Outcomes after acute traumatic spinal cord injury in Botswana: from admission to discharge.

STUDY DESIGN: Prospective follow-up study. OBJECTIVES: To increase the knowledge regarding clinical and functional outcomes after traumatic spinal cord injuries (TSCI) in a resource-constrained setting. A special focus was placed on secondary complications such as pressure ulcers. SETTING: The national referral hospital in Gaborone, Botswana. METHODS: The study included all patients admitted with an acute TSCI during a 2-year period (n=39). Data collection was conducted at the time of discharge, and clinical characteristics, length of stay and pressure ulcers were analysed using descriptive and inferential statistics. RESULTS: Completeness of injury and presence of pressure ulcers were the factors found to significantly prolong hospitalization, which was 5 months (median). One patient died before discharge and one was discharged to rehabilitation in South Africa; all other patients were living with close or distant family members after discharge. Patients were supplied with electrical or manual active wheelchairs. Self-catheterization or suprapubic catheters were the main methods for bladder management, and ano-rectal stimulation to manage the bowel. Pressure ulcers, urinary tract infections and pain were the most frequent complications during in-patient care. CONCLUSIONS: Rehabilitation of patients with TSCI in Botswana has been going through big changes, and new rehabilitation objectives, such as techniques used for the management of bladder and bowel dysfunctions and the provision of technical aids, have been implemented, which likely can contribute to an overall improvement in the outcomes. However, basic care at the general wards is still lagging behind, causing high rates of pressure ulcers that significantly extend hospitalization periods.

Outcomes 2 years after traumatic spinal cord injury in Botswana: a follow-up study.

STUDY DESIGN: Prospective follow-up study. OBJECTIVES: To identify indicators leading to compliance with yearly controls (YCs) and to describe the clinical and functional outcomes 2 years after traumatic spinal cord injury (SCI). SETTING: The national SCI rehabilitation centre in Botswana. METHODS: Included in the study were all people who were admitted with a traumatic SCI during a 2-year period and survived to be discharged (n=38). Data were collected at the YCs and included demographic characteristics and clinical and functional outcomes. Comparisons were made between those who did or did not attend YCs and between those who did or did not develop pressure ulcers (PUs). RESULTS: The follow-up rate was 71% (27/38) with higher attendance among those with complete injuries and those with secondary complications, especially pain. Age, gender, distance to the centre and education did not affect the follow-up rate. Self-catheterisation and suprapubic catheter were the preferred methods to manage neurogenic bladder dysfunction. Despite high rates of PUs (48%) and urinary tract infections (UTIs; 41%), no death had occurred during the follow-up period. Furthermore, one-third had resumed work. CONCLUSION: Despite high rates of UTIs and PUs developed in the home environment, this study showed a high survival rate 2 years after traumatic SCI, which might be explained by the establishment of a specialised SCI unit and the high follow-up rate. In addition, the continuing contact with the SCI staff might have facilitated the relatively high return-to-work rate. Long-term follow-up seems possible even in resource-constrained settings with clearly stated objectives, transport, dedicated staff and well-educated patients and families.

A prospective study of pain and psychological functioning following traumatic spinal cord injury.

STUDY DESIGN: Longitudinal study. OBJECTIVES: To study prospectively pain characteristics, change in pain over time and the associations between pain and psychological functioning in adults with traumatic spinal cord injury (SCI). SETTING: Neurosurgical departments, SCI rehabilitation centres and the community. METHODS: Adults with traumatic SCI admitted over a 3-year period to two neurosurgical departments underwent clinical examination and questionnaires within 3 months after injury (baseline) and at 6, 12 and 42 months following SCI. Pain intensity and interference within the last 7 days, a global quality of life (QoL) item, the 5-item Mental Health Index and the 6-item Catastrophizing scale were used. RESULTS: Ninety individuals were recruited, of which 81 completed a telephone interview on average 3.5 (s.d., 0.6) years after the SCI. Pain was present in 75% at 3.5 years. Baseline pain catastrophizing scores did not predict pain intensity at 3.5 years. Both psychological functioning and QoL increased over time. QoL scores increased less in participants who reported an increase in pain intensity from baseline to the 3.5-year follow-up, and the change in QoL score correlated with the change in pain interference. Neuropathic pain had an onset within the first 12 months and tended to become persistent, whereas musculoskeletal pain more often had a late onset or resolved in cases of early onset. CONCLUSIONS: A large proportion of SCI participants continue to experience pain many years after SCI. Teaching individuals with SCI skills to minimise pain's impact on function as soon as possible following injury may prove beneficial.

Traumatic spinal cord injury in Botswana: characteristics, aetiology and mortality.

STUDY DESIGN: Descriptive study with a cross-sectional design. OBJECTIVES: To describe the epidemiology of traumatic spinal cord injuries (TSCIs) in Botswana, with a specific focus on road traffic crashes (RTC). SETTING: Main public referral hospital, Gaborone, Botswana. METHOD: Two samples were included. Sample one described the epidemiology and included patients admitted during a 2-year period with acute TSCI. Sample two included only patients with TSCI due to RTC. RESULTS: Annual incidence was 13 per million population. Epidemiology of TSCI: 49 patients were included, 71% male, age ranging from 4 to 81 years, 80% ⩽ 45 years. Tetraplegia was more common than paraplegia (59/41%), and 39% had C1-C4 level of injury. The main cause of TSCI was RTC (68%), followed by assault (16%) and falls (10%). Mortality was 20%, where all, but one, had tetraplegia (18%). Median time from injury to spinal surgery was 12 days, with longer time for women, 16 days compared with 8 for men. Burst tire was the primary cause of RTC resulting in a TSCI, followed by hitting animals on the road. The majority had been passengers and 72% were involved in single crashes. CONCLUSION: The most common cause for TSCI was RTC, followed by assault. In-hospital mortality was high and the waiting period from the time of accident to spinal surgery was long, especially for women. The aetiology and high mortality of TSCI in Botswana indicate that improvements in roadway safety and medical care may decrease the TSCI incidence and mortality.

Effects of an exercise programme on musculoskeletal and neuropathic pain after spinal cord injury--results from a seated double-poling ergometer study.

OBJECTIVES: To assess pain relieving effects of an intensive exercise programme on a seated double-poling ergometer in individuals with spinal cord injury (SCI). SETTING: Stockholm, Sweden. METHODS: A total of 13 wheelchair-dependent individuals with a thoracic or lumbar SCI were recruited to a 10-week training period (three times weekly) assessing the effects of regular training on upper-body strength, aerobic and mechanical power, and crossover effects on functional performance, as well as cardiovascular risk factors. Eight of the participants reported pain and were included in this exploratory pain protocol and assessed using the International SCI Basic Pain Data set, the Wheelchair Users' Shoulder Pain Index and International SCI Quality of Life Basic Data set. RESULTS: For those with neuropathic pain, median pain intensity ratings decreased from 5 on a 0-10 numerical rating scale at base-line to 3 at the end of study, and four of seven participants reported an improvement on the Patient Global Impression of Change scale. For those with musculoskeletal pain (n = 5), median pain intensity ratings improved from 4 at baseline to 0 at the end of study. All but one rated no musculoskeletal pain at all at the end of study and number of days with pain per week decreased from 5.5 to 0.7. None of the participants developed pain, because of overuse during the training period and few reported unwanted side effects. CONCLUSION: Considering its promising effects and safety, an intensive exercise programme can be tried for treating musculoskeletal pain and also neuropathic pain following SCI.

International Spinal Cord Injury Pain (ISCIP) Classification: Part 2. Initial validation using vignettes.

STUDY DESIGN: International validation study using self-administered surveys. OBJECTIVES: To investigate the utility and reliability of the International Spinal Cord Injury Pain (ISCIP) Classification as used by clinicians. METHODS: Seventy-five clinical vignettes (case histories) were prepared by the members of the ISCIP Classification group and assigned to a category by consensus. Vignettes were incorporated into an Internet survey distributed to clinicians. Clinicians were asked, for each vignette, to decide on the number of pain components present and to classify each using the ISCIP Classification. RESULTS: The average respondent had 86% of the questions on the number of pain components correct. The overall correctness in determining whether pain was nociceptive was 79%, whereas the correctness in determining whether pain was neuropathic was 77%. Correctness in determining if pain was musculoskeletal was 84%, whereas for visceral pain, neuropathic at-level spinal cord injury (SCI) and below-level SCI pain it was 85%, 57% and 73%, respectively. Using strict criteria, the overall correctness in determining pain type was 68% (versus an expected 95%), but with maximally relaxed criteria, it increased to 85%. CONCLUSIONS: The reliability of use of the ISCIP Classification by clinicians (who received minimal training in its use) using a clinical vignette approach is moderate. Some subtypes of pain proved challenging to classify. The ISCIP should be tested for reliability by applying it to real persons with pain after SCI. Based on the results of this validation process, the instructions accompanying the ISCIP Classification for classifying subtypes of pain have been clarified.

International spinal cord injury pain classification: part I. Background and description. March 6-7, 2009.

STUDY DESIGN: Discussion of issues and development of consensus. OBJECTIVE: Present the background, purpose, development process, format and definitions of the International Spinal Cord Injury Pain (ISCIP) Classification. METHODS: An international group of spinal cord injury (SCI) and pain experts deliberated over 2 days, and then via e-mail communication developed a consensus classification of pain after SCI. The classification was reviewed by members of several professional organizations and their feedback was incorporated. The classification then underwent validation by an international group of clinicians with minimal exposure to the classification, using case study vignettes. Based upon the results of this study, further revisions were made to the ISCIP Classification. RESULTS: An overall structure and terminology has been developed and partially validated as a merger of and improvement on previously published SCI pain classifications, combined with basic definitions proposed by the International Association for the Study of Pain and pain characteristics described in published empiric studies of pain. The classification is designed to be comprehensive and to include pains that are directly related to the SCI pathology as well as pains that are common after SCI but are not necessarily mechanistically related to the SCI itself. CONCLUSIONS: The format and definitions presented should help experienced and non-experienced clinicians as well as clinical researchers classify pain after SCI.

Pain, referred sensations, and involuntary muscle movements in brachial plexus injury.

OBJECTIVES: Examination of the relationship between pain, sensory hypersensitivity, referred sensations and involuntary muscle jerks in patients with brachial plexus injury. MATERIALS AND METHODS: Fourteen patients with brachial plexus lesions were included. Spontaneous background and paroxysmal pain and mechanically and thermally evoked pain were recorded. Areas with sensory hypersensitivity and referred pain were mapped on a body chart. This was supplemented by electrophysiological analysis in three patients. RESULTS: Sensory hypersensitivity and areas with pinprick-induced referred phantom sensations were present in adjacent dermatomes. There was no clear relationship between chronic neuropathic pain and referred sensations, but there was a correlation between pain paroxysms and sensory hypersensitivity in dermatomes adjacent to deafferented areas. In three patients, simultaneous referred sensations and short latency motor action potentials ipsilateral to the denervated side suggested origin at subcortical sites. CONCLUSION: The study suggests a possible role of a spinal generator for sensory hypersensitivity and referred sensations following denervation.