Preliminary psychometric analyses of the International Spinal Cord Injury Quality of Life Basic Data Set.

STUDY DESIGN: Secondary psychometric analysis of cross-sectional previously collected data. OBJECTIVES: Explore the floor and ceiling effects, convergent, and divergent validity of the International Spinal Cord Injury Basic Quality of Life Data Set (SCI QoL-BDS) in a sample of people with spinal cord damage (SCD) from different countries, with different causes (both traumatic and non-traumatic), and different settings. SETTING: Community dwellers with SCD in Australia, Brazil, India, The Netherlands, and USA, and inpatient rehabilitation: India. METHODS: Adults (>18 years) with chronic SCD with either traumatic or non-traumatic aetiologies living in the community (n = 624), in inpatient rehabilitation following the onset of SCI (India; n = 115) and able-bodied controls (Australia; n = 220) had the following data collected by survey or face-face interview: SCI QoL-BDS, demographic and clinical characteristics (e.g., age, gender, years post SCI/SCD, education, employment) and reference measures of quality of life, disability and depression. RESULTS: For the whole sample, there were no notable floor or ceiling effects, internal consistency was good (Cronbach's alpha = 0.84) and the corrected item-total correlations generally were acceptable (all > 0.3 except for in Brazilian cohort). Convergent and divergent validity were largely confirmed though there were some aspects of validity that were suboptimal. CONCLUSIONS: Only minor psychometric issues were identified. This preliminary analysis suggests that there are no reason for concern about the use of the SCI QoL-BDS for clinical or research purposes, notwithstanding the need for further studies.

Global mapping for the epidemiology of paediatric spinal cord damage: towards a living data repository.

STUDY DESIGN: Literature review. OBJECTIVES: Globally map key paediatric spinal cord damage epidemiological measures and provide a framework for an ongoing repository of data. SETTING: Worldwide, initiative of ISCoS Prevention Committee. METHODS: Literature search of Medline (1946-March 2017) and Embase (1974-March 2017). Relevant articles in any language regarding children with spinal cord damage included. Stratification of data quality into Green/Yellow /Red 'zones' facilitated comparison between countries. RESULTS: A total of 862 abstracts were reviewed and data from 25 articles were included from 14 countries in 6 of the 21 Global Regions. Fourteen studies involved paediatric traumatic spinal cord injury (SCI) and seven were regarding non-traumatic spinal cord dysfunction (SCDys). An additional four articles provided both paediatric SCI and SCDys data. The median SCI incidence rates in Global Regions were: Asia, East 5.4/million population/year; Australasia 9.9/million population/year; Western Europe 3.3/million population/year and North America, High Income 13.2 million population/year. The median SCDys incidence rates in Global Regions were: Australasia 6.5/million population/year; Western Europe 6.2/million population/year and North America, High Income 2.1/million population/year. SCI was mostly due to land transport (46-74%), falls (12-35%) and sport/recreation (10-25%) and SCDys was mostly caused by tumours (30-63%) and inflammatory/autoimmune causes (28-35%). CONCLUSIONS: There is a scarcity of quality epidemiology studies of paediatric SCD regarding incidence, prevalence, aetiology and survival. Recent ISCoS frameworks provide guidance for researchers to use established classification of SCDys and age group cut-off levels in future studies, thereby improving the ability to compare and combine data.

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.

International Retrospective Comparison of Inpatient Rehabilitation for Patients With Spinal Cord Dysfunction: Differences According to Etiology.

OBJECTIVES: To describe and compare epidemiologic characteristics and clinical outcomes of patients with nontraumatic spinal cord dysfunction according to etiology. DESIGN: Retrospective, multicenter open-cohort case series. SETTING: Spinal rehabilitation units (SRUs) in 9 countries. PARTICIPANTS: Patients (N=956; men, 60.8%; median age, 59.0y [interquartile range, 46-70.0y]; paraplegia, n=691 [72.3%]) with initial onset of spinal cord dysfunction consecutively admitted between January 1, 2008, and December 31, 2010. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Etiology of spinal cord dysfunction, demographic characteristics, length of stay (LOS) in rehabilitation, pattern of spinal cord dysfunction onset, discharge destination, level of spinal cord damage, and the American Spinal Injury Association Impairment Scale (AIS) grade on admission and discharge. RESULTS: The most common etiologies were degenerative (30.8%), malignant tumors (16.2%), infections (12.8%), ischemia (10.9%), benign tumors (8.7%), other vascular (8.5%), and other conditions (12.1%). There were major differences in epidemiologic characteristics and clinical outcomes of patients with different etiologies of spinal cord dysfunction. Paraplegia was more common in patients with a malignant tumor and vascular etiologies, while tetraplegia was more common in those with a degenerative etiology, a benign tumor, and infections. Patients with a malignant tumor tended to have the shortest LOS in the SRU, while those with a vascular etiology tended to have the longest. Except for patients with a malignant tumor, all patient groups had a significant change in their AIS grade between admission and discharge. CONCLUSIONS: This international study of spinal cord dysfunction showed substantial variation between the different etiologies regarding demographic and clinical characteristics, including changes in AIS between admission and discharge.

Estimating the incidence and prevalence of traumatic spinal cord injury in Australia.

OBJECTIVES: To determine estimates of the incidence and prevalence of traumatic spinal cord injury (TSCI) in Australia as of June 30, 2011. DESIGN: Population modeling using cohort survival. SETTING: Australia. PARTICIPANTS: Hospital data regarding people with TSCI in Australia. INTERVENTIONS: Modeling using the following data: 2 population-based databases of hospital separations of patients with TSCI, giving upper and lower estimates of incidence; national population profiles and life tables; levels of TSCI based on Australian Spinal Cord Injury Registry; and life expectancy for persons with spinal cord injury under 3 scenarios--1 constant and 2 with a trend standardized mortality ratio (SMR). MAIN OUTCOME MEASURES: Age- and sex-specific incidence and prevalence estimates. RESULTS: The lower estimate of incidence was 21.0 per million population per year, and the upper estimate was 32.3 per million population per year. The derived prevalence rates ranged from 490 per million population (10,944 persons--lower incidence, trend SMR with survival from 1948) up to 886 per million population (19,784 persons--higher incidence, constant SMR). The prevalence was highest in males, persons aged 46 to 60 years, and those with tetraplegia. CONCLUSIONS: We have reported a method for calculating an estimate of the prevalence of TSCI which provides information that will be vital to optimize health care planning for this group of highly disabled members of society.

International retrospective comparison of inpatient rehabilitation for patients with spinal cord dysfunction epidemiology and clinical outcomes.

OBJECTIVE: To describe and compare epidemiologic characteristics of patients with spinal cord dysfunction admitted to spinal rehabilitation units (SRUs) in 9 countries (Australia, Canada, Italy, India, Ireland, The Netherlands, Switzerland, United Kingdom, and United States). DESIGN: Retrospective multicenter open-cohort case series. SETTING: SRUs. PARTICIPANTS: Patients (N=956) with initial onset of spinal cord dysfunction consecutively admitted between January 1, 2008, and December 31, 2010. Median age on admission was 59 years (interquartile range [IQR], 46-70), and 60.8% of patients were men. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic characteristics (eg, age, sex), time frame over which clinical symptoms of spinal cord dysfunction developed, etiology, length of stay in hospital, level of lesion and American Spinal Injury Association Impairment Scale (AIS) grade, discharge destination, and inpatient mortality. RESULTS: The time frame of onset of spinal cord dysfunction symptoms was as follows: ≤1 day (28.5%); ≤1 week (13.8%); >1 week but ≤1 month (10.5%), and >1 month (47.2%). Most common etiologies were degenerative conditions (30.8%), malignant tumors (16.2%), ischemia (10.9%), benign tumors (8.7%), and bacterial infections (7.1%). Most patients (72.3%) had paraplegia. The AIS grade on SRU admission was grade A in 14%, grade B in 6.5%, grade C in 24%, grade D in 52.4%, grade E in 0.2%, and missing in 2.9%. AIS grade significantly improved by discharge (z=-10.1, P<.0001). Median length of stay in the SRU was 46.5 days (IQR, 17-89.5). Most (80.5%) patients were discharged home. Differences between countries were found for most variables. CONCLUSIONS: This international study of spinal cord dysfunction showed substantial variation of etiology, demographic, and clinical characteristics across countries. Further research, including multiple centers per country, are needed to separate country effects from center effects.

Retrospective study of functional outcomes and disability after non-ischaemic vascular causes of spinal cord dysfunction.

Objective: Describe demographic characteristics, functional outcomes and disability following rehabilitation for non-ischemic vascular spinal cord dysfunction (SCDys).Design: Retrospective, open cohort, case series.Setting: Tertiary rehabilitation unit, Victoria, Australia.Participants: Patients with non-ischemic vascular SCDys admitted over a 21-year-period (01/01/1995-31/12/2015) were identified using International Classification of Diseases codes.Outcome Measures: Demographic characteristics, etiology, neurologic classification, length of stay (LOS), and complications. On admission and discharge, the following were collected: functional independence measure (FIM) motor subscale, details on bowel, bladder, mobility, living arrangement, and support services.Results: 36 patients (female 58%; mean age 69 ± 16 years) were identified. The main causes of non-ischemic vascular SCDys were epidural hematoma (39%), dural arteriovenous fistula (17%), and arteriovenous malformation (11%). 22 cases (61%) were iatrogenic. Most (86%) had incomplete paraplegia. Urinary tract infection was the most common complication (64%). Median LOS in rehabilitation was 68 days. Significant improvement in FIM motor scores was observed from admission (median 25, interquartile range [IQR] 20-38) to discharge (median 69, IQR 38-77) (P < 0.001). On discharge, 4 patients (11%) walked >100 m unaided, 6 (17%) walked >100 m with assistive device, 10 (28%) walked >10 m with assistive device, 15 (41%) were wheelchair dependent and 1 (3%) patient remained non-mobile. 20 patients (56%) were discharged home, 8 (22%) to nursing home, and 8 (22%) transferred to another hospital.Conclusion: Most patients returned home with significantly improved functional outcomes compared to rehabilitation admission, but with the majority having ongoing major disabilities based on FIM motor scores.

The evidence supporting single-use intermittent catheters in people with spinal cord injury.

Intermittent catheterization (IMC) is the accepted evidence-based best practice for bladder management in people with voiding dysfunction due to neurogenic bladder. The two methods for performing IMC over the decades since this practice was introduced are reuse and single-use catheters. There are perceived advantages and disadvantages of each method of performing IMC. There is considerable evidence that single-use IMC is associated with better health outcomes, including reduced risk of urinary tract infection, urethral trauma, and quality of life. People performing IMC also indicate a preference for single-use, although there are advantages of reuse that need to be acknowledged. Ideally, further research is needed in this area, particularly around the washing and storage of reuse catheters, as well as an adequately powered multicenter RCT comparing reuse with single-use IMC, but there are numerous challenges associated with progressing this research.

Correction: Severe chronic pain following spinal cord damage: a pragmatic perspective for prescribing opioids.

[This corrects the article DOI: 10.1038/s41394-018-0094-3.].

A Narrative Review of Pediatric Nontraumatic Spinal Cord Dysfunction.

This article provides a narrative review of seven key issues relevant to pediatric onset of spinal cord damage not due to trauma, or spinal cord dysfunction (SCDys). The first topic discussed is terminology issues. There is no internationally accepted term for spinal cord damage not due to trauma. The implications of this terminology issue and an approach to addressing this are discussed. Second, a brief history of SCDys is presented, focusing on conditions relevant to pediatrics. Third, the classification of SCDys is outlined, based on the International Spinal Cord Injury Data Sets for Non-Traumatic Spinal Cord Injury. Following this, a summary is given of the epidemiology of pediatric SCDys, primarily focused on the incidence, prevalence, and etiology, with a comparison to traumatic spinal cord injury. Next, important clinical rehabilitation principles unique to children with SCDys are highlighted. Then important prevention opportunities for SCDys in children are discussed. Finally, trends, challenges, and opportunities regarding research in SCDys are mentioned.

Pulse article: opioid prescription for pain after spinal cord damage (SCD), differences from recommended guidelines, and a proposed algorithm for the use of opioids for pain after SCD.

Study design: Online questionnaire of spinal cord injury (SCI) physicians. Objectives: The objective of this study is to characterize the approach to opioid prescription for persons with spinal cord damage (SCD). Setting: An international online questionnaire. Methods: A survey was posted online and circulated among international societies within the field of SCI medicine from August to November 2018. Results: One hundred and twenty-three physicians responded to the survey. Of these, 107 (92%) managed pain for persons with SCD. Most (82%) felt that opioid prescription was appropriate for uncontrolled acute pain, but fewer (67%) felt it was appropriate for chronic pain. Of those who felt opioids had a role in the treatment of neuropathic pain, 46% did not think there should be a specific upper limit of opioid dose. The majority (85%) would continue prescribing high doses (250 morphine milligram equivalent (MME) doses/day) if that dose were effective. Tramadol was the most common opioid prescribed first line. Conclusion: Most physicians who responded to this survey prescribe opioids for intractable pain after SCD. A significant proportion of respondents believed that there should not be a specific upper limit of opioid dose prescribed if the drug is tolerated; this does not align with current recommendations. Most physicians do not feel influenced in their prescribing habits by regulatory bodies. If physicians decide to taper an opioid that is being tolerated well, it is most commonly related to a fear of the patient developing an opioid-use disorder. The authors propose an algorithm that may help align practice patterns with current recommended practice guidelines.

The International Spinal Cord Injury Pediatric Activity and Participation Basic Data Set.

Study design: International focus groups. Objectives: The objective of this project was to develop the International Spinal Cord Injury (SCI) Pediatric Activity and Participation (A&P) Basic Data Set. Methods: A focus group of experts in pediatric and adult SCI, and contributors of the existing adult International SCI Adult A&P Basic Data Set convened to develop an initial draft of the data set, which was iteratively refined over a 12 month period based on relevant literature and existing outcome measures that evaluate pediatric activity and participation. The draft was reviewed and approved by the larger project working group and then distributed to the International Spinal Cord Society (ISCoS), American Spinal Injury Association (ASIA), and relevant expert groups for review. Feedback received was considered before the final data set was approved. Results: The International SCI Pediatric A&P Basic Data Set is comprised of 13 variables: administration date, mobility, dressing, feeding, toileting, communication, family outings, spending time with friends, being out with friends, participating in team or club activity, paid work, dating, and physical activity. It is intended for children between 6 and 17 years of age, who have been discharged from initial rehabilitation/hospitalization for a minimum of 3 months. Conclusion: The International SCI Pediatric A&P Basic Data Set was developed to standardize the recording of a minimal amount of information about activities and participation in children with SCI. Further work on reliability and cultural validation is needed. Sponsorship: This study was funded by the Rick Hansen Institute, Research Award #G2015-27 (Mulcahey, PI).

Emotional Consequences of Delays in Spinal Rehabilitation Unit Admission or Discharge: A Qualitative Study on the Importance of Communication.

Objective: To explore the influence of health communications on the emotional consequences of delays in transfer from acute hospital into a spinal rehabilitation unit (SRU) or delays in discharge from SRU. Methods: Semi-structured interviews were conducted in this exploratory, thematic qualitative research design in an SRU, Melbourne, Australia. Results: Six patients experienced delay in admission to (n = 4) or discharge from (n = 3) the SRU, with one person experiencing both an admission and discharge delay. Median admission delay was 41.5 days, primarily related to bed availability and staffing issues. Participants experiencing a delay in transfer from the acute hospital reported feelings of uncertainty, frustration, disappointment, and concern due to a perception that their functional recovery was compromised because of delayed access to specialist rehabilitation. Psychological issues were less common than emotional responses. One participant spent some of the delay period waiting for admission to the SRU in a non-spinal rehabilitation unit and reported no concerns about his recovery. Median discharge delay was 27 days, largely due to a wait in obtaining funding for equipment. Emotional and psychological responses to delayed discharge, particularly frustration, appeared to be influenced by having a sense of control over the discharge process. Conclusion: Patients' experiences during the delay periods partially mitigated the emotional and psychological consequences of a delayed admission or discharge on their psychological well-being. Locus of control, where participants reported being able to effect some influence on their situation, appeared to moderate their emotional state. The findings suggest that clinicians can draw on the concept of control to better support patients through periods of delay.

Review of the History of Non-traumatic Spinal Cord Dysfunction.

Background: The incidence of non-traumatic spinal cord dysfunction (SCDys) is reported to be higher than traumatic spinal cord injury (SCI) in many countries. No formal review of the history of SCDys has been published. Objective: This article aims to identify key highlights in the history of SCDys. Method: An electronic literature search was conducted (January 2017) using MEDLINE (1946-2016) and Embase (1974-2016) databases for publications regarding the history of SCDys. Publications on the history of SCI and a selection of neurology textbooks and books on the history of neurology were reviewed for potentially relevant references. The focus of the literature search was on identifying publications that detail key highlights regarding the history of the diagnosis and management of the most common SCDys conditions, as well as those of historical significance. Results: The electronic search of MEDLINE and Embase identified 11 relevant publications. The majority of publications included were identified from the authors' libraries and a selection of books on neurology and the history of neurology. Conclusions: This review outlines the history of SCDys, taking a broader historical perspective and covering the increasing awareness of the role of the spinal cord and knowledge of neuroanatomy. Key milestones in the history of the diagnosis and management of the most common SCDys conditions are presented. An appreciation of the history of SCDys increases our understanding of the large number of people who contributed to our current knowledge of these conditions and in some situations helps guide efforts regarding prevention of SCDys.

The validity, reliability, responsiveness and minimal clinically important difference of the de Morton mobility index in rehabilitation.

PURPOSE: Determine the clinimetric properties of the de Morton Mobility Index (DEMMI) in an adult inpatient rehabilitation population. METHOD: Prospective open cohort case series. DEMMI and functional independence measure assessed within three days of admission and discharge and seven-point Likert assessment of global change in mobility during inpatient rehabilitation reported by the patient, physical therapist and rehabilitation physician. RESULTS: A total of 366 patients had assessments of the DEMMI completed on both admission into and discharge from rehabilitation. There was no floor or ceiling effect observed in the sample, but there was a mild (19%) ceiling effect at discharge in patients with a stroke. Evidence was obtained for the convergent, discriminant and known group validity of the DEMMI. The minimal clinically important difference was obtained using two methods. The DEMMI was highly responsive to change (Cohen's d = 1.3). CONCLUSIONS: The findings give support to the use of the DEMMI in rehabilitation patients and on the basis of previous studies, support the use of the DEMMI across the continuum of hospital settings. Implications for rehabilitation This study provides evidence that the clinimetric properties of the de Morton Mobility Index (DEMMI) are sound. The findings give support to the use of the DEMMI in rehabilitation patients. Our findings, in conjunction with previous research, support the use of the DEMMI across the continuum of hospital settings.

Rehabilitation of people with spinal cord damage due to tumor: literature review, international survey and practical recommendations for optimizing their rehabilitation.

BACKGROUND/OBJECTIVES: People with spinal cord dysfunction (SCDys) due to tumor (benign and malignant) pose enormous rehabilitation challenges. Objectives were: conduct literature search regarding epidemiology, clinical features and outcomes for SCDys due to tumor following rehabilitation, the ideal setting for rehabilitation and practical considerations for rehabilitation; and propose framework and practical considerations for managing people with SCDys due to tumor in spinal rehabilitation units (SRUs). DESIGN: Survey of rehabilitation health care professionals, consensus opinion from experts and literature search. SETTING: Workshop at International Spinal Cord Society and American Spinal Injury Association combined annual meeting, May 16, 2015, Montréal, Canada. PARTICIPANTS: Workshop attendees and experts in the rehabilitation of people with SCDys due to tumor. OUTCOMES MEASURES: Reports of services offered to people with SCDys due to tumor, including whether those with benign and malignant tumors are admitted into rehabilitation, any admission criteria used and the rational for declining admission. RESULTS: Most respondents (n = 33, 83%) reported that people with benign tumors were routinely admitted for rehabilitation but only 18 (45%) reported that people with malignant tumors were routinely admitted. A range of criteria and reasons for declining admission were given. Evidence from the literature and the opinion of experts support the admission of people with SCDys due to tumor into specialist SRUs. CONCLUSIONS: A framework and practical considerations for managing people with SCDys due to tumor in SRUs are proposed. Patients with tumor causing SCDys should be given greater access to specialist SRU in order to achieve the best outcomes.

Important Clinical Rehabilitation Principles Unique to People with Non-traumatic Spinal Cord Dysfunction.

Background: Non-traumatic spinal cord dysfunction (SCDys) is caused by a large range of heterogeneous etiologies. Although most aspects of rehabilitation for traumatic spinal cord injury and SCDys are the same, people with SCDys have some unique rehabilitation issues. Purpose: This article presents an overview of important clinical rehabilitation principles unique to SCDys. Methods: Electronic literature search conducted (January 2017) using MEDLINE and Embase (1990-2016) databases for publications regarding SCDys. The focus of the literature search was on identifying publications that present suggestions regarding the clinical rehabilitation of SCDys. Results: The electronic search of MEDLINE and Embase identified no relevant publications, and the publications included were from the authors' libraries. A number of important clinical rehabilitation principles unique to people with SCDys were identified, including classification issues, general rehabilitation issues, etiology-specific issues, and a role for the rehabilitation physician as a diagnostic clinician. The classification issues were regarding the etiology of SCDys and the International Standards for Neurological Classification of Spinal Cord Injury. The general rehabilitation issues were predicting survival, improvement, and rehabilitation outcomes; admission to spinal rehabilitation units, including selection decision issues; participation in rehabilitation; and secondary health conditions. The etiology-specific issues were for SCDys due to spinal cord degeneration, tumors, and infections. Conclusions: Although there are special considerations regarding the rehabilitation of people with SCDys, such as the potential for progression of the underlying condition, functional improvement is typically significant with adequate planning of rehabilitation programs and special attention regarding the clinical condition of patients with SCDys.

Trends, Challenges, and Opportunities Regarding Research in Non-traumatic Spinal Cord Dysfunction.

Background: Spinal cord dysfunction (SCDys) is caused by heterogeneous health conditions, and the incidence is increasing. Despite the growing interest in rehabilitation research for SCDys, research into SCDys faces many challenges. Objective: The objective of this project was to perform a clinical review of changes in SCDys research over the last 4 decades; identify challenges to conducting research in SCDys; and propose opportunities for improving research in SCDys. Methods: A triangulation approach was used for obtaining evidence: literature search (January 2017) using MEDLINE and Embase databases for publications in English (1974-2016) regarding SCDys; workshop discussions at the International Spinal Cord Society annual meeting, September 16, 2016, Vienna, Austria; and our collective expertise in SCDys clinical rehabilitation research. Results: There has been a substantial increase in publications on SCDys over the 4 decades, from 1,825 in 1974-1983 to 11,887 in the decade 2004-2013, along with an improvement in research methodology. Numerous challenges to research in SCDys rehabilitation were grouped into the following themes: (a) identification of cases; (b) study design and data collection; and (c) funding, preclinical, and international research. Opportunities for addressing these were identified. Conclusions: The increase in scientific publications on SCDys highlights the importance of this heterogeneous group among the research community. The overall lack of good quality epidemiological studies regarding incidence, prevalence, and survival in these patients serves as a benchmark for guiding improvements to inform evidence-based care and policy.

The costs and adverse events associated with hospitalization of patients with spinal cord injury in Victoria, Australia.

STUDY DESIGN: Analysis of patient-level diagnostic and cost data from an administrative database. OBJECTIVE: To describe complications and cost differentials for hospitalized patients with traumatic spinal cord injury (T-SCI) and nontraumatic spinal cord injury (NT-SCI). SUMMARY OF BACKGROUND DATA: Numerous studies have reported costs for T-SCI, but few have involved NT-SCI. METHODS: All patients with SCI admitted between June 1, 2003 and June 30, 2004 were identified using coding from the International Classification of Diseases and Related Health Problems 10th edition, Australian modification (ICD-10-AM). Analysis of database from 45 major acute care public hospitals included in the Victorian Cost Weights Study hospitals (n = 1605 episodes with a SCI). Complications were identified using the Victorian Department of Human Services C-prefix, assigned to hospital-acquired ICD-10-AM diagnoses. RESULTS: Most (85.5%) SCI episodes involved NT-SCI. The ratio of acute to chronic admissions was high for T-SCI (1:0.05), but reversed for NT-SCI (1:1.36). Complications were documented in 38% of SCI episodes. T-SCI showed a higher rate of complications (56%) than NT-SCI (35%). SCI admissions with a complication were significantly more costly (mean, $A43,410) compared with those without a complication (mean, $A10,102). Length of stay was extended by an average of 32 days in the presence of a complication. CONCLUSIONS: SCI entails costly hospital care and high risk of hospital-acquired illness. Some of these complications are preventable. Better understanding of the financial costs of these episodes can assist healthcare providers and funders to weigh the benefits of interventions to reduce the rates of complications in these vulnerable patients.

Critical appraisal and review of the Rankin scale and its derivatives.

BACKGROUND AND PURPOSE: Efforts to reduce stroke burden require accurate assessment of outcomes in order to compare treatments. The Rankin Scale and its derivatives, the Modified Rankin Scale and the Oxford Handicap Scale, taken together, are among the most common outcome measures that have been used in stroke research. The aim of this study was to perform a critical appraisal of the clinimetric properties of these scales. It was also planned to review the use of these scales in a selection of articles to illustrate concerns raised by the critical appraisal. SUMMARY OF REVIEW: A literature search was performed using electronic databases to locate relevant articles about the reviewed scales. The scales were appraised using a structured format regarding the following properties: purpose, development, presentation, language, method of administration, content validity, face validity, feasibility, construct validity, reliability, responsiveness, and generalizability. There are concerns in each of the appraised areas regarding the clinimetric properties of these scales. CONCLUSION: Further work is needed to improve the clinimetric properties of the reviewed scales to ensure that they are more useful tools in determining the outcome of stroke. Alternatively, a newer global outcome scale with improved clinimetric properties may be a better option for future stroke research.