Autonomy, a person’s capacity to judge, decide, and act on the basis of their own attitudes and reasoning, is a key concept in the treatment of people with spinal cord injury. Autonomy is generally held to be a fundamental patient right. However, little study has been done about patients’ own individual ideas or experience of autonomy.

When patient perception is taken into account, the picture of what autonomy means in a rehabilitative or household setting becomes more complex. Patients typically have three categories of activities: 1) tasks they would like to delegate, over which they do not wish to retain control; 2) tasks they would like to delegate, but remain in charge of; and 3) tasks they would like to perform themselves.

How tasks get sorted into these categories is a complicated interaction between the patient, his or her environment, and the nature of the disability. There may be social, emotional, or other costs and benefits associated with all of these. For example, a patient may wish to attend a community event. However, to do so would require him to ask for a ride, which he feels encroaches on his independence and may place stress on his caregivers. In addition, sitting in one position for a long time at the event may carry a risk of exacerbating his pressure ulcers.

Rehabilitation professionals can help patients learn to negotiate these processes, and empower their sense of agency.

Van de Velde, D, Bracke, P, Van Hove, G, et al. The illusion and the paradox of being autonomous, experiences from persons with spinal cord injury in the period of their transition from hospital to home. Disability & Rehabilitation. (2001).

Our country is notoriously difficult for epidemiological research because of its diversity not only culturally and socioeconomically, but also in healthcare and the ability to track diagnoses.

In an attempt to conduct an epidemiological study of spinal cord injury within a closed system, a recent study used the US military to describe the risk factors for spinal cord injury. The military represents a diverse demographic that is not affected by state-to-state differences of economy or healthcare.

Their major findings were that being male, white, and between the ages of 20 and 39 represented the most significant risk factors for spinal cord injury. In addition, the study found that lower ranking military were also at higher risk, which may reflect socioeconomic differences. Some of the limitations of the study are obvious—women and older adults are misrepresented in the military. However, the study only represented injuries sustained during the course of service and not during combat, and therefore does have usefulness as a representation of civilian spinal cord injury in the US.

Schoenfeld AJ, McCriskin B, Hsaio M, & Burks R. Incidence and epidemiology of spinal cord injury within a closed American population: The United States military (2000-2009). Spinal Cord. (September 2011).

An important factor to both rehabilitation and litigation efforts is the length of time it takes for a spinal cord injury patient to return to work. Currently, the average time to return to work is five years. However, this can vary greatly (research shows between 3 months and 20 years) and depends on several factors.

One important factor is the ability to return to the previous employer. People who have the opportunity to return to their pre-injury job are more likely to do so much faster than those who have to look for a different job. Older age and less education are factors related to a greater amount of time needed to return to work. Both rehabilitation and litigation efforts need to assess the feasibility of further education or the likelihood of returning to work at all. And, although most people who do return to work do so full time, there is the possibility that a patient may only be able to work part time.

In addition, the current economy significantly limits work opportunities for a spinal cord injury patient. Although disability policies may be in place, employers may be less likely to enforce them in light of hard economic times. Employers have been showing a bias towards hiring people who are currently employed or just recently unemployed. This bias may extend to people who have been unemployed for long periods of time due to disability.

Ramakrishnan K, Mazlan M, Julia PE, & Latif LA. Return to work after spinal cord injury: Factors related to time to first job. Spinal Cord. (September 2011).

There are various factors that influence how and when a spinal cord injury patient returns to work—such as type of pre-injury employment, amount of family support, or years of education. A recent study focused on the factors that influenced the length of delay between the time of injury and the first post-injury job.

The results of this study found that returning to work for the same employer as before the injury shortened the delay of return to work after injury. In addition, having a higher level of education and being Caucasian were factors associated with a quick return to work. Interestingly, when transitioning from first post-injury job to first post-injury full-time job, Caucasian men were more likely to have a quick transition into full-time work after injury. Non-Caucasians, and women took longer to find full-time work after injury.

The implication of this research is that women, non-Caucasians, and people with lower levels of education may find themselves at a disadvantage when finding post-injury work. This can result in longer intervals of unemployment, lower earnings, and greater difficulty in paying medical and rehabilitation bills.

Krause JS, Terza JV, Saunders LL, & Dismuke CE. Delayed entry into employment after spinal cord injury: Factors related to time to first job. Spinal Cord. (June 2010).

Suicide bombing has increased in the last decade, and causes death or injury to surrounding victims (often military). A recent study from a military hospital based in Pakistan has discovered an unusual pattern of spinal cord injury to victims of suicide bombing blasts. This pattern includes:

• Injury to the thoracic area of the spine, which could be because people who suffer an injury to the cervical area of the spine do not often survive the time it takes to evacuate a site and receive medical attention.
• Additional injuries to soft tissue, intestines, and bones as a result of flying parts of the bomb.
• Low rates of neurological improvement, probably because of multiple and complex injuries. Only half of the patients described in this study showed any neurological improvement.

The researchers felt that spinal cord injury resulting from suicide bombings is probably more frequent than we currently understand, and the lack of adequate spinal cord care in Pakistan may be of detriment to both military and civilian survivors.

Rathore FA, Ayub A, Farooq S, & New PW. Suicide bombing as an unusual cause of spinal cord injury: A case series from Pakistan. Spinal Cord. (August 2011).

Spinal cord injury in children is fairly uncommon, and research that compares pediatric versus adult spinal cord injury is even more so. A recent research review, however, has revealed a few major differences in the two:

• First, the review found that pediatric patients have a different mechanism of injury. Younger children are more likely to experience injury from a car accident, and adolescents from sports.
• Second, pediatric spinal cord injury patients recover slightly better than adults. Although the research on this is limited, there is some evidence that children are more likely than adults to experience some neurological recovery.
• Third, children who are injured during adolescence are more likely to develop scoliosis as a result.
• Finally, there is no evidence that supports the use of neuroprotective therapies such as steroids after pediatric spinal cord injury.

The reviewers recommended that children who show abnormalities in the neck or neurological exam should be further examined for injury.

Parent S, Mac-Thiong J-M, Roy-Beaudry M, Sosa JF, & Labelle H. Spinal cord injury in the pediatric population: A systematic review of the literature. Journal of Neurotrauma. (August 2011).

Depression is such a common symptom after injury to the brain or spinal cord that antidepressant therapy has become almost compulsory. Although research on outcomes of antidepressant use after injury has been mixed, patients are still put on antidepressant therapy with a general belief that it will improve outcome.

However, a new study shows that antidepressant therapy after brain or spinal cord injury may actually interfere with recovery. When comparing antidepressant use in stroke, traumatic brain injury, and spinal cord injury patients, the study found that people who began antidepressant therapy in the rehabilitation unit had significantly longer stays than people who had not used antidepressants at all, or who had only used them for a short period in the acute stages of the injury.

The researchers suggest that the explanation for this surprising result may lie within the effects of the medication, and not the symptoms of depression itself. Patients who had depression, but who were not treated, stayed in the rehabilitation unit for shorter lengths of time than those who were treated.

Weeks DL, Greer CL, Bray BC, et al. Association of antidepressant medication therapy with inpatient rehabilitation outcomes for stroke, traumatic brain injury, or traumatic spinal cord injury. Archives of Physical Medicine and Rehabilitation. (May 2011).

Timing of exercise training after spinal cord injury (as well as traumatic brain injury) has been thought to be critical to recovery. However, researchers have not reached consensus—some studies show that early intervention is best, while others suggest that a delayed intervention is more effective.

A recent animal study found that an early intervention (one day after spinal cord injury) of a moderate exercise program resulted in significantly more recovery that a delayed intervention (eight days after injury). Damage across spinal areas was also significantly less in the early intervention than in the delayed intervention.

This study supports early exercise training, and suggests that there may be a critical period in which the spinal cord is more plastic and therefore more receptive to repair.

Brown Ak, Woller SA, Moreno G, et al. Exercise therapy and recovery after SCI: Evidence that shows early intervention improves recovery of function. Spinal Cord. (March 2011).

Human spinal cord injury is typically a permanent injury that results in a devastating loss of function. There has been much research on promoting regeneration and re-growth of spinal structures, but unfortunately there has been little progress to date.

Certain classes of fish are of interest to spinal cord research because, although their spinal cords are very similar to ours, these classes of fish are capable of spontaneous recovery of both structure and function. A recent review of spinal cord regeneration in fish has summarized the specific factors that may allow for spontaneous recovery in the Teleost fish.

Factors such as increased stem cell generation and recruitment, an overall better response to injury, and a more complementary environment for repair are of interest to researchers who are hoping to find a way to translate these factors into useful treatment for human spinal cord injury.

Sirbulescu RF, & Zupanc GKH. Spinal cord repair in regeneration-competent vertebrates: Adult teleost fish as a model system. Brain Research Reviews. (January 2011).

People with spinal cord injury may be more susceptible to premature aging, possibly because the additional stress on physical systems such as organs or muscles is beyond the injured body’s capacity for repair.

A recent research review has found significant evidence of premature aging after spinal cord injury within cardiovascular, endocrine, and musculoskeletal systems. Specifically, people with spinal cord injury are predisposed to premature carbohydrate and lipid abnormalities, hormone deficiencies, and rapid bone loss (both density and mass). Other physical systems may also be negatively affected, but more studies are required to confirm this.

When looking ahead at the needs and challenges facing a spinal cord injury patient, the effects of premature aging should therefore be given serious consideration.

Hitzig SL, Eng JJ, Miller WC, & Sakakibara BM. An evidence-based review of aging of the body systems following spinal cord injury. Spinal Cord. (January 2011).