Medical rehabilitation of people with spinal cord injury during 40 years of academic physiatric practice.

There are many different paths that lead to an academic physiatric career and a lifelong interest in spinal cord injury (SCI) medicine. It is unfortunate that after decades of cellular-based research in multiple laboratories, there are still no interventions available that can reverse the neurologic loss that follows SCI. In contrast, medical rehabilitation research during the last 40 yrs has led to remarkable improvements in the lives of persons with SCI as evident in their increased life expectancy, shorter hospitalizations, fewer rehospitalizations, and more effective treatments for male sexual dysfunction and fertility, as well as spasticity, heterotrophic ossification, and neuropathic pain. Application of modern technology has improved the mobility of persons with SCI with better designed wheelchairs, decreased their dependency on others, facilitated their access to information, made communication and community integration easier, and so on. Although deaths related to urinary tract complications are now rare, better methods of managing the neurogenic bladder are still needed. Furthermore, better management methods are also needed for the neurogenic bowel, SCI pain, and osteoporosis of the paralyzed limbs. Even with proper prophylaxis, deep vein thrombosis and pulmonary embolism are still common, and clinicians have paid too little attention to reducing the risk for persons with SCI of developing obesity, diabetes mellitus, and cardiovascular disease. These challenges need to be met by medical rehabilitation research, by advocating for insurance policies that support the healthcare needs of persons with SCI, and by developing comprehensive disability policies, all with the support and leadership of academic physiatrists.

Traumatic brain injury research since the 1998 NIH Consensus Conference: accomplishments and unmet goals.

In 1998, an NIH sponsored Consensus Conference on Traumatic Brain Injury (TBI) Rehabilitation identified 30 different areas of needed research. A comprehensive review of recently generated research knowledge in the field of TBI has shown that a large number of Class III and IV evidence studies have been published, but relatively few of the more scientifically rigorous Class I or II studies. A rapid growth of publications on TBI rehabilitation has generated new knowledge in the epidemiology of TBI, the management of TBI and its secondary medical complications, rehabilitation of cognitive impairment, impact of TBI on community integration and quality of life, incidence of psychiatric dysfunction, and how caregivers and family members are affected. However, there is need to replicate many of these studies using more scientifically rigorous methodologies, while other areas of important TBI research remain largely unexplored.

Reliability of the Bryce/Ragnarsson spinal cord injury pain taxonomy.

BACKGROUND/OBJECTIVE: Pain is a common secondary complication of spinal cord injury (SCI). However, the literature offers varying estimates of the numbers of persons with SCI who develop pain. The variability in these numbers is caused in part by differences in the classification of pain; there is currently no commonly accepted classification system for pain affecting persons after SCI. This study investigated the interrater reliability of the Bryce/Ragnarsson SCI pain taxonomy (BR-SCI-PT). The hypothesis was that, when used by physicians with minimal training in the BR-SCI-PT, it would have high interrater reliability for the categorization of reported pains. METHODS: One hundred thirty-five vignettes, each of which described a person with SCI with one or more different etiologic subtypes of pain, were evaluated by 5 groups of up to 10 physicians with SCI subspecialization (39 respondents total). Physician classifications were compared with those made by the investigators. RESULTS: Of 179 pain descriptions, 83% were categorized correctly to one of the 15 BR-SCI-PT pain types; 93% were categorized correctly with respect to level (above/at/below neurological level of injury), whereas 90% were categorized correctly as being either nociceptive or neuropathic. Subjects expressed a generally high confidence in the correctness of their classifications. CONCLUSIONS: Substantial interrater agreement was achieved in determining subtypes of pain within the BR-SCI-PT. The agreement was improved for categorizing within less restrictive categories (ie, with respect to the neurological level of injury and whether the pain was nociceptive or neuropathic).

The effect of electrically induced lower extremity ergometry on an ischial pressure ulcer: a case study.

BACKGROUND: Individuals with spinal cord injury (SCI) are at an increased risk of pressure ulcer development. Electrical stimulation of adjacent muscles may be underutilized as a tool for pressure ulcer healing in individuals with SCI. METHOD: Single case study. SUMMARY: A 27-year-old man with C4 tetraplegia developed a left ischial pressure ulcer that for 23 months responded slowly and inconsistently to conventional treatment. Electrically induced lower extremity ergometry (EILEE) was introduced to facilitate wound healing. The pressure ulcer healed completely in 6.5 months. CONCLUSION: This case illustrates the potential important contribution of EILEE in the healing of an ischial pressure ulcer in individuals with SCI.

Results of the NIH consensus conference on "rehabilitation of persons with traumatic brain injury".

In 1998, the National Institute for Health (NIH) organized a consensus conference about the rehabilitation of persons with traumatic brain injury (TBI). The conference results are based on an extensive bibliography from the scientific literature and presentations at the conference. The focus of this conference was the evaluation of rehabilitative measures for the cognitive and behavioral consequences of TBI, and the extent to which specific interventions are supported by existing evidence. Specifically, the conference considered the following aspects and their implications for rehabilitation: the epidemiology of TBI in the United States, the consequences in terms of pathophysiology, impairments, functional limitations, disabilities, societal limitations, and economic impact, the mechanisms underlying functional recovery following TBI, the common therapeutic interventions for the cognitive and behavioral sequelae of TBI, and the models for comprehensive coordinated multi-disciplinary rehabilitation. Based on the answers to these questions, the conference tried to give recommendations regarding rehabilitation practices for people with TBI, and identified areas where further research is needed.

Rehabilitation of the patient with chronic critical illness.

Patients with CCI have continuing profound medical needs, poor prognosis for significant functional recovery, and a high mortality rate. Nonetheless, some survive for months or years, but unfortunately, often with functional skills and quality of life lower than need be. Careful evaluation of each patient's medical condition and potential for functional improvement, early involvement of the rehabilitation team, prevention and treatment of medical conditions associated with prolonged bed rest and immobility, reduction of the emotional and financial burden of family members, and establishment of reasonable goals can increase self-sufficiency and quality of life regardless of discharge destination.