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Spinal Cord Injury: Progress, Promise, and Priorities D TOOLS TO ASSESS SPINAL CORD INJURY OUTCOMES A number of tools can be used to assess the outcomes of spinal cord injuries. Many of these are already being used to assess the outcomes of spinal cord injuries, while others are used in related fields and could be modified for use with spinal cord injury. The following table lists outcome measures and their potential shortcomings and can be divided into the following categories: (1) recovery measures in animals, (2) recovery measures in humans, and (3) measures of quality of life. Tools to Assess Spinal Cord Injury Outcomes Animal Functional recovery Basso, Beattie, and Bresnahan (BBB) scale, an open-field locomotor test for rats • Is based on 5-point Tarlov scale • Analyzes hind-limb movements of a rat in an open field • Is a 21-point scale used to assess locomotor coordination • Rates parameters such as joint movements, the ability for weight support, limb coordination, foot placement, and gait stability • Small changes in tissue correlate to large changes on the scale • Assesses walking, not other movements requiring coordinated spinal cord activity • Does not assess pain, bowel, bladder, or sexual function Basso Mouse Scale (BMS), an open-field locomotor test for mice • Is an adaptation of rat BBB scale to examine the recovery of hind-limb locomotor function
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Spinal Cord Injury: Progress, Promise, and Priorities • Assesses walking, not other movements requiring coordinated spinal cord activity • Does not assess pain, bowel, bladder, or sexual function Tarlov scale • 5-point scale to assess upper and lower limb locomotion • Uses scores ranging from 0 (paraplegia) to 4 (animal can run and has a normal motor system with no other weaknesses); uses MEPs and SSEP (see below) • Looks at action potentials in muscle and nerves • Hard to assess minor but significant changes in locomotion • Does not assess pain, bowel, bladder, or sexual function Durham scale • Includes Tarlov scale, as well as functional task, bowel hygiene, and neck position • Is better than Tarlov scale at predicting spinal cord disorders • Hard to assess minor but significant changes in locomotion • Better suited for assessment of incomplete injuries • Does not assess pain, bowel, bladder, or sexual function Neuronal activity assessment by electrophysiology • Assesses MEPs or SSEP • Stimulates corresponding cortical areas of the brain and records response in target nerves to see if connections are still functional • Correlates to impairment of locomotor activity • Is noninvasive • Neuronal activity may not correlate with functional changes • Hard to assess subtle but critical improvements to circuitry • Does not directly assess pain, bowel, bladder, or sexual function Directed forepaw reaching • Looks at coordinated limb and muscle movement • Requires rats to reach under a barrier and pick up food with forepaws • Limited scale for assessment • Does not assess pain, bowel, bladder, or sexual function Grooming response • A little water is sprinkled on the head of a rat to elicit grooming with the rat’s forelimbs and measure forelimb function • Is a brain stem-mediated spontaneous reflex sensitive to the level and severity of the injury • Looks only at forelimb response • Difficult to discriminate between loss of communication with brain stem or damage to other part of the nervous system Rearing • A rat is placed in a cylinder and is scored on how often it rears and simultaneously touches the walls of the cylinder with its forelimbs • Looks only at forelimb response
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Spinal Cord Injury: Progress, Promise, and Priorities Walking speed • Is used to assess locomotor training techniques • Does not assess sensory modalities influenced by muscle strength • Does not assess pain, bowel, bladder, or sexual function Rotor rod • Is used to examine sensory feedback, coordination, and muscle strength required for locomotion • Is performed by placing the animal on a rotating bar and timing how long it takes for animal to lose balance • Only measures recovery of locomotion and does not assess restoration of fine motor control or other complications associated with spinal cord injury Inclined plane • Is used to examine sensory feedback, coordination, and muscle strength required for locomotion • Is performed by placing animal on a ramp of a preset incline • Only measures recovery of locomotion and does not assess restoration of fine motor control or other complications associated with spinal cord injury Footprint • Examines an animal’s gait by analyzing paw position and toe drags • Only measures recovery of locomotion and does not assess restoration of fine motor control Grid walking • Tests the ability of mice and rats to walk over a wire mesh grid • Only investigates coordinated walking and not fine motor control Forepaw withdrawal • Investigates recovery of heat perception • The forepaw is placed on a heat block and the time that it takes for the animal to withdraw it is measured • Forepaw withdrawal requires motor function • Does not assess pain, bowel, bladder, or sexual function Assessment of autonomic dysreflexia • Changes in blood pressure are determined by comparing the animals baseline blood pressure and peak blood pressure during moderate cutaneous pinches to the skin rostral and caudal to the injury • Autonomic dysreflexia is also characterized in patients by sweating, flushed skin, and piloerection, which are not assessed in mouse model Morphological assessment of recovery Histology • Is used to look at the morphology of axons and assess the degree of tissue sparing, injury, and recovery
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Spinal Cord Injury: Progress, Promise, and Priorities • Is used for anterograde and retrograde tracing of axons: a substance is injected above or below the location of the injury to determine if the neuron transports it up past the injury location • Uses electron microscopy to look at the morphology of the spinal cord at very high resolution • Uses antibody staining to determine the protein distribution in cells • Assessments cannot be made in real time • Cannot be performed with living animals Real-time imaging of the spinal cord • Uses MRI, CT, and PET, which are safe, noninvasive methods that provide detailed images of hard-to-view areas of the spine • Resolution is not high enough to detect changes to individual cells Genetically encoded reporter molecules • Axon regrowth and formation of functional connections are visualized by use of genetically encoded reporter molecules in intact animal models or in isolated spinal cord preparations • Requires a correlation to improvements in physiological function Human Functional recovery American Spinal Injury Association (ASIA) International Standards for Neurological Classification • Analyzes the effect that the injury has on both motor and sensory systems • Is based on the extent of injury and muscle strength • Uses an alphabetical score from A (the most severe) to E (the least severe) • Insensitive to small but significant changes in motor and sensory functions • May not be sensitive enough to detect even several spinal levels of regeneration in thoracic injuriesa • Does not specifically address functions that affect a patient’s quality of life • Does not assess pain, bowel, bladder, or sexual function Includes: • ASIA Impairment Scale ○ Is based on the extent of injury and muscle strength ○ Uses an alphabetical score from A (the most severe) to E (the least severe) ○ Insensitive to small but significant changes in motor and sensory functions Lower-extremity motor scores • Assess the functions of five key muscle groups of each leg • Uses scores from 0 (no movement) to 5 (normal resistance) • Looks only at lower extremities, not at fine hand movements • Does not assess sensory, pain, bowel, bladder, or sexual function
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Spinal Cord Injury: Progress, Promise, and Priorities Functional Independence Measure (FIM) • Is an 18-item, 7-level ordinal scale • Is designed to assess areas of dysfunction in activities that commonly occur • The scale has few cognitive, behavioral, and communication-related functional items • Is not specific for spinal cord injuries but is designed to assess neurological, musculoskeletal, and other disorders Functional Assessment Measure (FAM) • Was developed to augment the FIM • Specifically addresses functional areas that are relatively less emphasized in FIM, including cognitive, behavioral, communication, and community functioning measures • The scale has few cognitive, behavioral, and communication-related functional items • Is not specific for spinal cord injuries but is designed to assess neurological, musculoskeletal, and other disorders Spinal Cord Independence Measure (SCIM) • Is specifically designed to assess spinal cord injuries and to be sensitive to changes • Analyzes self-care, respiration, and sphincter management and mobility • Is more sensitive than FIM for spinal cord injuries Walking Index for Spinal Cord Injury (WISCI) • Scale measures functional limitations in walking of individuals after a spinal cord injury • Grades physical assistance and devices required for walking after paralysis of the lower extremities • Documents changes in functional capacity in respect to ambulation in a rehabilitation setting • Limited to assessment of walking Spinal Cord Injury-Functional Ambulation Inventory • Analyzes ambulation in individuals with spinal cord injuries relating to gait parameters, assistive device use, and temporal-distance measures • Limited to assessment of walking Barthel Index • Measures individual’s independence in mobility • Assesses many deficits, including those after a stroke • Is designed to measure three categories of function: self-care, continence of bowel and bladder, and mobility • Functional ability can be a predictor of discharge from hospital • Floor and ceiling of scale are not sensitive enough to measure small but significant changes in function
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Spinal Cord Injury: Progress, Promise, and Priorities Visual Analog Scale (VAS) • Is a pain assessment test • Uses a graphic rating scale • Solely based on self-assessment Electrophysiology • Assesses MEPs or SSEP • Stimulates corresponding cortical areas of the brain and records the response in target nerves to see if connections are still functional • Is correlated to impairment of locomotor activity • Is noninvasive • Electrical activity may not coordinate with function • Hard to assess subtle but critical improvements to circuitry • Does not assess pain, bowel, bladder, or sexual function Ashworth scale for spasticity • 6-point scale to assess muscle tone • Too crude for assessment of the daily variability in spasticity The Stroke Rehabilitation Assessment of Movement (STREAM) • Measures voluntary movement and basic mobility • Is designed to be able to assess reemergence of voluntary movement and basic mobility • Assesses 30 mobility items, including upper and lower extremity mobility, using a 3- or 4-point scale • Can be used as a predictor of discharge from hospital Timed “up and go” (TUG) • Is considered the best test of functional mobility • The individual sits in a chair and is then required to stand and walk forward 3 meters • Requires patient to be able to walk Box and Block test • Is used to measure unilateral gross manual dexterity • The individual moves blocks, one by one, from one compartment to another in 60 seconds • Requires significant muscle strength and control Quantitative Sensory Testing (QST) • Was developed for sensory assessment, primarily in individuals with peripheral nerve disorders • Measures activity in three types of sensory nerve fibers: fast Ab (touch, joint position, mild pressure, vibration), small Aδ (cold sensation, pain), and C fibers (warmth sensation, pain) • Sensitive to different methodological aspects, including site of testing, pressure of stimulator, subject training, and stimulator size • Test is time-consuming if many dermatomes are examined
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Spinal Cord Injury: Progress, Promise, and Priorities Quality of life NAGI Classification • Disability is a function of the interaction of the individual with his or her social and physical environments • Is affected by individual and environmental factors • Was presented in 1991 by IOM Activities of Daily Living (ADL) • Measures basic tasks of everyday living • Is used as a predictor of admission to nursing homes and hospitals • Lots of variation, depending on which items are measured and how a disabling condition is classified SF-12, SF-36, and SF-54 • Measure changes in quality of life, mental health, pain, and social function • Reflect the individual’s perceptions and preferences about physical, emotional, and social well-being • Hard to detect changes in quality of life over time • Questions about walking can be construed as offensive to individuals with SCI Assessment of Life Habits Scale • Assesses social participation • Relates accomplishments of daily habits from personal factors and environmental factors Satisfaction with Life Scale (SWLS) • Consists of five items that are completed by the patient • Can assess life satisfaction in a particular domain of life (e.g., work or family) or globally • Is based on the individual’s emotions International Classification of Impairment, Disabilities, and Handicaps (ICIDH) • Was designed by the World Health Organization to classify the consequences of disease and their implications on the patient’s life • Defines impairment, disabilities, and handicaps • ICIDH-2 incorporates disability as a dynamic process and holds that environmental factors can influence the impairment Craig Handicap Assessment and Reporting Technique (CHART) • Is based on the World Health Organization model of handicap dimensions • Uses 27 questions and a 5-point scale to look at physical independence, economic self-sufficiency, social integration, mobility, and occupational functioning Needs Assessment Checklist (NAC) • Is used as a rehabilitation outcome measure designed specifically for spinal cord injury population • Uses a 4-point scale • Consists of 199 behavioral indicators that assess patient achievement in nine categories required for maintenance of health and quality of living • Is not subject to floor or ceiling effects
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Spinal Cord Injury: Progress, Promise, and Priorities Awareness Questionnaire (AQ) • Was developed as a measure of impaired self-awareness after traumatic brain injury • Consists of three forms to be filled out by the patient, the patient’s family, and a clinician familiar with the patient • Assesses the ability of the patient to perform tasks before and after the injury using a 5-point scale ranging from “much worse” to “much better” Community Integration Questionnaire (CIQ) • Provides a measure of community integration after a traumatic brain injury • Consists of 15 items relating to home integration, social integration, and productive activities Craig Hospital Inventory of Environmental Factors (CHIEF) • Is designed to assess the environmental factors and understand which elements of the environment impede or facilitate the lives of people with disabling conditions • Respondents use a 5-point scale to quantify the barriers experienced within five domains of environmental factors (policies, physical and structural, work and school, attitudes and support, services and assistance) Disability Rating Scale (DRS) • Is intended to measure general functional changes over the course of recovery • Assesses arousability, awareness, and responsiveness; cognitive ability for self-care activities; dependence on others; and psychosocial adaptability • Is relatively insensitive at the low end of the scale • Inability to reflect more subtle but sometimes significant changes Family Needs Questionnaire (FNQ) • Provides information about family members’ unique needs after a family member has a traumatic brain injury • Contains 40 items representing diverse needs that may arise during acute rehabilitation, soon after discharge, and in the long term • Indicates the importance of each perceived need and then rates the degree to which the need has been met Service Obstacles Scale (SOS) • Evaluates a patient’s and/or caregiver’s perceptions of brain injury services in the community with regard to quality and accessibility • Uses a 7-point Likert-type scale ranging from strongly disagree to strongly agree to assess (1) satisfaction with treatment resources, (2) finances as an obstacle to receiving services, and (3) transportation as an obstacle to receiving services aNational Institute of Neurological Disorders and Stroke Translating Spinal Cord Injuries workshop, February 3-4, 2003. NOTE: Abbreviations: MEPs = motor evoked potential; SSEP = somatosensory evoked potential; MRI = magnetic resonance imaging; CT = computed tomography; PET = positron emission tomography; IOM = Institute of Medicine.
Representative terms from entire chapter: