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3.  2009 Review and Revisions of the International Standards for the Neurological Classification of Spinal Cord Injury 
Summary:
The International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) were recently reviewed by the ASIA's Education and Standards Committees, in collaboration with the International Spinal Cord Society's Education Committee. Available educational materials for the ISNCSCI were also reviewed. The last citable reference for the ISNCSCI's methodology is the ISNCSCI Reference Manual, published in 2003 by ASIA. The Standards Committee recommended that the numerous items that were revised should be published and a precedent established for a routine published review of the ISNCSCI. The Standards Committee also noted that, although the 2008 reprint pocket booklet is current, the reference manual should be revised after proposals to modify/revise the ASIA Impairment Scale (AIS as modified from Frankel) are considered. In addition, the Standards Committee adopted a process for thorough and transparent review of requests to revise the ISNCSCI.
PMCID: PMC2964022  PMID: 21061894
Spinal cord injuries; Evidence-based medicine; International Standards for the Neurological Classification of Spinal Cord Injury
4.  Correction 
PMCID: PMC2964023
5.  Physiotherapy Secretion Removal Techniques in People With Spinal Cord Injury: A Systematic Review 
Objective:
To address whether secretion removal techniques increase airway clearance in people with chronic spinal cord injury (SCI).
Data Sources and Study Selection:
MEDLINE/PubMed, CINAHL, EMBASE, and PsycINFO were searched from inception to May 2009 for population keywords (spinal cord injury, paraplegia, tetraplegia, quadriplegia) paired with secretion removal–related interventions and outcomes. Inclusion criteria for articles were a research study, irrespective of design, that examined secretion removal in people with chronic SCI published in English.
Review Methods:
Two reviewers determined whether articles met the inclusion criteria, abstracted information, and performed a quality assessment using PEDro or Downs and Black criteria. Studies were then given a level of evidence based on a modified Sackett scale.
Results:
Of 2,416 abstracts and titles retrieved, 24 met the inclusion criteria. Subjects were young (mean, 31 years) and 84% were male. Most evidence was level 4 or 5 and only 2 studies were randomized controlled trials. Three reports described outcomes for secretion removal techniques in addition to cough, whereas most articles examined the immediate effects of various components of cough. Studies examining insufflation combined with manual assisted cough provided the most consistent, high-level evidence. Compelling recent evidence supports the use of respiratory muscle training or electrical stimulation of the expiratory muscles to facilitate airway clearance in people with SCI.
Conclusion:
Evidence supporting the use of secretion removal techniques in SCI, while positive, is limited and mostly of low level. Treatments that increase respiratory muscle force show promise as effective airway clearance techniques.
PMCID: PMC2964024  PMID: 21061895
Spinal cord injuries; Paraplegia; Tetraplegia; Respiratory complications; Ventilation; Physiotherapy; Airway clearance; Assisted breathing devices; Paripep; Flutter; Threshold
6.  Soleus H-Reflex Modulation After Motor Incomplete Spinal Cord Injury: Effects of Body Position and Walking Speed 
Objective:
To examine position-dependent (semireclined to standing) and walking speed–dependent soleus H-reflex modulation after motor incomplete spinal cord injury (SCI).
Participants:
Twenty-six patients with motor incomplete SCI (mean: 45 ± 15 years) and 16 noninjured people (mean: 38 ± 14 years).
Methods:
Soleus H-reflexes were evoked by tibial nerve stimulation. Patients were tested in semireclined and standing positions (experiment 1) and in midstance and midswing positions (experiment 2).
Results:
H-reflexes were significantly greater after SCI in all positions compared with noninjured people (P < 0.05). Position-dependent modulation from semireclined to standing (normally observed in noninjured people) was absent after SCI. In SCI patients, H-reflex modulation was not significantly different at 1.2 m/s compared with 0.6 m/s treadmill walking speed; in noninjured people, H-reflex modulation was significantly greater at 1.2 m/s compared with 0.6 m/s treadmill walking speed. There was a significant positive correlation between modified Ashworth scores, a clinical measure of spasticity and soleus H-reflex amplitudes tested in all positions. A significant negative correlation was also found between H-reflexes in standing and midstance positions and the amount of assistance patients required to walk.
Conclusions:
An improvement in position-dependent and walking speed–dependent reflex modulation after SCI may indicate functional recovery. Future studies will use H-reflex testing to track changes as a result of therapeutic interventions.
PMCID: PMC2964025  PMID: 21061896
Spinal cord injuries, incomplete; Ambulation; Spasticity; Locomotor training; Standing; Walking speed; Assistive devices; Treadmill; Rehabilitation; Soleus H-reflex
7.  Effects of Gender on Inpatient Rehabilitation Outcomes in the Elderly With Incomplete Paraplegia From Nontraumatic Spinal Cord Injury 
Objective:
To examine gender differences in rehabilitation outcomes for patients with nontraumatic spinal cord injury.
Research Design:
Secondary analysis was conducted on Medicare beneficiary data from 65 to 74 year olds with incomplete paraplegia discharged from inpatient rehabilitation facilities in 2002 through 2005.
Main Outcome Measures:
Length of stay, Functional Independence Measure instrument motor item and subscale scores on discharge, and discharge destination.
Results:
Among patients with degenerative spinal disease, men had significantly longer rehabilitation stays than women (P < 0.001). Men with degenerative spinal disease had significantly lower discharge Functional Independence Measure scores than women, indicating more dependence in self-care (P < 0.001) and mobility (P < 0.001). Among patients with degenerative spinal disease, men were less likely to walk (odds ratio  =  0.58; 95% CI  =  0.38–0.87) and less likely to be independent with bladder management (odds ratio  =  0.44; 95% CI  =  0.31–0.62). Among patients with vascular ischemia, men were more independent (B  =  2.59; 99% CI  =  0.42–4.76) in mobility than women. There were no gender differences in the malignant spinal tumors group. There were no gender differences in being discharged to a community-based residence.
Conclusions:
Gender distributions varied by etiology. Gender differences were found in demographics, length of stay, and functional outcomes but not discharge destination. Men were more dependent than women at discharge in the etiology group with the least overall disability (degenerative spinal disease) and more independent in mobility than women at discharge in the etiology group with the most overall disability (vascular ischemia).
PMCID: PMC2964026  PMID: 21061897
Elderly; Gender; Outcomes, paraplegia; Spinal cord injuries, nontraumatic; Rehabilitation, physical; Disability; Myelopathy; Degenerative spinal disease, spinal tumor or vascular ischemia
8.  The Relationship of Pressure Ulcers, Race, and Socioeconomic Conditions After Spinal Cord Injury 
Objective:
To identify risks factors associated with pressure ulcers (PrU) after spinal cord injury (SCI) by examining race and indicators of socioeconomic status (measured by income and education). We hypothesize African Americans will have a greater risk for PrUs than whites, but this relationship will be mediated by the 2 socioeconomic status indicators.
Design:
Cohort study.
Setting:
A large rehabilitation hospital in the southeastern US.
Participants:
1,466 white and African American adults at least 1-year post-traumatic SCI.
Outcome Measures:
(a) PrUs in the past year, (b) current PrU, (c) surgery to repair a PrU since injury.
Results:
In preliminary analyses, race was significantly associated with having a current PrU and with having surgery to repair a PrU since injury. In multivariable analyses, the relationships of PrU with having a current PrU and with having surgery to repair a PrU were both mediated by income and education such that the relationships were no longer significant. Lower income was associated with increased odds of each PrU outcome. After controlling for other variables in the model, education was associated with increased odds of having a current PrU.
Conclusion:
These findings help clarify the relationships between race and socioeconomic status with PrUs after SCI. Specifically, a lack of resources, both financial and educational, is associated with worse PrU outcomes. These results can be used by both providers and policy makers when considering prevention and intervention strategies for PrUs among people with SCI.
PMCID: PMC2964027  PMID: 21061898
Spinal cord injuries; Race; Pressure ulcer; Socioeconomic factors
9.  Surgery for Pressure Ulcers Improves General Health and Quality of Life in Patients With Spinal Cord Injury 
Study Design:
Prospective clinical study.
Background:
Pressure ulcers interfere with the rehabilitation process in patients with spinal cord injury (SCI) and are a significant deterrent to participation in activities that contribute to independent, productive, and satisfying life.
Objective:
To evaluate the effect of surgery for pressure ulcers on general health and quality of life in patients with SCI.
Setting:
Tertiary care center in northern India.
Methods:
Various types of flap surgery were performed on 30 patients with SCI and 32 pressure ulcers (stages III and IV). Outcome was evaluated using general improvement in health (hemoglobin, serum proteins, and general well-being), patient satisfaction, and global quality of life scores (according to the visual analog scale).
Results:
At admission, the mean values of global quality of life, hemoglobin, serum albumin, and total serum proteins were 50.15 (range, 30–65), 8.75 g/dL (range, 6–12 g/dL), 3.12 g/dL (range, 2.9–4.3 g/dL), and 5.21 (range, 5–6.2 g/dL), respectively. At 6-month follow up, mean values of global quality of life score, hemoglobin, serum albumin, and total serum proteins were 87.36 (range, 44–96), 10.85 g/dL (range, 8.2–13.5 g/dL), 3.89 g/dL (range, 3.2–4.5 g/dL), and 6.43 g/dL (range, 5.85–6.70 g/dL), respectively. The overall rise in quality of life scores, hemoglobin, serum albumin, and total serum proteins was statistically significant. Most of the patients (76.7%) reported improvement in subjective well-being, and 83.3% were satisfied with the ultimate outcome of the surgery.
Conclusion:
Results suggest that surgery for stages III and IV pressure ulcers offers the greatest benefit to the patients in terms of improvement in general health (anemia, hypoproteinemia, and general well-being) and quality of life.
PMCID: PMC2964028  PMID: 21061899
Spinal cord injuries; Pressure ulcers; Rehabilitation; Quality of life; Surgery, flap
10.  Neuroprotective Effects of Alpha-Lipoic Acid in Experimental Spinal Cord Injury in Rats 
Background:
Oxidative stress is a mediator of secondary injury to the spinal cord following trauma.
Objective:
To investigate the putative neuroprotective effect of α-lipoic acid (LA), a powerful antioxidant, in a rat model of spinal cord injury (SCI).
Methods:
Wistar albino rats were divided as control, vehicle-treated SCI, and LA-treated SCI groups. To induce SCI, a standard weight-drop method that induced a moderately severe injury (100 g/cm force) at T10 was used. Injured animals were given either 50 mg/kg LA or saline at 30 minutes postinjury by intraperitoneal injection. At 7 days postinjury, neurologic examination was performed, and rats were decapitated. Spinal cord samples were taken for histologic examination or determination of malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO) activity, and DNA fragmentation. Formation of reactive oxygen species in spinal cord tissue samples was monitored by using a chemiluminescence (CL) technique.
Results:
SCI caused a significant decrease in spinal cord GSH content, which was accompanied with significant increases in luminol CL and MDA levels, MPO activity, and DNA damage. Furthermore, LA treatment reversed all these biochemical parameters as well as SCI-induced histopathologic alterations. Conversely, impairment of the neurologic function caused by SCI remained unchanged.
Conclusion:
The present study suggests that LA reduces SCI-induced oxidative stress and exerts neuroprotection by inhibiting lipid peroxidation, glutathione depletion, and DNA fragmentation.
PMCID: PMC2964029  PMID: 21061900
Alpha-lipoic acid; Antioxidants; Spinal cord injuries; Trauma; Neuroprotection; Lipid Peroxidation; Glutathione, Myeloperoxidase; DNA damage
11.  Obesity and Myelomeningocele: Anthropometric Measures 
Objective:
To evaluate the appropriate use of arm span measurements as a substitute for height/linear length to evaluate obesity in people with myelomeningocele by comparing calculated body mass indices (BMIs) with recently published BMI graphs by the Centers for Disease Control and Prevention (CDC) and National Center for Health Statistics standards (NCHS) published in 2000.
Study Design:
Retrospective analysis of collected data on patients seen in the University of Washington Birth Defects Clinic from July 1, 1965, through June 1, 2008. Observations included degree of paralysis, presence of scoliosis, height (linear length), weight, and arm span. We compared published CDC/NCHS BMIs with our data using both height and arm span in place of height/linear length. There were 14,701 measures collected during 4,968 visits from 709 patients. Mean values were calculated using age, gender, and lesion level as independent variables.
Results:
Comparison of BMI means of patients with myelomeningocele suggests that our observations using arm span and height are comparable with the CDC/NCHS BMI means using height for the 2 least paralyzed groups but not for those groups with paralysis from high-level lesions that are more likely to exhibit lower extremity deformities or scoliosis.
Conclusions:
Published CDC/NCHS graphs, with their percentiles, are appropriate for estimating normal growth by BMI for children born with myelomeningocele when arm span is substituted for length if severe body differences due to high-level paralysis are taken into consideration.
PMCID: PMC2964030  PMID: 21061901
Spina bifida; Myelomeningocele; Paralysis; Obesity; Anthropometric measures; Body mass index
12.  Nontraumatic Acute Paraplegia Associated With Cervical Disk Herniation 
Background:
Acute paraplegia is a true emergency. It is often the result of trauma but is rarely reported in association with cervical disk herniation in patients without antecedent injury.
Methods:
Case report.
Findings:
This 75-year-old man presented with acute paraplegia due to severe compression of the spinal cord by herniation of the C4-C5 cervical disk. He underwent emergency diskectomy and anterior fusion. Postoperatively, his neurologic functions improved gradually.
Conclusions:
Cervical disk herniation should be considered in the differential diagnosis of nontraumatic acute paraplegia. Pre-existing narrowed canal is an important predisposing factor and excessive neck movements are believed to be triggering factors. Immediate early decompressive surgery is recommended to avoid irreversible progression of neurologic deficit.
PMCID: PMC2964031  PMID: 21061902
Paraplegia, acute, nontraumatic; Cervical vertebrae; Intervertebral disk displacement; Spinal cord compression; Rehabilitation, physical
13.  Acute Transverse Myelitis Associated With Dengue Viral Infection 
Background:
Acute transverse myelitis is a rare manifestation of dengue viral infection. Four cases have been previously reported in the literature.
Objective:
To report a case of a 61-year-old woman who developed acute transverse myelitis 6 days after the onset of a dengue viral infection.
Findings:
Magnetic resonance imaging of spinal cord showed hypersignal intensity on T2W at T9-T10. Laboratories studies revealed a high titer of hemagglutination inhibition of dengue virus. Treatment with intravenous pulse methylprednisolone and physiotherapy yielded a partial recovery, followed by complete resolution at 1 year postinfection.
Conclusion:
Acute transverse myelitis is a rare manifestation of dengue infection that can occur in either the peri-infectious or postinfectious phases.
PMCID: PMC2964032  PMID: 21061903
Acute transverse myelitis, paraplegia; Dengue fever; Dengue hemorrhagic fever; Methylprednisolone; Flavivirus
14.  Unilateral Hyperhidrosis From a Contralateral Source in an Individual With C4 Complete Tetraplegia 
Setting:
Outpatient clinic of a spinal cord injury rehabilitation center.
Design:
Case report.
Participant:
A 40-year-old man with a 20-year history of C4 complete tetraplegia complained of 5 years of excessive intermittent left-sided sweating. The sweating occurred only in the seated upright position. There was no associated headache, blurred vision, or blood pressure variability.
Findings:
When examined upright, the patient sweated excessively on the left face and body. When he was laid down, sweating ceased. Skin examination revealed intact ischial regions. Pressure applied to the right ischium for several minutes caused sweating to recur on the left forehead, but it then subsided with release of pressure. This phenomenon was repeatable. Local lidocaine injection in the subcutaneous tissues around the right ischium and subsequent use of lidocaine transdermal patches halted the contralateral sweating in the upright position. Pressure mapping analysis showed increased pressure in the region of the right ischial tuberosity. The patient's gel cushion was replaced with an air-filled cushion, providing significant ongoing relief from the hyperhidrosis.
Conclusion/Clinical Relevance:
Unilateral hyperhidrosis can be caused by a contralateral source of irritation. Use of techniques that interrupt the afferent arm of the autonomic pathway may be effective in the management of hyperhidrosis in individuals with spinal cord injury.
PMCID: PMC2964033  PMID: 21061904
Spinal cord injuries; Heterotopic ossification; Tetraplegia; Hyperhidrosis; Lidocaine, transdermal; Cushions, air-filled, gel
15.  Cervical Cord Compressive Myelopathy in a Man With a Primary Complaint of Knee Pain 
Background:
Diagnosing patients with cervical cord compressive myelopathy in a timely manner can be challenging due to varying clinical presentations, the absence of pathognomonic findings, and symptoms that are usually insidious in nature.
Objective:
To describe the clinical course of a patient with primary complaint of left medial knee pain that was nonresponsive to surgical and conservative measures; the patient was subsequently diagnosed with cervical cord compressive myelopathy.
Design:
Case report.
Subject:
A 63-year-old man with a primary complaint of left medial knee pain.
Findings:
Physical examination of the left knee was normal except for slight palpable tenderness over the medial joint line. During treatment, he noted loss of balance during activities of daily living. Reassessment revealed bilateral upper extremity hyperreflexia, bilateral Babinski reflex, and positive bilateral Hoffman reflex. Magnetic resonance imaging of the cervical spine demonstrated moderately severe spinal stenosis at the C3-C4, C5-C6, and C6-C7 levels. After C3-C7 laminoplasty for cervical cord compressive myelopathy, he reported substantial improvement of his left medial knee. Three years later, he had no complaint of knee pain.
Conclusion:
Appropriate diagnosis and treatment of cervical cord compressive myelopathy may avoid unnecessary diagnostic imaging, medical evaluations, invasive procedures, and potential neurologic complications.
PMCID: PMC2964034  PMID: 21061905
Spondylosis, cervical; Myelopathy, compressive; Tetraparesis; Paraparesis; Pain
17.  Influence of Season, Ethnicity, and Chronicity on Vitamin D Deficiency in Traumatic Spinal Cord Injury 
Background:
Inadequate levels of vitamin D increase the risk of osteoporosis, a highly prevalent condition in patients with traumatic spinal cord injury (SCI). Reduced sunlight and dark skin further contribute to low vitamin D levels.
Objectives:
To compare serum 25-hydroxy vitamin D [vitamin D25(OH)] levels in acute and chronic SCI and to explore seasonal and ethnic differences among patients with acute and chronic SCI.
Patients/Methods:
Patients (N  =  96) aged 19 to 55 years with C3-T10 motor complete SCI participated. Acute SCI was 2 to 6 months after injury, whereas chronic SCI was at least 1 year from injury. Serum vitamin D25(OH), calcium, and parathyroid hormone were drawn during summer or winter months. Vitamin D deficiency (<13 ng/mL), insufficiency (<20 ng/mL), and subtherapeutic (<32 ng/mL) levels were compared for all groups. A 3-way analysis of covariance was adopted to determine significant main effects of season, chronicity, and ethnicity. Interactions between season and chronicity, season and ethnicity, and chronicity and ethnicity were evaluated. Evaluation of a 3-way interaction among season, chronicity, and ethnicity was completed.
Results:
In summer, 65% of patients with acute SCI and 81% of patients with chronic SCI had subtherapeutic vitamin D levels, whereas in winter, 84% with acute SCI and 96% with chronic SCI had vitamin D25(OH) (<32ng/mL). Lower vitamin D25(OH) levels were observed in African Americans relative to whites. Significant main effects were noted for season (P  =  0.017), chronicity (P  =  0.003), and ethnicity (P < 0.001). However, interactions between 2 or more factors were not found.
Conclusions:
Vitamin D insufficiency and deficiency are found in the majority of patients with chronic SCI and in many with acute SCI. Initial screening for serum vitamin D25(OH) levels should be performed early in rehabilitation. Periodic monitoring in the chronic setting is highly recommended.
PMCID: PMC2920113  PMID: 20737793
Spinal cord injuries, acute, chronic; Nutritional deficiencies; Vitamin D deficiency; Bone loss; Hyperparathyroidism; Hypovitaminosis; Osteoporosis; Cholecalciferol; Ergocalciferol; Ethnicity
18.  Underestimation of Bone Loss of the Spine With Posterior-Anterior Dual-Energy X-Ray Absorptiometry in Patients With Spinal Cord Injury 
Background:
Bone mineral density (BMD) of the lumbar spine (L-spine) has been reported to be normal by routine posterior-anterior (PA) bone density imaging in patients with chronic spinal cord injury (SCI).
Objective:
To determine BMD of the L-spine by PA and lateral (LAT) dual-energy radiographic absorptiometry (DXA) in patients with chronic SCI.
Design:
Prospective study.
Setting:
Veterans Affairs Medical Center and a private rehabilitation facility.
Methods:
Measurements of the PA and LAT L-spine and hip were performed in 15 patients with SCI: 9 with tetraplegia and 6 with paraplegia. The DXA (GE Lunar Advance DXA) images were obtained using standard software. Results are reported as mean ± SD.
Results:
The mean age was 35 ± 15 years (range  =  20–62 years), and the duration of injury was 57 ± 74 months (range  =  3–240 months). T- and Z-scores were lower for the LAT L-spine than those for PA L-spine (T-scores L2: −0.7 ± 1.2 vs 0.0 ± 1.4, P < 0.01; L3: −0.9 ± 1.6 vs 0.3 ± 1.3, P < 0.002; L2-L3: −0.8 ± 1.3 vs 0.2 ± 1.3, P < 0.001; Z-scores L2: −0.3 ± 1.1 vs 0.2 ± 1.2, P < 0.05; L3: −0.6 ± 1.3 vs 0.5 ± 1.3, P < 0.01; L2-L3: −0.4 ± 1.1 vs 0.4 ± 1.2, P < 0.005). The T- and Z-scores for the total hip (−1.1 ± 1.0 and −1.0 ± 1.0, respectively) and L2-L3 LAT L-spine demonstrated remarkable similarity, whereas the L2-L3 PA L-spine scores were not reduced. Bone mineral density of the LAT L-spine, but not the PA L-spine, was significantly reduced with increasing duration of injury.
Conclusions:
Individuals with SCI may have bone loss of the L-spine that is evident on LAT DXA that may be misdiagnosed by PA DXA, underestimating the potential risk of fracture.
PMCID: PMC2920114  PMID: 20737794
Spinal cord injuries; Paraplegia; Tetraplegia; Bone mineral density; Vertebral body; Dual-energy X-ray absorptiometry; Osteoporosis
19.  Statewide Investigation of Medically Attended Adverse Health Conditions of Persons With Spinal Cord Injury 
Background/Objective:
To report over a 10-year period the statewide prevalence and incidence of medically attended adverse health conditions in people with new traumatic spinal cord injury (TSCI).
Design:
Retrospective cohort study.
Methods:
(a) Identified all new TSCI cases discharged alive from statewide acute care hospitals, 1996 to 2000, using ICD-9-CM methodology. (b) Followed cases from 1996 to 2005 to quantify medically attended health conditions documented during emergency department visits, acute care hospitalizations, and outpatient hospital visits. (c) Used the life table method to calculate the prevalence and incidence of health conditions. (d) Examined Cox proportional hazard ratio of mortality by gender controlling for age and TSCI severity.
Results:
Nine hundred eighty-eight residents (257 women, 731 men) with TSCI were alive 90 days after discharge from acute care hospitalization from 1996 to 2000. Nine hundred twenty-three (251 female, 672 male) (93.4%) residents had an observed medically attended adverse health condition in the 10-year follow-up period. The most prevalent classes of diseases and disorders were (a) muscle and connective tissue, (b) renal and urinary, (c) digestive, (d) circulatory, (e) respiratory, (f) endocrine/nutritional/metabolic, and (g) infectious. Incidence of new injury was 29.0% for males and 26.9% for females. During the follow-up period, 49 women (19%) and 104 men (14%) died.
Conclusions:
People with TSCI experience diverse adverse health conditions in the 10 years after initial injury. An interdisciplinary health care provider team approach to allocating resources and implementing countermeasures to prevent or limit occurrence of these conditions is vital to these patients' continuum of care.
PMCID: PMC2920115  PMID: 20737795
Spinal cord injuries, traumatic; Demographics; Secondary complications, age, gender; Prevalence; Incidence
20.  Comparing Quantification of Pain Severity by Verbal Rating and Numeric Rating Scales 
Background:
Researchers have reported widely varying correlations among the 3 main instruments used to quantify pain severity, Visual Analog Scale (VAS), Verbal Rating Scale (VRS), and Numeric Rating Scale (NRS), both at the level of groups and at the level of individuals.
Objective:
To assess the comparability of reports of pain severity using a VRS and a NRS in a spinal cord injury (SCI) sample.
Methods:
Data were taken from a longitudinal observational study. Patients were 168 individuals with new traumatic SCI admitted for inpatient rehabilitation who completed the VRS and NRS multiple times, each time for multiple pains as appropriate.
Results:
For 1,114 ratings of pain, VRS and corresponding NRS ratings were correlated weakly (Spearman correlation, rho  =  0.38). For 36 individuals with at least 10 completions of paired VRS and NRS, rho ranged from −0.55 to 0.76. Variation in NRS rating for each VRS adjective was reduced by about 25% when between-patient variation was eliminated. Mean NRS ratings by VRS adjective, for patients who had used each of at least 2 adjectives at least 5 times each, showed large differences in mean NRS scores between individuals using the same VRS adjective.
Conclusion:
There are considerable differences between individuals in how NRS and VRS are used; there also seem to be individuals whose understanding of the meaning of the VRS adjectives is completely different from what was assumed by the creators of this VRS. Both VRS and NRS data must be used with extreme caution by SCI clinicians and researchers.
PMCID: PMC2920116  PMID: 20737796
Spinal cord injuries; Pain, neuropathic, musculoskeletal, central; Reproducibility; Pain measurement; Visual Analog Scale; Verbal Rating Scale; Numeric Rating Scale
21.  Fever During Rehabilitation in Patients With Traumatic Spinal Cord Injury: Analysis of 392 Cases From a National Rehabilitation Hospital in Turkey 
Objective:
To determine the incidence and etiology of fever and the risk factors related to fever in adults with spinal cord injury (SCI) at the rehabilitation stage.
Design/Subjects:
A retrospective examination of records of 392 consecutive adult patients with traumatic SCI who received inpatient rehabilitation program.
Setting:
A national rehabilitation center in Turkey.
Outcome Measures:
Incidence and etiology of fever, period of hospitalization (days).
Results:
A total of 187 patients (47.7%) had fever at least once during their rehabilitation program. The most common etiology was urinary tract infection. The rate of fever occurrence was significantly higher in patients with complete SCI (P  =  0.001). In patients with fever, the use of an indwelling catheter was significantly higher compared with clean intermittent catheterization and spontaneous voiding (P  =  0.001). The hospitalization period of patients with fever was significantly longer than that of patients without fever (P  =  0.006).
Conclusions:
A high rate of fever was seen in patients with SCI during rehabilitation. Fever was caused by various infections, of which urinary tract infection was the most common. Patients with motor complete injuries and those with permanent catheters constituted higher risk groups. Fever prolonged the length of rehabilitation stay and hindered active participation in the rehabilitation program.
PMCID: PMC2920117  PMID: 20737797
Spinal cord injuries, complete, incomplete; Fever, etiology; Rehabilitation, physical; Urinary tract infection; Bladder management
22.  Age, Gender, and Side Differences of Cutaneous Electrical Perceptual Threshold Testing in an Able-Bodied Population 
Objective:
To investigate age, gender, and left-right differences in cutaneous electrical perceptual threshold (EPT) testing in an able-bodied, Australian sample.
Study Design:
Prospective experimental.
Setting:
Hospital-based spinal cord injuries unit.
Methods:
Cutaneous electrical stimulation of the 28 dermatomes at ASIA sensory key points (C2-S4/S5) was performed on 29 female and 16 male healthy volunteers aged 21 to 76 years. Mean EPTs for each dermatome were compared (repeated measures ANOVA) for left-right, gender-related, and age-related (50 years of age) differences.
Results:
There was no group difference between sides (repeated measures ANOVA, P  =  0.934). Women across all ages had lower group mean EPTs than men (P < 0.0001). Women younger than age 50 years had lower mean EPTs than those older than age 50 years (P  =  0.008). There was no group difference between younger and older men (P  =  0.371). Analysis of individual dermatomes revealed no significant differences in thoracic dermatomes between genders or age groups, contrary to the limb dermatomes.
Conclusion:
There were gender differences in EPT values across all ages. Women had higher EPTs as they advanced in age, but this was less clear in men. There was considerable somatotopic variability in EPTs, especially in the lower limbs. If EPT testing is to be applied to detect subclinical changes within a dermatome, establishment of age- and gender-specific somatotopic normograms is a prerequisite.
PMCID: PMC2920118  PMID: 20737798
Electrical perceptual thresholds, gender, age; Dermatomes; Quantitative sensory testing; Cutaneous electrical stimulation; Demographic differences
23.  Spinal Schistosomiasis: Differential Diagnosis for Acute Paraparesis in a US Resident 
Background:
Spinal schistosomiasis is a severe presentation of Schistosoma mansoni infection, which is endemic in South America, the Middle East, and sub-Saharan Africa. With increasing international travel, a disease can spread from an endemic area to another part of the world easily.
Objective:
To present a case of a US resident who developed acute paraparesis due to spinal schistosomiasis after traveling to sub-Saharan Africa.
Participant:
A 45-year-old woman presented with abdominal pain radiating into the bilateral lower extremities. She was diagnosed with a pelvic mass and underwent an urgent hysterectomy with right salpingo-oopherectomy. Postoperatively, she developed progressive weakness with worsening pain in her bilateral lower extremities and neurogenic bladder. Magnetic resonance imaging showed an abnormal T2 hyperintense signal in the entire spinal cord below the T3 level with abnormal contrast enhancement from T9 through the conus medullaris. Spinal fluid analysis showed lymphocytic pleocytosis and elevated protein. The patient was diagnosed with transverse myelitis. Subsequently, a detailed history revealed a visit to Ethiopia 2 years earlier. Tests for S mansoni were positive. After treatment with praziquantel and prednisone, her neurologic function began to improve.
Conclusions:
An increasing incidence of international travel is increasing the likelihood of US physicians' encountering this treatable condition. Travelers with spinal schistosomiasis may not have symptoms of systemic infection. Therefore, it is important to include spinal schistosomiasis in the differential diagnosis of acute inflammatory myelopathy, particularly with a history of travel to endemic areas.
PMCID: PMC2920119  PMID: 20737799
Schistosomiasis, spinal; Schistosoma; Schistosoma mansoni; Paraparesis; Myelopathy; Myeloradiculopathy; Praziquantel; Parasites, helminthic
24.  Electrical Stimulation of the Urethra Evokes Bladder Contractions in a Woman With Spinal Cord Injury 
Objective:
Electrical stimulation of pudendal urethral afferents generates coordinated micturition in animals and bladder contractions in men after spinal cord injury (SCI), but there is no evidence of an analogous excitatory urethra-spinal-bladder reflex in women. The objective of this study was to determine whether electrical stimulation of the urethra could evoke bladder contractions in a woman with SCI.
Case Report:
A 38-year-old woman with a C6 ASIA A SCI who managed her bladder with clean intermittent catheterization and oxybutynin demonstrated neurogenic detrusor overactivity on urodynamics. Oxybutynin was discontinued 2 days prior to urodynamic testing with a custom 12F balloon catheter mounted with ring-shaped electrodes located in the bladder neck, mid urethra, and distal urethra. The inflated balloon was placed against the bladder neck to stabilize the catheter electrodes in place along the urethra. However, the balloon limited emptying during contractions. Urodynamics were performed at a filling rate of 25 mL/minute until a distention-evoked bladder contraction was observed. The urethra was stimulated over a range of bladder volumes and stimulus parameters to determine whether electrical stimulation could evoke a bladder contraction.
Findings:
Electrical stimulation via urethral electrodes evoked bladder contractions that were dependent on bladder volume (>70% capacity) and the intensity of stimulation.
Conclusions:
This is the first report of an excitatory urethra-spinal-bladder reflex in a woman with SCI. Future studies will determine whether this reflex can produce bladder emptying.
PMCID: PMC2920120  PMID: 20737800
Spinal cord injuries; Electrical stimulation; Neurogenic bladder; Oxybutynin
25.  Autonomic Dysreflexia as a Complication of a Fecal Management System in a Man With Tetraplegia 
Background/Objective:
To present a case of autonomic dysreflexia caused by the use of a fecal management system in a patient with tetraplegia.
Design:
Case report.
Setting:
Military rehabilitation center.
Results:
A man with tetraplegia had a fecal management system inserted to divert stool away from his sacral pressure ulcer to reduce contamination and infection risk. Two days later, he developed severe autonomic dysreflexia that improved after removal of the system.
Conclusions:
Autonomic dysreflexia, a life-threatening complication, has not been reported before as a side effect of a fecal management system. These systems should be used with caution in patients with high-level spinal cord injury.
PMCID: PMC2920121  PMID: 20737801
Autonomic dysreflexia; Fecal management system; Spinal cord injuries; Tetraplegia; Pressure ulcer

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