Correlation among lesion level, muscle strength and hand function in cervical spinal cord injury.

BACKGROUND: Few epidemiological data are available regarding distribution of cervical spinal cord injury with respect to level of lesion and the relationship between the neurological level of lesion and residual hand function. Such data are important to evaluate the relevance of innovative therapeutic approaches, and to plan prospective clinical trials. AIM: To examine the frequency distribution of neurological level of lesion and to investigate the correlation among level, active muscles in the arm and the relation to hand function. DESIGN: Cross-sectional study. SETTING: Two spinal units in the Lombardy region of Italy. POPULATION: Patients with cervical spinal cord lesion. METHODS: Consecutive records, taken from an 8-year interval of admission to either spinal unit, of patients with a cervical spinal cord lesion were examined, and individuals with a C5 to C7 neurological level of lesion were called in for clinical examination. The arm muscles were evaluated according to the International Classification for Surgery of the Hand in Tetraplegia (ICSHT), and hand function was tested with the Action Research Arm Test (ARAT). A correlation analysis was made of the ICSHT, ARAT and neurological level of lesion. RESULTS: In 253 clinical records we found the most frequent lesions to be C5 (21%), C6 (31%) and C7 (21%); 76 of these patients were enrolled for a clinical evaluation. Both ICSHT (Spearmans' rho=0.6; P<0.001) and ARAT (rho=0.2; P<0.05) were poorly correlated with the neurological level of lesion. ARAT was also poorly correlated with the ICSHT group (rho=0.5; P<0.001). CONCLUSION: Our study suggests that 73% of tetraplegic subjects have a neurological level of lesion between C5 and C7, and that it is not possible to accurately predict residual hand function from the level of lesion obtained from the clinical records, or from an ICSHT evaluation. CLINICAL REHABILITATION IMPACT: The results of our work show that a large number of patients with cervical spinal cord lesion have impaired hand function. Residual hand function must be assessed with specific functional tests; it cannot be derived simply from a lesion's neurological level.

Osteopathic manipulative treatment is effective on pain control associated to spinal cord injury.

STUDY DESIGN: This study was designed as an experimental study (trial). OBJECTIVES: To verify the effects of the association between conventional pharmacological treatment and osteopathic manipulative treatment (OMT) for chronic pain management in spinal cord injury (SCI). SETTING: This study was carried out at Spinal Unit, Ospedale Niguarda Ca' Granda, Milan, Italy. Istituto Superiore di Osteopatia, Milan, Italy. METHODS: We enrolled 47 patients with SCI, 26 with pain of both nociceptive and neuropathic origin, and 21 with pure neuropathic pain. In all, 33 patients had a complete spinal cord lesion (ASIA level A) and 14 had incomplete lesion (ASIA level B, C and D). The patients were subdivided in a pharmacological group (Ph), a pharmacological osteopathic (PhO) group and a osteopathic (Os) group. The verbal numeric scale (VNS) was used at various time intervals to evaluate treatment outcomes. RESULTS: Ph patients reached a 24% improvement in their pain perception, assessed by the VNS scale after 3 weeks of treatment, whereas Os patients reached a 16% improvement in their pain perception for the same weeks. Both treatments per se failed to induce further improvements at later time points. In contrast, the combination of the two approaches yielded a significantly better pain relief both in patients with nociceptive or pure neuropathic pain in the PhO group. CONCLUSIONS: Our results suggest the OMT is a feasible approach in patients in whom available drugs cannot be used. Moreover, a benefit can be expected by the association of OMT in patients treated according to existing pharmacological protocols.

Treatment of neurogenic bowel dysfunction using transanal irrigation: a multicenter Italian study.

STUDY DESIGN: Thirty-six patients with unsatisfactory treatment of neurogenic bowel dysfunctions (NBD) were enrolled from Spinal Units and Rehabilitation Centers in Italy. Treatment was for 3 weeks using a newly developed integrated system with an enema continence catheter for transanal irrigation (Peristeen, Coloplast A/S Kokkedal Denmark). OBJECTIVES: To evaluate the effects of Peristeen Anal Irrigation on NBD and patient quality of life (QoL). SETTING: Italy. METHODS: Lesion level, ambulatory status and hand functionality were determined in all patients. NBD symptoms and QoL were evaluated before and after treatment, using a specific questionnaire. Statistical analysis was performed using McNemar Test and Sign Test. RESULTS: Thirty-six patients were enrolled, and 32 patients completed the study. At the end of the treatment, 28.6% of patients reduced or eliminated their use of pharmaceuticals. Twenty-four patients became less dependent on their caregiver. There was a significant increase in patients' opinion of their intestinal functionality (P=0.001), QoL score (P=0.001) and their answers regarding their degree of satisfaction (P=0.001). A successful outcome was recorded for 68% of patients with fecal incontinence, and for 63% of patients with constipation. CONCLUSION: Peristeen Anal Irrigation is a simple therapeutic method for managing NBD and improving QoL. It should be considered as the treatment of choice for NBD, playing a role in the neurogenic bowel analogous to that of intermittent clean catheterization in bladder treatment.

Interdisciplinary treatment of spina bifida children.

In the Spina Bifida Centre, Niguarda Ca' Granda Hospital (Milan, Italy), from June 1985 to June 1990, 60 spina bifida children have been treated. The results of the rehabilitation programme (including orthopaedic, urological and psychosocial aspects) at the time of the survey were: (a) Neuromotor function: 72% of the patients achieved ambulation, 52% of these being less than 2 years of age, and 20% older than 2 years; 18% were too young for walking. Thus, considering the children's age, about 90% of the subjects achieved the standing position, and 89% achieved ambulation. (b) Bladder function: 83% of the children had a complete urological evaluation; 40% of those with a neuropathic bladder had a hyperreflex type, 54% areflexic, and 6% normoreflexic. Thirty-two percent of the patients had signs of 'high pressure' bladder function. Urinary continence was: 36% > or = 2 hours, 20% < 2 hours, 44% not detectable (age < 2 years). Forty percent of the subjects used intermittent catheterisation. (c) Psychosocial aspect: child adaptation to the disease and to the rehabilitation programme was good in 61% of the patients; family problems were identified in 70% of the patients; enrollment in preschool and school programmes was normal (or with specialist teaching) in about 74%; 33.3% of the subjects had disturbance of affect. The results clearly showed that the interdisciplinary approach favoured the social integration of these children.