Effect of age on bowel management in traumatic central cord syndrome.

STUDY DESIGN: A retrospective multicenter study. OBJECTIVES: To investigate the characteristics of bowel dysfunction in elderly people with traumatic central cord syndrome (TCCS). SETTING: A total of 28 Rosai hospitals in Japan. METHODS: The Rosai Hospital registry included 3006 persons with spinal cord injury during 1997-2007. The study subjects were 186 patients with TCCS (160 men, 26 women; mean age, 61.7±11.6 years, ±s.d.). Patients were divided according to age into the young group (<50 years, n=30), the middle-age group (50-69 years, n=112) and the elderly group (≥70 years, n=44). We assessed the differences in bowel management techniques (spontaneous, rectal medications and manual emptying) and activity of daily living (ADL) with respect to bowel care at discharge among the three groups. RESULTS: Continent spontaneous defecation was the most common bowel management method (50%, 93/186). The percentage of elderly subjects on continent spontaneous defecation (36.4%) was significantly less than that of the young group (66.7%; P<0.05). Furthermore, the percentage of elderly patients who required no bowel care (18.2%) was significantly less than those of the young (53.3%) and middle-age groups (41.1%; P<0.01). However, few differences in bowel care-related ADL were recognized among the three groups in patients who required manual emptying. CONCLUSION: The results identified significantly fewer patients aged ≥70 years with 'continent spontaneous defecation' or 'independent for bowel care' compared with younger patients. The results also highlighted the clinical importance of bowel dysfunction associated with TCCS especially in elderly people.

Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury.

STUDY DESIGN: A retrospective, multicenter study. OBJECTIVES: To investigate the relationship between bowel and bladder management methods and symptomatic autonomic dysreflexia (AD) during hospitalization in patients with spinal cord injury (SCI). SETTING: Twenty-eight Rosai hospitals in Japan. METHODS: The study subjects were 571 patients with SCI who had been admitted to 28 Rosai hospitals between April 1997 and March 2007 for rehabilitation therapy and fulfilled the following criteria: (1) SCI at or above sixth thoracic level, (2) discharged from hospital after more than 4 months of admission for initial injury and (3) lack of pressure ulcers, deep venous thrombosis, ureteral and renal stones or heterotopic ossification throughout hospitalization to exclude possible influence of these complications on cardiovascular reflexes. The study subjects were examined for the incidence of symptomatic AD according to age, sex, ASIA Impairment Scale, injury level, bowel and bladder management techniques at discharge. RESULTS: The Rosai Hospital registry included 3006 persons with SCI during 1997-2007, and 571 patients fulfilled the above criteria. The highest incidence of symptomatic AD was diagnosed in subjects using reflex voiding and in those using manual removal of stool. By contrast, the lowest incidence of symptomatic AD was in those on continent spontaneous voiding and continent spontaneous defecation. CONCLUSION: Medical staff should evaluate the presence of AD in patients with SCI at or above the T6 level under bladder and bowel management such as reflex voiding and manual removal of stool.

Topical anesthesia blunts the pressor response induced by bowel manipulation in subjects with cervical spinal cord injury.

DESIGN: Prospective double-blind study. OBJECTIVE: Manual emptying of rectal contents is necessary for patients with spinal cord injury to prevent bowel obstruction; however, this maneuver induces a rise in blood pressure (BP) and autonomic dysreflexia (AD). The purpose of this prospective double-blind study was to investigate whether topical anorectal anesthesia attenuates the BP rise and AD during bowel manipulation in patients with cervical spinal cord injury (CSCI). SETTING: Kibikogen Rehabilitation Center for Employment Injuries. METHODS: The study subjects were 25 consecutive clinically stable patients with CSCI. Each subject received a complete bowel program involving manual removal of stool in lateral recumbency, after topical application of lidocaine or placebo jelly to the anorectal area. Systolic and diastolic BP, heart rate and symptoms of AD were recorded before, during and after bowel manipulation. RESULTS: Systolic BP was significantly lower during the lidocaine arm of the study compared with placebo at insertion of rectal medication, digital stimulation, beginning of stool flow, manual removal of stool, end of stool flow and at 5-min after emptying. The mean maximal increase in systolic BP during lidocaine treatment (33.2+/-14.6 mm Hg) was less than during placebo (50.2+/-19.5 mm Hg, P<0.001). CONCLUSION: On the basis of our findings, we recommend induction of lidocaine jelly immediately before rectal manipulation in patients with CSCI to minimize the incidence and severity of AD.

Early rehabilitation effect for traumatic spinal cord injury.

OBJECTIVE: To determine the natural course of traumatic spinal cord injury (SCI) and the effect of early rehabilitation on it. DESIGN: A retrospective, multicenter study. SETTING: Sixteen Rosai hospitals and 1 medical school. PARTICIPANTS: One hundred twenty-three SCI patients (104 men, 19 women; mean age, 48.8 +/- 17.7yr) enrolled. INTERVENTIONS: Dividing the subjects into an early rehabilitation group and a delayed group; differences were ensured by international classification of SCI. MAIN OUTCOME MEASURES: Using the American Spinal Injury Association (ASIA) classifications, the motor recovery rate (MRR) was defined as (ASIA motor score at discharge - ASIA motor score at admission)/(100 - ASIA motor score at admission). The regression lines for FIM instrument score and ASIA motor score were determined for 6 subgroups (early or delayed tetraplegia, central cord injury, paraplegia) by the MRR staging. The regression lines for physical or cognitive FIM score and ASIA motor score were also determined for 6 subgroups. RESULTS: Three stages were obtained: acute stage: 2 weeks postinjury; recovery stage: 2 weeks to 6 months postinjury; and chronic stage: more than 6 months postinjury. Regression lines showed that rehabilitation improved physical functional independence for ASIA motor score, especially in the early rehabilitation subgroups. There was no correlation between cognitive FIM score and ASIA motor score in 6 subgroups. CONCLUSION: Early SCI rehabilitation contributes to good physical activities of daily living for motor function.

Evaluation of wheelchair cushions by means of pressure distribution mapping.

We studied the seated buttock pressure distribution in six paraplegic patients by means of computerized pressure mapping. They were all male and their age ranged from 18 to 48 years old. Their level of paralysis varied from Th5 to L1. Five kinds of wheelchair cushions were studied: an air cushion, a contour cushion, a polyurethane foam cushion, a Cubicushion (which is made of polyurethane foams) and a silicone gel cushion. A tactile sensor consisting of 2064 matrices was used for measuring the buttock pressure distribution and the data was analyzed on a personal computer. Peak pressures measured for each cushion were as follows (in descending order): the Cubicushion, the polyurethane foam cushion, the contour cushion, the silicone gel cushion, and the air cushion. The areas of total contact measured for each cushion were as follows (in descending order): the air cushion, the silicone gel cushion, the polyurethane foam cushion, the contour cushion and the Cubicushion. Based on these findings, we conclude that the most advantageous cushion is the air cushion or the silicone gel cushion. Likewise, we conclude that the Cubicushion is not practical for pressure sore prevention.

A survey of wheelchair use by paraplegic individuals in Japan. Part 1: Characteristics of wheelchair cushions.

The characteristics of wheelchair cushions used by 218 paraplegic patients who lived independent lives were surveyed to clarify the present state of wheelchair cushioning for pressure sore prevention in Japan. Out of 586 cushions surveyed, 91.0% were ready-made and the rest were custom-made. The outstanding popularity of polyurethane foam ready-made cushions (76.3%) suggested that insufficient consideration was taken in the selection of cushions. Custom-made cushions displayed unique modifications to relieve contact pressure or to stabilize sitting posture, which should be systematically provided for all patients. The variety of cushion types and the frequent dissatisfaction with cushions seen in patients with current pressure sores suggested a strong demand for the effective prescription of cushions. Furthermore, 30% of all cushions had had an excessively prolonged use, indicating insufficient follow-up. A medical system including deliberate prescription and regular follow-up of wheelchair cushions should be established for the effective prevention of pressure sores.

A survey of wheelchair use by paraplegic individuals in Japan. Part 2: Prevalence of pressure sores.

A cross-sectional survey was done to clarify the incidence of pressure sores in 218 self-supported Japanese paraplegic patients and to determine effective measures for prevention. The majority of patients (85.7%) had previous pressure sores, and 46.3% had undergone multiple surgeries. Some patients (17.9%) were still suffering from persistent sores which commonly developed at the ischial tuberosities, suggesting insufficiency of self-care practice during wheelchair activities. Sensory disturbance over the seating surface, urinary incontinence, and general complications were seen in 85.8%, 49.5%, and 18.8% of total subjects, respectively. They were seen as risk factors for pressure sores, but only urinary incontinence clearly increased the current pressure sore prevalence. Nevertheless, both self-care practice and sports activities, seen in 85.3% and 36.2% of total subjects, respectively, contributed to greatly reduce the incidence. A patient education system including acquisition of basic knowledge and proper technique should be established to promote effective prevention of pressure sores in Japan.

Survey of above knee (A/K) prostheses currently used in the Chugoku-Shikoku district of Japan.

To determine the extent to which recent advances in biomechanical technology have been implemented and to evaluate these new technologies, 84 unilateral above knee (A/K) amputees and their prostheses were surveyed in the Chugoku-Shikoku district of Japan, especially in regard to the types, sockets and components of A/K prostheses currently in use. Background factors such as age and sex of the A/K amputees and the period after amputation were also surveyed. Of the 84 amputees surveyed, 74 (88.1%) were over 40 years old and 40 (47.6%) were over 60 years old. There were 10 women (11.9%) and 74 men (88.1%). The period after amputation was under 25 years in 58 (69.0%) cases. Regarding the type of A/K prostheses, one-third of the prostheses was of the exoskeletal type and two-thirds were of the endoskeletal type. Although the endoskeletal type is becoming more popular recently, elderly A/K amputees tend to use the exoskeletal type. Thirty-one (36.9%) had plug-fit sockets which are preferable for those who follow the Japanese practice of sitting on the floor, especially for elderly amputees. Thirty-seven (44.0%) had a lock-knee, 27 (73.0%) of which were used by amputees over 60 years old. Seventy-three (86.9%) had a single-axis ankle which is generally considered to be the most stable ankle. Thus, the most common combination of prosthetic components for elderly A/K amputees was the plug-fit socket, lock-knee joint and single-axis ankle.

Kinesiological study of push-up motion using a three-dimensional floor reaction on a force plate.

To find an effective way to handle wheelchairs, 3-dimensional floor reactions of the hand and angular deviation of the elbow and wrist joints during push-up motion were studied in 10 healthy men. The push-up was carried out using 3 hand positions (fist, finger and palm) and a push-up device. In all hand positions, anteroposterior force (Fx) and the mediolateral force (Fy) appeared after the vertical force (Fz). The end point of Fx and Fy was observed before that of Fz. Among the 4 different hand positions, Fx and Fy appeared first in the palm, followed by the finger and fist positions, and lastly in the push-up devices. The results indicate that the more unstable pushing-up the body is, the earlier and longer Fx and Fy are. Thus, Fx and Fy are considered to be good indicators of body balance during the push-up motion. The elbow joint showed a hyperextended position only when using the palm position in the maintenance phase. The wrist joint showed palmar flexion only when using the fist position.

Stump problems in traumatic amputation.

Stump problems in amputations resulting from employment related injuries were investigated in 397 cases in the Chugoku and Shikoku districts of Japan between 1987 and 1991. Ninety-seven patients (24%) had stump problems which interfered the prosthetic fitting. Stump problems of the upper extremity were seen in about 9% (17 amputees), two thirds of which were skin troubles. Stump problems of the lower extremity were seen in about 37% (80 amputees). Certain complaints were associated with specific methods of amputation; abnormal keratosis in Syme's amputation, equinus deformity in Chopart's amputation, reduced muscle power in above the knee (A/K) amputation and joint dysfunction in below the knee (B/K) amputation. Adequate prosthetic fitting was achieved by the modification of the socket and alignment in almost all amputees with stump problems. In only two cases, Chopart's amputation required subsequent Syme's amputation due to equinus deformity with abnormal keratosis. In almost every case, stump problems are avoidable by means of surgeons' deliberate evaluation of the affected limb and adequate choice of the amputation level.

Spinal cord injuries in Okayama Prefecture: an epidemiological study '88-'89.

An epidemiological survey of spinal cord injury in Okayama Prefecture was carried out by reviewing the registration lists contained in the Law for the Welfare of the Physically Disabled. The authors computed the annual incidence of spinal cord injuries (SCI) in Okayama Prefecture (April 1988-March 1989) to be 49.0 (28.6 for traumatic cases) per one million inhabitants from a population of 1,920,000. In addition, distribution by age, aetiology, paralysis level and residential area were investigated.

Gait analysis of slope walking: a study on step length, stride width, time factors and deviation in the center of pressure.

Determination was made of step length, stride width, time factors and deviation in the center of pressure during up- and downslope walking in 17 healthy men between the ages of 19 and 34 using a force plate. Slope inclinations were set at 3, 6, 9 and 12 degrees. At 12 degrees, walking speed, the product of step length and cadence, decreased significantly (p less than 0.01) in both up- and downslope walking. The most conspicuous phenomenon in upslope walking was in cadence. The steeper the slope, the smaller was the cadence. The most conspicuous phenomenon in downslope walking was in step length. The steeper the slope, the shorter was the step length.

Electromyographic kinesiology of lower extremity muscles during slope walking.

To investigate the phasic activity of the lower extremity muscles during up- and downslope walking, five muscles of ten healthy men were examined by telemetered electromyography (EMG). The muscles were the tibialis anterior (TA), gastrocnemius (Gc), rectus femoris (RF), semitendinosus (St) and gluteus maximus (GM). The inclination of the slope was 3, 6, 9 and 12 degrees. EMG of the muscles and the time factors of a walking cycle were recorded by a 12-channel polygraph simultaneously. In upslope walking, the duration of TA, St and GM activity was longer and that of RF activity was shorter than in level walking. The phasic pattern of Gc in upslope walking was the same as in level walking. In downslope, the duration of Gc and RF activity was longer than on the level. St showed biphasic activities. The phasic pattern of TA and GM was nearly the same as in level walking. The phasic activity of the muscles altered with an inclination over 6 degrees in upslope, and over 3 degrees in downslope. The findings indicate that the muscles stabilize the knee and ankle joint much more in slope walking than in level walking, and in slope walking they also exert themselves to elevate or lower the body weight.