High-level Tetraplegia Research Articles

Identification and assessment of Electronic Aids for Daily Living considered essential by persons with high level tetraplegia: a case series

Although assistive technology (AT) is recognized as a basic human right, access to AT, and particularly electronic aids to daily living (EADL), is limited. We aimed to understand how persons with high level spinal cord injury (SCI) prioritize EADL needs and assess satisfaction and efficacy of self-identified EADL. Thus, in this case series, we recruited three participants with C4, C5 or C6 SCI receiving in-patient SCI rehabilitation. Each received dedicated occupational therapy-based assistance in identifying EADL items within an unrestricted envelope of support ($5000 CDN) for use in maximizing physical independence and supporting their return to community-based living. Items identified were categorized by need (emergency/security; home environment control; or virtual access to the outside world). Each participant selected distinct EADL. Evaluation of selected EADL items indicated very high satisfaction. The selected EADL contributed to participants’ returns to employment, community life, or reduced requirements for attendant services. These findings suggest that identification of essential technology should reflect the unique needs of each person and the context in which it will be used. These findings also support use of mainstream technology to meet EADL needs of individuals with limited physical abilities.

Bladder management in individuals with spinal cord injury or disease during and after primary rehabilitation: a retrospective cohort study.

The purpose of this study was to investigate the course of bladder evacuation and the predictors of intermittent self-catheterization (ISC) in individuals with neurogenic lower urinary tract dysfunction (NLUTD) during and after primary rehabilitation. The patient database of a single spinal cord injury rehabilitation center was screened for patients with NLUTD admitted for primary rehabilitation. Patient characteristics and bladder evacuation details were collected during and after rehabilitation. Binary logistic regression analysis was used to evaluate predictors of ISC: sex, age > 65years, injury severity, and bladder capacity ≥ 400ml. Data of 255 men (74.3%) and 88 women (25.7%) with a mean age of 54 ± 19years were analyzed. Early in rehabilitation, 21.6% of the evaluated individuals used ISC. In 17.8%, the bladder was evacuated by transurethral catheterization (TUC). The proportion of TUC decreased during rehabilitation and dropped below 2% at the last follow-up. In contrast, the proportion of ISC and suprapubic catheterization (SPC) increased to 28% and 12.8%, respectively, during rehabilitation. These proportions increased further thereafter and reached 37.7% and 18.6% for ISC and SPC, respectively. Age and injury severity were significant (p ≤ 0.041) negative predictors, whereas male sex and above-average bladder capacity were positive predictors of ISC. There is a shift toward bladder evacuation by ISC and SPC during and after primary rehabilitation. Bladder evacuation by ISC, regarded as the gold standard, is less common in individuals > 65years or with high-level tetraplegia. The optimal bladder evacuation method needs to be established individually, considering all medical and psychosocial factors rather than simply following a guideline.

Restoration of Arm Function in People With High-level Tetraplegia

Restoration of Arm Function in People With High-level Tetraplegia

Word prediction software in people with cervical spinal cord injury: A literature review

Individuals with cervical spinal cord injury (ICSCI) have difficulty accessing computers through conventional methods. The purpose of this paper was to provide a critical narrative review on types of computer access devices and word prediction software for ICSCI. A search was conducted in several electronic databases. There is limited data about Test Input Speed (TIS) in ICSCI. One study showed that TIS in ICSCI was significantly lower [mean = 11 words per minute (wpm)] ( P = 0.001) than TIS of abled-bodied individuals (19 wpm). In a sample of ICSCI, there was a significant difference between voice recognition system (mean = 18 wpm), a standard keyboard (mean = 8 wpm) and an onscreen keyboard (mean = 3 wpm) ( P < 0.001). However, the literature suggested that the impact of Word Prediction Software (WPS) for increasing TIS remains questionable. Indeed, there is limited scientific documentation of the influence of the parameters of WPS on TIS. Regarding the number of words displayed in the prediction list, this parameter did not increase TIS. For the parameter “frequency of use”, use of WPS with the activation of frequency of use increased TIS in participants with high-level tetraplegia. For participants with low-level tetraplegia, the use of WPS with frequency of use activated only decreased the number of errors. Each professional could provide clear and accurate information on the benefits of WPS for people with cervical SCI. WPS must be set regarding the needs of people with cervical SCI. If not, the use of these software's may go against the expected benefits.

Feasibility of robotic exoskeleton ambulation in a C4 person with incomplete spinal cord injury: a case report.

To determine whether an individual with C4 incomplete spinal cord injury (SCI) with limited hand functions can effectively operate a powered exoskeleton (Ekso) to improve parameters of physical activity as determined by swing-time, up-time, walk-time, and total number of steps. A 21-year-old male with incomplete chronic (>1 year postinjury) SCI C4, participated in a clinical exoskeleton program to determine the feasibility of standing up and walking with limited hand functions. The participant was invited to attend 3 sessions including fitting, familiarization and gait training separated by one week intervals. Walk-time, up-time and total number of steps were measured during each training session. A complete body composition assessment using dual-energy X-ray absorptiometry (DXA) of the spine, knees and hips was conducted before training.Using a platform walker and cuffing both hands, the participant managed to stand up and ambulate successfully using exoskeleton. Over the course of 2 weeks, maximum walk-time increased from 7 to 17 min and number of steps increased from 83 to 589 steps. The total up-time increased from 19 to 31 min. Exoskeleton training may be a safe and feasible approach for persons with higher levels of SCI after effectively providing a supportive assistive device for weight shifting. The current case study demonstrates the use of a powered exoskeleton for an individual with high level tetraplegia (C4 and above) and limited hand functions.

Electronic device use by individuals with traumatic spinal cord injury

Objective: To describe use of several electronic devices among individuals with traumatic spinal cord injury (SCI).Study Design: Cross-sectional survey.Setting: Community.Methods: Potential participants consisted of all individuals with traumatic SCI, ages 7 and older, who had received care through a large academic medical center in the Midwest between January 1, 2003, and January 2, 2013. All eligible individuals received the survey as part of a four-stage mailing that asked questions about electronic device use in addition to questions about demographic and injury-related characteristics.Results: Mailings were sent to 820 individuals; of those, 451 completed and returned the survey. Descriptive and nonparametric statistics were performed. Individuals with high-level tetraplegia were less likely to use tablet and handheld electronic devices than individuals at all other SCI levels. Individuals aged 65 years and older were less likely to own or use tablet computers and handheld devices than all other age groups.Conclusion: While electronic devices hold considerable potential as a treatment modality for individuals who have sustained SCI, there is diversity in the particular electronic devices that are used by such individuals due to injury-related characteristics and age.

The effect of word prediction settings (frequency of use) on text input speed in persons with cervical spinal cord injury: a prospective study

Purpose: To determine whether activation of the frequency of use and automatic learning parameters of word prediction software has an impact on text input speed.Methods: Forty-five participants with cervical spinal cord injury between C4 and C8 Asia A or B accepted to participate to this study. Participants were separated in two groups: a high lesion group for participants with lesion level is at or above C5 Asia AIS A or B and a low lesion group for participants with lesion is between C6 and C8 Asia AIS A or B. A single evaluation session was carried out for each participant. Text input speed was evaluated during three copying tasks:• without word prediction software (WITHOUT condition)• with automatic learning of words and frequency of use deactivated (NOT_ACTIV condition)• with automatic learning of words and frequency of use activated (ACTIV condition)Results: Text input speed was significantly higher in the WITHOUT than the NOT_ACTIV (p< 0.001) or ACTIV conditions (p = 0.02) for participants with low lesions. Text input speed was significantly higher in the ACTIV than in the NOT_ACTIV (p = 0.002) or WITHOUT (p < 0.001) conditions for participants with high lesions.Conclusions: Use of word prediction software with the activation of frequency of use and automatic learning increased text input speed in participants with high-level tetraplegia. For participants with low-level tetraplegia, the use of word prediction software with frequency of use and automatic learning activated only decreased the number of errors.Implications in rehabilitation Access to technology can be difficult for persons with disabilities such as cervical spinal cord injury (SCI). Several methods have been developed to increase text input speed such as word prediction software.This study show that parameter of word prediction software (frequency of use) affected text input speed in persons with cervical SCI and differed according to the level of the lesion.• For persons with high-level lesion, our results suggest that this parameter must be activated so that text input speed is increased.• For persons with low lesion group, this parameter must be activated so that the numbers of errors are decreased.• In all cases, the activation of the parameter of frequency of use is essential in order to improve the efficiency of the word prediction software.• Health-related professionals should use these results in their clinical practice for better results and therefore better patients ‘satisfaction.

Changing demographics of spinal cord injury over a 20-year period: a longitudinal population-based study in Scotland.

Study design:A retrospective cohort study.Objectives:To review demographic trends in traumatic spinal cord injury (TSCI) and non-traumatic spinal cord injury (NTSCI).Setting:The Queen Elizabeth National Spinal Injuries Unit (QENSIU), sole provider of treatment for TSCI in Scotland; a devolved region of the UK National Health Service.Methods:A retrospective review of the QENSIU database was performed between 1994 and 2013. This database includes demographic and clinical data from all new TSCI patients in Scotland, as well as patients with severe NTSCI.Results:Over this 20-year period there were 1638 new cases of TSCI in Scotland; 75.2% occurring in males. TSCI incidence increased non-significantly (13.3 per million population to 17.0), while there were significant increases in mean age at time of TSCI (44.1–52.6 years), the proportion of TSCIs caused by falls (41–60%), the proportion of TSCIs resulting in an American Spinal Injury Association Impairment Scale score of C and D on admission (19.7–28.6% and 34.5–39.5%, respectively) and the proportion of cervical TSCIs (58.4–66.3%). The increase in cervical TSCI was specifically due to an increase in C1–C4 lesions (21.7–31.2%). NTSCI patients (n=292) were 5 years older at injury, more likely to be female (68.1% male) and had a range of diagnoses.Conclusion:This study supports the suggestion that demographic profiles in SCI are subject to change. In this population, of particular concern is the increasing number of older patients and those with high level tetraplegia, due to their increased care needs. Prevention programmes, treatment pathways and service provision need to be adjusted for optimum impact, improved outcome and long-term care for their target population.

Influence of word prediction settings (number of words displayed and frequency of use) on text input speed in persons with cervical spinal cord injury

Different devices have been developed to enable persons with cervical spinal cord injury (SCI) to use a computer. However, text input speed (TIS) remains low for these persons. Several methods have been developed to increase TIS, such as word prediction software (WPS). Data in the literature are discordant regarding the effect of WPS on TIS, with decreases of up to 71% in some studies and increases of up to 45% in others. The main reason suggested for these differences is the cognitive load caused by the visual searching for words in the prediction list. It is thus likely that the number of words in the prediction list influences TIS. Moreover, WPS can be customized using different settings. For example, the prediction list can be ordered according to the frequency of occurrence of words in the language (frequency of use) and the automatic learning of new words can be activated. Until now, no studies in the literature have evaluated the influence of these parameters on TIS. The aims of this study are to determine if the number of words displayed in the WPS list and activation of the frequency of use and automatic learning parameters of WPS affects TIS in people with tetraplegia. Forty-five persons with cervical SCI between C4 and C8 Asia AIS A or B and who were computer users were included. For the parameter “Number of Words displayed”, TIS was evaluated during 4 10-minute copying tasks (without WPS, with a display of 3 6 8 predicted words). For the parameter “frequency of use”, TIS was evaluated during 3 copying tasks (without WPS (WITHOUT), with automatic learning of words and frequency of use desactivated (NOT_ACTIV) or activated (ACTIV)). There was no effect of the number of words displayed in a word prediction list on TIS, however perception of TIS differed according to lesion level. Use of word prediction software with activation of frequency of use and automatic learning increased TIS in participants with high-level tetraplegia. For participants with low-level tetraplegia, use of word prediction software with frequency of use and automatic learning activated only decreased the number of errors.

Electrophysiological diaphragmatic exploration in high-level tetraplegia and therapeutic implication

Electrophysiological diaphragmatic exploration in high-level tetraplegia and therapeutic implication

Implanted Neuroprosthesis for Restoring Arm and Hand Function in People With High Level Tetraplegia

ObjectiveTo develop and apply an implanted neuroprosthesis to restore arm and hand function to individuals with high level tetraplegia. DesignCase study. SettingClinical research laboratory. ParticipantsIndividuals with spinal cord injuries (N=2) at or above the C4 motor level. InterventionsThe individuals were each implanted with 2 stimulators (24 stimulation channels and 4 myoelectric recording channels total). Stimulating electrodes were placed in the shoulder and arm, being, to our knowledge, the first long-term application of spiral nerve cuff electrodes to activate a human limb. Myoelectric recording electrodes were placed in the head and neck areas. Main Outcome MeasuresSuccessful installation and operation of the neuroprosthesis and electrode performance, range of motion, grasp strength, joint moments, and performance in activities of daily living. ResultsThe neuroprosthesis system was successfully implanted in both individuals. Spiral nerve cuff electrodes were placed around upper extremity nerves and activated the intended muscles. In both individuals, the neuroprosthesis has functioned properly for at least 2.5 years postimplant. Hand, wrist, forearm, elbow, and shoulder movements were achieved. A mobile arm support was needed to support the mass of the arm during functional activities. One individual was able to perform several activities of daily living with some limitations as a result of spasticity. The second individual was able to partially complete 2 activities of daily living. ConclusionsFunctional electrical stimulation is a feasible intervention for restoring arm and hand functions to individuals with high tetraplegia. Forces and movements were generated at the hand, wrist, elbow, and shoulder that allowed the performance of activities of daily living, with some limitations requiring the use of a mobile arm support to assist the stimulated shoulder forces.

Selection of muscle and nerve-cuff electrodes for neuroprostheses using customizable musculoskeletal model

Neuroprosthetic systems based on functional electrical stimulation aim to restore motor function to individuals with paralysis following spinal cord injury. Identifying the optimal electrode set for the neuroprosthesis is complicated because it depends on the characteristics of the individual (such as injury level), the force capacities of the muscles, the movements the system aims to restore, and the hardware limitations (number and type of electrodes available). An electrode-selection method has been developed that uses a customized musculoskeletal model. Candidate electrode sets are created based on desired functional outcomes and the hard ware limitations of the proposed system. Inverse-dynamic simulations are performed to determine the proportion of target movements that can be accomplished with each set; the set that allows the most movements to be performed is chosen as the optimal set. The technique is demonstrated here for a system recently developed by our research group to restore whole-arm movement to individuals with high-level tetraplegia. The optimal set included selective nerve-cuff electrodes for the radial and musculocutaneous nerves; single-channel cuffs for the axillary, suprascapular, upper subscapular, and long-thoracic nerves; and muscle-based electrodes for the remaining channels. The importance of functional goals, hardware limitations, muscle and nerve anatomy, and surgical feasibility are highlighted.

Prediction of Imagined Single-Joint Movements in a Person With High-Level Tetraplegia

Cortical neuroprostheses for movement restoration require developing models for relating neural activity to desired movement. Previous studies have focused on correlating single-unit activities (SUA) in primary motor cortex to volitional arm movements in able-bodied primates. The extent of the cortical information relevant to arm movements remaining in severely paralyzed individuals is largely unknown. We record intracortical signals using a microelectrode array chronically implanted in the precentral gyrus of a person with tetraplegia, and estimate positions of imagined single-joint arm movements. Using visually guided motor imagery, the participant imagined performing eight distinct single-joint arm movements, while SUA, multispike trains (MSP), multiunit activity, and local field potential time (LFPrms), and frequency signals (LFPstft) were recorded. Using linear system identification, imagined joint trajectories were estimated with 20-60% variance explained, with wrist flexion/extension predicted the best and pronation/supination the poorest. Statistically, decoding of MSP and LFPstft yielded estimates that equaled those of SUA. Including multiple signal types in a decoder increased prediction accuracy in all cases. We conclude that signals recorded from a single restricted region of the precentral gyrus in this person with tetraplegia contained useful information regarding the intended movements of upper extremity joints.

Brachialis-to-Extensor Carpi Radialis Longus Selective Nerve Transfer to Restore Wrist Extension in Tetraplegia: Case Report

Active wrist extension allowing tenodesis grip is the key function in high-level tetraplegic patients. It is absent and cannot be restored by traditional tendon transfer in patients who have no transferable muscle below the elbow. We present a 36-year-old man with high-level tetraplegia treated 12 months after injury who regained active wrist extension after transfer of the brachialis muscle branch of the musculocutaneous nerve to the extensor carpi radialis longus muscle branch of the radial nerve. No functional deficit of elbow flexion occurred after reconstruction.

Resolution of tracheostomy complications by decanulation and conversion to noninvasive management for a patient with high-level tetraplegia.

To report conversion from tracheostomy (TIV) to noninvasive intermittent positive pressure ventilation (NIV) for a continuously ventilator-dependent patient with high-level spinal cord injury (SCI) with no measurable vital capacity (VC = 0 mL) to resolve tracheostomy-associated complications. A case report of a 38-year-old female in a chronic care facility in Japan with a 10-year history of ventilator-dependent tetraplegia (C1 ASIA-A) presented for increasing difficulty vocalizing. She had been using a fenestrated cuffed tracheostomy tube to produce speech with the cuff deflated. Speech was increasingly hypophonic, because of tracheostoma enlargement, tube migration, and tracheal granulation. The NIV was provided via nasal and oral interfaces, the ostomy was surgically closed, and vocalization resumed. Airway secretions were expulsed using manually assisted coughing. The patient returned to the community. Conversion to NIV should be considered for ventilator-dependent patients with SCI who have adequate bulbar-innervated muscle function to permit effective speech and assisted coughing.

A Novel Command Signal for Motor Neuroprosthetic Control

Background. Neuroprostheses can restore functions such as hand grasp or standing to individuals with spinal cord injury (SCI) using electrical stimulation to elicit movements in paralyzed muscles. Implanted neuroprostheses currently use electromyographic (EMG) activity from muscles above the lesion that remain under volitional control as a command input. Systems in development use a networked approach and will allow for restoration of multiple functions but will require additional command signals to control the system, especially in individuals with high-level tetraplegia. Objective. The objective of this study was to investigate the feasibility of using muscles innervated below the injury level as command sources for a neuroprosthesis. Recent anatomical and physiological studies have demonstrated the presence of intact axons across the lesion, even in those diagnosed with a clinically complete SCI; hence, EMG activity may be present in muscles with no sign of movement. Methods. Twelve participants with motor complete SCI were enrolled and EMG was recorded with surface electrodes from 8 muscles below the knee in each leg. Results. Significant activity was evident in 89% of the 192 muscles studied during attempted movements of the foot and lower limb. At least 2 muscles from each participant were identified as potential command signals for a neuroprosthesis based on 2-state, threshold classification. Conclusions. Results suggest that voluntary activity is present and recordable in below lesion muscles even after clinically complete SCI.

Trends in New Injuries, Prevalent Cases, and Aging With Spinal Cord Injury

DeVivo MJ, Chen Y. Trends in new injuries, prevalent cases, and aging with spinal cord injury. Objective To determine the characteristics of the newly injured and prevalent population with spinal cord injury (SCI) and assess trends over time. Design Prospective cohort study. Setting SCI Model Systems and Shriners Hospital SCI units. Participants The study population included people whose injuries occurred from 1935 to 2008 (N=45,442). The prevalent population was estimated based on those who were still alive in 2008. Losses to follow-up (approximately 10%) were excluded from the prevalent population. Interventions Not applicable. Main Outcome Measures Demographic and injury characteristics, mortality, self-reported health, rehospitalization, FIM, Craig Handicap Assessment and Reporting Technique, and the Diener Satisfaction with Life Scale. Results Mean age at injury increased 9 years since the 1970s. Injuries caused by falls and injuries resulting in high-level tetraplegia and ventilator dependency are increasing, while neurologically complete injuries are decreasing. Discharge to a nursing home is increasing. The mean age of the prevalent population is slightly higher than that of newly injured individuals, and the percentage of incident and prevalent cases older than 60 years is the same (13%). Prevalent cases tend to be less severely injured than incident cases, and less than 5% of prevalent cases reside in nursing homes. Within the prevalent population, life satisfaction and community participation are greater among persons who are at least 30 years postinjury. These findings are a result of very high mortality rates observed after 60 years of age. Conclusions Within the prevalent population, the percentage of elderly persons will not increase meaningfully. Those who reach older ages will typically have incomplete and/or lower-level injuries and will have relatively high degrees of independence and overall good health.

Scapular Stabilization in Patients With Spinal Cord Injury

Background: Severe scapular instability can be a considerable problem for people with high-level cervical spinal cord injury. Scapular instability reduces the effectiveness of the already weakened shoulder flexors and abductors, thereby limiting hand-to-mouth and hand-to-head activities. The winged scapula may cause inferior pole skin breakdown, as well as neck and shoulder pain.Objective: To report the efficacy of a fusionless scapular stabilization procedure as a means to enhance function in a consecutive group of patients with high-level cervical spinal cord injury.Methods: Four people with spinal cord injury at C4-C5 (2 male, 2 female; mean age = 17.3 years, range = 14-20 years) underwent scapular stabilization via scapulothoracic fusion (N = 2) or by tethering the scapula to the rib cage with Mersilene tape as a fusionless stabilization (N = 2). One patient died of unrelated causes 18 months after surgery, and the remaining 3 were followed for 26, 39, and 41 months, respectively. Data collection included radiographic analysis, active range of motion measures, and functional assessment.Results: Active shoulder flexion and abduction remained unchanged in 2 patients, but functional scores improved with regard to feeding and grooming capability. All patients reported satisfaction with postoperative appearance, and 3 patients reported considerable reduction in shoulder pain after surgery. Radiographs demonstrated maintenance of stable scapular alignment in all patients at final follow up. Wound breakdown, requiring removal of instrumentation, occurred in 2 patients.Conclusion: Scapular stabilization with or without fusion is a viable option to improve appearance, pain, and upper extremity function in people with high-level tetraplegia and scapular instability.

Long-Term Ventilation for High-Level Tetraplegia: A Report of 2 Cases of Noninvasive Positive-Pressure Ventilation

Toki A, Tamura R, Sumida M. Long-term ventilation for high-level tetraplegia: a report of 2 cases of noninvasive positive-pressure ventilation. Ventilator-dependent patients with tetraplegia rarely use noninvasive positive-pressure ventilation (NPPV) for long-term ventilation. We report 2 patients with high-level traumatic tetraplegia who were able to return home after being changed from traditional ventilation to NPPV. When they were referred to our hospital from acute care hospitals 2 to 6 months after injury, both were on tracheostomy ventilation with a cuff inflated 24 hours a day, and tidal volume (V t) settings were low. In case 1, a man with complete C1 tetraplegia was admitted to our hospital 6 months after injury. We changed ventilator settings to high V t and introduced NPPV. He was discharged home with NPPV with a volume-setting ventilator. Case 2 involved a man in his late twenties with complete C1 tetraplegia who was discharged home with NPPV. After discharge, he trained in glossopharyngeal breathing by himself, enabling him to breathe up to 1900mL of maximum insufflation capacity. Both have lived nearly 1 year without pulmonary complications in the community. They use visiting nurses 3 times a week and services of visiting caregivers. Further study is needed to determine the usefulness of NPPV for long-term ventilatory management.

Gastric Dysmotility After Abdominal Surgery in Persons With Cervical Spinal Cord Injury: A Case Series

Background: Spinal cord injury (SCI) has been found to affect the physiology of the gastrointestinal tract. Changes in gastric motility occur in tetraplegia because of dissociation of antral and duodenal motility. Among individuals with high-level tetraplegia, antral quiescence has been hypothesized as a manifestation of autonomic dysreflexia after surgery. This case series shows the issues with gastric hypomotility after gastrointestinal surgery in tetraplegic patients with tetraplegia, including management strategies.Objective: To report 3 patients with complete high cervical SCI who developed gastroparesis after abdominal surgery and discuss the effect of autonomic dysfunction on gastric motility.Methods: Retrospective chart review of 3 cases.Results: Gastroparesis occurred after abdominal surgery in 3 patients with C4 American Spinal Injury Association (ASIA) A tetraplegia and seemed to be a sign of autonomic hyperreflexia caused by postoperative pain. Management was challenging because it consisted of balancing of appropriate pain medication and dealing with absorption issues and dysmotility. Often gastric motility agents were not effective in improving gastric emptying. However, increased use of pain medication improved gastric emptying, which supports the hypothesis that this issue represents gastric dysfunction from autonomic hyperreflexia.Conclusions: In persons with complete cervical SCI who have undergone abdominal surgery, postoperative gastroparesis can be a manifestation of pain. This may occur as the excessive sympathetic response from autonomic hyperreflexia inhibits distal antral activity. Thus, treatment of postoperative gastroparesis should focus on improved pain control to decrease excessive splanchnic sympathetic output and circulating norepinephrine.