Demystifying Spinal Cord Injury

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Demystifying Spinal Cord Injury

• Suzanne L. Groah, MD, MSPH
• Director of Spinal Cord Injury Research
• Director of the National Capital Spinal Cord
  Injury Model System
• National Rehabilitation Hospital, Washington, DC

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• Funded by the National Institute on Disability
  and Rehabilitation Research (NIDRR), Office of
  Special Education Services,
• U.S. Department of Education
• Washington, D.C.
• Grant H133N060028

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Definition of Spinal Cord Injury

• Any injury to the spinal cord via blunt or
  penetrating trauma
• Contrast with spinal cord disease
• Manifests as variable loss of neurological
  function below the injury site
• Motor and sensory impairment
• Autonomic, bowel, bladder and sexual dysfunction
• Catastrophic injury with long-term medical and
  psychosocial consequences

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Spinal Cord Injury Model Systems

• The Spinal Cord Injury Model Systems (SCIMS)
  program was established by the Rehabilitation
  Services Administration in the early 1970s
• The SCIMS are specialized programs of care in SCI
  which gather information and conduct research
  with the goal of improving long-term functional,
  vocational, cognitive, and quality-of-life
  outcomes for individuals with SCI

Lammertse, Jackson and Sipski, 2004 NIDRR
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Spinal Cord Injury Model Systems

• Model System grantees contribute data to a
  national statistical center that tracks the
  long-term consequences of SCI and conduct
  research in the areas of medical rehabilitation,
  health and wellness, service delivery, short- and
  long-term interventions, and systems research.
• Each Model System also is charged with
  disseminating information and research findings
  to patients, family members, health-care
  providers, educators, policymakers and the
  general public.

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Current SCI Model Systems
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National SCIMS Database

• Captures approximately 13 of all new SCI
  occurring in the U.S.
• Established at the University of Alabama at
  Birmingham in 1983
• Coordinates data collected by all SCI Model
  Systems Centers
• Registry 10,357 participants
• Form I 25,415 participants
• Form II 115,448 participants, up to 30 years
  post injury

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SCI Descriptive Data Summary, 1973 - 2007

• Source Annual Report (2007) for the Spinal Cord
  Injury Model SystemsNational Spinal Cord Injury
  Statistical CenterBirmingham, AL

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SCI Epidemiology

• Incidence
• 40/million
• 12,000 new cases per year
• Does not include those who die at scene
• 4/million or 1,000 per year
• Prevalence
• 255,702 (range 227,080 300,938)

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SCI Epidemiology

• Age at injury
• Mean 39.5 years (since 2005)
• More people 60 years at time of injury
• 77 male
• Etiology
• 42 MVC, 27 falls, 15 violence, 7 sports
• MVC 1 cause if lt45 years
• Falls 1 cause if gt45 years

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Age at Injury
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Education
13
Marital Status
14
Occupational Status
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Race
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SCI Epidemiology

• Severity of injury
• Complete 49
• Sensory incomplete 10.3
• Motor incomplete (weak) 11.2
• Motor incomplete 29.1
• Normal function 0.8

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SCI Epidemiology

• Neurologic level of injury (LOI)
• Incomplete tetraplegia 34.1
• Complete paraplegia 23.0
• Complete tetraplegia 18.3
• Incomplete paraplegia 18.5
• Full neurologic recovery lt1

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Spinal Cord Injury Mortality

• 6.3 die in first year
• Mortality associated with
• Older age
• Male
• Violence
• C4 or higher injury level
• Vent dependent status
• Neurologically complete injury
• Medicare/Medicaid

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Life Expectancy
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Classification of injury and prognosis for
recovery
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Classification of Spinal Cord Injury

• Level of injury (LOI)
• Motor, sensory, and sacral examinations
• Severity of injury
• Complete (ASIA A)
• Incomplete (ASIA B, C, D, E)
• Incomplete syndromes
• Anterior Cord Syndrome
• Central Cord Syndrome
• Brown-Sequard Syndrome
• Cauda Equina Syndrome

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ASIA Impairment Scale
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Prognosis for Recovery

• Neurologic assessment at 72h 1 week superior to
  earlier testing
• Repeat testing within 72 h 1 week window
• Sensory exam better for predicting motor recovery
  in LE than UE

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Prognosis for Recovery

• 50-67 of total 1-year recovery occurs in first 2
  months
• Slower recovery during 3-6 mos
• Motor recovery documented up to 2 yrs

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Recovery by ASIA Impairment Grade

• Proportion of subjects exhibiting spontaneous AIS
  grade conversion
• 75-80 AIS A remain A
• 35-40 AIS B convert to C or D
• 60-80 AIS C convert to D
• Nearly all AIS D remain D

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Anterior Cord Syndrome

• Compression of the anterior spinal artery, bony
  fragments or herniated disc
• Loss/decreased strength bilaterally
• Incomplete sensory loss
• Loss/decreased pain and temperature
• Preserved vibration sense

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Central Cord Syndrome

• Seen in older persons, hyperextension injury
  secondary to a fall
• Greater motor and sensory impairmentof the hands
  and arms than the legs
• Variable bowel and bladder impairment

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Brown-Sequard Syndrome

• Hemisection of cord
• Usually due to penetrating injury
• Ipsilateral loss of motor function,
  proprioception, and vibration
• Contralateral loss pain and temperature

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Cauda Equina Syndrome

• Peripheral nerve injury
• Variable loss in motor and sensory function of
  lower extremities

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Contemporary issues in sci care The Health care
system, rehabilitation aging issues
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Changes to the System of Care

• Financial resources declining for trauma and
  emergency care
• More patients are arriving at acute
  rehabilitation with significant secondary
  conditions
• Fewer ventilator-capable rehabilitation centers
• Acute rehabilitation length of stay declining
• Rehospitalizations increasing
• People leaving rehabilitation less prepared to
  care for themselves and often without proper
  equipment

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Secondary Conditions

• Neurologic system
• Late neurologic deterioration
• Musculoskeletal system
• Overuse syndromes
• Genitourinary system
• Bladder infections, stones, cancer
• Kidney infections, stones, other
• Gastrointestinal system

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Secondary Conditions

• Integument
• Skin breakdown
• Pulmonary system
• Pneumonia, impaired cough, other
• Cardiovascular system
• Autonomic imbalance, low/high blood pressure
• Risk for early cardiovascular disease
• Sexuality/Fertility

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Secondary Conditions

• Metabolic
• Altered body composition
• Carbohydrate and lipid disorders
• Bone
• Universal osteoporosis
• Psychosocial
• Adjustment to disability, depression, fatigue
• Participation
• Substance abuse

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Rehabilitation research for improved health and
recovery after spinal cord injury
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Emerging Rehabilitative Research

• Once solely focused on prevention of secondary
  conditions
• Now, with increasing numbers of clinical trials
• Body-weight supported ambulation
• Neuromuscular electrical stimulation
• Functional electrical stimulation
• Activity-based rehabilitation
• Therapies for neurorecovery and restoration

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Challenges of Translational Research

• Lack of refined outcome measures
• ASIA motor and sensory exam
• Ashworth
• Functional Independence Measure (FIM)

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Problems With Outcome Measures

• Using AIS
• Ex 2 grade changes in AIS (A to C) as in Sygen
  trial
• Baseline C5 AIS A with UEMS15
• Recovery After treatment UEMS42
• Functional paraplegic
• Outcome Subject still AIS A and according to
  trial did not respond to treatment

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Problems With Outcome Measures

• Using AIS
• Ex Using 10 point improvement of motor
• Baseline C4 AIS A
• Recovery After treatment subject acquires
  sensation/motor at S4-S5 and some muscles have
  non-functional improvement (UEMS14, LEMS10) No
  functional change
• Outcome Subject had 20 point motor improvement
  and is considered a success but little functional
  change

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Functional Independence Measure

• A measure of disability (functional limitation),
  burden of care, performance
• 18 items in 6 categories (self care, sphincter
  control, mobility, locomotion, communication,
  social cognition)
• SCI inter-rater .83 for total score, individual
  items .42
• Recommended by ASIA in 1992, dropped in 2000
• Significant floor and ceiling effects for
  patients with SCI
• This is our second most common tool,
• Not all aspects relevant to SCI

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FIM by ASIA Change A to C
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Emerging Outcome Measures

• ASIA sub-scores
• Electrophysiologic testing
• QST
• SCIM III

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Power Issues

• Number of enrolled subjects necessary to show a
  statistical difference between experimental and
  control groups using modest change in AIS motor
  score
• Approx 60 AIS A tetra subjects to show 10 point
  difference
• Approx 200 AIS A tetra subjects to show 5 point
  difference
• Number of participants may increase 4X when
  incomplete subjects enrolled

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Timing of Intervention

• Most functional change occurs within 3 months of
  injury and plateaus after 1 year
• Thus, number of subjects needed decreases with
  delayed treatment
• Highest probability for detecting clinical
  benefit is during chronic SCI
• However, this is potentially most difficult time
  biologically to influence the cord

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Clinical Targets

• Many pharmacologic and cell-based therapeutics
  are applied near the site of injury
• Consider how to track segmental improvement
• Spontaneous functional improvement of one spinal
  level is common
• Spontaneous improvement of 2 spinal levels less
  common (5-20) in AIS A tetraplegics

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Translational Research

• Public pressure
• Lack of knowledge about scientific evidence
  development
• Impatience with slow methodical pace of science
• Impact of quasi-scientific case series
  masquerading as research

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Consumers Preferences

• Tetraplegia
• Arm/hand 48.7
• Sexual 13
• Trunk stability 11.5
• BB 8.9
• Walking 7.8
• Sensation 6.1
• Chronic pain 4

• Paraplegia
• Sexual 26.7
• BB 18
• Trunk stability 16.5
• Walking 15.9
• Chronic pain 12
• Sensation 7.5
• Arm/hand 3.3

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References

• Lammertse DP, Jackson AB, Sipski ML. Research
  from the model spinal cord injury systems
  Findings from the current 5-year grant cycle.
  Arch Phys Med Rehabil. 200485(11)1737-1739.
• National Institute on Disability and
  Rehabilitation Research - Disability and
  Rehabilitation Research Projects and Centers
  Program - Spinal Cord Injury Model Systems
  Centers and Disability Rehabilitation Projects.
  Federal Register. Vol 70.238 December 13,
  200573738-73741.
• Compilation of database research contributed by
  SCIMS investigators
• Books (1986, 1990, 1995) and special issues of
  Archives of Physical Medicine and Rehabilitation
  (1999, 2004)

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References

• Online Syllabus and Data Collection Forms
• (http//www.spinalcord.uab.edu/show.asp?durki2448
  0)
• Facts Figures at a Glance
• http//www.spinalcord.uab.edu/show.asp?durki11697
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• Mid-year and Annual Statistical Reports
• http//www.spinalcord.uab.edu/show.asp?durki11689
  1

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ASIA
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Paralyzed Veterans of America
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Spinal Cord Injury Rehabilitation Evidence
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Thank you

• For more information, email Suzanne.L.Groah_at_Medsta
  r.Net