Clinical prognostic factors for bladder function recovery of patients with spinal cord and cauda equina lesions.

OBJECTIVE: To investigate the relationship between lesion severity and other clinical factors and bladder function recovery. PATIENTS AND METHODS: The charts of 269 patients with traumatic and non traumatic spinal cord lesion (SCL) were reviewed and the following information was recorded: lesion to admission time, injury variables, length of stay and neurological status. At five months, urological outcome was assessed by voiding modalities, and urodynamics according to International Continence Society. Logistic approach with univariate and multivariate analysis. RESULTS: Both ASIA impairment at admission and age were significantly correlated with bladder function outcome. None of the patients with ASIA A impairment at admission reached volitional voiding at five months. ASIA B patients had a 90% lower probability of achieving good bladder control and ASIA C ones a 65% lower than ASIA D patients (p < 0.05). Older patients had a significant lower probability (60%) of achieving volitional voiding than younger ones (p < 0.05). Of the 121 patients with ASIA D impairment at discharge only 78 voided spontaneously and showed a higher frequency of cervical lesions and a lower frequency of detrusor-external sphincter dyssynergia. DISCUSSION AND CONCLUSION: Bladder recovery in patients with complete SCL is limited. ASIA B patients showed a better neurological recovery and, concurrently, better bladder function recovery than ASIA A patients, thus demonstrating the importance of sensation preservation for recovery. Younger patients show better bladder recovery than older ones, probably because of different efficiency of spinal cord plasticity. Finally, patients with good neurological recovery may not achieve volitional voiding. Patients with bladder function recovery show a higher frequency of central cord and Brown-Sequard syndromes (with better prognosis) and a lower frequency of detrusor-sphincter dyssynergia.

Utility of delayed spinal cord injury rehabilitation: an Italian study.

The objective was to examine the utility of delayed spinal cord injury rehabilitation. The design was a retrospective study in the spinal unit of a large rehabilitation hospital. The participants were 117 patients at their first rehabilitation admission with an event to admission time of 90 days or more. The main outcome measures were the Barthel Index, Rivermead Mobility Index, Walking Index for Spinal Cord Injury and motor scores at admission and discharge; relative changes were examined. Patients showed a significant increase in all the outcome measures and achieved independence or assisted independence; significant neurological improvement and improvement in walking were recorded too; most of the patients were discharged home. The present data demonstrate the utility of delayed rehabilitation and highlight the importance of having rehabilitation in a specialised setting.

Cross-cultural differences in preference for recovery of mobility among spinal cord injury rehabilitation professionals.

STUDY DESIGN: Direct observation of a constrained consensus-building process in three culturally independent five-person panels of rehabilitation professionals from the US, Italy and Canada. OBJECTIVES: To illustrate cultural differences in belief among rehabilitation professionals about the relative importance of alternative functional goals during spinal cord injury (SCI) rehabilitation. SETTING: Spinal Cord Injury Units in Philadelphia-USA, Rome-Italy and Vancouver-Canada. METHODS: Each of the three panels came to independent consensus about recovery priorities in SCI utilizing the features resource trade-off game. The procedure involves trading imagined levels of independence (resources) across different functional items (features) assuming different stages of recovery. RESULTS: Sphincter management was of primary importance to all three groups. The Italian and Canadian rehabilitation professionals, however, showed preference for walking over wheelchair mobility at lower stages of assumed recovery, whereas the US professionals set wheelchair independence at a higher priority than walking. CONCLUSIONS: These preliminary results suggest cross-cultural recovery priority differences among SCI rehabilitation professionals. These dissimilarities in preference may reflect disparities in values, cultural expectations and health care policies.

Walking index for spinal cord injury (WISCI): criterion validation.

STUDY DESIGN: Retrospective examination. OBJECTIVES: To compare the Walking Index for Spinal Cord Injury (WISCI) and current scales for their sensitivity to walking changes in subjects with a spinal cord lesion (SCL) and further validate the WISCI for use in clinical trails. SETTING: A large rehabilitation hospital in the center of Italy. PATIENTS AND METHODS: Retrospective review was performed on 284 patient records with an SCL. Measurements included neurological evaluation with Lower Extremity Motor Scores (LEMS) according to the American Spinal Injury Association (ASIA) and walking status assessed by Barthel Index (BI (0-15)), Rivermead Mobility Index (RMI (three levels)), Functional Independence Measure (FIM (1-7)), Spinal Cord Independence Measure (SCIM (0-8)), and WISCI (0-20). The WISCI is a 21-level hierarchical scale which incorporates gradations of physical assistance and devices required for walking. Improvement in walking is based on the change of scores from admission to discharge. Statistical analysis included Spearman rank correlation and chi2 test; P<0.05. RESULTS: There was a significant positive correlation between WISCI and other scales (WISCI and BI r=0.67, P<0.001; WISCI and RMI r=0.67, P<0.001; WISCI and SCIM r=0.97, P<0.001; WISCI and FIM r=0.7, P<0.001). The initial ASIA grade was predictive of mobility outcome on the WISCI: of the 78 ASIA A patients, only five achieved independent walking versus 4/17 ASIA B (P=0.02), 56/109 ASIA C (P<0.001) and 39/44 ASIA D (P<0.001). The correlation of LEMS to the WISCI was 0.58 (P<0.001). At discharge, patients were distributed into 12 WISCI levels versus four FIM, three BI, two RMI and five SCIM levels. The most frequent WISCI levels at discharge were 13 (walker, no braces or assistance), 16 (two crutches, no braces or assistance) and 20 (no devices or assistance). CONCLUSIONS: Similar correlation between the WISCI and the other scales indicates that all these measures address the same concept, mobility, which is a measure of concurrent validity. The correlation is not 100% because of conceptual differences (the WISCI incorporates gradations of physical assistance and devices required for walking while most of the other scales focus on burden of care or mobility in the environment). The WISCI is more detailed and appears more sensitive to walking recovery than the other scales, as demonstrated by our patients' score distribution at discharge. Within each of the most frequent WISCI levels (13, 16, 20) LEMS and other walking features varied; therefore the scale would benefit from further refinement based on speed, distance and energy cost.

A prototype of an adjustable advanced reciprocating gait orthosis (ARGO) for spinal cord injury (SCI).

OBJECTIVE: To develop a reciprocating gait orthosis which could be used in different sized patients. DESIGN: Clinical trial and orthotic development. SETTING: A large rehabilitation hospital in Rome, Italy PATIENTS AND METHODS: To carry out this project normal reciprocating gait orthosis parts were used. The device was modified to adjust the hip-ankle height, and the hip-hip distance. It was tested, by five patients already walking with standard ARGO, to evaluate the performances of the orthosis. The device has been tested on seven newly injured patients fulfilling specific criteria of different height and weight. MAIN OUTCOME MEASURES: Prototype suitability; patients appreciation. RESULTS: The device can be used for persons between 1.60 m and 1.85 m tall, weighing up to 100 kg. The orthosis allows an upright position without the use of the hands, and walking with a walker or with two canes. The foot orthosis cover sizes 36-40 (British 3-7) and 41-45 (British 7-11). With the exception of donning, doffing and lifting, the walking performances of the prototype and the general appreciation is comparable with those of a standard device. After a short period of training all seven patients were able to walk in the parallel bars. All of them expressed general appreciation for the device; despite this only four patients wanted the orthosis, two refused it and one has not decided yet. CONCLUSIONS: The prototype allows the same standing and walking performances of normal ARGO. It could be used in spinal cord injury patients to let them test the potential of the device and thus be useful in the effort to reduce the percentage of ARGO rejection.

Pressure sores and blood and serum dysmetabolism in spinal cord injury patients.

STUDY DESIGN: Spinal cord injury (SCI) patients with pressure sores were studied before and after surgical intervention for ulcer healing and compared with matched SCI patients without sores and with patients with pressure sores and other diseases. OBJECTIVE: To analyse the relationship between pressure sores and anaemia and serum protein alteration in SCI patients. To study the pathogenesis of these alterations and suggest appropriate therapy. SETTING: Spinal cord unit in Rome, Italy. SUBJECTS: A total of 13 SCI patients with pressure sores, 13 comparable patients without pressure sores and four patients with other diseases and pressure sores. MAIN MEASURES: Haematochemical parameters. RESULTS: Patients with pressure sore showed significant decreased red cells, decreased haemoglobin and haematocrit, increased white cells and ferritin and decreased transferrin and transferrin saturation; total hypoproteinemia and hypoalbuminemia with increased Alfa-1 and gamma globulins increased erythrocyte sedimentation rate and C-reactive protein were also present. The alterations returned to normal after surgical intervention for pressure sore healing. CONCLUSIONS: Patients with pressure sores suffer from anaemia and serum protein alteration that fells within the range of metabolic alteration of chronic disorders and neoplastic diseases. The alterations depend on a decreased utilisation of iron stores in the reticuloendothelial system and on inhibition of the hepatic synthesis of albumin. With regard to treatment, iron treatment should be avoided because of the risk of haemochromatosis.

Effects on age on spinal cord lesion patients' rehabilitation.

STUDY DESIGN: The present study was undertaken to focus the age-related characteristics of a population of traumatic and nontraumatic spinal cord patients. OBJECTIVES: to examine demographic, injury and outcome characteristics of older adults with spinal cord lesions as a result of trauma and nontrauma, and to compare these characteristics with those of younger patients in matched cohorts. SETTING: Spinal Cord Unit, Fondazione Santa Lucia IRCCS, a large rehabilitation hospital of the centre-south of Italy. METHODS: In total, 284 consecutive newly injured patients with traumatic and nontraumatic spinal cord lesions were retrospectively reviewed and divided according to age into two groups: under 50 years (group 1) and over 50 years (group 2). The following information was collected: onset of lesion to admission; injury variables: aetiology, level, associated injuries, medical complications and surgical intervention; length of stay; American Spinal Injury Association (ASIA) impairment and motor scores; Barthel Index (BI) and Rivermead Mobility Index (RMI) to assess independence in daily living; Walking Index for Spinal Cord Injury to assess ambulation; patients destination at discharge. In a subset of 130 subjects, a block design, matching procedure was used to control for the covariant effects of injury characteristics, time from lesion and aetiology on age effects. RESULTS: In the entire group of 284 patients, older subjects had a higher probability of having incomplete tetraplegia of nontraumatic origin; they also showed a shorter length of stay and a higher rate of complications. In the matched cohorts, younger patients showed better neurologic recovery (intended as ASIA impairment grade improvement and motor scores increase), significantly higher Barthel Index and RMI at discharge, a higher level of independence in spontaneous bladder and bowel management and a higher frequency of independent walking. CONCLUSION: Older individuals with spinal cord injury and disease do well, but have a less favourable outcome in regard to walking, bladder and bowel independence than younger subjects and have more associated medical problems. Different rehabilitative strategies, therefore, are required for older subjects, which maximises the shorter length of stay and provides the necessary medical care and increased physical assistant resources following discharge.