Reliability Validity and Responsiveness of the Spinal Cord Independence Measure 4th Version in a Multicultural Setup.

OBJECTIVE: To examine the fourth version of the Spinal Cord Independence Measure for reliability and validity. DESIGN: Partly blinded comparison with the criterion standard Spinal Cord Independence Measure III, and between examiners and examinations. SETTING: A multicultural cohort from 19 spinal cord injury units in 11 countries. PARTICIPANTS: A total of 648 patients with spinal cord injury. INTERVENTION: Assessment with Spinal Cord Independence Measure (SCIM IV) and Spinal Cord Independence Measure (SCIM III) on admission to inpatient rehabilitation and before discharge. MAIN OUTCOME MEASURES: SCIM IV interrater reliability, internal consistency, correlation with and difference from SCIM III, and responsiveness. RESULTS: Total agreement between examiners was above 80% on most SCIM IV tasks. All Kappa coefficients were above 0.70 and statistically significant (P<.001). Pearson's coefficients of the correlation between the examiners were above 0.90, and intraclass correlation coefficients were above 0.90. Cronbach's alpha was above 0.96 for the entire SCIM IV, above 0.66 for the subscales, and usually decreased when an item was eliminated. Reliability values were lower for the subscale of respiration and sphincter management, and on admission than at discharge. SCIM IV and SCIM III mean values were very close, and the coefficients of Pearson correlation between them were 0.91-0.96 (P<.001). The responsiveness of SCIM IV was not significantly different from that of SCIM III in most of the comparisons. CONCLUSIONS: The validity, reliability, and responsiveness of SCIM IV, which was adjusted to assess specific patient conditions or situations that SCIM III does not address, and which includes more accurate definitions of certain scoring criteria, are very good and quite similar to those of SCIM III. SCIM IV can be used for clinical and research trials, including international multi-center studies, and its group scores can be compared with those of SCIM III.

Effect of early treatment with zoledronic acid on prevention of bone loss in patients with acute spinal cord injury: a randomized controlled trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVES: To determine the effect of zoledronic acid on bone loss in people with acute spinal cord injury (SCI) SETTINGS: Sawai Man Singh Medical College, India. METHODS: Sixty patients with acute SCI were randomized to receive either standard treatment alone or standard treatment with zoledronic acid within 3 months after injury. Areal bone mineral density (aBMD) was measured at the hip using dual-energy X-ray absorptiometry (DXA) at baseline 3, 6, and 12 months. RESULTS: Significant differences in aBMD were found between the standard treatment alone and standard treatment plus zoledronic acid group at the femoral neck (-0.13; 95% CI, -0.18 to -0.09, p < 0.0001), and total hip (-0.16; 95% CI, -0.19 to -0.12, p < 0.0001), respectively, at 1 year and bone loss was reduced in the zoledronic acid treated group as compared to the standard treatment group. Significant differences in aBMD between the groups at 6 months post infusion was also observed at these sites. [Femoral neck -0.08; 95% CI, -0.12 to -0.03; p = 0.002 and total hip -0.12; 95% CI, -0.15 to -0.08; p < 0.0001] CONCLUSION: A zoledronic acid 5 mg infusion given within 3 month significantly reduces bone loss at the hip after 6 months post infusion in patients with acute SCI.

Impact of rehabilitation on functional outcome during the first year of moderate and severe traumatic brain injury.

OBJECTIVES: To describe the functional level after 1 year in moderate and severe traumatic brain injury (TBI). STUDY DESIGN: Prospective, cross-sectional study. SETTING AND PARTICIPANTS: Seventy individuals with TBI were admitted directly from acute care hospitals to a rehabilitation facility in Sawai Mansingh Medical College and Hospital, Jaipur (SMS). A follow-up of 58 patients was done up to 1 year later in the period from July 2011 to July 2012. RESULTS: Mean change in FIM scores from admission to discharge was 51.26 and from admission to 12 months it was 85.3 in the moderate injury group. Mean change in DRS from admission to discharge was -8.19 and from admission to 12 months it was -17.76 in the moderate injury group and -8.55 and -19 in the severe injury group, respectively. The correlation coefficient (r) between FIM and GOSE was 0.570 and between FIM and DRS was -0.8190, both of which were significant. CONCLUSIONS: All individuals improved significantly in the inpatient rehabilitation facility in the acute phase, with maximum gain in function seen from admission to discharge as assessed on FIM and DRS. The majority of the individuals continued to improve up to 6 months post-injury.

Occurrence of neuropathic pain and its characteristics in patients with traumatic spinal cord injury.

OBJECTIVES: Assess the occurrence of neuropathic pain in spinal cord injured persons (SCIP) and define the relationship between neuropathic pain with demographic and clinical characteristics in SCIPs. METHODS: This Analytical cross-sectional study was conducted on 104 SCIPs treated at our tertiary care hospital. Initial clinical evaluation was done according to the American Spinal Injury Association (ASIA) impairment scale. A clinical evaluation was done. All subjects were screened with the Leeds Assessment of Neuropathic Symptoms, Signs (LANSS) and DN4 questionnaire for neuropathic pain. The Visual Analogue Scale (VAS) was used to measure the severity of neuropathic pain. Later two groups were created based on the presence and absence of neuropathic pain. RESULTS: The mean age was 35.04 ± 13 years. Fifty-eight patients (55.8%) had a complete injury (ASIA grade A), 41 (39.4%) patients had an incomplete kind of injury (ASIA grade B-D) and 5(4.8%) patients had no deficits (ASIA grade E). Neuropathic pain was present in 77(74.0%) and absent in 27(26.0%) patients. Seventy-one patients (92.2%) experience neuropathic pain in the first year after traumatic SCI. Medicines were a common pain-relieving factor 64(83.1%). CONCLUSION: 74% of patients complained of neuropathic pain, indicating a significant complication. A comprehensive evaluation and treatment are necessary to address it while including variables like the completeness of injury, duration and timing.

A multi-center international study on the spinal cord independence measure, version IV: Rasch psychometric validation.

CONTEXT: The Spinal Cord Independence Measure is a comprehensive functional rating scale for individuals with spinal cord lesion (SCL). OBJECTIVE: To validate the scores of the three subscales of SCIM IV, the fourth version of SCIM, using advanced statistical methods. STUDY DESIGN: Multi-center cohort study. SETTING: Nineteen SCL units in 11 countries. METHODS: SCIM developers created SCIM IV following comments by experts, included more accurate definitions of scoring criteria in the SCIM IV form, and adjusted it to assess specific conditions or situations that the third version, SCIM III, does not address. Professional staff members assessed 648 SCL inpatients, using SCIM IV and SCIM III, at admission to rehabilitation, and at discharge. The authors examined the validity and reliability of SCIM IV subscale scores using Rasch analysis. RESULTS: The study included inpatients aged 16-87 years old. SCIM IV subscale scores fit the Rasch model. All item infit and most item outfit mean-square indices were below 1.4; statistically distinct strata of abilities were 2.6-6; most categories were properly ordered; item hierarchy was stable across most clinical subgroups and countries. In a few items, however, we found misfit or category threshold disordering. We found SCIM III and SCIM IV Rasch properties to be comparable. CONCLUSIONS: Rasch analysis suggests that the scores of each SCIM IV subscale are reliable and valid. This reinforces the justification for using SCIM IV in clinical practice and research.

Rehabilitation in Low-Resource Areas.

Earlier rehabilitation interventions, like community-based rehabilitation (CBR), could not make a remarkable impact because they ran parallel to the health system, but the newer model establishes health-related rehabilitation as an integral part of the health care system at all levels and thus should be implemented as such. Collaborating with other players relevant to the CBR matrix, such as social and vocational services, can be imparted for the empowerment of a disabled group at the village level through the CBR center. A multipurpose rehabilitation worker, through skill transfer or task shifting, can start rehabilitation at the primary health center.

Evaluation of extent and pattern of neurocognitive functions in mild and moderate traumatic brain injury patients by using Montreal Cognitive Assessment (MoCA) score as a screening tool: An observational study from India.

INTRODUCTION: Cognitive impairment is one of the most important culprit influencing the long-term neurological outcome commonlyobserved in TBI survivors. AIMS: To examine the performance of patients with Mild and Moderate traumatic brain injury (TBI) on the Montreal Cognitive Assessment (MoCA) using as a screening tool. RESULTS: Total 228 (127 Mild TBI & 101 Moderate TBI) patients were recruited in this study. Results showed that patients with moderate TBI had lower score on the MoCA as compared to patients with mild TBI (p Value = 0.031). This difference was observed statistically significant among mild and moderate TBI for the cube copy (p = 0.039) and clock (p = 0.017) i.e. visuospatial/executive function, Digit span test (p value = 0.040) i.e. concentration and recall memory (p = 0.04). MoCA Score were higher for patients with higher GCS score at admission. Education status was also correlated with MoCA scores; those patients with higher level of education had significant association with higher MoCA scores (p value = 0.012). This study showed that age and gender were insignificant variables to determine cognitive function. CONCLUSION: Assessment of cognitive impairment should be considered as a mandatory protocol while evaluating post TBI patients, even in cases of mild TBI. Visuospatial/Executive function, memory and attention are the most commonly impaired cognitive functions in patients of TBI, and these are the main domain of cognition which differentiates mild impairment from moderate impairment. This information enables us and provides insight to our experience to predict the burdens of problem and plan to develop post TBI dedicated rehabilitating programme.

Urodynamic patterns after traumatic spinal cord injury.

OBJECTIVES: To study the correlation between neurological level of spinal injury and bladder functions as detected by urodynamic study. STUDY DESIGN: Analytical study. SETTING AND PARTICIPANTS: Seventy individuals with traumatic spinal cord injury (SCI) admitted to the Department of Physical Medicine and Rehabilitation, S.M.S. Medical College and Hospital, Jaipur. Detailed clinical, neurological evaluation as per American Spinal Injury Association Classification and radiological assessment were done along with clinical examination of bladder and urodynamic study. RESULTS: Out of 65 patients with suprasacral injuries, 53 (81.5%) demonstrated hyperreflexia with or without detrusor sphincter dyssynergia, 6 (9.2%) detrusor areflexia, and 6 (9.2%) had normal bladders, 41 (59.4%) low compliance (<20 ml/cmH2O), and 47 (72.30%) had high detrusor leak pint pressures (>40 cmH2O). Of the five patients with sacral injuries, one (20%) showed detrusor hyperreflexia, four (80%) detrusor areflexia, and one (20%) had low bladder compliance; all five (100%) had high detrusor leak point pressures. CONCLUSIONS: The correlation between somatic neurologic findings, spinal imaging studies, and urodynamic findings in patients with SCI is not exact. Therefore, bladder management should not completely rely only on clinical bladder evaluation or neurological examination alone, but should always include urodynamic studies.

Bladder calculi formed over a hair nidus in spinal injury cases.

Clean intermittent catheterization has been demonstrated to be a safe and effective method of bladder drainage in patients with neurogenic bladder dysfunction. However, breakdowns in technique may allow the introduction of foreign matter into the bladder and thereby result in bladder calculi. The three cases reported herein demonstrate this potential problem in persons with spinal cord injury (SCI) with hair nidus as the source of bladder calculi causing neurogenic bladder. In each situation, the problem was identified, calculi were removed cystoscopically and the patient and/or the ancillary aid were reinstructed. We recommend annual renal function tests, ultrasound and cytoscopic screening in high suspicion cases to allow early detection of bladder calculi in persons with SCI and prevent further urinary tract infections. This report also emphasizes the need for patient education and a careful follow-up preventing bladder calculi and thus, minimizing the morbidity in persons with SCI.

Effect of serial casting in spastic cerebral palsy.

OBJECTIVE: Cerebral palsy (CP) is a range of non progressive syndromes of posture and motor impairment due to an insult to developing brain. Spasticity and incoordination are major causes of disability in these children which can be managed by different modalities like casting, botulinum toxin, surgery etc. Cast application in spastic equinus is a well established procedure in CP but cast application in patients of CP with bilateral involvement of hip, knee and ankle is not document. METHODS: A study was conducted on 22 children of spastic CP in age range of 3-8 years with bilateral involvement of hip, knee and ankle in 20 cases, hip and ankle in one case and only ankle in one case. Sixty eight % children were spastic diplegics. Serial weekly cast with (11 cases) or without abductor bar (11 cases) was applied for four weeks. They were followed up variably with an average period of 7 months. RESULTS: Significant improvement was noticed in range of motion around hip, knee and ankle which as maintained over hip and knee after average follow up. Spasticity was also reduced as measured by Modified Ashworth Scale (MAS). This ultimately improved the ambulatory status and functional ability of these children. CONCLUSION: Thus serial casting is a very simple, safe and cost effective procedure which can be applied even in children with mental sub normality having all three major joints involved bilaterally.

Effect of serial casting in spastic cerebral palsy.

OBJECTIVE: Cerebral palsy (CP) is a range of non progressive syndromes of posture and motor impairment due to an insult to developing brain. Spasticity and incoordination are major causes of disability in these children which can be managed by different modalities like casting, botulinum toxin, surgery etc. Cast application in spastic equinus is a well established procedure in CP but cast application in patients of CP with bilateral involvement of hip, knee and ankle is not document. METHODS: A study was conducted on 22 children of spastic CP in age range of 3-8 years with bilateral involvement of hip, knee and ankle in 20 cases, hip and ankle in one case and only ankle in one case. Sixty eight % children were spastic diplegics. Serial weekly cast with (11 cases) or without abductor bar (11 cases) was applied for four weeks. They were followed up variably with an average period of 7 months. RESULTS: Significant improvement was noticed in range of motion around hip, knee and ankle which as maintained over hip and knee after average follow up. Spasticity was also reduced as measured by Modified Ashworth Scale (MAS). This ultimately improved the ambulatory status and functional ability of these children. CONCLUSION: Thus serial casting is a very simple, safe and cost effective procedure which can be applied even in children with mental sub normality having all three major joints involved bilaterally.