Consideraciones acerca del contenido científico del 49 Congreso de la SERMEF en Toledo / Observations on the scientific content of the 49th Congress of SERMEF in Toledo

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[A robotic system for gait re-education in patients with an incomplete spinal cord injury]. / Sistema robotizado para la reeducación de la marcha en pacientes con lesión medular incompleta.

INTRODUCTION: A spinal cord injury involves the loss or alteration of motor patterns in walking, the recovery of which depends partly on the rearrangement of the preserved neural circuits. AIM. To evaluate the changes that take place in the gait of patients with incomplete spinal cord injuries who were treated with a robotic walking system in association with conventional therapy. PATIENTS AND METHODS: The study conducted was an open-label, prospective, descriptive trial with statistical inference in patients with C2-L3 spinal cord injuries that were classified as degrees C and D according to the American Spinal Injury Association (ASIA) scale. The variables that were analysed on the first and the last day of the study were: number of walkers, 10-m gait test, the Walking Index for Spinal Cord Injury scale revision, technical aids, muscle balance in the lower limbs, locomotor subscale of the measure of functional independence, modified Ashworth scale for spasticity and the visual analogue scale for pain. At the end, data were recorded from the impression of change scale. The analysis was conducted by means of Student's t, chi squared and Pearson's correlation; p < or = 0.05. RESULTS: Forty-five patients, with a mean age of 44 +/- 14.3 years, finished the study; 76% were males, injury was caused by trauma in 58% of cases, and the time of progression was 139 +/- 70 days. Statistically significant increases were observed in the number of subjects capable of walking, walking speed, less need for technical aids, strength in the lower limbs and independence in activities of daily living. CONCLUSIONS: Treatment using the robotic system in association with conventional therapy improves walking capacity in patients with incomplete spinal cord injuries.

Sistema robotizado para la reeducación de la marcha en pacientes con lesión medular incompleta / A Robotic system for gait re-education in patients with an incomplete spinal cord injury

Resumen. Introducción. La lesión medular supone una pérdida o alteración de los patrones motores de marcha, cuya recuperación depende, en parte, de la reorganización de los circuitos neurales preservados. Objetivo. Evaluar los cambios en la marcha de los lesionados medulares incompletos que realizaron tratamiento con un sistema robotizado de marcha asociado a la terapia convencional. Pacientes y métodos. Estudio abierto, prospectivo, descriptivo, con inferencia estadística en lesionados medulares C2-L3 clasificados según la escala de la American Spinal Injury Association (ASIA) en grados C y D. Las variables analizadas el primer y el último día del estudio fueron: número de ambulantes, test de marcha de los 10 m, índice de marcha para la lesión medular Walking Index for Spinal Cord Injury, scale revision, ayudas técnicas, balance muscular de las extremidades inferiores, subescala locomotora de la medida de independencia funcional, escala de Ashworth modificada para la espasticidad y escala visual analógica para el dolor. Al final se registraron los datos de la escala de impresión de cambio. El análisis se realizó mediante la t de Student, chi al cuadrado y la correlación de Pearson; p ≤ 0,05. Resultados. 45 pacientes finalizaron el estudio con una edad media de 44 ± 14,3 años; el 76% fueron hombres, la etiología de la lesión fue traumática en el 58%, y el tiempo de evolución fue de 139 ± 70 días. Aumentaron de forma estadísticamente significativa el número de sujetos con capacidad de marcha, la velocidad en la marcha, la menor necesidad de ayudas técnicas, la fuerza de extremidades inferiores y la independencia en las actividades de la vida diaria. Conclusión. La terapia con el sistema robotizado asociado a la terapia convencional mejora la capacidad de marcha de los lesionados medulares incompletos. (AU)

Summary. Introduction. A spinal cord injury involves the loss or alteration of motor patterns in walking, the recovery of which depends partly on the rearrangement of the preserved neural circuits. Aim. To evaluate the changes that take place in the gait of patients with incomplete spinal cord injuries who were treated with a robotic walking system in association with conventional therapy. Patients and methods. The study conducted was an open-label, prospective, descriptive trial with statistical inference in patients with C2-L3 spinal cord injuries that were classified as degrees C and D according to the American Spinal Injury Association (ASIA) scale. The variables that were analysed on the first and the last day of the study were: number of walkers, 10-m gait test, the Walking Index for Spinal Cord Injury scale revision, technical aids, muscle balance in the lower limbs, locomotor subscale of the measure of functional independence, modified Ashworth scale for spasticity and the visual analogue scale for pain. At the end, data were recorded from the impression of change scale. The analysis was conducted by means of Student’s t, chi squared and Pearson’s correlation; p ≤ 0.05. Results. Forty-five patients, with a mean age of 44 ± 14.3 years, finished the study; 76% were males, injury was caused by trauma in 58% of cases, and the time of progression was 139 ± 70 days. Statistically significant increases were observed in the number of subjects capable of walking, walking speed, less need for technical aids, strength in the lower limbs and independence in activities of daily living. Conclusions. Treatment using the robotic system in association with conventional therapy improves walking capacity in patients with incomplete spinal cord injuries (AU)

Prevalencia de lesiones asociadas a lesionados medulares simultáneas al evento traumático / Prevalence of associated lesions in patients with acute traumatic spinal cord injury

Introducción. Los traumatismos suelen ocasionar otras lesiones más allá de la lesión medular (LM) que pueden pasar desapercibidas en los primeros momentos, acarreando riesgo vital, retrasos en la recuperación funcional o aumento de la discapacidad. Los objetivos de este trabajo son determinar la prevalencia de las lesiones asociadas entre los pacientes que sufrieron una lesión traumática aguda, conocer su tipo y la relación con las variables epidemiológicas y con las complicaciones concurrentes durante el ingreso. Material y método. Se realizó un estudio transversal en los pacientes ingresados en el Hospital Nacional de Parapléjicos, que presentasen LM traumática aguda, edad igual o superior a 18 años, haber sufrido al menos una lesión asociada simultánea a la LM y que no fueran dados de alta en la semana del estudio. De los 196 pacientes ingresados, se seleccionaron por lesión traumática 90, de los que 62 tenían lesiones asociadas agudas. Se evaluaron edad, género, etiología, prevalencia de lesiones óseas y viscerales, traumatismo craneoencefálico, hemotórax, neumotórax, lesiones de plexo y factores psicosociales. Resultados. La prevalencia de lesiones asociadas fue 68,9 %. La edad media de estos pacientes fue significativamente menor. El género no se asoció a mayor vulnerabilidad para lesiones asociadas. Etiologicamente los tráficos doblaron a las caídas.Aquellos que sufrieron fractura o LM dorsal presentaron un número mayor de lesiones asociadas con significación estadística. Conclusión. Las lesiones agudas asociadas deben ser siempre tenidas en cuenta en la valoración inicial por su prevalencia alta, especialmente si hay fractura o LM dorsal (AU)

Introduction. Traumatic patients afflicted with spinal cord injury (SCI) could have lesions in other anatomical regions.These lesions frequently receive delayed diagnosis and may increase the mortality risk, modify the course of recovery and produce worse functional outcomes.The aims of the present work is to determine the prevalence, etiology, epidemiology and complications of associated lesions in patients with acute traumatic SCI. Material and methods. We perfomed a cross-sectional study of associated lesions in acute traumatic SCI patients admitted to the National Paraplegic Hospital of Toledo.The selection criteria were to suffer an acute traumatic SCI, to be older than eighteen years, to have at least one associated lesion concomitant with the SCI and not to be discharged during the time of acquisition data (one week). 90 out of 196 admitted patients had an acute traumatic SCI, 62 of them showing associated lesions.We obtained data regarding age, gender, etiology, prevalence of simultaneous visceral or bone lesions, traumatic brain injury, pneumothorax, hemothorax, braquial plexus injury and psychosocial profile. Results. The prevalence of associated lesions in acute traumatic SCI patients was 68.9 % with a mean age lower than the reported in other series and without gender differences. Traffic accidents doubled in frequency to falls as cause of the SCI. Statistical test showed that the frequency of associated lesions was significantly in patients with thoracic SCI or thoracic vertebrae fractures, compared to patients with injuries at other spinal or vertebrae levels. Conclusions. Taking into consideration the high prevalence of associated lesions in patients with acute traumatic SCI, it is of major importance to suspect them in the initial clinical assessment, particularly in patients with thoracic SCI or vertebral trauma (AU)

Mielitis transversa asociada a lupus eritematoso sistémico / Transverse myelitis associated with systemic lupus erythematosus

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[Gait training in incomplete spinal cord injuries with body weight support]. / Entrenamiento de la marcha en lesiones medulares incompletas con soporte del peso corporal.

INTRODUCTION: A spinal cord injury implies the loss of or alteration to the gait pattern. Stimulating the pattern generating centres in the sublesional spinal cord determines the appearance of flexion and extension automatisms that are useful for gait training in patients with spinal cord injuries. These centres can be stimulated using a treadmill and supporting the body weight by means of a harness. AIMS: To be able to trigger spinal cord automatisms and to stimulate pattern generating centres. To determine the value of an electromechanical system for mobilising the lower limbs as a complement to the treadmill and body weight support. To study changes in muscle tone. PATIENTS AND METHODS: A short gait training programming was carried out with ten individuals with incomplete spinal cord injuries who satisfied eligibility-exclusion criteria using a treadmill in association with a body weight support system and an electromechanical system for mobilising the lower limbs. RESULTS AND CONCLUSIONS: Spinal cord flexion and extension automatisms were stimulated and an important improvement in spasticity was achieved. Longer programmes are needed in order to evidence changes in the gait pattern and in muscular balance.

Entrenamiento de la marcha en lesiones medulares incompletas con soporte del peso corporal / Gait training in incomplete spinal cord injuries with body weight support

Introducción. La lesión medular supone una pérdida o alteración del patrón de la marcha. La estimulación de los centros generadores de patrones de la médula sublesional determina la aparición de automatismos de flexión y extensión útiles para el entrenamiento de la marcha en lesionados medulares. Estos centros pueden estimularse empleando un tapiz rodante asociado a la descarga del peso corporal con un arnés. Objetivos. Conseguir desencadenar los automatismos medulares y estimular los centros generadores de patrones. Valorar la utilidad de un sistema electromecánico de mo vilización de los miembros inferiores como complemento al tapiz rodante y a la descarga del peso corporal. Estudiar cambios en el tono muscular. Pacientes y métodos. Se ha realizado un programa de entrenamiento de la marcha de corta duración a diez individuos con lesión medular incompleta que cumplían los criterios de inclusión-exclusión, utilizando un tapiz rodante asociado a un sistema de soporte del peso corporal y a un dispositivo electromecánico de movilización de los miembros inferiores. Resultados y conclusión. Se ha conseguido la estimulación de automatismos de flexión y extensión medulares y una importante mejoría de la espasticidad. Para objetivar cambios en el patrón de marcha y en el balance muscular es necesario llevar a cabo programas de mayor duración (AU)

Introduction. A spinal cord injury implies the loss of or alteration to the gait pattern. Stimulating the pattern generating centres in the sublesional spinal cord determines the appearance of flexion and extension automatisms that are useful for gait training in patients with spinal cord injuries. These centres can be stimulated using a treadmill and supporting the body weight by means of a harness. Aims. To be able to trigger spinal cord automatisms and to stimulate pattern generating centres. To determine the value of an electromechanical system for mobilising the lower limbs as a complement to the treadmill and body weight support. To study changes in muscle tone. Patients and methods. A short gait training programming was carried out with ten individuals with incomplete spinal cord injuries who satisfied eligibility-exclusion criteria using a treadmill in association with a body weight support system and an electromechanical system for mobilising the lower limbs. Results and conclusions. Spinal cord flexion and extension automatisms were stimulated and an important improvement in spasticity was achieved. Longer programmes are needed in order to evidence changes in the gait pattern and in muscular balance (AU)

Management of urinary tract infection in patients with spinal cord injuries.

Urinary tract infection (UTI) is responsible for major morbidity and mortality in spinal cord injury (SCI) patients. Several factors appear to be responsible for an increased risk of infection in the neurogenic bladder. Incomplete voiding, elevated intravesical pressure and catheter use contribute to an increased risk of symptomatic urinary tract infection. Frequent exposure to antibiotics increases the risk of infection by resistant organisms. UTIs interfere with rehabilitation, and may lead to secondary urologic complications. The classic symptoms of UTI are unreliable indicators in SCI patients with neurogenic bladder. Lack of pyuria reasonably predicts the absence of UTI in SCI patients. Asymptomatic bacteriuria need not be treated with antibiotics. Symptomatic UTI warrants therapy in all patients.

Estudio de prevalencia de la espasticidad en el paciente con lesión medular / Study on the prevalence of spasticity in the patient with medullary lesion

Introducción: Dentro de la pluripatología que conlleva el Síndrome de Lesión Medular, la aparición de espasticidad es una complicación que, en muchas ocasiones, dificulta el tratamiento rehabilitador. El abordaje de la misma es pluridisciplinar y precisa la concurrencia de varios especialistas. Con ánimo de conocer la epidemiología de la espasticidad y sus tratamientos se planteó un estudio de prevalencia. Material y Métodos: Se desarrolló desde el 20-27 marzo de 2000. Se incluyeron todos los pacientes con lesión medular ingresados en plantas. Para la selección de la muestra se adiestró a cinco médicos internos residentes de rehabilitación en la utilización de la escala de Ashworth que se utilizó como instrumentalización de la medición. Variable de estudio: espasticidad. Variables independientes: demográficas, de tipificación de la lesión y tratamientos. Análisis estadístico: Prevalencia de la espasticidad (número de pacientes con espasticidad susceptible de tratamiento/ ingresos por ciento). Prevalencia de los tratamientos (número de pacientes con el tratamiento estudiado / número de pacientes tratados por ciento) (p<0,05).Resultados: El estudio se realizó en 71 pacientes espásticos que precisaban algún tipo de tratamiento. Prevalencia de espasticidad susceptible de tratamiento 39 por ciento. Se obtuvieron diferencias significativas entre la intensidad de la espasticidad y la asociación de espinas irritativas indicando que provocan un agravamiento de la misma. Por orden decreciente, la prevalencia de los tratamientos es: baclofén 89 por ciento, diacepam 19 por ciento, electroestimulación funcional 13 por ciento, hidroterapia 10 por ciento, clonacepam 11 por ciento, clonidina 3 por ciento, tizanidina y toxina botulínica 1 por ciento. Atendiendo a la intensidad de la espasticidad, los grados 1 y 11 de Ashworth son tratados con baclofén, benzodiacepinas y técnicas físicas todas de manejo preferente por el médico rehabilitador. En el grado 111 y sobre todo en el IV colaboran en el tratamiento el resto de los especialistas (AU)

Epidemiology and risk factors for urinary tract infection in patients with spinal cord injury.

PURPOSE: To our knowledge risk factors for urinary tract infection associated with various drainage methods in patients with spinal cord injury have never been evaluated overall in the acute period. We identified the incidence and risk factors associated with urinary tract infection in spinal cord injured patients. MATERIALS AND METHODS: We prospectively followed 128 patients at our spinal cord injury reference hospital for 38 months and obtained certain data, including demographic characteristics, associated factors, methods of urinary drainage, bladder type, urological complications and predisposing factors of each infection episode. Logistic regression modeling was done to analyze variables and identify risk factors that predicted urinary tract infection. RESULTS: Of 128 patients 100 (78%) were male with a mean age plus or minus standard deviation of 32 +/- 14.52 years. All patients had a nonfatal condition by McCabe and Jackson guidelines, and 47% presented with associated factors. The incidence of urinary tract infection was expressed as number episodes per 100 patients daily or person-days. The overall incidence of urinary tract infection was 0.68, while for male indwelling, clean intermittent, condom and female suprapubic catheterization, and normal voiding the rate was 2.72, 0.41, 0.36, 0. 34 and 0.06, respectively. The risk factors associated with urinary tract infection were invasive procedures without antibiotic prophylaxis, cervical injury and chronic catheterization (odds ratio 2.62, 3 and 4, respectively). Risk factors associated with repeat infection were a functional independence measure score of less than 74 and vesicoureteral reflux (odds ratio 10 and 23, respectively). CONCLUSIONS: Spinal cord injured patients with complete dependence and vesicoureteral reflux are at highest risk for urinary tract infection.