Impaired respiratory function and associations with health-related quality of life in people with spinal cord injury.

STUDY DESIGN: Follow-up measurement in a multicenter prospective cohort study. OBJECTIVES: To examine the prevalence of impaired respiratory function (pulmonary function and perceived respiratory function), the incidence of respiratory infection and the associations among these parameters in people with spinal cord injury (SCI) 5 years after initial inpatient rehabilitation. Second, we assessed associations between respiratory function and health-related quality of life (HRQOL). SETTING: Eight rehabilitation centers with specialized SCI units in the Netherlands. METHODS: Measurements were performed 5 years after discharge of inpatient rehabilitation. Pulmonary function was determined by forced vital capacity (FVC) and perceived respiratory function by self-reported cough strength and dyspnea. HRQOL was measured using the Sickness Impact Profile 68 and the 36-item Short Form Health Survey. RESULTS: One-hundred forty-seven people with SCI participated. Of this sample, 30.9% had impaired FVC, 35.9% poor or moderate cough strength, 18.4% dyspnea at rest and 29.0% dyspnea during activity. In the year before the measurements, 8.9% had had respiratory infection. FVC was associated with cough strength, but not with dyspnea. All respiratory function parameters were associated with social functioning, whereas other HRQOL domains were associated with dyspnea only. CONCLUSION: Five years after initial inpatient rehabilitation, impaired respiratory function and respiratory infection were common in people with SCI. More severely impaired respiratory function was associated with lower HRQOL. SPONSORSHIP: The Netherlands Organisation for Health Research and Development.

Fatigue in persons with subacute spinal cord injury who are dependent on a manual wheelchair.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To determine the prevalence and severity of fatigue in persons with subacute spinal cord injury (SCI), assess whether demographic and lesion characteristics are related to fatigue and determine the relationship with physical fitness and physical behavior. SETTING: Measurements were performed 2 months before discharge from inpatient rehabilitation. METHODS: Thirty-six persons with subacute SCI, dependent on a manual wheelchair, mean age 43±15 and 83% men, completed the Fatigue Severity Scale (FSS). FSS scores >4 indicated fatigue. We recorded age and lesion characteristics, measured body mass index, measured peak power output and peak oxygen uptake during a maximal handcycling test and determined physical behavior using an accelerometer-based activity monitor. T-tests were used to test for differences in fatigue between subgroups based on age and lesion characteristics, and regression analyses to assess the relationship with physical fitness and physical behavior. RESULTS: Mean FSS was 3.3±1.3. Fatigue, including severe fatigue, was prevalent in 31% (95% confidence interval: 16-46) of participants compared with 18% in the general population. Furthermore, mean fatigue was significantly higher in persons with incomplete compared with complete lesions (t=2.22, P=0.03). Mean scores between other subgroups did not differ significantly. Of the physical fitness and physical behavior measures, only peak oxygen uptake tended to be related to more fatigue (B=-1.47, P=0.05). CONCLUSION: Fatigue was prevalent and is of concern in persons with subacute SCI. Those with incomplete lesions seem to be at higher risk. Because fatigue is known to persist among persons with SCI, interventions to reduce fatigue seem necessary.

A more active lifestyle in persons with a recent spinal cord injury benefits physical fitness and health.

STUDY DESIGN: A prospective cohort study. OBJECTIVES: To study the longitudinal relationship between objectively measured everyday physical activity level, and physical fitness and lipid profile in persons with a recent spinal cord injury (SCI). SETTING: A rehabilitation centre in the Netherlands and the participant's home environment. METHODS: Data of 30 persons with a recent SCI were collected at the start of active rehabilitation, 3 months later, at discharge from inpatient rehabilitation, and 1 year after discharge. Physical activity level (duration of dynamic activities as % of 24 h) was measured with an accelerometry-based activity monitor. Regarding physical fitness, peak oxygen uptake (VO(2)peak) and peak power output (POpeak) were determined with a maximal wheelchair exercise test, and upper extremity muscle strength was measured with a handheld dynamometer. Fasting blood samples were taken to determine the lipid profile. RESULTS: An increase in physical activity level was significantly related to an increase in VO(2)peak and POpeak, and an increase in physical activity level favourably affected the lipid profile. A nonsignificant relation was found with muscle strength. CONCLUSION: Everyday physical activity seems to have an important role in the fitness and health of persons with a recent SCI. An increase in physical activity level was associated with an increase in physical fitness and with a lower risk of cardiovascular disease.

Effect of wearing an activity monitor on the amount of daily manual wheelchair propulsion in persons with spinal cord injury.

STUDY DESIGN: An experimental study. OBJECTIVES: To assess the effect of reactivity related to wearing a multi-sensor activity monitor (AM) on the amount of manual wheelchair propulsion during daily life in wheelchair-bound persons with spinal cord injury (SCI). In addition, to establish the subjectively experienced burden of wearing the AM. SETTING: Rehabilitation centre and home-based study. METHODS: In 10 persons with SCI, during a 7-day period, the daily amount of manual wheelchair propulsion was measured by means of a rotation counter. During this period, an AM was worn for 1 day (AM+ day) by the participants. Experienced burden was measured by a questionnaire based on visual analogue scale scores. RESULTS: The overall median of the number of rotations per minute was 1.38 (range 0.63-1.83). No significant difference was found in the amount of daily manual wheelchair propulsion between AM+ and AM- days (P=0.33, median difference: -0.06 rotations per minute). Experienced burden was not different between subgroups that differed in reactivity. CONCLUSION: The results seem to indicate that wearing the AM of this study does not systematically influence the amount of daily manual wheelchair propulsion. Although low to moderate burden was experienced when wearing the AM, this does not seem to affect the amount of manual wheelchair propulsion.

Physical fitness in people with a spinal cord injury: the association with complications and duration of rehabilitation.

OBJECTIVE: To assess the association between physical fitness and its recovery over time on the one hand, and complications and duration of phases of rehabilitation on the other. DESIGN AND SETTING: Prospective cohort study at eight rehabilitation centres. SUBJECTS: People with a spinal cord injury were assessed four times: at the start of active rehabilitation (n = 110), three months later (n = 92), at discharge (n = 137) and a year after discharge from inpatient rehabilitation (n = 91). MAIN MEASURES: Physical fitness was defined as aerobic capacity, determined at each occasion by the peak oxygen uptake (peak Vo(2); L/min) and the peak power output (peak PO; W) during a maximal exercise test. On these occasions, spasticity, musculoskeletal and neurogenic pain were determined (1 = present; 0 = absent). During inpatient rehabilitation, complications (urinary tract infection, pulmonary infection or pressure sore) and bed rest were registered (1 = complication; 0 = no complications, and 1 = bed rest; 0 = no bed rest). Complications and bed rest occurring during the year after discharge were registered similarly. RESULTS: Multilevel random coefficient analyses revealed associations in multivariate models (P

Physical capacity in wheelchair-dependent persons with a spinal cord injury: a critical review of the literature.

STUDY DESIGN: Review of publications. OBJECTIVE: To assess the level of physical capacity (peak oxygen uptake, peak power output, muscle strength of the upper extremity and respiratory function) in wheelchair-dependent persons with a spinal cord injury (SCI). SETTING: Erasmus MC, University Medical Centre Rotterdam, The Netherlands. METHODS: Pubmed (Medline) search of publications from 1980 onwards. Studies were systematically assessed. Weighted means were calculated for baseline values. RESULTS: In tetraplegia, the weighted mean for peak oxygen uptake was 0.89 l/min for the wheelchair exercise test (WCE) and 0.87 l/min for arm-cranking or hand-cycling (ACE). The peak power output was 26 W (WCE) and 40 W (ACE). In paraplegia, the peak oxygen uptake was 2.10 l/min (WCE) and 1.51 l/min (ACE), whereas the peak power output was 74 W (ACE) and 85 W (WCE). In paraplegia, muscle strength of the upper extremity and respiratory function were comparable to that in the able-bodied population. In tetraplegia muscle strength varied greatly, and respiratory function was reduced to 55-59% of the predicted values for an age-, gender- and height-matched able-bodied population. CONCLUSIONS: Physical capacity is reduced and varies in SCI. The variation between results is caused by population and methodological differences. Standardized measurement of physical capacity is needed to further develop comparative values for clinical practice and rehabilitation research.

Validity of the detection of wheelchair propulsion as measured with an Activity Monitor in patients with spinal cord injury.

STUDY DESIGN: Validation study. OBJECTIVES: An accelerometry-based Activity Monitor (AM) has proven to be a valid instrument to quantify mobility-related activities (lying, sitting, standing, walking, cycling, general (noncyclic) movement). The aim of this study was to assess whether, additional to other activities, wheelchair propulsion (hand-rim wheelchair propulsion and handbiking) can be validly detected by the AM in patients with spinal cord injury (SCI). SETTING: Rehabilitation center. METHODS: In all, 10 patients with SCI (aged 19-63 years; five patients with poor triceps strength and five patients with good triceps strength) participated. Patients performed a series of representative daily life activities (involving wheelchair propulsion and nonwheelchair propulsion activities), according to a standard protocol, in a seminatural setting. Continuous registrations of signals from body-fixed accelerometers were made and the AM output (after automatic analysis) was compared with visual analysis of simultaneously made video recordings (reference method). Validity scores (agreement, sensitivity, specificity) between the output of the AM and the video analysis were calculated. RESULTS: Agreement, sensitivity and specificity for the detection of wheelchair propulsion were overall 92 (range, 87-96)%, 87 (76-99)% and 92 (85-98)%, respectively. Sensitivity was smaller in patients with poor triceps strength compared to patients with good triceps strength; 81 (76-89)% and 95 (89-99)%, respectively (P<0.01). Mean overestimation in duration of wheelchair propulsion by the AM was 3.9% (P<0.05). CONCLUSION: Besides already validated other activities, wheelchair propulsion (hand-rim wheelchair propulsion and handbiking) can be validly detected by the AM in patients with SCI, both with good and poor triceps strength. Therefore, the AM offers the possibility to obtain objective and detailed information on all major mobility-related activities performed by patients with SCI. SPONSORSHIP: Stichting Rotterdams Kinderrevalidatie Fonds Adriaanstichting.

Tetraplegia Hand Activity Questionnaire (THAQ): the development, assessment of arm-hand function-related activities in tetraplegic patients with a spinal cord injury.

STUDY DESIGN: Development of Tetraplegia Hand Activity Questionnaire (THAQ). SETTING: Patients and spinal cord injury (SCI) professionals from five rehabilitation centres in the Netherlands and Belgium. OBJECTIVE: To construct a disease-specific questionnaire to evaluate interventions to the arm-hand of tetraplegics in terms of gained and lost activities relevant to the patient. METHODS: All arm-hand function-related activities were inventoried by examining existing scales and interviewing spinal cord injury patients and professionals in the field. Subsequently, item reduction was achieved; first, in the technical construction by incorporating all activities in an item list, then reducing the list by selecting the items most likely to be sensitive to change after surgical or functional electro stimulation interventions on the arm-hand as judged by an expert panel, using a Delphi method. RESULTS: The arm-hand-related activity inventory comprised 652 activities. The technical construction of the items and the Delphi procedure resulted in a questionnaire with 153 items. The experts considered many of the 'new' activities more relevant for the evaluation of hand function interventions than those found in scales studied in the literature. This is reflected in a relatively large proportion of new activities (69%) for the item list of the THAQ, and even more in the domains work/admin/telecom (88%) and leisure (100%). CONCLUSION: The questionnaire constructed to assess hand function-related activities contains relevant activities to evaluate arm-hand function-related interventions for tetraplegic SCI patients.

Traumatic brain injury: classification of initial severity and determination of functional outcome.

PURPOSE: The aim of the present manuscript is to review current methods for classifying initial severity and final outcome in traumatic brain injury (TBI) and to suggest a direction and form of further research. METHOD: The literature on valid and reliable measurements used in TBI-research for classifying initial severity and final outcome was reviewed. RESULTS: Classifying initial severity in patients with head injury according to clinical condition or CT-parameters is valid. Classifying outcome according to measurement tools of disability showed adequate validity and reliability. CONCLUSIONS: Future research in TBI outcome, particularly in rehabilitation medicine, should focus on determinants of outcome, identifying those patients who will have the greatest chance of benefiting from intensive rehabilitation programmes. More research is needed to determine the long-term functional outcome in TBI, the long-term socio-economic costs, and the influence of behavioural problems on family cohesion. Finally, validation of outcome measures is required in the TBI-population; the relative value of various outcome measures needs to be determined, and the usefulness and applicability of measures for health related quality of life in TBI should be established.

Dimensionality and hierarchical structure of disability measurement.

Since the D-code of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) in its full form has proven to be impractical, an instrument based on a selection of 28 items is used to measure disability in Dutch patients undergoing rehabilitation. The items are categorized into 5 domains of physical, activities of daily living (ADL), social, psychological, and communicative activity. Measurement is made on a 4-point scale ranging from 0 (not disabled) to 3 (severely disabled). As a result of the ordinal character of the rating, statistical and mathematical manipulations of the scores are complicated. The aim of this study was to obtain more insight in the dimensionality and hierarchical structure of the items, to overcome problems in comparing disability between items, between patients, and within patients between different moments in time. Mokken scale analysis of the disability scores from 1,967 rehabilitation inpatients showed that the 28 items constitute hierarchical scales. However, categorization of the items into the 5 original domains was not replicated. Five other scales or dimensions were investigated, measuring the level of extended ADL, extended psychological, fine motoric, work/leisure, and hearing/seeing activity, respectively. The number of items per dimension ranges from 14 in the extended ADL dimension to 2 each in the work/leisure and hearing/seeing dimensions. Although each disability item may be of importance in clinical case management, a reduced set of extended ADL items suffices to describe the disability level in this dimension for epidemiological research purposes. The other dimensions need further specification to provide reliable and sensitive measuring of disability.

Characteristics of patients from hospital-based in-patient rehabilitation in The Netherlands.

The University Hospital Dijkzigt in Rotterdam is one of the first hospitals in The Netherlands to have a rehabilitation department providing multidisciplinary, hospital-based-in-patient rehabilitation (HBIR). The main goals of HBIR are to estimate the final optimum level of patient's functioning, to investigate the most appropriate treatment setting to achieve this and to fulfil requirements for discharge from hospital as soon as possible. One of the central issues in rehabilitation in the Netherlands is to obtain more insight into the current daily practice of HBIR. The aim of this study was to describe the characteristics of the patients treated in HBIR in Dijkzigt Hospital. Registered data from 1967 HBIR patients treated between 1988 and 1990 were analysed retrospectively. The patients were on average 53.1 ( +/- 19.7) years old; the men (63%) were significantly younger than the women (mean age of 50.8 and 57.0 years, respectively). The main diagnostic groups were stroke (27%), progressive and regressive neurological conditions (17%), hand injuries (9%), spinal cord lesion (9%), orthopaedic injuries (8%) and amputation of lower extremity (8%). The median duration of HBIR and hospitalization were 13 days and 33 day, respectively. Most patients were discharged home (63%), or to a nursing home (14%) or a rehabilitation centre (8%). The results of this study can be used in policy discussions on HBIR and provides a description of the population which needs to be studied longitudinally in future research on the outcomes of HBIR.

[Orbital veins and arteries in relation to the connective tissue system of the orbit]. / Les veines et les artères orbitales en relation avec l'appareil conjonctif de l'orbite.

Our study revealed that the relationships between the vessels and the connective tissue, which forms a constant and bilateral symmetrical system of connective tissue septa bordering adipose tissue compartments, are characteristics and constant but essentially different for veins and arteries. The arteries run within the adipose tissue compartments only contacting the connective tissue septa where they perforate them. As to the veins, their relationship with the connective tissue apparatus is completely different. These vessels run within the septa firmly connected with their connective tissue fibres, forming a continuity between the adventitia of the veins and the walls of the adipose tissue compartments. This difference between arteries and veins results in a different spatial structure for the two vascular systems. The arterial system is a radiating system, whereas the venous system is an anastomosing complex of venous rings which are arranged circularly inside as well as outside the muscle cone. It seems likely that the relationships of the vessels, particularly of the veins, with the connective tissue apparatus play an important role in the well-functioning of the orbital blood-circulation.

Some histological aspects of the structure of the connective tissue system and its relationships with the blood vessels in the human orbit.

The connective tissue septa in the human orbit are organized in a constant and characteristic fashion. In the collagen fibre meshwork of the septa, anteroposteriorly directed collagen fibre bundles are relatively rare. The number of smooth muscle cells present in a septum depends on the orbital level explored. In the apical region only few of these cells are found, at eye-ball level they are more numerous. No further regularity in distribution of smooth muscle cells in the septa is present. All connective tissue septa contain elastic fibres. Blood vessels and connective tissue form an integrated system. The venous walls merge with the fibrous structure of the septa; the arteries only make contact with the septa when they perforate them. In doing so, the arteries mainly run between the septal fibre bundles, only loosely connected to some of them. The microvascular system is predominantly confined to the adipose tissue compartments. The interrelationships of the vascular system and the connective tissue system are likely to be important factors in controlling and regulating orbital blood-flow. In addition, the well-defined morphological organization of the connective tissue in its interrelationships with the vascular system might serve a mechanical regulating function by both allowing and restricting certain eye-ball movements. For these functions, the physico-chemical properties of the connective tissue system and the microstructure of the vascular system are probably of considerable interest. Thus, the highly organized architecture of the connective tissue system in the human orbit together with its intricate interrelationships with the vascular system, might prove to be important for mechanical as well as metabolic purposes and so have consequences for interventions, diagnostic or surgical, in the orbit.

Microvessels in the human orbit in relation to the connective tissue system.

In the connective tissue system of the human orbit, the microvascular bed mainly arises from and drains into relatively large-calibre arteries and veins. The microvascular system shows a density increase from the apical region of the orbit towards the hind part of the eye-ball. Some of the microvessels are long, often arranged in loops. The smallest-sized vessels, branches of these long microvessels, show a dichotomous branching pattern and are in general confined to one adipose tissue compartment. Besides a "metabolic" function, the microvascular system, due to its compartmentalized structure, makes theoretically possible selective blood-filling of one or more adipose tissue compartments. If this does in fact occur, the microvascular bed, in co-operation with the orbital connective tissue "organ", could serve an important biomechanical function in controlling and regulating eye-ball movements. At microvascular level, the orbital vascular system is intensively interconnected with the extra-orbital vascular system. In the next article some histological aspects of the orbital connective tissue system will be described.

Relationships between the arteries and veins and the connective tissue system in the human orbit.

The arteries and veins in the apical region of the orbit occupy different areas. Furthermore, there is a difference in their relationships to the connective tissue system. In this part of the orbit, where only a few connective tissue septa are present, the arteries are mainly concentrated in the inner-space. The veins, on the other hand, are predominantly found peripherally, outside the muscle cone. The arteries are surrounded by adipose tissue. They are only in contact with connective tissue fibres when perforating the septa on their way to the outer regions of the inner-space. A small number of vessels, the posterior ciliary arteries and the central artery of the retina, keep their central position, grouped around the optic nerve. The conduct of this group of arteries in respect to the connective tissue is somewhat different than that of the other arteries. The ciliary arteries and the central retinal artery have varying contacts with the optic sheath. In contrast to the arteries, which in general lack firm connections with fibrous connective tissue, the major veins are encased in the tight connective tissue of the orbital fissures, or enveloped in connective tissue septa. For the smaller veins, these fibrous relationships are usually less intimate and occasionally disrupted. More extensive discussion and conclusions will be given in the following article. This will deal with the rest of the retrobulbar part of the orbit.

Relationships between the arteries and veins and the connective tissue system in the human orbit.

From 60 mu histological serial sections, we learned that retrobulbarly in the orbit there is a marked difference between the relationships of the arteries on the one hand, and the veins on the other, to the connective tissue system. In addition, areas with a relatively high arterial density could be differentiated from areas with a relatively high venous density. These morphological and topographical differences may be of significance to the optimal functioning of the whole of the visual apparatus, of which the vascular system forms an integrated part. In the next article we will see whether or not these very specific relationships are the same in bulbar parts of the orbit.

A literature review of the vascular system in the human orbit.

Some clinical ophthalmological problems led us to a study of literature data about the blood vessels in the human orbit. This inquiry confronted us with a profound knowledge of individual vessels. Remarkably, the arterial system appears to be in general more variable than the venous system. Radiologists have also noticed the difference in variability between the two vascular systems. Mainly for this reason, they consider topographical information obtained from phlebograms more useful than that obtained from arteriograms. However, the spatial arrangement of the orbital vessels has been given little consideration in literature. The same can be said of the relationship of the vessels with their immediate surroundings, connective tissue. Of the arterial system, only the ophthalmic artery and the posterior ciliary arteries have been described in this way, and only in relation to the optic sheath. Of the venous system, few authors mention the relation of parts of it with elastic tissue and the tight connective tissue of the superior orbital fissure. Only one author observed a complete septal structure in which the superior ophthalmic vein is suspended. The reports on the connective tissue relationships thus appear to be fairly fragmentary. Finally, the architecture of orbital microvascularization has also hardly been dealt with. A field for further anatomical study thus seemed to invite exploration.