CDE Detailed Report | NINDS Common Data Elements

Disease: Spinal Cord Injury
Subdomain Name: Physical Examinations
CRF: Clinical Assessment

Displaying 101 - 126 of 126

CDE ID	CDE Name	Variable Name	Definition	Short Description	Question Text	Permissible Values	Description	Data Type	Disease Specific Instructions	Disease Specific Reference	Population	Classification (e.g., Core)	Version Number	Version Date	CRF Name (CRF Module / Guidance)	Subdomain Name	Domain Name	Size	Input Restrictions
C06427	Spinal column injury indicator	SpnlColmInjInd	Indicator of whether there was any disruption through the spinal column including the bony vertebral elements and their supporting ligaments, capsules, discs, and other supporting soft tissues	Indicator of whether there was any disruption through the spinal column including the bony vertebral elements and their supporting ligaments, capsules, discs, and other supporting soft tissue	Spinal column injury (-ies)	No;Yes;Unknown	No;Yes;Unknown	Alphanumeric	Being able to distinguish between single versus multiple levels of spinal column injury is often challenging. Critical to this distinction is the fact that a single injury may occur; i) at one vertebral level (e.g. C6 Burst Fracture); ii) at a single motion segment (e.g. a C5-6 bilateral facet dislocation) where a motion segment is defined as two adjacent vertebrae and their interconnecting discs and ligamentous structures; or iii) over two or more adjacent and contiguousmotion segments (e.g. a "teardrop" fracture of C6 where the injury spans C5-C7). Alternately, a multiple level injury consists of two or more single column injuries separated by at least one completely intact vertebra or motion segment(e.g. a C5-6 facet dislocation and a C2 hangman's fracture).	Dvorak MF, Wing PC, Fehlings MG, Vaccaro AR, Itshayek E, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury Spinal Column Injury Basic Data Set. Spinal Cord. 2012 Nov;50(11):817-821; doi: 10.1038/sc.2012.60.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C06015	Bladder empty method main type	BladEmpMethdMainTyp	Main method of bladder emptying	Main method of bladder emptyin	Bladder emptying	Bladder expression;Bladder reflex triggering;External compression bladder expression;Indwelling catheter;Intermittent catheterisation;Intermittent catheterisation by attendant;Intermittent self-catheterisation;Involuntary bladder reflex triggering;Non-continent urinary diversion/ostomy;Normal voiding;Other method, specify;Sacral anterior root stimulation;Straining bladder expression;Suprapubic;Suprapubic indwelling catheter;Transurethral indwelling catheter;Unknown;Voluntary bladder reflex triggering	Comprises 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).;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).;Includes CredÉ manoeuvre.;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).;Is defined as drainage or aspiration of the bladder or urinary reservoir/continent urinary diversion with subsequent removal of the catheter.;Is performed by an attendant (e.g. family member or personal aid);Is performed by the individual with spinal cord lesion himself/herself;Implies 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.;Non-continent urinary diversion/ostomy;Voluntary initiation of micturition without reflex stimulation or compression of the bladder. This does not presume entirely normal function (Levi and Ertzgaard 1998).;Other method, specify;Sacral anterior root stimulation;Includes abdominal straining, Valsalva's manoeuvre.;Suprapubic;indicates, that the urine is drained through a catheter via the abdominal wall.;Indicates, that the urine is drained through a catheter placed in the urethra.;Unknown;Indicates that the bladder reflex is triggered by the spinal cord lesioned individual him/herself or by the attendant.	Alphanumeric	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".	Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002:21;167-78. Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30. Levi R, Ertzgaard P, The Swedish Spinal Cord Injury Council 1998. Quality indicators in spinal cord injury care: A Swedish collaboration project. Scand J Rehabil Med 1998;Suppl.38:1-80.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C06186	Defecation awareness past four week status	DefctnAwarePstFourWkStatus	Awareness of the need to defecate within the last four weeks	Awareness of the need to defecate (within the last four weeks):	Awareness of the need to defecate within the last four weeks	Normal;Indirect;None;Not applicable;Unknown	Normal (Direct);Indirect (For example: Abdominal cramping or discomfort, abdominal muscle spasms, spasms of lower extremities, perspiration, piloerection, headache or chills);None;Not applicable (too young to determine);Unknown	Alphanumeric	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.	Krogh K, Nielsen J, Djurhuus JC, Mosdal C, Sabroe S, Laurberg S. Colorectal function in patients with spinal cord lesions. Dis Colon Rectum 1997; 40: 1233-1239. Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C19476	Bladder empty method supplementary other text	BladEmpMethdSupplOTH	The free-text field to specify the supplementary method of bladder emptying	The free-text field to specify the supplementary method of bladder emptyin	Other method, specify			Alphanumeric		Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations	4000	Free-Form Entry
C06247	Cardiovascular event after spinal cord lesion type	CardioEvntAfterSpnlCrdLesnTyp	Events related to cardiovascular functions that may have occurred at any time after the spinal cord lesion.	Events related to cardiovascular functions that may have occurred at any time after the spinal cord lesion.	Events related to cardiovascular function after spinal cord lesion	Cardiac pacemaker;Deep vein thrombosis;Myocardial infarction;None;Other,specify;Pulmonary embolism;Stroke;Unknown (any cardiovascular disorder)	Cardiac pacemaker;Deep vein thrombosis;Myocardial infarction;None;Other, specify;Pulmonary embolism;Stroke;Unknown (any cardiovascular disorder)	Alphanumeric	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.	Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Multiple Pre-Defined Values Selected
C06451	Neuromuscular scoliosis assessment method type	NeromusclrSclsisAssmntMethdTyp	Type of method(s) used to determine the presence of neuromuscular scoliosis	Type of method(s) used to determine the presence of neuromuscular scoliosi	If scoliosis is present, method of assessment (check all that apply)	Observation in sitting;Observation in standing;Plain radiographs in sitting;Plain radiographs in standing	Observation in sitting;Observation in standing;Plain radiographs in sitting;Plain radiographs in standing	Alphanumeric	Check all that apply The clinical and physical examination is pivotal to the diagnosis of scoliosis and is evidenced by the observed lateral deviation of the head, trunk and pelvis over the spine and shoulder asymmetry. For the evaluation of neuromuscular scoliosis, it is important to temporarily remove any modification to a wheelchair or seating system that is providing external support to maintain head and spine alignment (for example, lateral supports, chest harness, etc) (Lubicky & Betz 1996; Lord et al. 1990; Mulcahey & Betz 2008). Likewise, any type of support to the trunk in the form of a brace or binder needs to be removed for assessment of the scoliosis. A diagnosis of scoliosis requires a plain radiograph that shows a Cobb Angle of at least 10 degrees (O'Brien 2005; Terminology committee of the Scoliosis Research Society 1976). While the Cobb Angle of 10 degrees is used as the definitive diagnoses for idiopathic scoliosis, there is evidence that strong inter-rater reliability of the Cobb Angle in SCI also falls within 10 degrees and hence, has been adopted as the radiographic diagnosis of neuromuscular scoliosis (Gupta et al. 2007).	O'Brien MF. (2005). Spinal Deformity Study Group Radiographic Measurement Manual Medtronic Sofamor Danek USA, Inc.<br />Biering-SØrensen F, Burns AS, Curt A, Harvey LA, Jane Mulcahey M, Nance PW, Sherwood AM, Sisto SA. International spinal cord injury musculoskeletal basic data set. Spinal Cord. 2012 Nov;50(11):797-802; doi: 10.1038/sc.2012.102.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Multiple Pre-Defined Values Selected
C06213	Defecation unsuccessful frequency	DefctnUnscsflFreq	The frequency of unsuccessful attempts at defecation within the last three months	The frequency of unsuccessful attempts at defecation within the last three month	Unsuccessful attempts at defecation (within the last three months):	Never;Less than once per month;Less than once per week but at least once per month;Once or more per week but not every day;1-3 times daily;4-6 times daily;7-9 times daily;10 times or more per day;Not applicable;Unknown	Never;Less than once per month;Less than once per week but at least once per month;Once or more per week but not every day;1-3 times daily;4-6 times daily;7-9 times daily;10 times or more per day;Not applicable;Unknown	Alphanumeric	Choose one. To be considered as one attempt the bowel emptying procedure should be separated from the previous bowel emptying procedure by some other activity. The code "Not applicable" is mainly for individuals with stomas.	Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C22704	Urinary incontinence past three months frequency	UrinIncntPstThreeMoFreq	Frequency of involuntary urine leakage (incontinence) within the last three months. Urinary incontinence is defined by International Continence Society (Abrams et al. 2002) as the complaint of any involuntary leakage of urine	Frequency of involuntary urine leakage (incontinence) within the last three months. Urinary incontinence is defined by International Continence Society (Abrams et al. 2002) as the complaint of any involuntary leakage of urin	If yes, indicate urine leakage average frequency	Average daily;Average monthly;Average weekly	Average daily (Implies leakage one or more times per day on average over the last three months).;Average monthly (Implies on average leakage one or more times per month but not weekly within the last three months).;Average weekly (Implies average leakage one or more times per week but not daily within the last three months).	Alphanumeric		Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002:21;167-78. <br />Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C06361	Gonadal male status	GondlMalStatus	Stage of gonadal development/senescence for males	Stage of gonadal development/senescence for males	Gonadal status (check appropriate stage):	Adult;Prepubertal;Pubertal;Unknown	Adult;Prepubertal;Pubertal;Unknown	Alphanumeric	Choose one. Data element should be checked against Gender. Question should be blank for Females.	Bauman WA, Biering-SØrensen F, Krassioukov A. International spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C17422	Urinary culture resistance pattern type	UrCultResistPattrnTyp	Type of resistance pattern of a particular bacteria species in the urine culture sample	Type of resistance pattern of a particular bacteria species in the urine culture sample	Resistance pattern (pick one only):	Normal;Multi-drug resistant	Normal;Multi-drug resistant (agents from 3 or more different drug classes)	Alphanumeric		Goetz LL, Cardenas DD, Kennelly M, Bonne Lee BS, Linsenmeyer T, Moser C, Pannek J, Wyndaele JJ, Biering-Sorensen F. International spinal cord injury urinary tract infection basic data set. Spinal Cord. 2013 Sep;51(9):700-4. doi: 10.1038/sc.2013.72.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C18795	Cardiovascular function after last three month other text	CardioFuncAfterLast3MnthOTH	The free-text field related to 'Cardiovascular function after last three month type' specifying other text. Types of cardiovascular function that may have occurred after the spinal cord lesion (within three months)	The free-text field related to 'Cardiovascular function after last three month type' specifying other text. Types of cardiovascular function that may have occurred after the spinal cord lesion (within three months	Other, specify			Alphanumeric		Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations	4000	Free-Form Entry
C06229	Bowel management independence past three months scale	BowelMngmntIndpdncPstThrMoScl	The scale that assesses the participant's degree of independence during bowel management within the last three months.	The scale that assesses the participant's degree of independence during bowel management within the last three months.	Degree of independency during bowel management (within the last three months):	Requires total assistance;Requires partial assistance, does not clean self;Requires partial assistance, cleans self independently;Uses toilet independently in all tasks but needs adaptive devices or special setting (e.g. bars);Uses toilet independently, does not need adaptive devices or special setting;Unknown	Requires total assistance;Requires partial assistance, does not clean self;Requires partial assistance, cleans self independently;Uses toilet independently in all tasks but needs adaptive devices or special setting (e.g. bars);Uses toilet independently, does not need adaptive devices or special setting;Unknown	Alphanumeric	Choose one	The codes used are identical to those used in the Spinal Cord Independence Measure III (SCIM III) (Catz 2007). Catz A, Itzkovich M, Tesio L, Biering-SØrensen F, Weeks C, Laramee MT, Craven BC, Tonack M, Hitzing SL, Glaser E, Zeilig G, Aito S, Scivoletto G, Mecci M, Chadwick RJ, El Marsy WS, Osman A, Glass CA, Silva P, Soni BM, Gardner BP, Savic G, Bergstrom EM, Bluvshtein V, Ronen J. A multicenter international study on the spinal cord independence measure; version III: Rasch psychometric validation. Spinal Cord 2007;45(4):275-91. Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C06428	Spinal column injury extent type	SpnlColmInjExntTyp	In the presence of an injury through the spine, this element documents whether there is a single level spinal column injury or if there are multiple levels involved	In the presence of an injury through the spine, this element documents whether there is a single level spinal column injury or if there are multiple levels involve	Single or multiple spinal column level injury (-ies)	Single;Multiple;Unknown	Single;Multiple;Unknown	Alphanumeric	Choose one	Dvorak MF, Wing PC, Fehlings MG, Vaccaro AR, Itshayek E, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury Spinal Column Injury Basic Data Set. Spinal Cord. 2012 Nov;50(11):817-821; doi: 10.1038/sc.2012.60.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C06017	Bladder empty method supplementary type	BladEmpMethdSuppTyp	Supplementary type(s) of bladder emptying method(s)	Supplementary type(s) of bladder emptying method(s)	Bladder emptying	Bladder expression;Bladder reflex triggering;External compression bladder expression;Indwelling catheter;Intermittent catheterisation;Intermittent catheterisation by attendant;Intermittent self-catheterisation;Involuntary bladder reflex triggering;Non-continent urinary diversion/ostomy;Normal voiding;Other method, specify;Sacral anterior root stimulation;Straining bladder expression;Suprapubic;Suprapubic indwelling catheter;Transurethral indwelling catheter;Unknown;Voluntary bladder reflex triggering	Comprises 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).;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).;Includes CredÉ manoeuvre.;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).;Is defined as drainage or aspiration of the bladder or urinary reservoir/continent urinary diversion with subsequent removal of the catheter.;Is performed by an attendant (e.g. family member or personal aid);Is performed by the individual with spinal cord lesion himself/herself;Implies 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.;Non-continent urinary diversion/ostomy;Voluntary initiation of micturition without reflex stimulation or compression of the bladder. This does not presume entirely normal function (Levi and Ertzgaard 1998).;Other method, specify;Sacral anterior root stimulation;Includes abdominal straining, Valsalva's manoeuvre.;Suprapubic;indicates, that the urine is drained through a catheter via the abdominal wall.;Indicates, that the urine is drained through a catheter placed in the urethra.;Unknown;Indicates that the bladder reflex is triggered by the spinal cord lesioned individual him/herself or by the attendant.	Alphanumeric	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).	Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002:21;167-78. Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30. Levi R, Ertzgaard P, The Swedish Spinal Cord Injury Council 1998. Quality indicators in spinal cord injury care: A Swedish collaboration project. Scand J Rehabil Med 1998;Suppl.38:1-80.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C06187	Defecation method bowel care procedure used past four week main type	DefctnMthdBwlProcedUseMainTyp	Type of main defecation method and bowel care procedures used within the last four weeks	Type of main defecation method and bowel care procedures used within the last four week	Defecation method and bowel care procedures (within the last four weeks).	Normal defecation;Straining/bearing down to empty;Digital ano-rectal stimulation;Suppositories;Digital evacuation;Mini enema;Enema;Colostomy;Sacral anterior root stimulation;Other, specify;Unknown	Normal defecation;Straining/bearing down to empty;Digital ano-rectal stimulation;Suppositories;Digital evacuation;Mini enema (Clysma = 150 mL);Enema (> 150 mL);Colostomy;Sacral anterior root stimulation;Other method, specify;Unknown	Alphanumeric	Choose one main method Individuals with SCI may use a combination of bowel emptying rocedures. For practical purposes one should be defined as the Main method. Supplementary methods should be performed at least once every week. More than one supplementary method can be used. The choice of defecation method and bowel care procedures may change with time and in the present data set they are given for the last four weeks. Digital ano-rectal stimulation is digital triggering of rectal contractions and anal relaxation and thus rectal emptying. Digital evacuation is the need to dig out stools with a finger. Mini enema (or Clysma) contains 150 ml or less and enema contain > 150 ml. In individuals having a colostomy, this is always considered the main method for defecation.	Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C19477	Pressure ulcer first appearance date and time	PressrUlcFrstApprncDateTime	Date and time of first appearance of pressure ulcer	Date and time of first appearance of pressure ulcer	Ulcer appearance date/time			Date or Date & Time	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.).	Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-SØrensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167.	Adult;Pediatric	Supplemental	1.00	2014-06-17 11:01:29.0	Clinical Assessment	Physical Examinations	Assessments and Examinations		Free-Form Entry
C06249	Cardiovascular function after last three month type	CardioFnctnAfterLast3MnthTyp	Types of cardiovascular function that may have occurred after the spinal cord lesion (within three months)	Types of cardiovascular function that may have occurred after the spinal cord lesion (within three months	Cardiovascular function after spinal cord lesion within the last three months	Autonomic dysreflexia;Cardiac conditions, specify;Dependent oedema;Hypertension;None;Orthostatic hypotension;Other,specify;Unknown (any cardiovascular disorder)	Autonomic dysreflexia;Cardiac conditions, specify;Dependent oedema;Hypertension;None;Orthostatic hypotension;Other, specify;Unknown (any cardiovascular disorder)	Alphanumeric	For each type of cardiovascular function after spinal cord lesion record whether it was experienced by the participant within the last three months. Cardiac conditions: Subjective symptoms related to the heart that occur post-spinal cord lesion should be documented (e.g. abnormal heart rates/rhythm, angina, palpitation etc.). Orthostatic hypotension: Symptomatic or asymptomatic decrease in blood pressure usually exceeding 20 mmHg systolic or 10 mmHg diastolic on moving from the supine to an upright position. Dependent oedema: A clinically detectable increase in extracellular fluid volume localized in a dependent area, such as a limb, characterized by swelling or pitting. Hypertension: (arterial blood pressure >140/90 mmHg). The diagnosis of hypertension in individual with SCI should be considered after careful monitoring and documentation of the level of arterial blood pressure and exclusion of possible elevation of BP due to episodes of AD. Autonomic dysreflexia: A constellation of signs and/or symptoms in SCI above T5-6 spinal cord segments in response to noxious or non-noxious stimuli below the level of injury defined by an increase in systolic blood pressure (> 20mm Hg above baseline), and which may include one of the following symptoms: headache, flushing and sweating above the level of the lesion, vasoconstriction below the level of the lesion, and dysrhythmia. This syndrome may or may not be symptomatic and may occur at any time following SCI.	Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. The Consensus Committee of the American Autonomic Society and the American Academy of Neurology. Neurol. 46, 1470 (1996). Gao,S.A., Ambring,A., Lambert,G. & Karlsson,A.K. Autonomic control of the heart and renal vascular bed during autonomic dysreflexia in high spinal cord injury. Clin. Auton. Res. 12, 457-464 (2002). Karlsson,A.K., Friberg,P., Lonnroth,P., Sullivan,L. & Elam,M. Regional sympathetic function in high spinal cord injury during mental stress and autonomic dysreflexia. Brain 121, 1711-1719 (1998). Kirshblum,S.C., House,J.G. & O'connor,K.C. Silent autonomic dysreflexia during a routine bowel program in persons with traumatic spinal cord injury: a preliminary study. Arch. Phys. Med. Rehabil. 83, 1774-1776 (2002). Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. Krassioukov,A. & Claydon,V.E. The clinical problems in cardiovascular control following spinal cord injury: an overview. Prog. Brain Res. 152, 223-229 (2006). Krassioukov,A.V., Furlan,J.C. & Fehlings,M.G. Autonomic dysreflexia in acute spinal cord injury: an under-recognized clinical entity. J. Neurotrauma 20, 707-716 (2003). Linsenmeyer,T.A., Campagnolo,D.I. & Chou,I.H. Silent autonomic dysreflexia during voiding in men with spinal cord injuries. J. Urol. 155, 519-522 (1996). Mathias,C.J. & Frankel,H.L. Autonomic Failure, A Textbook of Clinical Disorders of the Autonomic Nervous System. Bannister,R. & Mathias,C.J. (eds.), pp. 839-881 (Oxford Medical Publications,2002). Pickering,T.G. et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circula. 111, 697-716 (2005).	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Multiple Pre-Defined Values Selected
C06454	Musculoskeletal other problem text	MusclskltlOthrProbTxt	Text describing the presence of any other musculoskeletal problems not described elsewhere	Text describing the presence of any other musculoskeletal problems not described elsewher	Other musculoskeletal problems, specify			Alphanumeric	This variable requires the assessor to specify any other type of musculoskeletal problem not captured in the other variables. This could among other issues include gibbus formation in relation to Pott's paraplegia (Benzagmout et al. 2011; Moon et al. 2003).	Biering-SØrensen F, Burns AS, Curt A, Harvey LA, Jane Mulcahey M, Nance PW, Sherwood AM, Sisto SA. International spinal cord injury musculoskeletal basic data set. Spinal Cord. 2012 Nov;50(11):797-802; doi: 10.1038/sc.2012.102.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations	255	Free-Form Entry
C06214	Rectal emptying incomplete frequency	RectEmptIncmpltFreq	The frequency of any sense of incomplete rectal emptying after defecation within the last three months.	The frequency of any sense of incomplete rectal emptying after defecation within the last three months.	Incomplete rectal emptying after defecation (within the last three months):	Daily;Not every day but at least once per week;Not every week but at least once per month;Less than once per month;Never;Not applicable;Unknown	Daily;Not every day but at least once per week;Not every week but at least once per month;Less than once per month;Never;Not applicable;Unknown	Alphanumeric	Choose one. Most individuals with complete SCI do not have any subjective sense of rectal filling. In such cases the code "Never" and not the code "Unknown" should be used. The code "Not applicable" is mainly for individuals with stomas.	Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C22705	Urinary incontinence collect appliance indicator	UrinInconColApplInd	Indicator for collecting appliances for urinary incontinence. Collecting appliances are any externally applied aids to avoid urinary leakage, or devices for collection of urine	Indicator for collecting appliances for urinary incontinence. Collecting appliances are any externally applied aids to avoid urinary leakage, or devices for collection of urin	Collecting appliances for urinary incontinence	No;Yes;Unknown	No;Yes;Unknown	Alphanumeric		Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30. <br />Levi R, Ertzgaard P, The Swedish Spinal Cord Injury Council 1998. Quality indicators in spinal cord injury care: A Swedish collaboration project. Scand J Rehabil Med 1998;Suppl.38:1-80.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Multiple Pre-Defined Values Selected
C06362	Gonadal female status	GonFemlStatus	Stage of gonadal development/senescence for females	Stage of gonadal development/senescence for females	Gonadal status (check appropriate stage):	Adult;Adult Menopausal;Adult Postmenopausal;Prepubertal;Pubertal;Unknown	Adult;Adult Menopausal;Adult Postmenopausal;Prepubertal;Pubertal;Unknown	Alphanumeric	Choose one. Data element should be checked against Gender. Question should be blank for Males.	Bauman WA, Biering-SØrensen F, Krassioukov A. International spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Single Pre-Defined Value Selected
C18153	Data unknown text	DataUnknwnTxt	The free-text field to Mark an "X" in to record if data are unknown or not available	The free-text field to Mark an "X" in to record if data are unknown or not availabl	Time Performed			Alphanumeric	Check box for Unknown	Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations	20	Free-Form Entry
C18797	Sexual problem unrelate spinal cord lesion specify text	SexProbUnrltSpnlCrdLesnST	The free-text field related to 'Sexual problem unrelate spinal cord lesion indicator'. Indicator of whether the person complained of sexual issues prior to or after the spinal cord lesion that are unrelated to the spinal cord lesion	The free-text field related to 'Sexual problem unrelate spinal cord lesion indicator'. Indicator of whether the person complained of sexual issues prior to or after the spinal cord lesion that are unrelated to the spinal cord lesio	Yes, specify			Alphanumeric	Choose one. If a preexisting or concomitant sexual problem is present it is not possible to determine the exact impact of the spinal cord lesion on sexual function and the data should be appropriately identified. Unknown refers to individuals who were not sexually active prior to their lesion, thus it would be unknown if sexual dysfunction was present.	Alexander MS, Biering-SØrensen F, Elliott S, Kreuter M, SØnksen J. International Spinal Cord Injury Female Sexual and Reproductive Function Basic Data Set. Spinal Cord. 2011 Jul;49(7):787-90. Alexander MS, Biering-SØrensen F, Elliott S, Kreuter M, SØnksen J. International Spinal Cord Injury Male Sexual Function Basic Data Set. Spinal Cord. 2011 Jul;49(7):795-8.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations	4000	Free-Form Entry
C06231	Bowel care facilitators past three months type	BwlCrFacltatrPstThrMoTyp	The indicator of whether the type of bowel care facilitator was practiced regularly within the past three months	The indicator of whether the type of bowel care facilitator was practiced regularly within the past three months.	Bowel care facilitators (within the last three months):	None;Digital stimulation or evacuation;Abdominal massage;Gastrocolonic response;Other, specify;Unknown	None;Digital stimulation or evacuation;Abdominal massage;Gastrocolonic response;Other, specify;Unknown	Alphanumeric	For each bowel care facilitator indicate if it was used regularly within the past three months.	Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Multiple Pre-Defined Values Selected
C06429	Spinal column injury number	SpnlColmInjNum	Number assigned to the spinal column injury. The spinal column injuries are assigned numbers starting with the most cephalic spinal column injury	Number assigned to the spinal column injury. The spinal column injuries are assigned numbers starting with the most cephalic spinal column injur	Spinal column injury number			Numeric Values	1 – Most cephalic spinal column injury involving one or more adjacent vertebral levels and/or one or more adjacent and contiguous motion segments. 2 – If there are two or more discrete spinal column injuries, this is the second most cephalic spinal column injury involving one or more adjacent vertebral levels and/or one or more adjacent and contiguous motion segments separated by at least one intact vertebral level to the above or below spinal column injury. 3, 4, etc. If there are three or more discrete spinal column injuries, this is the third, fourth, etc. most cephalic spinal column injury involving one or more adjacent vertebral levels and/or one or more adjacent and contiguous motion segments separated by at least one intact vertebral level to the above or below spinal column injury. 99 - Unknown	Dvorak MF, Wing PC, Fehlings MG, Vaccaro AR, Itshayek E, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury Spinal Column Injury Basic Data Set. Spinal Cord. 2012 Nov;50(11):817-821; doi: 10.1038/sc.2012.60.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Free-Form Entry
C06019	Bladder average empty per day past week number	BladAvgEmpPerDayPstWkNum	Average amount of voluntary bladder emptyings per day during the last week	Average amount of voluntary bladder emptyings per day during the last week	Average number of voluntary bladder emptyings per day during the last week			Numeric Values	The average number of voluntary bladder emptying per day during the last week is given separately. This number refers to the number of voluntary bladder emptying irrespective of the method. Any of the following methods may be used separate or in combination: normal voiding, voluntary bladder reflex triggering, bladder expression, intermittent catheterization, or sacral anterior root stimulation. If a combination of methods is used during the same bladder emptying it should only be counted as one bladder emptying. The number is given as an average for the last week only, as the individual is not expected to remember this for a longer period of time. The number is given as the nearest integer number.	Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30.	Adult;Pediatric	Supplemental	3.00	2013-07-17 09:26:36.973	Clinical Assessment	Physical Examinations	Assessments and Examinations		Free-Form Entry