Very early Charcot spinal arthropathy associated with forward bending after spinal cord injury: a case report.

Introduction: Charcot spinal arthropathy (CSA) is an uncommon clinical entity following spinal cord injury (SCI). It is characterized by progressive cartilaginous and bony destruction and is felt to be due to loss of proprioceptive and nociceptive feedback from the spine. CSA is typically diagnosed many years following SCI and has the potential to lead to progressive neurologic decline if left untreated. Case presentation: We describe the case of a 49-year-old male who fell approximately thirty feet from a ladder and sustained a fracture/dislocation at T3-4 and T8-9 resulting in a T4 ASIA A SCI. He underwent T2-T12 posterior spinal stabilization and, within 1 year and 2 months of initial injury, developed an unusual back protuberance, decreased spasticity, and change in bladder function. The patient's imaging and physical exam were consistent with CSA. Discussion: This case is notable in two respects. First, this is one of the earliest cases of CSA identified in the literature. Although CSA is generally considered a late complication of SCI, CSA should be placed in the differential for all individuals with spinal cord presenting with clinical findings typical of CSA. Second, this case was associated with unsupervised attempts to improve range of motion (ROM) in a SCI patient with a fused spine. The association of unsupervised stretching and CSA has not been previously described.

The effect of low-magnitude whole body vibration on bone density and microstructure in men and women with chronic motor complete paraplegia.

OBJECTIVE: To examine the effect of low-magnitude whole body vibration on bone density and microstructure in women and men with chronic motor complete paraplegia. METHODS: We studied nine subjects (four women and five men) with motor complete paraplegia of 2 years duration or more, age 20-50 years. Subjects were instructed to stand on a low-magnitude vibration plate within a standing frame for 20 minutes per day, 5 days a week, and for 6 months. Bone density at the proximal femur by dual-energy X-ray absorptiometry and bone microstructure at the distal tibia by high-resolution peripheral quantitative computed tomography were assessed at four timepoints over 12 months (baseline, at 3 months and 6 months while on intervention, and after 6 months off intervention). RESULTS: Standing on the low-magnitude vibration plate with a standing frame was well tolerated by participants. However, most subjects did not show an improvement in bone density or microstructure after 6 months of intervention, or any relevant changes 6 months following the discontinuation of the low-magnitude vibration. CONCLUSION: We were unable to identify an improvement in either bone density or microstructure following 6 months use of a low-magnitude vibration plate in women or men with chronic motor complete paraplegia. Longer duration of use may be necessary, or it is possible that this intervention is of limited benefit following chronic spinal cord injury.

Discharge disposition to skilled nursing facility after endovascular reperfusion therapy predicts a poor prognosis.

OBJECTIVE: We explore the impact of discharge disposition (independent rehabilitation facility (IRF) vs skilled nursing facility (SNF)) on 90 day outcomes in persons with stroke who received acute endovascular treatment. METHODS: Using a database from a single primary care stroke center, discharge disposition, National Institutes of Health Stroke Scale (NIHSS), Totaled Health Risks in Vascular Events (THRIVE), Houston Intra-Arterial Therapy 2 (HIAT-2), and Acute Physiology and Chronic Health Evaluation (APACHE II) scores, and successful reperfusion were obtained. Univariate analysis was performed to assess predictors of good clinical outcome, as defined by 90 day modified Rankin Scale (mRS) scores ≤2. A binary logistic regression model was used to determine the impact of placement to an IRF versus an SNF on clinical outcomes. RESULTS: 147 subjects were included in the analysis with a mean age of 63±14 years and median NIHSS of 18 (IQR 14-21). Final infarct volumes, and modified APACHE II, THRIVE, and HIAT-2 scores were similar between those discharged to an IRF and those discharged to an SNF.However, their 90 day outcomes were significantly different, with far fewer patients at SNFs achieving good clinical outcomes (25% vs 46%; p=0.023). Disposition to SNF was significantly associated with a lower probability of achieving an mRS score of 0-2 at 90 days (OR = 0.337 (95% CI 0.12 to 0.94); p<0.04). CONCLUSIONS: Subjects discharged to SNFs and IRFs after thrombectomy have similar medical and neurological severity at admission and similar final infarct volumes at discharge. Despite these similarities, patients discharged to an SNF had a significantly lower probability of achieving a good neurological outcome. These results have implications for future acute stroke trial design.

Body composition of women and men with complete motor paraplegia.

OBJECTIVES: To examine body composition, including the relationship between body mass index (BMI) and total body fat, in women and men with complete motor paraplegia and to make comparisons with able-bodied controls. METHODS: In 13 subjects with traumatic, complete motor paraplegia (six women, seven men) and 39 sex-, age-, and BMI-matched controls from the community (18 women, 21 men), we measured total and regional (upper extremities, trunk, and lower extremities) lean and fat mass using total body dual-energy X-ray absorptiometry. RESULTS: Both women and men with paraplegia had significantly lower lean mass in their lower extremities, as would be expected, and in their total body when compared with controls. However, they had significantly greater lean mass in their upper extremities than controls (4.4 kg vs. 3.6 kg, P = 0.004 and 8.6 kg vs. 6.7 kg, P < 0.001 in women and men, respectively); all subjects with paraplegia studied used manual wheelchairs. Although total body fat mass was significantly greater in women (P = 0.010) and men (P = <0.001) with paraplegia compared with controls, for the equivalent total body fat mass, BMI was actually lower in women and men with paraplegia than controls (e.g. 20.2 kg/m² vs. 25.0 kg/m², respectively). CONCLUSION: We report on body composition in persons with complete motor paraplegia, including women on whom limited information is currently available. Our results support the need to define better assessments of obesity in both women and men following spinal cord injury, particularly of central body fat distribution, as BMI underestimates adiposity in this population.

Weight bearing through lower limbs in a standing frame with and without arm support and low-magnitude whole-body vibration in men and women with complete motor paraplegia.

OBJECTIVE: The aim of the study was to determine the proportion of body weight borne through the lower limbs in persons with complete motor paraplegia using a standing frame, with and without the support of their arms. We also examined the effect of low-magnitude whole-body vibration on loads borne by the lower limbs. DESIGN: Vertical ground reaction forces (GRFs) were measured in 11 participants (six men and five women) with paraplegia of traumatic origin (injury level T3-T12) standing on a low-magnitude vibrating plate using a standing frame. GRFs were measured in four conditions: (1) no vibration with arms on standing frame tray, (2) no vibration with arms at side, (3) vibration with arms on tray, and (4) vibration with arms at side. RESULTS: GRF with arms on tray, without vibration, was 0.76 ± 0.07 body weight. With arms at the side, GRF increased to 0.85 ± 0.12 body weight. With vibration, mean GRF did not significantly differ from no-vibration conditions for either arm positions. Oscillation of GRF with vibration was significantly different from no-vibration conditions (P < 0.001) but similar in both arm positions. CONCLUSIONS: Men and women with paraplegia using a standing frame bear most of their weight through their lower limbs. Supporting their arms on the tray reduces the GRF by approximately 10% body weight. Low-magnitude vibration provided additional oscillation of the load-bearing forces and was proportionally similar regardless of arm position.

What accounts for rib fractures in older adults?

To address the epidemiology of rib fractures, an age- and sex-stratified random sample of 699 Rochester, Minnesota, adults age 21-93 years was followed in a long-term prospective study. Bone mineral density (BMD) was assessed at baseline, and fractures were ascertained by periodic interview and medical record review. During 8560 person-years of followup (median, 13.9 years), 56 subjects experienced 67 rib fracture episodes. Risk factors for falling predicted rib fractures as well as BMD, but both were strongly age-related. After age-adjustment, BMD was associated with rib fractures in women but not men. Importantly, rib fractures attributed to severe trauma were associated with BMD in older individuals of both sexes. Self-reported heavy alcohol use doubled fracture risk but did not achieve significance due to limited statistical power. Bone density, along with heavy alcohol use and other risk factors for falling, contributes to the risk of rib fractures, but no one factor predominates. Older women with rib fractures, regardless of cause, should be considered for an osteoporosis evaluation, and strategies to prevent falling should be considered in both sexes.

Influence of season, ethnicity, and chronicity on vitamin D deficiency in traumatic spinal cord injury.

BACKGROUND: Inadequate levels of vitamin D increase the risk of osteoporosis, a highly prevalent condition in patients with traumatic spinal cord injury (SCI). Reduced sunlight and dark skin further contribute to low vitamin D levels. OBJECTIVES: To compare serum 25-hydroxy vitamin D [vitamin D25(OH)] levels in acute and chronic SCI and to explore seasonal and ethnic differences among patients with acute and chronic SCI. PATIENTS/METHODS: Patients (N=96) aged 19 to 55 years with C3-T10 motor complete SCI participated. Acute SCI was 2 to 6 months after injury, whereas chronic SCI was at least 1 year from injury. Serum vitamin D25(OH), calcium, and parathyroid hormone were drawn dUring summer or winter months. Vitamin D deficiency (<13 ng/mL), insufficiency (<20 ng/mL), and subtherapeutic (<32 ng/mL) levels were compared for all groups. A 3-way analysis of covariance was adopted to determine significant main effects of season, chronicity, and ethnicity. Interactions between season and chronicity, season and ethnicity, and chronicity and ethnicity were evaluated. Evaluation of a 3-way interaction among season, chronicity, and ethnicity was completed. RESULTS: In summer, 65% of patients with acute SCI and 81% of patients with chronic SCI had subtherapeutic vitamin D levels, whereas in winter, 84% with acute SCI and 96% with chronic SCI had vitamin D25(OH) (<32 ng/mL). Lower vitamin D25(OH) levels were observed in African Americans relative to whites. Significant main effects were noted for season (P = 0.017), chronicity (P = 0.003), and ethnicity (P < 0.001). However, interactions between 2 or more factors were not found. CONCLUSIONS: Vitamin D insufficiency and deficiency are found in the majority of patients with chronic SCI and in many with acute SCI. Initial screening for serum vitamin D25(OH) levels should be performed early in rehabilitation. Periodic monitoring in the chronic setting is highly recommended.

Assessment of autonomic dysfunction following spinal cord injury: rationale for additions to International Standards for Neurological Assessment.

We present a preliminary report of the discussion of the joint committee of the American Spinal Injury Association (ASIA) and the International Spinal Cord Society concerning the development of assessment criteria for general autonomic function testing following spinal cord injury (SCI). Elements of this report were presented at the 2005 annual meeting of the ASIA. To improve the evaluation of neurological function in individuals with SCI and therefore better assess the effects of therapeutic interventions in the future, we are proposing a comprehensive set of definitions of general autonomic nervous system dysfunction following SCI that should be assessed by clinicians. Presently the committee recommends the recognition and assessment of the following conditions: neurogenic shock, cardiac dysrhythmias, orthostatic hypotension, autonomic dysreflexia, temperature dysregulation, and hyperhidrosis.

Reduction of renal stone risk by potassium-magnesium citrate during 5 weeks of bed rest.

PURPOSE: Exposure to the microgravity environment of space increases the risk of kidney stone formation, particularly for calcium oxalate and uric acid stones. This study was performed to evaluate the efficacy of potassium alkali as potassium-magnesium citrate in reducing renal stone risk and bone turnover. MATERIALS AND METHODS: This study was performed as a double-blind, placebo controlled trial. We studied 20 normocalciuric subjects randomized to either placebo or potassium-magnesium citrate (42 mEq potassium, 21 mEq magnesium, 63 mEq citrate per day) before and during 5 weeks of strict bed rest. The study was performed in the General Clinical Research Center and under a controlled dietary regimen composed of 100 mEq of sodium, 800 mg of calcium, 0.8 gm/kg animal protein and 2,200 kcal per day. Two 24-hour urine collections were obtained under oil each week for assessment of stone risk parameters and relative saturation of calcium oxalate, brushite and undissociated uric acid. Blood was also collected for determination of serum immunoreactive parathyroid hormone and vitamin D metabolites. RESULTS: Bed rest promoted a rapid increase in urinary calcium excretion of approximately 50 mg per day in both groups. Despite this increase subjects treated with potassium-magnesium citrate demonstrated significant decreases in the relative saturation of calcium oxalate and in the concentration of undissociated uric acid compared to placebo. Immunoreactive parathyroid hormone, serum 1,25-dihydroxyvitamin D and intestinal calcium absorption all decreased in both groups with no difference in response between the 2 treatment arms. CONCLUSIONS: Provision of alkali as potassium-magnesium citrate is an effective countermeasure for the increased risk of renal stone disease associated with immobilization. Despite an increase in urine calcium concentration, the relative saturation of calcium oxalate decreased due to citrate chelation of calcium and the concentration of undissociated uric acid decreased due to the significant increase in urine pH.

Predicting walking at discharge from inpatient rehabilitation after a traumatic spinal cord injury.

OBJECTIVE: To investigate how injury level and American Spinal Injury Association Impairment Scale (AIS) grade at rehabilitation admission are related to walking at discharge after traumatic spinal cord injury (SCI). DESIGN: Retrospective study. SETTING: Comprehensive rehabilitation hospital. PARTICIPANTS: A total of 343 adult inpatients with traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: FIM instrument walking rating of 3 (moderate assistance) or higher at discharge. RESULTS: Significantly more subjects admitted with AIS grade C (28.3%) than AIS grade A or B injuries (0.9%) walked at discharge. Significantly more subjects admitted with AIS grade D (67.2%) than AIS grade C (28.3%) injuries walked at discharge. Level of injury did not significantly affect walking after AIS grade C or D injuries. Being 50 years or older had a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries. CONCLUSIONS: Admission AIS grades give information about walking for treatment and discharge planning during acute inpatient rehabilitation, including the following: (1) patients admitted with AIS grade C injuries should not be considered functionally complete when predicting walking (FIM score > or = 3; no more than moderate assistance) at discharge, (2) level of injury does not affect walking for those with AIS grade C or D injuries, and (3) being 50 years or older has a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries.

Osteoporosis treatment for patients with stroke.

PURPOSE: Little is known about the frequency of use of medications to maintain bone health for patients with stroke. This study was undertaken at an urban academic rehabilitation center to determine the prevalence of use of agents that could reduce bone loss in the stroke population. METHOD: A clinical database was searched for all patients 18 years old and over with stroke. The sample included 1,219 inpatients and 2,776 outpatients. Demographic information (age, gender, and race) and medications were obtained for each patient. RESULTS: Among inpatients with stroke, 7.1% were taking osteoporosis medications (bisphosphonates, calcitonin, parathyroid hormone, or hormone replacement therapy), 11.3% were taking calcium supplements, 5.9% were taking vitamin D supplements, and 45.1% were taking multivitamin supplements. Among outpatients with stroke, 5.7% were taking osteoporosis medication, 5.8% were taking calcium supplements, 2.2% were taking vitamin D supplements, and 16.0% were taking multivitamin supplements. Patients being treated with specific osteoporosis therapies tended to be older and female by calculated odds ratios. The use of multivitamins was not related to age, gender, or race. CONCLUSION: Overall, relatively few stroke patients were taking osteoporosis medications or supplements. There is a need to increase the recognition, prevention, and treatment of bone loss in this high-risk population.

Spinal cord injury medicine. 1. Epidemiology and classification.

UNLABELLED: This self-directed learning module reviews the demographics of traumatic and nontraumatic spinal cord injuries (SCIs). It is part of the study guide on SCI medicine in the Self-Directed Physiatric Educational Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the changing demographics of traumatic SCI, the classification of SCI, the common causes of nontraumatic SCI, and the incidence and prevalence of myelomeningocele. OVERALL ARTICLE OBJECTIVE: To summarize the demographics and classification of traumatic and nontraumatic spinal cord injuries in adults and children.

Spinal cord injury medicine. 2. Acute care management of traumatic and nontraumatic injury.

UNLABELLED: This self-directed learning module highlights the basic acute care management of traumatic and nontraumatic spinal cord injury (SCI). It is part of the chapter on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Acute traumatic SCI is optimally managed in a level 1 trauma center. Decompression of the neural elements, stabilization of the spine, and maintenance of tissue perfusion are fundamental to optimizing outcomes. SCI patients are at high risk of pressure ulcers, venous thromboembolism, stress ulceration, bowel impaction, dysphagia, and pulmonary complications. Physiatric interventions are needed to prevent these complications. Prognostication of neurologic outcome based on early examination is an important skill to aid in creating a rehabilitation plan and to test for efficacy of early interventions. Nontraumatic SCI is an increasing population in rehabilitation centers. Establishing a diagnosis and treatment plan is essential, in conjunction with prevention of complications and early physiatric intervention. OVERALL ARTICLE OBJECTIVES: (a) To describe the diagnostic evaluation of traumatic and nontraumatic spinal cord injuries and (b) to summarize the medical, surgical, and physiatric interventions during acute hospitalization for these injuries.

Spinal cord injury medicine. 3. Rehabilitation phase after acute spinal cord injury.

UNLABELLED: This self-directed learning module highlights the rehabilitation aspects of care for people with traumatic spinal cord injury (SCI). It is part of the chapter on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the formulation of a rehabilitation plan based on functional goals by level of injury. Such a plan includes mobility, activities of daily living, equipment needs, and adjustment issues after injury. The effect of a concomitant brain injury on rehabilitation is discussed. Medical complications seen in the rehabilitation stage such as autonomic dysreflexia, heterotopic ossification, neurogenic bowel, and orthostasis are addressed. Preparation for discharge is crucial to allow for a smooth transition to home. There have been advances in SCI rehabilitation research including in wheelchair technology, functional electric stimulation, and partial body weight-supported ambulation. OVERALL ARTICLE OBJECTIVE: To describe outcomes and issues that may arise during the rehabilitation phase after spinal cord injury.

Spinal cord injury medicine. 4. Community reintegration after spinal cord injury.

UNLABELLED: This self-directed learning module highlights community reintegration after spinal cord injury (SCI). It is part of the study guide on spinal cord injury medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on physical, social, psychologic, and environmental barriers that affect people with SCI and on how these issues affect relations with others. Recreational and exercise options are also discussed. OVERALL ARTICLE OBJECTIVE: To summarize the barriers and opportunities of community reintegration for people with spinal cord injury.

Spinal cord injury medicine. 5. Long-term medical issues and health maintenance.

UNLABELLED: This self-directed learning module highlights long-term care issues in patients with spinal cord injury (SCI). It is part of the study guide on SCI in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The most common secondary medical complications include pressure ulcers, pneumonia, and genitourinary issues. Health care maintenance is important to prevent medical complications, for general health as well as for issues specific to SCI. Women with SCI have gender-specific issues regarding amenorrhea, sexuality, fertility, and menopause. Options exist to assist disabled men with sexuality and fertility complications. Pain is a common complication after SCI. Many new areas of research in the field of SCI are discussed. OVERALL ARTICLE OBJECTIVE: To discuss long-term care issues in patients with spinal cord injury, including health maintenance, secondary conditions, women's health, sexual function, pain, and spinal cord regeneration and recovery.

Spinal cord injury medicine. 6. Economic and societal issues in spinal cord injury.

UNLABELLED: This self-directed learning module presents a variety of social and economic issues facing people with spinal cord injury (SCI). It is part of the study guide on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses on the economic consequences of SCI, ethical issues in SCI, and the legislative efforts that have improved access and quality of life for people with disabilities. Costs of SCI include direct health care expenditures and lost earnings as a result of unemployment after SCI. Lifelong costs can be anticipated with the development of a comprehensive life care plan. Barriers to vocational reintegration continue to limit full participation for most people with SCI. Ethical issues central to SCI are related to the principles of autonomy and justice. As cure research becomes clinically applicable, the SCI community must work together to develop appropriate procedures to respect moral decision-making by all parties. Key legislation in the past century has resulted in important advances in the rights of people with disabilities. OVERALL ARTICLE OBJECTIVES: (a) To review the economic consequences of spinal cord injury, including lifelong direct costs, life care planning, and factors affecting employment and (b) to identify current ethical issues facing the spinal cord injury community and review the advances made in the rights of people with disabilities in the United States through legislation.

Predictors of psychosocial adaptation among people with spinal cord injury or disorder.

OBJECTIVE: To examine the influence of disability-related medical and psychologic variables on psychosocial adaptation to spinal cord injury or disorder (SCI/D). DESIGN: A structural equation modeling design linking 3 sets of predictive variables to an outcome measure of adaptation. SETTING: Two outpatient SCI clinics (1 veteran, 1 civilian) in Texas. PARTICIPANTS: Veterans (n=181) and civilians (n=132) with SCI/D. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The adaptation outcome was measured by 2 subscales (acknowledgment, adjustment) of the Reactions to Impairment and Disability Inventory (RIDI) and by the Quality of Life Scale. The predictive variables were measured by a demographic questionnaire, 3 subscales (intrusion, re-experiencing, hyperarousal) of the Purdue Posttraumatic Stress Disorder-Revised scale, the McMordie-Templer Death Anxiety Scale, and 3 subscales (anxiety, depression, denial) of the RIDI. RESULTS: Goodness-of-fit indices suggested that a revised model of adaptation was a moderately good fit to the data. The revised model of adaptation indicated that there were medium total effects (direct plus indirect) on psychosocial adaptation by 2 latent variables (disability severity and impact, negative affectivity) and small total effects on psychosocial adaptation by disengagement coping. The latent factor of disengagement coping had the strongest direct effect on adaptation (although not statistically significant). Disability severity and impact had medium indirect effects and negative affectivity had small indirect effects on psychosocial adaptation. All of the aforementioned effects had a negative coefficient. CONCLUSIONS: Negative emotional responses (eg, depression, anxiety) to SCI/D, disengagement-type coping (eg, disability denial, avoidance), and the severity and impact of disability were related to lower levels of adaptation to SCI/D.

Changes in detrusor smooth muscle myosin heavy chain mRNA expression following spinal cord injury in the mouse.

AIMS: Smooth muscle myosin heavy chain (SMMHC) isoform composition has been shown to be developmentally regulated and to be associated with functional changes in smooth muscle activity. In this study, we sought to determine expression patterns of SMMHC isoforms in a murine model of spinal cord injury (SCI) and to compare these expression patterns to neurologic, cytometric, and morphometric findings. MATERIALS AND METHODS: Baseline cystometry was performed on adult, female mice followed by either thoracic spinal cord transection (SCI) or sham operation (Sham). At 1, 3, or 6 weeks postoperatively neurologic evaluation and cystometry were performed, bladders were harvested, and expression patterns of SMMHC isoforms (SM1 vs. SM2 and SMA vs. SMB) were assessed by RT-PCR. Morphometrics utilizing computer-assisted color image analysis was also performed on all bladders. RESULTS: There was a significant increase in bladder weight and capacity 1 week following SCI which normalized over time, however, morphometric analysis did not reveal an alteration in tissue composition amongst the three groups. One week following SCI, SM1 was predominantly expressed over SM2 and began to normalize at 3 weeks. This coincided with the emergence of reflex voiding and detrusor overactivity. SMA was expressed following SCI only, and the number of bladders found to express SMA decreased with increasing duration since SCI. CONCLUSIONS: Smooth muscle myosin heavy chain mRNA expression patterns appear to be affected by SCI. We believe the induction of SMA may be a factor in altered bladder function following injury.