The course of fatigue after acute spinal cord injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To determine the prevalence and course of fatigue following acute spinal cord injury (SCI) during rehabilitation and after discharge. SETTING: Tertiary spinal cord rehabilitation facility. METHODS: Fifty-two patients with traumatic SCI were assessed after admission to rehabilitation and followed until 6-months post discharge into the community. Fatigue was measured using the Fatigue Severity Scale (FSS) and the Modified Fatigue Impact Scale for Spinal Cord Injury (MFIS-SCI) at admission, discharge and 6 months after discharge. Clinically significant fatigue was defined as FSS scores ⩾4 or MFIS-SCI scores ⩾24.5. RESULTS: The mean (s.d.) age of our mainly male (78.8%) sample was 46.3 (17.8) years of age. Half had cervical and 61.6% had complete injuries. Mean (s.d.) FSS scores were 3.7 (1.6) at baseline, 3.4 (1.5) at discharge and 3.7 (1.7) post discharge. Mean (s.d.) MFIS-SCI scores were 24.4 (16.1) at baseline, 23.4 (16.3) at discharge and 27.8 (17.5) post discharge. Fatigue on the FSS was present in 51.9% at baseline, 38.3% at discharge and 48.1% post discharge. Fatigue on the MFIS-SCI was present in 44.2% at baseline, 44.7% at discharge and 51.9% post discharge. There was no relationship between fatigue and injury level or completeness. CONCLUSIONS: Fatigue is common in SCI patients admitted to rehabilitation. Fatigue remained stable during rehabilitation and after discharge into the community. Clinicians should consider early screening for fatigue and interventions to reduce the consequences of fatigue in people with SCI. SPONSORSHIP: The British Columbia Medical Services Foundation funded our study.

The relationship between fatigue and participation in spinal cord injury.

STUDY DESIGN: Cross-sectional national survey. OBJECTIVES: To explore the association between fatigue and community participation frequency and provide an adjusted model of the relationship including important covariates. SETTING: Canada; Community. METHODS: Data were obtained from the Rick Hansen Spinal Cord Injury Registry Community Survey. We used multi-variable regression analyses with hierarchical backward elimination, including variable specification, interaction assessment and confounding assessment. Variables with statistically significant correlation with the primary-dependent variable (participation) were included for modeling. RESULTS: The crude model of association between fatigue and participation accounted for 7.2% of the variance in participation scores. The full model with all a priori selected variables accounted for 25.1% of variance in participation scores. The adjusted model, including the identified confounders (pain, depressive mood, comorbidities and level of injury), accounted for 21.1% of variance in participation scores. Depressive mood variables had the highest standardized beta coefficients, reflecting the largest contribution to this model. CONCLUSION: Fatigue has a statistically significant negative association with participation for individuals with spinal cord injury, when controlling for pain, depressive mood, comorbidities and level of injury. Multifaceted clinical interventions and research addressing fatigue, pain and depressive symptoms are warranted.

Measurement properties of a telephone version of the Modified Fatigue Impact Scale among individuals with a traumatic spinal cord injury.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To validate a telephone-administered version of the Modified Fatigue Impact Scale spinal cord injury scores among individuals with a traumatic SCI 6 months post discharge from rehabilitation. SETTING: GF Strong Rehabilitation Center in Vancouver, British Columbia, Canada. METHODS: Data from 42 participants who were ≥19-years-old with a confirmed American Spinal Injury Association Impairment Scale classification of A, B, C or D resulting from a traumatic SCI, and 6 months post discharge from rehabilitation were analyzed. The internal consistency was ascertained using Cronbach's alpha. Support for validity was provided by conducting correlations between the 21-item MFIS-SCI and Fatigue Severity Scale curve was constructed. Sensitivity, specificity and likelihood ratios were calculated to assess the diagnostic accuracy. RESULTS: Cronbach's alpha was 0.97. Correlations between the MFIS-SCI and FSS were in the a priori hypothesized direction and magnitude. The area under the ROC curve was 0.78 (95% confidence interval=0.65-0.92). At the optimal cutoff score of 24.5, both the sensitivity and specificity were 0.67. The positive and negative likelihood ratios were 2.03 and 0.49, respectively. CONCLUSION: There is support for the validity of the MFIS-SCI scores and it should be considered for the comprehensive measurement of the impact of fatigue in persons with a traumatic SCI.

Medication use is associated with fatigue in a sample of community-living individuals who have a spinal cord injury: a chart review.

OBJECTIVES: To investigate the relationship between medications known to cause fatigue in spinal cord injury (SCI) and fatigue severity and to describe the pattern of prescription of these medications. STUDY DESIGN: Retrospective chart review. SETTING: GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada. METHODS: Medical charts of 136 individuals admitted to the GF Strong Outpatient SCI Program between December 2004 and May 2007 were reviewed. Data collected included information on medications, clinical and demographic characteristics and Fatigue Severity Scale (FSS) scores. Multiple linear regression techniques were used to analyse the data. RESULTS: Fifty-two percent of the subjects had clinically relevant fatigue. As a group, the subjects were taking 147 different medications; 41/147 medications were identified as causing fatigue. The two most commonly prescribed categories of medications were antispasticity medications (75 subjects) and analgesic medications (61 subjects). Although several variables were found to contribute to the FSS scores including the use of fatigue-causing medications, the presence of pain (7.6% of variance) and the use of fatigue-causing analgesics (4.2% of variance) explained the most variance in the scores. CONCLUSION: Fatigue is prevalent in outpatients with SCI. Fatigue-causing medications contribute to a higher FSS score. Clinicians treating persons with SCI should be aware that fatigue is a common and significant problem. Clinicians should be aware that fatigue may be exacerbated by the use of medication and should enquire about the effects of medication on fatigue when assessing and prescribing new medications.

Measurement properties of the CESD scale among individuals with spinal cord injury.

BACKGROUND: Depression is common after spinal cord injury (SCI), yet it can be difficult and costly to diagnose. Screening tools such as the Center for Epidemiological Studies Depression scale (CESD) can assist with case identification; however, insufficient knowledge of their measurement properties exists to use them in the SCI population. OBJECTIVES: To assess the reliability and validity of the CESD-20 and the CESD-10. SETTING: Tertiary care centre in Vancouver, British Columbia, Canada. METHODS: A 2-week retest study of 47 individuals with traumatic SCI. Subjects >or=19, who had their SCI for >or=1 year and had American Spinal Injury Association Impairment scale ranking of A or B. Short Form-36 (SF-36) subscales and a visual analogue scale for fatigue (VAS-F) were used to assess validity using Pearson's correlations coefficients. Internal consistency was assessed using Cronbach's alpha, retest reliability was assessed using intraclass correlation coefficients (ICCs) and Bland-Altman plots. Normative data are presented based on key demographic and clinical factors. RESULTS: Cronbach's alpha was 0.91 and 0.86 and retest reliability was ICC=0.87 (95% confidence interval (CI) 0.79-0.93) and ICC=0.85 (95% CI 0.75-0.92) for the CESD-20 and CESD-10, respectively. Minimal bias was evident based on the Bland-Altman plots. The strongest correlations were with outcomes representing mental health (r=-0.71), vitality (r=-0.60) and the VAS-F (r=0.57). The weakest correlation was with the physical function score of the SF-36 (r=-0.37). CONCLUSION: The CESD-20 and CESD-10 are quick and easy to use. This study provides evidence in support of the reliability and validity.

Clinical correlates of fatigue in spinal cord injury.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To determine the prevalence of fatigue in an outpatient spinal cord injury population and to examine the clinical variables contributing to that fatigue. SETTING: GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada. METHODS: Medical charts of 76 individuals admitted to the GF Strong Outpatient SCI Program between December 2004 and December 2005 were reviewed. Data collected included information on clinical characteristics, demographics and Fatigue Severity Scale (FSS) scores. Multivariable analysis was completed to determine the independent association between these variables and fatigue severity. RESULTS: A total of 57% (95% confidence interval (CI)=45-67%) of the sample were found to have fatigue severe enough to interfere with function. People that were admitted for medical reasons; had pain, spasticity, incomplete injuries, and/or were on more that one medication with a known side effect of fatigue had significantly higher FSS scores. Multivariable analysis indicated incomplete injury was the only statistically significant predictor of a higher FSS scores; pain approached significance (P=0.07, CI=-0.09, 2.06). Together these variables account for 18% of the variance in FSS scores in this sample. CONCLUSION: Fatigue among individuals with spinal cord injury who are seeking outpatient rehabilitation is very common. The severity of fatigue was greater for individuals with incomplete lesions. Pain was also a potentially important covariate of fatigue. Further research is required to determine what else contributes to fatigue severity beyond these clinical variables as only minimal variance was accounted for in our model.

Clinical utility of a portable ultrasound device in intermittent catheterization.

OBJECTIVE: To evaluate the clinical utility of a new portable ultrasound device (PUD) in the management of intermittent catheter programs in patients with neuropathic bladder. DESIGN: Intervention study using randomized control trial. SETTING: Tertiary care center providing inpatient and ambulatory rehabilitation services to persons with neurologic disabilities. PARTICIPANTS: Thirty-eight inpatients and outpatients with neuropathic bladders requiring intermittent catheterization. MAIN OUTCOME MEASURES: Mean frequency of intermittent catheterization, mean number of episodes of overdistension, and patient satisfaction as measured with a Patient Satisfaction Questionnaire. RESULTS: The mean frequency of catheterization per day was reduced in the PUD group in comparison with controls (2.99 vs 4.12, p = .026). The number of episodes of overdistension was also reduced in the PUD group but did not reach statistical significance (12.45 vs 14.76, p = .61). Subjects generally expressed satisfaction with the PUD, with 16 of 18 patients at least somewhat satisfied with the device. CONCLUSION: The PUD is a useful tool for clinicians in patients undergoing intermittent catheterization programs that can reduce the number of required catheters. It is associated with a high degree of patient satisfaction.

The performance of a limited set of items from the Functional Independence Measure for use in acute trauma care and rehabilitation.

OBJECTIVE: To evaluate the performance of a limited set of three items from the Functional Independence Measure--eating, walking, and expression--(henceforth referred to as the Set) for use in acute trauma care and rehabilitation. DESIGN: Retrospective comparison of the Set-scores (3-item total) to the Functional Independence Measure (FIM) scores in 83 consecutive patients with a primary diagnosis related to trauma (90% of those eligible) over a 2-year period, on an acute rehabilitation unit in a tertiary care university hospital. METHODS: The age distributions of gender and diagnostic categories were examined. The sensitivity and specificity of the Set-score in detecting changes in the FIM were evaluated across a range of cut-off values. Correlation between FIM scores and Set-scores at admission, at discharge, and for interval change were assessed using the intraclass correlation coefficient. Sources of the Set's weaknesses were explored. RESULTS: Age distribution reflects the predisposition of older women to hip fractures and males to the other trauma. No degree of change in the Set-score provided a combination of sensitivity and specificity satisfactory for detecting potentially important changes in the FIM. Intraclass Correlation Coefficients (ICC) for Set-scores and FIM scores on admission and discharge were both .12. The ICC for the interval change data was .11. (95% confidence limits:--.11 to .34). CONCLUSION: This Set is not a useful measure of functional disability in a heterogeneous population of trauma patients.

Cerebrospinal fluid cell count following spinal cord injury.

Cerebrospinal fluid (CSF) changes after spinal cord injury (SCI) were evaulated by retrospective analysis of all patients admitted to the Acute Spinal Cord Injury Unit (ASCIU) at University Hospital, Shaughnessy Site in Vancouver, British Columbia. A total of 1,917 admissions occurred during the 10-year study period with 1,151 due to acute trauma. The charts of all patients with SCI due to trauma were reviewed to identify patients in whom a CSF puncture was performed for any reason. Traumatic SCI is associated with elevations in the corrected white blood cell count (cWBC) that we believe reflect an inflammatory response to injury. The elevation in cWBC is greatest in the first week after injury. Elevations in cWBC more than 1 week after injury do occur but are uncommon. The white cell differential count consists primarily of lymphocytes and polymorphonucleocytes. Three weeks after injury cell counts should be normal. Protein levels are elevated after trauma and should not be used to assess the presence of infection. LP should be part of the septic workup of SCI patients just as it would be for any other population if meningitis is a consideration.

Frozen shoulder.

The frozen shoulder is a common cause of shoulder pain and disability. Most patients slowly improve over 12 to 24 months. Some have prolonged loss of movement, pain, and associated disability. Treatments include physiotherapy, corticosteroid injections, and manipulation. Clinical trials of these treatments have produced conflicting results.

Anemia after traumatic spinal cord injury.

The incidence and natural history of anemia in patients with spinal cord injuries (SCI) were investigated in a prospective study of 68 patients consecutively admitted to a regional acute SCI unit. Fifty had SCI and 18 had spine injuries (SI) without neurologic deficit. Thirty-six of 41 males (88%) and six of nine females (67%) with SCI were anemic on at least one occasion. In the first two weeks after injury, in females and in males, there was no significant difference in mean hemoglobin level between SI and SCI patients. At six weeks, no male with SI was anemic, and males with SCI had significantly lower mean hemoglobin levels than those with SI (121.6 g/L vs 145.4 g/L, p less than .001). Identified early causes of anemia were blood loss due to bony soft tissue or visceral injury, gastrointestinal bleeding, and surgery. In the postacute phase (more than six weeks after injury), anemia occurred in 25 of 41 male and three of nine female SCI patients, and its occurrence was associated with the presence of an identified chronic disease, especially urinary tract infection.

Visual neglect and extinction: a new test.

A new computerized test for visual neglect and extinction was developed and evaluated by testing twenty-five patients with right-hemisphere cerebrovascular accidents. The test consisted of a series of unilateral or bilateral lights on a semicircular array to which the subject responded by pushing a button. A computer controlled the sequence of stimuli and stored the responses. Results of the computer test were compared to conventional occupational therapy and beside clinical tests. Extinction was present in 16 subjects on the computerized test, and in 11 on the clinical test. Neglect was present in 13 subjects on the computerized test, in seven subjects on the occupational therapy test, and in five subjects on the clinical test. The computerized test was more sensitive than the other tests. On both computerized and clinical testing, all subjects with left-sided neglect also had left-sided extinction, but not all subjects with extinction had neglect. Neglect may represent a more severe manifestation of an underlying perceptual defect that produces both neglect and extinction.

Posttraumatic syringomyelia: the British Columbia experience.

Posttraumatic syringomyelia is an uncommon late complication of spinal cord injury. This study identified nine patients with posttraumatic syringomyelia and examined initial presentation, neurologic status, ability to perform functional activities, and results of treatment. Pain and numbness were the most common presenting symptoms. Motor impairment occurred later but was more disabling. Functional abilities depended mainly on the level of the original spinal cord injury. Three patients were managed conservatively and have had no significant progression of their neurologic deficit. Six patients were managed with syringoperitoneal or syringosubarachnoid shunts. Pain improved most consistently after surgery. Motor power improved less and sensation least. Ability to perform activities of daily living did not significantly change after surgery. Posttraumatic syringomyelia remains a difficult therapeutic problem in the spinal cord-injured population.