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Coma se manifesta ca o pierdere de durata a constientei, asociata cu fe-

nomene vegetative mai mult sau mai putin grave. Ea poate fi produsa
prin leziuni ale SNC, boli sistemice complicate ori prin intoxicatii exo-
sau endo-/gene. In absenta unei terapii intensive adecvate si imediate,
se poate ajunge la deces prin hipoxie.
Sincopa este o pierdere de constienta de scurta durata, ce poate fi produ-
sa prin scaderea brusca a irigatiei cerebrale de diverse cauze, cea mai
frecventa fiind hipotensiunea arteriala.
Starea vegetativa se considera a fi o coma care nu isi revine dupa
10-14 zile (un sindrom clinic evolutiv, dup o leziune cerebral grav
care iniial induce o stare de com si in care bolnavul nu raspunde la
stimuli verbali dar poate tine ochii deschisi fara a intelege comenzile).
Leziunile generatoare cele mai frecvente sunt encefalice supratentoriale.
Meninerea peste 3 (12) luni a tabloului patologic reprezint grania
dintre formele evolutive clinice: starea vegetativ tranzitorie (SVT)
i starea vegetativ persistent (SVP).
Suficienta conservare a funciilor autonome ale hipotalamusului i trunchiu-
lui cerebral permite supravieuirea ndelungat, cu: ingriiri medicale palia-
tive, nursing sistematic (inclusiv ngrijiri la domiciliu calificate - IDC - n.n.).
... Desi in sistemul de clasificare al bolilor nu figureaza rubrici distincte pentru
aceste entitati clinice, anual, in serviciile de terapie intensiva sunt ingrijite
estimativ 10-12.000 de cazuri ce depasesc 10-14 zile de intemare - stri
vegetative (dintre care unele vor deveni persistente - GOS 2/ 4).
Cele mai importante cauze sunt politraumatismele la varste tinere.
La aceste cazuri sunt solicitati diferiti specialisti: chirurgi generali, neurochirurgi,
ortopezi, neurologi, internisti, cardiologi, ORL-isti, oftalmologi. Coordonarea este
unica si trebuie sa apartina obligatoriu intensivistului - dar fiecare specialist este
independent si responsabil - scopul fiind supravietuirea fiecarui bolnav cu seche-
le cat mai mici posibil - rezult astfel, insa: veterani ai medicinei contemporane.
Pe langa parametrii vitali in care hemodinamica este prioritara, se urmaresc:
imunonutritia, evolutia starii neurologice (arousal-ul), raspunsul si
capacitatatea de a suporta manevrele de reabilitare.
Totul se inscrie pe fise de evolutie zilnica.
Un rol esential il are prevenirea complicatiilor si a leziunilor secundare.
De la intrarea in terapie intensiva trebuie gandit la Weaning (dezv) - suprima-
rea cat mai precoce a tuturor mijloacelor de sustinere artificiala, astfel incat
sa nu se ajunga la ireversibilitatea functiilor organelor periferice cu efecte de
feed-back infaust (ulterior) asupra recuperarii: preventia leziunilor musculaturii
respiratorii, mentinerea functionalitatii digestive, asistarea/ incercarea de
restabilire a functiilor automate ale vezicii urinare si ampulei rectale. ...
Glasgow Outcome Score (GOS) scale
GOS = 1: Decedat

GOS = 2: Stare vegetativ Neresponsiv la stimuli exteriori.


persistent
GOS = 3: Disfuncionalitate Dependen parial sau total de asisten exterioar. Abilitati de comunicare limitate, rspunsuri
sever comportamentale sau emoionale anormale.

GOS = 4: Disfuncionalitate Gradul de autonomie funcional se rezum la ADL. Incapacitate de a participa la activiti socio-
moderat familiale sau de munc.

GOS = 5: Recuperare bun Capacitile functionale se rezum la activiti cotidiene sau sociale cu toate c poate exista un deficit
minor funcional sau phihologic, sau simptome asociate
...
Starea de minima constienta (SMC), descrisa in
2002 de JTGiacino, este o obnubilare marcata
din care pacientul poate fi trezit si are reactii
adaptatate la comenzi simple, intelege si
raspunde uneori adecvat, apoi recade in somn;

pacientii cu SMC au recuperat procesele


integrative superioare, ce realizeaz
interconectarea funcional dintre ariile cortexului
temporal auditiv primar, secundar i ariile

asociative prefrontale (condiii similare ...


... cu cele fiziologice); un stadiu evolutiv superior/
favorabil: constienta redusa (low awareness).
(Mutismul akinetic: aspecte de aparent stare de
contien, cu paucitatea micrilor spontane i
mai ales a vorbirii (pacientul este imobil, nu
vorbete - dei nu este paralizat).
Compromiterea sever a comportamentului motor
este rezultatul lezrii bilaterale a tractusurilor
reticulo-corticale (la nivelul substanei reticulate
paramedian a trunchiului cerebral i a dience-
falului, ctre ariile frontale bazale sau mediale)
sau a conexiunilor dintre paleo-neocortex.
Mutismul akinetic este considerat o variant
clinic de SMC.) ...
Sindromul de zvorre (locked-in syndrome): pacientul este perfect
constient, dar nu poate raspunde decat prin clipit sau miscari ale
globilor oculari. Are tetraplegie si adesea este ventilat mecanic.
Leziunea este de obicei in punte, sub coliculii cvadrigemeni.
Additionally, it is to be noticed that clinical tests with BCI remained
focused on the neediest patients (eg.:cervical SCI, brainstem stroke,
muscular dystrophy or amyotrophic lateral sclerosis (ALS) or other mo-
tor neuron diseases or epilepsy* (one main initial indication, in cases
who continue to have seizures despite maximal medical management):
those whose state of paralysis made it too difficult to communica-
te by other means**although unfortunately, exactly in this respect the-
re seem to arise the greatest difficulties (a meta-analysis, over a pe-
riod of arround 10 years, on 29 patients with ALS and 6 with other
severe neurological diseases in different stages of physical impair-
ment who were trained with a BCI - different related studies in the
same laboratory - emphasized whether locked-in state (LIS) patients
can transfer learned brain control, to the complete locked-in states
(CLIS)*Birbaumer N:The status of clinical brain-computer interface (BCI) research - Plenary Lecture at the 5 World Congress of the
th

International Society of Physical & Rehabilitation Medicine, Istanbul/ Turkey, June, 2009; **http://www.braingate2.org/neurology.asp ...
Nu exista o uniformitate de incadrare a acestor cazuri: unii autori (G.
Moonen-Liege) considera ca in 40% din diagnostice incadrarea este
eronata necesitatea/ importanta evaluarii clinico-bio-functionale.
Acest fapt determina o atitudine diferita fata de decizia de a conti-
nua sau nu ingrijirile intensive/ R/NR - uneori cu supravietuirea
si recuperarea pacientului - decizie cu consecintejuridice/ familiale/
sociale majore.
In astfel de cazuri, pentru luarea unor decizii, atitudinea etica poate
fi determinanta. Astfel, este obligatoriu ca in atari situatii, persoanele
implicate sa aiba un minimum de cunostinte, sa nu emita pareri fara
suport medical si moral, in caz contrar aparand situatii conflictuale.
Optiunea este influentata uneori negativ de factori religiosi,
etnici, sociali, mediatici, gradul de dezvoltare economica si de
mentalitate/culturala, etc.
In principiu, se considera util ca in luarea deciziei terapeutice
sa se aib in vedere doua variante:
efort medico-social maxim (ideal)
efort mediu sau minim (real) proportional cu situatia sistemului medi-
cal (INTERCOMPARTIMENTE - n.n. - a se vedea mai departe)
...
Cea mai eficienta cale de regenerare neuronala este mentinerea semnalelor
musculo-tendinoase, senzoriale, cognitive, spre SN prin miscari pasive segmen-
tare - inclusiv articulare, schimbarea posturilor si a (W.L. Lanier-teoria aferentarii).
Echipele complexe de medicina fizica si reabilitare trebuie sa fie independente,
dedicate si supraspecializate, activand in concordanta cu ceilalti specialisti si mai
ales, egal tratate - altfel, efectele pozitive sunt discutabile.
Stabilirea zilnica si in evolutie a scorurilor de gravitate - inscrise in fise trebuie sa
fie standardizata, uniform folosita de persoane cu experienta, altfel apar diferente
semnificative, cu concluzii discordante asupra evolutiei si prognosticului. Astfel,
daca un pacient in decubit dorsal are scor Glasgow Coma Scale (GCS) 7, imediat
ce este ridicat in pozitie sezanda si examinat din nou, bland si competent, poate
fi notat cu scor GCS:10-12. Manevrele de nursing reprezinta totdata si un
instrument de evaluare a gradului de revenire din coma.
Este de dorit sa fie consemnat fiecare manevra de aspiratie a secretiilor din
tractul respirator sau orice manevra de toaleta a extremitatii cefalice, ca si
manevrele de mica chirurgie, chiar sub analgosedare.
Nursingul acestor cazuri poate fi un model de competenta si tenacitate.
Trebuie sa existe unele centre universitare si judetene incluse in programe de
nursing neurologic cu rol metodologic pentru formarea personalului specializat al
acestor cazuri.

In ingrijirea acestor cazuri, prevenirea leziunilor secundare si a complicatiilor
este cheia succesului iar calitatea manevrelor de nursing este fundamentala.
Deosebit de importanta este profilaxia leziunilor cutanate si trofice si a esca-
relor, ce pot aparea chiar dupa 30 de minute (M. Botez): se vor schimba pozi-
tiile pentru prevenirea leziunilor trofice cutanate/ escarelor si pentru drena-
jul postural al secretiilor traheo-bronsice.
Se urmareste inlaturarea casexiei complexe: se monitorizeaza i se combate
catabolismul post-lezional - inclusiv in alimentatia pe sonda nazo-gastrica
sau prin gastro-stoma (masticaia i deglutiia - etapele voluntare: labial i
bucal sunt sever compromise; inconstant etapa reflex faringian este con-
servat sau se recupereaz.
Se opteaza pentru kinetoterapia asociata cu imunonutritie adecvata; in faza a-
cuta, se vor interzice masajul intempestiv si transportul exagerat al pacient.
Se vor stabili contacte intre echipa de reabilitare si pacient, eventual cu
familia, care poate si trebuie sa se instruiasca asupra modului cum va fi
continuata reabilitarea dupa 5 (cinci) saptamani in spitalul teritorial de
doimiciliu al pacientului sau ulterior, acasa - IDC..
Astfel, sonda traheala cu sistem de aspiratie a secretiilor subglotice nu face
inutila umectarea, la interval de 30-60 de minute, a caii nazo-buco-fahngiene
cu clorhexidina 1%o sau betadina 1%o - cu supraveghere stricta a concentra-
iei de oxigen si CO2 (programul global de puls/oximetrie).*
*Alexianu D - Come i tulburri de contien n terapia intensiv. Viaa Medical, nr. 29-30, 23 iulie, 2010
BACKGROUND
... TBI) is .. pervasive (omniprezent) health problem ...
with ... estimated incidence of 1.4 million
new injuries per year.
... 80-85% of TBI ... are ... mild ... remaining 15-20%
comprising individuals with more severe ....
estimated ... over 5.3 million people living with
disability in the United States as a result of TBI*

Such an incidence is higher than tat of: epilepsy,


stroke, and multiple sclerosis.

*Struchen MA, Davis LC, McCauley SR - Assisting Patients with Traumatic Brain Injury: A Brief Guide for Primary
Care Physicians - http://www.tbicommunity.org/resources/podcasts/podcastTranscript.doc
BACKGROUND
In Romania, in the Neurosurgery departments - accor-
ding to the results of a preliminary epidemiological re-
search, deployed in 1997 by the Neurotrauma group,
of the Romanian Society of Neurosurgery (RSN) - the
weight of TBIs ranged between 25-95%, with a morta-
lity of 60-90% for the severe ones (much bigger than
the mean of the same indicator within the European
Union - EU - which was arround 31%, in 1996)* and for
instance - but not exclusively - as regards the Neuro-
surgery clinic division in Cluj-Napoca, they are the
main cause of death withn the related pathology**.
*http://www.cursurimedicina.ro/files/Curs%20I%20-%20studenti%20-%20traumatologie%20craniocerebrala.doc
**http://www.esanatos.com/ghid-medical/chirurgie/neurochirurgie/Traumatismele-cranio-cerebrale95568.php
BACKGROUND
The International Initiative for Traumatic Brain Injury
Research (InTBIR) is a collaborative effort of the
European Commission (EC), the Canadian Institutes
of Health Research (CIHR) and the National Institutes
of Health (NIH). Formally established in October 2011
to advance clinical traumatic brain injury research,
treatment and care, InTBIR is a global effort to co-
ordinate and harmonize clinical research activities
across the full spectrum of TBI injuries with the long-
term goal of improving outcomes and lessening
the global burden of TBI by 2020.*
*http://www.cihr-irsc.gc.ca/e/45665.html
BACKGROUND

The spine and the SC:


complementary morph-
functional synyhetic
overview, showing
anatomical/ steric
relations between
vertebraee and spinal
nerve roots, and the
spinal nerves related
sensation territories
of distribution - by (**)

The head, containing the brain and


the spinal column, containing the
spinal cord (SC), together with
the essential muscles and somatic/
visceral related functions, depending
on the SC and respectively, on the
emerging spinal nerves, at
corresponding metameric levels - by (*)
*http://www.eskimo.com/~jlubin/disabled/grap
hics/#48 **www.apparelyzed.com/spinalcord.html
SCI usually generate severe and rather
permanent impairment or even loss of
basic functions, such as:
voluntary/ active motility,
sensitivity,
micturition and/or defecation control,
erection/ ejaculation/ fertility [15-18];
therefore, they are, in most of the cases
devastating, especially as being
frequently irreversible

REFERENCES:
15.Lin Vernon W, Cardenas Diana D, et al - Spinal Cord Medicine: principle and practice - Demos Medical
Publishing, Inc., New York, 2003
16.Maynard FM, Jr, Bracken MB, Creasey G, Ditunno JF Jr, Donovan WH et al - International Standards for
Neurological and Functional Classifcation of Spinal Cord Injury - Spinal Cord, 35: 266- 274, 1997
17.Dahlberg A, Perttila I, Wuokko E et al - Bladder management in persons with spinal cord lesion The spinal columnn, containing the spinal
Spinal Cord 42:694-698, 2004 cord (SC), and the essential muscles and
18.Srensen FB, Snksen J - Sexual function in spinal cord lesioned men -Spinal Cord 39:455-470, 2001 somatic, respectively visceral functions
19. http://www.eskimo.com/~jlubin/disabled/graphics/#48 depending on the spinal cord/ nerves, at
corresponding metameric levels - by [19]
They are usually associated, on long-term or (quasi)
continuously, with serious co-morbidities, emerging from:
tissue distrophicity (mainly pressure sores),
urinary tract infections (UTI - chronic/recurrent),
metabolic and/or (including related) circulation
disturbances, of:
blood pressure [20], respectively of the venous-lymphatic flow
- especially anti-gravitational, in lower limbs [21] - kinds
emotional consequently affecting
REFERENCES:
20. Claydon VE, Steeves JD, Krassioukov A - Orthostatic hypotension following spinal cord injury: understanding clinical
pathophysiology - Spinal Cord 44: 341351, 2005
21. Onose G, Cardei V, Ciurea AV, Ciurea J et al - Achievement of an experimental mechatronic orthotic device to assist/
rehabilitate orthostatism and walk in patients with complete paraplegia and other specific severe disabling conditions - poster
presented at the 47th ISCoS Annual Scientific Meeting, Durban, South Africa, Sept. 2008, Communication at The Annual
National Conference of the Romanian Society of Neurosurgery, with International Participation, Sept.-Oct., Iai, Romania, 2008
and published - a short form - in Proceedings of the 7th Mediterranean Congress of Physical and Rehabilitation Medicine,
Portorose, Slovenia, in Edizioni Minerva Medica: 40-42, Torino, Italy, 2008
Background. SCI epidemiological current
data: Europe, Romania

The total population of the European Union (EU) is


now about 500 million people (*).
In the member states of the Council of Europe, it is
appreciated to be at least 330.000 post SCI sub-
jects with about 11.000 new cases every year.

Some 40% to 50% of these injuries are the


result of road accidents and most occur at a
young age(**)
*http://epp.eurostat.ec.europa.eu/tgm/table.do?tab=table&language=en&pcode=tps00001&tableSelection=1&footnotes=ye
s&labeling=labels&plugin=1
*http://assembly.coe.int/Documents/AdoptedText/ta02/EREC1560.htm
In Romania, according to our query of the Na-
tional Database of Inpatient, we found, in 2008,
419 new cases of hospitalized, surviving patients
with SCI, accounting for an incidence of 0.0190*
and in 2009, 407 such new cases (incidence:
0.0185** - a slight decrease possibly due to the
reduction of the overall motor vehi-cles market,
related to the onset of the economic crisis)
Consequently, we could estimate the total
number of patients living with SCI in Romania, to
be around 15,000 +/- a few thousands. The
average age was 41.4 years *
*Onose G, Anghelescu A, Georgescu F, et al - Initiation of a National Informatics Network for Patients with Sequels after Spinal
Cord Injury - Report at the 5th Annual Congress of the European Spinal Cord Injuty Federation (ESCIF), Vienna/ Austria, 2009
**Address no. 602/17.03.2010 of the Romanian National School for Public Health, Management and Perfecting in the Sanitary Domain,
Bucharest

As SCI frequently occur in (poly)traumatic situations,
about half of all cases have, at least initially,
other lesions, too *,**.

The mortality/ (crude) death rate following SCI is big


enough - mainly in the following year(s) - being signifi-
cantly higher (for instance, in the first 12 years after SCI
thisis more than ten folds (9.3%***) the general one
(8.8****), particularly for those severely injured *****
*http://www.sci-info-pages.com/facts.html
**Onose G, Ciurea A, Anghelescu A, Mardare DC, Mihescu AS et al - The Teaching Emergency Hospital "Bagdasar - Arseni"/
Physical & Rehabilitation Medicine Clinic Divisions Expertise in Neurotrauma Within Poly-trauma, Complex, Post-Acute
Approach - Communication at the Swiss-Romanian Joint Symposium on Trauma Care, Bucharest/ Romania, 2008
***DeVivo MJ, Black KJ, Stover SL - Causes of death during the first 12 years after spinal cord injury - Arch Phys Med Rehabil.,
74(3):248-254, 1993
****http://www.medterms.com/script/main/art.asp?articlekey=2913
*****https://www.nscisc.uab.edu/public_content/pdf/Facts%202011%20Feb%20Final.pdf
SCI medical/ scio-economic data
The related direct costs/ economic burden for post SCI persons, their families and
society (i.e. lifetime costs: the average yearly health care and living expenses and the
estimated lifetime costs that are directly attributable to SCI; to these direct costs must
be added indirect ones, such as losses in wages, fringe benefits and productivity which
average $66,626 per year in December 2010 dollars (*) - all significantly differing by
injurys level and severity and its long-term associated pathology, respectively by level
of qualification, pre-injury employment profile and - again - severity of injury) are
sythematized in the below joined table (**,***). One must notice the constant augmentation Related part of
1195421696248988212
(about twice) of the average expenses per year and the estimated lifetime costs between molumen_world_map_s
2004 and 2010 (without a spectacular improvement of the survival duration): vg_med (****)
Severity of Injury 2004 Average Yearly Expenses Estimated Lifetime Costs by
(in 2004, dollars) Age At Injury (discounted at 2%)
First Year Each Subsequent Year 25 years old 50 years old
High Tetraplegia (C1-C4) $682,957 $122,334 $2,693,887 $1,585,906
Low Tetraplegia (C5-C8) $441,025 $50,110 $1,523,204 $ 964,608
Paraplegia $249,549 $25,394 $ 900,085 $ 613,915
Incomplete Motor Functional
at Any Level $201,273 $14,106 $600,424 $435,139
Data Source:http://images.main.uab.edu/spinalcord/pdffiles/Facts%2004.pdf (*****)
2010 Average Yearly Expenses (in dollars)
First Year Each Subsequent Year 25 years old 50 years old
High Tetraplegia (C1-C4) $985,774 $171,183 $4,373,912 $2,403,828
Low Tetraplegia (C5-C8) $712,308 $105,013 $3,195,853 $1,965,735
Paraplegia $480,431 $63,643 $2,138,824 $1,403,646
Incomplete Motor Functional
at Any Level $321,720 $39,077 $1,461,255 $1,031,394
Data Source: Economic Impact of SCI published in the journal Topics in SCI Rehabilitation Volume 16 No. 4 in 2011 - cited by (**)

*http://www.sci-info-pages.com/facts.html
**https://www.nscisc.uab.edu/
***http://blog.lib.umn.edu/devag002/myblog/2011/04/
****http://www.clker.com/clipart-9213.html
*****http://images.main.uab.edu/spinalcord/pdffiles/Facts%2004.pdf
BACKGROUND
Injuries to the CNS consist in two main categories of lesions:
primary injuries, that occur at the moment of
trauma - currently most difficult, from medical point of
view, to be prevented (not speaking by educational - see
the short movie - and social/ legal measures)/limited and
even therapeutically, to be approached
secondary injuries, which occur after the initial
trauma, as a consequence of a complex and rather
specific to the CNS path-physiological events casca-
de and produce effects/damages that may continue
for long time (the first: minutes, hours and days - or even
months (o.n.) - for instance, after SCI*), considerably
worsening evolution and prognosis
*Hall ED, Springer JE - Neuroprotection and Acute Spinal Cord Injury: A Reappraisal.NeuroRx I (1):80-100, 2004
BACKGROUND
Traumatic and ischemic injuries of both, the
brain and the spinal cord (i.e. the CNS/ nevrax) -

- as path-physiological events cascade


that leads to secondary lesions -

have resembling and rather


overlapping types of mechanisms*
Both the early primary events and the delayed
secondary alterations contribute to the resulting
neurological deficits.**
*Onose G, Anghelescu A, Muresanu DF, Padure L, Haras MA et al. - Spinal Cord, 47 (10):716-726, 2009
Onose G, Ciurea AV et al. **Loane DJ, Faden AI Neuroprotection for traumatic brain injury: translational challenges and emerging therapeutic
Still, between spinal cord and brain
are some important structural
non-similarities too,
resulting also in different pathways of
responses to traumatic insults:
spinal cord crucial tracts are placed close
to the dural surface (superficial)
brain - deeper structures are basically
critical ones
Types of brain primary injuries:

primary injuries can manifest as focal ... (e.g.: skull


(penetrating) fractures/ wounds, intracranial
hematomas, lacerations, contusions), or
be diffuse (as in diffuse axonal injury - DAI)
.
Quantitatively, it seems the amount of brain dama-
ge is directly proportional to the rotational acce-
leration achieved and the mass of the brain*

*Dawodu ST - Traumatic Brain Injury (TBI) - Definition, Epidemiology, Pathophysiology -


http://emedicine.medscape.com/article/326510-overview#aw2aab6b4
BACKGROUND
... The major lesions/path-physiological conditions fol-
lowing primary injuries and involved in the secondary
brain damages development, are currently considered:
1. hemorrhage (extradural, subdural, subarachnoid,
intracerebral, intraventricular)
2. brain tissue swelling
3. loss of the local/regional blood flow ischemia
4. (and possibly/added) infection*.To be mentioned that
elevated intra-cranial pressure (ICP - especially over 40
mm Hg) aggravates TBI severiy - up to cerebral mass
herniation - andinviciouscircle, theitems2 & 3above, with
consequenthydrocephalusand hipoxia, respectively**...
*Teasdale GM, Bannan PE - in: Reilly P and Bullock R, editors - London: Chapman & Hall, pp.: 423-38, 1997
** Dawodu ST - Definition, Epidemiology, Pathophysiology - (Chief Ed.: Campagnolo DI): http://emedicine.medscape.com/article/326510-
overview
BACKGROUND
Another key aspect of the primary injury, at intimate
level, is the impact depolarization: effusion from
the disrupted cells of the potassium ions and of the
neurotransmitter glutamate - resulting in early and
very dangerous excitotoxicity phenomena, as an
important pathphysiological base for further
secondary injuries/damages.
As for primary injury in relationship to the subsequent
evolution, transsection of the pituitary stalk - with
consequent failure of it - and/or severe lesions of the
brain stem, are of poor prognostics
*Kochanek PM, Clark RSB, Jenkins LW - TBI: Pathobilogy - in: Zasler ND, Katz DI, Zafonte RD (Eds.) - Brain Injury Medicine: Principles
and Practice - Demos Medical Publishing, LLC, New York, 2007;
http://books.google.ro/books?id=Td100Pun9dYC&pg=PA758&lpg=PA758&dq=Haliday+al+pathophysiology++1999&source=bl&ots=l7l-
5SnFJ&sig=bcqlX_kdoaJqDmEpCP45opRT_CA&hl=en&sa=X&ei=l28HUuv3KciQ4gT8g4GYBw&ved=0CDYQ6AEwAQ#v=onepage&q=H
aliday%20al%20pathophysiology%20%201999&f=false
Factors and mechanisms, stimulating and inhibiting,
oxidative stress - by*
*Youdim MBH, Buccafusco JJ - Review. Trends in Pharmacological Sciences, 26 (1):27-35, 2005 (with a few adding)

Quercetin

Haber-Weiss: chemistry (reaction)


H2O2 O2- su)peroxid (anion) radical


Fibrillar aggregates of misfolded amyloid proteins ...
involved in ... variety of diseases ...: Alzheimer disease
(AD), type 2 diabetes, Parkinson, Huntington and prion-
related diseases.
... AD amyloid (A) peptides ... toxicity of amyloid
oligomers and larger fibrillar aggregates ... related to
perturbing ... biological function of ... adjacent cellular
membrane.*
*Florentina Tofoleanu & Nicolae-Viorel Buchete (2012) Alzheimer A peptide interactions with lipid membranes, Prion, 6:4, 339-345,
DOI: 10.4161/pri.21022; http://www.tandfonline.com/doi/full/10.4161/pri.21022#.VHjiKTccTIU
The mechanisms of primary injury themselves are not yet
completely elucidated. The contusive model is the most fre-
quent. From a morphological point of view, the epicenter of
the SCI is represented by a central hemorrhagic necrosis,
surrounded by surviving axons with a centrifugal distribution.
There are two paradigms that describe a primary axonal injury.
Probably the initial loss of axons has a centrifugal pattern, ex-
plicable by a longitudinal displacement of the cords central
content; this is assimilated to the mechanical events occurring
in a compressed toothpaste tube. In addition, the axiom a
chain is as strong as its weakest link may explain the vulnera-
rability of large, myelinated axons to trauma; the myelinated
portions of these axons are stiff and do not stretch well (al-
though they are generally quite distensible and can elongate
more than twice their normal length without breaking but
only when slowly stretched, at less than 0.5ms*).
*Blight AR, Decrescito V Morphometric analysis of experimental spinal cord injury in the cat; the relation of injury intensity to survival
of myelinated axons. Neuroscience; 19:321341, 1986
... The crititical velocity of tissue movement, which
will lead to an axonal tear in a spinal cord contu-
sion, is 0.5-1ms*. The distribution of tissue veloci-
ties in the rostral and caudal directions concentrates
most of the stretching and shearing forces in the
central part of the spinal cord,where the greatest
disruptions occur. Almost all of the stretch and
shear forces concentrate on the nodes of Ranvier
the weakest link which can easily break down. Seve-
red axons tend to retract, forming club endings. *,**
The hallmark of the secondary injuries are conside-
red, including recently, the oxidativedamages/stress***
*Blight AR, Decrescito V Morphometric analysis of experimental spinal cord injury in the cat; the relation of injury intensity to survival
of myelinated axons. Neuroscience; 19: 321341, 1986
**Onose G, Anghelescu A, Muresanu DF, Padure L, Haras MA et al. A review of published reports on neuro-protection inspinal cord
injury.Spinal Cord, 47 (10):716-726, 2009
***Jia Z, Zhu H, Li J, Wang X, Misra H, Li Y- Oxidative stress in spinal cord injury and antioxidant-based intervention. Spinal Cord
ETIOPATOGENIA ACCIDENTULUI/
ATACULUI CEREBRAL (AVC) ISCHEMIC

AVC
ISCHEMIC

AVC
AVC AVC
ATEROTROMBO-
ATEROTROMBOTIC CARDOIEMBOLIC
EMBOLIC

*Adams R.D,Victor M,,Adamc and Victors Principles of Neurology


BACKGROUND

high levels of ATP - enhanced hundreds of times than normal - provided


by astrocytes [they use the P2X7:death receptor to latch on neurons and
send them floods of signals, causing, by metabolic (di-)stress, their death (*)]
and respectively, cAMP depletion
by-products of many reactions, of the events cascade pathways, also sti-
mulate glial cells: they become hypertrophic, proliferative, up-regulating the
expression of glial fibrillary acidic protein (GFAP), and form a dense network
of glial processes both at - and extending - from the lesion site, involving also
secretion of a variety of cytokines and production of cell adhesion and
extracellular matrix (ECM) molecules.
Some of these products are inhibitory to regeneration, such as chondroitin
sulfate proteoglycans (CSPG) and collagen IV (**); there it results mainly in
gliosis
and in scars [a major source for further limits in CNS - including SC - recovery (***)]
*Goldman SA, Nedergaard M.- Erythropoietin strikes a new cord. Nat Med; 8:785-7, 2002
**Yona Goldshmit,Mary P. Galea1,Graham Wise, Perry F. Bartlett, Ann M. Turnley1 Axonal Regeneration and Lack of Astrocytis
Gliosis in EphA4-Deficient Mice The Journal of Neuroscience, 10 November 2004, 24(45):10064; 10.1523/JNEUROSCI.2981-04.2004
***Ciurea A.V., Onose G. et alBrain Limits in Neurorehabilitation After Head Injury,. - Invited paper at the 3rd World Congress
BACKGROUND
Usually, post injury, no significant regenerative
processes naturally occur in the CNS:
conversely, there are strong intrinsic
hampering (para)physiological - and
respectively, also pathological - processes that
prevent spontaneous recovery, thus explaining
the still poor therapeutic/ rehabilitative outcomes,
obtained in approaching of such conditions*
*Onose G - invited lecture presented at the 6th World Congress for Neurorehabilitation, Viena Austria March 21-25, 2010
BACKGROUND
... Mainly because:
neurons, lacking centrosoms, cannot reproduce/
regenerate
there are pre-formate pathways, which, from yet
unknown reasons, exert active opposition
to axonal re-growth.
But, at the same time, these: intrinsic, misfortunate
brakes to self-recovery and respectively, propensity
to detrimental evolutive pathways, are principal
actual targets for neuroprotective/pleiotropic (even
possibly, multimodal) therapies
BACKGROUND
Overall, it is considered that to prevent regeneration
within the CNS, there are - for resons yet unclear -
complex and well structured pathways, generically
called the "braking" machinery in neurons (entailing
mainly: NOGO proteins and receptors*,**,***, the Rho
family of receptors****, the TNF receptors larger
family) fitted for reacting with growth-inhibitory
molecules in myelin - hence propensive to block CNS
injured axons (re)-growth*****.
*Kartje GL, Schulz MK, Lopez-Yunez A, Schnell L, Schwab ME- Ann Neurol 1999; 45: 778786
**Buchli AD, Schwab ME - Ann Med 2005; 37: 556567
*** Schwab ME - Invited lecturree at the Summer School for the Biological Treatment of Chronic Spinal Cord Injury, Vienna, Austria, Oct. 2008
****McKerracher L, Higuchi H - Targeting Rho to stimulate repair after spinal cord injury - J Neurotrauma. ;23(3-4):309-17, 2006
*****5hao Z, Browning JL, Lee X, Scott ML, Shulga-Morskaya S et al, - Neuron, 45(3): 353 -9, 2005
Principale (alte) suferine ale sistemului nervos central -
(SNC) - exceptnd:TVM,TCC, AVC, sindroame demenia-
le, maladia Parkinson - cu potenial sever invalidant,
deci necesitante/ beneficiare de R/ NR (inclusiv de IDC):

- stri vegetative (de minim - sau respectiv - redus,


contien) sau tulburri neuro-psihice secundare TCC,
AVC, encefalopatii hipoxice - a se vedea mai departe

- boli demielinizante (n principal leuconevraxite: sclero-


za multipl - SM/ n plci - i oftalmoneuromielita
i respectiv, encefalomielite demielinizante primitive -
n majoritatea lor considerate n relaie cu triggeri
infecioi - virali)
- boli ale neuronului motor (combinate - sup. i inf.- scleroza late-
ral amiotrofic - SLA, cu diverse forme: sporadic, familial/ ere-
ditar, juvenil, complexul SLA parkinsonism-demen Western
Pacific, atrofia muscular progresiv, etc. -, ale neuronului motor
superior - parapareza spastic ereditar, virale: HIV sau de leuce-
mie uman cu celule T -, ale neuronului motor inferior - atrofia mus-
cular spinal sau respectiv, bulbo-spinal, poliomielita i sd. post-
polio, encefalita-(/mielita) prin infecie cu virusul West Nile, paraneo-
plazice)
- boli ale jonciunii neuro-musculare: miastenia gravis, sd.
Eaton-Lambert
- miopatii: ereditare (distrofii musculare - progresive, tip
Duchenne sau Becker -, miopatii metabolice sau mitocondriale,
canalopatii, motonii, paralizii periodice) sau dobndite: miopatii
metabolice, din boli: endocrine, inflamatorii/ asociate n boli sistemi-
ce/ infecioase/ toxice - inclusiv induse medicamentos)
BACKGROUND
Actually, at least regarding the SCI treatment - this is
generally limited to surgical intervention - SC:
decompression, drainage and spine stabilization -
and to complex (supportive and assistive) care,
intricated with long term rehabilitation programs and
respectively, follow-up.

Still, after the 1990's, advances in medical, surgical


and rehabilitative technologies, improved length and
quality of life (QOL) for people with TBI and SCI
INTRODUCTION. BACKGROUND
The modern, complex management of patients

with sub-/post-acute/sub-chronic conditions following

severe CNS lesions, entails (aside neurosurgical

and/or intensive care intervention(s) if

necessary) endeavors for (see further): balanced

pharmacological and not only


...
...
stimulation of neuroprotection, neurotrophicity

(and even to some limited extent) of neuro-/synap-

togenesis and respectively, modulation of neuro-

plasticity all, together and in judicious synergy,

with physical/kinesiological (including

rehabilitation nursing) speech and/or cognitive-

behavioral, therapies; accordingly, this resulted in


...
INTRODUCTION. BACKGROUND
...
an opportunity (not yet effective enough as referred to the
expectation horizon of such cases often severe and pos-
sibly characterized by definitive disability) to achieve,
nowadays, quite better clinical outcomes, compared
to the situation in previous decades.
All this frames including within the advanced holistic
and minutely comprehensive paradigm/integrative
perspective of Neurorestoratology*.
*Onose G. - Chapter approaching ssynthetic notions of neurorehabilitationn, integrated in the complex clinical management in post TBI
conditions - in the Neurosurgery volume, within the new edition of the (Romanian) National Surgery Textbook (in press)
Consequently, we stress upon some therapeutic
suggestions regarding this subject matter, syste-
matizing the most, to date, efficient obviously,
within major limits, according to the very low ca-
pabilities of CNS/spinal cord (SC) to post injury
self preserve and recover and accessible drugs,
respectively those having been already introdu-
ced in clinical practice (but at present, mainly used
to treat other, including neurological, conditions)
and hence, with relatively well known, determined
effects and/or respectively, restrictions.* ...
*Onose G, Haras M, Anghelescu A et al. Integrative emphases on intimate, intrinsic propensity/ pathological processes - causes of
self recovery limits and also, subtle related targets for neuroprotection/ pleiotropicity - in spinal cord injuries. Journal of Medicine and
Life, Vol.3, No.3:262-274, 2010
... This fully matches the spirit of the Beijing
Declaration of the IANRs statement (point/
article no. 7): Neurorestoratology recognizes
the importance of small functional gains that
have significant effects on quality of life.
Neurorestoratology is interested in the mecha-
nisms of spontaneous activity and enhancing
this recovery. (cited including in the recent work
Global clinical neurorestoration in complete
chronic spinal cord injury*).
*Huang HY et al. Global clinical neurorestoration in complete chronic spinal cord injury. Neuroreport Vol. 25, Issue 3:144; Feb 12, 2014
BACKGROUND
Because, at present, there is no cure for the CNS
lesions and their devastating sequels, many resear-
chers are addressing this matter and consequently, there
have been made progresses, but in the laboratory.

None of them succeeded, by now, to produce


the expected/long awaited by patients, radically
effective healing outcome, i.e. to spectacularly
improve the neurological/functional status. ...
BACKGROUND
... Although the secondary events cascade after CNS
(including traumatic brain - but quite similar in both, the
brain and the spinal cord) injuries, entails an extremely
profound and extended - as shown - reaction, it proved
at least partially, possible to be prevented/ reduced.
Minimizing the secondary damage cascade could result
in maximizing post-injury favorable evolution/recovery,
including more rapid and consistent neuro-rehabilitative
outcomes.
Therefore, the concept of secondary CNS injuries has
become the basis - many of them being related intimate
targets - for a developing array of neuroprotective
Onose et al. modern therapies ...
In our articles reviewing the main published reports
on neuroprotection in SCI and respectively, in TBI,
we have presented a synthetic/systematized, quite
exhaustive, list (and related details/comments) of the-
rapeutic means: pharmacological and/or procedures -
some of them experimantal or still in trials - considered
to have, more or less, neuroprotective properties in spi-
nal cord and brain injuries, within a color code*,** and
respectively, some accessible such related ones*** ...
*Onose G, Anghelescu A, Muresanu DF, Padure L, Haras MA et al. - Spinal Cord, 47 (10):716-726, 2009
**Onose G, Daia-Chendreanu C, Haras M,. Ciurea AV, Anghelescu A - Romanian Neurosurgery, Vol. XVIII, 1:11-30, 2011
***Onose G., Haras M, Anghelescu A, Mureanu D, Guiglea C et al. - Journal of Medicine and Life, Vol.3, No.3:262-274, 2010
...
Below, we present a relatively complete list of drugs and
procedures we reviewed as neuroprotective in spinal cord and
brain injuries, within a color code, illustrated as follows:
in SCI in TBI
mainly
researched/(relatively)
effective in SCI

rather equally
researched/
(relatively)
effective in SCI
and brain injuries

mainly
researched/(relatively)
effective in brain injuries
BACKGROUND
The Functional Independence Measurement
(FIM) is the most widely accepted functional
assessment measure in use in the rehabilitation
community. The FIM(TM) is an 18-item ordinal
scale, used with all diagnoses within a
rehabilitation population. It is viewed as most
useful for assessment of progress during
inpatient rehabilitation.*
It is also our opinion and related option for our
patients clinical-functional evaluation - at
admission and in dynamics, periodically. ...
*http://www.strokecenter.org/trials/scales/rankin.html
...Specifically,FIMconsistsof 13physical-that,in
sum,resultintheMotorSubtotalScore-and 5 cog-
nitive-that,insum,resultinthe CognitiveSubtotal
Score- items (separate scoring is acceptable, too);
eachitemisscoredfrom1 to 7points,accordingtothe
evaluatedpersonsneedofassistance(thehighestco-
rrespondstocomplete/unmodifiedindividualindepen-
dence,whereasthelowest designatesthedemand
for total assistance within complete dependence.
Hence, the maximal score obtainable - by a normal
person - is 126 points*. ...
*http://www.google.ro/#hl=ro&gs_nf=1&cp=39&gs_id=2&xhr=t&q=MEASUREMENT+SCALES+USED+IN+ELDERLY+CARE&pf=
p&output=search&sclient=psy-
ab&oq=MEASUREMENT+SCALES+USED+IN+ELDERLY+CARE&gs_l=&pbx=1&bav=on.2,or.r_gc.r_pw.r_qf.&fp=7a5d87c28fc409&
biw=998&bih=665 - (pdf) The Functional Independence measure
BACKGROUND
... Synergistically/complementary,weperform
(andrecommend to be done), whenever applicable,
testing for:
- articular function (Range Of Motion - ROM*)
- muscular force (the Medical Research Council -
MRC - scale**)
- (basic) activities of daily living (B/ADL)***
- instrumental activities of daily living (I/ADL)****
- spasticity - the modified Ashworth Scale (MAS)*****
...
* http://www.continuing-ed.cc/hsgoniometry/goniometrystandards.pdf
**Vanhoutte EK, Faber CG, van Nes SI et al. - Modifying the Medical Research Council grading system through Rasch Analyses -
Brain, doi:10.1093/brain/awr318; pp.:10-11, December, 2011
***Katz Index of Independence in Activities of Daily Living - www.consultgerirn.org/uploads/File/trythis/try_this_2.pdf
****Lawton & Brody - www.abramsoncenter.org/pri/documents/iadl.pdf
*****Bohannon RW, Smith MB - Interrater Reliability of a Modified Ashworth Scale of Muscle Spasticity. PHYS THER. 67:206-207,
BACKGROUND
...
Additionally -whenever necessary/applicable -
testing for:
- cognition (the Minimental State Examination -
MMSE*)
- communication (Boston Diagnostic Aphasia
Examination - BDAE** -/Boston Naming Test***)
- quality of life (QOL)****.
*Folstein - http://enotes.tripod.com/mmse.pdf
**Goodglass, Kaplan - http://www.d.umn.edu/~mmizuko/3411/may11.htm
***Graves RE,. Bezeau SC, Fogarty J, and Blair R - Boston Naming Test Short Forms: A Comparison of Previous Forms with New
Item Response Theory Based Forms. Journal of Clinical and Experimental Neuropsychology Vol. 26, No. 7, pp. 891-902, 2004;
web.uvic.ca/psyc/graves/Papers/JCEN-BNT_
****Flanagan (short form) - qol.pdf - Instructions for Scoring the Quality of Life Scale - Burckhardt CS;
www.uib.no/isf/people/doc/qol/qol.pdf; http://qol.thoracic.org/sections/instruments/fj/pages/flan.html
(by *von
Wild KR -
A more detailed
Early
rehabilitation
of higher
variantofFIMisthe
cortical
brain Functional As-
functioning
in
neurosurger
sessment Measu-
y,
humanizing
the
re (FAM) - aside
restoration
of human thecontent of FIM,
skills after
acute brain
lesions. Acta
it includesalso o-
Neurochir
Suppl. 99:3-
10, 2006) -
ther12items:swal-
EXHAUS-
TIVE/ VERY
lowing, of mobility
DETAILED/
THOROUGH psycho-cognitive/
emotional, socio-
communityinterac-
tiontypeetc. - recom-
mended (?) FIM+FAM
(* - see for FIM)
BACKGROUND
Particularly in the Anglophone literature, a cognitive function
assessment tool is often described: "Rancho Los Amigos Levels of
Cognitive Functioning Scale (Hagen, Malkmus, Durham, 1972
"Rancho Los Amigos Cognitive Scale Revised" - Malkmus, Stenderup ,
1974)*, **, ***, ****, highlighting the contributory elements (the testing is
applicable at any of post-critical/ rehabilitative evolution stage and gives
useful information for the medical team and the patient's family, and
even for the patient - in the advanced stages of his/her rehabilitation) as
well as the methods limits: some patients do not progress in order to
achieve sufficient recovery levels for significant differentiation, the
instrument being, therefore, useful in current medical care, but of
reduced value for research; also, since it is relatively dense in terms of
descriptive information, collected during its fulfillment, it may be difficult
to be carried on in outpatients
*Cifu DX, Kreutzer JS, Slater DN, Taylor L - Rehabilitation after Traumatic Brain Injury - in: Braddom R.L. et al. - Physical Medicine & Rehabililitation (3rd
edition). W. B. Saunders Company, Philadelphia, U.S.A., 2007
**Boake C, Francisco GE, Ivanhoe CB, Kothari S - Brain Injury Rehabilitation - in: Braddom R.L. et al. - Physical Medicine & Rehabililitation (2nd edition). W. B.

Saunders Company, Philadelphia, U.S.A., 2000


***Whyte J, Ponsford J, Watanabe T, Hart T - Traumatic Brain Injury - in: Frontera WR, DeLisa JA, Gans BM et al. (Eds.) - DeLisas Physical Medicine &

Rehabilitation Principles and Practice, Fifth Edition, Vol. I, Woltres Kluwer Health. Lippincott Williams & Wilkins, Philadelphia, USA, 2010
****http://www.northeastcenter.com/rancho_los_amigos_revised.htm]
BACKGROUND
It is a method of analysis structured in 8 (10 - as revised)
stages of cognitive-behavioral reactivity (1 - complete non-
responsiveness - to 8: quasi-normal, person consistently oriented
to self, space and time, having the ability to understand and react
appropriately to environmental stimuli, memory, attention and
autonomy - both: home/ Activity and in community/ Participation,
ICF - regained, even with the ability to perform, once learned,
tasks without mandatory supervision, but may still persist
diminished social skills, emotional and cognitive, or - as per level
10 of the revised scale - fatigue, requiring more frequent breaks,
relatively slow in making decisions and/or in performing various
self-serving tasks, namely socio-professional as well as, possibly
requiring "compensatory strategies" for initiation/ completion, or
episodes of depression and/or frustration/irritability in stressful
medical and/or social conditions - yet without becoming
significantly behavioral decompensate in public.
BACKGROUND
In SCI, main used, including by us, evaluation methods/ scales, are the:
- Rapid neurological assessment (Determine approximate neuro-
logical level. Screen sensation by running a finger or cotton swab
for light touch or a pin wheel for pin prick over the injured legs, trunk
and arms. Screen motor power by having the patient (flex - o.n.)/
extend the (thighs - o.n.)/knee, wiggle the toes, flex the elbow and
squeeze your finger. Determine completeness or incompleteness
of injury. Assess the sacral segments, particularly if the injury seems
otherwise complete. Perform a digital rectal examination with a glo-
ved finger, for deep pressure sensation, voluntary sphincter con-
traction and reflex activity (bulbo-cavernosus reflex - see next slide).
Check pinprick sensation in the perianal region and note the pre-
sence or absence of the anal wink (ano-cutaneos - o.n.) reflex. Per-
form detailed examination of zone of injury. Conduct a detailed as-
sessment of sensation and strength at the zone of injury. This should
include muscles and dermatomes one to two levels above and be-
low the injury level.*(Marino R - Neurologic Assessment of Spinal Cord Dysfunction - in: Lin Vernon W (Ed.-in-Chief), Cardenas
Diana D, Cutter NC (Associate Eds. et al.) - Spinal Cord Medicine Principles and Practice. Demos Medical Publishing, LLC., New York, 2003 ...
...

Bulbo-
cavernosus
reflex (with
permission, by
elearnSCI.org
Submodule:
Clinical
assessment of
patients with
SCI - Doctors
Module - Aito S
(Coordinator) et
al., 2012 -
http://www.elea
rnsci.org/

American Spinal Injury Association (ASIA) Impairment Scale (AIS) scoring (after:
http://www.scribd.com/doc/37064936/2006-Classif-Worksheet) - with included/ adapted Frankels grading semi
quantitative system - to describe/ assess the severity of lesion (neurologic and functional consequent

impairment( including with some main related clinical syndromes - see next two slides, too) ...
...

*Thomas FP, Woolsey RM Acute


Nontraumatic Myelopathies in: Lin
Vernon W (Ed.-in-Chief), Bono
Christopher M, Cardenas Diana D
(Associate Eds. et al.) - Spinal Cord
Medicine Principles and Practice - *
(inverse paraplegia)
Second Edition. Demos Medical
Publishing, LLC., New York, 2010
**Aito S (Coordinator) et al. -
Submodule: Clinical assessment of
patients with SCI - Doctors Module -
(http://www.elearnsci.org/) , 2012 ** ***
Posterior (dorsal) cord syndrome
,
***Woolsey RM, Martin DS - Acute Nontraumatic
Myelopathies in: Lin Vernon W (Ed.-in-Chief), Transverse/ transsection (total) cord syndrome
Cardenas Diana D, Cutter NC (Associate Eds. et al.) -

Medical Publishing, LLC., New York, 2003 http://www.scribd.com/doc/37064936/2006-Classif-Worksheet with some adding ...
Spinal Cord Medicine Principles and Practice. Demos After: http://www.asia-spinalinjury.org/publications/59544_sc_Exam_Sheet_r4.pdf;
... BACKGROUND
- American Spinal Injury Association (ASIA) Impairment
Scale (AIS) scoring - with included/adapted Frankels
grading, semi quantitative system - to describe/assess the
severity of lesion (neurologic and functional impairment)
- Functional Independence Measure (FIM - see previous)
- Spinal Cord Independence Measure (SCIM-III - because
it is now at its trird version): a more specific -of 94 cate-
gories (possible activities to be or not/ partially performed
- o. n.) that define 18 individual tasks (items) divided into 3
subscales (areas of function) as follows: self-care (score
range, 0-20), respiration and sphincter management (ran-
ge, 0-40), and mobility (range, 0-40) - including currently
considered to have each area scored according to its pro-
portional weight in their general activity and to be more sen-
sitive to changes in their clinical/functional evolution ...
...
BACKGROUND
Likewise within the FIM, the basic ranking
paradigm assumes that higher scores reflect
higher functionality.
After long-term and sustained clinical testing and
successive work for its validation, about SCIM III,
it has been very recently concluded that The chan-
ges in SCIM III grades and the stability of their rela-
tionship with the total SCIM III scores (TSS)
throughout rehabilitation, support the validity and
the reliability of the classification. *,**,***,****,***** ...
*Catz A, Itzkovich M, Agranov E, Ring H, Tamir A. SCIM - Spinal Cord Independence Measure: A new disability scale for patients with
spinal cord lesions. SpinalCord.;35(12):85056, 1997
**Catz A, Itzkovich M, Steinberg F, Philo O, Ring H, Ronen J, et al. The Catz-Itzkovich SCIM: a revised version of the Spinal Cord
Independence Measure. Disabil Rehabil.15;23(6):263-8, 2001
***Catz A, Itzkovich M, Tesio L, Biering-Sorensen F, Weeks C, Laramee MT, et al. A multicenter international study on the Spinal Cord
Independence Measure, version III: Rasch psychometric validation. Spinal Cord. 45(4):275-91, 2007
...

(after: http://www.scientificspine.com/spine-scores/spinal-cord-independency-measure_(SCIM).html) ...


... Other evaluation (with more restrcted focuses or less specific) ins-
truments/tools used, including to approach post SCI patients:
- the Spinal Cord Index of Function (SIF) - a new instrument on
activity level, measuring the ability to perform various transfers in non-
walking patients with a spinal cord lesion *
- the Walking index for spinal cord injury (WISCI - including revised
and submitted to validation in US and Europe related populations**,***- see further)
- the Timed 10-Meter Walk Test****
- the Six-Minute Walk Test*****
- the AuSpinal test of hand function - new, submitted to validation - for
quantifying unilateral hand function in tetraplegics******
- the Jebsen Test of Hand Function*******
- the quality of life (QOL) SF test - see a previous slide ...
*Johansson C, Bodin P, Kreuter M - Validity and responsiveness of the spinal cord index of function: an instrument on activity evel. Spinal
Cord 47(11):817-21,2009; Epub 2009 Jun 16
**Dittuno PL, Ditunno JF Jr - Walking index for spinal cord injury (WISCI II): scale revision. Spinal Cord 39(12):654-6, 2001.
***Ditunno JF, Scivoletto G, Patrick M, Biering-Sorensen F, Abel R, Marino R - Validation of the walking index for spinal cord injury in a US and
European clinical population. Spinal Cord 46(3):181-8, 2008 Epub 2007 May 15
****,*****http://www.google.ro/#hl=ro&gs_nf=3&pq=validation%20ofthe%20walking%20index%20for%20spinal%20cord%20injury%20in%20a%2
0us%20and%20european%20clinical%20population&cp=24&gs_id=2m&xhr=t&q=10+meter+walk+test+and+6&pf=p&sclient=psy-
ab&oq=10+meter+walk+test+and+6&gs_l=&pbx=1&bav=on.2,or.r_gc.r_pw.r_qf.&fp=bee276c149b7ab73&bpcl=35466521&biw=1366 &bih=673
******Coates SK, Harvey LA, Dunlop SA, Allison GT - The AuSpinal: a test of hand function for people with tetraplegia. Spinal Cord. 49(2):219-29,
2011;Epub 2010 Aug 3
*******http://www.google.ro/#hl=ro&gs_nf=3&cp=11&gs_id=16&xhr=t&q=jebsen-taylor+hand+function+test&pf=p&sclient=psy-ab&oq=jebsen-
tayl&gs_l=&pbx=&bav=on.2,or.r_gc.r_pw.r_qf.&fp=bee276c149b7ab73&bpcl=35466521&biw=1366&bih=673
...
SCI can be divided in two main types of lesion/
functional damage, i.e.:
complete and incomplete.
Complete means there is no function/control
below the cord level of injury : no
sensations and no voluntary movement is
preserved (including) in the sacral segments

S4,5 *,** ...


*Maynard FM, Jr, Bracken MB, Creasey G, Ditunno JF Jr, Donovan WH et al - International Standards for Neurological and
Functional Classifcation of Spinal Cord Injury - Spinal Cord, 35: 266- 274, 1997

**Onose G - What do (rehabilitation) physicians know about para/ (tetra)plegia and tell their patients after SCI, presented at the
6th World Congress for Neurorehabilitation, Viena Austria march 21-25, 2010
...
assisting/ trainig the process (usually required)
to evacuate urine (bladder catheterization, initially
continuously, and subsequently, intermittently - for
which previous training may be done by clipping
the probe - then, intermittent catheterization itself is
an element of training - with some limited recovery

facets on bladder control)

bowel management and control training - the


above considerations can be similarly made concer-
ning digital annal evacuation/ manipulation) ...
Some of the previous mentioned measures include,
critical steps; therefore they are mandatory and
urgent (e.g.: tracheal/ brochial aspiration, urine/ stools
evacuation) and do not require patients
effort - such as for active kinetotherapy.

This is mainly the case for RN, set immediately


after taking in charge the inpatient - still in acute
spinal shock and/or even further, if having
hyperchronic evolution - usually characterized by
weakness and fragility
To these, in the post acute phase (usually with
duration of weeks), begin to be added,
progressivelly, physical - kinetological more pro-
active procedures, towards theswitch, from
upmost RN to mainly properly rehabilitative

programmes:

assist, facilitate or (re)training of active


movements - where appropriate, also skills in
the limbs - and/or trick gestures, with
propensity for self care