Motor Incomplete SCI Research Articles

Lack of improvement in anorectal manometry parameters after implementation of a pelvic floor/anal sphincter biofeedback in persons with motor-incomplete spinal cord injury.

Effect of biofeedback on improving anorectal manometric parameters in incomplete spinal cord injury is unknown. A short-term biofeedback program investigated any effect on anorectal manometric parameters without correlation to bowel symptoms. This prospective uncontrolled interventional study comprised three study subject groups, Group 1: sensory/motor-complete American Spinal Injury Association Impairment Scale (AIS) A SCI (n = 13); Group 2 (biofeedback group): sensory incomplete AIS B SCI (n = 17) (n = 3), and motor-incomplete AIS C SCI (n = 8), and AIS D SCI (n = 6); and Group 3: able-bodied (AB) controls (n = 12). High-resolution anorectal manometry (HR-ARM) was applied to establish baseline characteristics in all subjects for anorectal pressure, volume, length of pressure zones, and duration of sphincter squeeze pressure. SCI participants with motor-incomplete SCI were enrolled in pelvic floor/anal sphincter bowel biofeedback training (2 × 6-week training periods comprised of two training sessions per week for 30-45 min per session). HR-ARM was also performed after each of the 6-week periods of biofeedback training. Compared to motor-complete or motor-incomplete SCI participants, AB subjects had higher mean intra-rectal pressure, maximal sphincteric pressure, residual anal pressure, recto-anal pressure gradient, and duration of squeeze (p < 0.05 for each of the endpoints). No significant difference was evident at baseline between the motor-complete and motor-incomplete SCI groups. In motor-incomplete SCI subjects, the pelvic floor/anal sphincter biofeedback protocol failed to improve HR-ARM parameters. Biofeedback training program did not improve anal manometric parameters in subjects with motor-incomplete or sensory-incomplete SCI. Biofeedback did not change physiology, and its effects on symptoms are unknown. Utility of biofeedback is limited in patients with incomplete spinal cord injury in terms of improving HR-ARM parameters.

Profiling Immunological Phenotypes in Individuals During the First Year After Traumatic Spinal Cord Injury: A Longitudinal Analysis.

Abstract Individuals with SCI are severely affected by immune system changes, resulting in increased risk of infections and persistent systemic inflammation. While recent data support that immunological changes after SCI differ in the acute and chronic phases of living with SCI, only limited immunological phenotyping in humans is available. To characterize dynamic molecular and cellular immune phenotypes over the first year, we assess RNA (bulk-RNA sequencing), protein, and flow cytometry (FACS) profiles of blood samples from 12 individuals with SCI at 0-3 days and at 3, 6, and 12 months post injury (MPI) compared to 23 uninjured individuals (controls). We identified 967 differentially expressed (DE) genes in individuals with SCI (FDR <0.001) compared to controls. Within the first 6 MPI we detected a reduced expression of NK cell genes, consistent with reduced frequencies of CD56bright, CD56dim NK cells present at 12 MPI. Over 6MPI, we observed increased and prolonged expression of genes associated with inflammation (e.g. HMGB1, Toll-like receptor signaling) and expanded frequencies of monocytes acutely. Canonical T-cell related DE genes (e.g. FOXP3, TCF7, CD4) were upregulated during the first 6 MPI and increased frequencies of activated T cells at 3-12 MPI. Neurological injury severity was reflected in distinct whole blood gene expression profiles at any time after SCI, verifying a persistent 'neurogenic' imprint. Overall, 2876 DE genes emerge when comparing motor complete to motor incomplete SCI (ANOVA, FDR <0.05), including those related to neutrophils, inflammation, and infection. In summary, we identify a dynamic immunological phenotype in humans, including molecular and cellular changes which may provide potential targets to reduce inflammation, improve immunity, or serve as candidate biomarkers of injury severity.

Isolating Transcutaneous Spinal Cord Stimulation Artifact to Identify Motor Response during Walking.

The objective of this investigation was to demonstrate the applicability of a custom-developed EMD-Notch filtering algorithm to isolate the scTS-induced artifact from sEMG signals during walking in an individual with motor-incomplete SCI. Overall, the EMD-Notch filtering algorithm provides an effective approach to isolate the scTS artifact, extract the sEMG data, and further study the modulation of the spinal neuronal networks during dynamic activities.Clinical Relevance- This investigation will help with the modification of individualized scTS parameters to achieve task-specific neuromodulatory effects.

Improvements in skilled walking associated with kinematic adaptations in people with spinal cord injury

IntroductionIndividuals with motor-incomplete SCI (m-iSCI) remain limited community ambulators, partly because they have difficulty with the skilled walking requirements of everyday life that require adaptations in inter-joint coordination and range of motion of the lower limbs. Following locomotor training, individuals with SCI show improvements in skilled walking and walking speed, however there is limited understanding of how adaptations in lower limb kinematics following training contribute to improvements in walking.ObjectiveTo determine the relationship between changes in lower limb kinematics (range of motion and inter-joint coordination) and improvements in walking function (walking speed and skilled walking) following locomotor training.MethodsLower limb kinematics were recorded from 8 individuals with chronic m-iSCI during treadmill walking before and after a 3-month locomotor training program. Data were also collected from 5 able-bodied individuals to provide normative values. In individuals with SCI, muscle strength was used to define the stronger and weaker limb. Motion analysis was used to determine, hip, knee and ankle angles. Joint angle-angle plots (cyclograms) were used to quantify inter-joint coordination. Shape differences between pre-and post-training cyclograms were used to assess the changes in coordination and their relation to improvements in walking function. Walking function was assessed using the 10MWT for walking speed and the SCI-FAP for skilled walking. Comparing pre- and post-training cyclograms to the able-bodied pattern was used to understand the extent to which changes in coordination involved the recovery of normative motor patterns.ResultsFollowing training, improvements in skilled walking were significantly related to changes in hip-ankle coordination (ρ = − .833, p = 0.010) and knee range of motion (ρ = .833, p = 0.010) of the weaker limb. Inter-joint coordination tended to revert towards normative patterns, but not completely. No relationships were observed with walking speed.ConclusionLarger changes in hip-ankle coordination and a decrease in knee range of motion in the weaker limb during treadmill walking were related to improvements in skilled walking following locomotor training in individuals with SCI. The changes in coordination seem to reflect some restoration of normative patterns and the adoption of compensatory strategies, depending on the participant.

Effects of Exoskeleton Training Intervention on Net Loading Force in Chronic Spinal Cord Injury.

The goal of this study was to understand the rehabilitative effects of longitudinal overground exoskeleton training $( >100$ hours) on gait mechanics, especially foot loading, for gains in walking speed in an individual with chronic motorincomplete SCI. Biomechanical measures included: normalized plantar loading forces, walking speed and bilateral weight transfer ratio during walking in the EksoGT $^{\mathrm{ TM}}$ exoskeleton. Longitudinal training with a robotic exoskeleton yielded improvements in clinical outcomes (AIS classification, ISNCSCI motor scores and 10MWT) and provided functional gains in terms of biomechanical outcomes (plantar forces, weight transfer point) to increase overall walking speed.

Fatigability, oxygen uptake kinetics and muscle deoxygenation in incomplete spinal cord injury during treadmill walking.

The purpose of the present study was to characterize hypothesized relationships among fatigability and cardiorespiratory fitness in individuals with chronic motor-incomplete SCI (iSCI) during treadmill walking. The theoretical framework was that exacerbated fatigability would occur concomitantly with diminished cardiorespiratory fitness in people with iSCI. Subjects with iSCI (n=8) and an able-bodied reference group (REF) (n=8) completed a 6-min walking bout followed by a walking bout of 30-min or until volitional exhaustion, both at a self-selected walking speed. Fatigability was assessed using both perceived fatigability and performance fatigability measures. Pulmonary oxygen uptake kinetics (VO2 on-kinetics) was measured breath-by-breath and changes in deoxygenated hemoglobin/myoglobin concentration (∆[HHb]) of the lateral gastrocnemius was measured by near-infrared spectroscopy. Adjustment of VO2 and ∆[HHb] on-kinetics were modeled using a mono-exponential equation. Perceived fatigability and performance fatigability were 52% and 44% greater in the iSCI group compared to the REF group (p=0.003 and p=0.004). Phase II time constant (τp) of VO2 on-kinetics and ∆[HHb] ½ time during resting arterial occlusion were 55.4% and 16.3% slower in iSCI vs REF (p<0.01 and p=0.047, respectively). The results of the present study may suggest that compromised O2 delivery and/or utilization may have contributed to the severity of fatigability in these individuals with iSCI. The understanding of the extent to which fatigability and VO2 and Δ[HHb] on-kinetics impacts locomotion after iSCI will assist in the future development of targeted interventions to enhance function.

Placebo-controlled study of rTMS combined with Lokomat® gait training for treatment in subjects with motor incomplete spinal cord injury.

High-frequency rTMS combined with gait training improves lower extremity motor score (LEMS) and gait velocity in SCI subjects who are able to walk over ground. The aim of this study was to optimize the functional outcome in early phases of gait rehabilitation in SCI using rTMS as an additional treatment to physical therapy. The present study included 31 motor incomplete SCI subjects randomized to receive real or sham rTMS, just before Lokomat gait training (15 subjects for real, 16 for sham rTMS). rTMS consisted of one daily session for 20days over vertex (at 20Hz). The subjects were evaluated using modified Ashworth scale (MAS) for spasticity, upper and lower extremity motor score (UEMS and LEMS, respectively), ten meters walking test (10MWT) and Walking Index for SCI (WISCI-II) for gait at baseline, after last rTMS session, and during follow-up. UEMS and LEMS improved significantly after last session in both groups and during follow-up period. The improvement was greater in real than in sham rTMS group. At follow-up, 71.4% of the subjects after real rTMS and 40% of the subjects after sham rTMS could perform 10MWT without significant differences in gait velocity, cadence, step length and WISCI-II between both groups. We conclude that 20 sessions of daily high-frequency rTMS combined with Lokomat gait training can lead to clinical improvement of gait in motor incomplete SCI. Such combined treatment improved motor strength in lower extremity in incomplete SCI subjects and in upper extremity in those with cervical SCI.

Hybrid therapy of walking with Kinesis overground robot for persons with incomplete spinal cord injury: A feasibility study

Rehabilitation of walking ability is one of the most important objectives after a spinal cord injury. Robotic and neuroprosthetic technologies hold a considerable potential for driving walking rehabilitation therapies. However, new developments are needed in order to improve the walking rehabilitation interventions based in these technologies.We recently presented a cooperative control strategy of Kinesis, a lower limb exoskeleton for providing hybrid therapy of walking (Del-Ama, 2014). Its design aimed to actively manage muscle fatigue caused by surface electrical stimulation, and to implement the assist-as-needed control paradigm in which both stimulation and robotic controller cooperate with the residual functionality of the user. In this article we present three case studies for investigating the feasibility of the hybrid therapy of walking delivered with Kinesis in patients with incomplete spinal cord injury. Besides, the adaptability features of Kinesis stimulation–robot cooperative control are assessed, characterizing the behavior of the cooperative controller while providing hybrid therapy of walking.Patients with incomplete spinal cord injury participated in the experiments. The protocol consisted of walking with Kinesis during 6 min. Three configurations of the cooperative controller were tested for each patient in separate sessions in order to investigate its adaptability features. The immediate impact of the hybrid therapy of walking was assessed through several variables that represent the physiological impact, user–exoskeleton physical interaction, stimulation intensity and user subjective perception of the hybrid therapy of walking.Results show that the cooperative controller of Kinesis adapted to patient functional deficits and voluntary actions during walking, modulating stimulation and robotic assistance, which was the aim of the controller design. Nevertheless, no noticeable differences were observed in the comparison between compliant and trajectory exoskeleton control. Further work is envisioned regarding several aspects of hybrid walking control: stimulation control based on muscle activation estimate, improved semi-automatic control of walking, and improved muscle fatigue monitoring. The hybrid walking therapy was tolerated by the patients without adverse effects, along with a tolerable physical demand. This shows a potential for walking rehabilitation in motor incomplete SCI patients, guaranteeing further research on this topic.

Bone Mineral Density and Biochemical Markers of Bone Turnover During the First Year of Injury in Patients with Spinal Cord Injury

BackgroundSpinal cord injury (SCI) is associated with bone mass loss that can be complicated by fractures, which result in further disabilities for patients. After a SCI, the body starts losing large amounts of calcium and other minerals in the urine (demineralisation). This study aimed to assess the changes in bone mineral density (BMD) during the 1st year of acute SCI in patients with neurological deficit. MethodsA total of 95 patients with acute SCI and neurological deficit were evaluated in this prospective study. Haematological investigations such as evaluation of serum calcium, serum phosphate, serum creatinine, and serum alkaline phosphatase (ALP) were carried out. Urinary investigations such as 24-hour urinary creatinine level and excretion of calcium and phosphate in the urine were measured. BMD was measured using dual-energy X-ray absorptiometry scan with Hologic QDR 2000 scanner (Explorer). All of the aforementioned parameters were measured again at 3, 6, and 12 months. ResultsSerum ALP at 1-year follow up was significantly raised (p<0.05). The BMD at 1-year follow up had statistically significant lower values than the initial BMD at the hip (p<0.05), proximal tibia (p < 0.00l), and distal tibial epiphysis (p < 0.001). The BMD in motor-complete SCI patients [American Spinal Injury Association (ASIA) grades A and B] had significant lower values than motor-incomplete SCI patients (ASIA C and D) at the hip (p < 0.05) and proximal tibial epiphysis (p < 0.05). ConclusionThere was a marked decrease in BMD in metaphyseal sites than below the neurological deficit level with maximum decrease at the proximal tibia during the 1st year of SCI. Although the markers of osteoblastic activity did not show much change, the decrease in BMD was influenced by the neurological recovery after SCI.

Exercise Intensity during Treadmill Walking with Gait-Patterned FES among Patients with Incomplete Spinal Cord Injury: Case Series

Purpose. To determine the feasibility of increasing the cardiopulmonary exercise intensity during walking with gait-patterned functional electrical stimulation (GP-FES) among individuals with motor incomplete SCI. Methods. Two men with motor-incomplete SCI (Subjects A and B, age 45 and 50 years; Level of Injury: C4 and T10; AIS score: D and D, resp.) performed a three sequential four-minute continuous walking sessions [(1) regular gait (non-GP-FES-1); (2) gait with GP-FES (GP-FES); (3) regular gait (non-GP-FES-2)]. Oxygen consumption (Vo2) was measured continuously during trials. Results. Vo2 was higher during GP-FES (Subjects A and B; 14.5 and 19.1 mL/kg/min, resp.) as compared to regular gait (Non-GP-FES-1: Subjects A and B; 13.4 and 17.0: mL/kg/min, resp.; non-GP-FES-2: Subjects A and B; 13.1 and 17.5: mL/kg/min, resp.). Conclusion. The exercise intensity of GP-FES walking was higher than that of regular walking among individuals with motor incomplete SCI. Further investigations are required to determine the clinical relevance of the exercise.

The amplitude of lower leg motor evoked potentials is a reliable measure when controlled for torque and motor task

Motor evoked potential (MEP) amplitudes have the disadvantage of a high variability when repeatedly assessed. This affects the reliability of MEP amplitude measurements taken during the course of motor incomplete spinal cord injury (iSCI). The study investigated the reliability of anterior tibial (TA) MEP measures controlled for dorsal flexion torque and motor task. TA MEPs were recorded at 10, 20, 40 and 60% of maximal voluntary contraction (MVC) during a static and dynamic (isometric increase of dorsal flexion torque) motor task. To determine reliability, 20 healthy and five chronic iSCI subjects were tested twice (> or =7 days) by the same investigator. Intraclass correlation coefficients (ICCs) were calculated. MEP amplitudes and latencies were compared between 20 healthy and 29 iSCI subjects. The reliability of MEP amplitude was in general good (ICC > or = 0.52) and was highest during the static task at 40% MVC (ICC = 0.77). The increased facilitation by the dynamic motor task showed the best reliability at 20% MVC (ICC = 0.48). The reliability was good to excellent for MEP latency (0.46 < or = ICC < or = 0.81), MVC (ICC > or = 0.90) and for the TMS threshold required to evoke a MEP response (ICC > or = 0.77). The torque generated by the MEP response ()0.02 < or = ICC < or = 0.55) and the duration of the silent period (0.07 < or = ICC < or = 0.50) were not reliable. Both MEP amplitudes and latencies differed significantly between healthy and iSCI subjects. Controlling for torque generation and motor task establishes a reliability of TA MEP amplitudes that is sufficient for longitudinal assessments in motor incomplete SCI.