National Academies Press: OpenBook

Spinal Cord Injury: Progress, Promise, and Priorities (2005)

Chapter: Appendix D Tools to Assess Spinal Cord Injury Outcomes

« Previous: Appendix C Glossary of Major Terms
Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×

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

Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×

 

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

Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×

 

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

Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×

 

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

Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×

 

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

Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×

 

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

Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×

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

Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×

 

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.

Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×
Page 260
Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×
Page 261
Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×
Page 262
Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×
Page 263
Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×
Page 264
Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×
Page 265
Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×
Page 266
Suggested Citation:"Appendix D Tools to Assess Spinal Cord Injury Outcomes." Institute of Medicine. 2005. Spinal Cord Injury: Progress, Promise, and Priorities. Washington, DC: The National Academies Press. doi: 10.17226/11253.
×
Page 267
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An estimated 11,000 spinal cord injuries occur each year in the United States and more than 200,000 Americans suffer from maladies associated with spinal cord injury. This includes paralysis, bowel and bladder dysfunction, sexual dysfunction, respiratory impairment, temperature regulation problems, and chronic pain. During the last two decades, longstanding beliefs about the inability of the adult central nervous system to heal itself have been eroded by the flood of new information from research in the neurosciences and related fields. However, there are still no cures and the challenge of restoring function in the wake of spinal cord injuries remains extremely complex.

Spinal Cord Injury examines the future directions for research with the goal to accelerate the development of cures for spinal cord injuries. While many of the recommendations are framed within the context of the specific needs articulated by the New York Spinal Cord Injury Research Board, the Institute of Medicine’s panel of experts looked very broadly at research priorities relating to future directions for the field in general and make recommendations to strengthen and coordinate the existing infrastructure. Funders at federal and state agencies, academic organizations, pharmaceutical and device companies, and non-profit organizations will all find this book to be an essential resource as they examine their opportunities.

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