Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis.

PURPOSE: To evaluate outcome measures and the factors affecting them in patients treated between 1962 and 2000 at Loewenstein Rehabilitation Hospital, Israel. METHOD: This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA. RESULTS: Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay. CONCLUSIONS: Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

Rupture of quadriceps tendon in a patient with postanoxic choreoathetosis.

PURPOSE: To describe a case of quadriceps tendon rupture in a patient with postanoxic choreoathetotic movements. CASE REPORT: A 20-year-old man was admitted to a rehabilitation hospital after anoxic brain injury. As a result of the injury, he developed continuous flowing choreoathetotic movements. He contracted fever and swollen and painful right knee, and only when periarticular edema decreased did a suprapatellar gap appear and quadriceps tendon rupture was diagnosed. CONCLUSIONS: Considering the possibility of tendon rupture when evaluating a patient with non-volitional movements and 'arthritic' presentation in a rehabilitation setting, may prevent delay of quadriceps surgical repair.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis.

PURPOSE: To evaluate outcome measures and the factors affecting them in patients treated between 1,962 and 2,000 at Loewenstein Rehabilitation Hospital, Israel. METHOD: This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA. RESULTS: Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay. CONCLUSIONS: Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

Disability assessment by a single rater or a team: a comparative study with the Catz-Itzkovich spinal cord independence measure.

The Catz-Itzkovich Spinal Cord Independence Measure was found to be reliable and more sensitive than the FIM to functional changes, when used by a multidisciplinary team. This study was performed to find out whether assessment may be similar when done by a single rater. Twenty-eight patients with spinal cord lesions participated in the study, in which examinations performed within a week by a single nurse or a team were compared for correlation, differences and agreement. The team members scored their relevant fields. A significant correlation was found between the nurse's scoring and that of physiotherapists and occupational therapists (r = 0.82-0.94; p < 0.0001), and the differences between the mean scores were small. The agreement between raters was modest, however (total agreement 38-90%, Kappa 0.17-0.73). It was concluded that although disability assessment performed by a single nurse may not be as accurate as by a multidisciplinary team, it could be reliable and valid.

[SCIM--spinal cord independence measure (version II): sensitivity to functional changes].

Until recently, the functional ability of patients with spinal cord lesions (SCL) was assessed by standardized scales designed for various disabilities. However, these scales have either a relatively low sensitivity to changes in the functions that are most important for SCL patients or a limited suitability for a specific SCL subgroup. To counter this problem the team of the Spinal Department of Loewenstein Rehabilitation Hospital developed the Spinal Cord Independence Measure (SCIM), which is specific for SCL patients, adjusts for disadvantages of earlier scales, and is user-friendly. It was found to be reliable and more sensitive to functional changes in SCL patients than the Functional Independence Measure (FIM), the most often used disability scale today. A second version (SCIM II) was constructed with improved phrasing of some of the components. It too, was found reliable, even more than the original version for certain functions. The present study examined the sensitivity of the SCIM II to changes in function in SCL patients compared to the FIM. Twenty-six patients with SCL underwent sequential SCIM II and FIM examinations during hospitalization for rehabilitation. A high correlation was found between the total scores of the two scales (r = 0.915; p < 0.0001). The mean change in function score from the first to the last examination was significantly larger with the SCIM II than with the FIM (p < 0.04), and the rate of detection of functional change was usually higher with the SCIM II. The advantage of the SCIM II over the FIM in detecting functional changes was evident in areas in which the two scales differ substantially. These results support the validity of the SCIM II. Studies with larger groups in different countries and cultures are still needed before the scale can be applied on an international basis.

A new instrument for outcome assessment in rehabilitation medicine: Spinal cord injury ability realization measurement index.

OBJECTIVES: To introduce a new measure of disability weighted for the neurologic deficit in patients with spinal cord lesions and to examine the effect on the instrument of being in rehabilitation. DESIGN: Development of instrument and preliminary comparative before-after study. SETTING: Spinal department in a rehabilitation hospital in Israel. PARTICIPANTS: Seventy-nine patients with spinal cord lesions. INTERVENTIONS: Patients were repeatedly assessed during rehabilitation with the American Spinal Injury Association Impairment Scale (AIS) to measure neurologic motor impairment and with the Spinal Cord Independence Measure (SCIM-II) to measure disability. Scores of the 2 assessments were combined to create the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI). MAIN OUTCOME MEASURES: A preliminary formula for the calculation of SCI-ARMI using the individual patients' SCIM-II and AIS motor scores and changes in SCI-ARMI values through rehabilitation. RESULTS: The highest observed SCIM-II scores at patients' AIS level correlated highly with the AIS motor scores (r=.96, P<.01). A regression performed for this linear relationship resulted in a preliminary SCI-ARMI formula. The calculated SCI-ARMI values improved during rehabilitation irrespective of patient age, gender, lesion level, or lesion severity (P<.001). CONCLUSIONS: The preliminary version of the SCI-ARMI can be used to assess quantitatively changes in functional ability, isolating them from the effect of neurologic changes.

Survival after nontraumatic spinal cord lesions in Israel.

OBJECTIVE: To assess survival in patients with nontraumatic spinal cord lesions (SCL). DESIGN: Retrospective cohort study. SETTING: Spinal department at a rehabilitation hospital in Israel. PARTICIPANTS: Patients with nontraumatic SCL (N=1085) admitted between 1962 and 2000. INTERVENTIONS: Demographic, clinical, and mortality data were collected from hospital charts and from the Population Registry of the Israel Ministry of Internal Affairs. MAIN OUTCOME MEASURES: Survival rates and mortality risk factors. Measures were estimated by using the product limit (Kaplan-Meier) method and the Cox model. RESULTS: Maximal survival time was 57 years. Median accumulated survival time was 24 years. Survival was significantly affected by lesion etiology, age, gender, severity of lesion, and recent decade of lesion onset; survival tended to be shorter in patients with higher level SCL. We found no significant difference between the effects of risk factors on mortality in nontraumatic SCL and traumatic SCL, other than the effect of age at lesion onset, which was a greater risk factor in the latter group. CONCLUSIONS: The survival rate of patients with nontraumatic SCL has improved significantly in Israel in the last decade. The survival rates of a mixed nontraumatic SCL population are similar to those of traumatic SCL but may differ in specific etiologic age groups.

Recovery of neurologic function following nontraumatic spinal cord lesions in Israel.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess neurologic recovery and the manner in which it is affected by various factors following nontraumatic spinal cord lesions (NTSCLs). SUMMARY OF BACKGROUND DATA: NTSCLs comprise a considerable portion of spinal cord lesions. However, information about neurologic recovery in these lesions is scarce. METHOD: The study sample included 1,085 patients with NTSCL treated between 1962 and 2000 at the premier referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from hospital charts. The degree of neurologic recovery was determined by comparing each patient's Frankel grades of neurologic deficit at first admission to rehabilitation and at discharge from the same hospitalization. The study population was also compared with previously studied 250 patients with traumatic spinal cord lesions (TSCLs). RESULTS: Complete or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred during rehabilitation in 51% of patients who were Grade A, B, or C on admission, and in 57% of those who were Grade C. Neurologic recovery in NTSCL during rehabilitation was significantly affected by initial Frankel grade and by NTSCL etiology. Age had a borderline effect. Gender, lesion level, and the decade of rehabilitation did not affect recovery. Recovery rate was usually higher in NTSCLs than in TSCLs. CONCLUSIONS: The prognosis for neurologic recovery is affected mainly by SCL severity and etiology, and is usually better in NTSCLs than in TSCLs.

Reliability of the Catz-Itzkovich Spinal Cord Independence Measure assessment by interview and comparison with observation.

OBJECTIVE: To examine the reliability of assessment with the Catz-Itzkovich Spinal Cord Independence Measure II (SCIM II) by interview and compare the findings with assessment by observation. DESIGN: In a cohort, comparative study, 28 inpatients with spinal cord lesions were assessed by two nurses using the Catz-Itzkovich SCIM II (interview) and by a multidisciplinary team (observation). RESULTS: Total agreement between interviewers ranged from 50% to 80% (Kappa coefficients 0.40-0.60). Pearson's coefficients of the correlation between scores obtained for the various SCIM subscales by interview or observation were 0.765-0.940 (P < 0.0001). The differences in mean scores obtained between the interview and observation methods were small and not statistically significant for most of the subscales. CONCLUSIONS: The results support the reliability of the Catz-Itzkovich SCIM assessment by interview and show it to be comparable with assessment by observation. The SCIM II interview may serve as an accurate measure of daily function in patients with spinal cord injury. However, with the sample of the study being relatively small, a larger scale examination is needed to generalize the results.

Recovery of neurologic function after spinal cord injury in Israel.

STUDY DESIGN: A retrospective cohort study was conducted. OBJECTIVE: To assess neurologic recovery and the manner in which it is affected by the severity of the neurologic damage after spinal cord injury. SUMMARY OF BACKGROUND DATA: Studies from various countries, but not from Israel, have shown considerable potential for recovery of the damaged human spinal cord. METHODS: The study sample included 250 patients with a traumatic spinal cord lesion treated between 1962 and 1992 at the major referral hospital for rehabilitation in Israel. Demographic and clinical data were collected from the hospital charts. The degree of neurologic recovery in each patient was determined by comparing the Frankel grade of neurologic deficit at first admission for rehabilitation with the grade at discharge from that hospitalization. RESULTS: There was median delay of 36 days between injury and admission for rehabilitation. During rehabilitation, full or substantial neurologic recovery (upgrade to Frankel Grade D or E) occurred in 27% of all the patients who were Grade A, B, or C on admission, and in 54% of those who were Grade C. The neurologic recovery was negatively associated with severity of the neurologic deficit. CONCLUSIONS: The outcome findings are similar to those reported from spinal rehabilitation units in other countries. The study is a further demonstration of the considerable potential for neurologic recovery after spinal cord injury, when posttraumatic or postsurgical management is focused on prevention of complications and maximal use of functional ability.