Cocaine-related cervical spinal cord infarction: a case report and review of the literature.

STUDY DESIGN: Case report. OBJECTIVES: To report a clinical case of spinal cord infarction due to cocaine use. SETTING: Spinal Center, IRCCS Fondazione S. Lucia, Rome (Italy). CASE PRESENTATION: Two days after recreational use of cocaine, a 27-year-old Caucasic man was admitted to the emergency department for acute cervical pain, weakness in all four limbs, and urinary retention. A cervical spinal magnetic resonance imaging scan, performed after 2 days, showed a "pencil-like" lesion extending from C4 to T1 metamer, compatible with acute ischemia in the anterior spinal artery territory. Other causes of vascular disorders, as well as inflammatory and infectious disorders were ruled out. At admission in our department, the patient had an incomplete tetraplegia at level C6, an indwelling catheter, and was unable to stand and walk. After 3 months of rehabilitation, he had an AIS score D tetraplegia at level C7, was able to stand and walk using parallel bars, and indwelling catheter was replaced by intermittent catheterization. DISCUSSION AND CONCLUSIONS: The etiology of medullary infarction may remain unexplained in nearly 30-40% of cases. Even if rare, cocaine-induced ischemic myelopathy should be considered and ruled out in the differential diagnosis of any acute nontraumatic myelopathy, especially in young patients.

Flumazenil therapy for a gabapentin-induced coma: a case report.

BACKGROUND: Spasticity and neuropathic pain are common in patients after spinal cord injury and negatively affect patients' quality of life. Gabapentin and baclofen are frequently used to treat these conditions. We present a flumazenil-reversed gabapentin-induced coma case, which, to our knowledge, is the second one described in scientific literature. CASE PRESENTATION: A 70-year-old Caucasian man was admitted to our neurorehabilitation ward following a fall with cervical trauma that resulted in immediate tetraplegia. During his stay, he suffered from lower limb pain, both neuropathic and due to severe spasticity. Gradual baclofen and gabapentin administration was prescribed, with reduction in both pain and spasticity. One morning, the patient was found unresponsive, with a Glasgow Coma Score of 3. Head computerized tomography, electrocardiogram, electroencephalogram, vital signs, blood tests, breathing, and blood oxygenation were normal. Renal and liver failure were ruled out. Intravenous 0.25 mg of flumazenil (Anexate) was administered, resulting in complete neurocognitive recovery with a Glasgow Coma Score of 15. DISCUSSION AND CONCLUSIONS: This case report highlights the importance of the individual response to certain pharmacological agents and suggests that further studies need to be conducted both on flumazenil and gabapentin pharmacodynamics to better understand their molecular-receptor activity, and on possible multiple flumazenil mechanisms of action, beyond its classical strict benzodiazepine antagonist action.

"My friend, the pain": does altered body awareness affect the valence of pain descriptors?

Background: Pain is a marker of bodily status, that despite being aversive under most conditions, may also be perceived as a positive experience. However, how bodily states represent, define, and interpret pain signals, and how these processes might be reflected in common language, remains unclear. Methods: Qualitative and quantitative methods were used to explore the relationship between bodily awareness, pain reactions, and descriptions. A list of pain-related terms was generated from open-ended interviews with persons with spinal cord injury (SCI), and 138 participants (persons with SCI, health professionals, and a healthy control group) rated each descriptor as representative of pain on a gradated scale. A lexical decision task was used to test the strength of the automatic association of the word "pain" with positive and negative concepts. The behavioral results were related to body awareness, experience of pain, and exposure to pain, by comparing the three groups. Results: Higher positive and lower negative pain descriptors, as well as slower response times when categorizing pain as an unpleasant experience were found in the SCI group. The effect was not modulated by either the time since the injury or the present pain intensity, but it was linked to the level of subjective bodily awareness. Compared with the SCI group, health experts and non-experts both associated more quickly the word "pain" and unpleasant in the lexical decision task. However, while health professionals attributed positive linguistic qualities to pain, pain was exclusively associated with negative descriptors in healthy controls group. Conclusions: These findings are discussed in terms of their theoretical and clinical implications. An awareness of bodily signals prominently affects both the sensory and linguistic responses in persons with SCI. Pain should be evaluated more broadly to understand and, by extension, to manage, experiences beyond its adverse side.

Observational study of the effectiveness of spinal cord injury rehabilitation using the Spinal Cord Injury-Ability Realization Measurement Index.

STUDY DESIGN: Retrospective observational study. OBJECTIVES: The objective of this study was to determine the rehabilitation potential and the extent to which it is realized in a cohort of spinal cord injury patients using the Spinal Cord Injury-Ability Realization Measurement Index (SCI-ARMI) and to study the clinical factors that influence this realization. SETTING: Two spinal units in Italy. METHODS: Consecutive patients were assessed at the end of an in-patient rehabilitation program using the Spinal Cord Independence Measure and the International Standards for Neurological Classification of Spinal Cord Injury. On the basis of these data and of the age and gender of the patients, we calculated the SCI-ARMI score. Regression analyses were performed to study the relationship between clinical factors and the extent to which rehabilitation potential is realized. RESULTS: We examined the data for 306 patients. Most patients were discharged without having reached their rehabilitation potential, with an SCI-ARMI score <80%. SCI-ARMI scores at discharge were positively influenced by etiology and the lesion level and correlated negatively with lesion severity and the presence of complications during rehabilitation. CONCLUSION: The SCI-ARMI is an effective tool that can be used to measure the achievement of rehabilitation potential in SCI patients and to identify groups of patients who are at risk of not meeting their rehabilitative potential.

Validation of the Italian version of the Spinal Cord Independence Measure (SCIM III) Self-Report.

STUDY DESIGN: Cross-sectional validation study. OBJECTIVES: To validate the Italian version of the Spinal Cord Independence Measure Self-Report (SCIM SR). SETTING: Two spinal cord injury (SCI) rehabilitation facilities in Italy. METHODS: The SCIM III comprises items on 19 daily tasks, grouped into three subscales: 'Self-care,' 'Respiration and sphincter management' and 'Mobility'. The total SCIM score ranges between 0 and 100. The Italian self-reported version (SCIM SR) was translated from the German tool. We studied 116 patients on their first hospitalization for rehabilitation after an SCI. At the time of discharge, patients were evaluated by the rehabilitation team using the SCIM III and self-assessed their independence with regard to activities of daily living using the SCIM SR. Pearson's correlation, Bland-Altman method, and stratified and regression analyses were used to examine the differences between evaluations. RESULTS: On the basis of Pearson's correlation, there was good agreement between the data from the SCIM III and SCIM SR (r=0.918 for 'Self-care,' 0.806 for 'Respiration and sphincter management,' 0.906 for 'Mobility' and 0.934 for total scores). By Bland-Altman analysis, patients rated their functioning nearly the same as professionals-the mean difference between SCIM III and SCIM SR scores was approximately 0 for all subscales and total scores. The stratified and regression analyses failed to identify any specific factor that was associated with differences between SCIM III and SCIM SR scores. CONCLUSIONS: These results support the validity of the Italian version of the SCIM SR, which can facilitate longer-term evaluations of the independence of individuals with SCIs.

Challenges for defining minimal clinically important difference (MCID) after spinal cord injury.

STUDY DESIGN: This is a review article. OBJECTIVES: This study discusses the following: (1) concepts and constraints for the determination of minimal clinically important difference (MCID), (2) the contrasts between MCID and minimal detectable difference (MDD), (3) MCID within the different domains of International Classification of Functioning, disability and health, (4) the roles of clinical investigators and clinical participants in defining MCID and (5) the implementation of MCID in acute versus chronic spinal cord injury (SCI) studies. METHODS: The methods include narrative reviews of SCI outcomes, a 2-day meeting of the authors and statistical methods of analysis representing MDD. RESULTS: The data from SCI study outcomes are dependent on many elements, including the following: the level and severity of SCI, the heterogeneity within each study cohort, the therapeutic target, the nature of the therapy, any confounding influences or comorbidities, the assessment times relative to the date of injury, the outcome measurement instrument and the clinical end-point threshold used to determine a treatment effect. Even if statistically significant differences can be established, this finding does not guarantee that the experimental therapeutic provides a person living with SCI an improved capacity for functional independence and/or an increased quality of life. The MDD statistical concept describes the smallest real change in the specified outcome, beyond measurement error, and it should not be confused with the minimum threshold for demonstrating a clinical benefit or MCID. Unfortunately, MCID and MDD are not uncomplicated estimations; nevertheless, any MCID should exceed the expected MDD plus any probable spontaneous recovery. CONCLUSION: Estimation of an MCID for SCI remains elusive. In the interim, if the target of a therapeutic is the injured spinal cord, it is most desirable that any improvement in neurological status be correlated with a functional (meaningful) benefit.

Walking Index for Spinal Cord Injury version II in acute spinal cord injury: reliability and reproducibility.

STUDY DESIGN: Administration of the walking index for SCI (WISCI) II is recommended to assess walking in spinal cord injury (SCI) patients. Determining the reliability and reproducibility of the WISCI II in acute SCI would be invaluable. OBJECTIVES: The objective of this study is to assess the reliability and reproducibility of the WISCI II in patients with traumatic, acute SCI. DESIGN: Test-retest analysis and calculation of reliability and smallest real difference (SRD). SETTING: SCI unit of a rehabilitation hospital. METHODS: Thirty-three patients, median age 44 years, median time since onset of SCI 40 days. Level: 20 cervical, 8 thoracic, 5 lumbar; ASIA (American Spinal Injury Association) impairment scale (AIS) grade: 32 D/1 C. Assessment of maximum WISCI II levels by two trained, blinded raters to evaluate interrater (IRR) and intrarater reliability. RESULTS: The intrarater reliability was 0.999 for therapists A and 0.979 for therapists B, for the maximum WISCI II level. The IRR for the maximum WISCI II score was 0.996 on day 1 and 0.975 on day 2. The SRD for the maximum WISCI II score was 1.147 for tetraplegics and 1.682 for paraplegics. These results suggest that a change of two WISCI II levels could be considered real. CONCLUSIONS: The WISCI II has high IRR and intrarater reliability and good reproducibility in the acute and subacute phase when administered by trained raters.

International survey of perceived barriers to admission and discharge from spinal cord injury rehabilitation units.

STUDY DESIGN: Survey. OBJECTIVES: To describe and compare perceived barriers with patient flow in spinal rehabilitation units (SRUs). SETTING: International. Ten SRUs (Australia, Canada, India, Ireland, Italy, Netherlands, Pakistan, Switzerland, UK and USA) that admit both traumatic and non-traumatic spinal cord injury patients. METHODS: Survey completed between December 2010 and February 2013 on perception of barriers for admission into and discharge from SRUs. Opinion was sought from the participants regarding the utility of collecting data on the timeliness of access to SRUs and occurrence of discharge barriers for benchmarking and quality improvement purposes. RESULTS: The perceived barriers in accessing SRUs ranged from no access problem to a severe access problem (no access problems n=3; minor access problems n=3; moderate access problems n=2; severe access problem n=1 and extreme n=1). Most units (n=9/10) agreed that collecting data on timeliness of access to SRUs for acute hospital patients may help improve patient outcomes and health system processes by providing information for benchmarking and quality improvement purposes. All units reported perceived barriers to discharge from SRUs. Compared with admission barriers, a greater perception of barriers to discharge was reported (minor problem n=3; moderate problem n=3; severe problem n=3; and extreme n=1). All units agreed that collecting data on barriers to discharge from SRU may help improve patient outcomes and system processes. CONCLUSIONS: Perceived barriers to patient flow in SRUs are reported in many countries. Projects to identify and minimise the occurrence and impact of admission and discharge barriers could increase access to rehabilitation and improve the rehabilitation outcomes for patients.

The Walking Index for Spinal Cord Injury (WISCI/WISCI II): nature, metric properties, use and misuse.

STUDY DESIGN: Literature review. OBJECTIVE: To critically review all publications/internet sites that have described/used the Walking Index for Spinal Cord Injury (WISCI II), as a measure of impairment of walking function after spinal cord injury (SCI), in order to identify its psychometric properties, clarify its nature, specify misuse and incorporate the findings in an updated guide. METHOD: A systematic literature search was done of Ovid MEDLINE, CINAHL, PsychINFO, Cochrane Central Register of Controlled Trials, Scopus and electronic sites using key words: WISCI or WISCI II, SCI, paraplegia/ tetraplegia/ quadriplegia and ambulation/gait/walking. Among 1235 citations retrieved, 154 relevant articles/sites were identified, classified and examined by the authors; recommendations were made based on findings. RESULTS AND DISCUSSION: The validity (face/concurrent/content/construct/convergent/criterion) and reliability of the WISCI II has been documented in clinical trials and clinical series, and considered adequate by systematic reviewers. In chronic SCI subjects, reliable determination of the maximum (as opposed to self-selected) WISCI II level requires more time and experience by the assessor. The correct use of WISCI II is clarified for testing acute/chronic phases of recovery after SCI, age of subjects, devices and settings. The WISCI II and walking speed measures may be performed simultaneously. CONCLUSION: The increased use of the WISCI II is attributed to its unique characteristics as a capacity measure of walking function and its strong metric properties. Appropriate use of the WISCI II was clarified and incorporated into a new guide for its use. Combining it with a walking speed measure needs further study.

Balance training improves static stability and gait in chronic incomplete spinal cord injury subjects: a pilot study.

BACKGROUND: Walking is considered the most important goal after an incomplete spinal cord injury (SCI). Only recently it has been demonstrated that balance is a key factor of walking recovery, but no data on the efficacy of balance training in supporting walking function in SCI subjects are available. AIM: The object of the study was to determine the efficacy of visual biofeedback task-specific balance training (vBFB) in improving balance performance and gait in SCI subjects compared with conventional over-ground rehabilitation (Rehab). DESIGN: Open-case study with retrospective matched control. SETTING: Chronic SCI outpatients and healthy subjects (H). POPULATION: Twelve SCI subjects with ASIA impairment scale grade D-6 in the vBFB group (EXP) and 6 in the Rehab group (CTRL)-and 6 H. METHODS: Data from H were used as reference for physiological balance and gait parameters. CTRL and EXP groups underwent 8 weeks of rehabilitation 5 times/week (CTRL group: 60 minutes devoted to Rehab; EXP group: 40 minutes of Rehab plus 20 of vBFB). At baseline (T0), every 10 vBFB sessions (T1-T2-T3), at the end of training (T4) and 1 and 2 months after vBFB was halted, data on the following parameters were collected and compared between groups and training steps: Berg Balance Scale, Walking Index for Spinal Cord Injury, 6-minute walking, 10-meter walk and timed up and go tests, balance performance (assessed with a stabilometric platform), and kinematic spatio-temporal gait parameters (collected using a 2-dimensional motion analysis system). RESULTS: At T4, only the EXP group experienced a significant improvement in balance and gait demonstrated by clinical and instrumental evaluation; the improvement was maintained at follow-up examinations. Further, in the EXP group, the enhancement in balance that existed at T1 preceded the improvement in gait, and significant correlations between the improvements in gait and balance were observed. In comparison with H data, vBFB treatment demonstrated a significant higher level of effectiveness than conventional Rehab. CONCLUSION: vBFB training is effective in improving balance and gait in chronic SCI subjects. CLINICAL REHABILITATION IMPACT: Inclusion of vBFB in rehabilitation protocols for chronic SCI subjects effects greater improvements in gait than conventional rehabilitation alone.

Distribution-based estimates of clinically significant changes in the International Standards for Neurological Classification of Spinal Cord Injury motor and sensory scores.

BACKGROUND: Although the psychometric properties and statistical significance of the International Standards for Neurological Classification of Spinal Cord Injury Patients (ISNCSCI) have been widely examined, the clinical significance of motor and sensory scores (i.e., the improvement in score that has a meaningful impact on patients) is unknown. AIM: To calculate the clinical significance of the International Standards for Neurological Classification of Spinal Cord Injury Patients (ISNCSCI). DESIGN: Analysis of prospectively collected data. SETTING: Spinal Cord Unit of a rehabilitation hospital in the centre of Italy. PATIENTS AND METHODS: Analysis of the data of 600 patients with registration of the ISNCSCI Motor scores (total score and separately upper and lower extremity scores) and ISNCSCI Sensory scores. Clinical significance was calculated per several distribution-based approaches: minimal important differences, effect size-based estimates for small and substantial changes, standard error of measurement, and minimal detectable change. The calculated clinical significance was compared with improvements by the patients to determine the percentage of patients who achieved significant improvement. Furthermore, the functional status (as evaluated by the Spinal Cord Independence measure [SCIM III]) was studied in patients who achieved significant improvement compared to those who did not achieve them. RESULTS AND DISCUSSION: The results of the study showed that motor scores were more amenable to change than sensory scores. A 5-point change in motor score resulted in a clinically significant improvement of 0.2 standard deviation units, and an 11-point change in motor score was associated with an improvement of 0.5 standard deviation units. The percentages of patients with a significant improvement varied from 8 to 80% according to the level and severity of the lesion. In some AIS grade/level of lesion groups, patients who achieved clinical significant scores also showed a better functional status with significantly higher SCIM III scores than those who did not achieve clinical significant scores: the functional relevance of the ISNCSCI change is maximal for AIS C cervical and thoracic lesions, whereas it appears to be limited for AIS A cervical and thoracic lesions, and null for lumbar lesions of any kind. CONCLUSION: The results of the study provide information on the amount of motor and sensory scores that can be considered as true and clinical significant, as well as on the percentage of patients that achieve clinical significant improvements. Worthy to note, most groups of patients showed a statistically significant improvement of MS and SS between admission and discharge, but in some of the groups (for example thoracic AIS A patients), this improvement was limited to a very low percentage of patients. CLINICAL REHABILITATION IMPACT: Our results provide useful benchmarks for clinicians and researchers with which changes in patient ISNCSCI motor and sensory scores can be interpreted as true and clinically meaningful, thus allowing a clinical judgment on interventions based on patients' progress. The proportion of patients with clinically significant improvements may be a useful benchmark in clinical trials: an intervention should be considered to be effective not only if it produces a greater statistically significant improvement in neurological status than another intervention or the natural course of the lesion, but also if it effects an increase in the percentage of subjects who achieve a clinically significant improvement.

International comparison of the organisation of rehabilitation services and systems of care for patients with spinal cord injury.

STUDY DESIGN: Survey. OBJECTIVES: Describe and compare the organisation and delivery of rehabilitation services and systems of care for patients with spinal cord injury (SCI). SETTING: International. Nine spinal rehabilitation units that manage traumatic SCI and non-traumatic SCI (NTSCI) patients. METHODS: Survey based on clinical expertise and literature review. Completed between November 2010 and April 2011. RESULTS: All units reported public/government funding. Additional funding sources included compensation schemes, private insurance and self funding. Six units had formal attachment to an acute SCI unit. Five units (Italy, Ireland, India, Pakistan and Switzerland) provided a national service; two units (the Netherlands and USA) provided regional and two units (Australia and Canada) provided state/provincial services. The median number of SCI rehabilitation beds was 23 (interquartile range=16-30). All units admitted both traumatic SCI and NTSCI patients. The median proportion of patients admitted who had traumatic SCI was 45% (IQR 20-48%) and 40% (IQR 30-42%) had NTSCI. The rehabilitation team in all centres determined patient readiness for discharge. There was great variability between units in the availability of SCI speciality services, ancillary services and staff/patient ratios. CONCLUSION: There was a wide range of differences in the organisation, systems of care and services available for patients with SCI in rehabilitation units in different countries. Understanding these differences is important when comparing patient outcomes from different settings. A standardised collection of these system variables should be considered as part of future studies and could be included in the ISCoS data set project.

A new grading for easy and concise description of functional status after spinal cord lesions.

BACKGROUND: Disability scales do not enable the transmission of concise, meaningful and daily function description for clinical purposes. STUDY DESIGN: Cross-sectional statistical analysis of 328 patients' Spinal Cord Independence Measure (SCIM) III item scores (SIS). OBJECTIVE: To develop a concise and clinically interpretable data-based characterization of daily task accomplishment for patients with spinal cord lesions (SCLs). SETTING: Multi-center study at 13 spinal units in 6 countries. METHODS: Patients were grouped into clusters characterized by smaller differences between the patients' SIS within the clusters than between their centers, using the k-medoides algorithm. The number of clusters (k) was chosen according to the percent of SIS variation they explained and the clinical distinction between them. RESULTS: Analysis showed that k=8 SIS clusters offer a good description of the patient population. The eight functional clusters were designated as A-H, each cluster (grade) representing a combination of task accomplishments. Higher grades were usually (but not always) associated with patients implementing more difficult tasks. Throughout rehabilitation, the patients' functional grade improved and the distribution of patients with similar functional grades within the total SCIM III score deciles remained stable. CONCLUSIONS: A new classification based on SIS clusters enables a concise description of overall functioning and task accomplishment distribution in patients with SCL. A software tool is used to identify the patients' functional grade. Findings support the stability and utility of the grades for characterizing the patients' functional status.

Consumer preference in ranking walking function utilizing the walking index for spinal cord injury II.

STUDY DESIGN: Blinded rank ordering. OBJECTIVE: To determine consumer preference in walking function utilizing the walking Index for spinal cord injury II (WISCI II) in individuals with spinal cord injury (SCI)from the Canada, the Italy and the United States of America. METHOD: In all, 42 consumers with incomplete SCI (25 cervical, 12 thoracic, 5 lumbar) from Canada (12/42), Italy (14/42) and the United States of America (16/42) ranked the 20 levels of the WISCI II scale by their individual preference for walking. Subjects were blinded to the original ranking of the WISCI II scale by clinical scientists. Photographs of each WISCI II level used in a previous pilot study were randomly shuffled and rank ordered. Percentile, conjoint/cluster and graphic analyses were performed. RESULTS: All three analyses illustrated consumer ranking followed a bimodal distribution. Ranking for two levels with physical assistance and two levels with a walker were bimodal with a difference of five to six ranks between consumer subgroups (quartile analysis). The larger cluster (N=20) showed preference for walking with assistance over the smaller cluster (N=12), whose preference was walking without assistance and more devices. In all, 64% (27/42) of consumers ranked WISCI II level with no devices or braces and 1 person assistance higher than multiple levels of the WISCI II requiring no assistance. These results were unexpected, as the hypothesis was that consumers would rank independent walking higher than walking with assistance. CONCLUSION: Consumer preference for walking function should be considered in addition to objective measures in designing SCI trials that use significant improvement in walking function as an outcome measure.

Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions.

STUDY DESIGN: Multicenter international cohort study. OBJECTIVE: The objective of this study was to establish target values for Spinal Cord Independence Measure (SCIM) III scoring in rehabilitation for clinically complete spinal cord lesion (SCL) neurological levels. SETTING: In total, 13 spinal cord units in six countries from North America, Europe and the Middle East were taken. METHODS: Total SCIM III scores and gain at discharge from rehabilitation were calculated for SCL levels in 128 patients with American Spinal Injury Association Impairment Scale (AIS) grade A on admission to rehabilitation. RESULTS: Median, quartiles, mean and s.d., values of discharge SCIM III scores and SCIM III gain for the various SCL levels are presented. Total SCIM III scores and gain were significantly correlated with the SCL level (r=0.730, r=0.579, P<0.001). CONCLUSIONS: Calculated discharge SCIM III scores can be used as target values for functional achievements at various neurological levels in patients after AIS A SCL. They are generally, but not always, inversely correlated with SCL level.

Recovery following ischemic myelopathies and traumatic spinal cord lesions.

BACKGROUND: As the general population ages, the rising prevalence of vascular lesions of the spinal cord will become significant. The aim of this study was to compare the neurological and functional outcomes of patients with ischemic spinal cord injury (ISCI) and traumatic spinal cord injury (TSCI). SETTING: Spinal cord unit of a rehabilitation hospital in Italy. STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: We studied 179 patients with a TSCI and 68 with an ISCI. At admission and discharge, patients were examined by American Spinal Injury Association (ASIA) standards, Barthel Index, Rivermead Mobility Index and Walking Index for Spinal Cord Injury. Bowel and bladder management and discharge destination were recorded at discharge. Analysis of covariance (ANCOVA) and logistic regression models were used to analyze the effects of the etiology of the lesion, AIS level at admission, site of the lesion and the presence of complications on measured outcomes. RESULTS: Patients with an ISCI were older and experienced fewer cervical lesions and complications at admission. By ANCOVA and logistic regression, age, AIS level and lesion level were the chief predictors of neurological and functional outcome, whereas etiology had no effect on outcome. CONCLUSIONS: A diagnosis of ischemia and trauma is not a determinant of neurological and functional recovery in spinal cord injury patients. Instead, the outcome of these patients is influenced by age, lesion level and AIS level.

Neoplastic myelopathies and traumatic spinal cord lesions: an Italian comparison of functional and neurological outcomes.

BACKGROUND: Although neoplastic spinal cord injuries (NSCIs) constitute ∼25% of all non-traumatic spinal cord lesions, patients with such pathologies are seldom, if ever, admitted to specialized centers; further, their rehabilitation typically is short because of the perception that rehabilitation prolongs hospital stays unnecessarily and is reserved only for patients with very good prognoses. STUDY DESIGN: This study is a retrospective analysis. OBJECTIVE: The objective of this study is to evaluate the neurological and functional outcomes of patients with NSCIs compared with those of patients with traumatic spinal cord injury (TSCI). METHODS: We evaluated 208 patients with TSCIs and 63 with NSCIs; using a matching cohorts procedure, 43 comparable couples were selected from each group. The measures used to assess these patients were the American Spinal Injury Association standards, the Barthel Index (BI), the Rivermead Mobility Index and the Walking Index for Spinal Cord Injury. RESULTS: In the general population, NSCI patients are older and have longer lesion-to-admission times and more incomplete lesions than TSCI patients. Therefore, the functional status at admission and outcomes differed between the groups. In the matching cohorts, TSCI patients had lower BI scores at admission than NSCI subjects. At discharge, the two groups had comparable functional outcomes. Neurological status was similar at admission and at discharge. CONCLUSIONS: Although they had slightly disparate functional levels at admission, NSCI and TSCI patients had the same outcomes at discharge. Our data suggest that in a selected cohort of NSCI patients, rehabilitation is as successful as that in TSCI subjects and allows most patients to be discharged instead of being institutionalized.

Validity and reliability of the 10-m walk test and the 6-min walk test in spinal cord injury patients.

STUDY DESIGN: The 10-m walk test (10MWT) and the 6-min walk test (6MWT) have been recommended for assessment of walking in spinal cord injury (SCI) patients. The study was designed on test-retest analysis of the 10MWT and 6MWT. OBJECTIVES: The objective of this study was to assess validity/reliability of different methods of performing the tests. SETTING: The study was set at an SCI unit of a rehabilitation hospital. PATIENTS AND METHODS: A total of 37 patients; whose median age was 58.5 years (interquartile range 40-66, full range 19-77); median time since onset of SCI was 24 months (interquartile range 16.25-70.5, full range 6-109). Non-traumatic etiology in 20 out of 37 patients; level: 12C, 14T and 11L; American Spinal Injury Association Impairment Scale grade: 35D/2C. Assessment with the 10MWT (with or without dynamic start) and the 6MWT (short or long track) by two blinded raters to evaluate inter/intra-rater reliabilities. RESULTS: The 10MWT was performed in a median of 19 s (25th-75th interquartile range 13-28) with the dynamic start and of 18.4 s (25th-75th interquartile range 12.6-29.9) with the static start (P=0.092). The correlation between the results of the two methods was between 0.98 and 0.99. The inter- and intra-rater reliabilities were between 0.95 and 0.99 for both the methods. The 6MWT showed significant differences according to the track length: patients walked a median of 226.7 m (25th-75th interquartile range 123.2-319) on the longer track and of 187.6 m (25th-75th interquartile range 69.7-240.6) on the short one (P<0.001). The correlation between the results of the two methods was between 0.91 and 0.93. The inter- and intra-rater reliabilities were between 0.98 and 0.99. CONCLUSION: The 10MWT shows high inter/intra-rater reliability and shows comparable results with both dynamic and static start. The different testing conditions of the 6MWT (track/turns) results in significant differences that need standardization for use in future trials.

SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions.

STUDY DESIGN: A multi-center international cohort study. OBJECTIVE: To evaluate the reliability and validity of the third version of the Spinal Cord Independence Measure (SCIM III), separately for patients with traumatic spinal cord lesions (SCLs). SETTING: A total of 13 spinal cord units in six countries from North America, Europe and the Middle-East. METHODS: SCIM III and Functional Independence Measure (FIM) were assessed for 261 patients with traumatic SCLs, on admission to rehabilitation and before discharge, by two raters. Conventional statistical measures were used to evaluate the SCIM III reliability and validity. RESULTS: In almost all SCIM III tasks, the total agreement between the paired raters was >80%. The κ coefficients were all >0.6 and statistically significant. Pearson's coefficients of the correlations between the paired raters were >0.9, the mean differences between raters were nonsignificant and the intraclass correlation coefficients (ICCs) were ≥ 0.95. Cronbach's α values for the entire SCIM III scale were 0.833-0.835. FIM and SCIM III total scores were correlated (r=0.84, P<0.001). SCIM III was more responsive to changes than FIM. In all subscales, SCIM III identified more changes in function than FIM, and in 3 of the 4 subscales, differences in responsiveness were statistically significant (P<0.02). CONCLUSION: The results confirm the reliability and validity of SCIM III for patients with traumatic SCLs in a number of countries.

Traumatic and non-traumatic spinal cord lesions: an Italian comparison of neurological and functional outcomes.

STUDY DESIGN: Retrospective study. OBJECTIVE: To compare the rehabilitation outcomes of non-traumatic and traumatic spinal cord injury patients. SETTING: Spinal cord unit of a rehabilitation hospital in Italy. PATIENTS AND METHODS: In total, 380 patients at first rehabilitation stay after the lesion (144 traumatic patients and 236 non-traumatic patients; 244 men and 136 women; mean age 46.1±19.9 years; mean lesion to admission time 49.6±39.8 days). INTERVENTIONS: Not applicable. MEASURES: American Spinal Injury Association standards; Barthel index (BI), Rivermead mobility index and walking index for spinal cord injury. STATISTICAL ANALYSIS: Poisson regression models with relative risks and 95% confidence intervals adjusted for the following confounders: age, sex, lesion level and Asia impairment. Models were stratified by age because a strong interaction between different variables and age was found. RESULTS: Traumatic and non-traumatic populations showed several significant differences with regard to age, level and severity of lesion. When adjusted for these factors patients with traumatic injuries showed a significantly lower BI score at admission and significantly better improvement in the BI score by discharge. The two populations were discharged with similar functional outcome. No significant differences were found with regard to the others outcomes. CONCLUSIONS: In clinically stable patients, spinal cord injury etiology does not seem to affect the rehabilitative prognosis. At admission, traumatic patients show lower autonomy in daily life activities, probably because of the associated lesions that these patients often have. At discharge, traumatic and non-traumatic spinal cord lesion patients achieved similar results with regard to neurological and functional improvement.