Lower extremity fractures after spinal cord injury: a retrospective study.

Lower extremity fractures after spinal cord injury (SCI) are more common in paraplegic than in quadriplegic persons, probably due to their greater activity level. Most of the fractures are pathologic in osteoporotic bones and most occur without known trauma or are caused by trivial injury. Supracondylar or shaft fractures of the femur are most common. Although callus formation is usually fast, exuberant fracture healing may be delayed. The main management goal, maintenance of functional independence without complications of SCI, is best obtained by a nonsurgical approach with traction or well-padded cast followed by early joint mobilization.

Amitriptyline in severely depressed spinal cord-injured patients: rapidity of response.

Nine severely depressed spinal cord-injured patients, six quadriplegic and three paraplegis, required psychiatric consultations and were treated with amitriptyline, with particular attention to the speed of response. The degree of depression was rated by using an Emergency Depression Rating Scale for Plegic Patients designed by one of the authors. All the study patients were initially rated as severely depressed, and within 72 hours their rating scores rose to the upper level of mild depression. These findings contrast with the accepted and widely reported phenomenon that in physically intact depressed patients, a positive response to tricyclic antidepressants is seen only after a 14- to 21-day interval. Several possible explanations of these findings are given, yet further in-depth explorations into the effects of tricyclic antidepressant medication on neurologically damaged patients are needed.

Pneumatic orthosis for paraplegic patients: functional evaluation and prescription considerations.

Fourteen paraplegic patients were studied during ambulation training, 11 with pneumatic orthoses and with conventional metal orthoses, and 3 with pneumatic orthoses only. The purposes of the study were to establish whether pneumatic orthoses could be used by paraplegic patients for effective ambulation, whether these devices presented any advantages or disadvantages over conventional orthoses and how their use would affect the expected level of rehabilitation and independence. As far as application, standing up, sitting down and ambulation within a rehabilitation center are concerned, similar skills and levels of independence were obtained with both types of orthoses. Reduced tendency for orthostatic hypotension, availability, light weight and better endurance make the pneumatic orthosis especially suitable for early ambulation training, but several mechanical problems, mainly its inflation with motorized and heavy compressor units, limit its usefulness for community ambulation.

Spinal cord injury: effect of thyrocalcitonin on periarticular bone formation in three subjects.

Sodium fluoride 18F scintimetry was performed before and after 1 month of salmon thyrocalcitonin treatment of 3 spinal cord injured patients with periarticular ossification of the hips and knees. Thyrocalcitonin therapy caused a marked diminution of 18F uptake in 1 patient with long-standing periarticular bone of both hips. Clinically, the range of motion in this subject increased by 25 degrees and there was a marked decrease in pain locally. The results were, however, not duplicated in the 2 patients with periarticular bone formation of short duration.

Environmental and typewriter control systems for high-level quadriplegic patients: evaluation and prescription.

A formal 44-month clinical evaluation was conducted to determine the suitability of selected electronic equipment for use in high-level quadriplegia. A total of 52 traumatic high-level quadriplegic patients (C-2 to C-5,6) participated in the testing of 13 commercial electronic assistive devices including 8 environmental control units, 1 self-contained telephone, and 4 typewriter systems. Most devices were pneumatically ("breath") controlled. Devices were tested in an occupational therapy laboratory, bedside, and homes. Testing yielded data on device reliability, suitability, and acceptance by patients.

Electronic assistive devices: their impact on the quality of life of high level quadriplegic persons.

The impact of electronic assistive devices (ie, the environmental control system or ECS) on the day-to-day living of high-level quadriplegics (C3-C5) was studied. Twenty male quadriplegic persons (7 ECS users and 13 nonusers) were interviewed using the following material: Activity Pattern Indicators (APIs), Bell Adjustment Inventory, Locus of Control, Multiple Affect Adjective Checklist and McClelland's adaptation of the Thematic Apperception Test. It was found that ECS impact was most clearly demonstrated in the API results. The ECS users made greater use of a variety of adaptive devices to function relatively more independently and with minimal assistance. The users participated in more activities and spent considerably more time educating themselves than the nonusers, who more frequently participated in quiet activities and spent more time in passive recreational activities in residence. Since the ECS and other adaptive devices have a positive impact on the lives of users, patients should be exposed to them as early as possible in their rehabilitation programs to promote their acceptance. Additionally, home planning and equipment ordering should be done conjointly before discharge so that patients and their families do not become acclimated to a less safe and less efficient way of functioning. An assessment protocol consisting of both intrapsychic and behavioral measures (similar to the one presented in this article) is recommended as a comprehensive and systematic way of evaluating both the short- and long-term effects of using assistive devices.

Pituitary-testicular axis dysfunction in spinal cord injury.

Concentrations of testosterone, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) in serum and 17-ketosteroids (17-KS) in urine of 10 paraplegic and 10 quadriplegic subjects were measured from onset of injury and followed once a week for 4 months. Compared with age-matched normal controls, paraplegic subjects showed significantly lower serum levels of LH and FSH for 2 weeks and of testosterone for 6 weeks after spinal cord trauma, following which periods of time these hormones attained normal levels. By contrast, in quadriplegic subjects, serum testosterone concentrations remained significantly lower than those of the controls during the entire 4-month testing period. Furthermore, in another group of 10 chronic (1 to 6 years after onset of injury) paraplegic and 10 chronic quadriplegic subjects, serum testosterone and FSH concentrations were comparable to those of the normal controls. Serum LH concentrations were at control levels in chronic paraplegic but significantly depressed in chronic quadriplegic subjects. The concentrations of urinary 17-KS exhibited sharp fluctuations over the 4-month period and were below control levels in paraplegic but within control limits in quadriplegic subjects. The results indicate that the function of the hypothalamic-pituitary-gonadal axis is disturbed for at least 4 months in quadriplegic subjects.

Spinal cord injury: effect of thyrocalcitonin on calcium, magnesium and phosphorus in paraplegic rats.

Calcium, magnesium and phosphorus balances were studied in 20 paraplegic rats (T5) fed ad libitum an 18% casein diet. Ten of the paraplegic animals were treated daily with 4MRC (Medical Research Council) units of thyrocalcitonin. Ten sham-operated rats served as controls. Spinal cord transection caused an immediate increase in urinary excretion of calcium, 550 +/- 70 micrograms/24 hr, compared with controls levels, 257 +/- 85 micrograms/24 hr. Paraplegia also resulted in an elevated excretion of fecal calcium, 39 +/- 5 mg/24 hr, phosphorus, 42 +/- 7 mg/24 hr, and magnesium, 4.6 +/- 0.8 mg/24 hr, compared with that of controls, 26 +/- 6 mg/24 hr, 32 +/- 6 mg/24 hr and 2.7 +/- 0.8 mg/24 hr for calcium, phosphorus and magnesium, respectively. Administration of thyrocalcitonin to paraplegic rats further increased urinary excretion of calcium, 835 +/- 186 micrograms/24 hr. However, fecal losses of calcium, 19 +/- 5mg/24 hr, phosphorus, 31 +/- 6mg/24 hr, and magnesium, 2.6 +/- 0.4mg/24 hr, which were elevated following spinal cord transection, were markedly reduced after thyrocalcitonin treatment. As a result, balances of these compounds, which were depressed in rats following spinal cord transection, were "normalized" after treatment with thyrocalcitonin. It would seem, therefore, worthwhile to study the effect of thyrocalcitonin in spinal cord injured humans in an effort to determine whether or not it would be helpful in improving mineral balances.

Mineral metabolism in spinal cord injury.

In 10 paraplegic and 10 quadroplegic subjects, bone resorption was investigated by determining urinary excretion of hydroxyproline, calcium, and phosphorus. Measurements were performed weekly from the onset to 4 months after injury. During the first 7 weeks following injury, urinary excretion of calcium in paraplegic and quadriplegic subjects reached the highest level (380 +/- 180 mg/24hr). From 7 to 16 weeks after injury average urinary excretion of calcium (245 +/- 72 mg/24hr) remained significantly greater than that in controls (100 +/- 25 mg/24hr; p less than 0.05). Urinary hydroxyproline was elevated in paraplegic subjects (80 +/- 18 mg/24hr) for 8 weeks and in quadriplegic subjects (102 +/- 37 mg/24hr) for the entire 16 weeks following injury compared with that in controls (48 +/- 12 mg/24hr; p less than 0.05). Both paraplegic and quadriplegic subjects excreted more phosphorus (1.6 +/- 0.4 gm/24hr) than controls (0.85 +/- 0.2 gm/24hr; p less than 0.05) only during the first 2 weeks following spinal cord injury. During the acute phase of the injury (0-3 months), urinary excretion of calcium and magnesium was significantly higher (p less than 0.05) in subjects with complete compared with incomplete spinal cord lesions.

Head-up tilt effect on glomerular filtration rate, renal plasma flow, and mean arterial pressure in spinal man.

Changes in glomerular filtration rate (GRF), renal plasma flow (RPF), and mean arterial pressure (MAP) were measured in subjects tested in supine and head-up tilt positions with various levels of spinal cord lesion and thus with different degrees of supraspinal sympathetic vasomotor control. Responses of paraplegic subjects to head-up tilt were not significantly different from those of normal controls but GFR and RPF were significantly lower in quadriplegics in the supine position. With tilt, MAP and RPF decreased significantly, but the fall in GFR was not significant. In all 3 groups, the GFR during head-up tilt was similar, indicating that in spite of the great loss of supraspinal sympathetic control, quadriplegic subjects apparently equally-constrict their afferent and efferent renal arterioles during orthostatic stress and thus prevent excessive fall of GFR.