Cough in spinal cord injured patients: the relationship between motor level and peak expiratory flow.

Pulmonary complications remain a major cause of morbidity and mortality in patients with higher level spinal cord injury. Neurologically intact individuals can cough in order to clear their air passage of lung secretions and foreign material. Patients with higher level cord injuries, with paralysis of the trunk and abdominal muscles, may not have the ability to generate an effective cough. If coughing is dependent on a caregiver, these patients will cough with reduced frequency. Because the innervation to the muscles involved in cough consists of nerves that arise from varying levels of the spinal cord, some patients with spinal cord injury have partial control over these muscles and thus can cough, though with reduced efficacy. Two hundred patients with varying levels of spinal cord injury were studied to determine if motor level and cough ability are correlated. Cough efficacy was measured using a peak expiratory flowmeter while patients were seated at 90 degrees. We concluded that there is indeed a direct relationship between motor level and peak expiratory flow produced during coughing.

Spinal cord injury rehabilitation. 1. Assessment and management during acute care.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on spinal cord injury rehabilitation for the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This section contains information about initial care after injury, injury classification, injury description, prevention of complications, and prognosis. New advances in this section include a description of research to enhance and restore neurologic function.

Spinal cord injury rehabilitation. 2. Medical complications.

This self-directed learning module highlights new advances in understanding medical complications of spinal cord injury through the lifespan. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers reasons for transferring patients to specialized spinal cord injury centers once they have been stabilized, and the management of common medical problems, including fever, autonomic dysreflexia, urinary tract infection, acute and chronic abdominal complications, deep vein thrombosis, pulmonary complications, and heterotopic ossification. Formulation of an educational program for prevention of late complications is also discussed, including late renal complications, syringomyelia, myelomalacia, burns, pathologic fractures, pressure ulcers, and cardiovascular disease. New advances covered in this section include new information on old problems, and a discussion of exercise tolerance in persons with tetraplegia, the pathophysiology of late neurologic deterioration after spinal cord injury, and a view of the care of these patients across the lifespan.

Spinal cord injury rehabilitation. 5. Through the lifespan.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This section explores the medical, psychologic, and social challenges facing an individual with an acquired spinal cord injury. Special emphasis is placed on the dynamic nature of these issues as one progresses through the lifespan.

Electrical stimulation and biofeedback effect on recovery of tenodesis grasp: a controlled study.

OBJECTIVE: Evaluate the effectiveness of electrical stimulation and biofeedback on the recovery of tenodesis grasp in tetraplegic individuals during the initial phase of acute rehabilitation. DESIGN: A 2 x 2 block design was used with subjects randomized to treatment groups. Forty-five subjects completed the study. SETTING: Inpatient occupational therapy department. SUBJECTS: Inpatients with tetraplegia, first admission for rehabilitation after an acute spinal cord injury. INTERVENTIONS: The four treatment groups were: conventional treatment, electrical stimulation, biofeedback, and combined electrical stimulation and biofeedback. The treatment period was between 5 and 6 weeks. MAIN OUTCOME MEASURES: Manual muscle testing and scoring of activities of daily living performance by a blinded evaluator. RESULTS: All four treatment groups showed improvements. No treatment group was superior to the others. CONCLUSIONS: Biofeedback and electrical stimulation alone or in combination offer no advantages over conventional rehabilitation treatment of wrist extensors in tetraplegic patients after spinal cord injury.

Benefits of rehabilitation for traumatic spinal cord injury: a case report.

Many studies report significant functional improvements in tetraplegic patients during rehabilitation. The majority of these studies, obviously, are limited by the lack of control groups. Thus, it has always been difficult to differentiate between effects of a rehabilitation program and natural muscle recovery or independent learning. In this case report, a 25 year old man with right C7 motor, left C8 motor, C6 sensory complete tetraplegia was admitted to a tertiary care rehabilitation facility 16 months after discharge from an acute care hospital. Following a comprehensive inpatient rehabilitation program, this patient's functional status improved from near complete dependence to virtual independence in most areas of self care and mobility as scored by the Functional Independence Measure (FIM), without any change in motor or sensory function. This case, in which the patient served as his own control, illustrates the effectiveness and importance of aggressive inpatient rehabilitation following spinal cord injury.

Management of impotence due to spinal cord injury using low dose papaverine.

Erectile dysfunction is a common complication of spinal cord injury. Of the 68 spinal cord injured men in whom treatment with papaverine was initiated a therapeutic dosage was determined in 50 (74%). Papaverine was injected into the base of one corpora cavernosum. The dose started at 3 mg and was increased at weekly or longer intervals until an effective dose was determined. There were 15 (30%) men with tetraplegia and 35 (70%) men with paraplegia. The dosage of papaverine did not relate to the level or extent of injury. Doses of 12 mg or less were used in 56% of patients. Low dose papaverine is a safe and effective means of restoring erections in spinal cord injured men.

Pressure ulcers: a review.

This article reviews the etiology, pathology, description, risk factors, prevention, medical and surgical management, and complications of pressure ulcers. Pressure ulcers, which develop primarily from pressure and shear, are also known as decubitus ulcers, bed sores, and pressure sores. They continue to occur in hospitals, nursing homes, and among disabled persons in the community. Estimates of the prevalence of pressure ulcers in hospitalized patients range from 3% to 14% and up to 25% in nursing homes. Persons with spinal cord injury and the elderly are two groups at high risk. The most common sites of development are the sacrum, ischium, trochanters, and about the ankles and heels. Areas of ongoing research such as electrical stimulation and growth factors are discussed.

Early onset posttraumatic cystic myelopathy complicating spinal cord injury.

Three cases of posttraumatic cystic myelopathy occurring early in the postinjury period are reported. A patient with C5 tetraplegia developed bilateral upper extremity paresthesias and right upper extremity weakness 2 and a half months postinjury necessitating immediate syringo-subdural shunting. A patient with C6 tetraplegia complained of left upper extremity paresthesias 2 months postinjury. A syringoperitoneal shunt was placed 19 months postinjury due to new onset intermittent weakness of the right upper extremity. A patient with C4 tetraplegia developed right upper extremity paresthesias, sensory loss, and weakness 56 days postinjury; it was treated conservatively. Two years postinjury he required surgery because of progression of symptoms. A review of the literature reveals that posttraumatic cystic myelopathy has been found to be an incidental pathologic finding at autopsy within 2 months postinjury. However, sensory and motor loss have not been clinically described as an early complication of spinal cord injury. We conclude that posttraumatic cystic myelopathy should be considered in the differential diagnosis of motor or sensory loss occurring early in the postinjury period.

Cough in spinal cord injured patients: comparison of three methods to produce cough.

Pulmonary complications are the major causes of morbidity and mortality for persons with cervical spinal cord injury. Diminished ability to cough constitutes a major contribution to the high incidence of pulmonary morbidity in this population. This article reports preliminary results for a new technique for providing assisted cough in this population. In this study, efficacy of cough (as measured by peak expiratory flow rate) was measured under three conditions: volitionally with no assistance, with manual assist of a therapist, and with electrical stimulation of abdominal muscles. Coughs produced by electrical stimulation were approximately as effective as manually assisted coughs. The results suggest this technique is worthy of more detailed study and may be a potentially effective new modality for assisting spinal cord injured persons to clear their airways.

Clean and sterile intermittent catheterization methods in hospitalized patients with spinal cord injury.

The purpose of this study was to compare the incidence of urinary infection using clean intermittent catheterization with the incidence of infection using sterile intermittent catheterization in patients hospitalized with spinal cord injury who were not receiving prophylactic antibiotics. Forty-six patients were assigned randomly to a clean (n = 23) or sterile (n = 23) study group. Catheterizations were done at least every six hours. Infection was defined as bacteriuria greater than or equal to 100,000 organisms/mL or greater than or equal to 10,000 organisms per mL with fever of 100 degrees F or greater. Results of urinary dipslides were recorded daily. Twenty-eight subjects (60.9%) converted to greater than or equal to 100,000 organisms per mL. Method of catheterization was neither associated significantly with development of greater than or equal to 100,000 organisms per mL. (X2[1,46] = .36, p = .55) nor with symptomatic infections (X2[1,46] = .15, p = .70). Data support the use of clean intermittent catheterization under the conditions used in this study, including the use of a sterile catheter each day and careful monitoring of infection and technique. Before using this method with other diagnostic groups or in different clinical settings, further investigation is needed.

Galactorrhea: a complication of spinal cord injury.

Galactorrhea, a secretion of milk or milk-like products from the breast in the absence of parturition, has been reported to occur in women with spinal cord injuries in association with amenorrhea and hyperprolactinemia. Four cases of galactorrhea in association with spinal cord injury are reported. Galactorrhea developed in four spinal cord injured women who had thoracic paraplegia. The onset of galactorrhea was from one month to five months after injury. Although the onset of galactorrhea may have been related to prescribed medications in all four cases, insufficient data exist to draw conclusions. The three women whose galactorrhea persisted declined treatment and galactorrhea continuing for more than two years in one instance. We conclude that galactorrhea with or without amenorrhea may develop after a spinal cord injury and that spinal cord injured women may have an enhanced sensitivity to medication-induced galactorrhea.

The older adult with a spinal cord injury.

Sixty-two consecutive acute spinal cord injury (SCI) patients who were aged 55 years or older were studied and compared to 296 SCI patients of age less than 55 years. Compared to younger patients, the older group had significantly more females (29%), preexisting medical conditions (87%), associated injuries (55%), incomplete quadriplegic patients (63%), and persons whose injuries resulted from falls (53%). There were no differences between groups in frequency of ventilator use, occurrence of medical complications, or acute length of stay, but older patients tended to have fewer surgical spinal fusions (40%), shorter rehabilitation stays (66.5 days), more indwelling urethral cathteters (31%), and more nursing home discharges (19%). With other factors being controlled, advancing age was predictive only of nursing home discharge, and not of acute or rehabilitation lengths of stay. Among older SCI patients, those with complete injuries were nearly 3 times as likely to have been discharged to nursing homes in our series compared to older patients with incomplete lesions. Although many aspects of the presentation, course, and care of older SCI individuals are similar to those of younger patients, there are several unique features of older adults with a SCI.

Neuromuscular stimulation in spinal cord injury. II: Prevention of secondary complications.

The spinal cord injured patient has been the focus of clinical and research efforts to restore functional movement and to obtain therapeutic benefits by electric stimulation of upper motor neuron paralyzed muscles. This review article treats developments in this field from 1983 to 1990. Efforts have been directed to restoring ventilatory and bladder function, and to preventing secondary complications. Electric stimulation for improving ventilatory function has had reasonable success, and systems are commercially available. Electric stimulation for improving bladder function remains in the research stage in the US, although it has had some clinical success reported in Europe. Electric stimulation techniques to prevent or treat secondary complications have been applied to pressure ulcers, deep-venous thrombosis, contractures, spasticity, deconditioning due to lack of exercise, and muscle atrophy. Therapeutic electric stimulation techniques are largely research techniques. Much additional work remains to be done to solve the difficult problems associated with applying this technology in the treatment of patients with spinal cord injury.

Neuromuscular stimulation in spinal cord injury: I: Restoration of functional movement of the extremities.

The spinal cord injured patient has been the focus of clinical and research efforts to restore functional movement and obtain therapeutic benefits by electric stimulation of upper-motor-neuron paralyzed muscles. Our review articles treat developments in this field from 1983 to 1990. Efforts have been directed to restoring hand function, standing, and walking (covered in part I), as well as prevention of secondary complications through ventilatory function, bladder function, and achieving therapeutic effects of electric stimulation (covered in Part II). The technology for hand function, standing, and walking is used primarily in the research laboratory, as clinical applications are minimal. Much work remains to be done to solve the difficult problems associated with applying this promising technology to spinal cord injury.

Traumatic cervical Brown-Sequard and Brown-Sequard-plus syndromes: the spectrum of presentations and outcomes.

Brown-Sequard syndrome (BSS) and Brown-Sequard-plus syndrome (BSPS) are characterised by asymmetrical paresis with hypalgesia more marked on the less paretic side. This study examined the clinical features of 38 patients (30 males and 8 females; mean age = 32 years) with traumatic cervical BSS or BSPS who underwent comprehensive inpatient rehabilitation. Twenty two injuries were caused by road traffic accidents, 8 by penetrating injuries, 5 by diving injuries, and 3 by other causes. After an average of 35 days in acute care and 79 days in rehabilitation, 37 patients had increased muscle strength, all 38 patients improved functional abilities, 29 patients walked independently, 34 had spontaneous bladder emptying, 36 were discharged home, and 14 were employed. Statistically significant increases (p less than 0.001) were made in modified Barthel index functional scores between admission and discharge. Patients with BSPS had a better prognosis than did those with 'pure' BSS. Patients with predominant upper limb weakness had more favourable outcomes than did those with predominant lower limb weakness. Few other potentially predictive demographic, injury, or neurological factors were associated with functional outcome. Patients with BSS or BSPS generally have a good prognosis for neurological and functional improvement.

Substance use and receipt of treatment by persons with long-term spinal cord injuries.

The purpose of this study was to assess the rate of self-reported substance use, consequent problems, perceived need for treatment, and receipt of treatment by persons with long-term spinal cord injury (SCI). Information was obtained from 86 persons with traumatic SCI who were between 13 and 58 years of age at injury, cognitively intact, injured more than two years earlier, English speaking, and recruited from two SCI organizations. The mean age of the sample was 39.5 years at recruitment: 69% were men. Participants reported substance use information across four periods covering six months before injury to an average of 13 years after injury. All participants reported use of substances with abuse potential at some time in their lives; the time of greatest use was injury to six months before first interview. The duration of this period ranged from 18 months to 43 years. Problems resulting from substance use were reported by 70%; more than half (52%) the sample reported problems during this postinjury period. Sixteen percent of the sample believed they needed treatment at some time; the time of greatest perceived need was in the period after injury. Treatment for substance abuse was received by 7%. Problems attributable to abuse of both prescription and nonprescription medication were reported, suggesting the importance of close monitoring of substance-use patterns in persons with SCI who are prescribed sedating or narcotic medications. Timely assessment of problems related to substance use and provision of treatment services to persons with traumatic injury are indicated to prevent a potential dual disability.

Superior mesenteric artery syndrome in acute traumatic quadriplegia: case reports and literature review.

Superior mesenteric artery syndrome is a condition in which the third portion of the duodenum is intermittently compressed by the overlying superior mesenteric artery, resulting in gastrointestinal obstruction. Predisposing factors include rapid weight loss, prolonged supine positioning, and using a spinal orthosis, all of which are common among acute traumatic quadriplegic patients. This paper presents three patients, aged 24, 16, and 20 years, with traumatic quadriplegia treated with supine positioning and cervical orthoses, who had postprandial nausea and emesis, bloating, and abdominal pain during rehabilitation. Upper gastrointestinal radiographic series demonstrated abrupt duodenal obstruction to barium flow in all three patients. Two of the patients had complete relief of symptoms with conservative management, and one required surgical duodenojejunostomy. Enhanced awareness of this condition may result in improved recognition of this disease as a cause of persistent, unexplained gastrointestinal disturbances in quadriplegic persons, thereby optimizing its treatment and reducing its potential morbidity.

Rehabilitation in spinal cord disorders. 4. Outcomes and issues of aging after spinal cord injury.

This self-directed learning module highlights current concepts in outcomes and issues of aging in spinal cord injury. It is part of the chapter on rehabilitation in spinal cord disorders for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This article includes discussion of the measurement of impairment, disability, and handicap, and outcomes with respect to employment, long-term adjustment, aging, life expectancy, and causes of death in spinal cord injury.

A new orthosis for central cord syndrome and brachial plexus injuries.

Proximal upper extremity weakness may develop secondary to central cord syndrome due to spinal cord injury or brachial plexus injury. Functional deficits, pain, decreased upper extremity arm swing during gait, and shoulder subluxation are common sequelae of these injuries. This report describes a new orthotic design that can be easily fabricated in two to four hours from readily available materials to compensate for these deficits. This orthosis allows for early participation in activities of daily living for patients with greater proximal than distal upper extremity weakness. The orthosis consists of a figure-eight shoulder harness and unilateral or bilateral forearm cuffs of orthoplast connected to the harness by flexible rubber tubing. The length of the tubing is adjustable through clamps connected to the forearm cuff to allow for variable arm positioning. Three patients, aged 14, 64, and 68, two with central cord syndrome and one with injury to the upper portion of the brachial plexus (Erb palsy) are described. Shoulder girdle musculature was less than 2, biceps less than 2, triceps less than 4, and hands less than 5 in all patients. Benefits from use of this orthosis may include improved arm swing and balance during ambulation, reduced shoulder pain and subluxation, and increased independence for tasks such as carrying lightweight objects, lower extremity dressing, bathing, light homemaking, and leisure activities such as gardening.