Tetraplegia Research Articles

Nothing is Impossible: Reflections on a New Life

Falling from a horse in 1995 left Christopher Reeve quadriplegic, dependent on a ventilator. He wanted to be on his feet by his 50th birthday (in September 2002), and although he has not achieved this goal he has made remarkable progress. Nothing is Impossible is not a confessional nor a diary but simply a collection of Reeves thoughts and opinions. The focus of the book is the potential for all of us to transcend our limitations, both internal and external, and not just to accept difficulties and problems …

Persons with C5 or C6 tetraplegia achieve selected functional gains using a neuroprosthesis

Alon G, McBride K. Persons with C5 or C6 tetraplegia achieve selected functional gains using a neuroprosthesis. Arch Phys Med Rehabil 2003;84:119-24. Objective: To test the efficacy and safety of the NESS Handmaster[trade ] neuroprosthesis with subjects with C5 or C6 tetraplegia. Design: Interventional, nonrandomized case series. Setting: Subjects' residence and university research laboratory. Participants: Men, 3 to 17 years after C5 (n=5) and C6 (n=2) spinal cord injury (SCI). Intervention: Subjects practiced with the neuroprosthesis daily to regain grasp, hold, and release ability and to restore selected functions of 1 of the 2 paralyzed hands. Subjects were observed 2 to 3 times weekly for 3 weeks. Main Outcome Measures: Three activities of daily living (ADL) tasks: (1) pick up a telephone, (2) eat food with a fork, and (3) perform 1 individually selected ADL task and 2 grasp, hold, and release tasks (lift a videocassette, lift a 150-g weight). Secondary outcomes were grip strength, electrically induced finger motion, and Fugl-Meyer spherical grasp. Nonparametric data were analyzed with the Wilcoxon signed-rank test, and parametric data (grip strength and finger motion) were analyzed by analysis of variance. All tests were considered significant at P equal to .01. Results: At study completion, all 7 subjects were 100% successful at using the Handmaster in the studied ADL and grasp, hold, and release tasks. Significant improvements occurred in grip strength (from .57[plusmn].98N at baseline to 16.5[plusmn]4.4N), finger linear motion (from 0.0cm at baseline to 8.4[plusmn]3.2cm), and Fugl-Meyer scores. No safety issues were encountered. Six of 7 subjects rated their overall performance as [ldquo ]excellent.[rdquo ] Conclusions: The Handmaster is a safe, noninvasive neuroprosthesis that improves hand function of selected subjects with C5 or C6 SCI. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Ｃ５頚髄損傷患者に対する新しい電動式把持装具の試み

The patient, a 34-year-old male, was admitted to our hospital for comprehensive rehabilitation 18 months after traumatic spinal cord injury. He was a complete C5 tetraplegia. Although he could drive a wheel chair using his right shoulder, his activity of daily living was severely restricted due to loss of pinch function. He could not switch from a spoon to a fork properly by himself at a meal, nor could he pick up a cup to drink water. He always needed a caregiver nearby him to provide care. Because of these embarrassments, he eagerly wanted to restore his pinch function. In the past, several orthoses have been developed for restoring the pinch function in spinal cord injury. However, these have not been widely used because of high cost and heavy weight. To overcome these difficulties, we developed a new electric flexor hinge splint using a commercially available motor, which is low cost and lightweight. He could use this orthosis easily and safely after relatively short training, and his activity of daily living was markedly improved with this orthosis.

The effect of level of spinal cord injury on shoulder joint kinetics during manual wheelchair propulsion

Objective. The effects of spinal cord injury level on shoulder kinetics during manual wheelchair propulsion were studied. Design. Single session data collection in a laboratory environment. Methods. Male subjects were divided into four groups: low level paraplegia ( n=17), high level paraplegia ( n=19), C7 tetraplegia (C7, n=16) and C6 tetraplegia (C6, n=17). Measurements were recorded using a six-camera VICON motion analysis system, a strain gauge instrumented wheel, and wheelchair ergometer. Shoulder joint forces and moments were calculated using the inverse dynamics approach. Results. Mean self-selected propulsion velocity was higher in the paraplegic (low paraplegia=90.7 m/min; high paraplegia=83.4 m/min) than tetraplegic (C7=66.5 m/min; C6=47.0 m/min) groups. After covarying for velocity, no significant differences in shoulder joint moments were identified. However, superior push force in subjects with tetraplegia (C7=21.4 N; C6=9.3 N) was significantly higher than in those with high paraplegia (7.3 N), after covarying velocity. Conclusions. The superior push force in the tetraplegic groups coupled with weakness of thoraco-humeral depressors increases susceptibility of the subacromial structures to compression. Relevance Increased vertical force at the shoulder joint, coupled with reduced shoulder depressor strength, may contribute to shoulder problems in subjects with tetraplegia. Wheelchair design modifications, combined with strength and endurance retention, should be considered to prevent shoulder pain development.

Simulation of acute spinal cord injury: effects on respiration

The respiratory effects of acute spinal injury and paralysis are difficult to study. Urgent medical needs of human spinal cord injury victims usually preclude study, while induction of spinal cord lesions in awake animals is not feasible ethically. We utilized controlled, segmental infusion of epidural anesthetic in awake, highly trained, implanted canines to reversibly simulate the effects of thoracic and cervical (paraplegic and quadriplegic) spinal cord injury. We studied six animals, an average of 29 days after implantation with electromyogram and sonomicrometry transducers in transversus abdominis, external intercostal, parasternal intercostal and costal diaphragm muscles. Anesthetic was infused through an epidural catheter inserted percutaneously, under fluoroscopic guidance. Asymmetrical motor blockade was prevented using repositioning during epidural infusions. By sequential infusion we were able to induce three distinct, functional levels of spinal paralysis showing cumulative paralysis of abdominal, external intercostal, and parasternal intercostal muscles. Paralysis of the abdomen and chest wall, sparing only the diaphragm, showed unexpected bradypnea and failure to maintain minute ventilation.

Effect of elbow flexion contractures on the ability of people with C5 and C6 tetraplegia to lift.

It is commonly assumed that minor elbow flexion contractures prevent people with C5-C6 tetraplegia and paralysis of the triceps brachii muscles from bearing full body weight through their upper limbs. The aim of the present study was to determine the effect of simulated bilateral elbow flexion contractures on the ability of these individuals to bear weight through their upper limbs and to determine whether full passive elbow extension is truly critical for lifting body weight. A biomechanical study was performed. Body weight lifted was measured under conditions that simulated bilateral elbow flexion contractures. Five people with motor complete C6 tetraplegia and one person with motor complete C5 tetraplegia, all with bilateral paralysis of the triceps brachii muscles, were recruited to the study. Subjects were fitted with bilateral elbow splints that restricted elbow extension but did not restrain elbow flexion nor prevent the elbow from collapsing, and were seated on an instrumented platform that measured vertical forces under the buttocks. Subjects pushed down through their hands and lifted under five different conditions, namely: with no elbow splints; with bilateral elbow splints adjusted to restrict elbow extension by 5-10 degrees; by 15-20 degrees; by 25-30 degrees and with bilateral elbow splints adjusted to allow unrestricted movement of the elbow joint. Maximal weight lifted from under the buttocks, for each condition, was expressed in relation to weight under the buttocks during unsupported sitting (that is, 'seated body weight'). Subjects lifted progressively less weight from under their buttocks as passive elbow restriction was progressively restricted. However, one subject lifted all his seated body weight when elbow extension was restricted by 5-10 degrees and another lifted all his seated body weight when elbow extension was restricted by 5-10 degrees and 15-20 degrees. Minor elbow flexion contractures will not alone prevent people with tetraplegia and paralysis of the triceps brachii muscles from lifting. Full passive elbow extension is not critical for the performance of this task.

Sitting position - posture and performance in C5 - C6 tetraplegia.

To investigate how sitting position and seating affect posture and performance (balance, transfers, wheelchair skills, physical strain during wheelchair propulsion, spasticity and respiration) in persons with C5 and C6 tetraplegia. Outpatient clinic 'Spinalhälsan', Göteborg, Sweden. Baseline measurements of sitting position and performance were performed followed by an intervention period. The intervention was individually adapted to each person with emphasis on reduction of kyphotic posture and pelvic obliquity. Furthermore, a functional requirement was that the new sitting position was used in everyday life and did not impair balance, transfers, wheelchair skills, physical strain during wheelchair propulsion, spasticity and respiration. Four persons with complete C5 - C6 tetraplegia who reported dissatisfaction with posture and seating took part in the study. A comparison of photographs before and after the intervention showed a reduction of kyphotic posture and pelvic obliquity. Balance, transfers, wheelchair skills, physical strain during wheelchair propulsion, spasticity and respiration were affected by the sitting position in an individual manner. Solution of problems concerning sitting and posture for persons with C5 - C6 tetraplegia requires good knowledge of the physical impairment, wheelchair adaptation, seating systems and cushions as well as an understanding of the individual's demands and wishes. Due to the complexity of the issue, standard solutions are not applicable. Thus, an analytical working method is required and co-operation between professionals - occupational therapists and physiotherapists - is important.

EMG-based prediction of shoulder and elbow kinematics in able-bodied and spinal cord injured individuals.

We have evaluated the ability of a time-delayed artificial neural network (TDANN) to predict shoulder and elbow motions using only electromyographic (EMG) signals recorded from six shoulder and elbow muscles as inputs, both in able-bodied subjects and in subjects with tetraplegia arising from C5 spinal cord injury. For able-bodied subjects, all four joint angles (elbow flexion-extension and shoulder horizontal flexion-extension, elevation-depression, and internal-external rotation) were predicted with average root-mean-square (rms) errors of less than 20 degrees during movements of widely different complexities performed at different speeds and with different hand loads. The corresponding angular velocities and angular accelerations were predicted with even lower relative errors. For individuals with C5 tetraplegia, the absolute rms errors of the joint angles, velocities, and accelerations were actually smaller than for able-bodied subjects, but the relative errors were similar when the smaller movement ranges of the C5 subjects were taken into account. These results indicate that the EMG signals from shoulder and elbow muscles contain a significant amount of information about arm moVement kinematics that could be exploited to develop advanced control systems for augmenting or restoring shoulder and elbow movements to individuals with tetraplegia using functional neuromuscular stimulation of paralyzed muscles.

Neuromuscular function and radioanatomical form of the myelomeningocele hip.

The aim of this study was to describe variants in neuromuscular function and radioanatomical form of the myelomeningocele hip based on the level of spinal paralysis. For this purpose, 84 hip joints of 44 children with myelomeningocele age 1 to 10.75 years were classified into five spinal paralysis groups. Using anteroposterior pelvic radiographs, the position of the capital epiphysis, represented by the epiphyseal angle, and the position of the greater trochanter apophysis, represented by the apophyseal angle, were evaluated. The epiphyseal angle of the five paralysis groups showed three categories of average values. The thoracic/thoracolumbar group had an average of 0 degree, groups 2 (distal L1/L2) and 3 (distal L3/L4) had average values of 5 degrees to 6 degrees, and groups 4 (distal L5) and 5 (distal S1) had average values of 13 degrees to 14 degrees. The average values of the apophyseal angle showed a characteristic curve: the values dropped from group 1 (67 degrees) to groups 2 (45 degrees) and 3 (34 degrees) and then rose in groups 4 (44 degrees) and 5 (52 degrees). The authors concluded that the insufficiency of the hip abductors leads to a reduction of the epiphysis angle, and the relative insufficiency of the small glutei compared with the knee extensors leads to a reduction of the apophysis angle.

Three surgical cases of spinal paralysis caused by metastasis of prostate cancer

Three surgical cases of spinal paralysis caused by metastasis of prostate cancer

An Analysis of Tetraplegic Hand Grips

To investigate the aspects involved in using the hands successfully to grasp an object, 30 British people with complete C6, C7 or C8 tetraplegia who had been injured for more than 12 months were divided into three groups according to their level of injury. The results indicated differences between the participants depending on their level of injury in the types of pre-grip preparation used, whether one or both hands were used and the speed with which a subtest was completed. These were considered intrinsic to the successful use of the hands when grasping objects. It is suggested that the aspects identified in this research could be used to formulate guidelines to be used by clients and therapists within a tetraplegic hand rehabilitation programme.

Making Freehand® their hand: the role of occupational therapy in implementing FES in tetraplegia

For persons with tetraplegia, improvements in function and independence are promoted by augmenting residual hand function. Assistive technology offers ways to enhance independence through enabling activities of daily living (ADL) performance. Splints and adaptive aids have traditionally been used to address functional hand deficits in persons with tetraplegia secondary to spinal injury. The Freehand System©R offers a brace free alternative for persons with C5 or C6 tetraplegia. By employing functional electrical stimulation (FES), The Freehand System©R provides stimulated grasp and release to paralyzed muscles of the hand. Occupational therapy plays an important role in assessment and implementation of the Freehand System. Clinical reasoning is used to develop a comprehensive plan for surgical planning, rehabilitation and functional training to meet individual needs. Training incorporates education on operation and care of the system and functional application toward valued ADL. Research with the Freehand system is ongoing. Clinical trials of the Freehand system with both adult and adolescent subjects have demonstrated measurable improvement in pinch force, hand function and level of independence in ADL [9,12]. Current focus of research by occupational therapists with the Freehand system has been the examination of home use and user satisfaction.

The applied neuropathology of human spinal cord injury.

The timeliness of a review of the neuropathology ofhuman spinal cord injury (SCI) centres on theincreasing interest in central axonal regeneration inthe search for a ‘cure’ of spinal paralysis. Neuropathol-ogy contributes to this end by describing the nature ofthe disorder to be cured. More broadly a knowledge ofthe neuropathology underlying SCI is essential also forthe clinician responsible for management of the patientas well as the neuroscientist working on SCI. There hasbeen spectacular progress in neurobiology in recentyears with CNS repair and regeneration now reportedby many centres. However, in order for thesediscoveries to be applied to human SCI an apprecia-tion of the neuropathology is required. The neurobiol-ogist must be aware of the nature of the condition tobe cured for the research to be relevant. Furthermore,before the experimental findings may be applied to thepatient it must be shown that the reactions to injuryare comparable in each. An outline of recent advancesin the neurobiology of experimental SCI is thereforeincluded in this review in order to bridge the gapbetween human SCI and the experimental models.Most importantly the insight provided by the complex-ity of the problem of finding a cure serves to informthose waiting for this to occur to be realistic in theirexpectations.

CERVICAL SPONDYLITIS AND EPIDURAL ABSCESS CAUSED BY SALMONELLA ENTERITIDIS WITH TETRAPLEGIA

CERVICAL SPONDYLITIS AND EPIDURAL ABSCESS CAUSED BY SALMONELLA ENTERITIDIS WITH TETRAPLEGIA

The Clinical Application of Clean Intermittent Self-catheterization

Clean intermittent self-catheterization (CISC) can be performed to manage acute or chronic bladder dysfunction. It is a safe and simple technique that may improve the quality of life in patients with urinary incontinence or urinative dysfunction because of a neuropathic or atonic bladder. However, some patients who are indicated for CISC may not have the opportunity to try self-catheterization because their doctors are not familiar with the procedure. The upper urinary tract function often gradually worsens in the hyper-reflexia neurogenic bladder. Whether CISC can alleviate urinary dysfunction was the subject of this study. To elucidate the practical value of CISC, we report here our preliminary experience on using this procedure on patients with urinary dysfunction due to various etiologies. From April 1995 through June 1997, 56 consecutive in-patients from our hospital who suffered from bladder dysfunction were enrolled in this study. All the patients who were admitted to the training program satisfactorily passed, with none of them withdrawn due to intolerance of the procedure. Four patients got mild urinary tract infection (UTI) and needed oral antibiotics during the follow-up period. Five patients with cervical spine injury and quadriplegia got rid of their long-term UTI by replacing the catheterization to CISC. All the patients with detrusor muscle failure showed improvement in their urinative function after a period of CISC. One of the two patients with myelomeningocele recovered from renal insufficiency after CISC. The other patient, however, finally required continuous hemodialysis. There was no renal function deterioration in patients with hyperreflexia. In conclusion, CISC is a safe, simple, and useful technique to releive urinary dysfuntion, it should be considered in both hospital-care and home-care programs.

Assessing the knowledge of future internists and gynecologists in caring for a woman with tetraplegia

Objective: To assess the knowledge base and comfort level of potential physician “gatekeepers” when treating women with spinal cord injuries. Residents with at least 1 year of training in either internal medicine (IM) or obstetrics and gynecology (Ob/Gyn) from a large academic urban medical center were surveyed. Study Design: This study used a written questionnaire that included a case scenario of a young woman with C6 tetraplegia who presented to her primary care physician for a routine visit. Information about the patient from her history and physical and laboratory exams was presented in stages, followed by open-ended queries to elicit information about the residents' problem-solving processes and management strategies. Results: Thirty-eight percent (30 of 79) of the IM residents and 64% (14 of 22) of the Ob/Gyn residents completed the questionnaire. Significant deficits in knowledge about physical accessibility, spasticity management, and potential disability-related medical complications in pregnancy were found. More Ob/Gyn residents were aware of the risk of autonomic hyperreflexia than IM residents, whereas the IM residents demonstrated greater awareness of neurogenic bladder and skin problems. Both groups indicated they were not very comfortable in managing the patient's care. Conclusions: The results raise concern about the adequacy of the training of primary care physicians to meet the needs of people with severe disabilities.

Myelodysplasia in adult life: the value of an outreach nursing service.

In the state of South Australia, infants with myelodysplasia have been treated by early intervention since 1963, and the majority have survived. Many are now adults, leading active lives despite having severe disabilities. A pilot study confirmed that this population has a high incidence of preventable ill health because of recurrent urinary infections, renal damage, and pressure ulcers. Many of these complications can be prevented by an outreach nursing service aimed at providing education in self-care, counseling, advocacy, and other appropriate nursing interventions, thus allowing clients to avoid hospitalization and maintain their independence. The study also showed that many clients were unaware of important social benefits, the knowledge of which should promote their financial independence. The outreach nursing service is an essential part of an integrated long-term support program for adults with myelodysplasia and other forms of congenital spinal paralysis.

An 88-year-old woman with tetraparesis after a fall.

An 88-year-old woman with tetraparesis after a fall.

Hyperthermia, rhabdomyolysis, and disseminated intravascular coagulation associated with baclofen pump catheter failure

A 29-year-old man with C6 tetraplegia (ASIA A) using an implanted baclofen pump and intrathecal catheter infusion system for spasticity control developed severe spasticity, hyperthermia, hypotension, rhabdomyolysis, and disseminated intravascular coagulation after catheter disconnection. Tracheal intubation and mechanical ventilation were necessary. Extensive workup for a concurrent infection was negative except for urine cultures. The patient remained febrile for 10 days despite empirical antibiotic trials. Administration of high-dose benzodiazepines was inadequate for spasticity control. Spasticity control and his clinical condition, including body temperature, did not improve until his catheter was surgically replaced and intrathecal baclofen administration was resumed. The pharmacopathology of abrupt baclofen withdrawal and the similarities between this presentation, sepsis, neuroleptic malignant syndrome, and malignant hyperthermia are discussed. High-dose dantrolene was not used; however, based on similarities between this patient's presentation and neuroleptic malignant syndrome, it may have been the drug of choice.

Rehabilitation of spinal cord injury in the national rehabilitation center for the disabled of Japan: profile of a spinal service.

The National Rehabilitation Center for the Disabled (hereunder abbreviated NRC) in Japan was established in 1979. It consists of four divisions: the hospital, the rehabilitation training center, the research institute, and the information service section. The spinal unit has been functioning and cooperating corelatively with all of these divisions. There were 1047 patients with a spinal cord injury treated in the 15 years from September, 1980 to August, 1994; consisting of 924 males (88.3%), and 123 females (11.7%). The breakdown of causes of injury were traffic accidents 44.9%, having a fall 14.7%, sports accidents 6.7%, and other causes of spinal paralysis 10.5%. The sites of the spinal cord lesions were cervical 372 (35.5%), thoracic 547 (52.5%), and lumbar spinal cord 128 patients (12.3%). The incidence of complete paralysis in those with a cervical spinal cord injury (SCI) was 68.8%, and for thoracic and lumbar SCI 79% each. The time for completion of activities of daily living (ADL) was 12.0 +/- 1.54 months in those with tetraplegia, and 5.6 +/- 1.71 months for those with paraplegia. The rate of employment for reentry into society was 59% in those with a cervical spinal cord injury, and 74% each in those with a thoracic or lumbar spinal cord injury.