Outcome measures in spinal cord injury: recent assessments and recommendations for future directions.

STUDY DESIGN: Review by the spinal cord outcomes partnership endeavor (SCOPE), which is a broad-based international consortium of scientists and clinical researchers representing academic institutions, industry, government agencies, not-for-profit organizations and foundations. OBJECTIVES: Assessment of current and evolving tools for evaluating human spinal cord injury (SCI) outcomes for both clinical diagnosis and clinical research studies. METHODS: a framework for the appraisal of evidence of metric properties was used to examine outcome tools or tests for accuracy, sensitivity, reliability and validity for human SCI. RESULTS: Imaging, neurological, functional, autonomic, sexual health, bladder/bowel, pain and psychosocial tools were evaluated. Several specific tools for human SCI studies have or are being developed to allow the more accurate determination for a clinically meaningful benefit (improvement in functional outcome or quality of life) being achieved as a result of a therapeutic intervention. CONCLUSION: Significant progress has been made, but further validation studies are required to identify the most appropriate tools for specific targets in a human SCI study or clinical trial.

International standards to document remaining autonomic function after spinal cord injury.

STUDY DESIGN: Experts opinions consensus. OBJECTIVE: To develop a common strategy to document remaining autonomic neurologic function following spinal cord injury (SCI). BACKGROUND AND RATIONALE: The impact of a specific SCI on a person's neurologic function is generally described through use of the International Standards for the Neurological Classification of SCI. These standards document the remaining motor and sensory function that a person may have; however, they do not provide information about the status of a person's autonomic function. METHODS: Based on this deficiency, the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) commissioned a group of international experts to develop a common strategy to document the remaining autonomic neurologic function. RESULTS: Four subgroups were commissioned: bladder, bowel, sexual function and general autonomic function. On-line communication was followed by numerous face to face meetings. The information was then presented in a summary format at a course on Measurement in Spinal Cord Injury, held on June 24, 2006. Subsequent to this it was revised online by the committee members, posted on the websites of both ASIA and ISCoS for comment and re-revised through webcasts. Topics include an overview of autonomic anatomy, classification of cardiovascular, respiratory, sudomotor and thermoregulatory function, bladder, bowel and sexual function. CONCLUSION: This document describes a new system to document the impact of SCI on autonomic function. Based upon current knowledge of the neuroanatomy of autonomic function this paper provides a framework with which to communicate the effects of specific spinal cord injuries on cardiovascular, broncho-pulmonary, sudomotor, bladder, bowel and sexual function.

International bowel function extended spinal cord injury data set.

STUDY DESIGN: International expert working group. OBJECTIVE: To develop an International Bowel Function Extended Spinal Cord Injury (SCI) Data Set presenting a standardized format for the collection and reporting of an extended amount of information on bowel function. SETTING: Working group consisting of members appointed by the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS). METHODS: A draft prepared by the working group was reviewed by Executive Committee of the International SCI Standards and Data Sets and later by the ISCoS Scientific Committee and the ASIA Board. Relevant and interested scientific and professional organizations and societies (around 40) were also invited to review the data set and it was posted on the ISCoS and ASIA websites for 3 months to allow comments and suggestions. The ISCoS Scientific Committee, ISCoS Council and ASIA Board received the data set for final review and approval. RESULTS: The International Bowel Function Basic SCI Data Set includes 26 items providing a thorough description of bowel-related symptoms as well as clinical assessment of anal sphincter function and description of total gastrointestinal or segmental colorectal transit times. CONCLUSION: An International Bowel Function Extended SCI Data Set has been developed. This Data Set is mainly for research purposes and it should be used in combination with the information obtained from the International SCI Core Data Set and the International Bowel Function Basic SCI Data Set.

International bowel function basic spinal cord injury data set.

STUDY DESIGN: International expert working group. OBJECTIVE: To develop an International Bowel Function Basic Spinal Cord Injury (SCI) Data Set presenting a standardized format for the collection and reporting of a minimal amount of information on bowel function in daily practice or in research. SETTING: Working group consisting of members appointed by the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS). METHODS: A draft prepared by the working group was reviewed by Executive Committee of the International SCI Standards and Data Sets, and later by ISCoS Scientific Committee and the ASIA Board. Relevant and interested scientific and professional (international) organizations and societies (approximately 40) were also invited to review the data set and it was posted on the ISCoS and ASIA websites for 3 months to allow comments and suggestions. The ISCoS Scientific Committee, Council and ASIA Board received the data set for final review and approval. RESULTS: The International Bowel Function Basic SCI Data Set includes the following 12 items: date of data collection, gastrointestinal or anal sphincter dysfunction unrelated to SCI, surgical procedures on the gastrointestinal tract, awareness of the need to defecate, defecation method and bowel care procedures, average time required for defecation, frequency of defecation, frequency of fecal incontinence, need to wear pad or plug, medication affecting bowel function/constipating agents, oral laxatives and perianal problems. CONCLUSION: An International Bowel Function Basic SCI Data Set has been developed.

Long-term effects of spinal cord injury on sexual function in men: implications for neuroplasticity.

STUDY DESIGN: Secure, web-based survey. OBJECTIVES: Elicit specific information about sexual function from men with spinal cord injuries (SCI). SETTING: World-wide web. METHODS: Individuals 18 years or older living with SCI obtained a pass-code to enter a secure website and then answered survey questions. RESULTS: The presence of genital sensation was positively correlated with the ability to feel a build up of sexual tension in the body during sexual stimulation and in the feeling that mental arousal translates to the genitals as physical sensation. There was an inverse relationship between developing new areas of arousal above the level of lesion and not having sensation or movement below the lesion. A positive relationship existed between the occurrence of spasticity during sexual activity and erectile ability. Roughly 60% of the subjects had tried some type of erection enhancing method. Only 48% had successfully achieved ejaculation postinjury and the most commonly used methods were hand stimulation, sexual intercourse, and vibrostimulation. The most commonly cited reasons for trying to ejaculate were for pleasure and for sexual intimacy. Less than half reported having experienced orgasm postinjury and this was influenced by the length of time postinjury and sacral sparing. CONCLUSION: SCI not only impairs male erectile function and ejaculatory ability, but also alters sexual arousal in a manner suggestive of neuroplasticity. More research needs to be pursued in a manner encompassing all aspects of sexual function.

Spinal cord injury influences psychogenic as well as physical components of female sexual ability.

STUDY DESIGN: Secure, web-based survey. OBJECTIVES: Elicit specific information about sexual function from women with spinal cord injuries (SCI). SETTING: World-wide web. METHODS: Individuals 18 years or older living with SCI obtained a pass code to enter a secure website and then answered survey questions. RESULTS: Bladder and/or bowel incontinence during sexual activity and/or sexual intercourse were significant concerns and prevented some women from seeking sexual activity. Autonomic dysreflexia (AD) during sexual activity was interpreted negatively by many and was found to interfere with sexual activity. Most subjects reported difficulty becoming psychologically aroused as well as physically aroused, which were both correlated with feeling that their SCI had altered their sexual sense of self. An inverse relationship existed between developing new areas of arousal above the level of lesion and not having sensation or movement below the lesion. The most commonly reported sexual stimulation leading to the best arousal involved stimulation of the head/neck and torso areas. The majority of subjects reported having experienced intercourse postinjury. Most participants reported difficulty with positioning during foreplay and intercourse, vaginal lubrication, and spasticity during intercourse. Almost half reported experiencing orgasm postinjury and this was positively associated with the presence of genital sensation. CONCLUSION: SCI significantly impairs psychological and physical aspects of female sexual arousal. In addition, bladder and bowel incontinence as well as AD negatively impact sexual activity and intercourse.

The impact of spinal cord injury on sexual function: concerns of the general population.

STUDY DESIGN: Secure, web-based survey. OBJECTIVES: Obtain information from the spinal cord injured (SCI) population regarding sexual dysfunctions, with the aim of developing new basic science and clinical research and eventual therapies targeting these issues. SETTING: Worldwide web. METHODS: Individuals 18 years or older living with SCI. Participants obtained a pass-code to enter a secure website and answered survey questions. A total of 286 subjects completed the survey. RESULTS: The majority of participants stated that their SCI altered their sexual sense of self and that improving their sexual function would improve their quality of life (QoL). The primary reason for pursuing sexual activity was for intimacy need, not fertility. Bladder and bowel concerns during sexual activity were not strong enough to deter the majority of the population from engaging in sexual activity. However, in the subset of individuals concerned about bladder and/or bowel incontinence during sexual activity, this was a highly significant issue. In addition, the occurrence of autonomic dysreflexia (AD) during typical bladder or bowel care was a significant variable predicting the occurrence and distress of AD during sexual activity. CONCLUSION: Sexual function and its resultant impact on QoL is a major issue to an overwhelming majority of people living with SCI. This certainly constitutes the need for expanding research in multiple aspects to develop future therapeutic interventions for sexual health and SCI.

Intersection syndrome in Buriram Hospital: a 4-yr prospective study.

OBJECTIVE: To determine the prevalence, demographic characteristics, symptoms, treatment, and outcome of patients who presented to Buriram Provincial hospital and were diagnosed with intersection syndrome. DESIGN: This was a 4-yr prospective study that included all patients with new complaints of forearm and hand pain who presented to Buriram hospital as inpatients or outpatients. RESULTS: The prevalence of intersection syndrome was found to be 0.37% of all patients (8080) with arm or hand pain. Of the 30 patients presenting with intersection syndrome, all had forearm pain, 22 (73.3%) had swelling, and 12 (40%) had crepitus noted in the intersected region. Fourteen (46.7%) patients reported pain provoked with twisting hand motions with radial deviations, 4 (13.3%) with pulling, and 12 (40%) with combinations of multiple hand movements (threshing, planting, hammering, hand washing, spraying and cementing). The majority of the patients were male (70%) farmers (60%). Twenty-nine patients received nonoperative treatment, including modified work activities to reduce stress on the wrist, nonsteroidal anti-inflammatory, and analgesic medications. One patient received only analgesic medication. One patient additionally required a resting hand splint. Every patient was seen for follow-up within the next 7 days. By 12-18 months posttreatment, there were only 14 patients (46.6%) remaining in follow-up, none with any symptom recurrence. CONCLUSION: Intersection syndrome is a relatively uncommon, overused syndrome that is associated with repeated radial deviation of the wrist and responds favorably to conservative treatment.

Atypical gastrointestinal symptoms are not associated with gallstones in patients with spinal cord injury.

OBJECTIVE: To determine if nonspecific gastrointestinal (GI) symptoms justify cholecystectomy in patients with spinal cord injury (SCI). DESIGN: The frequency of GI symptoms was determined in a sample of patients with SCI in whom the presence or absence of gallstones had been previously determined by screening ultrasonography or a known history of cholecystectomy. The prevalence of various symptoms in patients with and without gallstones was compared. SETTING: The Spinal Cord Injury Unit of the Veterans Affairs Puget Sound Health Care System, which provides rehabilitation and longitudinal primary care for SCI veterans. PATIENTS: Two hundred ninety-four patients who had undergone either right upper quadrant ultrasonography or cholecystectomy in the past, and who completed a questionnaire concerning GI symptoms. MAIN OUTCOME MEASURE: Bivariate logistic regression was used to calculate odds ratios (ORs) to determine the strength of associations between the presence of each symptom and the presence of gallstones. RESULTS: Pain in the right upper quadrant or epigastrium that occurred after meals or at night was significantly associated with gallstones (OR: 3.5; 95% confidence interval [CI] 1.02-11.73). Abdominal pain in other locations and nonspecific symptoms such as bloating and nausea, were not predictive of the presence of gallstones. CONCLUSIONS: Nonspecific symptoms in patients with SCI are not associated with gallstones and do not justify cholecystectomy in patients with otherwise asymptomatic gallstones.

Antegrade continence enema for the treatment of neurogenic constipation and fecal incontinence after spinal cord injury.

OBJECTIVE: To describe the effects of an antegrade continence enema stoma formed in a paraplegic man with intractable constipation and fecal incontinence. DESIGN: Case report. SETTING: Spinal cord injury unit, Veterans Affairs hospital. PARTICIPANTS: Spinal cord injury (SCI) patient with T12 paraplegia. INTERVENTION: Surgical formation of antegrade continence enema stoma. MAIN OUTCOME MEASURES: Time of bowel program care, ease of fecal elimination, safety of procedure. RESULTS: Bowel care time was decreased from 2 hours to 50 minutes daily; 6 bowel medications were discontinued; fecal incontinence was eliminated; and no surgical or medical side effects noted after the procedure. CONCLUSION: The antegrade continence enema procedure is a safe and effective means of treating intractable constipation and fecal incontinence in the adult SCI patient. This option should be considered for those persons in whom medical management of bowel care has been unsuccessful.

Neurologic recovery and neurologic decline after spinal cord injury.

Physicians caring for patients with spinal cord injury facilitate neurologic recovery by optimizing nutrition and general health, by coordinating active exercise and functional training to enhance the underlying synapse growth, reversal of muscle atrophy, and motor learning, and by controlling interfering spasticity. SCI physicians also must monitor for neurologic decline during initial rehabilitation and later in life, diagnose promptly and accurately such decline, and orchestrate the appropriate intervention.

The presentation of gallstones and results of biliary surgery in a spinal cord injured population.

BACKGROUND: Since spinal cord injured patients lack visceral sensation, their clinical manifestations of gallstones could be relatively occult. A higher proportion of these individuals may present with advanced biliary disease compared with the general population. Prophylactic cholecystectomy for asymptomatic stones may therefore be justified. METHODS: All spinal cord injured patients seen at the Seattle Veterans Hospital over a 5-year period were retrospectively surveyed to define a set of patients who had undergone a cholecystectomy. The operative indications and results were compared with those from a series of cholecystectomies in neurologically intact patients. RESULTS: The presentation of biliary disease in spinal cord injured patients was not more advanced than that of neurologically intact patients. Patients with high cord injuries presented in a similar fashion to those with low injuries. CONCLUSIONS: Since most spinal cord injured patients with biliary disease present with typical findings, prophylactic removal of gallstones in these patients is not warranted.

The prevalence and natural history of gallstones in spinal cord injured patients.

BACKGROUND: Individuals with a spinal cord injury are at increased risk for the development of gallstones. Because these patients cannot reliably manifest classic symptoms of biliary colic, they may be more likely to present with advanced biliary complications than patients with intact abdominal innervation. The natural history of gallstones in spinal cord injured patients has not been described. STUDY DESIGN: All spinal cord injured patients seen at the Seattle Veterans Affairs Medical Center from January 1, 1993, to December 31, 1997 were included in the study. For each patient, the presence or absence of gallstones had been determined previously through screening abdominal ultrasonographic evaluations. Pertinent demographic information was obtained from medical records and patient interviews. Patients with gallstones were followed until death, cholecystectomy, or the conclusion of the study, and the annual incidence of biliary complications and patients requiring a cholecystectomy were determined. The prevalence of gallstones was established by studying the subset of patients seen at the Seattle Spinal Cord Injury Unit from January 1, 1995 to December 31, 1997. RESULTS: Among the spinal cord injured patients, 31% either had gallstones or had undergone a cholecystectomy at some point after their injury. Increasing age, female gender, and greater severity of injury were risk factors for the formation of gallstones. Over the first 5 years after the diagnosis of gallstones, the annual incidence of cholecystectomy or biliary complications was 6.3% and 2.2%, respectively. CONCLUSIONS: Spinal cord injured patients are at increased risk for the development of gallstones. Patients with gallstones are at an increased risk for the development of biliary complications compared with neurologically intact patients, but the magnitude of this risk does not warrant prophylactic cholecystectomy.

Electrodiagnosis in spinal cord injured persons with new weakness or sensory loss: central and peripheral etiologies.

OBJECTIVE: To assess the prevalence and causes of late neurologic decline of persons with spinal cord injury (SCI). DESIGN: Retrospective review of persons with SCI over a 9-year period. Those with complaints of new weakness or sensory loss were grouped into three categories based on clinical examination, electrodiagnosis, and imaging: (1) central pathology (ie, brain, spinal cord, or nerve root); (2) peripheral pathology (plexus or peripheral nerve); or (3) no identifiable etiology. The specific diagnoses of late neurologic decline were identified. SETTING: Regional Veterans Affairs Spinal Cord Injury Service. PATIENTS: Five hundred two inpatient and outpatient adults with SCI. RESULTS: Nineteen percent of the study population complained of new weakness and/or sensory loss. Neurologic abnormalities were noted in 13.5%, 7.2% with central and 6.4% with peripheral causes. The most common pathologies were posttraumatic syringomyelia (2.4%) and cervical (1.6%) and lumbosacral (1.2%) myelopathy/radiculopathy. A specific etiology was not determined in 6 cases (1.6%). Peripheral involvement was mostly from ulnar nerve entrapment (3.4%) and carpal tunnel syndrome (3.0%). CONCLUSIONS: Late-onset neurologic decline is common after SCI and can result from central or peripheral pathology. Regular neurologic monitoring of SCI patients is recommended, since many with neurologic decline respond favorably if diagnosed and treated early.

Incomplete spinal cord injury: neuronal mechanisms of motor recovery and hyperreflexia.

OBJECTIVE: To understand neuronal mechanisms of motor recovery and hyperreflexia after incomplete spinal cord injury (SCI), and their role in rehabilitation. DESIGN: Reviewed and compared clinical, neurophysiologic, and neuropathologic data from human SCI patients with behavioral, neurophysiologic, and neuroanatomic data from animals to postulate underlying neuronal mechanisms. OUTCOME: A postulation that two neuronal mechanisms-receptor up-regulation and synapse growth-act sequentially, to explain the gradual appearance of motor recovery after incomplete SCI. These same mechanisms may also act in spinal reflex pathways to mediate hyperreflexia caudal to SCI. RESULTS: After incomplete SCI, walking ability and hyperreflexia often develop. Initially, cord neurons are hyperpolarized and less excitable because of loss of normal descending facilitation; this is spinal shock. Then, gradually, voluntary movement recovers and hyperreflexia develops. Early (hours to days), these changes develop simultaneously, suggesting a common postsynaptic mechanism-likely, an increase in postsynaptic receptor excitability, possibly receptor up-regulation. Late (weeks to months), recovery and reflex changes occur at a slow rate, are no longer simultaneous, and are long-lasting, which suggests a presynaptic mechanism, such as local synapse growth in spared descending pathways and in reflex pathways. This presumed synapse growth is seemingly enhanced by active use of the growing pathway. Also, developing hyperreflexia appears to limit motor recovery. CONCLUSIONS: These observations suggest that rehabilitation for incomplete SCI should (1) increase activity in spared descending motor pathways, (2) initially use reflex facilitation or central nervous system stimulants to assist spared descending inputs in depolarizing cord neurons, and (3) later minimize reflex input, when spared descending inputs can depolarize cord neurons without reflex facilitation. Better understanding of neuronal mechanisms that underlie motor recovery after incomplete SCI promises better outcomes from rehabilitation.

Polyethylene glycol versus vegetable oil based bisacodyl suppositories to initiate side-lying bowel care: a clinical trial in persons with spinal cord injury.

INTRODUCTION: Neurogenic bowel dysfunction resulting from spinal cord injury (SCI) frequently requires bowel care (BC) with stimulant suppositories for initiation of effective defecation. The excessive time required for BC and bowel complications have limited quality of life after SCI. OBJECTIVE: To test the hypothesis that: the time required for bowel care with bisacodyl suppositories can be reduced by substituting a polyethylene glycol base (PGB) for the traditional hydrogenated vegetable oil base (HVB) in the suppository. SETTING: Inpatient SCI medicine unit. SUBJECTS: Fourteen persons with SCI with chronic stable paralysis from upper motor neuron SCI for greater than one year with a stable HVB bisacodyl suppository initiated BC. DESIGN: Crossover Controlled. METHOD: Subjects received HVB bisacodyl suppositories for six sequential BC sessions and then were crossed over to PGB bisacodyl suppositories for six more BCs. OUTCOME MEASURES: BC event times were utilized to derive BC intervals: suppository insertion to first flatus= Time to flatus, first flatus until the beginning of stool flow = Flatus to stool flow, begin stool flow until end stool flow = Defecation period, end stool flow until end of clean up = Clean up, and suppository insertion until end clean up = Total bowel care time. RESULTS: The data included two groups of BC sessions: HVB (n = 84) and PGB (n = 81). Mean times in minutes and P values from t tests for paired samples yielded: Time to flatus: (HVB 31, PGB 12.8 P < 0.002), Defecation period: (HVB 58, PGB 32, P < 0.0005), Clean up: (HVB 1.9, PGB 3.2 P = 0.165), Total bowel care time: (HVB 102, PGB 51.2 P < 0.0005). CONCLUSION: This analysis suggests that PGB based bisacodyl suppositories may stimulate reflex defecation sooner and shorten the Total BC Time as compared with HVB bisacodyl suppositories.

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.

Pharmacologically initiated defecation for persons with spinal cord injury: effectiveness of three agents.

OBJECTIVE: To compare the effectiveness of hydrogenated vegetable oil-based bisacodyl (HVB) suppositories, polyethylene glycol-based bisacodyl (PGB) suppositories, and polyethylene glycol-based, glycerine, docusate sodium mini-enemas (TVC) in subjects with upper motor neuron spinal cord lesions. STUDY DESIGN: Prospective randomized double blind. Fifteen subjects received one of 3 HVB and 3 PGB suppositories in randomized sequence for each of six scheduled bowel care sessions. Additionally, 10 subjects received 3 TVC. The analysis used timed events that divided the bowel care sessions into discrete intervals. The analysis also compared digital simulations, incontinence, and quantity of stool. Wilcoxon rank sum tests and paired t tests were used to compare the means of intervals during bowel care initiated by HVB, PGB, and TVC. RESULTS: (means in minutes and p values): Time to Flatus-HVB, 32; PGB, 15; TVC, 15; p < .026, HVB-PGB; p < .983, PGB-TVC; Flatus to Stool Flow-HVB, 6.7; PGB, 5.5; TVC, 3.9; p < .672, HVB-PGB; p < .068, PGB-TVC; Defecation Period-HVB, 36; PGB, 20; TVC, 17; p < .037, HVB-PGB; p < .479, PGB-TVC; Wait Until Transfer-HVB, 10.9; PGB, 10.7; TVC, 7.4; p < .932, HVB-PGB; p < .043, PGB-TVC; Total Time for the bowel program-HVB, 74.5; PGB, 43; TVC, 37; p < .010, HVB-PGB; p < .458, PGB-TVC; percent incidence of incontinence between bowel care sessions-HVB, .067; PGB, .067; TVC, .033; p < 1.0, HVB-PGB; p < .678, PGB-TVC; amount of stool produced-HVB, 3.30; PGB, 3.49; TVC, 3.38; p < .276, HVB-PGB; p < .630, PGB-TVC; average number of digital stimulations per bowel care procedure-HVB, 4.4; PGB, 4.1; TVC, 3.8; p < .411, HVB-PGB; p < .293, PGB-TVC; time per digital stimulation in seconds-HVB, 107; PGB, 40; TVC, 83; p < .149, HVB-PGB; p < .352, PGB-TVC; and the total time, in minutes, spent performing digital stimulations during bowel care-HVB, 10.0; PGB, 2.7; TVC, 5.9; p < .151, HVB-PGB; p < .325, PGB-TVC. CONCLUSION: Bowel care took less time when initiated with the PGB bisacodyl suppository or TVC mini-enema as compared with the HVB bisacodyl suppository (p < .01).

Spinal cord injury rehabilitation. 2. Medical complications.

This self-directed learning module highlights new advances in understanding medical complications of spinal cord injury through the lifespan. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers reasons for transferring patients to specialized spinal cord injury centers once they have been stabilized, and the management of common medical problems, including fever, autonomic dysreflexia, urinary tract infection, acute and chronic abdominal complications, deep vein thrombosis, pulmonary complications, and heterotopic ossification. Formulation of an educational program for prevention of late complications is also discussed, including late renal complications, syringomyelia, myelomalacia, burns, pathologic fractures, pressure ulcers, and cardiovascular disease. New advances covered in this section include new information on old problems, and a discussion of exercise tolerance in persons with tetraplegia, the pathophysiology of late neurologic deterioration after spinal cord injury, and a view of the care of these patients across the lifespan.

Spinal cord injury rehabilitation. 3. Functional outcomes.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article contains information about mobility, ambulation, upper extremity function, bowel management, and technology to enhance function in the community. New advances covered in this section include functional electrical stimulation for enhancing mobility and upper extremity function.