Comparison of speeds used for the 15.2-meter and 6-minute walks over the year after an incomplete spinal cord injury: the SCILT Trial.

BACKGROUND: Timed walking speed for 6 to 15 m and the distance walked in 2 to 12 minutes are frequently used outcome measures in rehabilitation trials, presumably reflecting different aspects of walking ability. The database from the Spinal Cord Injury Locomotor Trial (SCILT), which tested 2 interventions for mobility upon admission for initial rehabilitation of an incomplete traumatic spinal cord injury (SCI), was used to compare the walking speed employed for each test. METHODS: From 66 to 70 patients with upper motor neuron lesions from C-5 to T-10 performed a 15.2-m and a 6-minute walk as fast as the patient deemed safe at 3 months (end of the trial intervention) and 6 and 12 months after entry. The means, standard errors, and quartiles were calculated for the speed used for each task. RESULTS: The mean speed for the 15.2-m walk did not differ from that used for the 6-minute walk at 3 and 6 months but was significantly faster at 12 months. Differences became apparent at each assessment in patients in the highest quartiles (>1.0 m/s) for the 15.2-m walk. Their speed was from 14% to 24% higher than the speed used for the 6-minute walk. CONCLUSION: The speed of the 15.2-m walk as a measure of walking ability compared to the distance walked in 6 minutes may not represent separable domains of mobility. Differences were apparent only in the most highly functional patients, who could ambulate in the community. Any difference in the walking speed used for these 2 tasks does not make enough of a clinical distinction to encourage including both a 6-minute walk and a 15.2-m walk as outcome measures in clinical trials of locomotor interventions for SCI.

The evolution of walking-related outcomes over the first 12 weeks of rehabilitation for incomplete traumatic spinal cord injury: the multicenter randomized Spinal Cord Injury Locomotor Trial.

BACKGROUND: The Spinal Cord Injury Locomotor Trial (SCILT) compared 12 weeks of step training with body weight support on a treadmill (BWSTT) that included overground practice to a defined but more conventional overground mobility intervention (CONT) in patients with incomplete traumatic SCI within 8 weeks of onset. No previous studies have reported walking-related outcomes during rehabilitation. METHODS: This single-blinded, randomized trial entered 107 American Spinal Injury Association (ASIA) C and D patients and 38 ASIA B patients with lesions between C5 and L3 who were unable to walk on admission for rehabilitation. The Functional Independence Measure (FIM-L) for walking, 15-m walking speed, and lower extremity motor score (LEMS) were collected every 2 weeks. RESULTS: No significant differences were found at entry and during the treatment phase (12-week mean FIM-L = 5, velocity = 0.8 m/s, LEMS = 35, distance walked in 6 min = 250 m). Combining the 2 arms, a FIM-L >or= 4 was achieved in < 10% of ASIA B patients, 92% of ASIA C patients, and all of ASIA D patients. Walking speed of >or= 0.6 m/s correlated with a LEMS near 40 or higher. CONCLUSIONS: Few ASIA B and most ASIA C and D patients achieved functional walking ability by the end of 12 weeks of BWSTT and CONT, consistent with the primary outcome data at 6 months. Walking-related measures assessed at 2-week intervals reveal that time after SCI is an important variable for entering patients into a trial with mobility outcomes. By about 6 weeks after entry, most patients who will recover have improved their FIM-L to >3 and are improving in walking speed. Future trials may reduce the number needed to treat by entering patients with FIM-L < 4 at > 8 weeks after onset if still graded ASIA B and at > 12 weeks if still ASIA C.

Treatment for spasticity in amyotrophic lateral sclerosis/motor neuron disease.

BACKGROUND: Spasticity commonly affects patients with motor neuron disease. It is likely to contribute to worsening muscle dysfunction, increased difficulty with activities of daily living and deteriorating quality of life. OBJECTIVES: The objective of this review is to systematically review treatments for spasticity in amyotrophic lateral sclerosis, also known as motor neuron disease. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group trials register (January 2003 and January 2005), MEDLINE (January 1966 to February 2005), EMBASE (January 1980 to February 2005), CINAHL (January 1982 to February 2005), AMED (January 1985 to February 2005) and LILACS (January 1982 to January 2003). We reviewed the bibliographies of the randomized controlled trials identified, and contacted authors and experts in the field. SELECTION CRITERIA: We included quasi-randomized or randomized controlled trials of participants with probable or definite amyotrophic lateral sclerosis according to the El Escorial diagnostic criteria (or a revised version) or the Airlie House revision. We would have included trials of physical therapy, modalities, prescription medications, non-prescription medications, chemical neurolysis, surgical interventions, and alternative therapies. Our primary outcome measure was reduction in spasticity at three months or greater as measured by the Ashworth (or modified Ashworth) spasticity scale. Our secondary outcome measures were: validated measures based on history, physical examination, physiological measures, measures of function, measures of quality of life, serious adverse events, and measures of cost. DATA COLLECTION AND ANALYSIS: We identified only one randomized controlled trial that met our inclusion criteria. Two authors extracted the data. We also contacted the author of the paper and obtained information not available in the published article. MAIN RESULTS: The included study was a trial of moderate intensity, endurance type exercise versus 'usual activities' in 25 patients with amyotrophic lateral sclerosis. At three months patients performing the 15 minute twice daily exercises had significantly less spasticity overall (mean reduction of -0.43, 95% CI -1.03 to +0.17 in the treatment group versus an increase of +0.25, 95% CI -0.46 to +0.96 in control) but the mean change between groups was not significant (-0.68, 95% CI -1.62 to +0.26), as measured by the Ashworth scale. AUTHORS' CONCLUSIONS: The single trial performed was too small to determine whether individualised moderate intensity endurance type exercises for the trunk and limbs are beneficial or harmful. No other medical, surgical or alternative treatment and therapy has been evaluated in a randomized fashion in this patient population. More research is needed.

A secure web-based approach for accessing transitional health information for people with traumatic brain injury.

A web-based transitional health record was created to provide regional healthcare professionals with ubiquitous access to information on people with brain injuries as they move through the healthcare system. Participants included public, private, and community healthcare organizations/providers in Eastern Ontario (Canada). One hundred and nineteen service providers and 39 brain injury survivors registered over 6 months. Fifty-eight percent received English and 42% received bilingual services (English-French). Public health providers contacted the regional service coordinator more than private providers (52% urban centres, 26% rural service providers, and 22% both areas). Thirty-five percent of contacts were for technical difficulties, 32% registration inquiries, 21% forms and processes, 6% resources, and 6% education. Seventeen technical enquiries required action by technical support personnel: 41% digital certificates, 29% web forms, and 12% log-in. This web-based approach to clinical information sharing provided access to relevant data as clients moved through or re-entered the health system. Improvements include automated digital certificate management, institutional health records system integration, and more referral tracking tools. More sensitive test data could be accessed on-line with increasing consumer/clinician confidence. In addition to a strong technical infrastructure, human resource issues are a major information security component and require continuing attention to ensure a viable on-line information environment.

Long-term intrathecal baclofen therapy in patients with intractable spasticity.

BACKGROUND: Severe spasticity unresponsive to oral drugs may respond satisfactorily to baclofen delivered intrathecally. METHODS: Intrathecal baclofen (IB) therapy delivered by means of implanted infusion pumps was used for nine patients with severe spasticity. Six patients had multiple sclerosis, two cervical spinal cord injury, and one head injury. All were non-ambulatory. RESULTS: Patients showed improvement in many areas, including ability to transfer, seating, pain control, personal care, and liability to skin breakdown. Before IB therapy, only three of the nine patients were able to live at home in the community and six were institutionalized. At the end of our follow-up period, only one patient remained institutionalized, three lived in group homes and five lived at home in the community. In the year preceding pump implantation, the nine patients spent a total of 755 days in acute care hospitals. In the year following onset of IB therapy, they spent only 259 days in hospital. CONCLUSIONS: IB therapy can improve patient quality of life and can be cost-effective in carefully selected patients with severe spasticity and disability. The drug delivery catheter is that part of the therapeutic system most vulnerable to failure. Because of the varied expertise required to manage these patients effectively, and the potential for a variety of complications, it is essential that an IB program is supported by a well-organized multi-disciplinary medical team.

Treatment for spasticity in amyotrophic lateral sclerosis/motor neuron disease.

BACKGROUND: Spasticity commonly affects patients with motor neuron disease and it is likely to contribute to worsening muscle dysfunction, increased difficulty with activities of daily living and deteriorating quality of life. OBJECTIVES: The objective of this review is to systematically review all types of treatments for spasticity in amyotrophic lateral sclerosis, also known as motor neuron disease. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group specialised trials register (searched January 2003), MEDLINE (January 1966 to January 2003), EMBASE (January 1980 to January 2003), CINAHL (January 1982 to January 2003), AMED (January 1985 to January 2003) and LILACS (January 1982 to January 2003) for randomized controlled trials. We reviewed the bibliographies of the randomized trials identified, and contacted trial authors and known experts in the field. SELECTION CRITERIA: We included quasi-randomized or randomized controlled trials of participants with probable or definite amyotrophic lateral sclerosis according to the El Escorial diagnostic criteria (or a revised version) or the Airlie House revision. We would have included trials of physical therapy, modalities, prescription medications, non-prescription medications, chemical neurolysis, surgical interventions, alternative therapies. Our primary outcome measure was reduction in spasticity at three months or greater as measured by Ashworth (or modified Ashworth) spasticity scale. Our secondary outcome measures were: validated measures based on history, physical examination, physiological measures, measures of function, measures of quality of life, serious adverse events, and measures of cost. DATA COLLECTION AND ANALYSIS: We identified only one randomized controlled trial that met the inclusion criteria for this review. Two authors extracted the data. We also contacted the author of the paper and obtained further information not available in the published article. MAIN RESULTS: The included study was a trial of moderate intensity, endurance type exercise versus 'usual activities' in 25 patients with amyotrophic lateral sclerosis. At three months patients performing the 15 minute twice daily exercises had significantly less spasticity (mean reduction of 0.43 Ashworth grades versus an increase of 0.25 in controls), as measured by the Ashworth scale. REVIEWER'S CONCLUSIONS: Individualized, moderate intensity, endurance type exercises for the trunk and limbs may help to reduce spasticity in motor neuron disease. No other medical, surgical or alternative treatment and therapy has been evaluated in a randomized fashion in this patient population.

Dens in dente in a six year old doberman pinscher.

Developmental abnormalities of tooth shape and form are rare. Identification of dens in dente is made by radiographic and clinical examination. Pulpitis, pulp necrosis and periapical inflammation can be associated with this abnormality. The tooth should be evaluated for endodontic therapy. A review of the literature related to dens in dente is described with the findings in a doberman pinscher.

Use of a resin-ionomer in crown-root fracture repair of a canine tooth of a dog.

A resin-ionomer material was used to repair a longitudinal sub-crestal crown-root fracture of a maxillary canine tooth of a young dog. Infinity, the resin-ionomer used in this report, has been shown in human studies to be biocompatible with soft and osseous tissues, making it appropriate for use as a subgingival restorative material. The tooth was treated endodontically to achieve apexification, followed by conventional endodontic treatment, crown-root fracture repair, and preparation for placement of an Inceram crown.

Evaluation of Bioglass/PerioGlas (Consil) synthetic bone graft particulate in the dog and cat.

This paper describes the use of Bioglass synthetic bone graft particulate (PerioGlas/Consil) in the treatment of osseous periodontal defects, and in post-extraction sites to maintain the vertical height and width of the alveolar ridge. The material is easy to use, inhibits epithelial down-growth, and acts as a mechanical hemostatic agent. Radiographic follow up in 36 dogs and 5 cats demonstrated significant bone fill. In the osseous periodontal defect treatment group, clinical probing depths decreased significantly, and there was an apparent gain in attachment level.

Use of videofluoroscopy in zoo dentistry: endodontic procedure in a tiger.

Videofluoroscopy was used as a radiographic technique to visualize a canine tooth during root canal therapy in a Siberian tiger. Videofluoroscopy was useful because the procedure was performed in a zoo setting with no access to an on-site darkroom. The fluoroscopic screen and videotape allowed for immediate viewing of the root canal system.

Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI.

OBJECTIVE: To compare the efficacy of step training with body weight support on a treadmill (BWSTT) with over-ground practice to the efficacy of a defined over-ground mobility therapy (CONT) in patients with incomplete spinal cord injury (SCI) admitted for inpatient rehabilitation. METHODS: A total of 146 subjects from six regional centers within 8 weeks of SCI were entered in a single-blinded, multicenter, randomized clinical trial (MRCT). Subjects were graded on the American Spinal Injury Association Impairment Scale (ASIA) as B, C, or D with levels from C5 to L3 and had a Functional Independence Measure for locomotion (FIM-L) score < 4. They received 12 weeks of equal time of BWSTT or CONT. Primary outcomes were FIM-L for ASIA B and C subjects and walking speed for ASIA C and D subjects 6 months after SCI. RESULTS: No significant differences were found at entry between treatment groups or at 6 months for FIM-L (n = 108) or walking speed and distance (n = 72). In the upper motor neuron (UMN) subjects, 35% of ASIA B, 92% of ASIA C, and all ASIA D subjects walked independently. Velocities for UMN ASIA C and D subjects were not significantly different for BWSTT (1.1 +/- 0.6 m/s, n = 30) and CONT (1.1 +/- 0.7, n = 25) groups. CONCLUSIONS: The physical therapy strategies of body weight support on a treadmill and defined overground mobility therapy did not produce different outcomes. This finding was partly due to the unexpectedly high percentage of American Spinal Injury Association C subjects who achieved functional walking speeds, irrespective of treatment. The results provide new insight into disability after incomplete spinal cord injury and affirm the importance of the multicenter, randomized clinical trial to test rehabilitation strategies.

Male erectile dysfunction following spinal cord injury: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: To review sexuality in persons with spinal cord injuries (SCIs), and to report the effectiveness of erectile interventions. METHODS: Reports from six databases (1966-2003), selected annual proceedings (1997-2002) and manufacturer's information were screened against eligibility criteria. Included reports were abstracted and data pooled from case-series reports regarding intracavernous injections and sildenafil. RESULTS: From 2127 unique reports evaluated, 49 were included. Male sexual dysfunction was addressed in these reports of several interventions (behavioural therapy, topical agents, intraurethral alprosatadil, intracavernous injections, vacuum tumescence devices, penile implants, sacral stimulators and oral medication). Penile injections resulted in successful erectile function in 90% (95% CI: 83%, 97%) of men. Sildenafil resulted in 79% (95% CI: 68%, 90%) success; the difference in efficacy was not statistically significant. Five case-series reports involving 363 participants with penile implants demonstrated a high satisfaction rate, but a 10% complication rate. CONCLUSIONS: A large body of evidence addressing sexuality in males focuses on erection. Penile injection, sildenafil and vacuum devices generally obviate the need for penile implants to address erectile dysfunction. Interventions may positively affect sexual activity in the short term. Long-term sexual adjustment and holistic approaches beyond erections remain to be studied. Rigorous study design and reporting, using common outcome measures, will facilitate higher quality research. This will positively impact patient care. SPONSORSHIP: Agency for Healthcare Research and Quality, US Department of Health and Human Services, 2101 East Jefferson Street, Rockville, MD 20852, USA.

Fertility following spinal cord injury: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVES: To review systematically fertility of persons with spinal cord injuries (SCI) and their partners. METHODS: Reports from six databases (1966-2003), selected annual proceedings (1997-2002) and manufacturer's information were screened against eligibility criteria. Searches covered female obstetrical issues, and the efficacy of vibration and electroejaculation for males, as well as advanced fertility (AF) treatments for partners of SCI males. Data were pooled from case-series reports on SCI males' ejaculation, and pregnancies and live births for partners of SCI males. RESULTS: In all, 2,127 unique reports were evaluated, of which 66 reports were included. No studies investigated fertility in SCI females. Ejaculation interventions in the last decade resulted in response rates of 95% (95% confidence intervals (CI) 91%, 99%), with 100% response rate reported in several recent publications. A total of 13 studies (1993-2001) yielded pregnancy rates of 51% (95% CI 42%, 60%) in partners of SCI males. Of these, 11 studies (1993-2003) yielded live birth rates of 41% (95% CI 33%, 49%). CONCLUSIONS: Fertility of SCI males is extensively studied. Semen for fertility purposes can generally be obtained using vibration and electroejaculation. AF techniques are increasing pregnancy rates. Research is needed to improve sperm quality. Freezing of sperm is unlikely to significantly improve fertility rates. Fertility of SCI females is addressed only in case reports and opinion articles. The opinion that female fertility is unaffected by SCI should be further investigated using appropriate research methodology.

Cardiovascular responses to acute exercise in patients with cerebrovascular accidents.

Blood pressure (BP) and heart rate (HR) responses to isometric hand grip, exercise with the cybex arm ergometer, and cybex fitron cycle ergometer were recorded for 19 stroke subjects and 19 control subjects matched by age and gender. Mean age in both groups was 66 years. There was no significant difference in the resting HR (controls: 69 +/- 10, patients: 70 +/- 11 beats per minute) and BP measurements (systolic--controls: 140 +/- 17, patients: 135 +/- 21; diastolic--controls 80 +/- 8, patients: 75 +/- 11mmHg). There was also no significant difference in either the mean HR (controls: 79 +/- 10, patients: 81 +/- 12 beats per minute) or BP (systolic--controls: 174 +/- 23, patients: 165 +/- 27; diastolic--controls: 98 +/- 15, patients: 92 +/- 14) response to exercise. With the arm ergometer test, the control group attained a significantly higher maximum systolic (190 +/- 23 mmHg) and diastolic blood pressure (102 +/- 15mmHg) than the stroke group (systolic 165 +/- 23; diastolic 91 +/- 10mmHg). During the leg ergometer exercise test, results were similar in both groups except that work completed was significantly higher for the control group (3592 +/- 1162kg) than for patients (2512 +/- 1348kg). None of the patients reported symptoms of dizziness, fainting, or chest pain. Prescribed exercise in stroke patients under supervision and within patient tolerance was found to be safe.

Effect of 4-aminopyridine on gait in ambulatory spinal cord injuries: a double-blind, placebo-controlled, crossover trial.

UNLABELLED: Animal and human research have shown that the drug 4-aminopyridine (4-AP) may improve gait in spinal cord lesions by enhancing nerve transmission to affected muscles. STUDY DESIGN: Prospective, randomized, double-blind, placebo-controlled, crossover trial. OBJECTIVES: To determine the efficacy of 4-AP in improving lower limb muscle strength and biomechanical gait patterns of chronic spinal cord injuries (SCI). SETTING: The Rehabilitation Centre (Ottawa, Canada). METHODS: In all, 15 chronic, ambulatory SCI persons were randomized to an initial 2 weeks of 40 mg/day, oral medication of either placebo or immediate-release, 4-AP and subsequently crossed over to the alternate medication for the following 2 weeks. Evaluations were conducted at baseline (before starting 4-AP or placebo medication), 2 weeks, and 4 weeks. Measures included dynamometer lower limb isometric muscle force and biomechanical gait measures including temporal-spatial parameters, electromyographic activation patterns, joint kinematics and kinetics. Subjective impressions of the drug by the participants were obtained from an exit survey. RESULTS: Despite some positive comments from subjects, statistical and clinical analyses showed no within-subject differences between placebo and 4-AP measures of lower limb muscle force and objective gait analyses (ANOVA statistic P>0.05). CONCLUSION: Results demonstrated the importance of placebo-controlled trials and quantitative outcome measures for the evaluation of 4-AP aimed to enhance gait for chronic, ambulatory SCI persons. Energy expenditure measures and mood may relate more to subjective comments and is suggested for future investigations.