Janice Eng, PhD, Robert Teasell, MD, William Miller, PhD, Dalton Wolfe, PhD, Andrea T ownson, MD , Jo-Anne Aubut, BA, Caroline Abramson, MA, Jane Hsieh, MSc, Sandra Connolly, BHScOT, and the SCIRE Research Team
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Janice Eng, PhD, Robert Teasell, MD, William Miller, PhD, Dalton
Wolfe, PhD, Andrea Townson, MD, Jo-Anne Aubut, BA, Caroline
Abramson, MA,
Jane Hsieh, MSc, Sandra Connolly, BHScOT, and the SCIRE Research
Team
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Editors:
Janice J. Eng, PhD, BSc (PT/OT), Robert Teasell, MD, FRCPC, William
C. Miller, PhD, OT, Dalton Wolfe, PhD,
Andrea F. Townson, MD, FRCPC, Jo-Anne Aubut, BA, Caroline
Abramson, MA, Jane Hsieh, MSc,
Sandra Connolly, BHScOT(C), OTReg. (Ont.)
This review has been prepared based on the scientific and
professional information available in 2005. The SCIRE information
(print, CD or web site
www.icord.org/scire) is provided for informational and educational
purposes only. Please feel free to use this information, as seen
fit, without alteration. If you have
or suspect you have a health problem, you should consult your
health care provider. The SCIRE editors, contributors and
supporting partners shall not be
liable for any damages, claims, liabilities, costs or obligations
arising from the use or misuse of this material.
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Chapter 1 Rehabilitation: From Bedside to Community
FollowingSpinal Cord Injury (SCI)
....................................................................
1-1 1-11
Chapter 2 Methods of the Systematic Reviews
................................................ 2-1 2-11
Chapter 3 Rehabilitation Practice and Associated Outcomes
Following Spinal Cord Injury
.............................................................................
3-1 3-44
Chapter 4 Community Reintegration Following Spinal Cord
Injury .................... 4-1 4-37
Chapter 5 Upper Limb Rehabilitation Following Spinal Cord
Injury ................... 5-1 5-58
Chapter 6 Lower Limb Rehabilitation Following Spinal Cord
Injury ................... 6-1 6-34
Chapter 7 Cardiovascular Health and Exercise Following Spinal
Cord Injury.... 7-1 7-28
Chapter 8 Respiratory Management Following Spinal Cord Injury
.................... 8-1 8-30
Chapter 9 Bone Health Following Spinal Cord
Injury......................................... 9-1 9-18
Chapter 10 Depression Following Spinal Cord Injury
.......................................... 10-1 10-19
Chapter 11 Sexual Health Following Spinal Cord Injury
...................................... 11-1 11-40
Chapter 12 Neurogenic Bowel Following Spinal Cord Injury
............................... 12-1 12-17
Chapter 13 Bladder Health and Function Following Spinal Cord
Injury .............. 13-1 13-77
Chapter 14 Pain Following Spinal Cord Injury
.................................................... 14-1
14-32
Chapter 15 Venous Thromboembolism Following Spinal Cord
Injury ................. 15-1 15-25
Chapter 16 Orthostatic Hypotension Following Spinal Cord
Injury ...................... 16-1 16-17
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Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Aubut J,
Abramson C, Hsieh JTC, Connolly S, editors. Spinal Cord Injury
Rehabilitation Evidence. 2006: Vancouver.
www.icord.org/scire
Chapter 18 Heterotopic Ossification Following Spinal Cord
................................ 18-1 18-8
Chapter 19 Nutrition Issues Following Spinal Cord
Injury.................................... 19-1 19-13
Chapter 20 Pressure Ulcers Following Spinal Cord
Injury................................... 20-1 20-26
Chapter 21 Spasticity Following Spinal Cord Injury
............................................. 21-1 21-56
Chapter 22 Outcome Measures
..........................................................................
22- 1 22-89
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i
FORWARD
Over the past few years, the volume of publications encompassing a
broad definition of rehabilitation after spinal cord injury (SCI)
has expanded exponentially. As in all rapidly expanding research
fields, it is helpful, from time to time, to review what has been
published and assess the quality of the data and conclusions of
these reports. Thus was born the SCIRE project.
This manual represents the first comprehensive synthesis of the
published evidence on rehabilitation strategies and community-based
programs designed to improve the functional outcomes and quality of
life for people living with a SCI. It is primarily intended as a
guide for professionals in the areas of SCI health care and
community care. It should also prove useful to SCI researchers,
public policy makers, and people with SCI and their families. The
goal is to provide everyone with the necessary objective
information to make better-informed decisions as to the strength
and validity of current rehabilitation programs and emerging
strategies, as well as to identify gaps in our knowledge and
possible research priorities.
A knowledge translation project as large as SCIRE requires
clearly identified validation criteria and the coordinated efforts
of a large number of individuals. The more than 40 invited
reviewers from across Canada have long-standing expertise on the
topics they reviewed. Drs. Janice Eng, Robert Teasell and William
Miller provided the vision, framework and critical leadership for
SCIRE and the ensuing team work between the Vancouver and London
sites. Their tireless efforts ensured the timely release of this
first version. Version 1 is just the beginning of SCIRE activities.
In the years to come, we can anticipate revised versions of SCIRE,
as new SCI research evidence comes to light and future best
practices in SCI rehabilitation are validated. In addition, this
compilation can form a basis for activities such as the development
of clinical practice guidelines and identification of disparities
between current practice and best practice.
On behalf of ICORD, The Ontario Neurotrauma Foundation, and The
Rick Hansen Foundation,
we offer thanks and congratulations to everyone who contributed to
the successful launch of SCIRE.
John D. Steeves John and Penny Ryan BC Leadership Professor
Director of ICORD Vancouver, Canada
September 2006
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This large-scale project represents the collaborations and
tremendous efforts of so many dedicated people.
We would like to thank the funding agencies that provided financial
support – the Rick Hansen Man in Motion Foundation and the Ontario
Neurotrauma Foundation.
The SCIRE Advisory Committee met regularly to provide feedback on
the process and translation methods for the SCIRE project and their
input was invaluable.
The SCIRE Advisory Committee members: Caroline Abramson, Research
Coordinator, GF Strong Rehab Centre/University of BC Jo-Anne Aubut,
Research Coordinator (Parkwood, London) Karen Anzai, Rehab
Consultant, SCI Program, GF Strong Rehab Centre Sandra Connolly,
OT, Spinal Cord Program (Parkwood, London) Armin Curt, MD,
Research Chair , ICORD Chris Fraser, Reg. Dietician, SCI &
ABI Programs, SCI consumer (Parkwood, London)
Chris McBride, PhD, Managing Director, ICORD Dave Metcalf,
Vocational Counselor, SCI consumer (GF Strong Rehab Centre) Kelly
Moore, Educator, SCI Program, GF Strong Rehab Centre Steve
Orenczuk, PsyD, SCI program (Parkwood, London) Andrea
Townson, MD, FRCPC, GF Strong Rehab Centre, Co-PI, SCIRE Project
Dalton Wolfe, PhD, SCI (Parkwood, London) Daryl Rock, Associate
Director, Knowledge Exchange Canadian Council on
Learning
In addition to the editors and contributors already recognized,
several individuals made significant contributions to assessing and
extracting data from Vancouver: Jennifer Cumal, Nicole Elfring,
Marcia Fukunaga, Chihya Hung, Emily Procter, and Jeff Tan and from
London: Joan Conlon and Dr. Jeff Jutai.
We are grateful to the GF Strong Rehab Centre (Vancouver Coastal
Health), Parkwood Hospital (St. Joseph’s Health Care) and Lawson
Health Research Institute which provided the space and
infrastructure support for undertaking the project.
We’d also like to recognize the support from ICORD, in particular,
Cheryl Niamath for her graphic designs and endless patience, Dave
Pataky for his web and CD development and Dr. John Steeves for his
guidance.
Lastly, we’d like to express our gratitude to the many SCI
rehabilitation scientists and clinicians who spent endless hours
putting the chapters together and made this project possible.
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1. SCIRE Project overview
The Spinal Cord Injury Rehabilitation Evidence (SCIRE) is a
synthesis of the research evidence underlying rehabilitation
interventions to improve the health of people living with SCI.
SCIRE covers a comprehensive set of topics relevant to SCI
rehabilitation and community re-integration. This project is
intended to translate existing knowledge to health professionals to
inform them of best practice. This research synthesis will also
enable relevant decision-making in public policy and practice
settings applicable to SCI rehabilitation. In addition, transparent
evidence-based reviews can guide the research community and funding
organizations to strategically focus their time and resources on
the gaps in knowledge and identify research priorities. People with
SCI and their families may also find the information useful to
understanding their health care.
The Spinal Cord Injury Rehabilitation Evidence developed from a
research collaboration between Vancouver and London (Ontario) and
involved their respective health centres (GF Strong Rehab Centre,
St. Joseph’s Health Care), research institutions (International
Collaboration on Repair Discoveries, Lawson Health Research
Institute) and universities
(University of BC, University of Western Ontario).
2. Methods
Systematic Review
An exhaustive search (keyword literature search, previous
practice guidelines and systematic reviews, review articles) was
used to identify published literature evaluating the effectiveness
of any treatment or therapy related to SCI rehabilitation. Topics
relevant to rehabilitation were selected with input from scientists
and clinicians in the field of SCI rehabilitation, in addition to
the SCIRE Advisory Committee (which included consumers with SCI and
policy-makers).
This search involved the review of over 17,000 titles and 8400
abstracts, and a final extraction and synthesis of almost 700
articles. A variety of study designs were included (from randomized
controlled trials to case reports), however, controlled trials were
given priority in generating conclusions. In order to provide
transparent and unbiased evidence-based reviews, the rigor and
quality of each study was scored on standardized scales by two
independent reviewers (Physiotherapy Evidence Database Scale for
randomized controlled trials and the Downs and Black Tool for all
other studies). Following this individual study assessment,
conclusions were drawn about the accumulated studies for each topic
of interest (e.g., pressure ulcers) using a modified version of
Sackett’s description of levels of evidence. In this 5 point scale,
the strongest evidence, level 1, was assigned if the intervention
was supported by at least one randomized controlled trial, while a
level 5 was assigned if no critical appraisal existed, but perhaps
was supported by clinical consensus. Conclusions were based on the
levels, quality
and concurring evidence. When conflicting data was present, an
explanation was provided as to how the conclusions were
derived.
Outcome measure assessment Outcome measures used in spinal cord
injury evaluation were identified by keyword search of the major
electronic databases and through hand searches of noted spinal cord
journals. Only measures with published studies of the psychometric
(reliability and validity) properties within the spinal cord
population were identified for review. The measures were
categorized into the
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domains of the World Health Organization’s International
Classification of Functioning, Disability and Health (body
function/structure, activity and participation). A fourth category
was created for quality of life measures. Approximately 160
measures were identified of which 63 were selected for review based
on clinician interest. The measures were evaluated using elements
of the Health Technology Assessment to assess the psychometric
properties, interpretability, acceptability, and feasibility.
Summary tables identifying the rigor and quality of the
psychometric properties were constructed. A clinical conclusion is
offered based on the synthesis of the review.
3. Findings from the Systematic Review of SCI Rehabilitation
Given that the SCIRE consists of over 800 pages of evidence, we
cannot represent all the findings here. What follows are selected
findings which demonstrate the scope of the research and the value
of the results.
Rehabilitation Practice Earlier admission to specialized,
interdisciplinary SCI care is associated with reduced length of
total hospital stay and greater and faster rehabilitation gains
with fewer medical secondary
complications (especially pressure sores).
Community Re-integration The average level of quality of life after
SCI is slightly lower than in people without disability but a
substantial number of people with SCI report good or excellent
levels of quality of life. The severity of injury and other
diagnostic factors do not significantly impact quality of life.
Their influence may become significant through restrictions in
community integration or social participation.
Upper Limb Rehabilitation Upper limb muscle strength is identified
as an important contributor to functional independence.
Neuromuscular stimulation-assisted exercise (e.g., during arm
ergometry) following a spinal
cord injury is effective in improving muscle strength, preventing
injury and increasing independence in all phases of rehabilitation.
Practice of repetitive movements in conjunction with low intensity
peripheral nerve stimulation may induce beneficial brain cortical
changes, in addition to improved arm and hand function.
Lower Limb Rehabilitation Body-weight supported treadmill exercise
using a suspended harness is a relatively new treatment of
interest. For patients less than 6 months post-SCI, body weight
supported treadmill training has equivalent effects on gait
outcomes to conventional rehabilitation consisting of overground
mobility practice. Body weight-support gait training strategies can
improve gait outcomes in chronic, incomplete SCI, but no single
specific body weight-support strategy (overground, treadmill, with
functional electrical stimulation) is more effective.
Cardiovascular Health and Exercise There appears to be an earlier
onset and increased prevalence of cardiovascular disease in
individuals with SCI in comparison to the general population.
Tetraplegics and paraplegics can improve their cardiovascular
fitness and physical work capacity through aerobic exercise
training (e.g., arm cycle or wheelchair ergometry), which are of
moderate intensity, performed 20-60 min day, at least three times
per week for a minimum of six to eight weeks.
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Respiratory Management Respiratory complications continue to be one
of the leading causes of morbidity and mortality in people with
spinal cord injury, especially among cervical and higher thoracic
injuries. Unlike the cardiovascular system, the lungs and airways
do not change appreciably in response to exercise training. For
exercise training to improve respiratory function, the training
intensity must be relatively high (70-80% of maximum heart rate)
performed three times per week for six
weeks.
Bone Health There is a significant risk for lower extremity
fragility fractures after SCI. Early assessment and ongoing
monitoring of bone health is an essential element of SCI care.
There is strong evidence from randomized controlled trials that
support the use of medications for the prevention and treatment of
bone loss following SCI. Non-pharmacological treatments have not
been found to prevent bone loss in the first year, however,
electrical stimulation can increase bone density over the area
stimulated in people with SCI more than 1 year post-injury.
Depression Depression is a common consequence of SCI. Cognitive
behavioural interventions provided in
a group setting appear helpful in reducing post-SCI depression. The
benefits of drug treatment (including selective serotonin reuptake
inhibitors and tricyclic antidepressants) in combination with
psychotherapy may alleviate depression. However, pharmacological
management for post- SCI depression is largely extrapolated from
studies in non-SCI populations. Programs to encourage regular
exercise, reduce stress, and improve or maintain health are
beneficial in reducing reports of depressive symptoms in persons
with SCI.
Sexual Health In men with SCI, erections are often not reliable or
adequate for sexual intercourse since there may be difficulties
with maintenance of the erection. The pharmacological agent,
Phosphodiesterase Type 5 Inhibitors (PDE5i, Viagra®) can be used
safely and effectively for treatment of erectile dysfunction in men
with SCI and are recommended as first line treatment
for erectile dysfunction after SCI.
Bowel Management Multifaceted programs incorporating intereventions
such as, nutrition, fluid consumption, routine bowel evacuation,
may improve movement of substances through the colon as well as
decrease the incidences of difficult bowel evacuations.
Pharmacological agents such as cisapride, prucalopride, and
metoclopramide are effective for the treatment of chronic
constipation in persons with SCI.
Bladder Management Disruption of the signals from the brain
resulting from a SCI prevents normal voluntary voiding without
assistance. Intermittent catheterization and spontaneous triggered
voiding are
associated with the lower complications compared to indwelling
catheters. Intermittent catheterization may be difficult to
continue at home for those with tetraplegia and complete injuries.
Assistive devices may enhance compliance with intermittent
catheterization for those with impaired hand function.
Pain Management Pain following a SCI is common, often severe and
has a significant effect on quality of life. A shoulder exercise
protocol (consisting of shoulder stretching and strengthening)
reduces the intensity of shoulder pain post-SCI. Reduce pain may be
achieved from massage, heat,
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acupuncture or hypnosis. A number of pharmacological agents can
provide pain relief, including the anticonvulsant Gabapentin,
Intrathecal Baclofen, and Lidocaine through a subarachnoid lumbar
catheter. Tricyclic antidepressants and Intrathecal Clonidine have
not been shown to reduce post-SCI pain.
Venous Thromboembolism
Venous thromboembolism (blood clot) is very common in untreated
spinal cord-injured patients. The pharmacological agent low
molecular weight heparin is more effective than standard heparin in
reducing the risk of venous thromboembolism post-SCI with less
bleeding complications. Physical interventions such as pneumatic
compression or pressure stockings may have some additional benefits
when used in combination with pharmacological agents.
Orthostatic Hypotension Orthostatic hypotension is an excessive
reduction in blood pressure with changes in body position and can
result in lightheadedness or dizziness. It is commonly experienced
following SCI due to the loss of muscle activation. Although a wide
array of physical and pharmacological measures are recommended for
the general management of orthostatic hypotension, very few have
been evaluated for use in SCI. Of the pharmacological
interventions, only midodrine was
found to be effective, while functional electrical stimulation is
one of the only non- pharmacological interventions which
demonstrates some evidence to support its use.
Autonomic Dysreflexia Autonomic dysreflexia is a
potentially life-threatening acute elevation of blood pressure
commonly experienced post-SCI. The identification of the possible
trigger and decrease of sensory stimulation to the spinal cord is
the most effective prevention strategy. Urinary bladder irritation
is one of the major triggers of autonomic dysreflexia following
SCI. The pharmacological agents, nifedipine or captopril are
commonly used and can prevent or control autonomic dysreflexia in
SCI individuals.
Heterotopic Ossification
Heterotopic ossification, the formation of pathological bone in
muscle or soft tissue, occurs frequently in the first two months
following SCI. Anti-inflammatory medications or warfarin (anti-
coagulant) can reduce the risk of heterotopic ossification
post-SCI. Once ossification is identified, the pharmacological
agent, etidronate or radiation therapy can reduce the progression
of heterotopic ossification.
Nutrition There is an increased risk for obesity, abnormal lipid
metabolism, cardiovascular disease, impaired glucose regulation and
diabetes mellitus post-SCI. Standard dietary counseling (daily
total fat <30% of total daily calories, saturated fat <10% of
total daily calories, cholesterol <300 mg, carbohydrates equal
to 60% of total daily calories) can reduce total cholesterol. A
holistic wellness program can help people adopt healthy nutritional
behaviours following a SCI. Vitamin
deficiency is common post-SCI, therefore individuals should be
screened and if needed, replacement therapy should be
initiated.
Pressure Ulcers Pressure ulcers are a serious, lifelong secondary
complication of SCI. A number of prevention strategies exist to
reduce the risk of pressure ulcers and appropriate seating is one
important consideration. No one cushion is suitable for all
individuals with SCI. Cushion selection should be based on a
combination of pressure mapping results, individual characteristics
and preference. Adding lumbar support to the wheelchairs of
individuals with chronic SCI is unlikely
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vii
to have a role in pressure ulcer prevention post-SCI. A forward
leaning position or the wheelchair tilted back position (> 65º)
are effective methods of pressure relief.
Spasticity Spasticity is the excessive involuntary motor activity
of a muscle or muscle group reacting to external stimuli. It is a
major obstacle for community and workplace integration following
SC.
Oral baclofen or intrathecal baclofen reduces muscle spasticity
following SCI. A number of non- pharmacological interventions
(transcutanous electrical stimulation, massage, assisted standing,
ice) have short term effects on spasticity lasting several minutes
to hours.
Outcome measures Numerous outcome measures are available for use in
SCI practice and research. Many SCI specific measures are gaining
acclaim such as the Spinal Cord Independence Measure which is
slowly replacing the Functional Independence Measure as the outcome
of choice for assessing personal activities of daily living.
Several new generic measures of participation in higher order
social activities and life habits are available. These tools are
conceptually well developed and support for psychometric properties
is accumulating.
4. Limitations in SCI Rehabilitation Literature
The task of compiling this vast amount of literature provided the
SCIRE team a unique opportunity to appraise the body of SCI
rehabilitation literature as a whole. There is a substantial amount
of literature available in SCI rehabilitation as highlighted in the
previous section. However, the SCIRE team noted several gaps and
recurring methodological issues across different topics in SCI
rehabilitation and highlight these limitations here.
Our topics were selected by clinicians, researchers and consumers
with SCI and not necessarily by the abundance of research papers in
a particular area. Little or no information was available in
several areas. Despite the inherent value we place on integrating
an individual in their community, we do not know the best methods
to facilitate successful re-entry into community
life and literature was either absent or based on observational
studies for this topic. There was also a dearth of literature
concerning sexual and reproductive health of women with SCI that
would potentially guide selection of contraception, enhancement of
sexual adjustment and response or access to routine gynecological
procedures. Women make up a significant proportion of the SCI
population (one-quarter to one-third) and were underrepresented
across all areas of SCI rehabilitation literature.
For many areas, we rely on information based primarily on other
medical conditions. Although guidelines exist for SCI related
conditions such as depression, autonomic dysreflexia, and deep vein
thrombosis, many of the recommendations are based on other patient
populations (not SCI). SCI is a complex condition with effects and
interactions on multiple systems and responses that are not always
predictable. For example, a simple dietary intervention such
as
increased fibre, had a response in SCI (worsened constipation)
which was opposite to what would be expected in able-bodied
individuals (reduced constipation).
The SCI rehabilitation literature suffers from several
methodological shortcomings, including small, heterogeneous
samples, few controlled trials, and a lack of consensus as to
common outcome measures. Study samples consisted of people who had
sustained different injuries: paraplegia and tetraplegia, complete
and incomplete injuries, and acute and chronic injuries. This was
prevalent throughout the current literature, despite the knowledge
that physiological responses from interventions are different in
these subgroups. As a result, a heterogeneous
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sample can also wash out what might have been important effects for
a subsample of the population. For example, bone health
interventions depend on the stage of injury; preventing bone loss
during the rapid bone mineral loss in the first 4-6 months compared
with maintaining or improving bone during the relative
stabilization after 1-2 years after SCI. However, some of the bone
health studies included participants within a few months to several
years post-injury representing physiologically different
phases.
Pharmacological interventions were supported by the largest
proportion of randomized controlled trials (level 1 evidence) while
other rehabilitation interventions were primarily supported by
single group, pre-test/post-test studies (level 4 evidence).
Without a comparable control group, one cannot determine if
improvements are attributed to the intervention or other factors
such as increased familiarity with the outcome measures, time
post-injury or attention from the clinician. Furthermore,
randomizing the subjects into the treatment and control group
reduces the biases associated with patient selection. It was not
surprising to see a number of interventions where the weaker
evidence demonstrated positive effects, but the more rigorous
controlled trials did not. For example, lower levels of study
design (pre-test/post-test study or non-randomized trial) suggested
that body-weight support treadmill training in sub-acute SCI
resulted in better outcomes than conventional rehabilitation;
however, stronger evidence from a
single-blinded RCT suggested that no differences between body
weight support treadmill training and conventional
rehabilitation.
Rigorous randomized trials with homogeneous groups require a large
available source of patients. The number of new spinal cord
injuries is relatively small compared to conditions like arthritis
or heart disease. There is no doubt that multi-site trials are
required if we strive to increase the certainty as to whether a
treatment is effective or not in SCI rehabilitation.
There is a lack of standardization when selecting the outcome
measures for an intervention. For example, the chapter authors
(Hsieh et al. 2006) noted that the spasticity interventions
included 66 different outcome measures. No single outcome measure
can capture the multi- dimensional nature of spasticity and its
effects and studies should include effective outcome
measures that meet minimum standards and that encompass the range
of health outcomes relevant to the treatment and the patients. In
addition, consensus on some common measures would assist the
interpretation of results across studies.
5. Conclusions
The SCIRE combined the efforts of expert scientists, clinicians,
consumers and stakeholders to increase the accessibility of quality
information in SCI rehabilitation. A broad range of topics are
evaluated, and future editions will continue to update, improve and
add new topics for people seeking information relevant to SCI
rehabilitation from bed side to community. The pre- appraised,
synthesized research from SCIRE can translate into improved health
for Canadians by keeping health care professionals, scientists,
policy-makers and consumers with SCI
informed of the latest evidence.
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EDITORS
Janice J Eng, PhD, BSc (PT/OT), is Professor, School of
Rehabilitation Sciences, University of BC, GF Strong Rehab Centre
and ICORD (Vancouver, Canada). Her program in neurological
rehabilitation spans mechanistic research, clinical trials to
knowledge translation. She is a Canadian Institutes of Health
Research Scholar and Michael Smith Scholar.
Robert Teasell, MD, FRCPC is Professor/Chair/Chief of the
Department of Physical Medicine and Rehabilitation at the
University of Western Ontario and Parkwood Hospital (SJHC). Dr.
Teasell’s research interests are in evidence-based applications to
clinical rehabilitation practice with a specific interest in
neurorehabilitation, and chronic pain, particularly the role of
personality in coping with pain.
William C Miller , PhD, OT, is Associate Professor, School of
Rehabilitation Sciences, University of BC and ICORD faculty. An
epidemiologist by background, his expertise is in the area of
measurement and examination of mobility limitations and daily
occupations
across diagnoses in older adults. He is a Canadian Institutes of
Health ResearchScholar.
Dalton Wolfe, PhD is an Associate Scientist in the Program of
Aging, Rehabilitation and Geriatric Care in the Lawson Health
Research Institute, London, ON, Canada. Dr. Wolfe has a background
in clinical neurophysiology and research methods. His current
research interests are in the areas of health promotion and
FES-assisted exercise for people with SCI.
Andrea F Townson, MD, FRCPC is Clinical Assistant Professor in the
Division of Physical Medicine and Rehabilitation, University of
British Columbia and ICORD. She is Medical Manager, SCI Rehab
Program at GF Strong Rehab Centre. Research interests
include high lesion spinal cord injuries, ventilator dependency,
fatigue and outcomemeasures.
Jo-Anne Aubut, BA is a research assistant in the Department of
Physical Medicine & Rehabilitation located at Parkwood
Hospital. She has worked on a variety of research projects through
the University of Western Ontario and the Lawson Health Research
Institute in London, ON.
Caroline Abramson, MA, is the Clinical Research Coordinator
for the Division of Physical Medicine and Rehabilitation. She works
with physiatrists and residents on a variety of research projects
through the University of British Columbia and GF Strong Rehab
Centre.
Jane Hsieh, MSc, has over 15 years in clinical research in both the
academic and biotechnology industry settings. Previously as the
senior director of Clinical Program at AcordaTherapeutics,
she oversaw a variety of phase 1, 2 & 3 studies mainly in SCI
and MS populations. Her current activities inlcude consultation to
both academic and industrial research groups.
Sandra Connolly, BHScOT(C), OTReg. (Ont.) is an occupational
therapist in the Spinal Cord Injury Rehabilitation Program at
Parkwood Hospital, St. Joseph's Health Care London.
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CONTRIBUTORS
Maureen Ashe, PhD, PT School of Rehabilitation Sciences University
of BC Vancouver, BC
Chris Fraser, HBSc, RD Rehabilitation Program Parkwood Hospital
London, ON
Najib Ayas, MD, MPH, FRCPC Faculty of Medicine University of BC
Vancouver, BC
Tal Jarus, PhD, OT School of Rehabilitation Sciences University of
BC Vancouver, BC
Jeff Blackmer, MD, FRCPC Physical Medicine and Rehab University of
Ottawa Ottawa, ON
Lyn Jongbloed, PhD, OT(C) School of Rehabilitation Sciences
University of BC Vancouver,BC
Sally Breen, RN, BSN, CRRN
Sexual Health GF Strong Rehab Centre Vancouver, BC
David Keast, MD, FRCPC
Outpatient Chronic Wound Management Parkwood Hospital London,
ON
Geri Claxton, RN Outpatient Nursing GF Strong Rehab Centre
Vancouver, BC
Andrei Krassioukov, MD, PhD Department of Medicine University
of BC, ICORD Vancouver, BC
B. Cathy Craven, MD FRCPC Bone Density Lab Toronto Rehabilitation
Institute
Toronto, ON
Tania Lam, PhD, PT School of Human Kinetics University of BC,
ICORD
Vancouver, BC
Armin Curt, MD, FRCPC Faculty of Graduate Studies University
of BC, ICORD Vancouver, BC
Kate McBride, RN Sexual Health GF Strong Rehab Centre Vancouver,
BC
Stacy Elliot, MD Department of Psychiatry University of BC, ICORD
Vancouver, BC
William B Mortensen, BScOT, MSc School of Rehabilitation Sciences
University of BC Vancouver, BC
Susan J Forwell, PhD, OT(C) School of Rehabilitation Sciences
University of BC, ICORD Vancouver, BC
Stephanie Muir-Derbyshire, MSc, SLP(C), Reg CASLPA Parkwood
Hospital London, ON
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xi
Vanessa Noonan, BScPT, MSc Dept of Orthopaedic Surgery University
of BC Vancouver, BC
A William Sheel, PhD School of Human Kinetics University of
BC, ICORD Vancouver, BC
Luc Noreau, PhD
Jim Slivinski, MA
Steven Orenczuk, PsyD Rehabilitation Program Parkwood Hospital
London, ON
Shannon Sproule, PT GF Strong Rehab Centre Vancouver, BC
Emily Procter, BSc GF Strong Rehab Centre Vancouver, BC
John Steeves, PhD John and Penny Ryan BC Leadership Chair, ICORD,
UBC/VCHRI
Vancouver, BC
MaryAnn Regan, RN, BScN Spinal Cord Injury Rehabilitation Program
Parkwood Hospital London, ON
Linh Tu, BHSc Physical Medicine and Rehabilitation Parkwood
Hospital, SJHC London, ON
W Darlene Reid, PhD, PT School of Rehabilitation Sciences
University of BC Vancouver, BC
Darren Warburton, PhD School of Human Kinetics University of BC,
ICORD Vancouver, BC
Candice Rideout, PhD (Candidate)Human Nutrition University of BC
Vancouver, BC
Maura Whittaker, PTGF Strong Rehab Centre Vancouver, BC
Bonita Sawatzky, PhD Dept of Orthopaedic Surgery University of BC
Vancouver, BC
Shannon Wilkinson, BScOT Spinal Cord Unit GF Strong Rehab Centre
Vancouver, BC
Keith Sequeira, MD, FRCPC Physical Medicine & Rehab
University of Western Ontario, ParkwoodHospital, London, ON
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Janice J Eng, PhD, BSc (PT/OT)
William C Miller, PhD, OT
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This review has been prepared based on the scientific and
professional information available in 2005. The SCIRE information
(print, CD or web site www.icord.org/scire) is provided for
informational and educational purposes only. If you have or suspect
you have a health problem, you should consult your health care
provider. The SCIRE editors, contributors and supporting partners
shall not be liable for any damages, claims, liabilities, costs or
obligations arising from the use or misuse of this material.
Eng JJ, Miller WC (2006). Rehabilitation: From Bedside To Community
Following Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC,
Wolfe DL, Townson AF, Aubut J, Abramson C, Hsieh JTC, Connolly S,
editors. Spinal Cord Injury Rehabilitation Evidence. Vancouver, p
1.1-1.11.
www.icord.org/scire
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Rehabilitation: From Bedside To Community Following Spinal Cord
Injury (SCI)
1.1 Background
The spinal cord extends from the foramen magnum (opening at the
base of the skull) to the conus medullaris (most distal bulbous
part of the cord) at the level of the first and second lumbar
vertebrae. It consists of 31 segments associated with 31 pairs of
spinal nerves (8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1
coccygeal). The ascending sensory nerves within the spinal cord
receive and transmit sensory information to the brain. The
descending motor nerves transmit information from the higher brain
structures to various parts of the body to initiate motor functions
such as movement and to regulate autonomic functions such as
respiration and blood pressure. The spinal cord is also critical
for transmitting and integrating information within the spinal
cord.
Figure 1.1
T1-11 T7-L1
Coccygeal
Intercostals Abdominals Muscle
Spinal cord injury (SCI) which results in disruption of the nervous
transmission can have considerable physical and emotion
consequences to an individual’s life. Paralysis, altered sensation,
or weakness in the parts of the body innervated by areas below the
injured region almost always occur. In addition to a loss of
sensation, muscle functioning and movement, individuals with SCI
also experience many other changes which may affect bowel and
bladder, presence of pain, sexual functioning, gastrointestinal
function, swallowing ability, blood pressure, temperature
regulation and breathing ability. Numerous secondary
complications
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may arise from SCI including deep vein thrombosis, heterotopic
ossification, pressure ulcers and spasticity.
The recovery can be long from the acute hospital admission to the
return of full participation in the individual’s community. Even
those individuals who make significant gains in rehabilitation may
experience difficulty when returning to pre-injury activities.
Thus, SCI has a severe effect
on quality of life. It also has an enormous cost on the health care
system. Dryden et al. (2005) examined the health care costs
following a SCI in Canada. The acute and rehabilitation care
represented 68.2% of the total health care costs incurred over the
first 6 years for an individual following an injury to the spinal
cord. The direct costs of a spinal cord injury were estimated at
$146,000 Canadian in the first year for a person with a complete
traumatic injury and $42,000 for an incomplete injury. Annual costs
in the subsequent 5 years post-injury were reported to be $5400
Canadian per person with a complete injury and $2800 for an
incomplete injury (Dryden et al. 2005). Compared to age and
gender-matched controls, individuals with SCI discharged from
hospital are more likely to be re-hospitalized, have physician
contact and use more hours of home care services (Dryden et al.
2004). The need for evidence-based SCI rehabilitation programs has
never been greater given the enormous cost of SCI rehabilitation,
the growing demands on the Canadian health care system and the
devastating impact that an SCI has on
the quality of lives of individuals.
1.2 Epidemiology
Injuries to the spinal cord have been classified as either
traumatic in cause (e.g., motor vehicle accidents, falls, violent
incidences, diving) or non-traumatic (e.g., tumors, spinal
stenosis, vascular). Traumatic SCI accounts for the larger
proportion of SCI injuries, however, the exact proportion compared
to non-traumatic SCI is difficult to ascertain because reporting of
non- traumatic SCI has been inconsistent. The percent of traumatic
SCI to overall SCI injury has been reported to range from 75% in
Germany (Exner & Meinecke 1997), 61% in the United States
(McKinley et al. 1999a) and 48% in the Netherlands (Schonherr et
al. 1996).
1.2.1 Traumatic SCI
Much of the following epidemiology data on traumatic spinal cord
injury in Canada has been extracted from the 2006 Canadian
Institute of Health Information Report on Traumatic SCI (CIHI
2006a) using 2003-2004 data from the Canadian National Trauma
Registry (NTR). Over 950 traumatic spinal cord injuries occurred in
2003-2004 (CIHI 2006a). Reports of the annual incidence vary in
part due to differing methods of identifying and tracking injuries,
and due to regional differences. The annual incidence has been
estimated at 52.5 per million population in
Alberta (Dryden et al. 2003) and 46.2 to 37.1 per million
population over the 1994 to 1999 period in Ontario (Pickett et al.
2003). The global incidence of SCI estimated primarily from
developed countries ranges between 10.4 to 83 per million
population per year when including only patients who survived
before hospital admission (Wyndaele & Wyndaele 2006).
In Canada, males comprise over three-quarters of these traumatic
injuries with the majority occurring in those under 35 years of
age. Motor vehicle accidents are the leading cause of SCI injury
(43%), while falls are the second leading cause (36%) (NTR 1999).
The number of spinal cord injuries resulting from falls are
increasing due to the growing older adult segment of the
population. This has contributed to the increase in age of a person
with traumatic SCI (from average age 46 in 1994 to average 49 in
1998). In fact, we are now seeing a bimodal distribution of SCI in
the population with one mode centralizing at approximately 30 years
of age and another mode centralizing at 60 years of age.
Interestingly, falls are the primary cause of
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spinal cord injury admissions in seniors (64%), while motor vehicle
accidents are the leading cause in young adults (NRT 1999).
Fractures of the vertebral column, in addition to spinal cord
injury represent 71% of all SCI hospital admissions (NTR 1999). Of
the SCI admissions, 44% result in paraplegia and 56% tetraplegia
(NTR 1999).
Traumatic SCI can be complex as motor vehicle accidents or other
violent incidents often result
in more than injury to the spinal cord. In particular, patients
with the dual diagnosis of traumatic brain injury and spinal cord
injury present a challenge to the rehabilitation professional as
they are often agitated and have poor concentration. The percentage
of SCI injuries which are accompanied by a traumatic brain injury
are substantial, for example, Lida et al. (1999) reported that 35%
of SCI had a traumatic brain injury.
There appears to be a trend towards more severe injuries in Canada.
In the 1970s, the Canadian Paraplegic Association (CPA) reported
that about 25% of injuries resulted in tetraplegia and 75%
paraplegia. Of the new injuries reported to CPA during 1999, 47%
resulted in tetraplegia and 53% resulted in paraplegia. This
increase in tetraplegic injuries concurs with a slight significant
increase from 53.5% tetraplegia in the 1970s to 56.5% in 2000 at
the facilities with the Model Spinal Cord Systems in the US
(Jackson et al. 2004). A survey of the
epidemiology literature (Wyndaele and Wyndaele 2006) suggests
increasing proportions of tetraplegia with a global proportion of
approximately two-thirds tetraplegia.
There have been some suggestions that there are increasing numbers
of incomplete lesions in some regions (Calancie et al. 2005).
However, these finding are not consistent. The Model Spinal Cord
Systems in the US (Jackson et al. 2004) reported an increase in
complete injuries in the 1990s which has since dropped back to
pre-1990 levels with just less than half of the injuries being
complete. The Australian Spinal Cord Injury Registry reported
increasing rates in elderly males, fall-related injury and
incomplete tetraplegia and complete paraplegia over an eleven year
period (O’Connor 2006).
1.2.2 Non-traumatic SCI
There are many different causes of non-traumatic SCI, the more
common conditions include spinal stenosis (narrowing of the spinal
canal), tumor compression and vascular ischemia. Individuals with a
non-traumatic SCI do not necessarily enter major trauma or
rehabilitation centres and thus are not easily tracked in SCI
registries or databases. Non-traumatic SCI has different
demographics than traumatic SCI as spinal stenosis and spinal
tumors are more common in adults over 50 years of age. In addition,
specific diseases such as multiple sclerosis, paediatric spina
bifida or poliomyelitis can also contribute to non-traumatic spinal
cord injury and each has demographics specific to the
condition.
Overall, compared to traumatic SCI, individuals with non-traumatic
SCI tend to be older with less severe injuries, more likely to be
female, married, retired, and have an incomplete
paraplegic injury (McKinley et al. 1999, 2002a, 2002b). Differences
in demographics, clinicalpresentation and rehabilitation outcomes
have important implications for management of non- traumatic
SCI.
1.3 Recovery
The majority of individuals experience some neurological recovery
(changes in motor or sensory status) following a SCI, in addition
to functional recovery. Given that all patients receive some
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treatment (e.g., pharmacological, self-care and mobility training),
it is difficult to separate the contributions of spontaneous
recovery with those from active rehabilitation in humans.
1.3.1 Neuroplasticity
Spontaneous neuronal plasticity occurs through various mechanisms
and has been
demonstrated primarily in animal models. Recovery mechanisms
following complete injuries may include recovery of nerve roots
beside the lesion level, changes in the gray matter of the spinal
cord at the lesion level, reorganization of existing spinal
circuits and peripheral changes (Bradbury & McMahon 2006; Kern
et al. 2005; Ding et al. 2005; Hagg & Oudega 2006; Ramer et al.
2005). The evidence for spontaneous axonal regeneration is limited
as a small proportion of fibres regenerate and over a modest
distance (Bradbury & McMahon 2006). However, cortical
re-organization can occur, for example, Lotze et al. (2006) showed
that cortical representation of elbow movements following a
complete thoracic injury in humans was moved toward cortical areas
which represented the injured thoracic regions. There is evidence
that a pattern-generating spinal circuitry (also known as a central
pattern generator) is retained following a complete injury which
can produce stepping-like movements and activation patterns with
epidural lumbar cord stimulation (Kern et al. 2005) or treadmill
stimulation (Dietz et al.
2002). However, the functional consequences of these observations
are yet to be determined.
Incomplete injuries may have a greater extent of axonal sprouting
and axonal growth (Ding et al. 2005; Hagg & Oudega 2006). In
incomplete spinal cord injury in rats, transected hindlimb
corticospinal tract axons sprouted into the cervical gray matter to
contact short and long propriospinal neurons (Bareyre et al. 2004).
Following cervical lesions of the rat dorsal corticospinal motor
pathway which contains more than 95% of all corticospinal axons,
there was spontaneous sprouting from the ventral corticospinal
tract onto medial motoneuron pools (Weidner et al. 2001). This
sprouting was paralleled by functional recovery. Ramer et al.
(2005) suggested that if axonal regeneration occurs or if synaptic
spaces become occupied with different axons, functional recovery
will require retraining to optimize these new circuits. The
neuroplastic changes which underlie spontaneous recovery may be
enhanced by physical
interventions (e.g., exercise, electrical stimulation) and
pharmacological agents (Ramer et al. 2005).
1.3.2 Measures of Recovery
Changes in the American Spinal Injury Association (ASIA)
International Classification of Spinal Cord Injury, neurological
level of injury and completeness of injury are often used to
indicate human neurological recovery.
ASIA International Standards for Neurological Classification
of Spinal Cord Injury consists of 1) 5 category ASIA Impairment
Scale (A-E), 2) motor score and 3) sensory score (ASIA 2002).
Twenty-eight dermatomes are assessed bilaterally using pinprick and
light touch sensation for
the sensory score (maximum of 112 for pinprick and 112 for light
touch sensation). Ten keymuscles are assessed bilaterally with
manual muscle testing for the motor score (maximum of 50 for lower
limbs and 50 for upper limbs). The results are used in combination
with evaluation of anal sensory and motor function as a basis for
the determination of the ASIA Impairment Scale and the 5 categories
are summarized below (ASIA 2002).
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Table 1.1 Descriptions of Categories from ASIA Impairment
Scale
Neurological level of injury is the most caudal level at which both
motor and sensory levels are intact and has been shown to change in
some individuals over recovery.
Completeness of injury are based on the ASIA standards where the
absence of sensory and motor functions in the lowest sacral
segments indicates a complete injury and preservation of sensory or
motor function below the level of injury, including the lowest
sacral segments indicates an incomplete injury. Sacral-sparing is
an important indicator of motor recovery and provides evidence of
the physiologic continuity of spinal cord long tract fibers with
the sacral fibers at the end of the cord. The requirement of sacral
sparing to identify an incomplete injury provides a more rigorous
definition and less patients will convert from incomplete to
complete injury over time when using this definition.
Stauffer (1976) proposed that individuals with tetraplegia would
recover one neurological level, although this has been revised in
recent years to qualify that recovery of one neurologic level in
subjects with tetraplegia depends on severity, initial level of the
injury and the strength of muscles below the level of injury
(Dittuno et al. 2005). Dittuno et al. (1992) reported that 70 to
80% of motor-complete tetraplegia subjects with some motor strength
at the injury level would recover to the next neurologic level
within 3 to 6 months. Although those with complete lesions
are generally limited to improvements of one or two levels,
subjects with incomplete lesions may exhibit recovery at multiple
levels below the injury site (Dittuno et al. 2005). Triceps elbow
extension (C7) is a significant determinant for functional
independence in self-care for community-living individuals with
tetraplegia (Welch et al. 1986).
For those with complete paraplegia, Waters et al. (1992) reported
that 73% of 108 patients (T2- L2) did not change in neurological
level at one year post-injury compared to the rehabilitation
admission assessment. 18% recovered to the next neurological level,
while 7% had 2 levels of recovery. For incomplete paraplegia, 78%
of 45 cases (T1-L3) had no changes in neurological level between
the first and 12th month but there was substantial improvement
in motor function particularly within the first 3 months (Waters et
al. 1994). 70% of this sample were able to ambulate within 1 or 2
years post-injury (27% without any devices). Patients with initial
grade 2
hip flexor and knee extensor motor strength achieved community
ambulation. In terms of function, individuals with a T2-T9 injury
have some trunk control and may be able to stand using braces and
an assistive device such as a walker. Although injuries below T11
have increased potential for ambulation with bracing, successful
community ambulation often involves individuals with an injury at
the L3 level or below.
Marino et al. (1999) assessed data from 21 Model System SCI systems
with 3585 individuals with SCI over the first year of recovery.
They found that 10 to 15% of those with initial complete
ASIA A: Complete injury where no sensory or motor function is
preserved in sacral segments S4-S5.
ASIA B: Incomplete injury where sensory, but not motor,
function is preserved below the neurologic level and extends
through sacral segments S4-S5.
ASIA C: Incomplete injury where motor function is preserved
below the neurologic level, and most key muscles
below the neurologic level have muscle grade less than 3 (active
full-range movement against gravity).
ASIA D: Incomplete injury where motor function is preserved
below the neurologic level, and most key muscles below the
neurologic level have muscle grade greater than or equal to
3.
ASIA E: Normal sensory and motor functions.
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ASIA A injuries converted to incomplete injuries. For ASIA B
injuries, 1/3 converted to ASIA C and 1/3 to ASIA D or E. For ASIA
C injuries, over 2/3 converted to ASIA D. However, the accurate
prediction of ASIA conversion can be fraught with problems. Burns
et al. (2003) found that individuals with cognitive factors (e.g.,
traumatic brain injury, alcohol intoxication, analgesic
administration, psychological disorders) and communication barriers
(e.g., language barriers, ventilatory dependency) had a higher
percent of ASIA conversion over the first year likely due to
an inaccurate initial assessment.
1.4 Rehabilitation
Rehabilitation has been defined by the World Health Organization as
a progressive, dynamic, goal-oriented and often time-limited
process, which enables an individual with an impairment to identify
and reach his/her optimal mental, physical, cognitive and social
functional level. Enhancing quality of life is regarded as an
inherent goal of rehabilitation services and programs given their
focus on interventions to minimize the impact of pain and physical
and cognitive impairment, and on enhancing participation in work
and everyday activities. SCI rehabilitation involves a multitude of
services and health professionals and is initiated in the acute
phase and continues with extensive and specialized inpatient
services during the sub-acute phase.
Inpatient rehabilitation is an important stepping stone towards
regaining and learning new skills for independent living. Here
patients engage in an intensive full day program with services
which may include nursing, physical therapy, occupational therapy,
respiratory management, medical management, recreation and leisure,
psychology, vocational counseling, driver training, nutritional
services, speech pathology, social worker, sexual health
counseling, assistive device prescription and pharmaceutical
services. Rehabilitation continues with planning for discharge back
to the community and finally, re-integration into former or new
roles and activities within the community. Family and peers have
important roles throughout the rehabilitation process.
In Canada, the median length of inpatient rehabilitation stay for
traumatic SCI is 59 days with longer stays for those with complete
injuries or tetraplegic injuries ranging from 49 days for those
with incomplete paraplegia to 101 days to those with complete
tetraplegia (CIHI 2006a).
SCI has the longest inpatient rehab length of stay over all other
rehabilitation patient groups except for burns (CIHI 2006b).
Functional recovery is often measured by the Functional
Independence Measure (FIM), an 18 item scale that is intended to
measure caregiver burden and includes tasks related to cognition,
mobility, bowel and bladder management and self-care. During
inpatient rehabilitation, patients with complete tetraplegia have
the lowest FIM admission score and make less change compared to
those with incomplete or paraplegic injuries (CIHI 2006a). Persons
with the dual diagnosis of spinal cord injury and traumatic brain
injury achieve smaller functional gains in rehabilitation
(Macciocchi et al. 2004).
Compared to traumatic SCI, the non-traumatic SCI rehabilitation
length of stay is shorter, with a
lower FIM change and fewer medical complications including deep
venous thrombosis,orthostatic hypotension, pressure ulcers, wound
infections, spasticity, autonomic dysrelfexia were less likely
(McKinley et al. 2002a, 2002b). The shorter length of stay may be a
result of the less severe injury. However, the earlier discharge in
metastatic tumors may reflect the terminal nature of the disease
and patients and family may wish for the remaining time to be spent
at home.
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1.5 Community Re-integration
There is a fundamental belief among consumers with SCI that there
needs to be a paradigm shift in the approach to rehabilitation from
an institutionally based physical restoration model to
a community-based independent living model (Rick Hansen SCI Network
2005). Going home is a frequent goal established by patients newly
admitted to hospital and 79% of individuals with traumatic SCI
injuries return home. Only 62% of individuals with complete
tetraplegia return home with 15% discharged back to acute care and
18% to long term care (CIHI 2006a). In a study of high lesion SCI
(C1-C4), it was found that 40% of these clients were discharged to
extended care units post rehabilitation, while the majority of
these respiratory dependent patients returned to the community
(Anzai et al. 2006).
Life expectancy is less than normal, particularly for people with
tetraplegia and who are ventilator-dependent (NSCISC 2004). The
life expectancy of a 40 year old paraplegic who has survived at
least 1 year post-injury is 10 years less than a person without a
SCI (NSCISC 2004).
Although the mortality rate during the first 2 years after
SCI has been reduced over the past 30
years, Strauss et al. (2006) noted that there has not been a
substantial change in life expectancy following the second year
post-injury. In contrast, there has been an increase in life
expectancy over the last 2 decades in the general population.
Given that the majority of traumatic SCI occur in young adults,
return to work or school is of high importance, but often
necessitates a change in vocation. Less than 18% of those employed
at the time of injury were able to return to the same job (CPA
1997). Within 3-6 months post inpatient rehabilitation, 14% of
people with SCI are employed, while 64% were employed prior to
injury. Approximately 9% are students (roughly double the
pre-injury status). The majority are unemployed (26%) or on
disability status (35%) at 3-6 months follow-up (CIHI 2006a).
Canadians living with SCI tend to have a higher level of education
than the general Canadian population (CPA 1997). In a survey of
Canadians who had been injured at least 5 years, 62%
were unemployed while 38% are employed (CPA 1997). Education is key
to employment – higher education or increasing education following
injury result in more success with employment. Of those who find
employment, 44% do so within 2 years of injury while 77% find
employment within 5 years.
Accessible infrastructure and disability support are two
major areas which people with SCI feel would improve quality of
life (RHMIMF 2004). When considering priorities for research,
individuals living with SCI rank finding a cure for SCI similarly
to developing advances in rehabilitation/therapy (RHMIMF 2004).
Regaining arm and hand function has been cited as one of the most
important priorities to tetraplegics, while regaining sexual
function has been cited as the highest priority for paraplegics
(Anderson 2004). Improving bladder and bowel function was important
to both injury groups (Anderson 2004). Although the majority of
participants indicated
that exercise was important to functional recovery, more than half
did not have access toexercise (Anderson 2004). Anderson (2004)
emphasized the need for researchers to be aware of the needs of SCI
consumers in their quest for discovery.
The continuum of health care in the community includes mechanisms
for people to access information resources about living with a SCI.
However, it appears that people with SCI do not approach
traditional health care sources for their information (e.g.,
physician, hospital). For people living with SCI, the internet was
by far the number one source for information about SCI (48%), while
support groups and media ranked higher than hospitals, books, rehab
centres,
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physicians and peers (RHMIMF 2004). It appears that the internet
can be an ideal medium for promoting health-related education. To
facilitate accessibility of information, the SCIRE information is
available on CD, print version, as well as through web-access
(www.icord.org/scire).
In a recent survey, the majority (70%) of individuals with SCI
rated the quality of life of people
with SCI as good or very good while 23% rated it as poor or very
poor (RHMIMF 2004). It is encouraging that 65% of individuals with
SCI felt that the quality of life of people with SCI has improved
over the past 5 years (RHMIMF 2004). As enhancing quality of life
is an inherent goal of rehabilitation, there is a continual
challenge to close the gap between treatment activities and
functional competence in the individual’s actual environment.
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This review has been prepared based on the scientific and
professional information available in 2005. The SCIRE information
(print, CD or web site www.icord.org/scire) is provided for
informational and educational purposes only. If you have or suspect
you have a health problem, you should consult your health care
provider. The SCIRE editors, contributors and supporting partners
shall not be liable for any damages, claims, liabilities, costs or
obligations arising from the use or misuse of this material.
Methods of the Systematic Reviews. In: Eng JJ, Teasell RW, Miller
WC, Wolfe DL, Townson AF, Aubut J, Abramson C, Hsieh JTC, Connolly
S, editors. Spinal Cord Injury Rehabilitation Evidence. 2006:
Vancouver, p 2.1-2.11.
www.icord.org/scire
Appendix 1. Specific Search Terms
.....................................................................................2-5
Appendix 2. The PEDro
Scale...............................................................................................2-8
Appendix 3. Downs and Black tool (Downs and Black 1998)
..........................................2-10
References..............................................................................................................................2-11
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2.1 Introduction
Providing a framework for evidence-base practice was championed in
the early 1990s, although it was practiced and discussed in medical
circles long before this. In 1992, the Evidence-Based Practice
Working Group (EBPWG) described a new framework of using research
to guide and augment the practice of medicine (Evidence-based
Medicine Working Group 1992). Dr. David Sackett, a pioneer in the
field and also a member of the original working group described
evidence-based practice as:
“Evidence based medicine is the conscientious, explicit, and
judicious use of current best evidence in making decisions about
the care of individual patients. The practice of evidence based
medicine means integrating individual clinical expertise with the
best available external clinical evidence from systematic
research.” (Sackett et al. 1996)
Although the original definitions were framed for the
practice of medicine, the practice has spread to all fields of
health care with the more generic term “evidence-based practice”.
Evidence-based practice does not ignore clinical experience and
patient preferences, but weights these against a background of the
highest quality scientific evidence that is available. The
importance of clinical judgement was emphasized by Dr. Sackett in
his original editorial: “Because it [evidence-based medicine]
requires a bottom up approach that integrates the best external
evidence with individual clinical expertise and patients' choice,
it cannot result in slavish, cookbook approaches to individual
patient care. External clinical evidence can inform, but can never
replace, individual clinical expertise, and it is this expertise
that decides whether the external evidence applies to the
individual patient at all and, if so, how it should be integrated
into a clinical decision.” Sackett et al. (1996)
to assess and synthesize the evidence of the effects of
rehabilitation healthcare interventions in SCI and is designed for
health professionals inform them of best practice. Consumers with
SCI and their families may also find the synthesis useful to better
understand their health care. In addition, such a research
synthesis will enable relevant decision-making in public policy and
practice settings applicable to SCI rehabilitation. Lastly,
transparent and unbiased evidence-based reviews will guide the
research community andfunding organizations to strategically focus
their time and resources on the gaps in knowledge and identify
research priorities.
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A systematic review was undertaken using multiple databases
(MEDLINE/PubMed, CINAHL®, EMBASE, PsycINFO) to identify and
synthesize all relevant literature published from 1980-
2005. An initial broad search was performed with five types of SCI
therapies searched: drug therapy, radiotherapy, diet therapy,
rehabilitation therapy and therapy. To further refine the search,
the search was limited to human subjects and articles published in
English.
Based on the above search criteria, the total number of references
from all databases was 8007. Two investigators reviewed both the
title of the citation and the abstract (of all 8007 references) to
determine its suitability for inclusion. Articles’ suitability was
based on the above inclusion criteria as well as the following
exclusion criteria: less than half the reported population had a
spinal cord injury; no measurable outcome associated with
treatment; animal studies. Unless there were no other supporting
literature, studies with less than 3 subjects were excluded.
Meta-analyses, systematic reviews and review articles were
identified at this point and studies cited with these works that
were not identified in the original literature search, were also
sought, through hand searching. The review was restricted to
published works.
MeSH headings were used with the keywords. Key words were paired
with spinal cord injury, tetraplegia, quadriplegia or
paraplegia
Specific SCI rehabilitation topics (e.g., pressure ulcers) were
identified by a multi-disciplinary team of expert scientists,
clinicians, consumers with SCI and policy-makers. These specific
topics were searched with additional keywords generated from expert
scientists and clinicians in SCI rehabilitation familiar with the
topic and more titles and abstracts were reviewed. The reference
lists of previous review articles, key articles, systematic reviews
and clinical practice
guidelines were hand searched. It is known that hand searching may
provide higher rates of return than electronic searching within a
particular subject area (Hopewell et al. 2002). The number of
titles and abstracts reviewed is approximately 8400. Additional
keywords used for each specific topic are outlined in Appendix
1.
2.2.2 Quality Assessment Tool and Data Extraction
Methodological quality of individual RCTs was assessed using the
Physiotherapy Evidence Database (PEDro) tool
(http://www.pedro.fhs.usyd.edu.au/scale_item.html ). PEDro was
developed for the purpose of accessing bibliographic details and
abstracts of randomized- controlled trials (RCT), quasi-randomized
studies and systematic reviews in physiotherapy. PEDro has been
used to assess both pharmacological and non-pharmacological studies
with
good agreement between raters at an individual item level and in
total PEDro scores (Foley etal. 2006). Maher et al. (2003) found
the reliability of PEDro scale item ratings varied from "fair" to
"substantial," while the reliability of the total PEDro score was
"fair" to "good. Studies included in this review using a
non-experimental or uncontrolled design (non-randomized comparative
trials, cohort studies or retrospective studies) could not be
assigned a PEDro score and were given a not applicable (n/a)
designation.
The PEDro is an 11-item scale, in which the first item relates to
external validity and the other ten items assess the internal
validity of a clinical trial. One point was given for each
satisfied
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criterion (except for the first item, which was given a YES or NO),
yielding a maximum score of ten. The higher the score, the better
the quality of the study and the following cut-points were used
where 9-10: excellent; 6-8: good; 4-5: fair; <4: poor. A point
for a particular criterion was awarded only if the article
explicitly reported that the criterion was met. The scoring system
is detailed in Appendix 2. Two independent raters reviewed each
article. Scoring discrepancies were resolved through
discussion.
All other studies with an intervention were assessed with the
Downs and Black Tool (Downs and Black 1998) for methodological
quality. This tool consists of 27 questions in the following sub-
sections: Reporting, External Validity, Internal Validity – bias
and Internal Validity – confounding (selection bias). The original
tool range from 0 to 32. However, we modified the last question
form a scale of 0 to 5 to a scale of 0 to 1 where 1 was scored if a
power calculation or sample size calculation was present while 0
was scored if there was no power calculation, sample size
calculation or explanation whether the number of subjects was
appropriate. Thus, our modified version ranged from 0 to 28, with a
higher score indicating higher methodological quality. The Downs
and Black tool is attached in Appendix 3.
Data were extracted to form tables. Sample subject characteristics
(Population), nature of the
treatment (Intervention), measurements (Outcome Measures) and key
results are presented in the tables. In cases, where a single study
overlapped into multiple chapters (e.g., treadmill training has
effects on the cardiorespiratory, lower extremity and bone health),
the results focus on the outcomes relevant to that chapter.
2.3 Determining Levels of Evidence and Formulating
Conclusions
Table 2.1 Five levels of evidence Level Research Design
Description
Level 1 Randomized controlled trial (RCT) Randomized controlled
trial, PEDro score ≥ 6. Includes within subjects comparison
with randomized conditions and cross- over designs
RCT Randomized controlled trial, PEDro score < 6.
Prospective controlled trial Prospective controlled trial (not
randomized)Level 2
Cohort Prospective longitudinal study using at least 2 similar
groups with one exposed to a particular condition.
Level 3 Case control A retrospective study comparing
conditions, including historical controls
Pre-post A prospective trial with a baseline measure,
intervention, and a post-test using a single group of
subjects.
Post-test A prospective post-test with two or more groups –
intervention, then post-test (no pre-test or baseline measurement)
using a single group of subjects.
Level 4
Case Series A retrospective study usually collecting
variables from a chart review.
Observational Study using cross-sectional analysis to interpret
relations.
Clinical Consensus Expert opinion without explicit critical
appraisal, or based on
physiology, biomechanics or "first principles"
Level 5
Case Report Pre-post or case series involving one subject
The levels of evidence used to summarize the findings are based on
the levels of evidence developed by Sackett et al. (2000). The
levels proposed by Sackett et al. (2000) were modified to collapse
the subcategories within a level (e.g., level 1a, 1b, 1c) into a
single level. This was performed to reduce the 10 categories from
Sackett et al. (2000) to a less complex system from level 1 to
level 5. We provided additional descriptions specific to the types
of research designs encountered in SCI rehabilitation to facilitate
the decision-making process. Sackett et al. (2000)
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distinguishes high and low quality randomized controlled trials
(RCTs) into level 1b and level 2b, respectively. To provide a more
reliable decision-making process, we required that a level 1 RCT
had a PEDro score of greater than or equal to 6 (good to excellent
quality), while a level 2 RCT had a PEDro score of 5 or less. The
appropriateness of the control group was assessed per study. In
some studies, an able-bodied group may not have been an adequate
control for the particular intervention used, but simply provided
“normative’ values for comparison. In those
studies, the study was considered “not controlled” and the level of
evidence reduced (e.g., level 4 pre-post).
RCTs received priority when formulating conclusions. Conclusions
were not difficult to form when the results of multiple studies
were in agreement. However, interpretation became difficult when
the study results conflicted. In cases where studies differed in
terms of quality, the results of the study (or studies) with the
higher quality score were more heavily weighted to arrive at the
final conclusions. Sometimes, interpretation was difficult, for
example, the authors needed to make a judgment when the results of
a single study of higher quality conflicted with those of several
studies of inferior quality. In these cases we attempted to provide
a rationale for our decision and to make the process as transparent
as possible.
As emphasized by Sackett et al. (1996), the evidence from
systematic research should be integrated with clinical expertise
and patients' choice to form best practice.
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Appendix 1. Specific Search Terms
Specific SCI rehabilitation topics were identified by a
multi-disciplinary team of expert scientists, clinicians, consumers
with SCI and policy-makers. These specific topics were searched
with additional keywords generated from expert scientists and
clinicians in SCI rehabilitation familiar with the topic and more
titles and abstracts are reviewed. MeSH headings were used with
the
keywords. Key words were paired with spinal cord injury,
tetraplegia, quadriplegia or paraplegia. The reference lists of
previous review articles, systematic reviews and clinical practice
guidelines were hand searched. It is known that hand searching may
provide higher rates of return than electronic searching within a
particular subject area (Hopewell et al. 2002).
Chapter 3: Rehabilitation
Practice: ("rehabilitation"[Subheading] OR
"Rehabilitation"[MeSH]) AND "Spinal Cord Injuries"[MeSH] AND
"Treatment Outcome"[MeSH]
Chapter 4: Community Reintegration: accessibility, attendant care,
attitudes, community + leisure + recreation, community involvement,
community Involvement, community living, community participation,
community reintegration, community reintegration, daily
functioning, domestic life, employment, empowerment, environment +
functioning, environment +
reintegration, environment + social, environment + social + home,
environmental policy, family involvement, HRQOL, intervention –
trial, control group, treatment group; income support, independent
living, interpersonal relations, leisure – intervention, control
group, treatment, clinical trials, leisure + use of time, life
happiness, life satisfaction, living independent, occupations,
personal assistance, personal satisfaction, productivity,
psychosocial rehabilitation, QOL – intervention, trial, control
group, treatment group, recreation therapy, school education, self
care, social environment, social interactions, social network,
social policy, social roles, social support, socializing, use of
technology, volunteer
Chapter 5: Upper Limb: upper limb, FES and upper limb,
exercise programs, upper limb injuries, splinting, specific
researchers [Popovic…]
Chapter 6: Lower Limb: 4-AP, 4-AP + ambulation, assisted walking
device, walking, assisted rehabilitation device, biofeedback, body
weight support, body weight supported treadmill training (BWSTT),
brace, bracing, Clonidine, Cyproheptadine, EMG + feedback, epidural
stimulation / epidural lumbar stimulation, FES + muscle,
flexibility, gait, gait + bracing, gait + orthotics, gait devices,
GM-1 ganglioside, knee-ankle-foot, leg + bracing, leg + FES,
locomotion, locomotor training, lower extremity spasticity,
orthotics, ortho