Department of Veterans Affairs Quality Enhancement Research Initiative for spinal cord injury.

Spinal cord injury (SCI) is a lifelong condition, requiring ongoing efforts by multiple disciplines to stabilize, diminish, or prevent impairments; avoid or limit secondary complications; and improve or maintain social role functioning and quality of life for the individual throughout his or her life. There are approximately 200,000 persons with SCI in the United States, of whom roughly 22% are veterans. The estimated national economic impact of SCI is approximately $9.73 billion per year. These figures illustrate why SCI is an important topic for the Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI). The SCI QUERI will identify gaps in knowledge of SCI treatment and management, develop research efforts to address these gaps, identify best practices for care and management of SCI, and assess whether best practices lead to improved outcomes, including health-related quality of life.

Posttraumatic syringomyelia: profound neuronal loss, yet preserved function.

Posttraumatic syrinxes may extend many cord segments rostral to a spinal cord injury (SCI) and significantly dilate the spinal cord, yet few neurologic deficits may be noted. Careful physical examination may reveal ascending loss of pain and temperature without evident functional motor decline. We present a 49-year-old man with T4 paraplegia and a large posttraumatic syrinx who died 3 weeks after syringoperitoneal shunting. Neuropathologic study revealed a large bilateral syrinx cavity from T1 to C6 that tapered to a small unilateral syrinx at C2. Light microscopy of sections from T1 to C2 showed massive loss of intermediate to intermedio-lateral gray neurons and moderate reduction of motoneurons at T1 to C6 levels. Despite these findings, manual muscle testing results remained normal for wrist extensors and elbow extensors, and the patient continued to perform independent sliding board transfers. We conclude that this large progressive syrinx did not merely dissect neural elements apart but caused extensive neuronal damage. Loss of interneurons was evident in spinal segments with preserved strength and function. Possible mechanisms to explain the relatively minimal clinical deficits in view of the neuronal loss are discussed.

Pressure ulcer incidence on a spinal cord injury unit.

Because of the high risk for pressure ulcers among hospitalized, spinal cord injured patients, one quality improvement measure is to monitor incidence of pressure ulcers. A retrospective chart review of each patient who developed an ulcer during an 18-month period revealed patient characteristics associated with pressure ulcer risk. Of 468 inpatient admissions, 35 patients developed 81 pressure ulcers. Patient variables associated with an incidence rate of 7.5% were an admission diagnosis of pressure ulcer, surgical repair of pressure ulcers, length of stay, new spinal cord injury, longstanding injury (> 10 years), and the use of condom catheters.

Techniques to improve function of the arm and hand in chronic hemiplegia.

We evaluated functional improvement in the upper limb of chronic (more than six months' duration) stroke patients who received one of two electrical stimulation treatments, conventional treatment, or no treatment. Twenty-two right-handed patients were assigned to one of four groups studied for 12 months posttreatment. Subjects received (1) EMG-initiated electrical stimulation of wrist extensors (EMG-stim), (2) low-intensity electrical stimulation of wrist extensors combined with voluntary contractions (B/B), (3) proprioceptive neuromuscular facilitation (PNF) exercises, or (4) no treatment. Subjects were treated for three months. Before treatment, upon completion of treatment, and three and nine months after treatment, subjects were evaluated by the Fugl-Meyer (FM) poststroke motor recovery test and by grip strength. Subjects also attempted three Jebsen-Taylor hand function tests and a finger tapping test at the same evaluation sessions, but many were unable to complete these tests. During the course of treatment, FM scores of subjects receiving PNF improved 18%, B/B improved 25%, and EMG-stim improved 42%. The aggregate FM improvement of the treated groups was significant from pretreatment to posttreatment, and the improvement was maintained at three-month and nine-month followups (all p less than .005). The treated subjects' improvement in grip strength was also maintained at both followups (p less than .10). In contrast, the control group showed no significant change in FM scores or grip strength. The four treated subjects who were able to perform the hand function tests and finger tapping at all four evaluations also improved on these tests.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantification of gaps in the EMG interference pattern in chronic hemiparesis.

This study presents a quantification of the impersistence in the EMG interference pattern (IP) produced during maximal effort by patients with chronic hemiparesis. Monopolar needles were used to record from the flexor carpi radialis (FCR) and extensor carpi radialis longus (ECR) muscles of both the paretic and non-paretic sides of 19 patients with a history of unilateral CVA and 10 healthy control subjects during maximal voluntary isometric wrist flexion or extension. We found more gaps in the IP and fewer total seconds of EMG activity in paretic than in non-paretic or control forearm muscles. The number of gaps was similar in paretic FCR and ECR, but the reduced active time in paretic ECR indicates proportionally more gaps per second of EMG activity. This method provides quantitative measures of both the lapses (gaps in the IP during maximal effort and the inability to sustain EMG activity (total seconds) during long contractions. The latter measure is sufficiently sensitive to distinguish the greater impairment of a paretic wrist extensor than a paretic wrist flexor muscle, and both may prove to be valuable for future comparisons of the severity of paresis and the progress of recovery. These results represent the first quantitative confirmation of previous qualitative descriptions of impersistent recruitment.

Co-contraction in the hemiparetic forearm: quantitative EMG evaluation.

Co-contraction of antagonist muscles is a recognized clinical phenomenon in patients surviving a cerebrovascular accident. Yet, discrepancies persist in the literature as to whether or not antagonist electromyographic activity is increased in hemiparesis. We have developed a technique to obtain simultaneous counts of motor unit activity in a wrist flexor and extensor muscle using monopolar needle electromyography. Stable stroke patients and age/sex matched control subjects were tested during maximal voluntary isometric wrist flexion and extension. Fewer agonist events (p less than 0.05) and more antagonist events (p less than 0.10) were counted in paretic than in control muscles. A co-contraction ratio of antagonist activity to total (agonist and antagonist) activity was much greater for patients than controls (p less than 0.01). We conclude that both agonist recruitment and antagonist inhibition are impaired in the hemiparetic arm.

Recruitment and termination of electromyographic activity in the hemiparetic forearm.

Motor unit control measured by timed recruitment and termination of intramuscular electromyographic (EMG) activity provides muscle-specific quantification of deficits of the arm in chronic hemiparesis. Latencies to recruitment and termination of EMG activity of flexor carpi radialis and extensor carpi radialis longus were recorded from nine stroke patients and five age- and sex-matched control subjects, in response to buzzer signals, during maximal isometric wrist flexion and extension. Both agonist and antagonist recruitment times were slower in paretic than in control forearms (p less than .01). Termination of EMG activity occurred earlier in paretic forearms, primarily because of inability to maintain a prolonged muscular contraction. The effects of the variable lengths of testing trials reinforced these conclusions. The paretic extensor carpi radialis longus showed the greatest impairment with a very long latency to contract, and frequent failure to maintain a contraction. This study presents a new method of quantifying a common clinical problem in rehabilitation medicine.

Diagnostic ultrasound: its value in acute urinary tract infection in spinal cord injury.

Two cases of acute urinary tract infection in patients with spinal cord injury highlight the complications of calculus and perinephric abscess. Rather than waiting the customary 48 hours to assess response to antibiotics before evaluation for secondary complications, diagnostic ultrasound is advocated upon diagnosis of pyelonephritis. The potential benefits of early imaging seem to far outweigh the negligible risk and expense.

Sensory perception threshold measurement: an evaluation of semiobjective testing devices.

Five semiobjective devices for testing sensory perception thresholds were concomitantly used on 36 normal subjects to determine normal threshold values, intersubject variability, and their correlation with age. The five devices include the Semmes-Weinstein monofilament (touch); three-point esthesiometer (two-point discrimination); Pfizer thermal tester (temperature); biothesiometer (vibration); and Optacon tactile tester (vibration). Each subject was tested at 12 upper extremity (UE) and ten lower extremity (LE) sites. The threshold was determined by the two-alternative forced choice method. Results showed that the mean threshold for each sensory perception modality in the UE sites was significantly lower than in the LE sites. The means of distally located sites for two-point discrimination and vibration thresholds were significantly lower than the means of the proximal sites in the UE. In the LE, touch perception threshold was significantly higher distally than proximally. Distally located nerves (median and ulnar) showed lower mean threshold values than proximally located nerves for two-point discrimination. There were also similar findings for the other sensory modalities in the UE and LE. The mean threshold of dermatomes showed significant variation across the trials for two-point discrimination and vibration sensation. Distally located dermatomes showed lower threshold values than those located proximally. The means of most sites tested for each sensory modality (except vibration tested by the Optacon) showed correlation with age. There was no difference in threshold values between men and women for any sensory modality. The mean values of standard deviation were provided for each peripheral sensory nerve and dermatome.(ABSTRACT TRUNCATED AT 250 WORDS)

Automated sphygmomanometer in spinal cord injured patients during head-up tilt: an evaluation.

Fifteen patients with spinal cord injury above T6 who were complete or had sensory sparing only were monitored during head-up tilt to evaluate the clinical application of an indirect blood pressure monitoring device, Vital Signs Measurement System. Comparisons of the machine's auscultatory and oscillometric modes were made to simultaneously auscultated blood pressures obtained by a physician. Mean differences and standard deviations were calculated. The comparison between automatic auscultatory and manual pressures yielded a mean difference and standard deviation of 1.8 mmHg and 4.2 mmHg for systolic, and -0.8 mmHg and 4.9 mmHg for diastolic pressures. The comparison between automatic oscillometric and manual pressures yielded a mean difference and standard deviation of 2.2 mmHg and 7.1 mmHg for systolic, and -12.7 mmHg and 7.5 mmHg for diastolic. All automatically obtained values except oscillometric diastolic pressure indicate machine accuracy suitable for clinical testing when compared to standards set by the Association for the Advancement of Medical Instrumentation for ideal test conditions. Uncontrolled patient or tubing movement, room noise, and the small subject population may have contributed to the less favorable values. This study suggests that the automatic sphygmomanometer tested is capable of clinically acceptable accuracy in a very dynamic setting.

Factors relating to the sensory acuity of limbs with peripheral vascular insufficiency.

We examined several possible causes for the high incidence of poor sensory acuity in the limbs of 176 patients with moderate to severe peripheral vascular insufficiency. We investigated the relationships of diabetes, alcoholism, and smoking, as well as the severity of peripheral vascular disease, to the integrity of basic sensory modalities such as two-point discrimination and perception of light touch. The presence or absence of diabetes exerted the strongest effect on peripheral sensation. In patients who did not have diabetes, sensation in the limbs was most strongly affected by whether the patient was an alcoholic. Smoking did not have a significant effect on limb sensation. Among nondiabetic, nonalcoholic patients, there was a weak residual effect related to the severity of the peripheral vascular insufficiency. Even among these patients, however, systemic factors predominated in determining the loss of sensation. We also examined the extent to which loss of sensation might be related to the development of ulcers. Among patients who were not diabetic, there was a highly significant relationship between loss of sensation and the presence of limb ulceration. Surprisingly, however, there was no discernable relationship between the presence of ulcers in diabetic patients and the degree of loss of peripheral sensation. This result suggests that a large percentage of ulcers seen in diabetic patients are not of neurogenic origin.

Multiple sclerosis: Part II. Common functional problems and rehabilitation.

Cognitive impairments, often unrecognized in multiple sclerosis, include memory loss, new learning problems, denial and depression. Spasticity and incoordination of the oropharyngeal and respiratory muscles create functional problems with speech and swallowing. Genitourinary problems include sexual dysfunction and neurogenic bladder. Specific measures can be used to alleviate these problems.

Multiple sclerosis: Part I. Common physical disabilities and rehabilitation.

Rehabilitation of the multiple sclerosis patient must be individualized because of the varied manifestations and fluctuating course of the disease. The activity schedule must be modified to compensate for muscle weakness and fatigability. Spasticity and the preventable complication of joint contractures may be treated with joint ranging, medications, motor-point blocks and surgical intervention. Mobility problems, such as foot drop, may be improved with an ankle-foot orthosis, but ultimately a patient may require a wheelchair. Measures to prevent pressure sores include position change, pressure release, incontinence management and special equipment.

Physical activity: its influence on nerve conduction velocity.

In a group of 40 healthy subjects, distal and proximal latencies of the median, tibial, and peroneal motor, and sural sensory nerves and their respective skin surface temperatures (Tsk) were measured before and after walking or bicycling. The baseline tests were performed 30 minutes after resting in a constant room temperature of 24C. The ambulation or bicycling task was continued for 30 minutes at a constant rate. Postactivity tests were performed within 30 minutes and between 45 to 60 minutes after termination of activity. Another test was done 75 to 90 minutes after bicycle exercise. After walking, there was a significant increase in Tsk in all lower extremity nerves tested (p less than 0.01). The increases were accompanied by faster distal and proximal latencies in both testing periods (p less than 0.01). Median nerve Tsk, distal and proximal latencies did not differ significantly from baseline values initially, but 45 minutes after walking Tsk was elevated and proximal latency had become faster (p less than 0.01). Following bicycling, lower extremity Tsk was significantly reduced over tibial, peroneal, and sural nerves by the third testing period (p less than 0.01) but only sural latencies were significantly prolonged (p less than 0.05) by this time. In the upper extremities median Tsk was significantly elevated and distal latency had become significantly faster 45 minutes after bicycling. Our data suggest that activity significantly influences nerve conduction latency results due to tissue temperature alteration. In addition, 30 minutes of rest after activity may not be sufficient time for the lower extremity temperatures to become stable.