Bone is lost following spinal cord injury (SCI) and in the long-term may become osteopenic and liable to fracture. Two non-invasive techniques, ultrasound bone densitometry (USBD) and dual energy X-ray absorptiometry (DXA), have been applied to monitor bone changes after spinal injury. 31 SCI patients were scanned using an ultrasound bone densitometer, to give measurements of speed of sound (SOS), broadband ultrasound attenuation (BUA) and 'stiffness'. The time since injury of these patients ranged between 5 weeks to 36 years with a mean of 5.87 ± 10.21 years. Ultrasonic properties at the calcaneus of these patients were significantly lower than the healthy reference population, and a rapid decline in ultrasound properties occurred in the first 3 months. The fall continued up to 54 months but at a slower rate. The normal linear relationship between SOS and BUA was not altered by SCI. Eighteen patients had DXA measurements at the lumbar spine and the right proximal femur. Bone mineral density (BMD) at the femoral neck was significantly lower than the normal reference population (P < 0.05). SOS and 'stiffness' correlated significantly with BMD at the lumbar spine, Ward's triangle, the femoral neck, the greater trochanter and the intertrochanteric site (P<0.05). BUA correlated significantly at all these sites with the exception of the trochanter. A negative correlation was found between the ultrasonic properties at the calcaneus and BMD at the lumbar spine which is in contrast to the positive relationship in normal subjects. There was a tendency for BMD to increase at the lumbar spine after the first 12 months after injury, although this trend was not significant overall. The 'stiffness' at the calcaneus and BMD at the femoral neck were lower than the reference population following 12 months since injury. These results show that bone deficit at the calcaneus occurs rapidly and to a severe degree after SCI, and that ultrasound has an important role to play in the assessment of bone status in these patients.
A survey of UK medical schools was undertaken to determine the teaching that was being offered on disability and rehabilitation. In general, teaching on this topic appeared fragmented and inadequate but a number of interesting innovations were identified. These included: a drama workshop run by a group whose members mainly have learning disabilities at St George's Medical School, student-directed learning at the University of Dundee and structured teaching programmes at the Universities of Leeds and Edinburgh. The General Medical Council Education Committee's 1991 discussion document on the undergraduate curriculum specifically mentions disability as an important topic. A number of schools mentioned that they were in the process of revising their curriculum as a consequence. Recommendations arising from the findings of the survey include integration of disability and rehabilitation into clinical teaching, focus of teaching on those types of disability which are common in the community, greater emphasis on functional assessment in teaching the physical examination, and the wider use of standard assessment instruments, for example for activities of daily living, cognitive impairment and locomotor disability. There is a need for improved communication between medical schools to facilitate the spread of educational activities on this topic.
As in other areas of rehabilitation, relatively small numbers and diversity--both of condition and of patients' goals--hinder the assimilation of robust evidence for the effectiveness of rehabilitation. Patients with spinal cord injury (SCI) tend to be gathered together in a small number of regional services, each with their own philosophy and each with different attitudes to outcome measurement, and thus collection of the existing trials for meta-analysis is problematic. The marked improvement in outcome from SCI that has occurred with the development of specialist rehabilitation programmes argues strongly for the effectiveness of rehabilitation, and we have progressed beyond the point where randomized controlled trials that deny a group such intervention could be considered ethical. Current research is aimed at teasing apart the aspects of different care models that are most effective, or the evidence for the usefulness of interventions for control of symptoms such as spasticity and pain. This evidence is reviewed and discussed.
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