The impact of early surgical treatment of tracheal stenosis on neurorehabilitation outcome in patients with severe acquired brain injury.

INTRODUCTION: Acquired tracheal stenosis (TS) is a potentially life-threatening condition following prolonged intubation and/or tracheostomy in adult patients with severe Acquired Brain Injury (sABI), requiring a tracheal resection and reconstruction. METHODS: We included 38 sABI adult patients with TS, admitted at a post-acute Neurorehabilitation Hospital. Disability Rating Scale (DRS) and other functional assessment measures were recorded at admission (t1), before TS surgical treatment (t2), and at discharge (t3). Patients were defined as 'improved' when they changed from a more severe to a less severe disability, between time t2 and time t3, and as "not improved" when they did not show any further improvement between t2 and t3, or they already exhibited a disability improvement since time interval t1-t2. RESULTS: Time interval between the injury onset and TS surgical treatment (t2-t0) was associated with the patient's disability improvement, suggesting the t2-t0 time interval ≤ 115 days as a cutoff value for a possible functional recovery. A t2-t0 time interval ≤ 170 days is also associated to absence of persistent dysphagia. CONCLUSIONS: Early TS surgical treatment within 115 days from the injury onset contributes to the improvement of the disability level in patients with sABI, optimizing their functional outcomes and recovery potential.

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.

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.

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.

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.

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.