CDE Detailed Report

Only answer if there is a history of pneumonia after spinal cord lesion and within the last year. If number of episodes is unknown then code 999 (999 = Unknown).

The results can be recorded as negative, positive or unknown. An unknown result could occur from the test being unreadable, unusable, or not done.

In individuals with episodes of fecal incontinence to solid stools before the last three months without any episodes within the last three months the code "Never" and not the code "Less than once per month" should used. The code "Not applicable" is mainly for individuals with stomas.

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).
Injury through the spinal column is defined as any break, rupture, ligament tear, disruption, or crack through the bony vertebral elements or through the non-bony disc and ligamentous soft tissues between the vertebrae from the occipital condyles to the sacrum. Patients with cervical spondylosis and spinal stenosis may suffer a traumatic spinal cord injury without a spinal column injury.

Based on physical examination

Record any assistance device utilized at the time of evaluation to augment ventilation. For each device indicate if it was utilized at the time of evaluation.
Respiratory insufficiency is common following spinal cord lesions. Ventilatory assistance devices include, but are not limited to: mechanical ventilators, phrenic nerve stimulators, diaphragmatic pacers, external
negative pressure devices, and bi-level positive airway pressure (BiPAP). These devices do not include routine administration of oxygen, intermittent positive pressure breathing (IPPB), or continuous positive airway pressure (CPAP). Wording of this variable reflects the International Spinal Cord Injury Core Data Set for the type of ventilatory assistance used to sustain respiration at discharge after the initial rehabilitation period following the spinal lesion (DeVivo et al. 2006). As the situation may have changed since discharge from the initial inpatient period the question is asked.

Choose one. The code "Not applicable" is mainly for individuals with stomas or individuals without sensation of need to defecate.

Choose one. Awareness of the need to empty the bladder indicates any kind of bladder sensation as defined by International Continence Society (Abrams et al. 2002), i.e. normal (the individual is aware of bladder filling and increasing sensation up to a strong desire to void), increased (the individual feels an early and persistent desire to void), reduced (the individual is aware of bladder filling but does not feel a definite desire to void) or non-specific bladder sensation (the individual reports no specific bladder sensation, but may perceive bladder filling as abdominal fullness, vegetative symptoms like sweating or spasticity). No awareness of the need to empty the bladder should be noted as "no". Absent bladder sensation according to the definition of bladder sensation by the International Continence Society (the individual reports no sensation of bladder filling or desire to void) (Abrams et al. 2002) is not exactly the same as filling sensation and desire to void can be absent while temperature sensation or electrosensation can be present. "Not applicable" is to be used when the individual with spinal cord lesion has for example an unclamped indwelling catheter or non-continent urinary diversion.

Response of "Not applicable" includes too young to determine.

Respiratory insufficiency is common following spinal cord lesions. Ventilatory assistance devices include, but are not limited to: mechanical ventilators, phrenic nerve stimulators, diaphragmatic pacers, external negative pressure devices, and bi-level positive airway pressure (BiPAP). These devices do not include routine administration of oxygen, intermittent positive pressure breathing (IPPB), or continuous positive airway pressure (CPAP). Wording of this variable reflects the International Spinal Cord Injury Core Data Set for the type of ventilatory assistance used to sustain respiration at discharge after the initial rehabilitation period following the spinal lesion (DeVivo et al. 2006). As the situation may have changed since discharge from the initial inpatient period the question is asked.

For each bowel care position indicate if it was used within the last three months

For each method of bladder emptying, indicate whether this is a main or a supplementary method. Two main and more supplementary methods may be indicated (adopted from Levi and Ertzgaard 1998).
Normal voiding: Voluntary initiation of micturition without reflex stimulation or compression of the bladder. This does not presume entirely normal function (Levi and Ertzgaard 1998).
Bladder reflex triggering comprises various manoeuvres performed by the individual with spinal cord lesion or an attendant in order to elicit reflex detrusor contraction by exteroceptive stimuli. The most commonly used manoeuvres are
suprapubic tapping, thigh scratching and anal/rectal manipulation (Abrams et al. 2002).
Voluntary bladder reflex triggering indicates that the bladder reflex is triggered by the spinal cord lesioned individual him/herself or by the attendant.
Involuntary bladder reflex triggering imply that there is no voluntary triggering of the voiding, but the individual with spinal cord lesion just let the urine run by itself when the reflex detrusor contraction occur by itself.
Bladder expressioncomprises various manoeuvres aimed at increasing intravesical pressure in order to facilitate bladder emptying. The most commonly used manoeuvres are abdominal straining, Valsalva's manoeuvre and CredÉ manoeuvre
(Abrams et al. 2002).
Straining includes abdominal straining, Valsalva's manoeuvre.
External compression includes CredÉ manoeuvre.
Catheterisation is a technique for bladder emptying employing a catheter to drain the bladder or a urinary reservoir (Abrams et al. 2002).
Intermittent catheterisation is defined as drainage or aspiration of the bladder or urinary reservoir / continent urinary diversion with subsequent removal of the catheter.
The following types of intermittent catheterisationare defined by the International Continence Society (Abrams et al. 2002):
Intermittent self-catheterisation is performed by the individual with spinal cord lesion himself/herself
Intermittent catheterisation can also be performed by an attendant (e.g. Family member or personal aid)
Indwelling catheterisation:an indwelling catheter remains in the bladder, urinary reservoir or urinary conduit for a period of time longer than one emptying (Abrams et al. 2002).
Transurethral indwelling catheterisationindicates that the urine is drained trough a catheter placed in the urethra.
Suprapubic indwelling catheterisation indicates that the urine is drained trough a catheter via the abdominal wall.
Sacral Anterior Root Stimulator (SARS): Emptying the bladder by electrical stimulation of the anterior sacral nerve roots via implanted electrodes.
Non-continent urinary diversion/ostomy: This includes ureteroileocutaneostomy (Bricker conduit), ileovesicostomy, vesicostomy. If any other method is used for bladder emptying it is recommended to be written in a text-field, from which it will be possible to retrieve more detailed data when necessary. Because other methods of bladder emptying are generally rare, it is not practical to give an inclusive list of bladder emptying methods. Use of diapers etc. because of incontinence is not to be reported here,but under "Collecting appliances for urinary incontinence".

For each event related to cardiovascular function after spinal cord lesion record whether it was experienced by the participant.
These time-limited cardiovascular events with long-term sequelae should have their dates documented to be able to compute the time since injury and to identify the data collected in relation to various time points. If more than one episode has occured the last one has to be documented.

Choose one
Many individuals with SCI lack any awareness of the need to defecate. Others have indirect symptoms. These are mainly abdominal cramping or discomfort and spasms of the abdominal muscles or lower extremities. Autonomic symptoms including headache, perspiration, piloerection, and chills before or during defecation are common, especially in individuals with lesions above Th6 (Krogh et al. 1997). Autonomic symptoms are often unpleasant to the individual and may indicate insufficient bowel emptying. Lack of awareness of the need to defecate is especially common in individual with complete lesions and increases the risk of fecal incontinence. Symptoms may change with time and in the present data set they are given for the last four weeks.

Choose one

For each method of bladder emptying, indicate whether this is a main or a supplementary method. Two main and more supplementary methods may be indicated (adopted from Levi and Ertzgaard 1998).

Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).