS: The odds of consciousness recovery were at least 54% at admission to ICCR, and 48%, 33%, 19%, and 7% at 3, 6, 9, and 12 months after admission, respectively. CONCLUSIONS: The rate of recovery from VS decreases significantly with time, but contrary to previous consensus, 6-12 months after admission to ICCR, the odds of recovery from VS after TBI and NTBI remain substantial.