A prospective study of pain and psychological functioning following traumatic spinal cord injury.

STUDY DESIGN: Longitudinal study. OBJECTIVES: To study prospectively pain characteristics, change in pain over time and the associations between pain and psychological functioning in adults with traumatic spinal cord injury (SCI). SETTING: Neurosurgical departments, SCI rehabilitation centres and the community. METHODS: Adults with traumatic SCI admitted over a 3-year period to two neurosurgical departments underwent clinical examination and questionnaires within 3 months after injury (baseline) and at 6, 12 and 42 months following SCI. Pain intensity and interference within the last 7 days, a global quality of life (QoL) item, the 5-item Mental Health Index and the 6-item Catastrophizing scale were used. RESULTS: Ninety individuals were recruited, of which 81 completed a telephone interview on average 3.5 (s.d., 0.6) years after the SCI. Pain was present in 75% at 3.5 years. Baseline pain catastrophizing scores did not predict pain intensity at 3.5 years. Both psychological functioning and QoL increased over time. QoL scores increased less in participants who reported an increase in pain intensity from baseline to the 3.5-year follow-up, and the change in QoL score correlated with the change in pain interference. Neuropathic pain had an onset within the first 12 months and tended to become persistent, whereas musculoskeletal pain more often had a late onset or resolved in cases of early onset. CONCLUSIONS: A large proportion of SCI participants continue to experience pain many years after SCI. Teaching individuals with SCI skills to minimise pain's impact on function as soon as possible following injury may prove beneficial.

Estimating the glomerular filtration rate using serum cystatin C levels in patients with spinal cord injuries.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To investigate the relationship between (51)chromium-ethylene-diamine-tetra-acetate ((51)Cr-EDTA) clearance, serum cystatin C (CysC), serum creatinine, creatinine clearance and estimated glomerular filtration rate (eGFR(MDRD), MDRD stands for modification of diet in renal disease) based on the serum creatinine in patients with complete or incomplete spinal cord injury (SCI) and to develop and evaluate a GFR-estimating equation using serum CysC. SETTINGS: Spinal Cord Injury Unit, Viborg Regional Hospital, Viborg, Denmark. METHODS: Ninety-eight men and 47 women with SCI were included in the study. Serum CysC levels were measured by an automated particle-enhanced nephelometric immunoassay, serum and urine creatinine levels were measured by an enzymatic method traceable to the IDMS creatinine reference method, and (51)Cr-EDTA clearance was measured by a multiple plasma sample method. RESULTS: The area under the curves (AUCs) in the non-parametric receiver operating characteristics (ROC) plots for serum CysC were compared with serum creatinine and to eGFR(MDRD) and revealed a significant difference (P-value < 0.05) for all SCI patients. There was no significant difference between the AUC for serum CysC compared with the AUC for creatinine clearance. GFR (ml min(-1) per 1.73 m(2)) can be calculated from serum CysC values (mg l(-1)) using the equation eGFR(CysC) = 212·exp(0.914·CysC). The model accurately predicted the GFR of 88% of patients within ± 30% of the measured GFR, and it was able to predict the GFR of 50% of patients within ± 10% of the measured GFR. CONCLUSION: In patients with SCI, GFR can be estimated independent of age, sex and muscle mass by a newly developed equation based on a single serum CysC value.

Reliability of the international spinal cord injury bowel function basic and extended data sets.

STUDY DESIGN: This study was designed as an international validation study. OBJECTIVE: The objective of this study was to assess the inter-rater reliability of the International Spinal Cord Injury Bowel Function Basic and Extended Data Sets. SETTING: Three European spinal cord injury centers. METHODS: In total, 73 subjects with spinal cord injury and a history of bowel dysfunction, out of which 77% were men and median age of the subjects was 49 years (range 20-81), were studied. The inter-rater reliability was estimated by having two raters complete both data sets on the same subject. First and second tests were separated by 14 days. Cohen's kappa was computed as a measure of agreement between raters. RESULTS: Inter-rater reliability assessed by kappa statistics was very good (≥0.81) in 5 items, good (0.61-0.80) in 11 items, moderate (0.41-0.60) in 20 items, fair (0.21-0.40) in 11 and poor (<0.20) in 5 items. CONCLUSION: Most items within the International Spinal Cord Injury Bowel Function Data sets have acceptable inter-rater reliability and are useful tools for data collection in international clinical practice and research. However, minor adjustments are recommended.

Levetiracetam in spinal cord injury pain: a randomized controlled trial.

STUDY DESIGN: A randomized, double-blind, placebo-controlled, crossover, multicenter trial. A 1-week baseline period was followed by two treatment periods of 5 weeks duration with levetiracetam increased from 500 mg b.i.d. to a maximum of 1500 mg b.i.d. separated by a 1-week washout period. OBJECTIVES: The objective of the study was primarily to evaluate the efficacy of the anticonvulsant levetiracetam in patients with spinal cord injury (SCI) at- and below-level pain and secondarily to evaluate the effect on spasm severity. SETTING: Outpatients at two spinal cord units and a pain center. METHODS: Patients were allowed to continue their usual pain treatment at a constant dose. The primary outcome measure was the change in median daily pain score (on a 0-10 point numeric rating scale) from 1-week baseline period to the last week of each treatment period. Secondary outcome measures included pain relief of at- and below-level pain, allodynia, spasms and spasticity. RESULTS: A total of 36 patients with SCI at- and or below-level pain were enrolled. Of these, 24 patients completed the trial. We found no effect of levetiracetam on the primary (P=0.46) or any of the secondary outcome measures. Only two patients continued levetiracetam treatment following the trial, and one patient was still in levetiracetam treatment at the 6-month follow-up. Levetiracetam was generally well tolerated with no serious adverse events. CONCLUSIONS: Levetiracetam does not relieve neuropathic pain or spasm severity following spinal cord injury.

A multi-purpose rehabilitation frame: a novel apparatus for balance training during standing of neurologically impaired individuals.

We present a novel mechanical apparatus, named Multi-purpose Rehabilitation Frame (MRF), and methods for balance training during standing of neurologically impaired individuals. The device has two degrees of freedom (DOF), which allow for constrained movement of both lower limbs and pelvis in the sagittal and frontal planes. The MRF aims at improving balancing in impaired individuals by providing a stiffness support and action of perturbations, which facilitate development of alternative balancing strategies. The level of stiffness support and strength of perturbations, which are generated by means of two hydraulic servo-controlled actuators, can be selected according to current balancing abilities of an impaired individual. We further present preliminary results of nine days of balance training in two paraplegic and two incomplete tetraplegic subjects standing in the MRF. All subjects improved their balancing abilities as measured from the level of needed supporting stiffness provided by the MRF.

Sensory function above lesion level in spinal cord injury patients with and without pain.

Patients with spinal cord injury (SCI) may or may not develop central neuropathic pain despite having cord lesions of apparently the same site, extension and nature. The consequences of the cord lesion in the central nervous system and the mechanisms underlying pain are unclear. In this study, we examined sensory detection and pain thresholds above injury level in 17 SCI patients with central neuropathic pain, in 18 SCI patients without neuropathic pain, and in 20 control subjects without injury and pain. The SCI pain group had significantly higher cold and warm detection thresholds compared with the SCI pain free group and controls and higher tactile detection thresholds compared with the SCI pain free group. No difference in pain or pain tolerance thresholds was seen among pain and pain free SCI patients. These data suggest changes in somatosensory function in dermatomes rostral to the segmental injury level linked to the presence of central neuropathic pain in SCI patients. The results are discussed in relation to current concepts of pain inhibitory and facilitating systems.

Serum cystatin C as a marker of the renal function in patients with spinal cord injury.

OBJECTIVE: To investigate the relationship between serum cystatin C, serum creatinine, and (51)Cr-EDTA-clearance in patients with spinal cord injury. SETTING: The Spinal Cord Unit, Viborg-Kjellerup County Hospital. METHODS: Twenty-four men and seven women aged 20.3 to 68.0 years with motor complete spinal cord injury (ASIA A or B) were included. Serum cystatin C was measured by an automated particle-enhanced nephelometric immunoassay (Dade Behring), serum creatinine by an enzymatic method (Vitros 950), and (51)Cr-EDTA-clearance by a multiple plasma sample method. RESULTS: A linear relationship was found between (51)Cr-EDTA-clearance and the reciprocal values of cystatin C and creatinine. The correlation coefficient between (51)Cr-EDTA-clearance and 1/cystatin C was 0.72 compared to the correlation coefficient between (51)Cr-EDTA-clearance and 1/creatinine being 0.26. Comparison of the area under the curves in the non-parametric receiver operating characteristics (ROC) plots for serum cystatin C (area under the curve (AUC)=0.912; SE=0.065), and serum creatinine (AUC=0.507; SE=0.115) revealed significant differences (P-values=0.0005). CONCLUSION: In patients with spinal cord injury serum cystatin C is a better marker of the renal function compared to serum creatinine.

Sensory function in spinal cord injury patients with and without central pain.

Spinal cord injury (SCI) frequently results in neuropathic pain. However, the pathophysiology underlying this pain is unclear. In this study, we compared clinical examination, quantitative sensory testing (QST) and somatosensory evoked potentials (SEPs) in SCI patients with and without pain below spinal lesion level, with a control group of 20 subjects without injury. All patients had a traumatic SCI with a lesion above T10; 20 patients presented with spontaneous central neuropathic pain below lesion level, and 20 patients had no neuropathic pain or dysaesthesia. Patients with and without pain had a similar reduction of mechanical and thermal detection and pain thresholds, and SEPs. SCI patients with central pain more frequently had sensory hypersensitivity (brush- or cold-evoked pain, dysaesthesia or pinprick hyperalgesia) in dermatomes corresponding to lesion level than SCI patients without pain. There was no difference in intensity of pain evoked by repetitive pinprick at lesion level between patient groups. There was a significant correlation between intensity of brush-evoked dysaesthesia at lesion level and spontaneous pain below lesion level of SCI. These data suggest that lesion of the spinothalamic pathway alone cannot account for central pain in SCI patients, and that neuronal hyperexcitability at injury or higher level may be an important mechanism for pain below injury level.

Pain and dysesthesia in patients with spinal cord injury: A postal survey.

STUDY DESIGN: A postal survey. OBJECTIVES: To assess the prevalence and characteristics of pain and dysesthesia in a community based sample of patients with spinal cord injury (SCI) with special focus on neuropathic pain. SETTING: Community. Western half of Denmark. METHODS: We mailed a questionnaire to all outpatients (n = 436) of the Viborg rehabilitation centre for spinal cord injury. The questionnaire contained questions regarding cause and level of spinal injury and amount of sensory and motor function below this level. The words pain and unpleasant sensations were used to describe pain (P) and dysesthesia (D) respectively. Questions included location and intensity of chronic pain or dysesthesia, degree of interference with daily activity and sleep, presence of paroxysms and evoked pain or dysesthesia, temporal aspects, alleviating and aggravating factors, McGill Pain Questionnaire (MPQ) and treatment. RESULTS: Seventy-six per cent of the patients returned the questionnaire, (230 males and 100 females). The ages ranged from 19 to 80 years (median 42.6 years) and time since spinal injury ranged from 0.5 to 39 years (median 9.3 years). The majority (> 75%) of patients had traumatic spinal cord injury. Of the respondents, 77% reported having pain or unpleasant sensations, and 67% had chronic pain or unpleasant sensations at or below lesion. Forty-eight per cent reported that P/D could be evoked by non-noxious stimulation of the skin indicating that allodynia is present in almost half of the patients. Forty-three per cent of respondents took analgesics, 7% received antidepressants or anticonvulsants. CONCLUSION: This survey suggests that pain and dysesthesia are common and serious complaints in SCI patients. Unexpectedly, only 7% of the patients were treated with drugs considered to be most effective in neuropathic pain. This emphasizes the need for a continued research and education on P/D in SCI.