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Objectives This scoping review was undertaken to synthetize and appraise the literature on the potential mechanisms of action of functional electrical stimulation therapy in combination with task-specific training (FEST + TST) in the rehabilitation following stroke, spinal cord injury, traumatic brain injury, or multiple sclerosis. Materials and methods The literature search was performed using multiple databases (including APA, PsycInfo, Medline, PubMed, EMBASE, CCRCT, and Cochrane Database of Systematic Reviews) from 1946 to June 2020. The literature search used the following terms: (spinal cord injury, paraplegia, tetraplegia, quadriplegia, stroke, multiple sclerosis, traumatic brain injury, or acquired brain injury) AND (functional electrical stimulation or FES). The search included clinical and preclinical studies without limits to language. Results Of the 8209 titles retrieved from the primary search, 57 publications fulfilled the inclusion and exclusion criteria for this scoping review. While most publications were clinical studies (n = 50), there were only seven preclinical studies using animal models. The results of this review suggest that FEST + TST can result in multiple effects on different elements from the muscle to the cerebral cortex. However, most studies were focused on the muscle changes after FEST + TST. Conclusions The results of this scoping review suggest that FEST + TST can result in multiple effects on different elements of the neuromuscular system, while most research studies were focused on the muscle changes after FEST + TST. Despite the efficacy of the FEST + TST in the neurorehabilitation after CNS injury or disease, the results of this review underline an important knowledge gap with regards to the actual mechanism of action of FEST + TST.

Objectives: To determine the cardiovascular risk burden rehabilitation discharge, and explore the association between recovery during rehabilitation and CVD-risk profile. Methods: We included adults without CVD history admitted for rehabilitation. We evaluated rehabilitation outcomes on admission and discharge. CVD-risk was assessed by Framingham risk score (FRS), high-density lipoprotein (HDL), and fasting glucose level. Results: We analyzed data from 706 participants (69.55% men) with median age of 53.5 years. The median time-since-injury was 14 days and the admission length was 5.2 months. Majority had paraplegia (53.26%), and motor incomplete injury (53.68%). One-third of the cohort had high cardiovascular risk profile pre-discharge. At discharge, poorer anthropometric measures were associated with higher FRS and lower HDL levels. Individuals with higher forced vital capacity (>2.72 L) and peak expiratory flow (>3.4 L/min) had 0.16 mmol/L and 0.14 mmol/L higher HDL compared to those with lower respiratory function, respectively. Individuals with higher mobility score (>12.5) and functional independence score (>74) had 0.21 mmol/L and 0.18 mmol/L higher HDL compared to those with lower scores. Conclusion: There is high cardiometabolic syndrome burden and CVD-risk upon rehabilitation discharge. Higher respiratory function, mobility, and overall independence were associated with better CVD profile, although with study design limitations and short follow-up. Future studies should explore whether rehabilitation outcomes could be used to prioritize screening., + ID der Publikation: unilu_68449 + Sprache: Englisch + Letzte Aktualisierung: 2023-06-30 11:55:35

International audience; Two multi-contact epineural electrodes were placed around radial and median nerves of two subjects with high tetraplegia C4, American Spinal Injury Association Impairment Scale (AIS) A, group 0 of the International Classification for Surgery of the Hand in Tetraplegia. The purpose was to study the safety and capability of these electrodes to generate synergistic motor activation and functional movements and to test control interfaces that allow subjects to trigger pre-programmed stimulation sequences. The device consists of a pair of neural cuff electrodes and percutaneous cables with two extracorporeal connection cables inserted during a surgical procedure and maintained for 28 days. Continuity tests of the electrodes, selectivity of movements induced, motor capacities for grasping and gripping, conformity of the control order, tolerance, and acceptability were assessed. Neither of the two participants showed general and local comorbidity. Acceptability was optimal. None of the stimulation configurations generated contradictory movements. The success rate in task execution by the electro-stimulated hand exceeded the target of 50% (54% and 51% for patients 1 and 2, respectively). The compliance rate of the control orders in both patients was >90% using motion inertial measurement unit (IMU)-based detection and 100% using electromyography (EMG)-based detection in patient 1. These results support the relevance of neural stimulation of the tetraplegic upper limb with a more selective approach, using multi-contact epineural electrodes with nine and six contact points for the median and radial nerve respectively.

To determine the differences in neurologic recovery in persons with initial cervical American Spinal Cord Injury Association Impairment Scale (AIS) grades A and B over time.Retrospective analysis of data from people with traumatic cervical spinal cord injury (SCI) enrolled in the National Spinal Cord Injury Model Systems (SCIMS) database from 2011-2019.SCIMS centers.Individuals (N=187) with traumatic cervical (C1-C7 motor level) SCI admitted with initial AIS grade A and B injuries within 30 days of injury, age 16 years or older, upper extremity motor score (UEMS) ≤20 on both sides, and complete neurologic data at admission and follow-up between 6 months and 2 years.Not applicable.Conversion in AIS grades, UEMS and lower extremity motor scores (LEMS), and sensory scores.Mean time to initial and follow-up examinations were 16.1±7.3 days and 377.5±93.4 days, respectively. Conversion from an initial cervical AIS grades A and B to motor incomplete status was 13.4% and 50.0%, respectively. The mean UEMS change for people with initial AIS grades A and B did not differ (7.8±6.5 and 8.8±6.1; P=.307), but people with AIS grade B experienced significantly higher means of LEMS change (2.3±7.4 and 8.8±13.9 (P≤.001). The increased rate of conversion to motor incomplete status from initial AIS grade B appears to be the primary driving factor of increased overall motor recovery. Individuals with initial AIS grade B had greater improvement in sensory scores.While UEMS recovery is similar in persons with initial AIS grades A and B, the rate of conversion to motor incomplete status, LEMS, and sensory recovery are significantly different. This information is important for clinical as well as research considerations.

Objective Explore trajectories of functional recovery that occur during the first two years after spinal cord injury (SCI). Design Observational cohort study. Setting Eight SCI Model System sites. Participants 479 adults with SCI completed four Spinal Cord Injury-Functional Index (SCI-FI) item banks within 4 months of injury and again at 2 weeks, 3, 6, 12, and 24 months following baseline assessment. Intervention None. Main Outcome Measures SCI-FI Basic Mobility/Capacity (C), Fine Motor Function/C, Self-Care/C, and Wheelchair Mobility/Assistive Technology (AT) item banks. Results Growth mixture modeling was used to identify groups with similar trajectory patterns. For the Basic Mobility/C and Wheelchair Mobility/AT domains, models specifying 2 trajectory groups were selected. For both domains, a majority class exhibited average functional levels and gradual improvement, primarily in the first six months. A smaller group of individuals made gradual improvements but had greater initial functional limitations. The Self Care/C domain exhibited a similar pattern; however, a third, small class emerged that exhibited substantial improvement in the first six months. Finally, for individuals with tetraplegia, trajectories of Fine Motor Function/C scores followed two patterns, with individuals reporting generally low initial scores and then making either modest or large improvements. In individual growth curve models, injury/demographic factors predicted initial functional levels but less so with regard to rates of recovery. Conclusions Trajectories of functional recovery followed a small number of change patterns, though variation around these patterns emerged. During the first two years after initial hospitalization, SCI-FI scores showed modest improvements; however, substantial improvements were noted for a small number of individuals with severe limitations in fine motor and self-care function. Future studies should further explore the personal, medical, and environmental characteristics that influence functional trajectories during these first two years and beyond.

The aim of our study is to describe the assessment of the upper limb in tetraplegic patients to follow his (her) neurological progression and to define the medical or surgical treatment program. We selected upper limb assessment tools and scales for tetraplegic patients described in the medical literature through a PubMed search over the last four decades. For each method, we present the implementation rules and its metrological properties, including its validity in French. We selected five clinical scales for functional evaluation of grasping, as well as four scales for evaluating the overall function of these patients. Finally, we identified three complementary precision assessment tools. The AIS (ASIA Impairment Scale) classification describes the level and the severity of the spinal cord lesion. The Giens classification is more practical for describing the upper limb in middle and low tetraplegia. Impairments can be assessed with most common generic scales and nonspecific measurement devices: range of motion, strength, sensory loss, spasticity, joint pain. Measurement of pinch and grip strength is widely used and easy to perform. The Capabilities of Upper Extremity (CUE) and the Jebsen Taylor Test are the best validated and usable scales. At a general functional level, the Spinal Cord Independence Measure (SCIM) is the most relevant scale in these patients. Motor nerve blocks, electromyography, movement analysis and echography are promising additional methods. Assessment of the upper limb of tetraplegic patients relies both on generic and specific assessment tools and scales.

Objective To establish responsiveness of 3 Spinal Cord Injury – Functional Index/Capacity (SCI-FI/C) item banks in the first year following SCI. Design Longitudinal patient-reported outcomes assessment replicated through secondary analysis of an independent data set. Setting 8 SCI Model Systems rehabilitation hospitals in the US. Participants Study 1 participants included 184 adults with recent (≤4 months) traumatic SCI and 221 community-dwelling adults (>1 year post injury). Study 2 participants were 418 individuals with recent SCI (≤4 months). Interventions In Study 1, SCI-FI/C computer adaptive tests were presented in a standardized interview format either in person or by phone call at baseline and 6-month follow-up. Responsiveness was examined by comparing 6-month changes in SCI-FI scores within and across samples (recently-injured vs. community-dwelling), as only the recent injury sample was expected to exhibit change over time. Effect sizes were also computed. In Study 2, the Study 1 results were cross-validated in a second recent SCI sample 1 year after baseline measurement. Study 2 also compared the SCI-FI/C measures’ responsiveness to that of the Self Report Functional Measure (SRFM) and stratified results by injury diagnosis and completeness. Main Outcome Measures The SCI-FI Basic Mobility/C, Self-Care/C and Fine Motor/C item banks (Study 1 and Study 2); Self Report Functional Measure (SRFM; Study 2 only). Results In Study 1, changes in SCI-FI/C scores between baseline and 6-month follow-up were statistically significant (p Conclusion The SCI-FI Basic Mobility/C and Self-Care/C banks demonstrate adequate sensitivity to change at 6 months and 1 year for all individuals with SCI, while the SCI-FI/C Fine Motor item bank is sensitive to change in individuals with tetraplegia or incomplete paraplegia. All SCI-FI/C banks demonstrate stability in a sample not expected to change. Results provide support for the use of these measures for research or clinical use.

Respiratory failure and chronic ventilator dependence in tetraplegics following cervical injuries located high on the spine (C1–C3) constitute significant challenges in the rehabilitation of patients given the occurrence of repeated hospitalizations and an ever-increasing financial burden. A 30-year-old man presented with posttraumatic tetraplegia following an unstable injury at the C1–C2 level with cord compression; he was managed by posterior stabilization and decompression followed by ventilator dependence and no rehabilitation until 6 months postinjury. We implanted phrenic nerve stimulator electrodes bilaterally for indirect diaphragm pacing by an implantable pulse generator that allowed for weaning from mechanical ventilation and spontaneous ventilator-free breathing at 20 weeks post-implantation and which facilitated post-tetraplegia rehabilitation. At 36 months after implantation, the patient is ventilator- free without any procedure-related complications or respiratory infections. Diaphragm pacing with phrenic nerve stimulation may be a way forward for ventilator-dependent tetraplegics in developing countries to pursue effective rehabilitation and improved quality of life.

Background: Spinal cord injury (SCI) is the injury of the spinal cord from the foramen magnum to the cauda equina which occurs as a result of compulsion, incision or contusion which is a life threatening condition that carries a high risk of morbidity and mortality. The Incidence of SCI varies from 9.2 to 56.1 per million. In the Indian setup, Approx. 20,000 new cases of SCI are added every year. Spinal cord injury (SCI) patients are at increased risk of chronic respiratory symptoms as Respiratory muscle paralysis both restricts maximum inflation of the lungs and impair the ability to cough. Patients with tetraplegia have decreased chest wall and lung compliance, rib cage stiffness with paradoxical chest wall movements. Material and method: A Pilot study was carried out on 04 Traumatic Spinal cord injury patients. The purpose of the study was To find out effectiveness of respiratory PNF on pulmonary functions (FVC & FEV1) & Chest Expansion in patients with spinal cord injury. The pulmonary Functions (FVC & FEV1) and chest expansion was measured by using Spirometer (PFT machine) and inch tape. The data was analyzed using standard statistical software. Result: In this study After 4 weeks of Intervention there was Significant Improvement in Pulmonary Functions ( Pre Mean of FEV1 & FVC 0.99 L & 1.03L and Post Mean of FEV1 & FVC was 1.25 L & 1.35L respectively) and Chest Expansion (Pre Mean was 1.15 cm and Post Mean was 1.62 cm at Xiphoid Process Level). Conclusion: This Study concluded that Respiratory PNF increases Pulmonary Functions and chest expansion in Patients with Spinal Cord Injury after 4 weeks of Intervention. Keywords: Spinal Cord Injury, Forced Expiratory Volume (FEV1), Forced vital Capacity, Peak expiratory flow rate, Respiratory Proprioceptive Neuromuscular Facilitation Technique.

KEY POINTS The functional role of motor cortical reorganization following spinal cord injury (SCI) remains largely unknown. Here, we tested motor maps in a hand muscle at rest and during voluntary contraction of the hand with and without voluntary contraction of a proximal arm muscle. Motor map area in participants with SCI decreased during hand voluntary contraction and further decreased during additional contraction of a proximal arm muscle compared with rest. In contrast, motor map area in controls increased during the same motor tasks. Participants with SCI with more severe sensory deficits in the hand showed larger decreases in motor map area. Ten minutes of hand muscle-tendon vibration increased the motor map area during voluntary contraction in SCI participants. These novel findings suggest that abnormal changes in motor cortical maps during voluntary contraction after SCI can be reshaped by sensory input, knowledge that can have implications for rehabilitation. ABSTRACT Motor cortical representations reorganize following cervical spinal cord injury (SCI). The functional role of this reorganization remains largely unknown. Using neuronavigated transcranial magnetic stimulation, we examined motor cortical maps during voluntary contraction in humans with chronic cervical SCI and age-matched controls. We constructed motor maps in the first dorsal interosseous (FDI) muscle at rest and during voluntary contraction of the FDI with and without voluntary contraction of the biceps brachi (BB). The role of sensory input into this reorganization was examined by muscle-tendon vibration. We found that, at rest, motor maps were larger in SCI (22.3 cm2 ) compared with control (12.6 cm2 , P

Aim: Spinal cord injury (SCI) patients may have intestinal dysmotility and digestive symptoms that are associated with small intestinal bacterial overgrowth (SIBO). The aim of this study is to describe the prevalence of SIBO in SCI patients and the risk factors of its development. Methods: Twenty-nine consecutive SCI patients were studied (10 women/19 men; mean age 47 years), 16 with subacute injuries (1 year). Nine patients were affected by tetraplegia and 15 by paraplegia. Each patient underwent a glucose breath test according to the North American Consensus and the presence of abdominal symptoms was evaluated during the test. The results were compared with 15 non-neurological patients with SIBO. Results: Six patients tested positive for SIBO (21%), all of them affected by SCI in the subacute phase, 6/16 vs 0/13 in the chronic phase (p < 0.05) and the majority with tetraplegia, 5/9 vs 1/19 with paraplegia (p < 0.05). No statistically significant relationship was found with other clinical characteristics. All the tests were positive for methane or mixed (methane and hydrogen), while only 67% of the controls had methane-predominant production. (p > 0.05). Conclusion: SCI patients can develop SIBO, more frequently in the subacute phase and in tetraptegic patients, highlighting a high production of methane. This complication should be considered in neurogenic bowel management. (C) 2021 Elsevier Espana, S.L.U. All rights reserved.

Acute Motor Axonal Neuropathy (AMAN) is an immune-mediated disorder of the peripheral nervous system, part of the spectrum of the Guillain-Barre syndrome (GBS). An infectious event most often triggers it reported a few weeks before the onset. The reported case is of a 56 years-old woman who developed acute motor axonal neuropathy three weeks after respiratory infection with influenza A virus subtype H1N1. Despite early treatment with plasmapheresis and intravenous immunoglobulins, the patient remained tetraplegic, mechanically ventilated for five months, with repetitive unsuccessful weaning trails. The probable cause was considered to be phrenic nerve palsy in the context of acute motor axonal neuropathy. This case highlights that acute motor axonal neuropathy is a severe and life-threatening form of Guillain-Barre syndrome associated with significant mortality and morbidity. Neurological and physical recovery strongly depend on the inter-professional effort in an intensive care unit and neurology professionals.

Integrating brain-computer interface (BCI) technology with functional electrical stimulation therapy (FEST) is an emerging strategy for upper limb motor rehabilitation after spinal cord injury (SCI). Despite promising results, the combined use of these technologies (BCI-FEST) in clinical practice is minimal. To address this issue, we developed KITE-BCI, a BCI system specifically designed for clinical application and integration with dynamic FEST. In this paper, we report its technical features and performance. In addition, we discuss the differences in distributions of the BCI- and therapist-triggered stimulation latencies.Two single-arm 40-session interventional studies to test the feasibility of BCI-controlled FEST for upper limb motor rehabilitation in individuals with cervical SCI.Rehabilitation programs within the University and Lyndhurst Centres of the Toronto Rehabilitation Institute - University Health Network, Toronto, Canada.Five individuals with sub-acute (6 months post-injury) SCI at the C4-C5 level, AIS B-D, and three individuals with chronic (24 months post-injury) SCI at C4 level, AIS B-C.We measured BCI setup duration, and to characterize the performance of KITE-BCI, we recorded BCI sensitivity, defined as the percentage of successful BCI activations out of the total number of cued movements.The overall BCI sensitivities were 74.46% and 79.08% for the sub-acute and chronic groups, respectively. The average KITE-BCI setup duration across the two studies was 11 min and 13 s.KITE-BCI demonstrates a clinically viable single-channel BCI system for integration with FEST resulting in a versatile technology-enhanced upper limb motor rehabilitation strategy after SCI.

The objective of the study was to evaluate the impact of distractions on intracortical brain–computer interface (BCI) performance. Two individuals with tetraplegia had microelectrode arrays implant...

We report a case and a literature review of delayed postoperative cervical spinal cord injury after thoraco-lumbar spine surgery. A 13-year-old Prader-Willi Syndrome female was treated by a T3-L5 posterior spine fusion for progressive scoliosis. Intraoperative neuromonitoring and immediate postoperative neurological examination were normal. Sixty hours after surgery, she developed a tetraplegia. The immediate MRI and CT scan of the spine were negative. Two days after, a new MRI revealed an ischemic cervical lesion at the level C5-C6. After 1 week, she gradually improved breathing and motility/sensibility at the extremities. After 4 months of intensive neurologic rehabilitation, the patient improved to ASIA grade D and was discharged. At 1-year follow, the neurologic recovery was nearly completed. We performed a systematic review of the literature through PubMed and Embase database focused on delayed postoperative cervical spinal cord lesion after a thoraco-lumbar fusion for spinal deformity. Only 14 cases of neurological injuries at levels above the site of surgery have been previously reported and never in Prader Willy Syndrome. All patients were adolescent and 86,7% were females but no specific risk factors were found. Delayed postoperative neurological deficit far from the surgical site can be considered a specific subgroup of these rare complication that can occur several hours after spine surgery, regardless of intraoperative complication. Despite the rarity of this complication, clinicians should be aware of it. Perioperative optimization of spinal cord perfusion and close neurological examination in first postoperative days may be helpful to quickly recognize and treat this complication.

Background: Tetraplegia that results from cervical injury is the most frequent neurologic category after spinal cord injury (SCI) and causes substantial disability. Traumatic Brain injury (TBI) is a shock or a penetrating injury to the head that disrupts the brain function leading to various impairments including upper limb dysfunction. Improving arm and hand function after these injuries is a major priority of rehabilitation due to its reflect on mobility, independency and quality of life. Advances of treatment approaches and technology have been introduced in research work; one of these approaches is task-oriented training (TOT). Aim of Study: This systematic review aims to find out the evidence on the effectiveness of TOT to improve the upper limb functions among patients with SCI and TBI. Material and Methods: This systematic review performed using the PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro) and the Egyptian Knowledge Bank (EKB) search engines and the associated keywords. The methodological quality assessment was done by two reviewers using PEDro scale. Random effect model and standardized mean differences were used for meta-analyses. Results: The search identified 8,424 records, of which only two trials were selected as eligible. Quality appraisal revealed the trials were of good or fair quality. Conclusion: This systematic review suggests moderate level of evidence for non-significant effect of Task-oriented training in improving upper limb function and hand dexterity in patients with spinal cord injuries and further primary research is recommended for both SCI and TBI.

In mucopolysaccharidoses (MPS), spinal cord compression (SCC) resulting from glycosaminoglycan (GAG) accumulation is a critical complication that can cause significant neurological and respiratory morbidities. However, clinically similar disorders such as mucolipidosis types II and III (ML) with SCC have been scarcely reported. Herein, we report four patients with ML who had SCC. Brain MRI revealed progressive spinal canal stenosis and SCC. In addition, T2-weighted high signal changes in the cervical cord were detected in two cases. Severe cases of SCC were detected as early as 1 year of age. All cases had respiratory problems. One case showed severe hypoxia and another, severe sleep apnea. In two cases, respiratory insufficiency and tetraplegia rapidly progressed as SCC progressed. Then, the patients became bedridden and needed artificial ventilation. In addition, two of the four patients died of respiratory failure. The autopsy of one patient revealed a compressed cervical cord and marked dura mater thickening due to GAG accumulation. These findings suggest that the accumulation of substrates in the dura mater caused SCC in the patients with ML. Our cases indicate that SCC is expected to be a common and critical complication of ML and MPS. MRI evaluation of cervical involvements and careful clinical observation are required in patients with ML.

Multiway-or tensor-based decoding techniques for brain-computer interfaces (BCIs) are believed to better account for the multilinear structure of brain signals than conventional vector-or matrix-based ones. However, despite their outlook on significant performance gains, the used parameter optimization approach is often too computationally demanding so that conventional techniques are still preferred. We propose two novel tensor factorizations which we integrate into our block-term tensor regression (BTTR) algorithm and further introduce a marginalization procedure that guarantees robust predictions while reducing the risk of overfitting (generalized regression). BTTR accounts for the underlying (hidden) data structure in a fully automatic and computationally efficient manner, leading to a significant performance gain over conventional vector-or matrix-based techniques in a challenging real-world application. As a challenging real-world application, we apply BTTR to accurately predict single finger movement trajectories from intracranial recordings in human subjects. We compare the obtained performance with that of the state-of-the-art. ispartof: IEEE TRANSACTIONS ON NEURAL NETWORKS AND LEARNING SYSTEMS vol:PP ispartof: location:United States status: Published online

Retrospective descriptive study. To summarize epidemiologic data on nontraumatic spinal cord injury (NTSCI) for the last 30 years and compare these findings to data from individuals with traumatic spinal cord injury (TSCI). National Rehabilitation Center affiliated with the Ministry of Health and Welfare in Korea. The medical records of 948 individuals with NTSCIs were retrospectively reviewed. Three groups were created based on onset period (1990–1999, 2000–2009, 2010–2019) and six groups based on age (≤15, 16–30, 31–45, 46–60, 61–75, and ≥76 years). Pearson’s chi-square and analysis of variance tests were used for statistical analysis. The male-to-female ratio was 1.30:1 for NTSCI individuals and 3.47:1 for TSCI individuals. The mean age (standard deviation [SD]) at the time of injury increased from 38.7 (SD = 18.1) years in the 1990s to 55.5 (SD = 16.6) years in the 2010s (F = 44.597, p ≤ 0.001). Vertebral column degenerative disorder was the primary cause of injury in 28.9% of the cases, and the most common neurologic level was T12-L2. Paraplegia occurred in 74.6% of cases, and tetraplegia in 25.4% of cases. The proportion of NTSCI individuals increased from 11.2% to 29.3% during the observation period. The proportion of NTSCI among total spinal cord injuries has increased in Korea over the last 30 years (1990–2019). Compared to individuals with TSCI, those with NTSCI had a higher age at onset, with different male-to-female ratios. Our study is the most comprehensive investigation of NTSCI in Korea, and our findings can inform research directions and medical guidelines.

STUDY DESIGN Descriptive study. OBJECTIVES To examine grouped and intra-individual relationships between 1) exercise intensity and heart rate (EI-HR); 2) EI and oxygen uptake (EI-VO2); 3) VO2 and HR (VO2-HR); and 4) perceived exertion and VO2 (PE-VO2) in persons with tetraplegia (C4/5-C8) during different modes of exercise. SETTING Community in Winnipeg, Canada. METHODS Participants exercised at 3 graded intensities during arm ergometry (ERG), wheeling indoors on cement (MWC), or hand-cycling outdoors (HC). EI (Watts, km/hr) and VO2, HR and PE were recorded. RESULTS 22 persons completed ERG, 14/22 also completed MWC and 5/22 completed ERG, MWC and HC. Regression analysis of grouped data showed a significant relationship between EI-VO2 but not for EI-HR or HR-VO2. Intra-individual analyses showed a strong correlation (r or ρ > 0.7) for VO2-HR for 16/22 during ERG. In the participants completing multiple exercise modes, a strong VO2-HR relationship was present in 12/14 in ERG, but in only 6/14 in MWC. The 5 persons exercising with all 3 modes had a strong HR-VO2 relationship in 5/5 for ERG, 2/5 in MWC and 1/5 in HC. A strong relationship for PE-VO2 was observed in a higher proportion of participants (versus HR-VO2) during MWC (9/14) and HC (2/4). CONCLUSION Within the same individual, the HR-VO2 relationship varies across modes, despite exercising over similar ranges of steady-state VO2. HR appears less able to predict VO2 compared to PE. Based on these new findings, systematic investigation of the HR-VO2 relationship across modes of exercise in tetraplegia is warranted.

We describe a 34-year-old soldier who sustained a blast injury in Syria resulting in tracheal 5 cm tracheal loss, cervical spine and cord injury with tetraplegia, multiple bilateral rib fractures, esophageal injury, traumatic brain injury, globe evisceration, and multiple extremity soft tissue and musculoskeletal injuries including a left tibia fracture with compartment syndrome. An emergent intubation of the transected trachea was performed in the field, and the patient was resuscitated with whole blood prehospital. During transport to the Role 2, the patient required cardiopulmonary resuscitation for cardiac arrest. On arrival, he underwent a resuscitative thoracotomy and received a massive transfusion exclusively with whole blood. A specialized critical care team transported the patient to the Role 3 hospital in Baghdad, and the DoD extracorporeal membrane oxygenation (ECMO) team was activated secondary to his unstable airway and severe hypoxia secondary to pulmonary blast injury. The casualty was cannulated in Baghdad approximately 40 hours after injury with bifemoral cannulae in a venovenous configuration. He was transported from Iraq to the U.S. Army Institute of Surgical Research Burn Center in San Antonio without issue. Extracorporeal membrane oxygenation support was successfully weaned, and he was decannulated on ECMO day 4. The early and en route use of venovenous ECMO allowed for maintenance of respiratory support during transport and bridge to operative management and demonstrates the feasibility of prolonged ECMO transport in critically ill combat casualties.

COVID-19 vaccination is an effective method for reducing COVID-19 infection rates. Several clinical publications, however, have linked the use of this vaccination to a variety of untoward events.Here we present the case of an 18-year-old adult who developed tetraplegia or quadriplegia, a day after taking the first dose of his Astra-Zeneca COVID-19 Vaccine, despite the absence of any other known triggers or predisposing factors. This finding suggests a link between the Astra-Zeneca COVID-19 vaccine and quadriplegia/Acute transverse myelitis.Adults who experience any sort of paresthesia or minor weakness in their limbs after receiving COVD-19 vaccine should seek medical attention right away, and health care providers should be on the lookout for indicators of paralysis.Sufficient evidence is needed to better understand the potential link between COVID-19 immunizations and quadriplegia, and if one is found, the risk must be weighed against the millions of people who have been safely vaccinated, as well as the known morbidity and death associated with COVID-19 infection.As vaccines become more widely available, its critical that all potential adverse reactions be reported so that we can keep an eye out for relatively uncommon but potentially dangerous side effects that were not found in vaccine studies.

Study design This is a retrospective study. Objectives To analyze the causes and risk factors of mortality in people admitted with complete acute traumatic spinal cord injury (ATSCI). Setting The study was performed at the Indian Spinal Injuries Centre, New Delhi. Methods Data between 2000 and 2016 were retrospectively collected from case records of people with ATSCI. Risk factors for mortality were examined using multivariable logistic regression. Results Mortality rate in ATSCI admissions (n = 758) during the study period was 10%. Median (IQR) age of study participants was 34 (21) years with a range of 14–85 years. Respiratory complications, septicemia, and cardiovascular causes were responsible for 42%, 28, and 18% of deaths. Mortality rate in people with paraplegia and tetraplegia was 3% and 22%, respectively. The proportion surviving at 6 weeks was significantly different across people with paraplegia and people with high and low tetraplegia (p

OBJECTIVE: To systematically determine whether usage of the spinal cord stimulation (SCS) system to restore cough may improve Bowel Management (BM) in individuals with SCI. DESIGN: Experimental studies (Clinical trial). SETTING: In-patient hospital setting for electrode insertion; out-patient setting for measurement of respiratory pressures; home setting for application of SCS. PARTICIPANTS: Participants (N = 5) with cervical spinal cord injury. INTERVENTION: A fully implantable SCS cough system was surgically placed in each subject. SCS was applied at home, 2-3 times/day, on a chronic basis, every time bowel regimen was performed and as needed for secretion management. Stimulus parameters were set at values resulting in near maximum airway pressure generation (P), which was used as an index of expiratory muscle strength. Participants also employed SCS during their bowel routine. MAIN OUTCOME MEASURE(S): Airway pressure generation achieved with SCS. Weekly completion of Bowel Routine Log including BM time, mechanical measures and medications employed. RESULTS: Mean P during spontaneous efforts was 30±8cmH(2)O. Following a period of reconditioning, SCS resulted in P of 146±21cmH(2)O. The time required for BM routines was reduced from 118±34 min to 18±2 min (p

Introduction The hybrid assistive limb (HAL) is a wearable exoskeleton cyborg that assists walking and lower limb movements via real-time actuator control by detecting the wearer's bioelectric signals on the surface of their skin. Purpose The purpose of this study was to report the improvement in walking ability following HAL gait training in a patient with tetraplegia after incomplete cervical spinal cord injury (SCI). Patient and methods A 47-year-old man with traumatic cervical SCI for six months after fall had incomplete tetraplegic SCI grade C as classified according to the American Spinal Cord Injury Association impairment scale and was unable to walk in conventional rehabilitation. Results The HAL gait training was received 2 or 3 times per week for 13 sessions. Improvement was observed in gait speed (baseline: 0.12; after training: 0.45 m/sec), step length (baseline: 0.30; after training: 0.45 m), and cadence (baseline: 23.1; after training: 59.6 steps/min) based on a 10-meter walking test; International Standards for Neurological and functional Classification of Spinal Cord Injury (ISNCSCI) motor score (baseline: 59; after training: 76); and walking index for spinal cord injury (WISCI) II score (baseline: 1; after training: 6). Conclusion We report the recovery of walking ability in a patient with chronic severe incomplete tetraplegic SCI following the HAL training.

The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a traumatic spinal cord injury (SCI), supraspinal influences on the peripheral nervous system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, sympathetic blunting, and parasympathetic dominance, resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions, and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of the less reported nontraumatic SCI (NTSCI), its classification, its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue. Finally, management strategies for NTSCI will be provided.

A boost for brain–computer interfaces The finely controlled movement of our limbs requires two-way neuronal communication between the brain and the body periphery. This includes afferent information from muscles, joints, and skin, as well as visual feedback to plan, initiate, and execute motor output. In tetraplegia, this neural communication is interrupted in both directions at the level of the spinal cord. Brain–computer interfaces have been developed to produce voluntary motor output controlled by directly recording from brain activity. Flesher et al. added an afferent channel to the brain–computer interface to mimic sensory input from the skin of a hand (see the Perspective by Faisal). The improvements achieved by adding the afferent input were substantial in a battery of motor tasks tested in a human subject. Science , abd0380, this issue p. 831 ; see also abi7262, p. 791

Objectives Wearable robotic exoskeletons (WREs) have been globally developed to achieve gait reconstruction in patients with spinal cord injury (SCI). The present study aimed to enable evidence-based decision-making in selecting the optimal WRE according to residual motor function and to provide a new perspective on further development of appropriate WREs. Methods The current review was conducted by searching PubMed, Web of Science, and Google Scholar for relevant studies published from April 2015 to February 2020. Selected studies were analysed with a focus on the participants’ neurological level of SCI, amount of training (number of training sessions and duration of the total training period), gait speed and endurance achieved, and subgroup exploration of the number of persons for assistance and the walking aid used among patients with cervical level injury. Results A total of 28 articles (nine using Ekso, three using Indego, ten using ReWalk, one using REX, five using Wearable Power-Assist Locomotor) involving 228 patients were included in the analysis. Across all WREs, T6 was the most frequently reported level of SCI. The amount of training showed a wide distribution (number of training sessions: 2–230 sessions [30–120 min per session]; duration of the total training period: 1–24 weeks [1–5 times per week]). The mean gait speed was 0.31 m/s (standard deviation [SD] 0.14), and the mean distance on the 6-min walking test as a measure of endurance was 108.9 m (SD 46.7). The subgroup exploration aimed at patients with cervical level injury indicated that 59.2% of patients were able to ambulate with no physical assistance and several patients used a walker as a walking aid. Conclusion The number of cervical level injury increased, as compared to the number previously indicated by a prior similar review. Training procedure was largely different among studies. Further improvement based on gait performance is required for use and dissemination in daily life. The translational potential of this article The present review reveals the current state of the clinical effectiveness of WREs for gait reconstruction in patients with SCI, contributing to evidence-based device application and further development.

The predominant tool used to predict outcomes after traumatic spinal cord injury (SCI) is the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). These measures have evolved based on analyses of large amounts of longitudinal neurological recovery data published in numerous separate studies. This article reviews and synthesizes published data on neurological recovery from multiple sources, only utilizing data in which the sacral sparing definition was applied for determination of completeness. Conversion from a complete to incomplete injury is more common in tetraplegia than paraplegia. The majority of AIS conversion and motor recovery occurs within the first 6–9 months, with the most rapid rate of motor recovery occurring in the first three months after injury. Motor score changes, as well as recovery of motor levels, are described with the initial strength of muscles as well as the levels of the motor zone of partial preservation influencing the prognosis. Total motor recovery is greater for patients with initial AIS B than AIS A, and greater after initial AIS C than with motor complete injuries. Older age has a negative impact on neurological and functional recovery after SCI; however, the specific age (whether >50 or >65 years) and underlying reasons for this impact are unclear. Penetrating injury is more likely to lead to a classification of a neurological complete injury compared with blunt trauma and reduces the likelihood of AIS conversion at one year. There are insufficient data to support gender having a major effect on neurological recovery after SCI.

BACKGROUND: A number of physiological and atmospheric variables are believed to increase spasticity in persons with spinal cord injury (SCI) based on self-reported measures, however, there is limited objective evidence about the influence of these variables on spasticity. OBJECTIVE: We investigated the relationship between physiological/ atmospheric variables and level of spasticity in individuals with SCI. METHODS: In 53 participants with motor-incomplete SCI, we assessed the influence of age, time since injury, sex, injury severity, neurological level of injury, ability to walk, antispasmodic medication use, temperature, humidity, and barometric pressure on quadriceps spasticity. Spasticity was assessed using the pendulum test first swing excursion (FSE). To categorize participants based on spasticity severity, we performed cluster analysis. We used multivariate stepwise regression to determine variables associated with spasticity severity level. RESULTS: Three spasticity groups were identified based on spasticity severity level: low, moderate, and high. The regression analysis revealed that only walking ability and temperature were significantly related to spasticity severity. CONCLUSIONS: These outcomes validate the self-reported perception of people with SCI that low temperatures worsen spasticity. The findings refine prior evidence that people with motor-incomplete SCI have higher levels of spasticity, showing that those with sufficient motor function to walk have the highest levels of spasticity.

Objectives: To reach agreement on standardized protocols for assessing upper limb strength and grip and pinch force for upper limb reconstructive surgery for tetraplegia. Methods: Selected members of an expert panel composed of international therapists formed at the 2018 International Congress for Upper Limb Surgery for Tetraplegia conducted a literature review of current practice that identified gaps and inconsistencies in measurement protocols and presented to workshop attendees. To resolve discrepancies, a set of questions was presented to workshop attendees who voted electronically. Consensus was set at 75% agreement. Results: For manual muscle testing, consensus was reached for using the Medical Research Council scale, without plus or minus, and the use of resistance through range when testing grade 4 and grade 5 strength. Pectoralis major and serratus anterior should be routinely tested, however there was no consensus on other shoulder muscles. Grip and pinch strength should be tested according to the American Society of Hand Therapists positioning. For grip strength, either the Jamar or Biometrics dynamometer expressed in kilograms should be used. For grip and pinch strength, three measurements should be performed at each testing. No consensus was reached on a device for pinch strength. Conclusion: This work is an important step to enable comparable data in the future. Further consensus methods will work toward developing more comprehensive guidelines in this population. Building international consensus for pre- and postoperative measures of function supports objective evaluation of novel therapies and interpretation of multicenter studies.

Systematic scoping review The purpose of this study was to understand the barriers to accessing upper extremity (UE) reconstructive surgery among those living with tetraplegia, and to identify gaps in knowledge. Using standardized scoping review methods, a literature search was conducted using four databases and 1069 articles were procured. Two independent reviewers systematically screened the articles in two phases. Retrieved articles underwent thematic analysis using a constructivist grounded theory methodology. The reviewed articles (n = 25) were published between 2002 and 2019, and study designs included: cross-sectional (64%), retrospective (16%), and review articles (8%). Common barriers to UE reconstruction were categorized into factors related to patients, providers, and systems. These general domains included lack of awareness of UE reconstruction and its benefits among people with tetraplegia and providers, poor interdisciplinary working relationships, and a lack of specialized centers that provide these reconstructive surgeries. Specific patient-related barriers related to intrinsic (coping skills, trust, fear) and extrinsic (support network, finances, postoperative course) factors that influenced decision-making. There are many barriers that prevent individuals with tetraplegia from accessing surgery at different levels of the healthcare system. Establishing specialized centers with strong interdisciplinary working relationships and raising awareness about the advantages and disadvantages of UE reconstruction through peer networks may help to improve accessibility. Using a value-based, patient-centered approach by exploring how individuals with SCI weigh each decision factor when considering surgery may help providers develop treatment options that better align with their goals.

We report a retrospective series of 44 transfers in 26 patients in whom a functioning supinator nerve was transferred to a paralyzed posterior interosseous nerve through a single, anterior approach to re-animate hand opening in mid-cervical tetraplegia. Eighteen patients underwent concurrent nerve or tendon transfers to re-animate grasp and/or pinch through the same anterior incision. We evaluated the strength of the innervated muscle at mean follow-up of 24 months (range 12–27). The strength attained in our patients was equivalent to the strength after the transfer through a posterior approach reported in the literature. Nineteen of our patients were satisfied with the hand opening procedure. First webspace opening was the only variable to correlate with patient satisfaction. We conclude that the anterior approach yields similar results to the posterior approach and has the advantage of allowing easier access for simultaneously performing nerve or tendon transfers to reconstruct grasp and pinch. Level of evidence: IV

We summarize the long-term motor outcome and disability level in a cluster of pediatric patients with acute flaccid myelitis (AFM) associated with the enterovirus D68 outbreak in 2015.This is a nationwide follow-up questionnaire analysis study. Clinical data including the motor function (manual muscle strength test) and other neurological symptoms were collected at the acute (nadir), recovery (six months), and chronic (three years) stages. We use the Barthel index, which measures 10 variables describing activity of daily living and mobility to assess the disability level.Clinical data of 33 patients with AFM (13 females, 20 males; median age = 4.1 years) were available. Among patients with tetraplegia or triplegia, paraplegia, and monoplegia at the acute stage, two of seven, four of thirteen, and two of thirteen exhibited complete recovery without paralysis; of those five of seven, eight of thirteen, and two of thirteen showed improvement with lesser limb involvement at the chronic stage, respectively. Nine patients (27%) demonstrated improvement at the recovery-to-chronic period. All six patients with positive isolation of enterovirus D68 from biological samples at the acute stage showed persistent motor deficits. Other neurological findings had better prognosis than motor weakness. Better Barthel index score at the chronic stage was observed (P 0.001; median difference [95% confidence interval], 53 [40 to 63]), implying an improved disability level even in patients with persistent motor deficits.AFM has a high rate of persistent motor deficits showing one- to two-limb paralysis. Disability level of patients with AFM, however, generally improved at the three-year time point.

RESUMEN La extrusión de disco intervertebral intradural-intramedular es un subtipo de herniación del núcleo pulposo hidratado y se presenta luego de ejercicio extremo o eventos traumáticos. Esta es una condición rara y su diagnóstico puede ser complejo ya que sus características clínicas e imágenes están pobremente caracterizados. Se comunica el caso de un Schnauzer de seis meses que sufrió una caída desde una altura de dos pisos. El paciente desarrolló tetraplejía espástica y se diagnosticó como lesión medular aguda cervical de cuarto grado. Los estudios por radiografías y tomografía computarizada solo reportaron una fractura simple en cuerpo vertebral de C3. El estudio de resonancia magnética reportó tractos lineales intramedulares, lesiones parenquimatosas y volumen de disco reducido en C3-C4. La condición clínica y su evolución, así como los hallazgos por imágenes fueron compatibles con extrusión de disco intervertebral intradural-intramedular. ABSTRACT Intradural-intramedullary intervertebral disc extrusion (IIVDE) is a subtype of herniation of the hydrated nucleus pulposus and occurs after extreme exercise or traumatic events. IIVDE is a rare condition, and its diagnosis can be complex since its clinical characteristics and images are poorly characterized. The case of a six-month-old Schnauzer who suffered a fall from a height of two stories is reported. The patient developed spastic tetraplegia and was diagnosed as a fourth-degree acute cervical spinal cord injury. The radiographic and computed tomography studies only reported a simple fracture in the vertebral body of C3. The magnetic resonance study reported intramedullary linear tracts, parenchymal lesions and reduced disc volume in C3-C4. The clinical condition and its evolution, as well as the imaging findings were compatible with IIVDE.

CONTEXT: Autonomic dysreflexia (AD), characterized by a transient increase in systolic blood pressure (BP), is experienced by individuals with spinal cord injury (SCI) and can be purposefully induced (‘boosting’) to counteract autonomic dysfunction that impairs cardiovascular responses to exercise. Herein, we demonstrate the impact of unintentional boosting observed during cardiopulmonary exercise testing (CPET) in an inactive male with SCI (C5, motor-complete). FINDINGS: On two separate occasions the individual performed a standard arm-crank CPET (1-min stages, 7W increase in resistance) following by a longer CPET (4-min stages, 12W increase in resistance), both to volitional exhaustion. The second CPET was performed to confirm the accuracy of exercise intensity prescription and verify peak exercise parameters. Immediately following the second CPET on the initial visit, the individual reported symptoms of AD, verified as a 58mmHg increase in systolic BP from baseline. Relative to the first CPET, performed only 35 min earlier, there were pronounced differences in peak exercise responses. In comparison to the longer CPET performed on the second visit without a concomitant episode of AD (thereby controlling for the type of CPET protocol administered), peak exercise outcomes were considerably elevated: power output (Δ19W), oxygen uptake (Δ3.61 ml·( )kg·(−1)min(−1)), ventilation (Δ11.4 L ·min(−1)) and heart rate (Δ9 b·min(−1)). CONCLUSION/CLINICAL RELEVANCE: This case raises important considerations around the nuances of CPET in this population. In individuals susceptible to BP instability, the physiologically boosted state may explain a significant proportion of the variance in peak aerobic capacity and should be closely monitored before and after clinical CPET.

Spinal cord injuries (SCIs) are devastating consequences of traumatic injuries with far-reaching health and socioeconomic implications. The objectives of this study were to describe the epidemiological characteristics of traumatic SCI and to analyse these epidemiological and clinical characteristics. This study was a retrospective observational study. We extracted data from the medical records of all cases of acute traumatic SCI that presented at the hospital between January 2013 and December 2017. We recorded 99 cases of traumatic SCI over the study period. The patients’ mean age was 37.15 ± 13.5 years with a male predominance (68.7%). Working age group accounted for 83.9% of cases. Motor vehicular accident (MVA) and falls accounted for 62.6% and 22.2% respectively. About a third of the cases (32.3%) presented within 24 hours of injury. The most frequently affected level was the cervical spine (63.6%), and complete tetraplegia was the most prevalent clinical pattern (31.3%). American Spinal Injury Association impairment scale (AIS) improved in 31.3% of cases. Twenty-nine patients (30.2%) had morbidity, with 21.2% developing pressure sores. Mortality accounted for 3%. Motor vehicular crash and fall-related traumatic SCI affected mostly males and the working age group with complete tetraplegia as the predominating clinical pattern. There is a need for strategic interventions to reduce MVA and improve pre-hospital care and health policies to ensure early definitive care.

A Lesão da Medula Espinhal (LME) é caracterizada como condição traumática que ocasiona em danos neurológicos, e propicia alterações na composição corporal (CC) do indivíduo. Essas alterações na CC pode aumentar o risco de doenças. O objetivo do estudo foi analisar o perfil da composição corporal de indivíduos sedentários com lesão da medula espinhal, correlacionar as medidas de circunferência abdominal e circunferência cintura e verificar a aplicabilidade do método bioimpedância elétrica (BIA). Estudo descritivo de corte transversal. Amostra de 20 indivíduos com LME do sexo masculino. Para análise do percentual de gordura (%G) foi utilizada a BIA da marca Maltron BF-900. Para análise dos dados foi utilizado teste de Shapiro Wilk, para a normalidade dos dados e para a comparação dos valores entre os grupos paraplegia e tetraplegia utilizou-se o teste t de student.Resultados: 45% estão com peso adequado, 50% estão sobrepeso e 5% estão com Obesidade grau I. O %G foi classificado da seguinte forma, 10% se encontram na média, 45% estão acima da média e 45% apresentam um índice muito alto.Conclusão: Os participantes apresentaram elevado percentual de gordura corporal e sobrepeso. A BIA se mostrou um método de fácil acesso para mesnurar a CC. Recebido em: 15/06/2020 Reformulado em: 08/07/2020 Aceito em: 13/07/2020

There is reduction in lung compliance in first week after spinal cord injury (SCI) that deteriorates further and neuroprotective therapies like strength training of respiratory muscles should begin in first month after SCI since both motor and sensory scores at baseline and their further recovery is maximum during this phase. Few studies on SCI subjects within first month of injury have supported use of resistive inspiratory muscle training (RIMT), but have advocated the need for further research in this patient population owing to pitfalls in these studies. The present study was a prospective randomized control trial being carried out to determine whether RIMT programme of four weeks duration is effective in improving respiratory functions and strength in motor complete cervical SCI patients (AIS grade A, B) during in-patient rehabilitation. Patients within first week of cervical SCI (C4-C7 level) were assigned to RIMT (48 patients) and Control (48 patients) group and completed 40 supervised training sessions over a period of four weeks. Outcome measures included: - Spirometry, inspiratory and expiratory muscle strength. No significant differences of Chi-square test (P < 0.05) and unpaired “t” test (P < 0.05) were found between RIMT and Control group for all demographic and pre-training measurements. Following results were recorded after 2 weeks and 4 weeks of training on all outcome measures: - Highly significant difference (P

Objective The purpose of this study was to report on long-term effects of low-frequency stimulation of the pelvic somatic nerves in patients with chronic spinal cord injuries who underwent laparoscopic implantation of neuroprosthesis (LION) in the pelvic lumbosacral nerves. Design Observational case report. Setting Tertiary referral unit specialized in advanced gynecologic surgery and neuropelveology. Participants Patients (N=29) with chronic SCI who underwent a LION procedure to the pelvic lower motor neurons for the recovery of standing and walking motion. Our study is not composed of preselected patients but includes patients across the entire range of SCIs: patients with paraplegia, patients with tetraplegia (except for high tetraplegia), patients with complete and incomplete SCIs, and even patients with flaccid or spastic paralysis. Intervention Patients underwent in-body functional electrical stimulation–assisted locomotor training and continuous low-frequency pelvic lumbosacral nerve neuromodulation. Main Outcome Measures Evolution of American Spinal Injury Association (ASIA) sensory score, ASIA Lower Extremity Motor Score, and Walking Index. Results All patients with incomplete SCI regained some voluntary control of previously paralyzed muscles after a few months of stimulation training. With a follow-up of 9 years, 20 patients (71.4%) were able to demonstrate an electrically assisted voluntary extension of the knee. Twenty-six patients could get to their feet when the pacemaker was switched on (92.8%). Five patients could walk 10 m (67.8%), 8 of them only at the bar (28.5%) and 11 of them with the aid of crutches or a walker and without braces (40%). Conclusions The major finding of our study is that 17 of 25 patients with complete motor chronic SCI (68%) developed enough recovery of supraspinal control of leg movements that voluntary walking became feasible, even though a minimal amount of stimulation may be required.

Introduction Neuromyelitis optica (NMO) and NMO spectrum disorders (NMO-SD) are inflammatory demyelinating diseases of the central nervous system. There are few epidemiological studies devoted to NMO, especially in Africa and the Middle East, but individual cases and series have been reported from many countries across the African continent. Objectives To describe the epidemiology, diagnosis, and management of NMO patients followed at the Mohammed VI University Hospital of Marrakech. Patients and methods This was a hospital-based retrospective study of 52 patients with NMO diagnosed and followed at the Neurology department of the University Hospital of Marrakech from 2004 to July 2019. The 2006 diagnostic criteria of NMOSD were used for patients admitted before 2015 for inflammatory disease of the central nervous system and the 2015 diagnostic criteria of NMO-SD for all patients thereafter. Collected data were analysed using SPSS software. Results The study concerned 52 patients, 18 males and 34 females. Median age at disease onset was 32.5 years (range 7–55). Mean time between symptom onset and diagnosis of NMO was nine months 18 days (range 7 days to 4 years). In most patients, manifestations included visual acuity, tetraparesis, and sensorial disorders. Refractory vomiting and hiccup were noted in the first attack in 19% of patients. Two patients had hypersomnia and polyphagia, and one had been treated for depression ten months before the development of severe tetraplegia. Magnetic resonance imaging did not show any brain lesions in 29% of patients. Cervical myelitis extending to more than three vertebrae was found in 60% of patients. AQP4-antibody assay was performed only in 57.7% of patients, and was positive in 38.4%; anti-MOG was positive in four anti-AQP4 seronegative patients. Management strategies for NMO-SD included methylprednisolone pulses (70% of patients), plasmapheresis (25%), and rituximab (since 2017) for 46%. Outcome was favourable in 40% of patients and has remained stable in 50% of them. Conclusion Anti-NMO assays, made available during the last five years with the help of The Guthy-Jackson Charitable Foundation, have led to a clear jump in the number of cases diagnosed. Major advances in the field of epidemiology, imaging, and pathophysiology of NMO-SD have led to improved patient care and outcome.

Objectives To evaluate the incidence and epidemiologic characteristics of acquired nontraumatic spinal cord injury (NTSCI) in Finland. Design Prospective 4-year epidemiologic multicenter study. Setting Two of the 3 spinal cord injury (SCI) centers in Finland responsible for acute care, immediate rehabilitation, and lifelong follow-up for all SCI patients in a population of 3,073,052 (as of 2013). Participants All newly diagnosed NTSCI patients (N=430) admitted to Tampere University Hospital between 2012 and 2015 and Oulu University Hospital between 2013 and 2016 based on the evaluation of the designated rehabilitation teams. Patients with NTSCI resulting from congenital etiologies or progressive neurologic diseases were excluded. Interventions Not applicable. Main Outcome Measures Incidence and variables, according to the International SCI Core Data Set and the International Standards for Neurological Classification of SCI, including etiology and the severity of injury. Results The incidence of NTSCI was 54.1 per million per year. NTSCI was more common in men (n=260, 60.5%) than women (n=170, 39.5%). The mean age was 62.0±14.6 years old. Degenerative causes were the most common etiology (n=219, 50.9%), followed by malignant (n=88, 20.5%) and benign (n=41, 9.5%) neoplasms. The injury resulted in tetraplegia in 177 patients (41.1%) and paraplegia in 249 patients (57.9%). American Spinal Injury Association Impairment Scale grade D injuries were common, with an incidence of 71% (n=304). Specialized inpatient rehabilitation was needed in 44% (n=189) of the cases. Conclusions There are no previous studies on the epidemiology of NTSCI in Finland, and international reporting has been limited. The incidence of NTSCI in our study was substantially higher than in most previous studies, which was likely owing to our study including individuals with less severe lesions who did not require inpatient rehabilitation.

From the U.S. president fist-bumping a brain-controlled robotic arm to monkeys playing brain-controlled Pong, the past few years have had a surge of neural interfaces in the news. Neural interfaces, which are used in brain–machine interface (BMI) and neurostimulation technologies, often conjure images of mind-controlled cyborgs and mind uploading. In reality, they offer incredible hope for patients with intractable neurological conditions. For example, just nine years ago came the first demonstration of a woman with tetraplegia (paralysis from the chest down) controlling a robotic prosthetic arm through electrical signals recorded directly from her brain, specifically, the motor cortex, which controls movement [1] . For 15 years, she had been unable to perform basic daily tasks, such as eating and drinking on her own, but with a BMI, she demonstrated the ability to pick up a cup of coffee and take a sip.

Background: The manual muscle test (MMT) is the traditional method to assess the intrinsic hand muscle test. However, this test is qualitative and subjective. A device capable of rapidly measuring motor output along a linear scale may be of value in the evaluation of hand recovery from any neurological impairment. Objective: To demonstrate inter-rater reliability of the Peg Restrained Intrinsic Muscle Evaluator (PRIME) device for measuring intrinsic hand muscle strength in adults with impaired hand functions. Methods: 16 subjects (2 female, 14 male, mean age=47±15 years) with cervical spinal cord injury were enrolled. Intrinsic hand muscle strength of adults were performed by two-tester with use of PRIME device and manual muscle testing, within the same session. Inter-tester correlation was tested by Pearson's correlation and Intraclass correlation coefficient (ICC). Results: Intraclass correlation coefficients for hypothenar, first dorsal interosseous, abductor pollicis brevis and opponence pollicis muscles ranged from 0.7 to 0.8 with hypothenar muscle test being lowest ICC=0.7 and thumb opposition highest, ICC=0.81. Conclusion: Results from this study suggest that PRIME device demonstrates good reliability within testers for quantified measuring of intrinsic hand muscle strength. Further use of PRIME in clinic will aid in diagnostics, medical decision making and evaluation of rehabilitation progress in patients with cervical spinal cord injury.

A 12-year-old castrated male dog with nonambulatory tetraplegia was diagnosed with spinal stenosis at C3-C4 through X-ray examination and with ventral extradural spinal compression at C3-C4 through myelography and computed tomography. The diagnosis of traditional Chinese veterinary medicine was local Qi and blood stagnation, spleen Qideficiency, blood deficiency, and kidney Yang deficiency. We initiated treatment using a combination of acupuncture and Chinese medicine iontophoresis with laser therapy. After 12 treatment days, there was a significant improvement in the dog's ambulation function, which was indicated by proper walking and flexible head-turning.This indicates that combining acupuncture and Chinese medicine iontophoresis could be a potential treatment for chronic progressive cervical intervertebral disk disease in dogs.Fallbericht: Bei einem 12-jährigen kastrierten Rüden mit Tetraplegie und Gehunfähigkeit wurde mittels Röntgenuntersuchung eine Spinalkanalstenose bei C3–C4 diagnostiziert und mittels Myelographie und Computertomographie eine ventrale extradurale Spinalkanalkompression bei C3–C4 nachgewiesen. Die Diagnose gemäß der traditionellen chinesischen Tiermedizin lautete lokale Qi- und Blutstagnation, Mangel an Milz-Qi, Blutmangel und ein Nieren-Yang-Mangel. Wir leiteten eine Kombinationstherapie mit Akupunktur und Iontophorese der chinesischen Medizin sowie Lasertherapie ein. Nach 12 Behandlungstagen war eine signifikante Verbesserung der Gehfunktion des Hundes zu beobachten, die sich durch regelrechtes Gehen und flexibles Drehen des Kopfes zeigte. Schlussfolgerung: Dies spricht dafür, dass die Kombination von Akupunktur und Iontophorese der chinesischen Medizin eine potenzielle Behandlungsmöglichkeit bei chronisch progredienter zervikaler Bandscheibenerkrankung bei Hunden sein könnte.

Purpose The objective of this study was to understand veteran perspectives of grief/loss associated with their spinal cord injury (SCI). Design/methods Qualitative descriptive design using semistructured interviews with veterans with SCI (n = 15) was performed using interview questions informed by the literature. Analysis was conducted using a deductive/inductive approach. Results The 15 participants' mean age was 64 years; six had paraplegia, eight had tetraplegia, one had unknown level of injury, six were ambulatory, and nine were not ambulatory. The grief/loss experience was individual and constant, consisting of seven phases: experiencing shock, releasing emotion, withdrawing, focusing on losses, problem solving, realizing strength and motivation, and accepting a new life. Veteran coping strategies used in each phase of the grief experience were also identified, as well as triggers that increased or decreased the grief/loss experience. Conclusions/clinical relevance A better understanding of veterans' living with SCI grief experience, coping strategies, and triggering events can help healthcare providers support veterans with SCI.

Background: People with spinal cord injury (SCI) present with impaired autonomic control when the lesion is above T6. This could lead to delayed cardiorespiratory recovery following vigorous physical activity. Objectives: To characterize and compare gas exchange off-kinetics following exhaustive exercise in individuals with SCI and an apparently healthy control group. Methods: Participants were 19 individuals with SCI who presented with the inability to voluntarily lift their legs against gravity (age, 44.6 ± 14.2 years; AIS A, n = 5; AIS B, n = 7; AIS C, n = 7; paraplegia, n = 14; tetraplegia, n = 5) and 10 healthy comparisons (COM; age, 30.5 ± 5.3 years). All participants performed an arm ergometer cardiopulmonary exercise test (aCPET) to volitional exhaustion followed by a 10-minute passive recovery. O2 uptake (V̇o2) and CO2 output (V̇co2) off-kinetics was examined using a mono-exponential model in which tau off (τoff) and mean response time (MRT) were determined. The off-kinetics transition constant (Ktoff) was calculated as ΔV̇o2/MRT. Student t tests were used to compare SCI versus COM group means. Results: COM had a significantly higher relative peak V̇o2 compared to SCI (1.70 ± 0.55 L/min vs 1.19 ± 0.51 L/min, p = .019). No difference was observed for τoff between the groups, however Ktoff for both V̇o2 and V̇co2 was significantly lower in the SCI compared to the COM group. Conclusion: A reduced Ktoff during recovery may suggest inefficiencies in replenishing muscle ATP stores and lactate clearance in these participants with SCI. These findings may contribute to the observed lower cardiorespiratory fitness and greater fatigability typically reported in individuals with SCI.

Objectives: To compare a standardized submaximal intensity (based on the rate of perceived exertion [RPE]) with the percentage of the average and peak torque during a familiarization session in individuals with different spinal cord injury (SCI) levels in gravity-resisted and gravity-assisted movements. Methods: This was a cross-sectional study at a rehabilitation hospital. Thirty-six individuals stratified in tetraplegia (TP), high paraplegia (HP), and low paraplegia (LP) groups and 12 matched control participants (CG) were enrolled in the study. Participants performed a maximum strength test using isokinetic dynamometry. The familiarization consisted of 10 submaximal repetitions with a level 2 (i.e., 20% of the maximum score) in the Resistance Exercise Scale (OMNI-RES). Fisher’s exact test compared the percentages of the average torque (%ATFam) and peak torque (%PTFam) of the familiarization (based on the peak torque during the maximum strength tests) to the %ATFam and %PTFam attained with 20% of RPE. The coefficient of variation (CV) was calculated to assess the torque dispersion during each familiarization set. Results: The %ATFam was lower for gravity-assisted compared to gravity-resisted movements for HP, LP, and CG (p ≤ .05). The CV was significantly lower in gravity-resisted movements during familiarization for TP, LP, and CG. Conclusion: Different RPE levels should be adopted for gravity-resisted or gravity-assisted upper limb exercises to maintain the same relative intensity during a familiarization session.

Recovery of the upper extremity (UE) and hand function is considered the highest priority for people with tetraplegia, because these functions closely integrate with their activities of daily living. Spinal cord transcutaneous stimulation (scTS) has great potential to facilitate functional restoration of paralyzed limbs by neuro-modulating the excitability of the spinal network. Recently, this approach has been demonstrated effective in improving UE function in people with motor complete and incomplete cervical SCI. However, the research thus far is limited by the lack of a comprehensive assessment of functional improvement and neurological recovery throughout the intervention. The goal of this study was to investigate whether scTS can also facilitate UE functional restoration in an individual with motor and sensory complete tetraplegia. A 38-year-old male with a C5 level, ASIA Impairment Scale-A SCI (15 years post-injury, left hand dominant pre- and post-injury), received 18 sessions (60 minutes/session) of scTS combined with task-specific hand training over the course of 8 weeks. The total score of the Graded Redefined Assessment of Strength, Sensibility, and Prehension significantly improved from 72/232 to 96/232 at post-intervention, and maintained ranging from 82/232 to 86/232 during the three months follow-up without any further treatment. The bilateral handgrip force improved by 283.4% (left) and 30.7% (right), respectively at post-intervention. These strength gains were sustained at 233.5% -250% (left) and 11.5%-73.1% (right) during the follow-up evaluation visits. Neuromuscular Recovery Scale demonstrated dramatic and long-lasting improvements following the completion of the intervention. Changes of spinal motor evoked potentials from pre- to post-intervention indicated an increased level of spinal network excitability. The present data offer preliminary evidence that the novel scTS intervention combined with hand training can enhance UE functional use in people with motor and sensory complete SCI.

Spinal cord injury (SCI) results in motor paralysis and sensory loss that places individuals at particularly high risk of pressure injuries. Multiple comorbidities associated with autonomic, cardiovascular, pulmonary, endocrine, gastrointestinal, genitourinary, neurological, and musculoskeletal dysfunction makes it even more likely that pressure injuries will occur. This manuscript will review the structure and function of the integumentary system, and address the multidisciplinary approach required to prevent and manage pressure injuries in this vulnerable population.