International Spinal Cord Society (ISCoS) database: Asian Spinal Cord Network (ASCoN) Pilot Project [IDAPP].

STUDY DESIGN: Global mapping project of ISCoS for traumatic spinal cord injury (T-SCI) highlighted paucity of data from low and middle income countries (LMICs). Recognizing this gap, IDAPP study of one year duration was proposed as the first step to develop an International SCI database. OBJECTIVES: Primary objective was to assess database variables, processes involved and web platform for their suitability with a view to provide guidance for a large scale global project. Secondary objective was to capture demographic and selected injury/safety data on patients with T-SCI with a view to formulate prevention strategies. SETTING: Nine centers from Asia. METHODS: All patients with T-SCI admitted for first time were included. International SCI Core Data Set and especially compiled Minimal Safety Data Set were used as data elements. Questionnaire was used for feedback from centers. RESULTS: Results showed relevance and appropriateness of processes, data variables and web platform of the study. Ease of entering and retrieval of data from web platform was confirmed. Cost of one year IDAPP study was USD 7780. 975 patients were enrolled. 790 (81%) were males. High falls (n = 513, 52%) as a cause and complete injuries (n = 547, 56%) were more common. There was a higher percentage of thoracic and lumbar injuries (n = 516, 53%). CONCLUSIONS: The study confirms that establishing the SCI database is possible using the variables, processes and web platform of the pilot study. It also provides a low cost solution. Expansion to other centers/regions and including non-traumatic SCI would be the next step forward.

Prevalence of pressure ulcers in Thai wheelchair users with chronic spinal cord injuries.

STUDY DESIGN: A cross-sectional study. OBJECTIVES: To study prevalence of pressure ulcers (PrUs), quality of life (QoL) and effect of wheelchair cushions used by Thai wheelchair users with chronic spinal cord injury (SCI). SETTING: Maharaj Hospital, Chiang Mai, Thailand. METHODS: Thai chronic SCI wheelchair users, aged over 18 years and non-ambulatory with ASIA impairment scale A, B or C were recruited. They completed the PrUs questionnaire and rated the EuroQoL-5D and their health status with a visual analog scale (VAS). Demographic data of each participant were extracted from medical records. The EQ-5D health states were transformed to utility scores by using the Thai algorithm and the prevalence of PrUs was reported. The EQ-5D, the utility scores and the health status VAS were compared between those with and without current PrUs and between those participants using foam and air-filled cushions. RESULTS: Of 129 participants, 26.4% had current PrUs at the time of the study, 27.9% had healed PrUs and 45.7% never had PrUs. The median VAS score for health status was 70 (Q1=50, Q3=80). Based on the EQ-5D, only one dimension (anxiety/depression) was significantly different between those with and those without current PrUs (P=0.015). Those using an air-filled cushions had a mean utility score four times higher than of those using a foam cushion (0.131 vs. 0.032, P=0.089) but not statistically significant. CONCLUSIONS: PrUs are still prevalent among Thai wheelchair users with chronic SCI. Anxiety/depression is associated with current ulcers.

Pulmonary embolism after manual muscle testing in an incomplete paraplegic patient: a case report.

OBJECTIVE: To report and discuss the case of an incomplete paraplegic patient who died of pulmonary embolism (PE) aggravated by manual muscle testing. SETTING: Acute spinal ward, Maharaj Hospital, Chiang Mai, Thailand. CASE REPORT: A 79-year-old man suffering from chest trauma, fractured ribs and a fracture of T11 with incomplete paraplegia, American Spinal Injury Association impairment scale D. Intercostal tubes were inserted at both sides due to haemothorax. Ten days after onset, T9 to L2 posterior instrumentation was successfully completed. A week after the operation, he was allowed to stand on a tilt-table and a rehabilitation specialist was consulted to assess and plan to encourage ambulation. After manual muscle testing of the right hip flexors and knee extensors, the patient suffered from a short period of unconsciousness and breathlessness. Electrocardiography showed right bundle branch block and a drop in oxygen saturation from 98 to 70%. After oxygenation with mask and bag, oxygen saturation increased to 90%. PE or acute myocardial infarction was suspected. After insertion of an endotracheal tube, the patient went into cardiac arrest. Cardiopulmonary resuscitation failed. The autopsy revealed large and small thromboemboli in both lungs, particularly in the pulmonary artery. CONCLUSION: Strong hip and knee muscle contractions during manual muscle testing were suspected of triggering massive pulmonary emboli from the proximal vein of the right leg of a paraplegic patient who had functional motor movements and did not receive any thromboembolic prophylaxis which caused unexpected fatal pulmonary emboli. Screening of venous thromboembolism risks and its symptoms/signs before mobilisation is mandatory.

Difficulty in moving around in a wheelchair as a presenting symptom of left atrial myxoma in a chronic paraplegic patient: a case report.

STUDY DESIGN: CASE REPORT. OBJECTIVES: To present and discuss a case of a chronic paraplegic patient who presented with difficulty in moving around in a wheelchair. SETTING: Rehabilitation Ward, Maharaj Hospital, Faculty of Medicine, Chiang Mai University, Thailand. CASE REPORT: A chronic complete paraplegic T4 man complained of difficulty in moving around in a wheelchair. He had experienced this difficulty for a week. He also complained of pain in the finger pads, and blackening had occurred in his little toes. Buerger's disease was suspected, but Doppler ultrasound showed no evidence of arterial occlusion. During admission, his vision suddenly dropped and magnetic resonance imaging revealed an ischemic stroke in the posterior cerebral artery. Erythematous lesions in all toe pads and soles were actually embolic signs but painless due to his paraplegia. Echocardiography showed a large left atrial myxoma. Six weeks after removal of the left atrial myxoma, he was discharged when he could propel his wheelchair more than 100 m without difficulty or pain. CONCLUSION: Experiencing difficulty in moving around in a wheelchair in conjunction with painful finger pads can be presenting symptoms of a rare cardiac lesion--left atrial myxoma with arterial embolism. After surgical excision of the tumour, the arterial embolic symptoms and signs subsided and the patient regained basic wheelchair mobility skills within 6 weeks.

www.elearnSCI.org: a global educational initiative of ISCoS.

OBJECTIVE: To develop a web-based educational resource for health professionals responsible for the management of spinal cord injury (SCI). The resource:www.elearnSCI.org is comprised of seven learning modules, each subdivided into various submodules. Six of the seven modules address the educational needs of all disciplines involved in comprehensive SCI management. The seventh module addresses prevention of SCI. Each submodule includes an overview, activities, self-assessment questions and references. DEVELOPMENT OF THE RESOURCE: Three hundred and thirty-two experts from The International Spinal Cord Society (ISCoS) and various affiliated societies from 36 countries were involved in developing the resource through 28 subcommittees. The content of each submodule was reviewed and approved by the Education and Scientific Committees of ISCoS and finally by an Editorial Committee of 23 experts. KEY FEATURES: The content of the learning modules is relevant to students and to new as well as experienced SCI healthcare professionals. The content is applicable globally, has received consumer input and is available at no cost. The material is presented on a website underpinned by a sophisticated content-management system, which allows easy maintenance and ready update of all the content. The resource conforms to key principles of e-learning, including appropriateness of curriculum, engagement of learners, innovative approaches, effective learning, ease of use, inclusion, assessment, coherence, consistency, transparency, cost effectiveness and feedback. CONCLUSION: www.elearnSCI.org provides a cost effective way of training healthcare professionals that goes beyond the textbook and traditional face-to-face teaching.

Functioning and disability in spinal cord injury from the consumer perspective: an international qualitative study using focus groups and the ICF.

STUDY DESIGN: Qualitative, multi-center study. OBJECTIVES: To examine the lived experiences of persons with spinal cord injury (SCI) in both the early post-acute and the long-term context using the International Classification of Functioning, Disability and Health (ICF) as a frame of reference. SETTING: International study sites representing the six World Health Organization world regions. METHODS: A qualitative study using focus groups methodology was conducted. Sample size was determined by saturation. The focus groups were digitally recorded and transcribed verbatim. The meaning condensation procedure was used for the data analysis. The resulting meaningful concepts were linked to ICF categories according to established linking rules. RESULTS: Forty-nine focus groups with 230 participants were performed. Saturation was reached in four out of the six world regions. A total of 3122 and 4423 relevant concepts were identified in the focus groups for the early post-acute and the long-term context, respectively, and linked to a total of 171 and 188 second-level categories. All chapters of the ICF components Body functions, Activities and participation and Environmental factors were represented by the linked ICF categories. In all, 36 and 113 concepts, respectively, are not classified by the ICF and 306 and 444, respectively, could be assigned to the ICF component Personal Factors, which is not yet classified. CONCLUSION: A broad range of the individual experiences of persons with SCI is covered by the ICF. A large number of experiences were related to Personal Factors.

ICF Core Sets for individuals with spinal cord injury in the long-term context.

STUDY DESIGN: A formal decision-making and consensus process integrating evidence gathered from preparatory studies was followed. OBJECTIVES: The objective of the study was to report on the results of the consensus process to develop the first version of a Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set, and a Brief ICF Core Set for individuals with spinal cord injury (SCI) in the long-term context. SETTING: The consensus conference took place in Switzerland. Preparatory studies were performed worldwide. METHODS: Preparatory studies included an expert survey, a systematic literature review, a qualitative study and empirical data collection involving people with SCI. Relevant ICF categories were identified in a formal consensus process by international experts from different backgrounds. RESULTS: The preparatory studies identified a set of 595 ICF categories at the second, third or fourth level. A total of 34 experts from 31 countries attended the consensus conference (12 physicians, 6 physical therapists, 5 occupational therapists, 6 nurses, 3 psychologists and 2 social workers). Altogether, 168 second-, third- or fourth-level categories were included in the Comprehensive ICF Core with 44 categories from body functions, 19 from body structures, 64 from activities and participation and 41 from environmental factors. The Brief Core Set included a total of 33 second-level categories with 9 on body functions, 4 on body structures, 11 on activities and participation and 9 on environmental factors. CONCLUSION: A formal consensus process integrating evidence and expert opinion based on the ICF led to the definition of the ICF Core Sets for individuals with SCI in the long-term context. Further validation of this first version is needed.

Identification of the most common problems in functioning of individuals with spinal cord injury using the International Classification of Functioning, Disability and Health.

STUDY DESIGN: Cross-sectional, multicenter study. OBJECTIVES: To identify the most common problems of individuals with spinal cord injury (SCI) in the early post-acute and the long-term context, respectively, using the International Classification of Functioning, Disability and Health (ICF) as a frame of reference. SETTING: International. METHODS: The functional problems of individuals with SCI were recorded using the 264 ICF categories on the second level of the classification. Prevalence of impairment was reported along with their 95% confidence intervals. Data were stratified by context. RESULTS: Sixteen study centers in 14 countries collected data of 489 individuals with SCI in the early post-acute context and 559 in the long-term context, respectively. Impairments in thirteen ICF categories assigned to Body functions and Body structures were more frequently reported in the long-term context, whereas limitations/restrictions in 34 ICF categories assigned to Activities and Participation were more frequently found in the early post-acute context. Eleven ICF categories from the component Environmental Factors were more frequently regarded as barriers, facilitators or both by individuals with SCI in the early post-acute context as compared with individuals with SCI in the long-term context. Only two environmental factors were more relevant for people with SCI in the long-term context than in the early post-acute context. CONCLUSION: The study identified a large variety of functional problems reflecting the complexity of SCI and indicated differences between the two contexts. The ICF has potential to provide a comprehensive framework for the description of functional health in individuals with SCI worldwide.

Neurologic urinary incontinence.

INTRODUCTION: This manuscript summarizes the work of Committee 10 on neurologic bladder and bowel of the International Consultation on Incontinence in 2008-2009. As the data are very large the outcome is presented in different manuscripts. This manuscript deals with neurologic urinary incontinence. METHODS: Through in debt literature review all aspects of neurological urinary incontinence were studied for levels of evidence. Recommendations for diagnosis and treatment, and for future research were made. RESULTS: Pathophysiology was summarized for different levels of lesions. For epidemiology, specific diagnostics, conservative treatment and surgical treatment of neurologic urinary incontinence, levels of evidence and grades of recommendation were made following ICUD criteria. CONCLUSIONS: Though data are available that advice and guide in the management of urinary incontinence in neurologic patients, not many data have a high level of evidence or permit a high grade of recommendation. More and well-structured research is needed.

Neurologic fecal incontinence.

INTRODUCTION: This manuscript summarizes the work of Committee 10 on neurologic bladder and bowel of the International Consultation on Incontinence in 2008-2009. As the data are very large the outcome is presented in different manuscripts. This manuscript deals with neurologic fecal incontinence (FI). METHODS: Through in debt literature review all aspects of neurologic urinary and FI were studied for levels of evidence. Recommendations for diagnosis and treatment, and for future research were made. RESULTS: Pathophysiology was summarized for different levels of lesions. For epidemiology, specific diagnostics, conservative treatment, and surgical treatment of neurologic FI levels of evidence and grades of recommendation were made. CONCLUSIONS: Though data are available that advice and guide in the management of FI in neurologic patients, not many data are with a high level of evidence or high grade of recommendation. More and well-structured research is needed.

ICF Core Sets for individuals with spinal cord injury in the early post-acute context.

STUDY DESIGN: A formal decision-making and consensus process integrating evidence gathered from preparatory studies was followed. OBJECTIVES: The aim of this study was to report on the results of the consensus process to develop the first version of a Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set and a Brief ICF Core Set for individuals with spinal cord injury (SCI) in the early post-acute context. SETTING: The consensus conference took place in Switzerland. Preparatory studies were performed worldwide. METHODS: Preparatory studies included an expert survey, a systematic literature review, a qualitative study and empirical data collection involving people with SCI. ICF categories were identified in a formal consensus process by international experts from different backgrounds. RESULTS: The preparatory studies identified a set of 531 ICF categories at the second, third and fourth levels. From 30 countries, 33 SCI experts attended the consensus conference (11 physicians, 6 physical therapists, 5 occupational therapists, 6 nurses, 3 psychologists and 2 social workers). Altogether 162 second-, third- or fourth-level categories were included in the Comprehensive ICF Core Sets with 63 categories from the component Body Functions, 14 from Body Structures, 53 from Activities and Participation and 32 from Environmental Factors. The Brief Core Set included a total of 25 second-level categories with 8 on Body Functions, 3 on Body Structures, 9 on Activities and Participation, and 5 on Environmental Factors. CONCLUSION: A formal consensus process-integrating evidence and expert opinion based on the ICF led to the ICF Core Sets for individuals with SCI in the early post-acute context. Further validation of this first version is needed.

The use of one-channel water cystometry in patients with a spinal cord lesion: practicalities, clinical value and limitations for the diagnosis of neurogenic bladder dysfunction.

STUDY DESIGN: Investigational technique evaluation. OBJECTIVE: To evaluate the clinical value and limitations of one-channel cystometry as a method for urodynamic testing in patients with spinal cord lesion (SCL). SETTING: Spinal Cord Injury Centers Asia. METHODS: Protocol, equipment and practical performance of the one-channel cystometry as used in Ho Chi Minh City and Chiang Mai were studied. RESULTS: One-channel cystometry permits to accurately evaluate bladder pressure development at constant filling speed. It shows detrusor muscle behaviour as detrusor overactivity and allows evaluating sensation of bladder filling. It can strongly suggest detrusor external sphincter dyssynergia. The need of bladder-relaxant drugs and their effectiveness can be evaluated. The major limitation is that the one pressure line will show changes of intravesical pressure independent of their cause, which makes a continuous thorough observation mandatory throughout the test. Other limitations are a filling rate higher than physiological and a filling solution at room temperature. As in more elaborate urodynamic testing, the observations do therefore not necessarily reflect the function of the lower urinary tract in daily life. CONCLUSION: One-channel cystometry is easy to perform, cheap and clinically valid. The results need to be integrated in the overall knowledge of the patient's neurological situation. The method permits one to gather a lot of information on bladder function in persons with SCL. With proper interpretation and a clear understanding of the shortcomings, it is a good guide for bladder management. It is applicable everywhere.

Extravasation of the contrast media during voiding cystourethrography in a long-term spinal cord injury patient.

OBJECTIVE: To present complications and pitfalls in voiding cystourethrography (VCUG) and introduce a guideline for performing VCUG in a long-term spinal cord injury (SCI) patient with neurogenic bladder dysfunction (NBD) and contracted bladder. STUDY DESIGN: A case report. SETTING: Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand. METHOD: We describe a chronic C(5) tetraplegic man with NBD and contracted bladder, who developed autonomic dysreflexia (AD), gross hematuria and extravasation of contrast median during VCUG. RESULT: A foley catheter was retained after VCUG. AD was resolved and urine cleared after a week of continuous bladder irrigation. CONCLUSION: VCUG should be performed with caution in a long-term SCI patient with NBD and contracted bladder. Forceful pushing of the contrast media by the hand-injection method caused abrupt distention of the contracted bladder, damaged bladder mucosa and aggrevated AD. We suggest a guideline as follows: report bladder capacity and AD, if present, in an X-ray requisition form; use the gravity-drip method, stop the drip and drain the contrast media if a sudden headache and rising of blood pressure (BP) develop; observe urine colour, and report if bleeding or AD occurs.

Reused silicone catheter for clean intermittent catheterization (CIC): is it safe for spinal cord-injured (SCI) men?

STUDY DESIGN: Study of reusable catheter. OBJECTIVE: To investigate whether a silicone cathether reused over years for clean intermittent catheterization (CIC) was safe for spinal cord injured (SCI) men. SETTING: Maharaj Hospital, Chiang Mai, Thailand. METHOD: A cross-sectional study was obtained from SCI men who had used CIC with a reusable silicone catheter for more than a year. Demographic data, urological management and urinary tract complications focusing on the radiologic status of the urethra were reviewed and analyzed. In addition, two reused and one new catheters were studied under electron microscope for catheter morphology (surface and lumen) and stiffness. RESULTS: There were 28 SCI men included in this study. The average duration of CIC use was 4.8 years and the average time of usage for each catheter was 3 years (range 1-7 years). In all, 26 men previously used indwelling catheterization (ID) during the acute phase. In all, 23 men performed self-catheterization. Regarding urinary complications, three reported urethral bleeding, five had episodes of pus per urethra, five had epididymitis, four had passing stones, 18 had occasional foul smelly urine, 10 developed fever and cloudy urine during the past year. Of 17 patients who had ultrasonography done, four had pathologic findings in kidney and one had bladder calculi. Demographic data, urinary management and complications did not have significant relation to the abnormality of the urethrogram or urinary tract infection. However, where the frequency of CIC was higher, the abnormality of the urethra was lower (P<0.05). All had serum Cr level < or =1.3 mg/dl. Electron microscopic findings of reused catheters for 2 years revealed encrustation but no obstruction in the lumens and 20% increase in stiffness. CONCLUSION: The clinical outcome, especially with regard to urethral abnormalities with this reusable silicone catheter is as good as with a disposable one. However, to reuse urinary catheters, one should consider the increasing risk of infection. For SCI patients in developing countries, CIC with a reusable silicone catheter may be a suitable and safe choice if one cleans and applies it properly to reduce infection. In order to answer the question how long a person in a developing country should use the same silicone catheter, further research should be conducted.

Conservative treatment of the neuropathic bladder in spinal cord injured patients.

Different conservative treatment modalities for the lower urinary tract dysfunction in patients with spinal cord lesion are reviewed. Conservative treatment is still the mainstay of the urological management in these patients. Growing experience has changed the classical approach. Spontaneous voiding with and without triggered voiding and/or bladder expression has proven to be less safe except in well defined patients with regular urological follow-up. Nowadays, intermittent catheterisation and self catheterisation with and without bladder relaxants are accepted as the methods of choice. Condom catheters are still needed if incontinence persists, while penile clamps have no place in the treatment of patients with spinal cord lesions. Long-term indwelling catheters should be avoided. External electrical stimulation can be used to correct the neurogenic dysfunction by neuromodulation and/or to induce a direct therapeutic response in the lower urinary tract.

Workshop on spinal cord injuries (SCI) management: the Chiang Mai experience.

OBJECTIVES: To give an opportunity to health workers in South Asia (SEA) to improve their knowledge in the comprehensive management of SCI. SETTING: Chiang Mai, Thailand; 5-7 November 1997. PARTICIPANTS: Sixteen faculty members (from Europe, Australia and Thailand) and 160 participants (94 Thais, 66 from SEA, China, India and Bangledesh). METHODS: Two days of lectures and 1 day of workshops and discussion. Evaluation was performed by questionnaires. Suggestions and comments are reported. RESULTS: Ninety-two per cent of participants said the workshop was really useful. Eighty-eight per cent were very satisfied with the quality of the programmes and 92% with the workshops and discussion on the last day. CONCLUSIONS: A follow-up study should be conducted by the Educational Committee of IMSOP. This will help to plan more efficacious training programmes for the future.

Leprosy neuropathy: correlation of clinical and electrophysiological tests.

This report describes the neurological and electrophysiological examination of 35 subjects with leprosy (average duration of symptoms 3.4 years, average time since diagnosis 7.5 months). Clinical examination in the distribution of non-dominant median and ulnar nerves was performed with the following clinical methods: touch sensation with 0.05 gm. Monofilament nylon, thermal sensation with a thermal sensitivity testing device, voluntary muscle testing and nerve palpation. At least one abnormality was found in 22 ulnar and 13 median nerves (63% and 37%, respectively). Nerve palpation was the most frequent clinical abnormality, while the other methods had similar frequencies of abnormality. Electrophysiological studies were performed on the ipsilateral side of the leprosy subjects and on 32 age-matched normal subjects. Electrophysiological responses from the leprosy subjects were evaluated by criteria established from normal subject data. Abnormal or absent responses were found in 21/35 ulnar sensory, 12/35 ulnar motor, 9/35 median sensory and 6/35 median motor responses among the leprosy subjects. The most important electrodiagnostic findings were: (i) low sensory amplitudes and (ii) drops in amplitude and NCV over the across-elbow segment of the ulnar nerve. Both clinical and nerve conduction abnormalities were positively associated with duration of leprosy symptoms. The four clinical methods were compared for concordance with nerve conduction data by cross-tabulation. The two sensory measures, monofilaments and the thermal sensitivity device, had the highest concordances. Usefulness of clinical tests for nerve damage in leprosy may vary depending on whether the purpose is for diagnosis, patient education or clinical follow-up.