Walking Index for Spinal Cord Injury version II in acute spinal cord injury: reliability and reproducibility.

STUDY DESIGN: Administration of the walking index for SCI (WISCI) II is recommended to assess walking in spinal cord injury (SCI) patients. Determining the reliability and reproducibility of the WISCI II in acute SCI would be invaluable. OBJECTIVES: The objective of this study is to assess the reliability and reproducibility of the WISCI II in patients with traumatic, acute SCI. DESIGN: Test-retest analysis and calculation of reliability and smallest real difference (SRD). SETTING: SCI unit of a rehabilitation hospital. METHODS: Thirty-three patients, median age 44 years, median time since onset of SCI 40 days. Level: 20 cervical, 8 thoracic, 5 lumbar; ASIA (American Spinal Injury Association) impairment scale (AIS) grade: 32 D/1 C. Assessment of maximum WISCI II levels by two trained, blinded raters to evaluate interrater (IRR) and intrarater reliability. RESULTS: The intrarater reliability was 0.999 for therapists A and 0.979 for therapists B, for the maximum WISCI II level. The IRR for the maximum WISCI II score was 0.996 on day 1 and 0.975 on day 2. The SRD for the maximum WISCI II score was 1.147 for tetraplegics and 1.682 for paraplegics. These results suggest that a change of two WISCI II levels could be considered real. CONCLUSIONS: The WISCI II has high IRR and intrarater reliability and good reproducibility in the acute and subacute phase when administered by trained raters.

Two phase 3, multicenter, randomized, placebo-controlled clinical trials of fampridine-SR for treatment of spasticity in chronic spinal cord injury.

STUDY DESIGN: Two randomized, double-blind, placebo-controlled trials. OBJECTIVE: To evaluate the efficacy and safety of fampridine sustained-release tablets (fampridine-SR) 25 mg twice daily for moderate-to-severe spasticity in patients with chronic spinal cord injury (SCI). SETTING: United States and Canada. METHODS: Patients with incomplete chronic SCI were randomized to twice daily fampridine-SR 25 mg or placebo, with a 2-week single-blind placebo run-in, a 2-week titration, 12 weeks of stable dosing, 2 weeks of downward titration and 2 weeks of untreated follow-up. Co-primary end points were the change from baseline, averaged over the double-blind treatment period, for Ashworth score (bilateral knee flexors and extensors) and a 7-point Subject Global Impression of treatment (SGI; 1, terrible; 7, delighted). Secondary end points were: Penn Spasm Frequency Scale; the motor/sensory score from the International Standards for Neurological Classification of SCI; Clinician's Global Impression of Change of neurological status; and the International Index of Erectile Function (men) or the Female Sexual Function Index (women). RESULTS: The populations were 212 and 203 patients in the two studies, respectively. Changes from baseline in Ashworth score were -0.15 (placebo) and -0.19 (fampridine-SR) in the first study, and -0.16 (placebo) and -0.28 (fampridine-SR) in the second study. The between-treatment difference was not significant for either the Ashworth score or the SGI and, with few exceptions, neither were the secondary end points. Fampridine-SR was generally well tolerated; treatment-emergent adverse events (TEAEs) and serious TEAEs were reported with similar frequency between treatments. CONCLUSION: Fampridine-SR was well tolerated. No significant differences were observed between treatment groups for the primary end points of Ashworth score and SGI.

The Walking Index for Spinal Cord Injury (WISCI/WISCI II): nature, metric properties, use and misuse.

STUDY DESIGN: Literature review. OBJECTIVE: To critically review all publications/internet sites that have described/used the Walking Index for Spinal Cord Injury (WISCI II), as a measure of impairment of walking function after spinal cord injury (SCI), in order to identify its psychometric properties, clarify its nature, specify misuse and incorporate the findings in an updated guide. METHOD: A systematic literature search was done of Ovid MEDLINE, CINAHL, PsychINFO, Cochrane Central Register of Controlled Trials, Scopus and electronic sites using key words: WISCI or WISCI II, SCI, paraplegia/ tetraplegia/ quadriplegia and ambulation/gait/walking. Among 1235 citations retrieved, 154 relevant articles/sites were identified, classified and examined by the authors; recommendations were made based on findings. RESULTS AND DISCUSSION: The validity (face/concurrent/content/construct/convergent/criterion) and reliability of the WISCI II has been documented in clinical trials and clinical series, and considered adequate by systematic reviewers. In chronic SCI subjects, reliable determination of the maximum (as opposed to self-selected) WISCI II level requires more time and experience by the assessor. The correct use of WISCI II is clarified for testing acute/chronic phases of recovery after SCI, age of subjects, devices and settings. The WISCI II and walking speed measures may be performed simultaneously. CONCLUSION: The increased use of the WISCI II is attributed to its unique characteristics as a capacity measure of walking function and its strong metric properties. Appropriate use of the WISCI II was clarified and incorporated into a new guide for its use. Combining it with a walking speed measure needs further study.

Validity and reliability of the 10-m walk test and the 6-min walk test in spinal cord injury patients.

STUDY DESIGN: The 10-m walk test (10MWT) and the 6-min walk test (6MWT) have been recommended for assessment of walking in spinal cord injury (SCI) patients. The study was designed on test-retest analysis of the 10MWT and 6MWT. OBJECTIVES: The objective of this study was to assess validity/reliability of different methods of performing the tests. SETTING: The study was set at an SCI unit of a rehabilitation hospital. PATIENTS AND METHODS: A total of 37 patients; whose median age was 58.5 years (interquartile range 40-66, full range 19-77); median time since onset of SCI was 24 months (interquartile range 16.25-70.5, full range 6-109). Non-traumatic etiology in 20 out of 37 patients; level: 12C, 14T and 11L; American Spinal Injury Association Impairment Scale grade: 35D/2C. Assessment with the 10MWT (with or without dynamic start) and the 6MWT (short or long track) by two blinded raters to evaluate inter/intra-rater reliabilities. RESULTS: The 10MWT was performed in a median of 19 s (25th-75th interquartile range 13-28) with the dynamic start and of 18.4 s (25th-75th interquartile range 12.6-29.9) with the static start (P=0.092). The correlation between the results of the two methods was between 0.98 and 0.99. The inter- and intra-rater reliabilities were between 0.95 and 0.99 for both the methods. The 6MWT showed significant differences according to the track length: patients walked a median of 226.7 m (25th-75th interquartile range 123.2-319) on the longer track and of 187.6 m (25th-75th interquartile range 69.7-240.6) on the short one (P<0.001). The correlation between the results of the two methods was between 0.91 and 0.93. The inter- and intra-rater reliabilities were between 0.98 and 0.99. CONCLUSION: The 10MWT shows high inter/intra-rater reliability and shows comparable results with both dynamic and static start. The different testing conditions of the 6MWT (track/turns) results in significant differences that need standardization for use in future trials.

Consumer preference in ranking walking function utilizing the walking index for spinal cord injury II.

STUDY DESIGN: Blinded rank ordering. OBJECTIVE: To determine consumer preference in walking function utilizing the walking Index for spinal cord injury II (WISCI II) in individuals with spinal cord injury (SCI)from the Canada, the Italy and the United States of America. METHOD: In all, 42 consumers with incomplete SCI (25 cervical, 12 thoracic, 5 lumbar) from Canada (12/42), Italy (14/42) and the United States of America (16/42) ranked the 20 levels of the WISCI II scale by their individual preference for walking. Subjects were blinded to the original ranking of the WISCI II scale by clinical scientists. Photographs of each WISCI II level used in a previous pilot study were randomly shuffled and rank ordered. Percentile, conjoint/cluster and graphic analyses were performed. RESULTS: All three analyses illustrated consumer ranking followed a bimodal distribution. Ranking for two levels with physical assistance and two levels with a walker were bimodal with a difference of five to six ranks between consumer subgroups (quartile analysis). The larger cluster (N=20) showed preference for walking with assistance over the smaller cluster (N=12), whose preference was walking without assistance and more devices. In all, 64% (27/42) of consumers ranked WISCI II level with no devices or braces and 1 person assistance higher than multiple levels of the WISCI II requiring no assistance. These results were unexpected, as the hypothesis was that consumers would rank independent walking higher than walking with assistance. CONCLUSION: Consumer preference for walking function should be considered in addition to objective measures in designing SCI trials that use significant improvement in walking function as an outcome measure.

Extent of spontaneous motor recovery after traumatic cervical sensorimotor complete spinal cord injury.

STUDY DESIGN: Retrospective, longitudinal analysis of motor recovery data from individuals with cervical (C4-C7) sensorimotor complete spinal cord injury (SCI) according to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). OBJECTIVES: To analyze the extent and patterns of spontaneous motor recovery over the first year after traumatic cervical sensorimotor complete SCI. METHODS: Datasets from the European multicenter study about SCI (EMSCI) and the Sygen randomized clinical trial were examined for conversion of American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade, change in upper extremity motor score (UEMS) or motor level, as well as relationships between these measures. RESULTS: There were no overall differences between the EMSCI and Sygen datasets in motor recovery patterns. After 1 year, up to 70% of subjects spontaneously recovered at least one motor level, but only 30% recovered two or more motor levels, with lesser values at intermediate time points. AIS grade conversion did not significantly influence motor level changes. At 1 year, the average spontaneous improvement in bilateral UEMS was 10-11 motor points. There was only moderate relationship between a change in UEMS and a change in cervical motor level (r(2)=0.30, P<0.05). Regardless of initial cervical motor level, most individuals recover a similar number of motor points or motor levels. CONCLUSION: Careful tracking of cervical motor recovery outcomes may provide the necessary sensitivity and accuracy to reliably detect a subtle, but meaningful treatment effect after sensorimotor complete cervical SCI. The distribution of the UEMS change may be more important functionally than the total UEMS recovered.

Outcome measures: evolution in clinical trials of neurological/functional recovery in spinal cord injury.

The need to determine the beneficial effect of the treatment of spinal cord injury (SCI) requires clearly defined standardized measures of the severity of injury and how well the function is restored. Improved neurological recovery should be linked to increased capacity to perform tasks such as walking, reaching and grasping, which results in meaningful gains in mobility and self-care. Measurements of recovery, capacity, mobility and self-care are the outcomes used to determine the benefits from the treatment and have evolved over the last century with contributions by the mentors and protégés of Sir Ludwig Guttmann, whom we honor today. Randomized clinical trials in the past 20 years have taught us many lessons as to which outcome measures have the greatest validity and reliability. The International Standards for Neurological Classification of SCI have become the clinical gold standard for measurement of severity, but would benefit from pathophysiological surrogates to better understand the mechanisms of recovery. Measurements of walking capacity have emerged as valid/reliable/responsive and upper extremity measures are in development, which help distinguish neurological improvement from rehabilitation adaptation. Performance of self-care and mobility has been linked to capacity and severity outcomes. In addition, new partnerships between clinical trial entities, professional societies, industry and federal agencies should facilitate identification of priorities and uniformity of measurement standards. Our ultimate goal is to improve the quality of life of those individuals with SCI whom we serve, but we must focus our investigative efforts carefully, systematically and rigorously as clinical scientists.

Immobilization hypercalcemia in acute spinal cord injury treated with etidronate.

Hypercalcemia developed in a 30-year-old C5 quadriplegic six months after he received a gunshot wound in the cervical spine. Short-term treatment consisted of fluids and diuretics, but conventional drug therapy for long-term maintenance of normocalcemia was not effective. A regimen of etidronate disodium was then instituted, which resulted in normocalcemia. When use of this drug was discontinued at intervals during the therapy, the hypercalcemia recurred. The patient's condition was maintained on the etidronate regimen until full mobilization occurred, at which time the drug therapy was discontinued and normocalcemia persisted. This case represents, to our knowledge, the first reported success with the use of etidronate in the treatment of hypercalcemia in the immobilized patient with acute spinal injury.

Denervation and reinnervation of fast and slow muscles. A histochemical study in rats.

A histochemical study, using myosin-adenosine triphosphatase activity at pH 9.4, was conducted in soleus and plantaris muscles of adult rats, after bilateral crushing of the sciatic nerve at the sciatic notch. The changes in fiber diameter and per cent composition of type I and type II fibers plus muscle weights were evaluated along the course of denervation-reinnervation curve at 1, 2, 3, 4 and 6 weeks postnerve crush. The study revealed that in the early denervation phase (up to 2 weeks postcrush) both the slow and fast muscles, soleus and plantaris, resepctively, atrophied similarly in muscle mass. Soleus increased in the number of type II fibers, which may be attributed to "disuse" effect. During the same period, the type I fibers of soleus atrophied as much or slightly more than the type II fibers; whereas the type II fibers of plantaris atrophied significantly more than the type I fibers, reflecting that the process of denervation, in its early stages, may affect the two fiber types differentially in the slow and fast muscles. It was deduced that the type I fibers of plantaris may be essentially different in the slow (soleus) and fast (plantaris) muscles under study. The onset of reinnervation, as determined by the increase in muscle weight and fiber diameter of the major fiber type, occurred in soleus and plantaris at 2 and 3 weeks postcrush, respectively, which confirms the earlier hypotheses that the slow muscles are reinnervated sooner than the fast muscles. It is suggested that the reinnervation of muscle after crush injury may be specific to the muscle type or its predominant fiber type.

Functional assessment measures in CNS trauma.

How effectively the survivor of CNS trauma can function in society is the ultimate clinical outcome. Many victims of spinal cord injury (SCI) and traumatic brain injury (TBI) are frequently left with permanent impairment. Measurements of impairment, and the direct relationship to the functional loss and resultant disability, should be the gold standard for determining the effectiveness of interventions. The primary impairments in SCI are motor and sensory loss while those in TBI are neurobehavioral disorders. Classifications for impairment are reasonably well defined in SCI and several approaches are gaining wide acceptance. We hope that internationally agreed upon standards will be forthcoming within the year. The functional independence measure (FIM), which was developed in the past 6-7 years, will be added to the standards. It shows good reliability for SCI as an overall assessment and some of the specific categories of self-care and mobility. An extension of the FIM is needed for more precise measurement of function in quadriplegic subjects. Classification of impairment in TBI has been more difficult. While the Glasgow Outcome Scale has gained international acceptance for almost 10 years, it has limitations in gradations from the moderate disability to the good recovery groups. The Disability Rating Scale (DRS) has shown good reliability, better precision than the Glasgow Outcome Scale, and greater reliability than other measures. An extension of the FIM, called the functional assessment measure (FAM), and the DRS are currently being tested by regional TBI centers in the United States. Functional assessment measures should be available within the next several years.

Motor power differences within the first two weeks post-SCI in cervical spinal cord-injured quadriplegic subjects.

The purpose of this study was to confirm the clinical impression that motor power significantly changed within the first 2 weeks after a spinal cord injury (SCI) and to determine the time for motor power assessment within the first 2 weeks post injury that best correlated with motor power determined 6 months post-SCI. Our hypothesis was that within the first 2 weeks postinjury, the manual muscle test (MMT) scores would change significantly from the < or = 24 h examination and that the post-24 h evaluations of strength would have a higher correlation with the 6 month measure of motor outcome than the evaluation of strength performed < or = 24 h after SCI. The biceps, extensor carpi radialis, triceps, flexor digitorum profundus, and interosseous muscle strength was measured in 40 subjects using the MMT (muscles graded 0/5 to 5/5) at < or = 24 h, 72 h, 1 week, 2 weeks, 3 months, and 6 months post-SCI. Upper extremity motor index scores (MIS) obtained at the four testing periods within 2 weeks of injury were analyzed using a Friedman analysis of variance with Duncan's post-hoc tests to identify significant differences. Separate analyses were performed on subgroupings of the total sample based on the strength of the most rostral key muscle having less than antigravity strength. There were three groups evaluated: initial MMT 0/5 (n = 22), initial MMT 1-1.5/5 (n = 17), and initial MMT 2-2.5/5 (n = 13).(ABSTRACT TRUNCATED AT 250 WORDS)

Wrist strength measured by myometry as an indicator of functional independence.

The purpose of this study was to show that independence of self care activities of motor complete quadriplegic patients related better to the force of contraction of the wrist extensor (WE) muscles measured by a hand held myometer than to the manual muscle test (MMT) for grades 3 to 5. The patients (n = 24), identified by having unilaterally or bilaterally functional WE muscle (MMT > or = 3/5) with bilateral elbow extensor (EE) muscles < 3/5, were evaluated at 2 to 6 months after injury for four feeding activities utilizing the Quadriplegia Index of Function (QIF). We found 54% were independent drinking from a cup, 58% using a spoon or fork, 13% cutting food, and 23% pouring liquids. Comparisons were made between right, left, and bilateral mean myometry scores and median MMT scores for each of the QIF activities. The independent group of patients had myometry scores 54 to 140% greater (p < 0.05) than those patients dependent in the self care activity except when the right or left WE myometric score was analyzed for cutting food (p = 0.1). MMT comparisons showed no significant median score differences in any activity performed. There were no patients with only one WE muscle > or = 3/5 (n = 9) who were able to cut food or pour liquids independently. In conclusion, myometry appeared to be a better indicator than the MMT for some self care activities evaluated utilizing the Quadriplegia Index of Function.

Capillary fiber ratio and electrolyte content of compensatory hypertrophied rat soleus.

Capillary-to-fiber ratio and the content (mu moles/g muscle) of Na, K, Mg, Ca and Zn was measured in compensatory hypertrophied (CH) soleus muscles of adult Sprague-Dawley rats. The soleus hypertrophy was induced by unilateral tenotomy of the gastrocnemius and the plantaris muscles. Seven days after synergistic tenotomy the compensatory hypertrophied Soleus muscles showed no difference in the capillary-fiber ratio, Sr-extractable calcium ([Ca]Ext.) or the total content of Na, K, Mg and Zn. However, compared to the contralateral control side, the CH muscles showed an increase in the wet muscle weight (31.6%, P less than 0.01) and a significant decline (57.1%, P less than 0.05) in the residual calcium ([Ca]Res.) and 43.2% (P less than 0.05) decrease in the total calcium ([Ca]Total) content. It is concluded that during compensatory hypertrophy of skeletal muscles, the residual Ca reserves are significantly depleted, which may lead to a lower isometric tension generation in the muscle.

Compensatory hypertrophy of the soleus in tumor-bearing rats.

Compensatory hypertrophy of the rat soleus was compared between normal rats (N) and rats bearing a non-metastasizing mammary tumor (TB). Two weeks after the tumor inoculation, introduced subcutaneously on the midline of the upper back, the two groups of rats underwent unilateral tenotomy of the plantaris and gastrocnemius muscles to induce functional overload or compensatory hypertrophy of the soleus. One week later, the body weight (BW), wet muscle weights (MW), percent of Type I (slow-twitch) and Type II (fast-twitch) muscle fibers and contractile parameters of the isometric twitch (Pt) and tetanic (Po) tensions were evaluated. The TB animals did not show any signs of cancer cachexia. The sham-operated control soleus muscles of the two groups were similar in wet MW, maximum isometric Pt and Po. The latent period (LP), the contraction time (CT), the half relaxation time (HRT) and the number of Type I (slow-twitch) fibers were increased significantly. The hypertrophied muscles in the N and TB rats showed significant declines in the maximum isometric Pt, compared to their respective controls. These data suggest that the compensatory hypertrophy of muscle is expressed similarly in both the normal and tumor-bearing rats but that it interferes with the generation of isometric twitch tension in the muscle.

Reanalysis of central cervical cord injury management.

Early investigators indicated that conservative management was superior to operative intervention in the treatment of central cord injuries. Their clinical data suggested that operative treatment, in fact, worsened the condition. Recent experience with this clinical entity, however, indicates that in selected patients operative intervention may be of value in improving the rate and degree of motor recovery. A retrospective study of all individuals admitted to our hospital (Delaware Valley Spinal Cord Injury Center) with central cervical spinal cord injury was done (28 patients). One-half had been treated with medical therapy alone (Group I); the others were treated both medically and surgically (Group II). Medical therapy consisted of intravenous mannitol, dexamethasone, and sodium bicarbonate given during the acute phase of the injury. Both groups were immobilized using either a halo or a Philadelphia collar. Criteria for entry into the surgical group were one or both of the following: (a) failure to improve progressively after an initial period of improvement, with persistent compression of neural tissue visualized on myelography and (b) unacceptable instability of the spinal bony elements. The patients were given neurological scores based on the motor power of the major muscle groups. The stability of the spine was scored using the Panjabi-White scale. The two groups were compared using Student's t-test and the two-factor analysis of variance. There was no significant difference in initial neurological scores between the groups. The surgical groups had a higher incidence of instability of the bony elements of the cervical spine, as judged by the Panjabi-White scale.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurological assessment in spinal cord injury.

Precise and reliable neurologic assessment is a necessary tool for determining the extent and pattern of recovery after SCI. Recently agreed upon international standards establish a uniform neurologic classification to measure clinical outcomes. They are currently in use in three multicenter studies in more than 40 SCI centers in the United States. The Model System SCI centers report the use of these measures, such as impairment grades and neurologic levels, in almost 15,000 cases over the past 20 years and, more recently, motor scores in 3,500 patients. The NASCIS II multicenter trial on methylprednisolone used motor and sensory scores as endpoints in close to 500 patients, but have incorporated the international standards, which include a disability measure, in NASCIS III. The study of ganglioside effectiveness also is using these measures in many patients. In more focused studies, neurologic assessment soon after injury can predict walking in motor complete injuries based on pin prick sensation, and in motor incomplete injuries based on impairment grade and age. Eventual upper extremity function can be estimated based on the motor examination within 72 hours of injury. Both the motor score and motor level are more reliable in predicting upper extremity function than the single sensory level. This presumably reflects the greater importance of motor recovery on functional outcome. The proximal muscles of the lower extremities caudal to the lesion site recover before distal muscles, and this may be mediated by axons descending in the ventral tracts, which control primarily proximal rather than distal muscles. These axons may be preferentially spared and/or have greater capacity to compensate than those present in the lateral columns. In conclusion, standard neurologic assessment in SCI is extremely valuable in monitoring recovery in order to prognosticate functional outcome, evaluate effectiveness of drug interventions, and provide valuable clues to possible underlying mechanisms of recovery. The elucidation of these mechanisms will aid in the refinement of current treatments and development of new strategies to enhance neurologic recovery and functional outcome.

Establishing prognosis and maximizing functional outcomes after spinal cord injury: a review of current and future directions in rehabilitation management.

STUDY DESIGN: Review article. OBJECTIVES: To review the medical literature and provide a framework for predicting neurorecovery and functional outcomes after spinal cord injury based on injury severity. SUMMARY OF BACKGROUND DATA: The ability to accurately predict the magnitude of neurorecovery and expected functional outcomes after spinal cord injury is of great importance. This information is needed to justify medical and rehabilitation interventions to third party payers as well as to begin the process of planning for postdischarge care. Over the past several decades, significant progress has been made in accurately predicting neurorecovery and its impact on functional outcomes. METHODS: Structured review of published reports obtained through MED-LINE search and texts. RESULTS/CONCLUSION: Within 72 hours to 1 month after a spinal cord injury, it is possible to predict with reasonable accuracy the magnitude of expected recovery based on physical examination. The impact of motor level on long-term functional outcomes is also clear and has remained relatively unchanged for several decades. Functional outcomes are likely to improve in upcoming years as novel interventions, such as drugs and functional neuromuscular stimulation, are developed with the goals of limiting secondary injury and restoring neurologic function. New training methods, such as body weight support, that use activity-dependent neuroplasticity will also have a more prominent role.

The management of neurogenic bladder and sexual dysfunction after spinal cord injury.

STUDY DESIGN: Review article. OBJECTIVES: To review the medical literature and comprehensively discuss the management of bladder and sexual dysfunction after spinal cord injury. SUMMARY OF BACKGROUND DATA: The physiologic alterations that accompany spinal cord injury can lead to significant bladder and sexual dysfunction. Fertility in men is also diminished. Without appropriate intervention, the above conditions can lead to significant morbidity and mortality. METHODS: Structured review of published reports obtained through a MED-LINE search and texts. RESULTS/CONCLUSION: With appropriate surveillance and management, morbidity and mortality from neurogenic bladder dysfunction can be successfully prevented. Current treatment interventions also facilitate the restoration of sexual function and fertility after spinal cord injury.

Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds.

The purpose of this study was to demonstrate that Gardner-Wells skull tong traction up to 140 lb was both safe and effective in reducing dislocation, without fractures, of facet joints involving the C4-C7 vertebral bodies when applied by experienced practitioners in a spinal cord injury center under close scrutiny. Twenty-four awake patients were selected for the study (age range, 16-82 years). These patients were evaluated for the number of millimeters (7-17 mm) of dislocation as measured from the posterior aspect of the superior vertebral body to the posterior aspect of the inferior vertebral body at the level of injury. The maximum weight required to produce the reduction of the facet joints and the time from the onset of traction were recorded. The patients' neurologic status was monitored before traction, after each increment in weight applied, and after reduction. Careful examination of motor function and sensation was done and recorded at each interval. The 24 patients with cervical spine dislocation of the facet joints underwent successful reduction with traction weights (range, 10-140 lb). Seventeen patients required weights of more than 50 lb. The traction procedures lasted for a period of 8-187 minutes per procedure. Worsening neurologic status did not occur in any of the patients involved in this study.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost of walking and locomotor impairment.

The aim of the present study was to evaluate the importance and the necessity of metabolic measurements to quantify locomotor impairment in a clinical context. Oxygen consumption, heart rate, pulmonary ventilation and walking speed were measured during locomotion in 14 normal subjects, used as a control group, and 82 patients with different pathologies [hemiparetic, paraparetic, tetraparetic, orthopaedic and paraplegic patients, who walked using a reciprocating gait orthosis (RGO)]. The subjects were characterized on the basis of a cumulative impairment score (CIS), based on clinical scales commonly used to evaluate impairment and disability in locomotion. Appropriate indices of energy, cardiac and ventilatory costs expressed per metre walked, globally called physiological costs, were obtained. It resulted that the most comfortable speed (MCS) of normal subjects was significantly higher than that of each group of patients. Normal subjects' physiological costs were found to be significantly lower than those of patients who needed either a device or the help of a person to walk. All measured parameters correlated significantly with each other. The MCS was found to be the most correlated parameter with the CIS (r = 0.8), and therefore it must be considered the best single measurement, if only one is to be used. Measurements more precise than MCS, such as the physiological costs, may be necessary in clinical trials.