8951639 spinal cord injury rehabilitation evidence

http://slidepdf.com/reader/full/8951639-spinal-cord-injury-rehabilitation-evidence 1/813
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
8/20/2019 8951639 Spinal Cord Injury Rehabilitation Evidence
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.
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

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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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
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.
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
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,
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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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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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
Janice J Eng, PhD, BSc (PT/OT)
William C Miller, PhD, OT

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
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
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
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).
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.
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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injured spinal cord spontaneously forms a new intraspinal circuit in adult rats. Nat Neurosci. 2004;7:269-277.
Burns AS, Lee BS, Ditunno JF Jr, Tessler A. Patient selection for clinical trials: the reliability of the early spinal cord injury examination. J Neurotrauma. 2003;20:477-482.
Calancie B, Molano MR, Broton JG. Epidemiology and demography of acute spinal cord injury in a large urban setting. J Spinal Cord Med. 2005;28:92-96.
Canadian Institute for Health Information (2006a). Life after traumatic spinal cord injury: From inpatient rehabilitation back to the community. Analysis in Brief.
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evoked potentials and ASIA scores. Arch Phys Med Rehabil. 1998;79:81-86. Ding Y, Kastin AJ, Pan W. Neural plasticity after spinal cord injury. Curr Pharm Des.
2005;11:1441-1450. Dietz V, Muller R, Colombo G. Locomotor activity in spinal man: significance of afferent input
from joint and load receptors. Brain. 2002;125:2626-2634. Ditunno JF Jr, Stover SL, Freed MM, Ahn JH. Motor recovery of the upper extremities in
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Dryden DM, Saunders LD, Jacobs P, Schopflocher DP, Rowe BH, May LA, Yiannakoulias N, Svenson LW, Voaklander DC. Direct health care costs after traumatic spinal cord injury. J Trauma. 2005;59:443-449.
Exner G, Meinecke FW. Trends in the treatment of patients with spinal cord lesions seen within
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Lotze M, Laubis-Herrmann U, Topka H. Combination of TMS and fMRI reveals a specific pattern of reorganization in M1 in patients after complete spinal cord injury. Restor Neurol Neurosci. 2006;24:97-107.
Macciocchi SN, Bowman B, Coker J, Apple D, Leslie D. Effect of co-morbid traumatic brain injury on functional outcome of persons with spinal cord injuries. Am J Phys Med Rehabil. 2004;83:22-26.
Marino RJ, Ditunno JF Jr, Donovan WH, Maynard F Jr. Neurologic recovery after traumatic spinal cord injury: data from the Model Spinal Cord Injury Systems. Arch Phys Med Rehabil. 1999;80:1391-1396.
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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
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.
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)
2-4
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.
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

8951639 spinal cord injury rehabilitation evidence

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