SCIM III (Spinal Cord Independence Measure version III): reliability of assessment by interview and comparison with assessment by observation.

STUDY DESIGN: Psychometric study. OBJECTIVES: The objective of this study was to examine the reliability of the Spinal Cord Independence Measure III (SCIM III) by interview and compare the findings with those of assessment by observation. SETTING: This study was conducted at Loewenstein Rehabilitation Hospital, Israel. METHODS: Thirty-five spinal cord lesion (SCL) patients who underwent rehabilitation at Loewenstein Rehabilitation Hospital in Israel were assessed during the last week before discharge with SCIM III by observation and by interview. Nineteen of the patients were also assessed by interview by a third rater to examine inter-rater reliability. Total agreement, kappa, Bland-Altman plots and intraclass correlation (ICC) were used for comparison between interviewers and between interviews and observations. RESULTS: Total agreement between the interviewers' scores and between interviews and observations was low to moderate (kappa coefficient 0.11-0.80). Bland-Altman analysis revealed good agreement, with low mean difference for almost all SCIM III subscales and total scores, between pairs of interviewers (bias -4.15, limits of agreement -22.51 to 14.19, for total score) and between interviews and observations (bias 1.62, limits of agreement -20.55 to 23.81, for total score). ICC coefficients for the SCIM III subscales and total scores were high (0.637-0.916). CONCLUSION: The findings of this study support the reliability and validity of SCIM III by interview, which appears to be useful for research of SCL patient groups. Individual scoring of SCIM III by interview, however, varied prominently between raters. Therefore, SCIM III by interview should be used with caution for clinical purposes, probably by raters whose scoring deviation, in relation to observation scores, is known.

Coronary artery disease and hypertension in a non-selected spinal cord injury patient population.

STUDY DESIGN: Retrospective observational comparative study. OBJECTIVES: The objectives of this study were to assess the atherosclerosis diseases and risk factors prevalence after spinal cored injury (SCI). SETTING: Loewenstein Rehabilitation Hospital, Israel. METHODS: Data of 154 traumatic and non-traumatic SCI patients were retrospectively collected. Coronary artery disease (CAD), myocardial infarction (MI), hypertension (HT) and risk factors for atherosclerotic diseases were examined after SCI for prevalence and effects, and compared with published corresponding data of the general population. RESULTS: CAD, MI and HT were found in 11.7, 6.7 and 29.2% of 120 patients, aged 53.4±11.1 years, 83.3% males, who survived until the end of the follow-up. Corresponding values for the general population, adjusted for age, gender and years of education, are 8.5, 6.6 and 24.9% in Israel, and 10.2% for CAD and 40.3% for HT, in US. Body mass index>30 increased the odds of acquiring CAD (P=0.016). Hypercholesterolemia and older age at injury increased the hazard for HT (P=0.044; P=0.019, respectively). A steady partner decreased the risk of CAD (P=0.029). HT was more prevalent at T4-T6 than above T4 (52 vs 23.3%, P=0.02). Patients with SCI below T6 had a higher rate of diabetes mellitus, hypercholesterolemia, and past smoking, and fewer years of education than those with SCI above T7 (P=0.016; P=0.032; P=0.034; P=0.014, respectively). CONCLUSION: The prevalence of CAD, HT and some of their risk factors after SCI is generally, but not consistently and not statistically significant, slightly higher than in the corresponding general population. The challenge is to reduce the prevalence of atherosclerotic morbidity after SCI below that in the general population.

Observational study of the effectiveness of spinal cord injury rehabilitation using the Spinal Cord Injury-Ability Realization Measurement Index.

STUDY DESIGN: Retrospective observational study. OBJECTIVES: The objective of this study was to determine the rehabilitation potential and the extent to which it is realized in a cohort of spinal cord injury patients using the Spinal Cord Injury-Ability Realization Measurement Index (SCI-ARMI) and to study the clinical factors that influence this realization. SETTING: Two spinal units in Italy. METHODS: Consecutive patients were assessed at the end of an in-patient rehabilitation program using the Spinal Cord Independence Measure and the International Standards for Neurological Classification of Spinal Cord Injury. On the basis of these data and of the age and gender of the patients, we calculated the SCI-ARMI score. Regression analyses were performed to study the relationship between clinical factors and the extent to which rehabilitation potential is realized. RESULTS: We examined the data for 306 patients. Most patients were discharged without having reached their rehabilitation potential, with an SCI-ARMI score <80%. SCI-ARMI scores at discharge were positively influenced by etiology and the lesion level and correlated negatively with lesion severity and the presence of complications during rehabilitation. CONCLUSION: The SCI-ARMI is an effective tool that can be used to measure the achievement of rehabilitation potential in SCI patients and to identify groups of patients who are at risk of not meeting their rehabilitative potential.

Development of the International Spinal Cord Injury Activities and Participation Basic Data Set.

STUDY DESIGN: Consensus decision-making process. OBJECTIVES: The objective of this study was to develop an International Spinal Cord Injury (SCI) Activities and Participation (A&P) Basic Data Set. SETTING: International working group. METHODS: A committee of experts was established to select and define A&P data elements to be included in this data set. A draft data set was developed and posted on the International Spinal Cord Society (ISCoS) and American Spinal Injury Association websites and was also disseminated among appropriate organizations for review. Suggested revisions were considered, and a final version of the A&P Data Set was completed. RESULTS: Consensus was reached to define A&P and to incorporate both performance and satisfaction ratings. Items that were considered core to each A&P domain were selected from two existing questionnaires. Four items measuring activities were selected from the Spinal Cord Independence Measure III to provide basic data on task execution in activities of daily living. Eight items were selected from the Craig Handicap Assessment and Reporting Technique to provide basic data on the frequency of participation. An additional rating of satisfaction on a three-point scale for each item completes the total of 24 A&P variables. CONCLUSION: Collection of the International SCI A&P Basic Data Set variables in all future research on SCI outcomes is advised to facilitate comparison of results across published studies from around the world. Additional standardised instruments to assess activities of daily living or participation can be administered, depending on the purpose of a particular study.

Development and validation of a self-report version of the Spinal Cord Independence Measure (SCIM III).

STUDY DESIGN: Cross-sectional validation study. OBJECTIVES: To develop and validate a self-report version of the Spinal Cord Independence Measure (SCIM III). SETTING: Two SCI rehabilitation facilities in Switzerland. METHODS: SCIM III comprises 19 questions on daily tasks with a total score between 0 and 100 and subscales for 'self-care', 'respiration & sphincter management' and 'mobility'. A self-report version (SCIM-SR) was developed by expert discussions and pretests in individuals with spinal cord injury (SCI) using a German translation. A convenience sample of 99 inpatients with SCI was recruited. SCIM-SR data were analyzed together with SCIM III data obtained from attending health professionals. RESULTS: High correlations between SCIM III and SCIM-SR were observed. Pearson's r for the total score was 0.87 (95% confidence interval (CI) 0.82-0.91), for the subscales self-care 0.87 (0.81-0.91); respiration & sphincter management 0.81 (0.73-0.87); and mobility 0.87 (0.82-0.91). Intraclass correlations were: total score 0.90 (95% CI 0.85-0.93); self-care 0.86 (0.79-0.90); respiration & sphincter management 0.80 (0.71-0.86); and mobility 0.83 (0.76-0.89). Bland-Altman plots showed that patients rated their functioning higher than professionals, in particular for mobility. The mean difference between SCIM-SR and SCIM III for the total score was 5.14 (point estimate 95% CI 2.95-7.34), self-care 0.89 (0.19-1.59), respiration & sphincter management 1.05 (0.18-2.28 ) and mobility 3.49 (2.44-4.54). Particularly patients readmitted because of pressure sores rated their independence higher than attending professionals. CONCLUSION: Our results support the criterion validity of SCIM-SR. The self-report version may facilitate long-term evaluations of independence in persons with SCI in their home situation.

Quality of life after spinal cord injury: a comparison across six countries.

STUDY DESIGN: An international cross-sectional study. OBJECTIVE: To examine the quality of life (QoL) of people with spinal cord injury (SCI) across six countries worldwide, controlling for socio-demographic and lesion-related sample characteristics and using a cross-culturally valid assessment. METHODS: Data from 243 persons with SCI from Australia, Brazil, Canada, Israel, South Africa and the United States were analyzed. QoL was measured using five satisfaction items from the World Health Organization Quality of Life Assessment. Cross-culturally valid, Rasch-transformed scores were used for comparison. RESULTS: Analysis of variance showed a significant difference in QoL between countries (F=3.938; df=5; P=0.002). Shorter time since injury, no paid employment and living in Brazil were significant predictors of lower QoL, explaining 13% of variance in linear regression. Using multilevel regression with country as higher-order variable, time since injury and paid employment remained significant predictors and explained 18% of variance in QoL. The intraclass correlation coefficient (0.05) indicates that 5% of the variability can be accounted for by country. CONCLUSION: This study showed QoL differences between countries that could not be explained by differences in demographic and lesion-related characteristics. Results point to the relevance of reintegration of people with SCI into the workforce. Further international comparative research using larger samples is recommended.

International Spinal Cord Injury Quality of Life Basic Data Set.

STUDY DESIGN: Survey of expert opinion, feedback, and development of final consensus. OBJECTIVE: Present the background, purpose, development process and results for the International Spinal Cord Injury (SCI) Quality of Life (QoL) Basic Data Set. SETTING: International. METHODS: A committee of experts was established to select and define data elements to be included in an International SCI QoL Basic Data Set. A draft data set was developed and disseminated to appropriate organizations for comment. All suggested revisions were considered, and a final version of the QoL data set was completed. RESULTS: The QoL data set consists of 3 variables: ratings of satisfaction with general quality of life, satisfaction with physical health, and satisfaction with psychological health. All variables are rated on a scale ranging from 0 (completely dissatisfied) to 10 (completely satisfied). CONCLUSION: Collection of the International SCI QoL Basic Data Set variables should be a part of all future studies of SCI QoL to facilitate comparison of results across published studies from around the world. Additional standardized instruments to assess other aspects of QoL can be administered based on the purpose of a particular study.

Non-linear formulas for the spinal cord injury ability realization measurement index.

STUDY DESIGN: The spinal cord injury ability realization measurement index (SCI-ARMI) assesses rehabilitation potential and efficacy based on the linear relationship between the Spinal Cord Independence Measure (SCIM) and the American Spinal Injury Association impairment scale (AIS) motor scores (AMS). OBJECTIVES: The objective of this study is to develop new SCI-ARMI formulas using a more flexible approach that is less sensitive to the distribution of the AMS score among spinal cord lesion (SCL) patients. SETTING: Loewenstein Rehabilitation Hospital, Raanana, and the Statistical Laboratory, School of Mathematics, Faculty of Exact Sciences, Tel-Aviv University, Israel. METHODS: SCIM III and AMS of 226 Israeli SCL patients were monitored. Linear formulas, quadratic formulas and non-parametric formulas were estimated to express the relationship between the 95th percentile of the SCIM III values for patients with given AMS at discharge from rehabilitation (SCIM95) and the corresponding AMS value. This relationship was used to calculate SCI-ARMI values, defined as the ratio of the observed SCIM score and the respective SCIM95 for a given patient's AMS score. RESULTS: The estimated quadratic formula for the relationship between the 95th percentile of the SCIM III and the AMS score was found to be most appropriate, and formulas are provided for SCIM95 calculation in the various areas of function. The use of these formulas to calculate SCI-ARMI values is presented. CONCLUSION: The new formulas improve the accuracy of calculated ability realization for any AMS. The new statistical procedure will be used for the upcoming data analysis of a larger-scale international SCI-ARMI study.

A new grading for easy and concise description of functional status after spinal cord lesions.

BACKGROUND: Disability scales do not enable the transmission of concise, meaningful and daily function description for clinical purposes. STUDY DESIGN: Cross-sectional statistical analysis of 328 patients' Spinal Cord Independence Measure (SCIM) III item scores (SIS). OBJECTIVE: To develop a concise and clinically interpretable data-based characterization of daily task accomplishment for patients with spinal cord lesions (SCLs). SETTING: Multi-center study at 13 spinal units in 6 countries. METHODS: Patients were grouped into clusters characterized by smaller differences between the patients' SIS within the clusters than between their centers, using the k-medoides algorithm. The number of clusters (k) was chosen according to the percent of SIS variation they explained and the clinical distinction between them. RESULTS: Analysis showed that k=8 SIS clusters offer a good description of the patient population. The eight functional clusters were designated as A-H, each cluster (grade) representing a combination of task accomplishments. Higher grades were usually (but not always) associated with patients implementing more difficult tasks. Throughout rehabilitation, the patients' functional grade improved and the distribution of patients with similar functional grades within the total SCIM III score deciles remained stable. CONCLUSIONS: A new classification based on SIS clusters enables a concise description of overall functioning and task accomplishment distribution in patients with SCL. A software tool is used to identify the patients' functional grade. Findings support the stability and utility of the grades for characterizing the patients' functional status.

Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions.

STUDY DESIGN: Multicenter international cohort study. OBJECTIVE: The objective of this study was to establish target values for Spinal Cord Independence Measure (SCIM) III scoring in rehabilitation for clinically complete spinal cord lesion (SCL) neurological levels. SETTING: In total, 13 spinal cord units in six countries from North America, Europe and the Middle East were taken. METHODS: Total SCIM III scores and gain at discharge from rehabilitation were calculated for SCL levels in 128 patients with American Spinal Injury Association Impairment Scale (AIS) grade A on admission to rehabilitation. RESULTS: Median, quartiles, mean and s.d., values of discharge SCIM III scores and SCIM III gain for the various SCL levels are presented. Total SCIM III scores and gain were significantly correlated with the SCL level (r=0.730, r=0.579, P<0.001). CONCLUSIONS: Calculated discharge SCIM III scores can be used as target values for functional achievements at various neurological levels in patients after AIS A SCL. They are generally, but not always, inversely correlated with SCL level.

SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions.

STUDY DESIGN: A multi-center international cohort study. OBJECTIVE: To evaluate the reliability and validity of the third version of the Spinal Cord Independence Measure (SCIM III), separately for patients with traumatic spinal cord lesions (SCLs). SETTING: A total of 13 spinal cord units in six countries from North America, Europe and the Middle-East. METHODS: SCIM III and Functional Independence Measure (FIM) were assessed for 261 patients with traumatic SCLs, on admission to rehabilitation and before discharge, by two raters. Conventional statistical measures were used to evaluate the SCIM III reliability and validity. RESULTS: In almost all SCIM III tasks, the total agreement between the paired raters was >80%. The κ coefficients were all >0.6 and statistically significant. Pearson's coefficients of the correlations between the paired raters were >0.9, the mean differences between raters were nonsignificant and the intraclass correlation coefficients (ICCs) were ≥ 0.95. Cronbach's α values for the entire SCIM III scale were 0.833-0.835. FIM and SCIM III total scores were correlated (r=0.84, P<0.001). SCIM III was more responsive to changes than FIM. In all subscales, SCIM III identified more changes in function than FIM, and in 3 of the 4 subscales, differences in responsiveness were statistically significant (P<0.02). CONCLUSION: The results confirm the reliability and validity of SCIM III for patients with traumatic SCLs in a number of countries.

Hemodynamic responses to head-up tilt after spinal cord injury support a role for the mid-thoracic spinal cord in cardiovascular regulation.

BACKGROUND: Data showing a role for the mid-thoracic spinal cord (SC) in the control of hemodynamic changes is scarce despite existing evidence for its involvement in autonomic regulation. STUDY DESIGN: On the basis of the open label prospective series comparing three groups. OBJECTIVE: To determine whether the mid-thoracic SC has a role in hemodynamic regulation during head-up tilt (HUT). SETTING: Spinal Research Laboratory, Loewenstein Rehabilitation Hospital. METHODS: A total of 13 healthy control subjects, 10 patients with T(4)-T(6) paraplegia and 11 with C(4)-C(7) tetraplegia were examined during supine rest and during HUT. Heart rate (HR), blood pressure (BP), HR spectral components (lower frequency fluctuation (LF), higher frequency fluctuations (HF) and LF/HF) and cerebral blood flow velocity (CBFV) were continuously measured or calculated. RESULTS: BP response to HUT differed among these groups (P<0.02). During HUT, BP decreased markedly in the tetraplegia group (from a mean value of 81.65 to 67.69 mm Hg), and increased in the control groups (from 92.89 to 95.44 mm Hg) and in the T(4)-T(6) paraplegia group (from 96.24 to 97.86 mm Hg). Significant correlation was found in the control and tetraplegia groups between increases in HR LF/HF and HR at HUT (r>0.7; P<0.01). No such correlation was found in the paraplegia group. HUT effect on HR and CBFV was significant in all groups (P<0.001), but group differences were statistically non-significant. CONCLUSION: Findings were generally compatible with those of comparable previously published studies, but they also support a role for the mid-thoracic SC in hemodynamic regulation, which should be considered in clinical setting and in research.

Insulin resistance in tetraplegia but not in mid-thoracic paraplegia: is the mid-thoracic spinal cord involved in glucose regulation?

STUDY DESIGN: Controlled experimental human study. OBJECTIVES: To assess insulin resistance (IR) in tetraplegia and paraplegia, and the role of the spinal cord (SC) in glucose regulation. SETTING: Laboratory of Spinal Research, Loewenstein Rehabilitation Hospital. METHODS: Glucose and insulin levels and the heart rate variation spectral components LF (low frequency), HF (high frequency) and LF/HF were studied at supine rest, head-up tilt and after a standard meal in three groups: 13 healthy subjects, 7 patients with T(4)-T(6) paraplegia and 11 patients with C(4)-C(7) tetraplegia. RESULTS: Glucose and insulin increased significantly after the meal in all groups (P<0.001). Glucose increased significantly more in the tetraplegia than in the other groups (P<0.01). Increases in insulin level tended to accompany increases in LF/HF after the meal in the tetraplegia and control groups but not in the paraplegia group. CONCLUSION: Post-prandial IR appears in C(4)-C(7) but not in T(4)-T(6) SC injury. The results of the study, combined with previously published findings, are consistent with the hypotheses that IR is related to activation of the sympathetic nervous system, and that below T(4) the mid-thoracic SC is involved in the regulation of glucose and insulin levels.

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.

Properties and outcomes of spinal rehabilitation units in four countries.

OBJECTIVE: Compare rehabilitation after spinal cord lesions (SCL) in different countries. DESIGN: Multicenter comparative study. SETTING: Four spinal rehabilitation units, in Denmark, Russia, Lithuania and Israel. SUBJECTS: 199 SCL patients. INTERVENTIONS: Information was collected about unit properties, rehabilitation objectives, American Spinal Injury Association (ASIA) scale and spinal cord independence measure (SCIM) assessments, and patient data. chi (2)-test, t-test, ANOVA and ANCOVA were used for statistical analysis. MAIN OUTCOME MEASURES: Time from lesion onset to admission for rehabilitation (TAR), length of stay in rehabilitation (LOS), SCIM and spinal cord ability realization measurement index (SCI-ARMI) scores, SCIM gain, SCI-ARMI gain and rehabilitation efficiency (RE). RESULTS: Differences were found between the units in rehabilitation objectives, facilities and special equipment for rehabilitation. Staff/bed ratio was 1.7 in Lithuania and Denmark, 1.1 in Israel and 0.9 in Russia. Russian patients were the youngest and had the most severe lesions among participating units. Admission SCIM and SCI-ARMI were the lowest in Israel: 25.1+/-17.2 and 34.3+/-17.3. TAR was highest in Russia (12.4 month) and lowest in Israel (2 weeks; P<0.01). LOS was longest in Denmark (176.9 days; P<0.001). SCIM score at the end of rehabilitation was highest in Denmark (67.3+/-23). SCIM gain and SCI ARMI gain were highest in Israel (36.9+/-18.3 and 38.5+/-19.4, respectively) and lowest in Russia (P<0.001). RE was highest in Lithuania and lowest in Denmark (P<0.001). CONCLUSIONS: In the participating units, SCL rehabilitation outcomes depend on SCL severity and unit-specific properties. A moderately delayed rehabilitation with long LOS achieved high functioning, and early or slightly delayed rehabilitation combined with shorter LOS achieved high functional gain or efficiency.

Survival, neurological recovery and morbidity after spinal cord injuries following road accidents in Israel.

DESIGN: A retrospective cohort study. OBJECTIVE: Assess outcomes in patients with spinal cord injuries (SCI) following road accidents, and factors that affect them. SETTING: Loewenstein Rehabilitation Hospital, Raanana, Israel. SUBJECTS: A total of 143 patients admitted for rehabilitation between 1962 and 2004. METHODS: Survival rates were estimated using the product limit (Kaplan-Meyer) method and their association with risk factors was analyzed with the Cox model. Neurological recovery was determined by comparing the Frankel grade at admission to rehabilitation and at discharge. The relation between recovery and various factors was tested with logistic regression. RESULTS: The risk of SCI in road accidents is higher among car drivers and motorcycle or bicycle riders. Median survival was 43 years. Survival was negatively associated with age at injury (P<0.0002) and with diagnosis of pressure sores (P=0.0065). Recovery of at least one Frankel grade occurred in 29.1% of patients. Useful recovery (upgrade to Frankel grade D or E) occurred in 23.1% of all patients. Neurological recovery was negatively associated with the severity of neurological deficit (P<0.001) and with thoracic injuries (P=0.046). The most common complications were pressure sores and those of the urinary and respiratory systems. CONCLUSIONS: In SCI following road accidents, survival rates were higher and recovery rates lower than in mixed types of trauma. This may be related to better compensation followed by better nursing for road accident victims in Israel, which may prevent life-shortening complications, and to more severe injuries caused by road accidents.

Cold pressor test in tetraplegia and paraplegia suggests an independent role of the thoracic spinal cord in the hemodynamic responses to cold.

BACKGROUND: Cold application to the hand (CAH) is associated in healthy people with increase in heart rate (HR) and blood pressure (BP). OBJECTIVE: To study hemodynamic responses to CAH in humans following spinal cord injuries of various levels, and examine the effect of spinal cord integrity on the cold pressor response. DESIGN: An experimental controlled study. SETTING: The spinal research laboratory, Loewenstein Hospital, Raanana, Israel. SUBJECTS: Thirteen healthy subjects, 10 patients with traumatic T(4-6) paraplegia and 11 patients with traumatic C(4-7) tetraplegia. MAIN OUTCOME MEASURES: HR, BP, HR and BP spectral components (low frequency, LF; high frequency, HF; LF/HF), cerebral blood flow velocity (CBFV) and cerebrovascular resistance index (CVRi). METHODS: The outcome measures of the three subject groups monitored for HR, BP and CBFV were compared from 5 min before to 5 min after 40-150 s of CAH. The recorded signals were digitized online and analyzed offline in both the time and frequency domains. RESULTS: During CAH, HR and CVRi increased significantly in all subject groups (P<0.001), and BP in control subjects and in the tetraplegia group (P<0.01). BP increase was not statistically significant in paraplegia, and CBFV, HR LF, HR HF and BP LF did not change significantly during CAH in any group. CONCLUSIONS: The CAH effect in tetraplegia and the suppressed BP increase in paraplegia, supported by the other findings, suggest a contribution of an independent thoracic spinal mechanism to the cold pressor response.

Modified cold pressor test by cold application to the foot after spinal cord injury: suggestion of hemodynamic control by the spinal cord.

OBJECTIVE: Study hemodynamic responses to cold application to the foot (CAF) to explore the autonomic cardiovascular control by the spinal cord. DESIGN: Controlled experimental study. Hemodynamic variables were measured or calculated for 13 healthy subjects, 10 patients with traumatic T4-T6 paraplegia, and 11 patients with traumatic C4-C7 tetraplegia. Subjects were continuously monitored for heart rate (HR), blood pressure (BP), and cerebral blood-flow velocity (CBFV) from 5 mins before to 5 mins after 40-120 secs of CAF by ice water foot immersion. The recorded signals were digitized online and analyzed offline in the time and frequency domains. RESULTS: During CAF, HR increased in the control group but decreased in patients (P < 0.001). BP increased significantly in the control and tetraplegia groups (P < 0.001) and nonsignificantly in the paraplegia group. HR and BP spectral components (LF, HF, LF/HF) did not change significantly. CBFV increased significantly in the patient groups (P < 0.05) but not in the control subjects. The cerebrovascular resistance increased significantly in the control and tetraplegia groups (P < 0.001), but not in the paraplegia group. CONCLUSIONS: The findings support the presence of hemodynamic autonomic control by the spinal cord and show that responses to CAF can be used to assess its integrity.

The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study.

PURPOSE: To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in a multi-center cohort study. METHOD: Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries from three continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission to rehabilitation and before discharge. RESULTS: Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statistically significant (P<0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclass correlation coefficients were above 0.94. Cronbach's alpha was above 0.7. The coefficient of Pearson correlation between FIM and SCIM III was 0.790 (P<0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration and sphincter management and Mobility indoors and outdoors. CONCLUSIONS: The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitations of the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can be safely used for clinical and research trials, including international multi-center studies.

Repeated botulinum toxin injections can improve mobility in patients with spinal cord lesions.

AIM: The aim of this study was to increase the knowledge about the response to botulinum toxin (BTX) injections to spastic leg muscle motor points (MP) in spinal cord lesion (SCL) patients, and describe improvement of mobility with repeated BTX injections. METHODS: Six patients with ASIA grade C or D SCL were studied at the Loewenstein Rehabilitation Center, Israel. The main outcome measures were: modified Ashworth scale scores, range of motion (ROM), and mobility spinal cord independence measure (SCIM) scores. BTX was injected twice within a few weeks' interval to the MP of spastic leg muscles. The outcome measures were monitored before each injection and 2 weeks or more after the second injection. RESULTS: Following the first BTX injection the tonus decreased, ROM increased in all 6 patients, and mo- bility functioning improved in 4 of them. Following the repeated injection the tonus further decrea- sed, ROM further improved in 5 of 6 patients, and mobility functions further improved in 4 of 6 patients. CONCLUSION: BTX can improve mobility in patients with SCL. Repeated injections may enhance the effect despite the concern for resistance formation. Further research is needed to support the findings and determine the optimal BTX doses and intervals between injections.