Lower Extremity Motor Score Research Articles

Lokomat Robotic-Assisted Versus Overground Training Within 3 to 6 Months of Incomplete Spinal Cord Lesion

Background. About 75% of persons with ASIA (American Spinal Injury Association) Impairment Scale C and D incomplete spinal cord injury (SCI) achieve walking ability. Objective. To compare a walking reeducation program using Lokomat with conventional overground training among individuals with incomplete SCI of both traumatic and nontraumatic etiology. Methods. A total of 80 participants from 3 to 6 months after onset admitted to 1 site for rehabilitation were included in a single-blind randomized clinical trial of 2 parallel groups, with blind evaluation by independent observers. Patients received 40 walking reeducation sessions of equal time using a Lokomat program with overground practice or overground mobility therapy alone. Primary measurements of outcome were walking speed and the Walking Index for Spinal Cord Injury (WISCI II). Secondary outcomes were the 6-minute walk test, locomotor section of the Functional Independence Measure, Lower Extremity Motor Score (LEMS), Ashworth Scale, and Visual Analog Scale for pain. Results. No significant differences were found at entry between treatment groups. Walking speed for Lokomat (0.4m/s [0.6-0.2]) and overground therapy (0.3m/s [0.5-0.2]) groups did not differ. The WISCI II for the Lokomat group (16 [8.5-19]) was better than for overground therapy (9 [8-16]). The 6-minute walk test and LEMS displayed significant differences in favor of Lokomat therapy but were not corrected for multiple comparisons. Conclusions. Robotic-assisted training was equivalent to conventional walk training in patients with a variety of nonprogressive spinal cord pathologies for walking speed, but the need for orthotics and assistive devices was reduced, perhaps because of greater leg strength in the robotic group.

Design and rationale of a Prospective, Observational European Multicenter study on the efficacy of acute surgical decompression after traumatic Spinal Cord Injury: the SCI-POEM study

Despite many years of research, there is currently no treatment available that results in major neurological or functional recovery after traumatic spinal cord injury (tSCI). In particular, no conclusive data related to the role of the timing of decompressive surgery, and the impact of injury severity on its benefit, have been published to date. This paper presents a protocol that was designed to examine the hypothesized association between the timing of surgical decompression and the extent of neurological recovery in tSCI patients. The SCI-POEM study is a Prospective, Observational European Multicenter comparative cohort study. This study compares acute (<12 h) versus non-acute (>12 h, <2 weeks) decompressive surgery in patients with a traumatic spinal column injury and concomitant spinal cord injury. The sample size calculation was based on a representative European patient cohort of 492 tSCI patients. During a 4-year period, 300 patients will need to be enrolled from 10 trauma centers across Europe. The primary endpoint is lower-extremity motor score as assessed according to the 'International standards for neurological classification of SCI' at 12 months after injury. Secondary endpoints include motor, sensory, imaging and functional outcomes at 3, 6 and 12 months after injury. In order to minimize bias and reduce the impact of confounders, special attention is paid to key methodological principles in this study protocol. A significant difference in safety and/or efficacy endpoints will provide meaningful information to clinicians, as this would confirm the hypothesis that rapid referral to and treatment in specialized centers result in important improvements in tSCI patients.

Motor and Gait Improvement in Patients With Incomplete Spinal Cord Injury Induced by High-Frequency Repetitive Transcranial Magnetic Stimulation

To assess the effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) on lower extremities motor score (LEMS) and gait in patients with motor incomplete spinal cord injury (SCI). The prospective longitudinal randomized, double-blind study assessed 17 SCI patients ASIA D. We assessed LEMS, modified Ashworth Scale (MAS), 10-m walking test (10MWT), Walking Index for SCI (WISCI II) scale, step length, cadence, and Timed Up and Go (TUG) test at baseline, after the last of 15 daily sessions of rTMS and 2 weeks later. Patients were randomized to active rTMS or sham stimulation. Three patients from the initial group of 10 randomized to sham stimulation entered the active rTMS group after a 3-week washout period. Therefore a total of 10 patients completed each study condition. Both groups were homogeneous for age, gender, time since injury, etiology, and ASIA scale. Active rTMS consisted of 15 days of daily sessions of 20 trains of 40 pulses at 20 Hz and an intensity of 90% of resting motor threshold. rTMS was applied with a double cone coil to the leg motor area. There was a significant improvement in LEMS in the active group (28.4 at baseline and 33.2 after stimulation; P = .004) but not in the sham group (29.6 at baseline, and 30.9 after stimulation; P = .6). The active group also showed significant improvements in the MAS, 10MWT, cadence, step length, and TUG, and these improvements were maintained 2 weeks later. Following sham stimulation, significant improvement was found only for step length and TUG. No significant changes were observed in the WISCI II scale in either group. High-frequency rTMS over the leg motor area can improve LEMS, spasticity, and gait in patients with motor incomplete SCI.

Spinal Cord Injury

Background. The description of the natural course of recovery from a spinal cord injury (SCI) with spontaneous improvement of neurological, neurophysiological, and functional measures is an important prerequisite in appraising effects of upcoming interventional therapies. Objective. To describe the spontaneous evolution of motor-evoked potentials of the anterior tibial muscle (TA-MEP) and their relation to outcomes of lower extremity motor scores (LEMS) and walking function in patients recovering from an acute SCI. Methods. TA-MEPs were assessed in 255 SCI subjects within 5 time intervals throughout the first year after SCI with combined neurological and functional measures. Tibial nerve conduction studies were performed to screen for peripheral nerve damage. Results. TA-MEP allowed stratification of SCI according to lesion severity and outcome. As MEP amplitudes increased over 12 months after SCI, this was paralleled by a significant improvement of LEMS and walking function. TA-MEP latencies remained usually stable. Conclusion. Clinical outcome and walking function after SCI can be predicted independent of clinical measures by assessment of TA-MEP reflecting corticospinal tract integrity.

Safety of Granulocyte-Colony Stimulating Factor (G-CSF) administration for post-rehabilitation spinal cord injury patients: a phase I open-label study

Background and Objective: Spinal cord injury (SCI) is a devastating neurological disorder causing various symptoms depending on the location, extent and degree of the damage. Granulocyte-colony stimulating factor (G-CSF) is a major growth factor in the activation and differentiation of granulocytes. This cytokine has been widely and safely employed clinically in different conditions over many years. On the other hand, the beneficial effects of G-CSF administration in spinal cord injury models have been shown in different studies. Patients and methods: This study was conducted in the Brain and Spinal Injury Research Center and all of its procedures were approved by Tehran University of Medical Sciences Ethics Committee. A total of 11 patients with spinal cord injury were enrolled in the study and subcutaneous administration of GCSF was performed for 5 days in all of them. Follow up period was about 1 year. The American Spinal Injury Association (ASIA) scale used for motor and sensory assessment and the Spinal Cord Independence Measure (SCIM III) was used to evaluate the changes on the ability of performing basic everyday tasks. Results: Based on ASIA neurological examination scale, mean upper extremity motor score changed from 28.36 ± 19.64(Mean ± SD) to 29.91 ± 19.95 and there was no change in lower extremity motor score, light touch and pin prick sensory score had a modest improvement 3.91 and 1.27 scores respectively. However, changes in motor and sensory scores were statistically significant (P

Factors that Influence Quiet Standing Balance of Patients with Incomplete Cervical Spinal Cord Injuries

ObjectiveTo investigate the factors influencing the quiet standing balance of patients with incomplete cervical spinal cord injuries. Also to find the correlations between posturographic parameters and clinical balance tests as well as to find the correlation between posturographic parameters and functional independence.MethodWe conducted a tetra-ataxiometric posturography, lower extremity motor score (LEMS), Korean version of the Berg Balance Scale (K-BBS), Timed Up and Go test (TUG), and Korean Version of the Modified Barthel Index (K-MBI) of 10 patients. 10 healthy adults carried out the posturography. We checked stability, weight distribution, Fourier and synchronization indices of eight positions, and the fall index of the posturography.ResultsThe patient group showed significantly higher stability and weight distribution indices in all eight positions. Stability indices significantly increased with eyes closed or standing on pillows. Weight distribution indices were significantly higher with eyes closed or the head bent backwards. The patient group showed significantly higher Fourier indices of low, low-medium, and high frequency in eight positions. The Fourier indices at high-medium frequency were significantly higher with eyes closed on pillows or in variable head positions. There were no significant differences of synchronization indices between the patient and the control group. The falling index of the patient group significantly correlated with K-BBS, TUG, and K-MBI. LEMS had significant correlation with some synchronization indices, but not with the falling index.ConclusionThe quiet standing balance of the patients was influenced by somatosensory limitations or insufficient visual compensation. We should try to improve the postural balance and functional independence of patients through proper proprioceptive and lower extremity strength training for better postural and pedal control, and to make efforts to minimize environmental hazards.

Motor and bladder dysfunctions in patients with vertebral fractures at the thoracolumbar junction

To present the motor deficits and type of neurogenic bladder dysfunction (NBD) in patients with vertebral fractures at thoracolumbar junction. Fifty-two patients with single level vertebra fracture over T11-L2 with onset duration of longer than 3 years were enrolled. All participants provided basic demographic data, ambulatory status and received neurologic examination and urodynamic studies. The differences in distribution of NBD types, neurologic injury sites and functional walkers in patients with different levels of vertebral injury were analyzed. Receiver operating characteristic curve analysis was used to define the cutoff value of lower extremities motor score (LEMS) in functional walker and non-walker. Of the 52 patients, the injured levels were 3 (5.8%) in T11, 21 (40.4%) in T12, 22 (42.3%) in L1, and 6 (11.5%) in L2 vertebrae. Eight (15.4%) patients had upper lumbar cord lesions, 26 (50.0%) had epiconus and lumbar roots lesions, 18 (34.6%) had conus medullaris or/and cauda equina lesions. Mean LEMS was 0 ± 0, 5.4 ± 7.7, 11.1 ± 10.2, and 28.0 ± 11.0 for patients with T11, T12, L1, and L2 fractures, respectively. Patients with L2 fractures had higher LEMS than other levels (p < 0.001). The cutoff value of LEMS for functional walking was set at 20, and both the sensitivity and specificity was 100%. Thirty-one (59.6%) patients had spastic NBD, 18 (35.6%) had flaccid NBD, and 3 (5.8%) had mixed type NBD. Positive prediction value of ankle spasticity for bladder and sphincter spasticity was 95.2 and 100%, respectively. Half of the patients had epiconus lesion following thoracolumbar junction fracture, and they had a clinical presentation of flaccid legs and spastic NBD. Patients with L2 fracture had higher LEMS than patients with T11, T12, and L1 fracture. Patients whose LEMS was higher than 20 could all walk functionally. Fracture at the thoracolumbar junction may cause spastic, flaccid, or mixed type NBD, and urodynamic study is an essential tool for the correct diagnosis and management. Ankle spasticity has a high positive predictive value for spastic bladder or sphincter.

Investigation of cartilage degradation in patients with spinal cord injury by CTX-II

Clinical cross-sectional study. To investigate the cartilage degradation by turnover of C-telopeptide fragments of collagen type-II (CTX-II), a molecule specific for articular cartilage in spinal cord injured patients with respect to clinical functional status. Physical Medicine and Rehabilitation Clinics, hospital settings. In 68 patients with spinal cord injury (SCI) level and severity of lesion, duration of disease, American Spinal Injury Association Impairment Scale (AIS), motor and sensory score, presence of spasticity, functional ambulation score (FAS) and duration of daily ambulation were evaluated. Cartilage degradation was demonstrated by urinary CTX-II (uCTX-II) measured by enzyme-linked immunosorbent assay. T test, analysis of variance and Pearson correlation analysis were used for statistical calculations. uCTX-II level was significantly higher in patients with AIS grade A, non-functional ambulators or in patients who did not ambulate at all (P<0.05). Although AIS grade, lower extremity motor score, FAS score and duration of daily ambulation were found to be correlated (P<0.05) with uCTX-II, duration of disease, level of neurological lesion, presence of spasticity were not. This is the first study providing evidence that cartilage degradation is associated with elevated uCTX-II levels in non-ambulating or non-functional ambulating SCI patients. AIS grade A, FAS zero score and no time for daily ambulation were found to cause significant differences in CTX-II level. It may be important to initiate therapeutic programs as soon as possible after SCI to prevent cartilage atrophy.

An evaluation of the muscle-bone unit theory among individuals with chronic spinal cord injury

Cross-sectional observation. To explore the association between muscle size and function, and indices of bone strength among a sample of adults with chronic spinal cord injury (SCI). Ontario, Canada. Sixty-five participants (n=47 men) with chronic SCI (C1-T12 American Spinal Injury Association Impairment Scale (AIS) A-D) were recruited, mean±s.d. age 49.4±12.8 years and years post-injury 14.3±10.7. Muscle cross-sectional area (CSA) and indices of bone strength at the distal tibia and tibia shaft were measured by peripheral quantitative computed tomography. Muscle CSA was multiplied by tibia length to obtain muscle-bending moment (MBM), a surrogate of torque. Plantar flexor components of the lower-extremity motor scores (pf-LEMS) were used as clinical measures of muscle function. Pearson's correlations (r) were used to determine the strength of relationships. Correlations were found between MBM and indices of bone strength at the distal tibia and tibia shaft (r=0.44-0.56), as well as between pf-LEMS and indices of bone strength at the distal tibia and tibia shaft (r=0.37-0.71). pf-LEMS had a stronger association with bone variables at the distal tibia compared with MBM (r=0.6 vs r=0.4). All relationships between muscle and bone remained significant when controlling for the duration of injury. It appears that lower limb muscle size and function are more strongly correlated with bone strength indices at the distal tibia than at the tibia shaft among individuals with SCI. The relationships between muscle and bone are clinically important, as muscle CSA and strength (motor scores) are potentially amenable to rehabilitation intervention(s).

The Relationship Between Quality of Life and Change in Mobility 1 Year Postinjury in Individuals With Spinal Cord Injury

Riggins MS, Kankipati P, Oyster ML, Cooper RA, Boninger ML. The relationship between quality of life and change in mobility 1 year postinjury in individuals with spinal cord injury. Objective To examine quality-of-life (QOL) factors and change in mobility in individuals with traumatic spinal cord injury (SCI) 1 year after injury. Design Retrospective case study of National SCI Database data. Setting SCI Model Systems (SCIMS) sites (N=18). Participants Subjects (N=1826; age >18y) who presented to an SCIMS site after traumatic SCI between June 2004 and July 2009 and returned for 1-year follow-up. All subjects had FIM mobility data for both assessments. Interventions Not applicable. Main Outcome Measures Assessment of impairment based on Lower-Extremity Motor Score. Assessment of QOL based on Craig Handicap Assessment and Reporting Technique, Patient Health Questionnaire, Satisfaction With Life Scale, Self-perceived Health Status, and pain severity scores. Results Of the sample, 55 individuals transitioned from walking to wheelchair use within 1 year of discharge. This group had the highest number of individuals from minority groups (52.8%) and the lowest employment rate (7.3%). Compared with individuals who transitioned from wheelchair use to walking or maintained wheelchair use or ambulation, the walking-to-wheelchair transition group had significantly lower QOL scores ( P<.01), including higher depression ( P<.01) and higher pain severity ( P<.001). Conclusions Individuals with SCI who transitioned from walking at discharge to wheelchair use within 1 year had low QOL factors, including high pain and depression scores. Rehabilitation professionals should consider encouraging marginal ambulators to work toward functional independence from a wheelchair, rather than primary ambulation during acute inpatient rehabilitation.

Upper- and Lower-Extremity Motor Recovery After Traumatic Cervical Spinal Cord Injury: An Update From the National Spinal Cord Injury Database

Marino RJ, Burns S, Graves DE, Leiby BE, Kirshblum S, Lammertse DP. Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the National Spinal Cord Injury Database. Objective To present upper- (UEMS) and lower-extremity motor score (LEMS) recovery, American Spinal Injury Association Impairment Scale (AIS) change, and motor level change in persons with traumatic tetraplegia from the Spinal Cord Injury Model Systems (SCIMS). Design Longitudinal cohort; follow-up to 1 year. Setting U.S. SCIMS. Participants Subjects (N=1436; age>15y) with tetraplegia with at least 2 examinations, the first within 7 days of injury. Subjects were 80% men injured by vehicular collisions (44%), falls (30%), sports (12%), and violence (11%). Interventions Not applicable. Main Outcome Measures Change in AIS, UEMS, LEMS, and motor levels. Results From a baseline of 7 days or less, 22% of subjects with AIS grade A converted to AIS grade B or better by rehabilitation discharge; and 30%, by 1 year, with 8% to AIS grade C and 7.1% to grade D. Conversion from complete to motor incomplete was not related to timing of the initial examination ( P=.54) or initial neurologic level ( P=.96). For AIS grade B, 34% remained motor complete, 30% became AIS grade C, and 37% became grade D by 1 year. Although 82.5% of those with AIS grade C improved to AIS grades D and E, mean 1-year UEMS score was only 35 points. UEMS scores in patients with AIS grade A increased a mean of 9 to 11 points, except for C1 to C3 and C8 to T1 motor levels (gain, 2–3 points). Motor level was unchanged or ascended in 35% and improved 1 level in 42%, 2 levels in 14%, and more than 2 levels in 9%. Motor zone of partial preservation of 2 segments or more was associated with gain of 2 or more motor levels, with a relative risk of 5.0 (95% confidence interval, 3.2–7.8; P<.001). Conclusions More patients with cervical complete spinal cord injury may be converting to AIS grade D compared with earlier reports. Motor level recovery in those with AIS grade A and UEMS recovery in those with AIS grade C injuries are potential outcomes for acute clinical trials.

The effect of polytrauma as a possible confounder in the outcome of monotraumatic vs polytraumatic paraplegic patients: a clinical cohort study

Clinical cohort study. To evaluate if the impact of the severity of the trauma as a possible confounding factor influences the neurological and functional recovery in paraplegia during the course of a 6-month follow-up period after injury. Spinal Cord Injury Center, Heidelberg University Hospital, Germany. A retrospective monocentric analysis, from 2002 to 2008, of the Heidelberg European Multicenter Study about spinal cord injury database was performed. We included 31 paraplegic patients (neurological level T1-T12) who were assigned either to a monotrauma (polytraumaschluessel (PTS) 1) or to a polytrauma (PTS≥2) group. The American Spinal Injury Association Impairment Scale, lower extremity motor score, pin prick, light touch and the spinal cord independence measure (SCIM) were obtained at five distinct time points after trauma. Data were analyzed using Mann-Whitney U-test (α<0.05). The changes in lower extremity motor score, pin prick and light touch showed no significant differences in both groups over the whole evaluation period. Polytraumatic paraplegics showed a significantly delayed increase of SCIM between 2 and 6 weeks compared with monotraumatic patients, followed by a quantitative increase in the subitems bladder management, bowel management, use of toilet and prevention of pressure sores between 3 and 6 months (P=0.031). The mean length of primary rehabilitation in the polytrauma group was 5.5 vs 3.6 months in monotrauma. The prognosis of polytraumatic paraplegics in terms of neurological recovery is not inferior to those with monotrauma. Multiple-injured patients need a prolonged hospital stay to reach the functional outcome of monotraumatic patients.

The Reproducibility and Convergent Validity of the Walking Index for Spinal Cord Injury (WISCI) in Chronic Spinal Cord Injury

Background. The Walking Index for Spinal Cord Injury II (WISCI II) is a hierarchical scale that measures improvements in walking following spinal cord injury (SCI). The WISCI II has good face validity, concurrent validity, and reliability following acute SCI; however, psychometric properties need to be determined for chronic SCI. Because prior studies have demonstrated a relationship between lower-extremity motor scores (LEMS) and walking, outcome measures for walking should demonstrate a linkage between the underlying impairment (weakness) and walking—convergent validity. Objective. To determine convergent validity and reproducibility of the WISCI II. Methods. Self-selected and maximum WISCI levels were assessed for 76 patients with chronic SCI (34 paraplegia, 42 tetraplegia); 10-m walking speeds were calculated. Convergent validity was assessed by correlating WISCI II levels to LEMS and walking speed. Reproducibility was assessed with the intraclass correlation coefficient (ICC) and the smallest real difference (SRD). Results. Convergent validity of the self-selected and maximum WISCI II with LEMS was moderate for paraplegia (ρ = 0.479 and ρ = 0.533) and strong for tetraplegia (ρ = 0.852 and ρ = 0.816). Tetraplegia, but not paraplegia, demonstrated convergent validity of walking speed at the self-selected and maximum WISCI levels with LEMS (ρ = 0.752 and ρ = 0.813). WISCI reproducibility was excellent (self-selected ICC = 0.994; maximum ICC = 0.995), resulting in SRDs of 0.785 (self-selected) and 0.597 (maximum), suggesting that a change of one WISCI level can be interpreted as real in a chronic patient. Conclusions. Results suggest that the WISCI II should be a very useful outcome measure for detecting changes in walking function following chronic SCI.

Diagnostic criteria of traumatic central cord syndrome. Part 3: Descriptive analyses of neurological and functional outcomes in a prospective cohort of traumatic motor incomplete tetraplegics

Prospective multicenter cohort study. To compare the neurological recovery and functional outcomes between traumatic central cord syndrome (TCCS) patients and motor incomplete tetraplegic patients. European Multicenter Study of human spinal cord injury. In 248 traumatic motor incomplete tetraplegics, initial phase (0-15 days) American Spinal Injury Association (ASIA) impairment grading, upper and lower extremity motor scores (UEMS and LEMS), upper and lower sensory scores and chronic phase (6 or 12 months) neurological outcomes were analyzed. In addition, chronic phase self-care and indoor mobility Spinal Cord Independence Measure (SCIM) items were studied. Tetraplegics were subdivided into three groups: (1) non-TCCS group (UEMSLEMS), (2) intermediate-TCCS group (UEMS=(1-9 points)<LEMS) and (3) TCCS group (UEMS=(10 points)<LEMS). Student's t-tests and χ(2)-tests were applied. A total of 89 non-TCCS subjects (AIS D, n=28), 62 int-TCCS (AIS D, n=43) and 97 TCCS (AIS D, n=80) subjects were analysed. Although minimal significant differences in chronic phase LEMS and UEMS outcomes were identified between TCCS and non-TCCS patients after stratification by the AIS grade, our data showed no significant differences in functional upper and lower extremity outcomes at 6 or 12 months post-injury. The AIS grading system, and not the diagnosis TCCS, continues to be the best available prognostic parameter for neurological and functional outcomes in motor incomplete tetraplegics. The authors recommend that for future outcome studies in motor incomplete tetraplegia, patients should not be selected based on, or stratified by, the diagnosis TCCS.

Comparison of lower extremity motor score parameters for patients with motor incomplete spinal cord injury using gait parameters

Retrospective investigation using gait analysis and medical records. To evaluate the relationship between ambulatory function improvement and an increase in lower-limb motor scores in persons with motor incomplete spinal cord injury (SCI) and to compare the efficiency of lower extremity motor score (LEMS) and ambulatory motor index (AMI) in representation of ambulatory function improvement using gait analysis. SCI Unit, Yonsei Rehabilitation Hospital, Seoul, Korea. The gait analysis from 43 patients with SCI (paraplegic, n=22, tetraplegic n=21) were reviewed. The gait analysis data were obtained with Vicon 370 system. The LEMS and AMI were assessed before the gait analysis and the influence of an increase in lower-limb motor scores were investigated with linear parameters of gait analysis. For group including both tetraplegic and paraplegic patients, both AMI and LEMS were statistically correlated with gait speed, step length and negative correlation with double-limb support. However, only LEMS was correlated with cadence. For the paraplegic group, with AMI and LEMS, there were correlation with gait speed, step length and right single-limb support and negative correlation with right double-limb support. However, only LEMS was correlated with left cadence and negative correlation with double-limb support. For the tetraplegic group, only left cadence was statistically correlated with AMI. Both AMI and LEMS were useful in terms of providing information for capability of ambulatory function for the paraplegic group. However, for the tetraplegic group, both AMI and LEMS do not provide sufficient information for ambulatory function of the incomplete SCI patients.

Characterization of neurological recovery following traumatic sensorimotor complete thoracic spinal cord injury

Retrospective, longitudinal analysis of sensory, motor and functional outcomes from individuals with thoracic (T2-T12) sensorimotor complete spinal cord injury (SCI). To characterize neurological changes over the first year after traumatic thoracic sensorimotor complete SCI. A dataset of 399 thoracic complete SCI subjects from the European Multi-center study about SCI (EMSCI) was examined for neurological level, sensory levels and sensory scores (pin-prick and light touch), lower extremity motor score (LEMS), ASIA Impairment Scale (AIS) grade, and Spinal Cord Independence Measure (SCIM) over the first year after SCI. AIS grade conversions were limited. Sensory scores exhibited minimal mean change, but high variability in both rostral and caudal directions. Pin-prick and light touch sensory levels, as well as neurological level, exhibited minor changes (improvement or deterioration), but most subjects remained within one segment of their initial injury level after 1 year. Recovery of LEMS occurred predominantly in subjects with low thoracic SCI. The sensory zone of partial preservation (ZPP) had no prognostic value for subsequent recovery of sensory levels or LEMS. However, after mid or low thoracic SCI, ≥3 segments of sensory ZPP correlated with an increased likelihood for AIS grade conversion. The data suggest that a sustained deterioration of three or more thoracic sensory levels or loss of upper extremity motor function are rare events and may be useful for tracking the safety of a therapeutic intervention in early phase acute SCI clinical trials, if a significant proportion of study subjects exhibit such an ascent.

Device use, locomotor training and the presence of arm swing during treadmill walking after spinal cord injury

ObjectivesDetermine the presence of walking-related arm swing following spinal cord injury (SCI), associated factors, and whether arm swing may change following locomotor training (LT).DesignObservational, cross-sectional study from a convenience sample with pre-test/post-test from a sample subset.SettingMalcom Randall VAMC and University of Florida, Gainesville, FL.MethodsArm movement was assessed during treadmill stepping, pre-LT, in 30 individuals with motor incomplete SCI (iSCI, American Spinal Injury Association Impairment Scale grade C/D, as defined by the International Standards for Neurological Classifications of SCI, with neurological level of impairment at or below C4). Partial body weight support and manual-trainer assistance was provided, as needed, to achieve stepping and allow arm swing. Arm swing presence was compared based on cervical versus thoracic neurological levels of impairment and device type. Leg and arm strength and walking independence were compared between individuals with and without arm swing. Arm swing was re-evaluated post-LT in the 21/30 individuals that underwent LT.ResultsOf 30 individuals with iSCI, 12 demonstrated arm swing during treadmill stepping, pre-LT. Arm movement was associated with device type, lower extremity motor scores, and walking independence. Among the 21 individuals that received LT, only 5 demonstrated arm swing pre-LT. Of the 16 individuals lacking arm swing pre-LT, 8 integrated arm swing post-LT.ConclusionDevices routinely used for walking post-iSCI appeared associated with arm swing. Post-LT, arm swing presence increased. Therefore, arm swing may be experience-dependent. Daily neuromuscular experiences provided to the arms may produce training effects, thereby altering arm swing expression.

Is the outcome in acute spinal cord ischaemia different from that in traumatic spinal cord injury? A cross-sectional analysis of the neurological and functional outcome in a cohort of 93 paraplegics

Retrospective cohort study. To compare the neurological outcome between paraplegic patients with acute spinal cord ischaemia syndrome (ASCIS) or traumatic spinal cord injury (tSCI) and to investigate the influence of SCI aetiology on the total Spinal Cord Independence Measure (SCIM)-II score. Level 1 trauma centre. Initial (0-40 days) and chronic-phase (6-12 months) American Spinal Injury Association (ASIA) sensory scores, lower extremity motor score (LEMS) and chronic-phase total SCIM-II scores were analysed. Differences between ASCIS and tSCI patients were calculated using Student's t-tests and Wilcoxon signed-rank tests. To assess which variables give rise to the prediction of total SCIM-II score, a multiple linear regression analysis was used. These predictor variables included complete (ASIA impairment scale A) or incomplete SCI (AIS B, C, and D), aetiology, age and gender. Out of 93 included patients, 20 ASCIS and 73 tSCI patients were identified. In the complete SCI group, the initial pinprick scores were higher (P<0.05) in ASCIS patients compared with tSCI patients, 37.9 (95% Confidence Interval (CI), 23.3-52.5) and 27.3 (95% CI, 24.1-30.4), respectively. No other relevant differences in neurological outcome were identified between ASCIS and tSCI patients; however, the total SCIM-II scores were higher (P<0.05) in tSCI patients after 12 months. Using the linear regression analysis, we were able to predict 31.4% of the variability. The aetiology was not significant in this model. The neurological outcome was independent of the diagnosis ASCIS or tSCI. Furthermore, the diagnosis ASCIS or tSCI was not a significant predictor for total SCIM II scores after 12 months. This study was granted by the 'Internationale Stiftung für Forschung in Paraplegie' (IFP), Zürich, Switzerland.

Relevance of the diagnosis traumatic cervical Brown-Séquard-plus syndrome: an analysis based on the neurological and functional recovery in a prospective cohort of 148 patients

Prospective multi-center cohort study. To compare the neurological and functional recovery between tetraplegic Brown-Séquard-plus syndrome (BSPS) and incomplete tetraplegia (non-BSPS). European Multicenter Study of Human Spinal Cord Injury (EM-SCI). BSPS was defined as a traumatic incomplete spinal cord injury (SCI) with ipsilateral weakness and contralateral loss of pinprick sensation at neurologic levels C2-T1. Acute (0-15 days) and chronic phase (6 or 12 months) were assessed for the American Spinal Injury Association (ASIA) sensory scores, upper extremity motor scores and lower extremity motor scores. Furthermore, chronic phase scores of all Spinal Cord Independence Measure (SCIM) II items were analyzed. Differences in neurological and functional outcome between BSPS patients and non-BSPS patients were calculated using Student's t-tests and Wilcoxon signed rank tests. Out of 148 tetraplegic patients, 30 were diagnosed with BSPS. Patients with an ASIA impairment scale (AIS) B were significantly (P<0.001) more identified in non-BSPS patients (25%) compared with BSPS patients (3%), respectively. After 12 months, the median scores for sphincter management of the bladder for both BSPS and non-BSPS patients were 15. Both 25 and 75% quartile median scores were 15 for BSPS patients and 12 and 15 for non-BSPS patients (P<0.02). Except for the difference in bladder function, no significant differences were identified in other SCIM II subitems and ASIA motor or sensory scores between BSPS and non-BSPS patients when stratified for injury severity by excluding AIS B patients. Compared with incomplete tetraplegic patients, patients with cervical BSPS have a similar neurological and functional recovery when matched for the AIS.

Diagnostic criteria of traumatic central cord syndrome. Part 1: A systematic review of clinical descriptors and scores

Systematic review. The applied definition of traumatic central cord syndrome (TCCS) lacks specific quantified diagnostic criteria. To review currently applied TCCS diagnostic criteria and quantitative data regarding the 'disproportionate weakness' between the upper and lower extremities described in original studies reporting on TCCS subjects. A MEDLINE (1966 to 2008) literature search was conducted. The descriptors applied to define TCCS were extracted from all included articles. We included original studies that reported on the differences in motor score (based on the Medical Research Council scale) between the total upper extremity motor score (UEMS) and the total lower extremity motor score (LEMS), in a minimum of five TCCS patients at the time of hospital admission. The mean difference between the total UEMS and the total LEMS of the patients included in each study was calculated. Case reports were excluded. None of the identified studies on TCCS patients reported inclusion and/or exclusion criteria using a quantified difference between the UEMS and LEMS. Out of 30 retrieved studies, we identified seven different clinical descriptors that have been applied as TCCS diagnostic criteria. Nine studies reporting on a total of 312 TCCS patients were eligible for analysis. The mean total UEMS was 10.5 motor points lower than the mean total LEMS. There is no consensus on the diagnostic criteria for TCCS. Nevertheless, this review revealed an average of 10 motor points between the UEMS and LEMS as a possible TCCS diagnostic criterion. However, further discussion by an expert panel will be required to establish definitive diagnostic criteria.