Motor Complete Spinal Cord Injury Research Articles

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.

Multisite Transcutaneous Spinal Stimulation for Walking and Autonomic Recovery in Motor-Incomplete Tetraplegia: A Single-Subject Design.

ObjectiveThis study investigated the effect of cervical and lumbar transcutaneous spinal cord stimulation (tSCS) combined with intensive training to improve walking and autonomic function after chronic spinal cord injury (SCI).MethodsTwo 64-year-old men with chronic motor incomplete cervical SCI participated in this single-subject design study. They each underwent 2 months of intensive locomotor training and 2 months of multisite cervical and lumbosacral tSCS paired with intensive locomotor training.ResultsThe improvement in 6-Minute Walk Test distance after 2 months of tSCS with intensive training was threefold greater than after locomotor training alone. Both participants improved balance ability measured by the Berg Balance Scale and increased their ability to engage in daily home exercises. Gait analysis demonstrated increased step length for each individual. Both participants experienced improved sensation and bowel function, and 1 participant eliminated the need for intermittent catheterization after the stimulation phase of the study.ConclusionThese results suggest that noninvasive spinal cord stimulation might promote recovery of locomotor and autonomic functions beyond traditional gait training in people with chronic incomplete cervical SCI.ImpactMultisite transcutaneous spinal stimulation may induce neuroplasticity of the spinal networks and confer functional benefits following chronic cervical SCI.

Trunk muscle activity and kinematics during boxing and battle rope exercise in people with motor-complete spinal cord injury

Context Recovery of seated balance is a rehabilitation priority for people with motor-complete spinal cord injury (mcSCI). Previous research has demonstrated that people with mcSCI can voluntarily engage their trunk muscles during different exercise programs that have the potential to improve seated balance control. Boxing and battle rope exercises could offer another opportunity to improve seated balance for people with mcSCI, but it is unknown if this type of exercise engages trunk musculature and challenges seated balance. Objective To describe the movement patterns of people with mcSCI compared to controls by characterizing the muscle activation patterns and kinematics of the trunk and upper-body during boxing and battle rope exercise. Design Cross-sectional study. Participants 4 males with mcSCI between C7-T9, and 4 able-bodied controls. Methods Participants performed different boxing and battle rope exercises while kinematics and electromyography (EMG) from the trunk and arms were recorded. Outcome Measures Trunk EMG amplitude, trunk and arm joint angles, and trunk curvature. Results Boxing and battle ropes elicited higher relative EMG activity in people with mcSCI compared to controls (P < 0.001). Participants with mcSCI had similar upper-limb kinematics during the exercises to controls, but demonstrated reduced trunk rotation and increased trunk curvature. Conclusions These findings suggest that boxing and battle rope can elicit trunk activity in people with mcSCI, though they may adopt increased trunk curvatures. Future research should explore if such exercise programs may improve seated balance in people with mcSCI.

Spinal cord imaging markers and recovery of standing with epidural stimulation in individuals with clinically motor complete spinal cord injury.

Spinal cord epidural stimulation (scES) is an intervention to restore motor function in those with severe spinal cord injury (SCI). Spinal cord lesion characteristics assessed via magnetic resonance imaging (MRI) may contribute to understand motor recovery. This study assessed relationships between standing ability with scES and spared spinal cord tissue characteristics at the lesion site. We hypothesized that the amount of lateral spared cord tissue would be related to independent extension in the ipsilateral lower limb. Eleven individuals with chronic, clinically motor complete SCI underwent spinal cord MRI, and were subsequently implanted with scES. Standing ability and lower limb activation patterns were assessed during an overground standing experiment with scES. This assessment occurred prior to any activity-based intervention with scES. Lesion hyperintensity was segmented from T2 axial images, and template-based analysis was used to estimate spared tissue in anterior, posterior, right, and left spinal cord regions. Regression analysis was used to assess relationships between imaging and standing outcomes. Total volume of spared tissue was related to left (p = 0.007), right (p = 0.005), and bilateral (p = 0.011) lower limb extension. Spared tissue in the left cord region was related to left lower limb extension (p = 0.019). A positive trend (p = 0.138) was also observed between right spared cord tissue and right lower limb extension. In this study, MRI measures of spared spinal cord tissue were significantly related to standing outcomes with scES. These preliminary results warrant future investigation of roles of supraspinal input and MRI-detected spared spinal cord tissue on lower limb motor responsiveness to scES.

Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis

The optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown. To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury. This multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020. Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment. The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury. Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment). Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, -4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients). These findings suggest that among patients with cervical SCI, early surgical treatment produced similar motor regain at 1 year after injury as delayed surgical treatment but showed accelerated recovery within the first 6 months. These exploratory results suggest that early surgical treatment leads to faster neurological recovery, which requires further validation. ClinicalTrials.gov Identifier: NCT01485458; umin.ac.jp/ctr Identifier: UMIN000006780.

A new balance assessment tool for quantifying balance impairment in patients with motor incomplete spinal cord injury: Pilot study

Objective: This study aimed to quantitatively and objectively evaluate the balance impairment in patients with motor incomplete spinal cord injury (SCI) using a new evaluation tool for balance and to assess its role in comprehensive balance assessment. Design: Retrospective pilot study. Setting: Rehabilitation hospital. Participants: 14 patients with motor incomplete spinal cord injury Interventions: None Outcome Measures: We retrospectively compared and analyzed the results of 14 patients with motor incomplete SCI who underwent various balance assessments, including the FRA510S test, using correlation. Results: The agreement between the FRA510S and existing balance assessment was confirmed through Bland–Altman plots; moreover, high degree of agreement was observed in Berg Balance Scale in the eye closed state and in Five Times Sit-to-Stand Test in the eye open state. Conclusions: It was confirmed that the FRA510S equipment provides quantitative values for balance function. Balance assessment using the FRA510S, along with neurological, electrophysiological, and clinical tests, may provide comprehensive additional information related to falls and gait rehabilitation in patients with SCI.

Voluntary Modulation of Evoked Responses Generated by Epidural and Transcutaneous Spinal Stimulation in Humans with Spinal Cord Injury.

Transcutaneous (TSS) and epidural spinal stimulation (ESS) are electrophysiological techniques that have been used to investigate the interactions between exogenous electrical stimuli and spinal sensorimotor networks that integrate descending motor signals with afferent inputs from the periphery during motor tasks such as standing and stepping. Recently, pilot-phase clinical trials using ESS and TSS have demonstrated restoration of motor functions that were previously lost due to spinal cord injury (SCI). However, the spinal network interactions that occur in response to TSS or ESS pulses with spared descending connections across the site of SCI have yet to be characterized. Therefore, we examined the effects of delivering TSS or ESS pulses to the lumbosacral spinal cord in nine individuals with chronic SCI. During low-frequency stimulation, participants were instructed to relax or attempt maximum voluntary contraction to perform full leg flexion while supine. We observed similar lower-extremity neuromusculature activation during TSS and ESS when performed in the same participants while instructed to relax. Interestingly, when participants were instructed to attempt lower-extremity muscle contractions, both TSS- and ESS-evoked motor responses were significantly inhibited across all muscles. Participants with clinically complete SCI tested with ESS and participants with clinically incomplete SCI tested with TSS demonstrated greater ability to modulate evoked responses than participants with motor complete SCI tested with TSS, although this was not statistically significant due to a low number of subjects in each subgroup. These results suggest that descending commands combined with spinal stimulation may increase activity of inhibitory interneuronal circuitry within spinal sensorimotor networks in individuals with SCI, which may be relevant in the context of regaining functional motor outcomes.

Epidural spinal cord stimulation as an intervention for motor recovery after motor complete spinal cord injury.

Spinal cord injury (SCI) commonly results in permanent loss of motor, sensory, and autonomic function. Recent clinical studies have shown that epidural spinal cord stimulation may provide a beneficial adjunct for restoring lower extremity and other neurological functions. Herein, we review the recent clinical advances of lumbosacral epidural stimulation for restoration of sensorimotor function in individuals with motor complete SCI and we discuss the putative neural pathways involved in this promising neurorehabilitative approach. We focus on three main sections: review recent clinical results for locomotor restoration in complete SCI; discuss the contemporary understanding of electrical neuromodulation and signal transduction pathways involved in spinal locomotor networks; and review current challenges of motor system modulation and future directions toward integrative neurorestoration. The current understanding is that initial depolarization occurs at the level of large diameter dorsal root proprioceptive afferents that when integrated with interneuronal and latent residual supraspinal translesional connections can recruit locomotor centers and augment downstream motor units. Spinal epidural stimulation can initiate excitability changes in spinal networks and supraspinal networks. Different stimulation parameters can facilitate standing or stepping, and it may also have potential for augmenting myriad other sensorimotor and autonomic functions. More comprehensive investigation of the mechanisms that mediate the transformation of dysfunctional spinal networks to higher functional states with a greater focus on integrated systems-based control system may reveal the key mechanisms underlying neurological augmentation and motor restoration after severe paralysis.

A comparison of one year outcomes between standardized locomotor training and usual care after motor incomplete spinal cord injury: Community participation, quality of life and re-hospitalization

Context/Objective Spinal cord injury (SCI) often results in a significant loss of mobility and independence coinciding with reports of decreased quality of life (QOL), community participation, and medical complications often requiring re-hospitalization. Locomotor training (LT), the repetition of stepping-like patterning has shown beneficial effects for improving walking ability after motor incomplete SCI, but the potential impact of LT on psychosocial outcomes has not been well-established. The purpose of this study was to evaluate one year QOL, community participation and re-hospitalization outcomes between individuals who participated in a standardized LT program and those who received usual care (UC). Design/Setting/Participants A retrospective (nested case/control) analysis was completed using SCI Model Systems (SCIMS) data comparing one year post-injury outcomes between individuals with traumatic motor incomplete SCI who participated in standardized LT to those who received UC. Outcome Measures Outcomes compared include the following: Satisfaction with Life Scale (SWLS™), Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF™), and whether or not an individual was re-hospitalized during the first year of injury. Results Statistically significant improvements for the LT group were found in the following outcomes: SWLS (P = 0.019); and CHART subscales [mobility (P = <0.001)]; occupation (P = 0.028); with small to medium effects sizes. Conclusion Individuals who completed a standardized LT intervention reported greater improvements in satisfaction with life, community participation, and fewer re-hospitalizations at one year post-injury in comparison to those who received UC. Future randomized controlled trials are needed to verify these findings.

Associations between upper extremity functioning and kinematics in people with spinal cord injury

IntroductionMore knowledge of the relationships between kinematic measures and clinical assessments is required to guide clinical decision making and future research.ObjectivesTo determine which kinematic variables obtained during a drinking task were associated with clinical assessments of upper extremity functioning in people with spinal cord injury (SCI).MethodsIn total, 25 individuals with chronic cervical (n = 17) or thoracic (n = 8) complete (n = 14) or motor incomplete (n = 11) SCI (mean age 58.4, SD 13.8) were included. Kinematic data, including movement time, smoothness and joint angles was captured with a 5-camera optoelectronic system during a unimanual drinking task. Action Research Arm Test (ARAT), Sollerman Hand Function Test (SHFT) and basic hand classification of the Upper Extremity Data Set (ISCI-Hand) were used as clinical assessments. Multiple regression analysis was used to identify kinematic variables associated with clinical assessments after controlling for potential confounding factors, such as, age, severity of SCI, sensory function, and hand surgery.ResultsMovement time, smoothness and movement pattern kinematics including trunk displacement, elbow and wrist joint angles were correlated (p < 0.05) with all three clinical scales while the velocity-related kinematics and inter-joint coordination showed low correlations. Multiple regression analysis revealed that wrist angle combined with movement time or smoothness explained 82% and 77% of the total variance in ARAT and SHFT, respectively. Wrist angle alone explained 59% of the variance in ISCI-Hand. The proprioception of the hand increased the explanatory power in the models of ARAT and SHFT. Associations between kinematics and clinical assessments in the subgroup with cervical SCI were equivalent to the whole group analyses. The number of participants in the subgroup with thoracic SCI was small and only allowed limited analysis.ConclusionsWrist angle, movement time, movement smoothness are the most important kinematic variables associated with upper extremity clinical assessments in people with SCI. The results are most valid for individuals with cervical SCI. All three assessments are appropriate for SCI. Further research with larger representative sample of thoracic SCI needed.