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Demystifying Spinal Cord Injury

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Title: Demystifying Spinal Cord Injury


1
Demystifying Spinal Cord Injury
  • Suzanne L. Groah, MD, MSPH
  • Director of Spinal Cord Injury Research
  • Director of the National Capital Spinal Cord
    Injury Model System
  • National Rehabilitation Hospital, Washington, DC

2
  • Funded by the National Institute on Disability
    and Rehabilitation Research (NIDRR), Office of
    Special Education Services,
  • U.S. Department of Education
  • Washington, D.C.
  • Grant H133N060028

3
Definition of Spinal Cord Injury
  • Any injury to the spinal cord via blunt or
    penetrating trauma
  • Contrast with spinal cord disease
  • Manifests as variable loss of neurological
    function below the injury site
  • Motor and sensory impairment
  • Autonomic, bowel, bladder and sexual dysfunction
  • Catastrophic injury with long-term medical and
    psychosocial consequences

4
Spinal Cord Injury Model Systems
  • The Spinal Cord Injury Model Systems (SCIMS)
    program was established by the Rehabilitation
    Services Administration in the early 1970s
  • The SCIMS are specialized programs of care in SCI
    which gather information and conduct research
    with the goal of improving long-term functional,
    vocational, cognitive, and quality-of-life
    outcomes for individuals with SCI

Lammertse, Jackson and Sipski, 2004 NIDRR
5
Spinal Cord Injury Model Systems
  • Model System grantees contribute data to a
    national statistical center that tracks the
    long-term consequences of SCI and conduct
    research in the areas of medical rehabilitation,
    health and wellness, service delivery, short- and
    long-term interventions, and systems research.
  • Each Model System also is charged with
    disseminating information and research findings
    to patients, family members, health-care
    providers, educators, policymakers and the
    general public.

6
Current SCI Model Systems
7
National SCIMS Database
  • Captures approximately 13 of all new SCI
    occurring in the U.S.
  • Established at the University of Alabama at
    Birmingham in 1983
  • Coordinates data collected by all SCI Model
    Systems Centers
  • Registry 10,357 participants
  • Form I 25,415 participants
  • Form II 115,448 participants, up to 30 years
    post injury

8
SCI Descriptive Data Summary, 1973 - 2007
  • Source Annual Report (2007) for the Spinal Cord
    Injury Model SystemsNational Spinal Cord Injury
    Statistical CenterBirmingham, AL

9
SCI Epidemiology
  • Incidence
  • 40/million
  • 12,000 new cases per year
  • Does not include those who die at scene
  • 4/million or 1,000 per year
  • Prevalence
  • 255,702 (range 227,080 300,938)

10
SCI Epidemiology
  • Age at injury
  • Mean 39.5 years (since 2005)
  • More people 60 years at time of injury
  • 77 male
  • Etiology
  • 42 MVC, 27 falls, 15 violence, 7 sports
  • MVC 1 cause if lt45 years
  • Falls 1 cause if gt45 years

11
Age at Injury
12
Education
13
Marital Status
14
Occupational Status
15
Race
16
SCI Epidemiology
  • Severity of injury
  • Complete 49
  • Sensory incomplete 10.3
  • Motor incomplete (weak) 11.2
  • Motor incomplete 29.1
  • Normal function 0.8

17
SCI Epidemiology
  • Neurologic level of injury (LOI)
  • Incomplete tetraplegia 34.1
  • Complete paraplegia 23.0
  • Complete tetraplegia 18.3
  • Incomplete paraplegia 18.5
  • Full neurologic recovery lt1

18
Spinal Cord Injury Mortality
  • 6.3 die in first year
  • Mortality associated with
  • Older age
  • Male
  • Violence
  • C4 or higher injury level
  • Vent dependent status
  • Neurologically complete injury
  • Medicare/Medicaid

19
Life Expectancy
20
Classification of injury and prognosis for
recovery
21
Classification of Spinal Cord Injury
  • Level of injury (LOI)
  • Motor, sensory, and sacral examinations
  • Severity of injury
  • Complete (ASIA A)
  • Incomplete (ASIA B, C, D, E)
  • Incomplete syndromes
  • Anterior Cord Syndrome
  • Central Cord Syndrome
  • Brown-Sequard Syndrome
  • Cauda Equina Syndrome

22
ASIA Impairment Scale
23
Prognosis for Recovery
  • Neurologic assessment at 72h 1 week superior to
    earlier testing
  • Repeat testing within 72 h 1 week window
  • Sensory exam better for predicting motor recovery
    in LE than UE

24
Prognosis for Recovery
  • 50-67 of total 1-year recovery occurs in first 2
    months
  • Slower recovery during 3-6 mos
  • Motor recovery documented up to 2 yrs

25
Recovery by ASIA Impairment Grade
  • Proportion of subjects exhibiting spontaneous AIS
    grade conversion
  • 75-80 AIS A remain A
  • 35-40 AIS B convert to C or D
  • 60-80 AIS C convert to D
  • Nearly all AIS D remain D

26
Anterior Cord Syndrome
  • Compression of the anterior spinal artery, bony
    fragments or herniated disc
  • Loss/decreased strength bilaterally
  • Incomplete sensory loss
  • Loss/decreased pain and temperature
  • Preserved vibration sense

27
Central Cord Syndrome
  • Seen in older persons, hyperextension injury
    secondary to a fall
  • Greater motor and sensory impairmentof the hands
    and arms than the legs
  • Variable bowel and bladder impairment

28
Brown-Sequard Syndrome
  • Hemisection of cord
  • Usually due to penetrating injury
  • Ipsilateral loss of motor function,
    proprioception, and vibration
  • Contralateral loss pain and temperature

29
Cauda Equina Syndrome
  • Peripheral nerve injury
  • Variable loss in motor and sensory function of
    lower extremities

30
Contemporary issues in sci care The Health care
system, rehabilitation aging issues
31
Changes to the System of Care
  • Financial resources declining for trauma and
    emergency care
  • More patients are arriving at acute
    rehabilitation with significant secondary
    conditions
  • Fewer ventilator-capable rehabilitation centers
  • Acute rehabilitation length of stay declining
  • Rehospitalizations increasing
  • People leaving rehabilitation less prepared to
    care for themselves and often without proper
    equipment

32
Secondary Conditions
  • Neurologic system
  • Late neurologic deterioration
  • Musculoskeletal system
  • Overuse syndromes
  • Genitourinary system
  • Bladder infections, stones, cancer
  • Kidney infections, stones, other
  • Gastrointestinal system

33
Secondary Conditions
  • Integument
  • Skin breakdown
  • Pulmonary system
  • Pneumonia, impaired cough, other
  • Cardiovascular system
  • Autonomic imbalance, low/high blood pressure
  • Risk for early cardiovascular disease
  • Sexuality/Fertility

34
Secondary Conditions
  • Metabolic
  • Altered body composition
  • Carbohydrate and lipid disorders
  • Bone
  • Universal osteoporosis
  • Psychosocial
  • Adjustment to disability, depression, fatigue
  • Participation
  • Substance abuse

35
Rehabilitation research for improved health and
recovery after spinal cord injury
36
Emerging Rehabilitative Research
  • Once solely focused on prevention of secondary
    conditions
  • Now, with increasing numbers of clinical trials
  • Body-weight supported ambulation
  • Neuromuscular electrical stimulation
  • Functional electrical stimulation
  • Activity-based rehabilitation
  • Therapies for neurorecovery and restoration

37
Challenges of Translational Research
  • Lack of refined outcome measures
  • ASIA motor and sensory exam
  • Ashworth
  • Functional Independence Measure (FIM)

38
Problems With Outcome Measures
  • Using AIS
  • Ex 2 grade changes in AIS (A to C) as in Sygen
    trial
  • Baseline C5 AIS A with UEMS15
  • Recovery After treatment UEMS42
  • Functional paraplegic
  • Outcome Subject still AIS A and according to
    trial did not respond to treatment

39
Problems With Outcome Measures
  • Using AIS
  • Ex Using 10 point improvement of motor
  • Baseline C4 AIS A
  • Recovery After treatment subject acquires
    sensation/motor at S4-S5 and some muscles have
    non-functional improvement (UEMS14, LEMS10) No
    functional change
  • Outcome Subject had 20 point motor improvement
    and is considered a success but little functional
    change

40
Functional Independence Measure
  • A measure of disability (functional limitation),
    burden of care, performance
  • 18 items in 6 categories (self care, sphincter
    control, mobility, locomotion, communication,
    social cognition)
  • SCI inter-rater .83 for total score, individual
    items .42
  • Recommended by ASIA in 1992, dropped in 2000
  • Significant floor and ceiling effects for
    patients with SCI
  • This is our second most common tool,
  • Not all aspects relevant to SCI

41
FIM by ASIA Change A to C
42
Emerging Outcome Measures
  • ASIA sub-scores
  • Electrophysiologic testing
  • QST
  • SCIM III

43
Power Issues
  • Number of enrolled subjects necessary to show a
    statistical difference between experimental and
    control groups using modest change in AIS motor
    score
  • Approx 60 AIS A tetra subjects to show 10 point
    difference
  • Approx 200 AIS A tetra subjects to show 5 point
    difference
  • Number of participants may increase 4X when
    incomplete subjects enrolled

44
Timing of Intervention
  • Most functional change occurs within 3 months of
    injury and plateaus after 1 year
  • Thus, number of subjects needed decreases with
    delayed treatment
  • Highest probability for detecting clinical
    benefit is during chronic SCI
  • However, this is potentially most difficult time
    biologically to influence the cord

45
Clinical Targets
  • Many pharmacologic and cell-based therapeutics
    are applied near the site of injury
  • Consider how to track segmental improvement
  • Spontaneous functional improvement of one spinal
    level is common
  • Spontaneous improvement of 2 spinal levels less
    common (5-20) in AIS A tetraplegics

46
Translational Research
  • Public pressure
  • Lack of knowledge about scientific evidence
    development
  • Impatience with slow methodical pace of science
  • Impact of quasi-scientific case series
    masquerading as research

47
Consumers Preferences
  • Tetraplegia
  • Arm/hand 48.7
  • Sexual 13
  • Trunk stability 11.5
  • BB 8.9
  • Walking 7.8
  • Sensation 6.1
  • Chronic pain 4
  • Paraplegia
  • Sexual 26.7
  • BB 18
  • Trunk stability 16.5
  • Walking 15.9
  • Chronic pain 12
  • Sensation 7.5
  • Arm/hand 3.3

48
References
  • Lammertse DP, Jackson AB, Sipski ML. Research
    from the model spinal cord injury systems
    Findings from the current 5-year grant cycle.
    Arch Phys Med Rehabil. 200485(11)1737-1739.
  • National Institute on Disability and
    Rehabilitation Research - Disability and
    Rehabilitation Research Projects and Centers
    Program - Spinal Cord Injury Model Systems
    Centers and Disability Rehabilitation Projects.
    Federal Register. Vol 70.238 December 13,
    200573738-73741.
  • Compilation of database research contributed by
    SCIMS investigators
  • Books (1986, 1990, 1995) and special issues of
    Archives of Physical Medicine and Rehabilitation
    (1999, 2004)

49
References
  • Online Syllabus and Data Collection Forms
  • (http//www.spinalcord.uab.edu/show.asp?durki2448
    0)
  • Facts Figures at a Glance
  • http//www.spinalcord.uab.edu/show.asp?durki11697
    9
  • Mid-year and Annual Statistical Reports
  • http//www.spinalcord.uab.edu/show.asp?durki11689
    1

50
ASIA
51
Paralyzed Veterans of America
52
Spinal Cord Injury Rehabilitation Evidence
53
Thank you
  • For more information, email Suzanne.L.Groah_at_Medsta
    r.Net
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