Thoracic Level Paraplegics Research Articles

Bladder management practices in spinal cord injury patients: A single center experience from a developing country

Context/Objective: Inadequate bladder management in spinal cord injury (SCI) patients results in significant morbidity and even mortality. Clean intermittent catheterization (CIC) is the recommended option for SCI patients. The objective of the study was to document the bladder management practices of SCI patients in a developing country.Design: Questionnaire based cross sectional surveySetting: Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, PakistanParticipants: All patients with SCI (irrespective of duration, level and etiology)Interventions: Data documentation included demographics, level, severity and time since injury, bladder management techniques used, details of CIC, results of Urodynamic studies (if available), complications resulting from bladder management technique and patient awareness of the yearly follow up. SPSS V 20 was used for analysis.Outcome Measures: Not applicableResults: Thirty four consenting patients were enrolled. All were males. Mean age was 31.24 ± 10.9. Most (17) of the patients were thoracic level paraplegics, while 12 patients had sustained a cervical SCI. Majority (23) had complete injury (ASIA A). Fifteen patients used CIC for bladder management followed by in dwelling Foley catheters in thirteen patients. Those using CIC performed the procedure every four hours and used disposable catheters. The same ‘disposable’ catheter was used for 5-7 days by half of these patients. Only Six patients independently performed CIC. Three patients on CIC reported urinary tract infection.Conclusions: In the largest spinal rehabilitation unit of a developing country; Pakistan CIC was the preferred method of bladder management followed by indwelling catheter. Re-use of disposable catheters is a common practice due to cost issues. The rate of UTI was significantly lower in patients on CIC.

Walking with functional electrical stimulation and unlocking braces in thoracic-level paraplegia

Walking was tested in 4 people with thoracic-level paraplegia using stimulation of quadriceps muscles, the flexor reflex and unlocking knee-ankle-foot orthoses (KAFO). Heart rate, speed, distance, kinematics and ground reaction forces were measured while subjects walked using a walker. None of the subjects could walk without the system; all could walk continuously for at least 4 minutes with it. Joint angles and some other kinematic features resembled normal walking, but the walking was too slow (average speed: 3.8 m/min.) and too demanding (heart rate: 128 b/min; physiological cost index: 15 b/m) to be practical. Subjects supported about 1/3 of their weight with their arms during stance and about 2/3 during swing. Our results suggest that the braces reduced the effort needed and that the low speeds were due to both a lack of power at push-off and the time needed to stabilize the hip and trunk. The high heart rates arose from excessive contraction of the arm and trunk muscles for balance and propulsion.

Relation Between Muscular Strength and Cardiorespiratory Fitness in People With Thoracic-Level Paraplegia

Zoeller RF, Riechman SE, Dabayebeh IM, Goss FL, Robertson RJ, Jacobs PL. Relation between muscular strength and cardiorespiratory fitness in people with thoracic-level paraplegia. Objectives To determine the relation between muscular strength, aerobic power (V o 2peak), submaximal blood lactate accumulation, and endurance performance in people with thoracic-level paraplegia. Design Participants performed tests of isokinetic strength, a graded exercise test, and 2 endurance performance tests. A Latin square counterbalanced design was used to determine the order of testing. Setting Research laboratory in a university setting. Participants Ten adult male volunteers with thoracic-level paraplegia. Interventions Not applicable. Main Outcome Measures The relations between strength, V o 2peak, submaximal blood lactate accumulation, and endurance were determined by correlation analysis. Results Shoulder flexion strength correlated with V o 2peak and power output at V o 2peak. Shoulder strength accounted for 68.4% of the variation in performance time. Greater isokinetic elbow flexion and extension strength was associated with higher V̇ o 2 and power output at a blood lactate concentration of 4mmol/L (flexion) and with a greater power output at V o 2peak (extension). Conclusions These findings suggest that in this population, greater muscular strength is associated with greater aerobic power and endurance. Greater muscular strength could exert a positive influence on exercise performance by enabling higher levels of cardiorespiratory stress as the result of reduced or delayed local muscle fatigue.

Reliability Of Arm Wingate Anaerobic Testing In Persons With Complete Paraplegia

Background: Accurate, reliable assessment of upper extremity muscular power in persons with paraplegia caused by spinal cord injury (SCI) would provide an objective indication of their ability to generate the forces necessary for the performance of daily activities. Wingate Anaerobic Testing (WAnT) consists of a 30-second sprint test on a cycle ergometer and has been used widely in both athletic and research settings.Purpose: To examine test-retest reliability of arm WAnT performance in persons with complete SCI and paraplegia.Methods: Forty-three participants with thoracic-level paraplegia (T2 through T12) performed 2 trials of arm WAnT with 2 to 7 days between each trial. Testing was performed using a Monarch 834E ergometer with participants seated in their wheelchairs. Participants were directed to crank at maximal pace for 30 seconds against a resistance load equivalent to 3.5% of their body mass. The SMI OptoSensor 2000 system was used to determine values of peak power (Ppeak), mean power (Pmean), minimum power, and rate of fatigue, which were compared between trials using 1-way analysis of variance for repeated measures. Coeffi cients of determination (r2) were calculated between trials for Ppeak and Pmean.Results: No significant diffe rence was found between trials for any of the power output variables. Regression analysis ind icat ed that Ppeak and Pmean were closely associated between the 2 trials (r2= 0.92 and 0.94, respectively).Conclusion: Arm WAnT is a reliable measurement tool for the assessment of upper extremity muscular power in persons with complete paraplegia.

An overview of the state of the art of noninvasive FES for independent ambulation by thoracic level paraplegics

This paper is an overview of the status of transcutaneous noninvasive (unbraced) functional electrical stimulation (FES) for independent standing and for independent ambulation by traumatic spinal-cord injured (SCI) paraplegics with complete spinal cord lesions at the thoracic level. The paper discusses aspects of patient selection, patient training, system performance, ambulation range, medical benefits and psychological benefits. It also considers problems relating to system adoption and long term system use. Furthermore, the paper discusses the various aspects of transcutaneous noninvasive FES as compared with implanted FES systems for ambulation by thoracic level SCI patients. [Neurol Res 2002; 24: 431-442]

Stochastically-modulated stimulation to slow down muscle fatigue at stimulated sites in paraplegics using functional electrical stimulation for leg extension

This short communication is a preliminary report on a study concerning slowing down the rate of muscle fatigue when FES (Functional Electrical Stimulation) is applied for standing and walking by complete (traumatic) thoracic-level paraplegics. It is shown that randomly modulating the inter-pulse interval between FES pulses (which serve to trigger action potentials in the peripheral nerves concerned) re~lJlts in a significantly lower rate ofmuscle fatigue, as tested in a series ofleg extensions, when FES was applied at the quadriceps. Specifically, we report that the best results (longest durations of leg extension prior to onset of muscle-fatigue) were achieved with a ± 5 msec uniformly-distributed (pseudo-) white-noise modulation at a 42 msec inter-pulse interval (24 pulses per sec). These resulted in an average increase in duration of leg extension ofapproximately 37% in this pilot study, as compared with unmodulated (fixed-rate) trains ofFES pulses. This significant increase, even in a very preliminary study appears to merit careful further examination, since it may allow a possibly significant increase in standing duration and in walking range of paraplegics using FES for ambulation. [Neural Res 2000; 22: 703-704]

Adverse Urologic Consequences of Spinal Cord Resection at the Time of Kyphectomy: Value of Preoperative Urodynamic Evaluation

Four children with thoracic level paraplegia and severe myelokyphosis underwent distal spinal cord resection at the time of kyphectomy. All four children were continent before spinal cord resection and became incontinent immediately afterward. Two children in retrospect had preoperative urodynamics that showed intact innervation to the external sphincter, and two had no preoperative urodynamic studies. All four had evidence of lower urinary tract denervation on urodynamic studies performed after cord resection. The urologic and urodynamic consequences of spinal cord resection at the time of kyphectomy in children with myelodysplasia are reviewed. Resection of the distal spinal cord in thoracic level myelodysplasia may cause postoperative incontinence in some previously continent patients. Preoperative urodynamic evaluation and urologic consultation is recommended. If individual evaluation indicates that residual sacral function is beneficial to urologic management, kyphectomy without cord resection is preferable.

Ambulation by traumatic T4-12 paraplegics using functional neuromuscular stimulation

The review describes and discusses the status of the major approaches to functional neuromuscular stimulation (FNS) for the purpose of ambulation by traumatic complete thoracic-level paraplegics, namely, hybrid body bracing with FNS, percutaneous FNS, fully implanted FNS, and transcutaneous FNS. For each approach, the review discusses the system for which the most published user data are available and, where relevant, where the largest user population exists. The review covers methodologies and system descriptions. The Analysis sections of the review discuss ambulation performance, patient-training aspects, and, when available, multi-user medical, physiological, and psychological evaluation data. A comparative tabulation is given in the Synthesis section of the review.

Arm-free paraplegic standing. II. Experimental results

In Part I, we proposed an approach for restoring unsupported standing to thoracic-level paraplegics. The theoretical analysis and simulation of an underactuated double inverted pendulum, representing the standing subject, showed that arm-free standing might be achieved. Here in Part II, we present the mechanical apparatus which we used in our experiments and experimental results from tests of the balance-control strategy. We demonstrate that an intact and a paraplegic subject could perform quiet standing with the ankle stiffness set to 8 Nm/degree or even less (the intact subject). Both were also able to recover from disturbances, imposed by the artificial ankle joint of the apparatus. Introducing cognitive auditory feedback greatly improved the standing abilities of both subjects.

Hemodynamic Responses to Peak Arm-Crank Exercise in Thoracic Level Paraplegics 483

It has long been debated in the literature as to whether upper body exercise is limited centrally or peripherally. It has been suggested that aerobic capacity in the spinal cord injured (SCI) may be limited by the relatively greater intramuscular pressure generated during upper body exercise. Brechue et al. (1995) concluded that “skeletal muscle VO2max is limited by O2 delivery secondary to a restriction of blood flow.” The purpose of this study was to measure the hemodynamic responses of paraplegics during a graded exercise test (GXT) to peak oxygen consumption and examine the relation of these responses to aerobic capacity(VO2peak). The subjects for this study were 10 thoracic level paraplegics. The GXT was performed on an arm-crank ergometer using an intermittent protocol. The following variables were measured: peak heart rate, peak systolic blood pressure (SBP), peak mean aterial pressure (MAP), and peak rate pressure product (RPP). Heart rate was measured by telemetry. Exercise blood pressures were measured by reducing the power output by one half and instructing the subject to continue cranking with one arm. Blood pressure was then measured on the free arm. These variables were then correlated with VO2peak with a significance level set at p*< 0.05:Table Results show a significant correlation between VO2peak and peak SBP. These findings are consistent with the hypothesis that aerobic capacity in the paraplegic population may be limited by the delivery of oxygen secondary to the ability to perfuse the exercising muscles.

Stabilization of Thoracic Spine Fractures Resulting in Complete Paraplegia

The impact of surgical stabilization on initial rehabilitation and complications in patients with traumatic thoracic level paraplegia was investigated. One hundred thirteen patient records were retrospectively reviewed. Forty-six patients had been treated with surgical stabilization and fusion. Nineteen patients had been treated by laminectomy alone. Forty-eight patients had been treated nonoperatively. The most common mechanism of injury was a motor vehicle accident (52.6%). The mean follow-up was 8.4 years. All inpatient and outpatient records at Craig Hospital were reviewed for patients who had sustained a thoracic spine fracture (T2-T9) that resulted in complete paraplegia (Frankel A). All patients were followed for a minimum of 5 years. Data were collected regarding initial length of inpatient rehabilitation, as well as early and late complications that affected rehabilitation and function during follow-up. This information was analyzed by treatment group. There was a statistically significant difference in the length of initial rehabilitation days between the surgically stabilized group and the laminectomy-only group. There was a trend toward fewer in-patient rehabilitation days between the surgically stabilized group and the nonoperatively treated group. The surgically treated group had twice as many complications as the nonoperative group. The surgical stabilization of thoracic (T2-T9) spine fractures with complete paraplegia tends to decrease initial rehabilitation days but is associated with increased overall complications. The treatment of this patient group clearly must be individualized.

Is Sphincterotomy the Best Management of the Spinal Cord Injured Bladder?

Transurethral incision of the external urinary sphincter with condom catheter drainage has long been used in the management of the male quadriplegic or high thoracic level paraplegic with neurogenic bladder. The decrease in outlet resistance is believed to lower the high intravesical pressures associated with detrusor-sphincter dyssynergia and obviate the need for an indwelling catheter, with its associated infectious complications. We reviewed 16 consecutive cases of sphincterotomy performed at our institution during the last 8 years to determine the long-term success rate and outcome of this mode of bladder management.Of the patients 13 are cervical level quadriplegics and 3 are thoracic level paraplegics who were unable to perform self-catheterization. Preoperative urodynamics most commonly demonstrated detrusor external sphincter dyssynergia, moderate to severe hyperreflexia and decreased compliance. Followup ranged from 3 months to 8 years (median 39 months). Only 8 of 16 patients still manage the bladder with a condom catheter, while 8 have an indwelling suprapubic cystostomy tube. Only 1 patient followed for more than 4 years postoperatively still uses condom catheter drainage. The most common reason for conversion to suprapubic drainage was difficulty with the external appliance but other reasons included desire for increased independence, high post-void residual volumes and renal deterioration. We conclude that sphincterotomy is generally effective in decreasing outlet resistance and improving voiding efficiency initially but that careful patient selection and close long-term followup are necessary to guarantee long-term success.

Early stabilization and decompression for incomplete paraplegia due to a thoracic-level spinal cord injury.

All patients treated between 1985 and 1990 for acute incomplete spinal cord injury between T2 and T11 were retrospectively studied. This level was chosen for study because by excluding cervical cord, conus, and cauda equina injuries, neurologic improvement could be attributed to improvement of spinal cord function. Only 14 patients with incomplete thoracic level paraplegia were identified, representing 1.2% of all spinal injuries. All 14 patients were treated by early operative reduction, stabilization, or decompression. Twelve patients had surgery within 24 hours of neurologic injury, one at 36 hours, and one at 5 days. Twelve patients had initial posterior instrumentation and fusion, one of whom subsequently had an anterior decompression. Two patients had initial anterior decompression and fusion. Both later had posterior instrumentation and fusion to treat progressive deformity. Follow-up averaged 20 months (range, 9-65 months). Neural function before surgery and at follow-up was given a Frankel grade and lower extremity motor index score. Of 13 surviving patients, seven were initially Frankel B and six Frankel C. Of the seven patients initially Frankel B, four recovered to Frankel E, two improved to Frankel D, and one remained Frankel B. Of the six patients originally Frankel C, five recovered to Frankel E and one improved to Frankel D. Average neurologic improvement was 2.2 Frankel grades per patient, lower extremity motor index improved from an average of 7 to 44. Early surgical reduction, stabilization, and decompression is safe and improves neurologic recovery in comparison to historical controls treated by postural reduction or late surgical intervention.

Etiology of children's spinal injuries at Rancho Los Amigos.

A review of 277 patients under the age of 16 years admitted to the pediatric spinal injury unit at Rancho Los Amigos Medical Center from 1960 to 1989 showed that 70% of the patients were male; complete and incomplete injuries were about equal; and the average age was 8.8 years. The cause of spinal injury by time period revealed that earlier time periods had etiologies similar to those reported in previously published series. Although the incidence of these traditional causes remained constant, violent injuries by gunshot steadily increased with time. In the most recent 5-year period, gunshot wounds equaled motor vehicle injuries as the most frequent cause of a child's spinal injury admitted to this hospital. Gunshot wound victims averaged 12 years old, 80% were male, and most were thoracic level paraplegics. Half of the 50 adolescents (12-16 years old) injured during the last 5 years were gunshot victims.

Physiological cost index of paraplegic locomotion using the ORLAU ParaWalker.

Energy expenditure is an important parameter in the assessment of gait and orthotic treatment of locomotor disabilities. Up until now oxygen uptake measurement has been the most common method used to assess this. In able bodied subjects heart rate monitoring is also increasingly used. In high thoracic level lesion paraplegics monitoring heart rate was considered to be unreliable because of suspicion of injury to the sympathetic contribution to the cardiac plexus. Bar-On & Nene found that in paraplegics below the lesion level T3 heart rate still shows linear relation to oxygen uptake. MacGregor combined the heart rate and speed of locomotion to produce a single index called physiological cost index. This study consists of monitoring heart rate and speed of 16 adult thoracic level paraplegics walking with the ORLAU ParaWalker, calculation of their physiological cost index, and establishing a range of physiological cost index of paraplegic locomotion using the ORLAU ParaWalker.

Relationship between heart rate and oxygen uptake in thoracic level paraplegics

In able-bodied subjects heart rate and oxygen uptake have a linear relation up to submaximal workloads. Cardiac response to exercise or physical stress is described to be under the control of the sympathetic nervous system. Various workers have claimed that the sympathetic contribution to the cardiac plexus arises between thoracic spinal cord levels T1 and T6. Paraplegics are participating in various sporting activities in increasing numbers. Theoretically, assessing the progress of physical fitness of paraplegics with lesions above T6 by monitoring heart rate alone becomes unreliable because of damage to their sympathetic system. Forty-four paraplegics with lesion levels between T3 and T10 were put through an arm cranking exercise routine with increasing power levels. Their heart rate and oxygen uptake was measured for each power level. For analytical purposes the subjects were grouped into two groups according to their lesion level. All the subjects with the lesion at T6 or above were in one group and the other group consisted of lesion at T7 or below. Almost linear relation was found between the heart rate and oxygen uptake in all subjects of both groups. The findings of this study suggest that either the sympathetic contribution comes from above spinal level T3, or the cardiac response to an increased demand in physical exercise is controlled by some other mechanism.

Walking rehabilitation possibilities in the Orlau ParaWalker

The fundamental requirements for successful human gait have been identified, the orthotic compensations necessary for its reproduction in an acceptable form by complete thoracic level paraplegics are proposed and a possible solution is described. Continuous research has developed the Parawalker solution beyond purely mechanical limits to provide electronic 'assists' as a hybrid orthosis. This still adheres to the fundamentals identified, but allows the objective of lowering the energy cost of walking to be pursued.

Sepsis of the hip in paraplegic patients.

For the treatment of chronic sepsis of the hip in paraplegic patients, we adopted three measures: (1) a Girdlestone procedure, (2) transposition of the vastus lateralis muscle into the void that was left by the removal of the femoral head and neck and the acetabular wall, and (3) external fixation to prevent unrestrained motion of the femoral shaft, which might damage the transposed muscle. The hip joint was spanned by a posterior pelvic-femoral skeletal external fixator. Nine patients, all of whom had thoracic-level paraplegia, were treated in this manner. The fixator was kept in place for three to six weeks while the patients were cared for in the prone position. All of the infections were fully healed by twelve weeks postoperatively. In two patients, the wound drained at the edge of the flap for a short time.

Factors affecting the ambulatory status of patients with spina bifida cystica.

Sixteen different factors that might affect the ambulatory status of patients with myelodysplasia after the age of five years were analyzed in ninety-eight patients using a linear regression technique (the Pearson correlation coefficient). Included in the study were fifty male and forty-eight female patients; the average age was fourteen years and four months (range, five years and nine months to thirty-one years and ten months). The sacral and fifth-lumbar paraplegics, with one exception, were all community ambulators. Fourth-lumbar paraplegics were usually functional ambulators, whose ability to walk was significantly influenced by musculoskeletal deformity of the spine, pelvis, hips, knees, feet, and ankles. Third-lumbar, first and second-lumbar, and thoracic level paraplegics usually were not functional ambulators. Ambulatory function was significantly influenced in third-lumbar paraplegics by hip deformity, in first and second-lumbar paraplegics by obesity and possibly by age, and in thoracic level paraplegics by age and by knee-foot-ankle deformities. Transitions in ambulatory status were usually to a lower functional level and were related to motivation, obesity, and musculoskeletal deformity. Ultimately, ambulatory status is probably related in large measure to the energy expenditure that is necessary to walk, but studies of energy requirements were not done. These findings emphasize the importance of controlling obesity as well as any musculoskeletal deformities that will influence the patient's ultimate walking ability.