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  1. #1


    Can anyone out there tell me where I can go to get articles on:

    1) how important rehab is to be started ASAP after sci; and
    2) how pressure sores can negatively effect the body by hindering:
    - breathing
    - AD
    - nutrients and anything else

    Cindy, tampa fl
    mom to Anthony C4,5,6
    inury 3/28/03
    still in hospital

  2. #2
    Cindy, early rehabilitation has been claimed to improve recovery but this of course is not particularly well documented. There has been no randomized clinical study of the impact of early rehabilitation. We also know that people with less severe injuries tend to go to rehabilitation earlier. So, I don't think that the data is convincing but common sense would suggest that the earlier the rehabiliation is started, more recovery will occur as a result of prevention of learned non-use and atrophy.

    Below are some studies published in the last three years on the subject.


    • Barbeau H and Fung J (2001). The role of rehabilitation in the recovery of walking in the neurological population. Curr Opin Neurol 14:735-40. Summary: Recent studies demonstrate that neurological patients show great potential for recovery in both the early and late stages following injury. Enhancement of the recovery process could be achieved with new rehabilitation approaches alone or in combination with pharmacological intervention. These new approaches have evolved from fundamental advances in both animal and human studies. To date few randomized clinical trials have addressed the efficacy or effectiveness of these new approaches. In this paper, important quantitative studies will be reviewed and discussed in relation to the important mechanisms of locomotor control and plasticity that take place following lesions of the central nervous system. School of Physical and Occupational Therapy, McGill University, 3630 Promenade-Sir-William-Osler, Montreal, Quebec H3G 1Y5, Canada.

    • Barbeau H, Ladouceur M, Mirbagheri MM and Kearney RE (2002). The effect of locomotor training combined with functional electrical stimulation in chronic spinal cord injured subjects: walking and reflex studies. Brain Res Brain Res Rev 40:274-91. Summary: With the new developments in traumatology medicine, the majority of spinal cord injuries sustained are clinically incomplete and the proportion is likely to continue to rise. Thus, it is necessary to continue to develop new treatment and rehabilitation strategies and understand the factors that can enhance recovery of walking following spinal cord injury (SCI). One new development is the use of functional electrical stimulation (FES) device to assist locomotion. The objective of this review is to present findings from some recent studies on the effect of long-term locomotor training with FES in subjects with SCI. Promising results are shown in all outcome measures of walking, such as functional mobility, speed, spatio-temporal parameters, and the physiological cost of walking. Furthermore, the change in the walking behavior could be associated with plasticity in the CNS organization, as seen by the modification of the stretch reflex and changes in the corticospinal projection to muscles of the lower leg. In conclusion, recovery of walking is an increasing possibility for a large number of people with SCI. New modalities of treatment have become available for this population but most still need to be evaluated for their efficacy. This review has focused on FES assisted walking as a therapeutic modality in subjects with chronic SCI, but it is envisaged that the care and recovery of SCI in the early phase of recovery could also be improved. School of Physical and Occupational Therapy, McGill University, 3630 Promenade Sir-William-Osler, Montreal, QC, Canada H3G 1Y5.

    • Kirshblum SC, Groah SL, McKinley WO, Gittler MS and Stiens SA (2002). Spinal cord injury medicine. 1. Etiology, classification, and acute medical management. Arch Phys Med Rehabil 83:S50-7, S90-8. Summary: This self-directed learning module highlights basic management and approaches to intervention-both established and experimental. The revised American Spinal Injury Association classification (2000) of spinal cord injury (SCI) further defines the examination and classification guidelines. The incidence of traumatic SCI remains at approximately 10,000 cases per year, with 32 years the average age at injury. Initial management includes establishment of oxygenation, circulation (mean blood pressure >85 mm Hg), radiographic evaluations for spine instability, intravenous methylprednisolone, and establishment of spinal alignment. Prevention measures for medical complications include pressure relief for skin, thromboembolism prophylaxis, prevention of gastric ulcers, Foley catheter drainage to prevent urine retention, and bowel care to prevent colonic impaction. Nontraumatic SCI from spinal stenosis, neoplastic compression, abscess, or multiple sclerosis becomes more common with aging. Experimental treatments for SCI include antibodies to block axonal growth inhibitors, gangliosides to augment neurite growth, 4-aminopyridine to enhance axonal conduction through demyelinated nerve fibers, and fetal tissue to fill voids in cystic spinal cord cavities. Early comprehensive rehabilitation at a SCI center prevents complications and enhances functional gains. OVERALL ARTICLE OBJECTIVE: To summarize the comprehensive evaluation and management of a newly injured individual. Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, West Orange, NJ, USA.

    • Lee YH, Rah JH, Park RW and Park CI (2001). The effect of early therapeutic electrical stimulation on bone mineral density in the paralyzed limbs of the rabbit. Yonsei Med J 42:194-8. Summary: The purpose of this animal experiment was to evaluate the changes of bone mineral density in paralyzed limbs, and to assess the effects of electrically stimulating muscle contraction upon bone mineral density (BMD) in paralyzed limbs during the four week period immediately following spinal cord injury (SCI). Ten rabbits were used for the study, spinal cords were totally transected at the T11 spine level. The paralyzed quadriceps femoris of one limb was contracted by electrical stimulation for 60-minutes daily, while the other side was not stimulated as a control. The BMD of each lower limb was measured by Dual Photon Absorptiometry before and four weeks after acute SCI. BMD of both limbs decreased in all rabbits four weeks after SCI. The decrease in BMD for stimulated and non-stimulated limbs was 6.130 +/- 3.212% and 9.098 +/- 3.831%, respectively during the four-week period after SCI. The BMD of stimulated limbs decreased significantly less than that of the non-stimulated limbs. Electrically induced muscular contraction reduced bone mineral loss in the paralyzed limb during the early stage of SCI in the rabbit. Department of Rehabilitation Medicine, Yonsei University Wonju College of Medicine, Korea.

    • Oo T, Watt JW, Soni BM and Sett PK (1999). Delayed diaphragm recovery in 12 patients after high cervical spinal cord injury. A retrospective review of the diaphragm status of 107 patients ventilated after acute spinal cord injury. Spinal Cord 37:117-22. Summary: STUDY DESIGN: The functional outcome of the diaphragm after acute spinal cord injury was reviewed over a 16 year period for 107 patients who had required assisted ventilation in the acute phase. OBJECTIVES: To quantify the incidence of recovery of diaphragm function which occurred beyond the period of acute oedema; to produce a time-related profile of this as a guide to clinicians considering phrenic nerve pacing; and to assess the value of phrenic nerve testing in predicting recovery. SETTING: The Southport Regional Spinal Injuries Centre, Southport, England. METHODS: Bilateral phrenic nerve and diaphragm integrity was assessed clinically, by spirometry, and by fluoroscopy without and with phrenic nerve stimulation. RESULTS: Thirty-one per cent of all the ventilated patients (33 cases), with a level of injury between C1 and C4 (Scale A in ASIA Impairment Scale), had diaphragmatic paralysis at the time of respiratory failure. The subsequent diaphragm recovery which appeared in seven of these patients, between 40 and 393 days (mean 143), permitted weaning from ventilatory support at 93 to 430 days (mean 246) after the acute injury, with a vital capacity of over 15 ml kg(-1) at that stage. The diaphragm recovery in a further five patients, whose vital capacity remained below 10 ml kg(-1) and who could not be fully weaned, occurred significantly later, between 84 and 569 days (mean 290), P=0.053. Negative phrenic nerve tests were followed by weaning at a later interval in several cases. By contrast, one patient with an early positive phrenic stimulation test and subsequent diaphragm activity could not be weaned from the ventilator. CONCLUSION: Twenty-one per cent of the patients with initial diaphragm paralysis were ultimately able to breathe independently after 4 and 14 months, whilst a further 15% had some diaphragm recovery. Phrenic nerve testing should be repeated at 3 monthly intervals for the first year after high tetraplegia. Regional Spinal Injuries Centre, Southport and Formby NHS Trust Hospital, Merseyside.

    • Pollard ME and Apple DF (2003). Factors associated with improved neurologic outcomes in patients with incomplete tetraplegia. Spine 28:33-9. Summary: STUDY DESIGN: Retrospective review of 412 patients with traumatic, incomplete, cervical spinal cord injuries, and an average follow-up period of 2 years. OBJECTIVES: To determine what patient characteristics, injury variables, and management strategies are associated with improved neurologic outcomes. In particular, the effects of intravenous steroids (NASCIS II protocol), early definitive surgery (<24 hours after injury), early anterior decompression for burst fractures or disc herniations [<24 hours after injury), and surgical decompression for stenosis without fracture were assessed. SUMMARY OF BACKGROUND DATA: Controversy surrounds the pharmacologic and surgical management of patients with spinal cord injuries. METHODS: Neurologic data were collected retrospectively and classified using American Spinal Injury Association guidelines. This information was recorded at the time of injury, on admission to rehabilitation, on discharge from rehabilitation, and at 1, 2, and final year of follow-up evaluation. Outcome measures included change in motor score, change in sensory score, final motor score, and final sensory score. The SPSS v10.0.7 statistical software package was used for data analysis. RESULTS: Neurologic recovery was not related to the following factors: gender, race, type of fracture, or mechanism of injury. Neurologic recovery also was not related to the following interventions: high-dose methylprednisolone administration, early definitive surgery, early anterior decompression for burst fractures or disc herniations, or decompression of stenotic canals without fracture. Improved neurologic outcomes were, however, noted in younger patients [ = 0.002), and those with either a central cord or Brown-Sequard syndrome [ = 0.019). CONCLUSIONS: The most important prognostic variable relating to neurologic recovery in a patient with a spinal cord injury is the completeness of the lesion. When an incomplete cervical spinal cord lesion exists, younger patients and those with either a central cord or Brown-Sequard syndrome have a more favorable prognosis for recovery. In this study, no evidence was found to support high-dose steroid administration, routine early surgical intervention, or surgical decompression in stenotic patients without fracture. Department of Orthopaedic Surgery, Atlanta Medical Center, Atlanta, Georgia, USA.

    • Sumida M, Fujimoto M, Tokuhiro A, Tominaga T, Magara A and Uchida R (2001). Early rehabilitation effect for traumatic spinal cord injury. Arch Phys Med Rehabil 82:391-5. Summary: OBJECTIVE: To determine the natural course of traumatic spinal cord injury (SCI) and the effect of early rehabilitation on it. DESIGN: A retrospective, multicenter study. SETTING: Sixteen Rosai hospitals and 1 medical school. PARTICIPANTS: One hundred twenty-three SCI patients (104 men, 19 women; mean age, 48.8 +/- 17.7yr) enrolled. INTERVENTIONS: Dividing the subjects into an early rehabilitation group and a delayed group; differences were ensured by international classification of SCI. MAIN OUTCOME MEASURES: Using the American Spinal Injury Association (ASIA) classifications, the motor recovery rate (MRR) was defined as (ASIA motor score at discharge - ASIA motor score at admission)/(100 - ASIA motor score at admission). The regression lines for FIM instrument score and ASIA motor score were determined for 6 subgroups (early or delayed tetraplegia, central cord injury, paraplegia) by the MRR staging. The regression lines for physical or cognitive FIM score and ASIA motor score were also determined for 6 subgroups. RESULTS: Three stages were obtained: acute stage: 2 weeks postinjury; recovery stage: 2 weeks to 6 months postinjury; and chronic stage: more than 6 months postinjury. Regression lines showed that rehabilitation improved physical functional independence for ASIA motor score, especially in the early rehabilitation subgroups. There was no correlation between cognitive FIM score and ASIA motor score in 6 subgroups. CONCLUSION: Early SCI rehabilitation contributes to good physical activities of daily living for motor function. Department of Rehabilitation Medicine, Kansai Rosai Hospital, Amagasaki City, Japan.

    • van der Putten JJ, Stevenson VL, Playford ED and Thompson AJ (2001). Factors affecting functional outcome in patients with nontraumatic spinal cord lesions after inpatient rehabilitation. Neurorehabil Neural Repair 15:99-104. Summary: OBJECTIVE: Patients with nontraumatic spinal cord lesions account for between one fourth and one half of all spinal cord injuries. In the management of this group of patients, an understanding of factors influencing functional improvement is essential to help define the most appropriate rehabilitation programme. Although it is possible to predict accurately the functional outcome for an individual patient with a complete traumatic spinal cord injury, few studies have looked at prognostic factors in patients with nontraumatic spinal cord disease. The aim of this study was to determine which, and how well, factors assessed on admission to a rehabilitation unit relate to functional improvement in this group. METHODS: The study sample consists of 100 patients with an incomplete nontraumatic spinal cord lesion who underwent inpatient neurorehabilitation. Possible prognostic factors were sought by identifying those variables with a significant difference in the Functional Independence Measure (FIM) motor change score above and below the median. A step-wise multiple regression analysis was then performed to determine which variables influenced functional outcome. RESULTS: Patients with larger functional gains had significantly lower disability scores on admission, a shorter time between symptom onset and rehabilitation, and a longer length of stay. They were more likely to have a cervical lesion and evidence of neurologic recovery. Multiple regression analysis demonstrated that the FIM motor score on admission and the time between symptom onset and rehabilitation predicted 54% of the variance of the FIM motor score gain. CONCLUSIONS: This finding suggests that early rehabilitation is an important factor in securing a good outcome. Department of Rehabilitation, Academic Medical Centre, Amsterdam.

    • Wang D, Teddy PJ, Henderson NJ, Shine BS and Gardner BP (2001). Mobilization of patients after spinal surgery for acute spinal cord injury. Spine 26:2278-82. Summary: STUDY DESIGN: A retrospective review was conducted covering records of patients who underwent spinal surgery after acute spinal cord injury. OBJECTIVE: To study the relation between time of operation and mobilization of patients. SUMMARY OF BACKGROUND DATA: No such report has existed in the literature. METHODS: Reviews were conducted for the medical records of 102 consecutive patients with acute spinal cord injury admitted to the National Spinal Injuries Center whose spines had been stabilized surgically. The surgeries had been performed either in the National Spinal Injuries Center or in hospitals of the United Kingdom or Continental Europe not specialized in comprehensive care of spinal cord injury. For the patients in three groups, the date of operation and the date of mobilization were compared. The causes for delay in mobilization were identified. RESULTS: A trend of negative correlation was found between the mean number of days from injury to operation and the mean number of days from injury to mobilization. Conversely, a trend of positive correlation was found between the mean number of days from injury to admission or transfer to the National Spinal Injuries Center and the mean number of days from injury to mobilization. Long stay in bed was associated with complications. None of the patients in Group A stayed in bed longer than 77 days, whereas 13 patients in Groups B and C combined had a longer stay. The difference was statistically significant (P = 0.02, chi2). Eight of these patients had pressure sores. CONCLUSION: To ensure early mobilization, early spinal surgery must be supported by specialized comprehensive care. National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, the Radcliff Infirmary, Oxford, United Kingdom.

  3. #3
    I would also encourage you to download, read and share with his team all of the documents on this site:

    Consortium for Spinal Cord Medicine Clinical Practice Guidelines

    Clinical practice guidelines are becoming more and more important in practice, and have been used in the legal arena to determine standard of care in malpractice cases.


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