Motor Complete Spinal Cord Injury Research Articles

Spinal Cord Transcutaneous Stimulation Enables Volitional Knee Extension in Motor-complete SCI.

Non-invasive spinal cord transcutaneous stimulation (scTS) is often applied to one or multiple spinal segments and may improve motor control after spinal cord injury (SCI). The purpose of this pilot study was to apply tonic scTS to an individual with motor-complete spinal cord injury (SCI) in order to initiate and maintain volitional control during a specific lower-extremity motor task. The participant's legs were placed in a gravity-neutral position, and he was asked to extend his knee, with and without the presence of tonic scTS. Our results show intentional voluntary control of knee extension with scTS (with no assistance). Our preliminary findings highlight how scTS neuromodulation of the spinal circuitry has the potential to restore motor function for people with motor-complete SCI. Clinical Relevance- This investigation is critical to better understand the neuromodulatory effects of tonic scTS for augmentation of voluntary-induced muscle activations in individuals with motor-complete SCI.

Applicability of the AO Spine Patient Reported Outcome Spine Trauma (PROST) in people with motor-complete spinal cord injury: a cognitive interview study.

Study designThis is a cognitive interview study.ObjectivesTo examine the applicability of the Patient Reported Outcome Spine Trauma (AO Spine PROST) in people with motor-complete traumatic or non-traumatic spinal cord injury (SCI).SettingTwo rehabilitation centers in The Netherlands.MethodSemi-structured cognitive interviews were conducted with 29 adults with a motor-complete SCI (AISA Impairment Scale A or B). Participants were asked to complete the AO Spine PROST and four additional evaluation questions rated on a 1–5-point Likert scale (5 most positive), while verbalizing their thoughts about their answers. Interviews were audio-recorded and transcribed. Codes were identified and linked to a coding scheme. Qualitative data were used to interpret the quantitative results.ResultsAlmost three-quarters of the participants (71.4%) had a traumatic SCI. Positive ratings of the measure were obtained regards comprehensibility (mean 4.0), non-offensiveness (4.6), relevance (4.2), and completeness (3.6). A question about the emotional impact of SCI was indicated to be missing. How using an assistive device should weigh in the score was a recurring topic. The use of multiple examples per item raised uncertainty, mostly solved by averaging their score. Some individuals indicated that the possibility to express even better function compared to before the onset of injury would be valuable.ConclusionsOverall, the AO Spine PROST appears applicable in adults with a motor-complete traumatic or non-traumatic SCI. Recommendations are made for improvement in instructions, terminology, and examples used in the tool. This study contributes to the further development of the AO Spine PROST in spine trauma care and research.

Targeting bladder function with network-specific epidural stimulation after chronic spinal cord injury

Profound dysfunctional reorganization of spinal networks and extensive loss of functional continuity after spinal cord injury (SCI) has not precluded individuals from achieving coordinated voluntary activity and gaining multi-systemic autonomic control. Bladder function is enhanced by approaches, such as spinal cord epidural stimulation (scES) that modulates and strengthens spared circuitry, even in cases of clinically complete SCI. It is unknown whether scES parameters specifically configured for modulating the activity of the lower urinary tract (LUT) could improve both bladder storage and emptying. Functional bladder mapping studies, conducted during filling cystometry, identified specific scES parameters that improved bladder compliance, while maintaining stable blood pressure, and enabled the initiation of voiding in seven individuals with motor complete SCI. Using high-resolution magnetic resonance imaging and finite element modeling, specific neuroanatomical structures responsible for modulating bladder function were identified and plotted as heat maps. Data from this pilot clinical trial indicate that scES neuromodulation that targets bladder compliance reduces incidences of urinary incontinence and provides a means for mitigating autonomic dysreflexia associated with bladder distention. The ability to initiate voiding with targeted scES is a key step towards regaining volitional control of LUT function, advancing the application and adaptability of scES for autonomic function.

TWIICE One powered exoskeleton: effect of design improvements on usability in daily life as measured by the performance in the CYBATHLON race

BackgroundSpinal cord injury leading to paraplegia affects the mobility and physiological well-being of one in a thousand people. Powered exoskeletons can temporarily restore the ability to walk. Their relevance in daily life is still limited because of low performance beyond ground that is even. CYBATHLON is an international competition promoting improvements in assistive technology. In this article, we present the latest design and results of testing of TWIICE One version 2018, one of the competing devices in the 2020 race.MethodsA person with a motor-complete spinal cord injury at thoracic level T10 participated as race pilot. Training ahead of the race took place over one week at a rate of 2 h per day. The time to perform each of the seven tasks of the competition was recorded together with the number of repetitions. Performance is compared over the training period and against the 2016 race results.ResultsProgression was observed in all tasks and accounted for by both user training and technology improvements. Final competition rank was second out of seven participating teams, with a record time of 4′40". This represents an average improvement of 40% with respect to comparable obstacles of the 2016 race, explaining the two ranks of improvement since then.ConclusionThese results help understand which features had a positive impact on the real-life performance of the device. Understanding how design affects performance is key information to create devices that really improve the life of people living with paraplegia.

Temporal Changes of Cardiac Structure, Function, and Mechanics During Sub-acute Cervical and Thoracolumbar Spinal Cord Injury in Humans: A Case-Series.

Individuals with cervical spinal cord injury (SCI) experience deleterious changes in cardiac structure and function. However, knowledge on when cardiac alterations occur and whether this is dependent upon neurological level of injury remains to be determined. Transthoracic echocardiography was used to assess left ventricular structure, function, and mechanics in 10 male individuals (median age 34 years, lower and upper quartiles 32–50) with cervical (n = 5, c-SCI) or thoracolumbar (n = 5, tl-SCI) motor-complete SCI at 3- and 6-months post-injury. Compared to the 3-month assessment, individuals with c-SCI displayed structural, functional, and mechanical changes during the 6-month assessment, including significant reductions in end diastolic volume [121 mL (104–139) vs. 101 mL (99–133), P = 0.043], stroke volume [75 mL (61–85) vs. 60 mL (58–80), P = 0.042], myocardial contractile velocity (S') [0.11 m/s (0.10–0.13) vs. 0.09 m/s (0.08–0.10), P = 0.043], and peak diastolic longitudinal strain rate [1.29°/s (1.23–1.34) vs. 1.07°/s (0.95–1.15), P = 0.043], and increased early diastolic filling over early myocardial relaxation velocity (E/E') ratio [5.64 (4.71–7.72) vs. 7.48 (6.42–8.42), P = 0.043]. These indices did not significantly change in individuals with tl-SCI between time points. Ejection fraction was different between individuals with c-SCI and tl-SCI at 3 [61% (57–63) vs. 54% (52–55), P < 0.01] and 6 months [58% (57–62) vs. 55% (52–56), P < 0.01], though values were considered normal. These results demonstrate that individuals with c-SCI exhibit significant reductions in cardiac function from 3 to 6 months post-injury, whereas individuals with tl-SCI do not, suggesting the need for early rehabilitation to minimize cardiac consequences in this specific population.

Walking and Balance Outcomes Are Improved Following Brief Intensive Locomotor Skill Training but Are Not Augmented by Transcranial Direct Current Stimulation in Persons With Chronic Spinal Cord Injury.

Motor training to improve walking and balance function is a common aspect of rehabilitation following motor-incomplete spinal cord injury (MISCI). Evidence suggests that moderate- to high-intensity exercise facilitates neuroplastic mechanisms that support motor skill acquisition and learning. Furthermore, enhancing corticospinal drive via transcranial direct current stimulation (tDCS) may augment the effects of motor training. In this pilot study, we investigated whether a brief moderate-intensity locomotor-related motor skill training (MST) circuit, with and without tDCS, improved walking and balance outcomes in persons with MISCI. In addition, we examined potential differences between within-day (online) and between-day (offline) effects of MST. Twenty-six adults with chronic MISCI, who had some walking ability, were enrolled in a 5-day double-blind, randomized study with a 3-day intervention period. Participants were assigned to an intensive locomotor MST circuit and concurrent application of either sham tDCS (MST+tDCSsham) or active tDCS (MST+tDCS). The primary outcome was overground walking speed measured during the 10-meter walk test. Secondary outcomes included spatiotemporal gait characteristics (cadence and stride length), peak trailing limb angle (TLA), intralimb coordination (ACC), the Berg Balance Scale (BBS), and the Falls Efficacy Scale-International (FES-I) questionnaire. Analyses revealed a significant effect of the MST circuit, with improvements in walking speed, cadence, bilateral stride length, stronger limb TLA, weaker limb ACC, BBS, and FES-I observed in both the MST+tDCSsham and MST+tDCS groups. No differences in outcomes were observed between groups. Between-day change accounted for a greater percentage of the overall change in walking outcomes. In persons with MISCI, brief intensive MST involving a circuit of ballistic, cyclic locomotor-related skill activities improved walking outcomes, and selected strength and balance outcomes; however, concurrent application of tDCS did not further enhance the effects of MST.Clinical Trial Registration[ClinicalTrials.gov], identifier [NCT03237234].

A Pilot Study of Intensive Locomotor-Related Skill Training and Transcranial Direct Current Stimulation in Chronic Spinal Cord Injury.

Improved walking function is a priority among persons with motor-incomplete spinal cord injury (PwMISCI). Accessibility and cost limit long-term participation in locomotor training offered in specialized centers. Intensive motor training that facilitates neuroplastic mechanisms that support skill learning and can be implemented in the home/community may be advantageous for promoting long-term restoration of walking function. Additionally, increasing corticospinal drive via transcranial direct current stimulation (tDCS) may enhance training effects. In this pilot study, we investigated whether a moderate-intensity motor skill training (MST) circuit improved walking function in PwMISCI and whether augmenting training with tDCS influenced outcomes. Twenty-five adults (chronic, motor-incomplete spinal cord injury) were randomized to a 3-day intervention of a locomotor-related MST circuit and concurrent application of sham tDCS (MST+tDCS sham ) or active tDCS (MST+tDCS). The primary outcome was overground walking speed. Secondary outcomes included walking distance, cadence, stride length, and step symmetry index (SI). Analyses revealed significant effects of the MST circuit on walking speed, walking distance, cadence, and bilateral stride length but no effect on interlimb SI. No significant between-groups differences were observed. Post hoc analyses revealed within-groups change in walking speed (ΔM = 0.13 m/s, SD = 0.13) that app-roached the minimally clinically important difference of 0.15 m/s. Brief, intensive MST involving locomotor-related activities significantly increased walking speed, walking distance, and spatiotemporal measures in PwMISCI. Significant additive effects of tDCS were not observed; however, participation in only 3 days of MST was associated with changes in walking speed that were comparable to longer locomotor training studies.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A386 ).

Robotic upright stand trainer (RobUST) and postural control in individuals with spinal cord injury

Context/objective: Assessed feasibility and potential effectiveness of using a novel robotic upright stand trainer (RobUST) to deliver postural perturbations or provide assistance-as-needed at the trunk while individuals with spinal cord injury (SCI) performed stable standing and self-initiated trunk movements. These tasks were assessed with research participants’ hands on handlebars for self-balance assistance (hands on) and with hands off (free hands). Design: Proof of concept study. Participants: Four individuals with motor complete (n = 3) or incomplete (n = 1) SCI who were not able to achieve independent standing and presented a neurological lesion level ranging from cervical 4 to thoracic 2. Outcome measures: Ground reaction forces, trunk displacement, and electromyography activity of trunk and lower limb muscles. Results: Research participants received continuous pelvic assistance via RobUST, and manual trainer assistance at the knees to maintain standing. Participants were able to attempt all tasks. Free hands trunk perturbations resulted in greater load bearing-related sensory information (73% ipsilateral vertical loading), trunk displacement (57%), and muscle activation compared to hands on. Similarly, free hands stable standing with RobUST assistance-as-needed resulted in 8.5% larger bodyweight bearing, 112% larger trunk movement velocity, and higher trunk muscles activation compared to standing with hands on. Self-initiated trunk movements controlled by hands on showed 116% greater trunk displacement, 10% greater vertical ground reaction force, and greater ankle muscle activation compared to free hands. Conclusion: RobUST established a safe and challenging standing environment for individuals with SCI and has the potential to improve training paradigms and assessments of standing postural control.

Prevalence of spasticity in humans with spinal cord injury with different injury severity.

Spasticity is one of the most common symptoms manifested following spinal cord injury (SCI). The aim of this study was to assess spasticity in individuals with subacute and chronic SCI with different injury severity, standardizing the time and assessments of spasticity. We tested 110 individuals with SCI classified by the American Spinal Injury Association Impairment Scale (AIS) as either motor complete (AIS A and B; subacute, n = 25; chronic, n = 33) or motor incomplete (AIS C and D; subacute, n = 23; chronic, n = 29) at a similar time after injury (subacute, ∼1 mo after injury during inpatient rehabilitation and chronic, ≥1 yr after injury) using clinical (modified Ashworth scale) and kinematic (pendulum test) outcomes to assess spasticity in the quadriceps femoris muscle. Using both methodologies, we found that among individuals with subacute motor complete injuries, only a minority showed spasticity, whereas the majority exhibited no spasticity. This finding stands in contrast to individuals with subacute motor incomplete injury, where both methodologies revealed that a majority exhibited spasticity, whereas a minority exhibited no spasticity. In chronic injuries, most individuals showed spasticity regardless of injury severity. Notably, when spasticity was present, its magnitude was similar across injury severity in both subacute and chronic injuries. Our results suggest that the prevalence, not the magnitude, of spasticity differs between individuals with motor complete and incomplete SCI in the subacute and chronic stages of the injury. We thus argue that considering the "presence of spasticity" might help the stratification of participants with motor complete injuries for clinical trials.NEW & NOTEWORTHY The prevalence of spasticity in humans with SCI remains poorly understood. Using kinematic and clinical outcomes, we examined spasticity in individuals with subacute and chronic injuries of different severity. We found that spasticity in the quadriceps femoris muscle was more prevalent among individuals with subacute motor incomplete than in those with motor complete injuries. However, in a different group of individuals with chronic injuries, no differences were found in the prevalence of spasticity across injury severity.

15‐Days of Therapeutic Mild Intermittent Hypoxia Improves Cardiovascular, Upper Airway and Motor Limb Function in Participants with Motor Incomplete Spinal Cord Injury and Severe Obstructive Sleep Apnea

IntroductionRepeated exposure to mild intermittent hypoxia (MIH) with sustained hypercapnia improves cardiovascular control in able‐bodied individuals with obstructive sleep apnea. Thus, we aimed to investigate if this treatment can improve cardiovascular function in individuals with motor incomplete spinal cord injuries (SCI). In addition, treatment with MIH improves cortical excitability, as well as, upper airway muscle and limb motor function. Consequently, we also explored if MIH improves upper airway motor function and walking endurance in individuals with motor incomplete SCI with concurrent sleep apnea.MethodsTwo individuals (age 51.0 ± 8.5) with traumatic motor incomplete SCI (T8, C6) and untreated severe obstructive sleep apnea (apnea hypopnea index 53.7 ± 34.0 events/hour) were treated with MIH for 15 days while receiving in‐home continuous positive airway pressure (CPAP) treatment. The MIH protocol consisted of twelve 2‐minute hypoxic exposures (PETO2 ≍ 50 mmHg) with PETCO2 maintained 2 mmHg above baseline. Therapeutic CPAP and the active critical closing pressure were measured before and after the 15‐day exposure period. In addition, blood pressure was measured over 24‐hours before and after the MIH protocol. Beat‐to‐beat blood pressure was measured during baseline (i.e. normoxia) prior to exposure to MIH on day 1 and day 15. Walking endurance was measured on the first and last day of the protocol prior to MIH exposure. Due to the small sample, Cohen’s D effect sizes are presented.Results24‐hour systolic (SBP), diastolic (DBP) and mean arterial (MAP) blood pressure (unit – mmHg) was reduced following 15 days of MIH (SBP: 131.4 ± 8.5 vs 113.4 ± 9.3, d= 2.0, DBP: 82.3 ± 1.4 vs 75.5 ± 3.9, d= 2.6, MAP: 98.5 ± 1.84 vs 88.0 ± 0.5, d= 9.04). Beat‐to‐beat blood pressure was also reduced following MIH (SBP: 135.3 ± 10.0 vs 116.9 ± 21.5, d= 1.2, DBP: 87.3 ± 0.46 vs 75.6 ± 3.1, d= 6.6, MAP 107.1 ± 0.4 vs 91.3 ± 7.0, d= 4.4). Additionally, an increase in indirect measures of cardiac output at rest (77.6 ± 39.9 vs 84.9 ± 30.2 L/min, d = 0.9) with concurrent reductions in total peripheral resistance (1.3 ± .7 vs 0.6 ± 0.1 mmHg*s/mL, d = 1.8) were found on the day 15. A reduction in therapeutic CPAP (11.0 ± 1.4 vs 9.0 ± 1.4 cmH2O, d= 1.4) and the critical closing pressure (4.5 ± 0.7 vs ‐0.6 ± 1.9 cmH2O, d = 3.9) was also evident following MIH. Lastly, walking endurance (155.8 ± 151.1 vs 240.5 ± 208.0 meters, d = 0.33) and walking velocity (0.4 ± 0.4 vs 0.7 ± 0.6 meters/second, d = 0.33) increased on day 15 compared to day 1.ConclusionFollowing 15 days of therapeutic MIH (i) blood pressure was reduced (ii) upper airway patency was improved and (iii) walking endurance and velocity increased in two individuals with motor incomplete SCI, hypertension and concurrent obstructive sleep apnea.

Cardiac structure and function relates to body composition and metabolic profiles in high spinal cord injury

Introduction/ObjectiveReduced cardiovascular function is common following high spinal cord injury (SCI), yet it is unknown whether cardiac structure and function are related to SCI‐induced changes in body composition and metabolic profiles. The objective of this study was to examine the correlation between cardiac structure and function and body composition and metabolic profiles after SCI.Materials/MethodsIn this IRB‐approved study, participants with chronic motor complete C4‐T4 SCI were included and completed informed consent. All participants underwent a dobutamine echocardiogram to assess cardiac structure and function. Dual‐energy x‐ray absorptiometry assessed body composition. Basal metabolic rate, respiratory quotient, and percent substrate oxidation were measured after a 12 h overnight fast using indirect calorimetry. Venipuncture was used to assess basic metabolic, lipid, and carbohydrate panels. Spearman correlations were used to evaluate relationships with an a priori alpha of 5%.ResultsSubjects were five males and one female (age: 43.2±10.8 y, body mass index: 30.6±10.8) with SCI of 8±10.8 years duration at the C6 to the T3 levels. Left ventricle internal systolic dimension correlated with both triglycerides (ρ=‐0.982, p=0.018) and very low‐density lipoprotein cholesterol (VLDL; ρ=‐0.982, p=0.018). Left ventricle internal diastolic dimension correlated with bone mineral content (ρ=0.953, p=0.047), high density lipoprotein cholesterol (ρ=0.956, p=0.044), low‐density lipoprotein cholesterol (LDL; ρ=‐0.976, p=0.024), and blood urea nitrogen (BUN; ρ=‐0.975, p=0.025). Both the interventricular septum diastolic thickness and interventricular internal diastolic dimension were related to subcutaneous fat (both ρ=0.999, p=0.029). Left atrium dimension correlated with total cholesterol (TC; ρ=‐0.979, p=0.021), LDL (ρ=‐0.990, p=0.010), BUN (ρ=‐0.958, p=0.042), and sodium (ρ=‐0.962, p=0.038). Similarly, the left atrium anteroposterior dimension correlated with TC (ρ=‐0.979, p=0.021), LDL (ρ=‐0.990, p=0.010), BUN (ρ=‐0.958, p=0.042), and sodium (ρ=‐0.962, p=0.038). Aortic root diameter (ρ=1.00, p=0.004) and aortic outflow area (ρ=1.00, p=0.011) correlated with visceral fat. Functionally, maximal heart rate correlated with android mass (ρ=0.947, p=0.015), android fat (AF; ρ=0.933, p=0.021), and percent AF (ρ=0.897, p=0.039). End diastolic volume correlated with lean body mass (ρ=0.993, p=0.007), android mass (ρ=0.980, p=0.020), AF (ρ=0.980, p=0.020), percent AF (ρ=0.989, p=0.011), visceral fat (ρ=1.00, p=0.010), respiratory quotient (ρ=0.973, p=0.027), and percent fat (ρ=0.977, p=0.023) and percent carbohydrate (ρ=0.977, p=0.023) oxidation during basal metabolic rate.ConclusionCardiac structure and function were related to body composition and metabolic profiles in high motor complete SCI.Significance/ImplicationThese findings demonstrate the need to consider body composition and metabolic profile in cardiac structure and function after SCI.

Rehabilitation outcome in people with spinal cord injuries resulting from diving in South Korea.

Retrospective electronic medical record review combined with a telephone interview. The purpose of this study was to describe the neurological and socio-professional outcomes of patients with diving injuries of the cervical spine. A tertiary hospital and its affiliated rehabilitation hospital in South Korea. Electronic medical records were reviewed for medical and neurological information. Telephone interviews were then conducted with questionnaire regarding specific circumstances at the time of injury and social status. A total of 33 patients with spinal cord injury (SCI) due to diving accidents were analyzed, of which 27 responded to telephone interviews. Thirty-two (97%) participants were men and 27 (81.8%) were younger than 40 years at the time of injury. The American Spinal Injury Association grade A was the most common of all grades in 16 participants (48.5%), whereas C4 was the most common neurologic level of the injury (n = 13, 39.4%). SCI due to diving accidents most commonly occurred in swimming pools in holiday lodges (n = 12, 36.4%). Five out of 13 married couples with motor complete SCI were divorced or separated after injury. Eight persons resumed work or studies after the injury, with a mean return time of 33 (24.4) months. SCI resulting from a diving accident not only causes severe functional impairment but can also result in changes in marital and employment status. This study may be used as a basic source of education and awareness to prevent further SCI due to diving accidents.

The effects of active upper-limb versus passive lower-limb exercise on quality of life among individuals with motor-complete spinal cord injury.

Multi-centre randomized clinical trial. (1) compare the effects of arm-cycle ergometry (ACET) and body weight supported treadmill training (BWSTT) on quality of life (QOL) and intermediary variables in individuals with spinal cord injury (SCI); (2) examine correlations between baseline measures, and changes in physical activity, QOL, and intermediaries. Hospital-based research institutes (Vancouver, Toronto) and University-based exercise program (Hamilton). 35 participants with motor-complete SCI above T6 completed baseline assessments of physical activity, life satisfaction, independence, autonomy, positive and negative affect, and pain. Twenty-eight participants were randomized to 72 sessions of ACET (n = 14) or BWSTT (n = 14) with measures repeated following 36 sessions, 72 sessions, and 6-months post-intervention. Neither intervention significantly impacted QOL. Pain was reduced in ACET compared to BWSTT (interaction effect p = 0.022) and was significantly less at 72 sessions vs. baseline in the ACET group (p = 0.009). At baseline, QOL was positively correlated with independence, autonomy, and positive affect and negatively correlated with negative affect (all p < 0.05). Following BWSTT, changes in moderate-vigorous physical activity correlated with changes in QOL (r = 0.87, p = 0.010). Following ACET, changes in autonomy and independence were positively correlated with changes in QOL (both r > 0.64, p < 0.048). Contrary to previous studies, there was no benefit of either intervention on measures of QOL. The social context of exercise may be important for improving QOL. However, individuals may benefit more from active (ACET) than passive (BWSTT) exercise modalities through reduced pain. Exercise interventions that improve autonomy and independence may lead to improvements in QOL.

Improvement of quality of life after 2-month exoskeleton training in patients with chronic spinal cord injury

Objective To examine changes in quality of life (QoL) after an eight-week period of robotic exoskeleton training in a homogeneous group of patients with chronic complete spinal cord injury (SCI). Design Prospective single-group pre-post study. Setting Rehabilitation center. Participants Patients with a chronic (>6 months) motor complete SCI (T1-L1). Intervention Twenty-four training sessions with the ReWalk exoskeleton over an eight-week period. Main outcome measure QoL, assessed with the sum score of the Short Form-36 with Walk Wheel modification (SF-36ww). Secondary outcome measures were the eight SF-36ww subdomains, satisfaction with bladder and bowel management, lower extremity joint passive range of motion (pROM), and lower extremity spasticity. Results Twenty-one participants completed the training. QoL significantly improved after the training period (average SF-36 sum score 621 ± 90) compared to baseline (571 ± 133) (t(20)=-2.5, P=.02). Improvements were seen on the SF-36ww subdomains for pain (P=.003), social functioning (P=.03), mental health (P=.02), and general health perception (P=.01). Satisfaction with bladder management (range 1-5) improved from median 3 at baseline to 4 after exoskeleton training (P=0.01). No changes in satisfaction with bowel management (P=.11), pROM (hip-extension (P=.49), knee-extension (P=.36), ankle dorsiflexion (P=.69)), or spasticity (P=.94) were found. Conclusion Even in patients with chronic motor complete SCI and a relatively high level of QoL at baseline, a short-term exoskeleton training improved their QoL, pain and satisfaction with bladder management; findings that warrant further controlled studies in this specific SCI population.

The effects of spasticity on glucose metabolism and soft tissue body composition in patients with spinal cord injury.

Objectives The aim of this study was to assess the effects of spasticity on glucose metabolism and percentage of fat-free mass (FFM%) in patients with spinal cord injury (SCI). Patients and methods A total of 33 patients (22 males, 11 females; mean age: 38.6±12.5 years; range, 20 to 64 years) with SCI defined by the American Spinal Injury Association Impairment Scale Grades A to D were included between September 2014 and May 2018. We assessed spasticity with the Modified Ashworth Scale (MAS) and evaluated spasms with the Penn Spasm Frequency Scale (PSFS). We assessed the glucose metabolism by calculating the Matsuda and HOMA-IR index, and measured FFM% by dual-energy X-ray absorptiometry. Results Fourteen patients had motor complete, and 19 had motor incomplete SCI. The neurological injury levels of the patients were C4-T12. There was a positive correlation between hip adductor muscle MAS and trunk, android, and gynoid FFM% and between hip extensor muscle MAS and android FFM% in patients with motor complete SCI. Hip extensor and knee flexor muscle MAS showed a negative correlation with the HOMA-IR. Hip adductor and extensor muscle MAS, as well as knee flexor and extensor muscle MAS, had a positive correlation with the Matsuda index in these patients. There was a positive correlation between knee extensor muscle MAS and gynoid FFM% and between PSFS and arms, trunk, gynoid, and total FFM% in patients with motor incomplete SCI. There was a negative correlation between hip adductor and extensor muscle MAS, PSFS, and level of fasting glucose in these patients. Conclusion This study supports the notion that spasticity has positive effects on the FFM% and glucose metabolism in patients with motor complete and incomplete SCI.

Impact of Surgical Timing on Motor Level Lowering in Motor Complete Traumatic Spinal Cord Injury Patients.

Patients with complete traumatic spinal cord injury (tSCI) have a low potential to recover ambulation. Motor level recovery, adjacent to the level of injury, could influence functional independency. This study addresses whether surgical timing influences motor level recovery in patients with motor complete (American Spinal Injury Association [ASIA] Impairment Scale A [AIS A]) and motor incomplete (AIS B) tSCI. A retrospective cohort study was performed in the Netherlands in patients with AIS A/B tSCI (C2-L2), who consecutively underwent surgery between January 2010 and April 2020. Neurological examination was performed directly at presentation to the emergency room and at discharge from the rehabilitation facility. Motor level lowering, AIS grade, and upper and lower extremity motor score recovery were calculated for patients who underwent early (< 24 h) and late (24 h+) surgery. A total of 96 patients met the inclusion criteria. In the multi-variate analysis, late surgical decompression (24 h+) was negatively associated with ≥1 motor level lowering and ≥2 AIS grade improvement [odds ratio (OR) 0.11 [95% confidence interval (CI): 0.01, 0.67], p = 0.046, and OR 0.06 [95% CI: 0.00, 047], p = 0.030. respectively). The presence of sacral sparing (AIS B) at initial examination, and cervical level of the tSCI were associated with ≥1 motor level lowering. In addition, AO Spine C-type injuries were negatively associated with any type of neurological recovery, except motor level lowering. Although sensorimotor complete injuries as well as thoracolumbar injuries negatively influence neurological recovery, early surgical decompression (< 24 h) appears independently associated with enhanced neurological recovery in patients with traumatic spinal cord injury despite level and severity of injury.

Sensory sparing does not change long-term outcomes in motor complete spinal cord injuries

BACKGROUND CONTEXTIn the acute postinjury setting, the prognostic value of sensory sparing among motor complete spinal injury patients has been well demonstrated. However, once final AIS grade is achieved 1 year postinjury, the value of sensory sparing alone has not been elucidated. We hypothesized that sensory sparing would lead to better outcomes in AIS B over AIS A patients at long-term, postrecovery follow-up. PURPOSETo evaluate for differences in medical, Physical and Social outcomes between AIS A and B patients at least 1 year postinjury. STUDY DESIGNRetrospective Cohort. PATIENT SAMPLEAdults over the age of 18 with AIS A or B spinal cord injury sustained between January 1, 1995 and September 13, 2019. Data Collected from the Spinal Cord Injury Model Systems Database. OUTCOME MEASURESSelf-reported Measures: PHQ-9 score; SCI-QOL Resilience Short Form score; VAS pain score; Life Satisfaction Score; Self-reported depression and sleep disturbances.Physiologic Measures: Body Mass Index, Diabetes Mellitus, Hypertension, Hyperlipidemia, Mortality, Incidence of Pressure Sores.Functional Measures: Bowel and Bladder Management; Illicit Substance use; Level of Education; Marital Status; Rehospitalization Rate. METHODSPatient data from the Spinal Cord Injury Model Systems Database were extracted for patients with a final, recovered American Spinal Injury Association Impairment Scale (AIS) grade of A or B at 1-year postinjury. Variables related to physical, mental and social functioning were compared between the two groups. RESULTSA total of 2,562 AIS A and 675 AIS B patient met inclusion criteria. Occurrence of pressure ulcers was 7% less in AIS B versus A (34.5% vs. 41.9%, p=.003). There were no statistical differences between groups in pain, bowel or bladder accidents, urinary tract infections, or the level of assistance for bowel or bladder management. There was no statistical difference for PHQ-9 depression scores, SCI-QOL Resilience Scores, rates of suicidality or sleep disturbance. There was no difference for illicit drug or alcohol abuse, life satisfaction scores, perceived health, and marriage or divorce rates. CONCLUSIONSExcept for a 7% reduction in pressure ulcer occurrence, there is no apparent long-term outcome advantage for motor complete spinal cord injury patients with AIS B sensory sparing over AIS A sensory complete. All other physical function domains were not different, nor were mental and social outcomes.

Finding the Way to Improve Motor Recovery of Patients with Spinal Cord Lesions: A Case-Control Pilot Study on a Novel Neuromodulation Approach

Robot-assisted rehabilitation (RAR) and non-invasive brain stimulation (NIBS) are interventions that, both individually and combined, can significantly enhance motor performance after spinal cord injury (SCI). We sought to determine whether repetitive transcranial magnetic stimulation (rTMS) combined with active transvertebral direct current stimulation (tvDCS) (namely, NIBS) in association with RAR (RAR + NIBS) improves lower extremity motor function more than RAR alone in subjects with motor incomplete SCI (iSCI). Fifteen adults with iSCI received one daily session of RAR+NIBS in the early afternoon, six sessions weekly, for eight consecutive weeks. Outcome measures included the 6 min walk test (6MWT), the 10 m walk test (10MWT), the timed up and go (TUG) to test mobility and balance, the Walking Index for Spinal Cord Injury (WISCI II), the Functional Independence Measure-Locomotion (FIM-L), the manual muscle testing for lower extremity motor score (LEMS), the modified Ashworth scale for lower limbs (MAS), and the visual analog scale (VAS) for pain. The data of these subjects were compared with those of 20 individuals matched for clinical and demographic features who previously received the same amount or RAR without NIBS (RAR − NIBS). All patients completed the trial, and none reported any side effects either during or following the training. The 10MWT improved in both groups, but the increase was significantly greater following RAR + NIBS than RAR − NIBS. The same occurred for the FIM-L, LEMS, and WISCI II. No significant differences were appreciable concerning the 6MWT and TUG. Conversely, RAR − NIBS outperformed RAR + NIBS regarding the MAS and VAS. Pairing tvDCS with rTMS during RAR can improve lower extremity motor function more than RAR alone can do. Future research with a larger sample size is recommended to determine longer-term effects on motor function and activities of daily living.

Improving Upper Extremity Strength, Function, and Trunk Stability Using Wide-Pulse Functional Electrical Stimulation in Combination With Functional Task-Specific Practice.

To evaluate upper extremity (UE) function, strength, and dynamic sitting balance in individuals with spinal cord injury (SCI) who received an intensive outpatient therapy program focused on UE training augmented with wide pulse/high frequency functional electrical stimulation (WPHF-FES). This prospective case series was conducted in an outpatient (OP) clinic in an SCI-specific rehabilitation hospital. Participants were a convenience sample (N = 50) of individuals with tetraplegia receiving OP therapy focused on UE recovery. Individuals participated in 60 minutes of UE functional task-specific practice (FTP) in combination with WPHF-FES 5 times/week for an average of 72 sessions. The primary outcome for this analysis was the Capabilities of Upper Extremity Test (CUE-T). Secondary outcomes include UE motor score (UEMS) and the modified functional reach (MFR). Fifty individuals (13 motor complete; 37 motor incomplete SCI) completed an OP UE training program incorporating WPHF-FES and were included in this analysis. On average, participants demonstrated significant improvements in the total CUE-T score of 14.1 (SD = 10.0, p < .0001) points; significant changes were also noted in UEMS and MFR, improving an average of 4.6 (SD = 5.2, p < .0001) points and 13.6 (SD = 15.8, p < .0001) cm, respectively. Individuals with tetraplegia demonstrated significant improvements in UE strength, function, and dynamic sitting trunk balance after receiving UE training augmented with WPHF-FES. Future comparative effectiveness studies need to be completed to guide efficacious treatment interventions in OP therapy.

Acute Ultrasonographic Changes in Lower Extremity Muscle Structure after Motor Complete Spinal Cord Injury.

There is a lack of studies examining ultrasonographic muscle changes in patients with acute spinal cord injury (SCI). We recruited adults with motor complete acute SCI and performed longitudinal ultrasound measurements. The primary outcome measures were rectus femoris and medial gastrocnemius thickness and echo intensity. This study recruited 20 patients, with a mean time to the first ultrasound measurement of 17.2 ± 2.14 days, with the second measurement done 4 weeks after the first measurement. We found that there was a mean decrease in the rectus femoris muscle thickness of 18.7% (P = 0.027), as well as a mean increase in the rectus femoris echo intensity of 13.0 a.u. (P = 0.009), although no significant differences were found for the medial gastrocnemius. This study demonstrates decreased thickness and increased echo intensity in the rectus femoris but not in the medial gastrocnemius in patients with motor complete SCI.