The effectiveness and satisfaction of web-based physiotherapy in people with spinal cord injury: a pilot randomised controlled trial.

STUDY DESIGN: A pilot randomised controlled trial. OBJECTIVES: The aims of this study were to evaluate the effectiveness and participant satisfaction of web-based physiotherapy in people with spinal cord injury (SCI). SETTING: Community patients of a national spinal injury unit in a university teaching hospital, Scotland, UK. METHODS: Twenty-four participants were recruited and randomised to receive 8 weeks of web-based physiotherapy (intervention), twice per week, or usual care (control). Individual exercise programmes were prescribed based on participants' abilities. The intervention was delivered via a website (www.webbasedphysio.com) and monitored and progressed remotely by the physiotherapist. RESULTS: Participants logged on to the website an average of 1.4±0.8 times per week. Between-group differences, although not significant, were more pronounced for the 6-min walk test. Participants were positive about using web-based physiotherapy and stated that they would be happy to use it again and would recommend it to others. Overall, it was rated as either good or excellent. CONCLUSIONS: Web-based physiotherapy was feasible and acceptable for people with SCI. Participants achieved good compliance with the intervention and rated the programme highly and beneficial for health and well-being at various states after injury. The results of this study warrant further work with a more homogeneous sample. SPONSORSHIP: This study was funded by the Queen Elizabeth National Spinal Injuries Unit, Glasgow, UK.

Changing demographics of spinal cord injury over a 20-year period: a longitudinal population-based study in Scotland.

STUDY DESIGN: A retrospective cohort study. OBJECTIVES: To review demographic trends in traumatic spinal cord injury (TSCI) and non-traumatic spinal cord injury (NTSCI). SETTING: The Queen Elizabeth National Spinal Injuries Unit (QENSIU), sole provider of treatment for TSCI in Scotland; a devolved region of the UK National Health Service. METHODS: A retrospective review of the QENSIU database was performed between 1994 and 2013. This database includes demographic and clinical data from all new TSCI patients in Scotland, as well as patients with severe NTSCI. RESULTS: Over this 20-year period there were 1638 new cases of TSCI in Scotland; 75.2% occurring in males. TSCI incidence increased non-significantly (13.3 per million population to 17.0), while there were significant increases in mean age at time of TSCI (44.1-52.6 years), the proportion of TSCIs caused by falls (41-60%), the proportion of TSCIs resulting in an American Spinal Injury Association Impairment Scale score of C and D on admission (19.7-28.6% and 34.5-39.5%, respectively) and the proportion of cervical TSCIs (58.4-66.3%). The increase in cervical TSCI was specifically due to an increase in C1-C4 lesions (21.7-31.2%). NTSCI patients (n=292) were 5 years older at injury, more likely to be female (68.1% male) and had a range of diagnoses. CONCLUSION: This study supports the suggestion that demographic profiles in SCI are subject to change. In this population, of particular concern is the increasing number of older patients and those with high level tetraplegia, due to their increased care needs. Prevention programmes, treatment pathways and service provision need to be adjusted for optimum impact, improved outcome and long-term care for their target population.

Detection of the motor points of the abdominal muscles.

PURPOSE: Abdominal functional electrical stimulation (AFES) is a technique intended to improve respiratory function in tetraplegia where breathing is affected due to abdominal muscle paralysis. Although it is known that optimal muscle contraction is achieved when electrical stimulation is applied close to the muscle motor point, AFES studies have used a variety of electrode positions. This study aims to investigate the feasibility of using Neuromuscular Electrical Stimulation to detect the motor points of the abdominal muscles, and to evaluate the intrasubject repeatability and intersubject uniformity of their positions, to find the most suitable AFES electrode location. METHODS: Low frequency stimulation (0.5 Hz) was applied to the abdominal muscles of 10 able bodied and five tetraplegic participants. The electrode positions which achieved the strongest muscle contractions were recorded as the motor point positions, with measurements repeated once. For five able bodied participants, assessments were repeated after 18 months, in seated and supine positions. RESULTS: Intersubject uniformity ranged from 2.8 to 8.8%. Motor point positions were identified with intrasubject repeatability of <1.7 cm, deemed adequate relative to standard AFES electrode size. Intrasubject repeatability shows motor point positions changed little (<1.7 cm) after 18 months but varied between seated and supine positions with repeatability of up to 3.1 cm. CONCLUSIONS: A simple technique to locate the motor points of the abdominal muscles is presented and shown to have an adequate intrasubject repeatability, enabling the optimum AFES electrode location to be identified for each user.

Predicting patient-specific rates of bone loss at fracture-prone sites after spinal cord injury.

PURPOSE: People with spinal cord injury (SCI) experience bone loss and have an elevated rate of fracture in the paralysed limbs. The literature suggests an exponential time course of bone loss after SCI, but true rates may vary between patients. We propose systematic evaluation of bone status in the early stages of SCI to identify fast bone losers. METHOD: A case series of six patients with complete SCI were scanned using peripheral quantitative computed tomography within 5 weeks and at 4, 8 and 12 months post-injury. Bone mineral density (BMD) and bone mineral content (BMC) were measured at fracture-prone sites in the tibia and femur. Patient-specific-predictions (PSP) of expected rates of bone loss were produced by individualising published model equations according to each patient's measured values at baseline. Wilcoxon Signed-Rank tests were used to identify changes between time-points; chi-squared tests for differences between measured and PSP values. RESULTS: In the lower limbs, mean values decreased significantly between baseline and 8 months post-injury, by 19-31% for trabecular BMD, 21-32% for total BMD, and 9-29% for BMC. Most subjects showed no significant differences between PSP and measured values, but individuals with significantly faster rates of bone loss than predicted should be investigated further. CONCLUSIONS: There was considerable intersubject variability in rates of bone loss after SCI. Patients showing the fastest bone loss could benefit from continued follow-up and possibly treatment.

Functional outcome and discharge destination in elderly patients with spinal cord injuries.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To describe functional outcome and discharge destination of elderly patients with traumatic spinal cord injuries. SETTING: National Spinal Injuries Unit, Glasgow, UK. METHODS: We collected data for 5 years on all patients >65 years old with a traumatic spinal cord injury treated at the National Spinal Injuries Unit. RESULTS: We identified 39 patients. Of these, nine patients died during admission; all had cervical spine injuries. The mean age of the 30 survivors was 73 years (range 65-88). The most common cause of injury was a fall: 26 patients (87%). In addition, 21 (70%) sustained injury to cervical cord, 3 (10%) had thoracic and 6 (20%) had lumbar spine fractures. In all, 23 patients (77%) were treated by orthosis and 7 (23%) underwent surgical intervention. Twelve (40%) patients showed an improvement in American Spinal Injury Association impairment scale. The median hospital stay was 136 days. Thus, 11 patients (37%), all with incomplete injuries, were discharged home, 10 (33%) were transferred to nursing homes/community hospitals and 9 patients (30%) were discharged back to the referring hospital, while they were awaiting adjustments at home. Patients who were discharged home had significantly higher Functional Independence Measure scores, both at the onset of rehabilitation and at discharge, than those who were discharged to a nursing home or other hospitals (P<0.01 and <0.001, respectively). DISCUSSION AND CONCLUSION: Although the elderly patients may benefit from the services of a dedicated spinal injuries centre, they should be carefully selected. The patient, relatives as well as the referring doctors should be alerted to the likely long-term outcomes early in the course of the injury. Elderly patients with complete lesions of the spinal cord will almost certainly remain institutionalized. Early endeavour should be made to find alternate rehabilitation settings with a lower-intensity treatment.

The horse-human dyad: can we align horse training and handling activities with the equid social ethogram?

This article examines the recently completed equid ethogram and shows how analogues of social interactions between horses may occur in various human-horse interactions. It discusses how some specific horse-horse interactions have a corresponding horse-human interaction - some of which may be directly beneficial for the horse while others may be unusual or even abnormal. It also shows how correspondent behaviours sometimes become inappropriate because of their duration, consistency or context. One analogue is unlikely to hold true for all horse-human contexts, so when applying any model from horse-horse interactions to human-horse interactions, the limitations of the model may eclipse the intended outcome of the intervention. These limitations are especially likely when the horse is being ridden. Such analyses may help to determine the validity of extrapolating intra-specific interactions to the inter-specific setting, as is advocated by some popular horse-training methods, and highlight the subsequent limitations where humans play the role of the 'alpha mare' or leader in horse handling and training. This examination provides a constructive framework for further informed debate and empirical investigation of the critical features of successful intra-specific interactions.

Automatic electrical stimulation of abdominal wall muscles increases tidal volume and cough peak flow in tetraplegia.

Paralysis of the respiratory muscles in people with tetraplegia affects their ability to breathe and contributes to respiratory complications. Surface functional electrical stimulation (FES) of abdominal wall muscles can be used to increase tidal volume (V_{T}) and improve cough peak flow (CPF) in tetraplegic subjects who are able to breathe spontaneously. This study aims to evaluate the feasibility and effectiveness of a novel abdominal FES system which generates stimulation automatically, synchronised with the subjects' voluntary breathing activity. Four subjects with complete tetraplegia (C4-C6), breathing spontaneously, were recruited. The automatic stimulation system ensured that consistent stimulation was achieved. We compared spirometry during unassisted and FES-assisted quiet breathing and coughing, and measured the effect of stimulation on end-tidal CO_2 (EtCO_2) during quiet breathing. The system dependably recognised spontaneous respiratory effort, stimulating appropriately, and was well tolerated by patients. Significant increases in V_T during quiet breathing (range 0.05-0.23 L) and in CPF (range 0.04-0.49 L/s) were observed. Respiratory rate during quiet breathing decreased in all subjects when stimulated, whereas minute ventilation increased by 1.05-2.07 L/min. The changes in EtCO_2 were inconclusive. The automatic stimulation system augmented spontaneous breathing and coughing in tetraplegic patients and may provide a potential means of respiratory support for tetraplegic patients with reduced respiratory capacity.

Hydrocephalus complicating a cervical spine fracture in a patient with ankylosing spondylitis.

We present a case of obstructive hydrocephalus secondary to ascending spinal cord oedema, sustained after cervical spine fracture in a patient with ankylosing spondylitis. To our knowledge, this is the first report of ascending oedema from a cervical cord injury causing obstructive hydrocephalus.

Arm-cranking exercise assisted by Functional Electrical Stimulation in C6 tetraplegia: a pilot study.

Tetraplegic volunteers undertook progressive exercise training, using novel systems for arm-cranking exercise assisted by Functional Electrical Stimulation (FES). The main aim was to determine potential training effects of FES-assisted arm-crank ergometry (FES-ACE) on upper limb strength and cardiopulmonary (fitness) in tetraplegia. Surface FES was applied to the biceps and triceps during exercise on an instrumented ergometer. Two tetraplegic volunteers with C6 Spinal Cord Injury (SCI) went through muscle strengthening, baseline exercise testing and three months of progressive FES-ACE training. Repeat exercise tests were carried out every four weeks during training, and post-training, to monitor upper-limb strength and cardiopulmonary fitness. At each test point, an incremental test was carried out to determine peak work rate, peak oxygen uptake, gas exchange threshold and oxygen uptake-work rate relationship during FES-ACE. Peak oxygen uptake for Subject A increased from 0.7 l/min to 1.1 l/min, and peak power output increased from 7 W to 38 W after FES-ACE training. For Subject B, peak oxygen uptake was unchanged, but peak power output increased from 3 W to 8 W. These case studies illustrate potential benefits of FES-ACE in tetraplegia, but also the differences in exercise responses between individuals.

A control system for automatic electrical stimulation of abdominal muscles to assist respiratory function in tetraplegia.

People with tetraplegia have poor respiratory function leading to limited tidal volume (V(T)) and reduced cough peak flow (CPF). These problems may cause respiratory failure during the initial admission or subsequent intercurrent illness. Electrical stimulation of the abdominal muscles during expiration can improve respiratory function by increasing V(T) and CPF. We developed a novel control system to automatically trigger muscle stimulation, synchronised with the subject's voluntary respiratory activity. The system was tested in four subjects with a functionally complete lesion at level C4 to C6, aged between 16 and 46 years, 3 months to 5 years post injury, who were breathing spontaneously. The algorithm delivered automatic stimulation patterns, detecting cough and quiet breathing while suppressing stimulation during other activities such as speaking. Marked increases in V(T) (between 9% and 71% of baseline) and CPF (between 31% and 54% of baseline) were observed, suggesting that the technique may have potential use in both acute and established tetraplegia to increase minute ventilation and to improve cough clearance of secretions.

Blunt cervical spine trauma as a cause of spinal cord injury and delayed cortical blindness.

STUDY DESIGN: Case report. OBJECTIVE: To present and discuss the case of a patient who sustained a significant flexion compression injury of the cervical spine with resulting tetraplegia and development of cortical blindness. SETTING: National Spinal Injuries Unit and Institute of Neurological Sciences, Southern General Hospital, Glasgow, Scotland, UK. METHODS: Clinical and radiological follow-up of the patient. RESULTS: Cortical blindness resulted from vertebral artery dissection associated with blunt cervical spine trauma. The patient is registered blind and is ventilator dependent. CONCLUSION: The potential complications of blunt vertebral artery injury remain poorly recognised. Screening is routinely not performed. Advances in noninvasive radiological techniques may result in recognition of asymptomatic disease and the potential for therapeutic intervention.

Comparison of stimulation patterns for FES-cycling using measures of oxygen cost and stimulation cost.

AIM: The energy efficiency of FES-cycling in spinal cord injured subjects is very much lower than that of normal cycling, and efficiency is dependent upon the parameters of muscle stimulation. We investigated measures which can be used to evaluate the effect on cycling performance of changes in stimulation parameters, and which might therefore be used to optimise them. We aimed to determine whether oxygen cost and stimulation cost measurements are sensitive enough to allow discrimination between the efficacy of different activation ranges for stimulation of each muscle group during constant-power cycling. METHODS: We employed a custom FES-cycling ergometer system, with accurate control of cadence and stimulated exercise workrate. Two sets of muscle activation angles ("stimulation patterns"), denoted "P1" and "P2", were applied repeatedly (eight times each) during constant-power cycling, in a repeated measures design with a single paraplegic subject. Pulmonary oxygen uptake was measured in real time and used to determine the oxygen cost of the exercise. A new measure of stimulation cost of the exercise is proposed, which represents the total rate of stimulation charge applied to the stimulated muscle groups during cycling. A number of energy-efficiency measures were also estimated. RESULTS: Average oxygen cost and stimulation cost of P1 were found to be significantly lower than those for P2 (paired t-test, p<0.05): oxygen costs were 0.56+/-0.03l min-1 and 0.61+/-0.04l min-1 (mean+/-S.D.), respectively; stimulation costs were 74.91+/-12.15 mC min-1 and 100.30+/-14.78 mC min-1 (mean+/-S.D.), respectively. Correspondingly, all efficiency estimates for P1 were greater than those for P2. CONCLUSION: Oxygen cost and stimulation cost measures both allow discrimination between the efficacy of different muscle activation patterns during constant-power FES-cycling. However, stimulation cost is more easily determined in real time, and responds more rapidly and with greatly improved signal-to-noise properties than the ventilatory oxygen uptake measurements required for estimation of oxygen cost. These measures may find utility in the adjustment of stimulation patterns for achievement of optimal cycling performance.

Delayed hydrocephalus as an unusual complication of a stab injury to the spine.

STUDY DESIGN: Case report. OBJECTIVE: To report a rare complication following a stab injury to the upper cervical spine and cord. SETTING: National spinal injury unit in a Scottish university teaching hospital. CASE REPORT: A 19-year-old male sustained a stab injury to his upper cervical spine, with a partial cord transection. After 5 months of rehabilitation, his condition deteriorated. CT scans showed hydrocephalus, which was treated by shunting. After shunting, the patient's condition improved but he remained tetraplegic requiring ventilatory support at night. CONCLUSION: Hydrocephalus as a late complication of a cervical spine injury is rare but should be considered if the condition of the patient with an upper cervical spine injury deteriorates. The likely mechanism of the hydrocephalus development is also discussed.

Spinal cord infarction due to a self-inflicted needle stick injury.

STUDY DESIGN: Case report. OBJECTIVE: To report a case of spinal cord infarction after a self-inflicted needle stick injury, following an injection of heroin into the cord. SETTING: National spinal injury unit in a Scottish University teaching hospital, Glasgow, UK. CASE REPORT: A 20-year-old male, injected street heroin accidentally into the cord through the left side of the neck, leading to sudden loss of power to all four limbs. Initial magnetic resonance imaging scans showed extensive cord oedema and follow-up scans showed signal changes within the anterior horns of the spinal cord in keeping with a cord infarct. CONCLUSION: Self-inflicted spinal cord injury with a small needle is difficult, but not impossible. Cord infarct as a result of a self-inflicted injury has not been previously reported. The mechanism of the injury resulting in cord infarction is explained by the vascular anatomy of the spinal cord circulation, and this may also explain the residual neurological status of the patient.

Rupture of tuberculous spinal abscess resulting in tuberculous empyema and chylothorax.

STUDY DESIGN: Case report with a review of scientific literature. OBJECTIVE: To describe the course of tuberculous spinal disease (Pott's disease) complicated by pyogenic and tuberculous empyema, and chylothorax as there has been an increase in the numbers of notified cases of tuberculosis in the UK(1). To the best of our knowledge, a similar case has not been reported previously in the UK, although there has been a report of bilateral chylothorax associated with Pott's disease. SETTING: A national spinal injuries unit in a Scottish university teaching hospital. METHODS: Review of literature on the chemotherapy of spinal tuberculosis and the role of streptokinase in the treatment of empyema and the relation between spinal tuberculosis, empyema and chylothorax. RESULTS: Although spinal tuberculosis was recognised and treated appropriately with chemotherapy, the patient sustained pleural involvement with later development of both empyema and chylothorax. CONCLUSION: The case highlights the difficulties in the treatment of tuberculosis of the spine inspite of the presence of fully sensitive organisms and early institution of appropriate chemotherapy. In the absence of surgical debridement, the duration and dosage of chemotherapy as practised in the initial period may have to be prolonged into the continuation phase. The thoracic duct can be damaged either because of extension of the tuberculosis itself or because of instillation of intrapleural streptokinase for treatment of pleural empyema leading to chylothorax. There is a need for randomised trials of intrapleural streptokinase treatment in tuberculous empyema.

Delayed presentation of post-traumatic aneurysm of the posterior inferior cerebellar artery in a patient with spinal cord injury.

STUDY DESIGN: A case report. OBJECTIVE: To present and discuss the case of a patient with serious head and spinal injuries who suffered delayed haemorrhage from a post-traumatic aneurysm of the right posterior inferior cerebellar artery following surgical treatment of vertebral fracture and hydrocephalus. SETTING: National Spinal Injuries Unit and Institute of Neurological Sciences, Southern General Hospital, Glasgow, Scotland, UK. METHODS: Clinical and radiological follow-up of the patient. RESULTS: The aneurysm was treated by coil occlusion of the right vertebral artery. Post-operative films showed that the aneurysm had been successfully obliterated. CONCLUSION: Post-traumatic cerebral aneurysms are very rare. Neurosurgical and rehabilitation teams need to be aware of this late treatable sequela of head injury.

Prophylaxis of thromboembolism in spinal injuries--results of enoxaparin used in 276 patients.

OBJECTIVE: To evaluate the results of thromboembolic prophylaxis using enoxaparin in acute spinal injury patients. BACKGROUND: Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality in patients with acute spinal injuries. A wide range of thromboprophylactic measures have been proposed. The present study describes the outcome of a regime of enoxaparin and antithromboembolic stockings in acute spinal injuries irrespective of neurological damage. SETTING: Scotland, UK. METHODS: Eighteen-month retrospective review of acute spinal injury patients admitted to a national spinal injuries unit. A thromboembolic prophylactic regimen of early mobilisation, use of antithromboembolic stockings, and subcutaneous administration of enoxaparin 40 mg once a day until patients could be mobilised for more than 4 h per day, was used. Patients with clinical suspicion of deep venous thrombosis or pulmonary embolism were investigated as appropriate. RESULTS: Out of 146 (53% of total) patients with spinal injuries with no neurological deficit only one patient (0.4%) developed clinical evidence of pulmonary embolism and out of 130 (47% of total) with spinal cord injury two (0.7%) developed clinical evidence of deep venous thrombosis while still on enoxaparin. Four patients (1.5%) developed deep venous thrombosis and one (0.4%) pulmonary embolism after discontinuing enoxaparin. There were no fatal pulmonary emboli and one suspected intraspinal bleeding. CONCLUSIONS: The present study suggests that, in addition to physical and mechanical measures, low molecular weight heparin in the form of enoxaparin 40 mg administered once daily compares favourably with previous studies for thromboprophylaxis in acute spinal injuries.

Cognitive abilities - the result of selective pressures on food acquisition?

Locating and capturing food are suggested as significant selection pressures for the evolution of various cognitive abilities in mammals and birds. The hypothesis is proposed that aspects of food procuring behaviour should be strongly indicative of particular cognitive abilities.Experimental data concerning higher mental abilities in mammals and birds are reviewed. These data deal with self-recognition studies, rule-learning experiments, number concept, deceptive abilities, tool-use and observational learning.A Darwinian approach reveals: (1) the adaptiveness of particular abilities for particular niches, (2) that in complex foraging environments, increases in foraging efficiencies in animals should result from the evolution of particular cognitive abilities, (3) that phenomena such as convergent mental evolution should be expected to have taken place across taxonomic groups for species exploiting similar niches, (4) that divergence in mental ability should also have taken place where related species have exploited dissimilar niches.Experimental data of higher mental abilities in animals concur with a Darwinian explanation for the distribution of these cognitive abilities and no anomalies have been found.There are, as a consequence, significant implications for the welfare of animals subject to training when training methodology gives little or no consideration to the various mental abilities of species.

Scottish national bronchoscopy audit: a prospective multicentre study of 3316 cases against agreed standards. Scottish Thoracic Society.

INTRODUCTION: Bronchoscopy guidelines address issues of patient and operator safety but do not give guidance on the expected yield of the procedure. Realistic standards for several outcome measures of bronchoscopy for investigating bronchial carcinoma have been derived by Scottish clinicians from a published national study. The present study describes the use of these agreed standards in prospective audit. METHODS: All Society members in Scotland (population 5.1 million) were invited to participate. Data were collected for 1 year and coded anonymously. STANDARDS: 1. Supervising bronchoscopist to have completed at least 100 procedures; 2. histology to be positive in 80% of cases where tumour seen; 3. 35%-55% of bronchoscopies to reveal a diagnosis; 4. 60% of patients admitted for bronchoscopy to be day cases; 5. 80% of day case patients to be in hospital for less than 6 h; 6. 90% of male patients and 80% of female patients willing to have repeat bronchoscopy. RESULTS: Three thousand, three hundred and sixteen bronchoscopies were performed by 45 senior pulmonologists at 22 centres. One centre reached all the standards and five centres met five standards. There was wide national variation in histological spectrum, incidence of small cell cancer ranged from 12% to 25% between centres. Participants found their own data helpful in identifying local areas for improvement. CONCLUSION: Bronchcoscopy standards set locally by practising pulmonologists can be used in collaborative audit to identify areas for improving practice. Variation in histology may be accounted for by case-mix or pathology techniques.