Incomplete Cervical Spinal Cord Injury Research Articles

Prolonged intermittent hypoxia differentially regulates phrenic motor neuron serotonin receptor expression in rats following chronic cervical spinal cord injury

Low-dose (< 2 h/day), acute intermittent hypoxia (AIH) elicits multiple forms of serotonin-dependent phrenic motor plasticity and is emerging as a promising therapeutic strategy to restore respiratory and non-respiratory motor function after spinal cord injury (SCI). In contrast, high-dose (> 8 h/day), chronic intermittent hypoxia (CIH) undermines some forms of serotonin-dependent phrenic motor plasticity and elicits pathology. CIH is a hallmark of sleep disordered breathing, which is highly prevalent in individuals with cervical SCI. Interestingly, AIH and CIH preconditioning differentially impact phrenic motor plasticity. Although mechanisms of AIH-induced plasticity in the phrenic motor system are well-described in naïve rats, we know little concerning how these mechanisms are affected by chronic SCI or intermittent hypoxia preconditioning. Thus, in a rat model of chronic, incomplete cervical SCI (lateral spinal hemisection at C2 (C2Hx), we assessed serotonin type 2 A, 2B and 7 receptor expression in and near phrenic motor neurons and compared: 1) intact vs. chronically injured rats; and 2) the impact of preconditioning with varied “doses” of intermittent hypoxia (IH). While there were no effects of chronic injury or intermittent hypoxia alone, CIH affected multiple receptors in rats with chronic C2Hx. Specifically, CIH preconditioning (8 h/day; 28 days) increased serotonin 2 A and 7 receptor expression exclusively in rats with chronic C2Hx. Understanding the complex, context-specific interactions between chronic SCI and CIH and how this ultimately impacts phrenic motor plasticity is important as we leverage AIH-induced motor plasticity to restore breathing and other non-respiratory motor functions in people with chronic SCI.

Mild Intermittent Hypoxia Improves Hand Function in a Participant with Motor Incomplete Cervical Spinal Cord Injury

Mild Intermittent Hypoxia Improves Hand Function in a Participant with Motor Incomplete Cervical Spinal Cord Injury

Neuropathic pain development and maintenance and its association with motor recovery after cervical spinal cord injury

Background In our published randomized controlled trial, we revealed that patients with acute ASIA Grade C incomplete cervical spinal cord injury (SCI) who underwent early surgery (within 24 h post-injury) had accelerated motor recovery at six months than those with delayed surgery (>2 weeks post-injury); however, neuropathic pain (NeP) worsened regardless of surgery timing. Here, we conducted post-hoc analyses to intensively assess NeP development and maintenance. Methods Of 44 patients (median 64.5 years; three female; early intervention, n = 26), NeP was categorized into at-level and below-level pain and evaluated at two weeks and one year after injury using the Neuropathic Pain Symptom Inventory (NPSI). We compared the two groups based on background characteristics. A mixed-design analysis of variance with sex as a covariate was conducted to analyze motor recovery and Health-related quality of life (HRQOL) in groups with severe (NPSI ≥ 10) or mild (NPSI < 10) pain. Results Upper and lower limb motor impairments were comparable between both groups regardless of pain severity. Severe at-level pain remained stable and worsened at one year than mild at-level pain; however, the upper- and lower-limb motor scores and HRQOL had comparable recovery. Background characteristics did not affect severity or time course of NeP. Patients with severe below-level pain demonstrated slower lower-limb motor recovery than those with mild below-level pain, whereas HRQOL improved regardless of pain severity. Conclusions Both at-level and below-level NeP developed and persisted relatively early in the course of traumatic SCI with incomplete motor paralysis; their severities worsened over time or remained severe since onset.

Effects of early mobilization within 48 hours of injury in patients with incomplete cervical spinal cord injury

Objective To investigate the effects of early mobilization within 48 h of injury on motor function and walking ability in patients with incomplete cervical spinal cord injury (SCI). Design A retrospective observational study. Setting Intensive care unit or high care unit of a university hospital emergency center. Participants Of 224 patients with SCI having American Spinal Injury Association impairment scale grades C and D, 158 consecutive patients hospitalized for at least 3 weeks after injury were included. Interventions Patients were categorized into two groups: an early mobilization group in which patients were mobilized within 48 h of injury and a delayed mobilization group in which they were mobilized after 48 h of injury. Outcome measures The upper extremity motor score (UEMS), lower extremity motor score (LEMS), and Walking Index for Spinal Cord Injury II (WISCI II) were compared using propensity score matching analysis. Results Of the 158 patients who met the eligibility criteria, 32 were matched between the groups. There was a significant difference in the change in LEMS from the initial assessment to the assessment 2 weeks postoperatively in the early mobilization group (median 9 points vs. 3 points, p < 0.05). There were no significant differences in UEMS or WISCI II. Conclusion Early mobilization within 48 h may improve lower extremity motor function in patients with acute incomplete cervical SCI.

Evolving trends in the surgical, anaesthetic, and intensive care management of acute spinal cord injuries in the UK.

We surveyed the treatment of acute spinal cord injuries in the UK and compared current practices with 10 years ago. A questionnaire survey was conducted amongst neurosurgeons, neuroanaesthetists, and neurointensivists that manage patients with acute spinal cord injuries. The survey gave two scenarios (complete and incomplete cervical spinal cord injuries). We obtained opinions on the speed of transfer, timing and aim of surgery, choice of anaesthetic, intraoperative monitoring, targets for physiological parameters, and drug treatments. We received responses from 78.6% of UK units that manage acute spinal cord injuries (33 neurosurgeons, 56 neuroanaesthetists/neurointensivists). Most neurosurgeons operate within 12h for incomplete (82%) and complete (64%) injuries. There is a significant shift from 10 years ago, when only 61% (incomplete) and 30% (complete) of neurosurgeons operated within 12h. The preferred anaesthetic technique in 2022 is total intravenous anaesthesia (TIVA), used by 69% of neuroanaesthetists. Significantly more intraoperative monitoring is now used at least sometimes, including bispectral index (91%), non-invasive cardiac output (62%), and neurophysiology (73-77%). Methylprednisolone is no longer used by surgeons. Achieving at least 80mmHg mean arterial blood pressure is recommended by 70% neurosurgeons, 62% neuroanaesthetists, and 75% neurointensivists. Between 2012 and 2022, there was a paradigm shift in managing acute spinal cord injuries in the UK with earlier surgery and more intraoperative monitoring. Variability in practice persists due to lack of high-quality evidence and consensus guidelines.

Verification of the minimal clinically important difference of the Capabilities of Upper Extremity Test in patients with subacute spinal cord injury

Context The number of patients with cervical spinal cord injury (CSCI) is increasing, and the Capabilities of Upper Extremity Test (CUE-T) is recommended for introduction in clinical trials. We calculated the minimal clinically important difference (MCID) of the CUE-T using an adjustment model with an interval of 1 month. Design This was a prospective study. Setting This study was conducted with participants from the Chiba Rehabilitation Center in Japan. Participants The participants were patients with subacute CSCI. Interventions The CUE-T and spinal cord independence measure (SCIM) III were performed twice within an interval of 1 month. Outcome Measures The MCID was calculated using an adjustment model based on logistic regression analysis. The participants were classified into an improvement group and a non-improvement group based on the amount of change in the two evaluations using the 10-point SCIM III MCID as an anchor. Results There were 52 participants (56.8 ± 13.5 years old, 45 men/7 women) with complete or incomplete CSCI: 18 in the improvement group and 34 in the non-improvement group. A significant regression equation was obtained when calculating the MCID, and the total, hand, and side scores were 7.7, 2.0, and 3.7 points, respectively. Conclusion The calculated MCID of the CUE-T in this study was 7.7 points. The results of this study provide useful criteria for implementation in clinical trials. Future studies should use patient-reported outcomes, a more recommended anchor, and calculate the MCID using methods such as the patient’s condition.

Effects of the combination of acupuncture and medication on orthostatic hypotension after incomplete cervical spinal cord injury

Effects of the combination of acupuncture and medication on orthostatic hypotension after incomplete cervical spinal cord injury

Knee Joint Extension Muscle Strength Required for Walking Independence by Patients with Acute Incomplete Cervical Spinal Cord Injury

Knee Joint Extension Muscle Strength Required for Walking Independence by Patients with Acute Incomplete Cervical Spinal Cord Injury

ASYMPTOMATIC DYSREFLEXIA AFTER POSTURAL CHANGES IN AN INCOMPLETE SPINAL CORD INJURY: CONSIDERATIONS FOR EXERCISE PHYSIOLOGISTS

BACKGROUND Autonomic dysreflexia (AD) is a potentially life threatening hypertensive syndrome prevalent among patients with chronic spinal cord injuries (SCI) at spinal segment T6 or above. AD is due to the loss of supraspinal control over sympathetic preganglionic neurons and is triggered by noxious stimuli below the level of injury. The treatment of AD is multifaceted, from conservative management to topical and oral antihypertensive medications. Understanding AD's rapid onset and severity are extremely important for exercise physiologists working with patients with SCI. CASE PRESENTATION A 67-year old male with chronic motor incomplete cervical SCI (i.e., ASIA C4 C) and persistent orthostatic hypotension (OH) was enrolled in a study to determine the effects of biofeedback on blood pressure (BP) modulation when an episode of asymptomatic AD occurred. Baseline and resting BP were recorded at 122/82, with a resting mean arterial pressure (MAP) of 96. The BP was continuously monitored using a telemetric device (Caretaker, Charlottesville, VA). Upon positional changes required to measure OH with a tilt table, the participant showed an antagonist response with a sudden increase in BP consistent with AD symptoms, reaching a maximum level of 199/121. The participant was asymptomatic during the AD episode. CASE MANAGEMENT/OUTCOME BP returned to baseline levels after the participant was transferred back to a seated position in the wheelchair without using other measurements or medications. The titl test was modified with the participant positioned in a semi supine position (30° incline) and then tilted to approximately 45and remained in this position for 3 minutes. DISCUSSION AD is prevalent among people with cervical or upper thoracic SCI, and often the episodes are asymptomatic. As a part of the training routine, many patients with SCI are placed in a supine position for passive stretching and exercising. We are presenting data on this episode of asymptomatic AD due to postural changes to bring awareness to exercise physiologists of this life threatening condition. Trainers should carefully check for signs of AD in this population and measure BP often during the training sessions if a continuous assessment of BP is unavailable. Seated is recommended over a supine or semi-supine position. This could be accomplished by using physical therapy wedge cushions to maintain blood pressure homeostasis.

Effect of Age at Injury on Walking Ability Following Incomplete Cervical Spinal Cord Injury: A Retrospective Cohort Study.

Recently, the cases of elderly individuals with spinal cord injuries are increasing in Japan. For individuals with spinal cord injury, regaining the ability to walk independently after an injury is one of the most important aspects of rehabilitation. Nevertheless, instead of age-optimized programs, uniform rehabilitation programs are currently provided to all patients because there is no information available for predicting prognosis based on age at the time of injury. This study aimed to elucidate the effect of age at the time of injury on the walking ability of patients with incomplete cervical spinal cord injury. Of the 1,195 patients registered in the Japan single-center study for spinal cord injury database, those hospitalized within 28 days after injury, followed up for >180 days, had a cervical spinal cord injury, and had a lower extremity motor score of ≥42 points were examined. Patients were stratified into three groups according to the age at the time of injury (≤59, 60-69, or ≥70 years). The walking ability scores and independence levels of mobility were compared; these data were evaluated based on indoor mobility (item 12) and outdoor mobility (item 14) in the Spinal Cord Independence Measure III and Walking Index for Spinal Cord Injury II. All comparisons used data at discharge. The walking ability scores and independence levels of mobility were significantly lower in the group aged ≥70 years than those in the remaining two groups. In patients with cervical spinal cord injuries with the same limb function, if the age at the time of injury was ≥70 years, the decline in physical function due to aging exerted a substantial effect on walking ability.

Developing guiding principles for technology-based rehabilitation program by engaging people with motor incomplete tetraplegia

BackgroundTechnology-aided rehabilitation is well established in the field of neurologic rehabilitation. Despite the widespread availability, the development of technology-based interventions that incorporate perspectives of the people who will use them is lacking.ObjectivesThis qualitative study aims to understand how people with chronic motor incomplete cervical spinal cord injury view rehabilitation technology to improve upper extremity function and neuromuscular recovery to inform future intervention development.MethodsSeven participants with chronic upper extremity impairment due to spinal cord injury/dysfunction trialed five rehabilitation technology devices. After a 30–45 min trial for each device, participants engaged in a semi-structured interview. Interviews were analyzed using a qualitative approach to explore the experience using and understand features that support motivation to use of rehabilitation technology.ResultsQualitative analysis revealed three major themes: (1) devices must be flexible to meet diverse needs; (2) intervention protocols must be individualized to address unique needs and contexts of users; (3) intervention protocols should be developed and updated by a skilled clinician. These themes and subthemes were used to describe guiding principles to inform future intervention design.ConclusionThe experiences of people with cervical spinal cord injury can be elicited as part of the intervention design process to systematically develop protocols for future feasibility trials. The findings from this study can be used to inform the development of technology-aided rehabilitation programs to improve upper extremity function in people with chronic motor incomplete tetraplegia.Clinical trials registration number: NCT04000256

Inspiratory muscle reflex control after incomplete cervical spinal cord injury.

In healthy individuals, loading inspiratory muscles by brief inspiratory occlusion produces a short-latency inhibitory reflex (IR) in the electromyographic (EMG) activity of scalene and diaphragm muscles. This IR may play a protective role to prevent aspiration and airway collapse during sleep. In people with motor and sensory complete cervical spinal cord injury (cSCI), who were able to breathe independently, this IR was predominantly absent. Here, we investigated the reflex response to brief airway occlusion in 16 participants with sensory incomplete cSCI [American spinal injury association impairment scale (AIS) score B or C]. Surface EMG was recorded from scalene muscles and the lateral chest wall (overlying diaphragm). The airway occlusion evoked a small change in mouth pressure resembling a physiological occlusion. The short-latency IR was present in 10 (63%) sensory incomplete cSCI participants; significantly higher than the IR incidence observed in complete cSCI participants in our previous study (14%; P = 0.003). When present, mean IR latency across all muscles was 58 ms (range 29-79 ms), and mean rectified EMG amplitude decreased to 37% preocclusion levels. Participants without an IR had untreated severe obstructive sleep apnea (OSA), in contrast to those with an IR, who had either had no, mild, or treated OSA (P = 0.002). Insufficient power did not allow statistical comparison between IR presence or absence and participant clinical characteristics. In conclusion, spared sensory connections or intersegmental connections may be necessary to generate the IR. Future studies to establish whether IR presence is related to respiratory morbidity in the tetraplegic population are required.NEW & NOTEWORTHY Individuals with incomplete cSCI were tested for the presence of a short latency reflex inhibition of inspiratory muscles, by brief airway occlusion. The reflex was 4.5 times more prevalent in this group compared with those with complete cSCI and is similar to the incidence in able-bodied people. Participants without this reflex all had untreated severe OSA, in contrast to those with an IR, who either had no, mild, or treated OSA. This work reveals novel differences in the reflex control of inspiratory muscles across the cSCI population.

Altered functional connectivity between primary motor cortex subregions and the whole brain in patients with incomplete cervical spinal cord injury.

To investigate the reorganizations of gray matter volume (GMV) in each subregion of primary motor cortex (M1) after incomplete cervical cord injury (ICCI) and to explore the differences in functional connectivity (FC) between the M1 subregions and the whole brain, and further to disclose the potential value of each M1 subregion in motor function rehabilitation of ICCI patients. Eighteen ICCI patients and eighteen age- and gender- matched healthy controls (HCs) were recruited in this study. The 3D high-resolution T1-weighted structural images and resting-state functional magnetic resonance imaging (rs-fMRI) of all subjects were obtained using a 3.0 Tesla MRI system. Based on the Human Brainnetome Atlas, the structural and functional changes of M1 subregions (including A4hf, A6cdl, A4ul, A4t, A4tl, A6cvl) in ICCI patients were analyzed by voxel-based morphometry (VBM) and seed-based FC, respectively. Compared with HCs, no structural changes in the M1 subregions of ICCI patients was detected. However, when compared with HCs, ICCI patients exhibited decreased FC in visual related areas (lingual gyrus, fusiform gyrus) and sensorimotor related areas (primary sensorimotor cortex) when the seeds were located in bilateral A4hf, A4ul, and decreased FC in visual related areas (lingual gyrus, fusiform gyrus) and cognitive related areas (temporal pole) when the seed was located in the left A4t. Moreover, when the seeds were located in the bilateral A6cdl, decreased FC in visual related areas (lingual gyrus, fusiform gyrus, calcarine gyrus) was also observed. Our findings demonstrated that each of the M1 regions had diverse FC reorganizations, which may provide a theoretical basis for the selection of precise stimulation targets, such as transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tCDS), meanwhile, our results may reveal the possible mechanism of visual feedback and cognitive training to promote motor rehabilitation.

Risk factors of AIS C incomplete cervical spinal cord injury for poor prognosis—The significance of anorectal evaluation

BackgroundAlthough the prognosis of incomplete cervical spinal cord injury (SCI) diagnosed as American Spinal Injury Association Impairment Scale grade C (AIS C) is generally favorable, some patients remain non-ambulatory. The present study explored the clinical factors associated with the non-ambulatory state of AIS C patients. MethodsThis study was a single-center retrospective observational study. Seventy-three participants with AIS C on admission were enrolled and divided into two groups according to ambulatory ability after one year. Prognostic factors of SCI were compared in ambulatory (A-group) and non-ambulatory participants (NA-group). Univariable and multivariable logistic regression analyses were performed on demographic information, medical history, mechanism of injury, presence of fracture, ASIA motor scores (MS) of the extremities, neurological findings, including an anorectal examination on admission, and imaging findings. ResultsForty-one patients were included in the A-group and 32 in the NA-group. Univariable analysis revealed that the following factors were related to poor outcomes (p < 0.05): older age, history of cerebrovascular disorder, impairment/absence of S4-5 sensory score, deep anal pressure (DAP) (−), voluntary anal contraction (VAC) (−), anorectal tone (−), anal wink reflex (−), and low MS of the upper and lower extremities. In the multivariable analysis using age, presence or absence of sacral abnormality, and history of cerebrovascular disorders (adjusted for these three factors), older age and presence of sacral abnormality on admission were independent risk factors for a non-ambulatory state at the 1-year follow-up. ConclusionsIncomplete AIS C SCI individuals with older age and/or impairment of anorectal examination could remain non-ambulatory at 1-year follow-up.

A Novel Method to Classify Cervical Incomplete Spinal Cord Injury Based on Potential for Recovery: A Group-Based Trajectory Analysis.

The outcomes of cervical incomplete spinal cord injury (SCI) are heterogeneous. This study sought to dissociate subgroups of cervical incomplete SCI patients with distinct longitudinal temporal profiles of recovery in upper limb motor function. Patients with cervical incomplete SCI (American Spinal Injury Association Impairment Scale [AIS] B-D; C1-C8) were identified from four prospective, multi-center SCI datasets. A group-based trajectory model was fit to longitudinal upper extremity motor scores out to 1 year. Multi-variable multinomial logistic regression was performed to identify features that characterize each trajectory group. A classification system for predicting trajectory group at baseline was developed by recursive partitioning. In total, 801 patients were eligible. Four distinct trajectory groups were identified: 1) "Poor outcome": Severe injury, very minimal recovery; 2) "Moderate recovery": Moderate-to-severe injury, moderate recovery; most recovery occurs by 6 months, with mild, gradual recovery continuing thereafter; 3) "Good recovery": Moderate injury, good recovery; most recovery occurs by 3 months, with mild, gradual recovery continuing thereafter; and 4) "Excellent outcome": Mild injury, recovery to normal/near-normal by 3 months. On adjusted analyses, older age was associated with lower likelihood of "excellent outcome" (p = 0.020). AIS C and D injuries were associated with "moderate recovery," "good recovery," and "excellent outcome" (p < 0.001). Mid-cervical injuries occurred more frequently in "moderate recovery," "good recovery," and "excellent outcome" (p < 0.001) groups. Early surgical decompression (< 24 h) was associated with increased propensity for "good recovery" (p = 0.039) and "excellent outcome" (p = 0.048). A classification model based on recursive partitioning could predict trajectory group using age, AIS grade, and neurological level with an area under the curve of 0.81. Patients with cervical incomplete SCI demonstrate distinct temporal profiles of recovery in upper limb motor function. The trajectory a patient is likely to follow may be predicted at baseline with fair accuracy.

21. Early vs delayed surgery for incomplete cervical spinal cord injury with pre-existing cervical stenosis: the OSCIS randomized clinical trial

<h3>BACKGROUND CONTEXT</h3> The timing of surgery for acute traumatic cervical spinal cord injury (SCI) has long been an issue of intense debate. The superiority of early surgical decompression for incomplete cervical SCI without concomitant bone injuries has not been established. <h3>PURPOSE</h3> The aim of this study was to determine whether early surgical decompression within 24 hours results in better motor recovery than delayed surgery following at least two weeks of conservative treatment. <h3>STUDY DESIGN/SETTING</h3> Multicenter randomized controlled trial conducted at 43 tertiary referral hospitals in Japan. <h3>PATIENT SAMPLE</h3> Patients aged 20 to 79 years with motor-incomplete cervical SCI with pre-existing canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. The presence of canal stenosis was verified based on baseline imaging studies, including MRI and CT. <h3>OUTCOME MEASURES</h3> The primary endpoints were improvement in the mean ASIA motor score, total score of the spinal cord independence measure (SCIM), and the proportion of patients able to walk independently at one year post-injury. <h3>METHODS</h3> Participants were allocated (11) by computer-based randomization to urgent surgery within 24 hours after admission or delayed surgery (later than two weeks post-injury). <h3>RESULTS</h3> Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; 5 women and 65 men) were included in the full analysis population at one year post-injury (37 patients assigned to early surgery and 33 to delayed surgery). We found a consistent, but insignificant, trend favoring early surgery more than delayed surgery (mean change in ASIA motor score, 53.7 vs 48.5, difference, 5.2; 95% confidence interval, -4.2 to 14.5; p=0.27; mean SCIM total score, 77.9 vs 71.3, p=0.34; the proportion of ambulatory patients, 70% vs 61.5%; p=0.51). A mixed-design analysis of variance revealed a significant difference in the ASIA motor scores between the groups (p=0.03). The early surgery group showed greater motor scores than the delayed surgery group at 2, 3 and 6 months post-injury. Complications were common in both groups (death, 3 patients vs 3 patients). <h3>CONCLUSIONS</h3> Among motor-incomplete cervical SCI patients, early surgery produced similar motor regain at one year post-injury as delayed surgery, but showed accelerated recovery within the first six months. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Minimal Clinically Important Difference of Graded Redefined Assessment of Strength, Sensibility, and Prehension Version 1 in Acute Cervical Traumatic Spinal Cord Injury.

The Graded Redefined Assessment of Strength, Sensibility, and Prehension Version 1 (GRASSP v1) is a validated measure of upper extremity impairment shown to be sensitive and responsive for traumatic cervical spinal cord injury (SCI) in both North American (NA) and European (EU) cohorts. The minimal clinically important difference (MCID) is the quantitative change in an assessment scale that patients perceive as being beneficial. Our aim was to establish the MCID of all subtests of the GRASSP v1 for cervical SCI. We prospectively analyzed 127 patients from NA and EU for up to six months after motor complete and incomplete cervical SCI using the GRASSP v1, Spinal Cord Independence Measure, and International Standards of Neurological Classification of Spinal Cord Injury. We used a patient global rating of change and the anchor-based method to calculate MCID of GRASSP v1 at six months post-injury. The MCID was established for the whole group, dividing the sample by "better" and "much better." Improvement in GRASSP v1 Strength and Prehension Performance scores of 13 and 3 are the MCID for the better category, and 19 and 7 are the MCID for the much better category, respectively. The MCID was also established for the motor complete and incomplete groups. Improvement in GRASSP v1 Strength and Prehension Performance scores of 12 and 6 are the MCID for the motor complete group, and 17 and 12 are the MCID for the motor incomplete group, respectively. The GRASSP v1 Strength subscore is the most sensitive for detecting meaningful clinical change in patients and is most closely related to measures of independence. Thus, use of GRASSP v1 Strength and Prehension Performance as measures of change is substantiated by this study.

수정된 양손집중연습이 불완전 경수 손상 환자의 손 기능과 작업수행에 미치는 영향

Objective: The purpose of this study is to investigate the effect of modified bimanual massed practice training on hand function and occupational performance of a incomplete tetraplegia patient. Methods: The participant was a 27 years old man diagnosed with C7/C7(s), C6/C6(m) incomplete tetraplegia ASIA-C. The patient performed developed modified bimanual massed practice with a total of 20 sessions, 30 minute 5 sessions per each week for 4 weeks modified according to domestic clinical setting. Results: The mean value of dynamometer on the right hand progressively improved through baseline A1(mean 2.96 kg), intervention B(mean 3.07 kg), baseline A2(mean 3.50 kg). And on the left hand, it also increased from B(mean 2.64 kg) to A2(mean 3.04 kg). In the Box and block test, the right hand improved from A1(47 unit) to B(52.55 unit) and maintained for A2, and the left hand improved through A1(46.4 unit), B(47.2 unit), and A2(49.8 unit). And the results of Assessment of Motor and Process skills showed that motor skills improved from before (0.0 logit) to after(0.7 logit), and process skills also improved from 0.7 logit to 1.0 logit. Conclusion: This study results support that the modified bimanual massed practice training is beneficial in improving hand function and occupational performance in a incomplete cervical spinal cord injury patient.&#x0D;

Lack of somatotopy among corticospinal tract fibers passing through the primate craniovertebral junction and cervical spinal cord: pathoanatomical substrate of central cord syndrome and cruciate paralysis.

In some cases of incomplete cervical spinal cord injury (iSCI) there is marked paresis and dysfunction of upper-extremity movement but not lower-extremity movement. A continued explanation of such symptoms is a somatotopic organization of corticospinal tract (CST) fibers passing through the decussation at the craniovertebral junction (CVJ) and lateral CST (LCST). In central cord syndrome, it has been suggested that injury to the core of the cervical cord may include selective damage to medially located arm/hand LCST fibers, without compromising laterally located leg fibers. Because such somatotopic organization in the primate CST might contribute to the disproportionate motor deficits after some forms of iSCI, the authors made a systematic investigation of CST organization in the CVJ and LCST using modern neuroanatomical techniques. High-resolution anterograde tracers were used in 11 rhesus macaque monkeys to define the course of the corticospinal projection (CSP) through the CVJ and LCST from the arm/hand, shoulder, and leg areas of the primary motor cortex (M1). This approach labels CST fibers of all sizes, large and small, arising in these areas. The CSP from the dorsolateral and ventrolateral premotor cortex and supplementary motor area were also studied. A stereological approach was adapted to quantify labeled fiber distribution in 8 cases. There was no evidence for somatotopic organization of CST fibers passing through the CVJ or contralateral LCST. Fiber labeling from each cortical representation was widespread throughout the CST at the CVJ and LCST and overlapped extensively with fibers from other representations. This study demonstrated no significant difference between medial versus lateral subsectors of the LCST in terms of number of fibers labeled from the M1 arm/hand area. This investigation firmly rejects the concept of somatotopy among CST fibers passing through the CVJ and LCST, in contrast with the somatotopy in the cortex, corona radiata, and internal capsule. All CST fibers in the CVJ and LCST would thus appear to be equally susceptible to focal or diffuse injury, regardless of their cortical origin. The disproportionate impairment of arm/hand movement after iSCI must therefore be due to other factors, including greater dependence of hand/arm movements on the CST compared with the lower limb. The dispersed and intermingled nature of frontomotor fibers may be important in motor recovery after cervical iSCI.

A critical reappraisal of corticospinal tract somatotopy and its role in traumatic cervical spinal cord syndromes.

The corticospinal tract (CST) is the preeminent voluntary motor pathway that controls human movements. Consequently, long-standing interest has focused on CST location and function in order to understand both loss and recovery of neurological function after incomplete cervical spinal cord injury, such as traumatic central cord syndrome. The hallmark clinical finding is paresis of the hands and upper-extremity function with retention of lower-extremity movements, which has been attributed to injury and the sparing of specific CST fibers. In contrast to historical concepts that proposed somatotopic (laminar) CST organization, the current narrative summarizes the accumulated evidence that 1) there is no somatotopic organization of the corticospinal tract within the spinal cord in humans and 2) the CST is critically important for hand function. The evidence includes data from 1) tract-tracing studies of the central nervous system and in vivo MRI studies of both humans and nonhuman primates, 2) selective ablative studies of the CST in primates, 3) evolutionary assessments of the CST in mammals, and 4) neuropathological examinations of patients after incomplete cervical spinal cord injury involving the CST and prominent arm and hand dysfunction. Acute traumatic central cord syndrome is characterized by prominent upper-extremity dysfunction, which has been falsely predicated on pinpoint injury to an assumed CST layer that specifically innervates the hand muscles. Given the evidence surveyed herein, the pathophysiological mechanism is most likely related to diffuse injury to the CST that plays a critically important role in hand function.