Motor Complete Spinal Cord Injury Research Articles

Poster (Knowledge Generation) ID 1969160

Background This ongoing cross-sectional study aims to examine the potential association between moderate-to-severe sleep apnea and severe cardiovascular dysfunction after spinal cord injury (SCI). Methods This cross-sectional study included participants who were newly diagnosed with sleep apnea using a home-based/hospital unattended sleep screening test that quantifies the apnea-hypopnea index (AHI). Episodes of AD were defined as a sudden increase in systolic blood pressure (BP) of at least 20 mmHg. We exclude episodes of AD during sleep that were caused by triggers other than apnea or hypopnea. Participants This study included English-speaking adults with subacute or chronic (≥1 month after SCI onset), cervical or high-thoracic (T6 or more cranial), complete or incomplete SCI, who reported clinical symptoms and/or signs suggestive of sleep apnea. Results This study included 45 individuals (14 females and 31 males; age range: 20 to 84 years, mean age: 57.0 years) with motor complete (n=22) or incomplete SCI at cervical (n=38) or high thoracic levels. Time since SCI varied from 1.5 months to 52 years. Their mean apnea-hypopnea index (AHI) was 16.0 events/hour (AHI range: 0.8 to 51.7 events/hour). Higher AHI was significantly correlated with more frequent silent episodes of AD (Rsqr=0.220, p=0.001) during sleep. The AHI was not associated with systolic BP (p=0.903), diastolic BP (p=0.639), mean arterial pressure (p=0.714), and heart rate (p=0.669) during sleep. Conclusions The results of this cross-sectional study suggest that more severe sleep apnea is associated with frequent silent episodes of AD during sleep among individuals living with cervical or high-thoracic SCI.

Poster (Knowledge Generation) ID 1969163

Background This ongoing study aims to examine the potential cognitive and psycho-social benefits of continuous positive airway pressure (CPAP) therapy in people with chronic spinal cord injury (SCI) and moderate-to-severe sleep apnea (SA). Methods This study included adults with chronic SCI who underwent a 4-month trial of CPAP therapy for management of recently diagnosed moderate-to-severe SA. Outcome measures included the Epworth Sleepiness Scale (ESS), Medical Outcomes Study Sleep Scale (MOS-SS), Fatigue Severity Scale (FSS), Depression, Anxiety & Stress Scale-21 (DASS-21), Montreal Cognitive Assessment (MoCA), SF-36, and Craig Handicap Assessment & Reporting Technique (CHART). The participants were also asked about their lived experience before and after CPAP trial (qualitative analysis). Results By February 2023, we screened 33 individuals (10 females, 23 males; age range: 37-79 years; mean age: 58.3 years) with motor complete (n=15) or incomplete SCI at cervical (n=22) or thoracic levels. Time since SCI varied from 4 to 793 months. The apnea-hypopnea index (AHI) varied from 2.6 to 83.7 events/hour. Of the 33 individuals, 25 participants with moderate-to-severe SA initiated CPAP therapy; 19 individuals have completed the CPAP trial. Daytime sleepiness and sleep quality, fatigue and quality of life significantly improved with CPAP therapy. There was a trend for improvement of cognitive, mental health and participation scores, but they have not reached significance yet (p=0.079, p=0.207, p=0.221, respectively). Conclusions Our preliminary results suggest that 4 months of CPAP therapy significantly improves sleep quality, and quality of life, and mitigates daytime sleepiness, fatigue, and anxiety in people with chronic SCI.

Poster (Health Services, Economics and Policy Change) ID 1969166

Background We studied the feasibility of a home-based screening sleep test (HBSST), the validity of four questionnaires used to screen for sleep-related breathing disorders (SRBDs), and the potential association between SRBD and clinical features in individuals with spinal cord injury (SCI). Methods Adults with subacute/chronic (>1 month post-injury) SCI were recruited for the cross-sectional study and qualitative analysis. Feasibility of the HBSST was objectively evaluated and participants shared their experience. We also examined the validity of the Berlin, STOP, Medical Outcomes Study Sleep Scale [MOS-SS], and STOP-Bang screening questionnaires. We investigated the association between the degree of SRBD and three features (i.e., neck circumference, body mass index [BMI] and oropharynx opening as assessed using the Modified Mallampati classification [MMC]). Results There were 13 females and 18 males with ages varying from 20 to 86 years (mean age: 54.7 years) with motor complete (n=8) or incomplete SCI at cervical (n=21) or thoraco-lumbar levels. Time since SCI varied from 1.5 to 474 months. Overall, 28 individuals completed the HBSST and endorsed its feasibility. Mean apnea-hypopnea index (AHI) was 17.3 events/hour (range: 0.5-83.7). AHI was significantly correlated with Berlin (p=0.036) and STOP-Bang scores (p=0.009). There was no significant correlation between AHI and MOS-SS (p=0.348) or STOP (p=0.165). AHI was not associated with neck circumference (p=0.614), BMI (p=0.958), or MMC (p=0.335). Conclusions Our results suggest that HBSST is a feasible screening method, and Berlin and STOP-Bang are valid screening questionnaires for the SCI population. AHI was not correlated with BMI, neck circumference, or MMC.

Prognostic validity of trunk control scales for mobility in individuals with motor complete thoracic SCI: a prospective cohort study.

Prospective cohort study. To investigate the sensitivity to change and prognostic validity of Trunk Control Test (TCT) and Thoracic-Lumbar Control Scale (TLC) in terms of mobility in persons with motor complete thoracic spinal cord injury (SCI). Participants were recruited at an Italian SCI rehabilitation facility from October 2015 to January 2020. Inclusion criteria were acute traumatic or non-traumatic event and T1-L1 neurological level. Trunk control and mobility were assessed at baseline, discharge, and at 6 and 18-month follow-ups. Mobility was measured using Spinal Cord Independence Measure III mobility subscale. Linear regression models were used to analyze changes in trunk control and mobility over time, and the relationship between these measures. The 39 participants were predominantly male, with a mean age of 38 years. Trunk control improved during rehabilitation, at 6-month follow-up, and remained stable thereafter, according to TCT and TLC scales. A higher baseline TCT score was associated with improvements in mobility at discharge and at follow-ups. Baseline TLC score and its change during rehabilitation were unrelated with changes in mobility. Results suggest that the TCT and TLC scales are useful to capture changes in trunk control during the acute and subacute phases. Improvements in functional mobility are however associated with TCT score only, suggesting the potential of this test as a useful prognostic indicator. Further research with larger sample sizes is warranted to determine whether these findings are consistent across neurological level strata.

LIFESTYLE-RELATED PREDICTORS OF TESTOSTERONE DEFICIENCY AMONG MALE PATIENTS WITH CHRONIC SPINAL CORD INJURY

Objectives: In the current study, the author evaluated the prevalence of low testosterone and its independent predictors among male patients with chronic spinal cord injury (SCI). Design: This descriptive type of observational study was conducted in the department of PMR at SMS Medical College. Methods: In this cross-sectional study, 120 patients with chronic SCI were recruited, serum testosterone levels were assessed, and testosterone levels below 300 ng/dL were considered low. The following eight suspected independent predictors for low testosterone levels were assessed: age, body mass index (BMI), nicotine users, total lipid profile, level of injury, American Spinal Injury Association (ASIA) impairment scale, leisure-time physical activity (LTPA) score (h/week) via LTPA questionnaire, and aging male’s symptom (AMS) score via AMS questionnaire. Results: The mean age of the patients was 33.2±7.8 years. Patients with low testosterone exhibited a significant association with dorsal SCI (70.9%), motor complete (ASIA A and B) SCI (76.4%), nicotine use (65.5%), a higher triglyceride (TG) level (168.5 mg/dL), a higher total lipid level (712.9 mg/dL), and a higher AMS score (35.7). Patients with low testosterone were found to be engaged in lower (9.4 h/week) LTPA. A significant negative correlation of total testosterone levels was observed with TG (r=−0.184, p=0.044), total lipid (r=−0.570, p<0.001), BMI (r=−0.504, p<0.001), and AMS scores (r=−0.549, p<0.001). Whereas there was a significant positive correlation observed between total testosterone and LTPA (r=0.380, p<0.001). Conclusion: The prevalence of low testosterone is found at 45.8%, and BMI, LPTA, AMS, and total lipids are identified as independent predictors of low testosterone.

Motor and autonomic concomitant health improvements with neuromodulation and exercise (MACHINE) training: a randomised controlled trial in individuals with spinal cord injury

IntroductionMotor and autonomic dysfunctions are widespread among people with spinal cord injury (SCI), leading to poor health and reduced quality of life. Exercise interventions, such as locomotor training (LT), can...

Epidural stimulation restores muscle synergies by modulating neural drives in participants with sensorimotor complete spinal cord injuries

Multiple studies have corroborated the restoration of volitional motor control after motor-complete spinal cord injury (SCI) through the use of epidural spinal cord stimulation (eSCS), but rigorous quantitative descriptions of muscle coordination have been lacking. Six participants with chronic, motor and sensory complete SCI underwent a brain motor control assessment (BMCA) consisting of a set of structured motor tasks with and without eSCS. We investigated how muscle activity complexity and muscle synergies changed with and without stimulation. We performed this analysis to better characterize the impact of stimulation on neuromuscular control. We also recorded data from nine healthy participants as controls. Competition exists between the task origin and neural origin hypotheses underlying muscle synergies. The ability to restore motor control with eSCS in participants with motor and sensory complete SCI allows us to test whether changes in muscle synergies reflect a neural basis in the same task. Muscle activity complexity was computed with Higuchi Fractal Dimensional (HFD) analysis, and muscle synergies were estimated using non-negative matrix factorization (NNMF) in six participants with American Spinal Injury Association (ASIA) Impairment Score (AIS) A. We found that the complexity of muscle activity was immediately reduced by eSCS in the SCI participants. We also found that over the follow-up sessions, the muscle synergy structure of the SCI participants became more defined, and the number of synergies decreased over time, indicating improved coordination between muscle groups. Lastly, we found that the muscle synergies were restored with eSCS, supporting the neural hypothesis of muscle synergies. We conclude that eSCS restores muscle movements and muscle synergies that are distinct from those of healthy, able-bodied controls.

Acute Intermittent Hypoxia and UE Strength and Function changes in Multiple Sclerosis: A Case Report

Background/Purpose Recovery of upper extremity (UE) function is a priority for individuals with multiple sclerosis (MS) whose disease sequalae often results in loss of UE strength and motor control. Acute Intermittent Hypoxia (AIH) is a novel intervention where an individual breathes bouts of air with low oxygen (∼9% O2) to set off a cascade of cellular events that may induce neuroplasticity and improve motor function. This intervention has shown promising effects in individuals with motor incomplete spinal cord injury (iSCI), even after a single bout. The purpose of this case report was to assess the ability of a single-bout AIH protocol to improve UE strength and function in an individual with chronic, relapsing-remitting MS. Methods A 30-year-old, right-handed female with a 10-year history of MS (Expanded Disability Status Scale score 3.0), who presented with LUE weakness and increased LUE tone participated in two treatment sessions. In the first session, she received a sham intervention where she was delivered normal room air, through the hypoxia generator for the entire treatment. The following week she received AIH. The 9-Hole Peg Test (9HPT) and Hand-held dynamometry (HHD) were performed immediately before and after the intervention Results Following the single bout of AIH, compared to baseline, left shoulder abduction strength increased 8% immediately after treatment and 21% at the 30-minute assessment. Left wrist extension strength increased 26% and 30%, respectively. Left shoulder flexion and elbow extension did not change. Comparatively, right shoulder abduction strength increased 27% and 7%. Right wrist extension strength increased 12% and 1%. Functionally, the participant's 9HPT time decreased from 44.88 to 41.41 seconds on her left but increased from 15.69 to 16.06 seconds on her right. Discussion AIH treatment was well tolerated by our participant and a single bout of AIH resulted in positive changes in UE strength and function on her more involved side. These results are promising, and further research is required to further assess safety, feasibility, and potential efficacy of AIH in people with MS. Recovery of upper extremity (UE) function is a priority for individuals with multiple sclerosis (MS) whose disease sequalae often results in loss of UE strength and motor control. Acute Intermittent Hypoxia (AIH) is a novel intervention where an individual breathes bouts of air with low oxygen (∼9% O2) to set off a cascade of cellular events that may induce neuroplasticity and improve motor function. This intervention has shown promising effects in individuals with motor incomplete spinal cord injury (iSCI), even after a single bout. The purpose of this case report was to assess the ability of a single-bout AIH protocol to improve UE strength and function in an individual with chronic, relapsing-remitting MS. A 30-year-old, right-handed female with a 10-year history of MS (Expanded Disability Status Scale score 3.0), who presented with LUE weakness and increased LUE tone participated in two treatment sessions. In the first session, she received a sham intervention where she was delivered normal room air, through the hypoxia generator for the entire treatment. The following week she received AIH. The 9-Hole Peg Test (9HPT) and Hand-held dynamometry (HHD) were performed immediately before and after the intervention Following the single bout of AIH, compared to baseline, left shoulder abduction strength increased 8% immediately after treatment and 21% at the 30-minute assessment. Left wrist extension strength increased 26% and 30%, respectively. Left shoulder flexion and elbow extension did not change. Comparatively, right shoulder abduction strength increased 27% and 7%. Right wrist extension strength increased 12% and 1%. Functionally, the participant's 9HPT time decreased from 44.88 to 41.41 seconds on her left but increased from 15.69 to 16.06 seconds on her right. AIH treatment was well tolerated by our participant and a single bout of AIH resulted in positive changes in UE strength and function on her more involved side. These results are promising, and further research is required to further assess safety, feasibility, and potential efficacy of AIH in people with MS.

Association of upper-limb neurological recovery with functional outcomes in high cervical spinal cord injury.

High cervical spinal cord injury (SCI) results in complete loss of upper-limb function, resulting in debilitating tetraplegia and permanent disability. Spontaneous motor recovery occurs to varying degrees in some patients, particularly in the 1st year postinjury. However, the impact of this upper-limb motor recovery on long-term functional outcomes remains unknown. The objective of this study was to characterize the impact of upper-limb motor recovery on the degree of long-term functional outcomes in order to inform priorities for research interventions that restore upper-limb function in patients with high cervical SCI. A prospective cohort of high cervical SCI (C1-4) patients with American Spinal Injury Association Impairment Scale (AIS) grade A-D injury and enrolled in the Spinal Cord Injury Model Systems Database was included. Baseline neurological examinations and functional independence measures (FIMs) in feeding, bladder management, and transfers (bed/wheelchair/chair) were evaluated. Independence was defined as score ≥ 4 in each of the FIM domains at 1-year follow-up. At 1-year follow-up, functional independence was compared among patients who gained recovery (motor grade ≥ 3) in elbow flexors (C5), wrist extensors (C6), elbow extensors (C7), and finger flexors (C8). Multivariable logistic regression evaluated the impact of motor recovery on functional independence in feeding, bladder management, and transfers. Between 1992 and 2016, 405 high cervical SCI patients were included. At baseline, 97% of patients had impaired upper-limb function with total dependence in eating, bladder management, and transfers. At 1 year of follow-up, the largest proportion of patients who gained independence in eating, bladder management, and transfers had recovery in finger flexion (C8) and wrist extension (C6). Elbow flexion (C5) recovery had the lowest translation to functional independence. Patients who achieved elbow extension (C7) were able to transfer independently. On multivariable analysis, patients who gained elbow extension (C7) and finger flexion (C8) were 11 times more likely to gain functional independence (OR 11, 95% CI 2.8-47, p < 0.001) and patients who gained wrist extension (C6) were 7 times more likely to gain functional independence (OR 7.1, 95% CI 1.2-56, p = 0.04). Older age (≥ 60 years) and motor complete SCI (AIS grade A-B) reduced the likelihood of gaining independence. After high cervical SCI, patients who gained elbow extension (C7) and finger flexion (C8) had significantly greater independence in feeding, bladder management, and transfers than those with recovery in elbow flexion (C5) and wrist extension (C6). Recovery of elbow extension (C7) also increased the capability for independent transfers. This information can be used to set patient expectations and prioritize interventions that restore these upper-limb functions in patients with high cervical SCI.

Assessment of Dorsiflexion Ability across Tasks in Persons with Subacute SCI after Combined Locomotor Training and Transcutaneous Spinal Stimulation.

In people with spinal cord injury (SCI), transcutaneous spinal stimulation (TSS) has an immediate effect on the ability to dorsiflex the ankle, but persistent effects are not known. Furthermore, TSS has been associated with improved walking, increased volitional muscle activation, and decreased spasticity when combined with locomotor training (LT). In this study, the persistent impact of combined LT and TSS on dorsiflexion during the swing phase of walking and a volitional task in participants with SCI is determined. Ten participants with subacute motor-incomplete SCI received 2 weeks of LT alone (wash-in phase), followed by 2 weeks of either LT + TSS (TSS at 50 Hz) or LT + TSSSham (intervention phase). There was no persistent effect of TSS on dorsiflexion during walking and inconsistent effects on the volitional task. There was a strong positive correlation between the dorsiflexor ability for both tasks. There was a moderate effect of 4 weeks of LT on increased dorsiflexion during the task (d = 0.33) and walking (d = 0.34) and a small effect on spasticity (d = -0.2). Combined LT + TSS did not show persistent effects on dorsiflexion ability in people with SCI. Four weeks of locomotor training was associated with increased dorsiflexion across tasks. Improvements in walking observed with TSS may be due to factors other than improved ankle dorsiflexion.

Untreated Moderate-to-Severe Sleep-Related Breathing Disorders Are Associated with Increased Frequency of Episodes of Autonomic Dysreflexia during Sleep in Individuals with Subacute or Chronic Spinal Cord Injury: A Prospective Cross-Sectional Study. (P1-13.002)

<h3>Objective:</h3> This ongoing cross-sectional study is focused on the potential association between moderate-to-severe sleep-related breathing disorders (SRBDs) and more severe cardiovascular dysfunction following spinal cord injury (SCI). <h3>Background:</h3> Sleep-related breathing disorders (SRBDs) are common and under-recognized among individuals living with spinal cord injury (SCI). SRBDs can affect the sympathetic response, but the impact of untreated SRBDs on cardiovascular autonomic function after SCI remains incompletely understood. <h3>Design/Methods:</h3> This cross-sectional study included adults with subacute/chronic (≥1 month after SCI onset), cervical or high-thoracic (T6 or above) SCI. The diagnosis of SRBD was established using a home-based/hospital unattended sleep screening test that quantifies the apnea-hypopnea index (AHI). Moderate-to-severe SRBD was defined as an AHI ≥ 15 events per hour. Episodes of autonomic dysreflexia (AD) were defined as a sudden increase in systolic blood pressure (BP) ≥ 20 mmHg. <h3>Results:</h3> This study included 45 individuals (14 females, 31 males with ages from 20 to 84 years; mean age: 57.0 years) with motor complete (n=22) or incomplete (n=24) SCI at cervical (n=38), or high thoracic levels. Time from SCI onset varied from 1.5 months to 52 years (mean time: 49.4 months). Mean AHI was 16.0 events per hour (AHI range: 0.8–51.7). The AHI was not associated with systolic BP (mean+/−SEM: 122.0+/−2.2 mmHg; p=0.903), diastolic BP (72.6+/−3.0 mmHg; p=0.639), mean arterial pressure (90.1+/−2.4 mmHg; p=0.714), and heart rate (70.6+/−1.4 bpm; p=0.669) during sleep. However, the AHI was significantly, positively correlated with the number of silent episodes of AD (mean +/− SEM: 3.6+/−0.4; Rsqr=0.220, p=0.001) during sleep, after excluding other causes of AD. <h3>Conclusions:</h3> The results of this cross-sectional study suggest that more severe SBRBs are associated with frequent silent episodes of AD during sleep among individuals with SCI. Future research is needed to assess the effects of continuous positive airway pressure (CPAP) therapy on cardiovascular dysfunction following SCI. <b>Disclosure:</b> The institution of Dr. Furlan has received research support from Wings for Life Spinal Cord Research Foundation. The institution of Dr. Furlan has received research support from Craig H Neilsen Foundation. The institution of Dr. Furlan has received research support from Ontario Neurotrauma Foundation. The institution of Dr. Furlan has received research support from Cervical Spine Research Society. The institution of Dr. Furlan has received research support from J P Bickell Foundation. The institution of Dr. Furlan has received research support from Praxis Spinal Cord Institute. The institution of Dr. Furlan has received research support from Cervical Spine Research Society. Dr. Loh has stock in Dara3D. Dr. Boulos has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Jazz Pharmaceuticals. Dr. Boulos has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Paladin Labs. Dr. Boulos has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Eisai. Dr. Boulos has received research support from Interaxon. The institution of Dr. Boulos has received research support from The Mahaffy Family Research Fund. The institution of Dr. Boulos has received research support from Canadian Institutes of Health Research. The institution of Dr. Boulos has received research support from Slamen-Fast New Initiatives in Neurology Award. The institution of Dr. Boulos has received research support from Green Mountain . Dr. Boulos has received personal compensation in the range of $5,000-$9,999 for serving as a speaker with Jazz Pharmaceuticals.

Spinal Cord Stimulation Prevents Autonomic Dysreflexia in Individuals with Spinal Cord Injury: A Case Series.

Spinal cord injury (SCI) results in severe cardiovascular dysfunction due to the disruption of supraspinal control. Autonomic dysreflexia (AD), an uncontrolled rise in blood pressure in response to peripheral stimuli including common bowel routine, digital anorectal stimulation (DARS), reduces the quality of life, and increases morbidity and mortality. Recently, spinal cord stimulation (SCS) has emerged as a potential intervention to mitigate unstable blood pressure following SCI. The objective of this case series was to test the real-time effect of epidural SCS (eSCS) at the lumbosacral spinal cord, the most common implant location, on mitigating AD in individuals with SCI. We recruited three individuals with cervical and upper thoracic motor-complete SCI who have an implanted epidural stimulator. We demonstrated that eSCS can reduce the elevation in blood pressure and prevent DARS-induced AD. The blood pressure variability analysis indicated that eSCS potentially reduced vascular sympathetic nervous system activity during DARS, compared to without eSCS. This case series provides evidence to support the use of eSCS to prevent AD episodes during routine bowel procedures, improving the quality of life for individuals with SCI and potentially reducing cardiovascular risks.

A case study of percutaneous epidural stimulation to enable motor control in two men after spinal cord injury

Two persons with chronic motor complete spinal cord injury (SCI) were implanted with percutaneous spinal cord epidural stimulation (SCES) leads to enable motor control below the injury level (NCT04782947). Through a period of temporary followed by permanent SCES implantation, spinal mapping was conducted primarily to optimize configurations enabling volitional control of movement and training of standing and stepping as a secondary outcome. In both participants, SCES enabled voluntary increased muscle activation and movement below the injury and decreased assistance during exoskeleton-assisted walking. After permanent implantation, both participants voluntarily modulated induced torques but not always in the intended directions. In one participant, percutaneous SCES enabled motor control below the injury one-day following temporary implantation as confirmed by electromyography. The same participant achieved independent standing with minimal upper extremity self-balance assistance, independent stepping in parallel bars and overground ambulation with a walker. SCES via percutaneous leads holds promise for enhancing rehabilitation and enabling motor functions for people with SCI.

Spatial characteristics of reactive stepping among people living with chronic incomplete spinal cord injury

Objective: Compare the spatial characteristics of reactive stepping between individuals with chronic motor incomplete spinal cord injuries (iSCI) and able-bodied (AB) individuals. Design: Cross sectional. Setting: Lyndhurst Centre. Participants: Twelve individuals with iSCI (3 males, 53.6 ± 15.2 years old) and 11 age- and sex-matched AB individuals (3 males, 54.8 ± 14.0 years old). Interventions: The Lean-and-Release test was used to elicit reactive stepping. A horizontal cable, attached at waist height, was released when 8-12% body weight was supported in a forward lean position. Participants underwent up to 10 Lean-and-Release trials in a session. Kinematic and kinetic data were recorded. Outcome measures: The length, width and height of the first reactive step of each trial were calculated. Standard deviation between trials was calculated to represent the variability in step length, width and height within a participant. Among participants with iSCI, correlation coefficients were used to explore the relationship between step length and width variability and (1) Lean-and-Release test behavioral responses, (2) 3-month fall history, and (3) lower extremity strength. Results: Step length (P = 0.94), width (P = 0.52) and height (P = 0.97), normalized for participant height, did not differ between groups. Participants with iSCI showed greater variability in step length (P = 0.02) and width (P = 0.01), but not height (P = 0.32). No correlation was found between step length or width variability and behavioral responses, 3-month fall history, or lower extremity strength. Conclusions: Individuals with iSCI showed increased variability in length and width of reactive stepping compared to AB individuals, which may contribute to their impaired ability to execute single-step reactive responses. Trial registration: ClinicalTrials.gov identifier: NCT02960178.

Lesional Antibody Synthesis and Complement Deposition Associate With De Novo Antineuronal Antibody Synthesis After Spinal Cord Injury.

Spinal cord injury (SCI) disrupts the fine-balanced interaction between the CNS and immune system and can cause maladaptive aberrant immune responses. The study examines emerging autoantibody synthesis after SCI with binding to conformational spinal cord epitopes and surface peptides located on the intact neuronal membrane. This is a prospective longitudinal cohort study conducted in acute care and inpatient rehabilitation centers in conjunction with a neuropathologic case-control study in archival tissue samples ranging from acute injury (baseline) to several months thereafter (follow-up). In the cohort study, serum autoantibody binding was examined in a blinded manner using tissue-based assays (TBAs) and dorsal root ganglia (DRG) neuronal cultures. Groups with traumatic motor complete SCI vs motor incomplete SCI vs isolated vertebral fracture without SCI (controls) were compared. In the neuropathologic study, B cell infiltration and antibody synthesis at the spinal lesion site were examined by comparing SCI with neuropathologically unaltered cord tissue. In addition, the CSF in an individual patient was explored. Emerging autoantibody binding in both TBA and DRG assessments was restricted to an SCI patient subpopulation only (16%, 9/55 sera) while being absent in vertebral fracture controls (0%, 0/19 sera). Autoantibody binding to the spinal cord characteristically detected the substantia gelatinosa, a less-myelinated region of high synaptic density involved in sensory-motor integration and pain processing. Autoantibody binding was most frequent after motor complete SCI (grade American Spinal Injury Association impairment scale A/B, 22%, 8/37 sera) and was associated with neuropathic pain medication. In conjunction, the neuropathologic study demonstrated lesional spinal infiltration of B cells (CD20, CD79a) in 27% (6/22) of patients with SCI, the presence of plasma cells (CD138) in 9% (2/22). IgG and IgM antibody syntheses colocalized to areas of activated complement (C9neo) deposition. Longitudinal CSF analysis of an additional single patient demonstrated de novo (IgM) intrathecal antibody synthesis emerging with late reopening of the blood-spinal cord barrier. This study provides immunologic, neurobiological, and neuropathologic proof-of-principle for an antibody-mediated autoimmunity response emerging approximately 3 weeks after SCI in a patient subpopulation with a high demand of neuropathic pain medication. Emerging autoimmunity directed against specific spinal cord and neuronal epitopes suggests the existence of paratraumatic CNS autoimmune syndromes.

146 Functional Priorities in High Cervical Spinal Cord Injury: Implications for Upper Limb Nerve Transfer Surgery

INTRODUCTION: High cervical spinal cord injury (SCI) results in complete impairment in upper limb function. Nerve transfer is an innovative reinnervation strategy for upper limb reanimation following SCI. However, the impact of upper limb motor recovery on the degree of long-term functional outcomes remains unknown. METHODS: A prospective cohort of high cervical SCI (C1-C4) patients enrolled in SCI model systems (SCIMS) was included. Baseline neurological examinations and functional independence measures (FIM) in eating, bladder-function, and transfers (bed/wheelchair/chair) were evaluated. At one-year follow-up, functional independence was compared in patients who gained recovery (motor grade &gt;=3) in C5-elbow flexion, C6-wrist extension, C7-elbow extension, and C8-finger flexion. A multivariable logistic regression evaluated the impact of motor recovery on functional independence on composite outcome of feeding, bladder-function, and transfers. RESULTS: Between 1992-2016, 405 high cervical SCI patients were included. At baseline, 97% patients had impaired upper limb function with inability in all functions. At one-year follow-up, the largest proportion of patients gaining independence in eating, bladder-function, and transfers had recovery in C8-finger-flexion and C6-wrist-extension. C5-elbow-flexion recovery had lowest translation into functional independence. Patients who achieved C7-elbow-extension were able to transfer independently. On multivariable analysis, C8-finger-flexion recovery had 12-times higher odds (p=0.004) and C6-wrist-extension recovery had 7-times higher odds (p=0.04) of gaining functional independence in composite outcome. Age &gt;=60 years and motor complete SCI (ASIA-A-B) were associated with reduced odds of gaining independence. 8% patients improved ASIA grades from baseline to 1-year. CONCLUSIONS: Following cervical SCI, C8-finger-flexion and C6-wrist-extension recovery can maximize functional independence. Recovery of C7-elbow-extension can increase transfer capability. This information may prioritize reinnervation strategies for individualized decision-making for nerve transfers in high cervical SCI.

Preservation of functional descending input to paralyzed upper extremity muscles in motor complete cervical spinal cord injury

ObjectiveSpinal cord injury (SCI) is classified as complete or incomplete depending on the extent of sensorimotor preservation below the injury level. However, individuals with complete SCIs can voluntarily activate paralyzed lower limb muscles alone or by engaging non-paralyzed muscles during neurophysiological assessments, indicating presence of residual pathways across the injury. However, similar phenomena have not been explored for the upper extremity (UE) muscles following cervical SCIs. MethodsEighteen individuals with motor complete cervical SCI (AIS A or B) and five age-matched non-injured (NI) individuals performed various UE events against manual resistance during functional neurophysiological assessment (FNPA), and electromyographic (EMG) activity was recorded from UE muscles. ResultsOur findings demonstrated i) voluntary activation of clinically paralyzed muscles as evident from EMG readouts, ii) increased activity in these muscles during events engaging muscles above the injury level, iii) reduced spectral properties of paralyzed muscles in SCI compared to NI participants. ConclusionsFunctional EMG activity in clinically paralyzed muscles indicate presence of residual pathways across the injury establishing supralesional control over the sublesional neural circuitry. SignificanceThe findings may help explain the neurophysiological basis for UE recovery and can be exploited in designing rehabilitation techniques to facilitate UE recovery following cervical SCIs.

Immediate Cooling and Early Decompression for the Treatment of Cervical Spinal Cord Injury: A Safety and Feasibility Study.

Cervical spinal cord injury (SCI) usually results in severe, long-term disability. Early therapeutic hypothermia (33-34°C) has been used to improve outcomes in preclinical studies, but previous clinical studies have commenced cooling after arrival at hospital. The objective of the study is to determine the feasibility and safety of early therapeutic hypothermia initiated by paramedics and maintained for up to 24 hours in hospital in patients with SCI. This is a pilot clinical study. The study was undertaken at Ambulance Victoria and The Alfred Hospital, Victoria, Australia. A total of 17 consecutive patients with suspected acute traumatic cervical SCI were enrolled. Patients with suspected cervical SCI were administered a bolus (up to 20 mL/kg) intravenous (IV) cold (4°C) normal saline in the prehospital phase of care. After hospital admission and spinal imaging, further cooling used IV catheter temperature control or surface cooling. Major complications and long-term outcomes were compared with historical controls admitted to the same center before the study. A decrease in core temperature of 1.1°C was achieved during prehospital care and the target temperature was achieved in 6 hours with mechanical temperature management devices in the hospital. There were no major safety concerns. Patients with motor complete SCI who underwent early decompressive surgery had a favorable rate of partial spinal cord recovery compared with historical controls. Therapeutic hypothermia induced using bolus, large-volume, ice-cold saline prehospital and maintained for 24 hours using mechanical devices appears to be feasible and safe in patients with SCI. Larger trials need to be undertaken to determine whether prehospital cooling combined with early decompressive surgery improves outcomes in patients with complete cervical SCI. Australian and New Zealand Clinical Trials Registry (ACTRN12616001086459).

Orthotic walking outcome of persons with motor complete low thoracic spinal cord injury-a retrospective study.

Retrospective study. To analyse the orthotic walking outcome of patients with Low Thoracic Spinal Cord Injury (LT-SCI). The Rehabilitation Institute at Christian Medical College, Vellore, India. Data between January 2005 and June 2015 were retrospectively collected from electronic medical reports of patients with motor complete LT- SCI who were admitted for the comprehensive rehabilitation program. The orthotic walking outcome of these patients was measured by the Walking index for SCI version II (WISCI II). Demographical and clinical parameters were measured and their association with the walking outcome was analyzed using regression analysis. A total of 430 patients were identified within the study period. Eighty-five percent of people (n = 365) achieved walking at the time of discharge (WISCI II level 12 = 260 and level 9 = 105). Out of 11 demographical and clinical parameters considered, eight of them were found to be significant predictors of walking in the univariate analysis. Age less than 30 years had the highest odds of predicting WISCI II level 9 and level 12 than those older in the multivariate analysis (OR 17.58; 95% CI 7.35-42.03). Single neurological level T12 increased the chance of achieving WISCI II level 12 by 10 times (OR 10.2; 95% CI 3.8-27.36). Orthotic walking for persons with motor complete low thoracic spinal cord injury is an achievable goal through a comprehensive rehabilitation program. The factors identified in this study will help rehabilitation professionals strategically select the ideal candidate for orthotic gait training.

Factors for predicting instant neurological recovery of patients with motor complete traumatic spinal cord injury

Factors for predicting instant neurological recovery of patients with motor complete traumatic spinal cord injury