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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.

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.

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.

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.

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

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.

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.

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.

It is estimated that up to 2500 people are injured or diagnosed with a spinal cord injury (SCI) within the UK every year (this was previously thought to be 1000 new cases each year). This corresponds to 35 newly diagnosed patients per week. These injuries can vary in ability to recover from complete to incomplete primarily depending on the location and level of the injury producing tetraplegia, hemiplegia or paraplegia. There is no known cure or effective treatment to reverse the damage that occurred to the spinal cord at the time of injury. The aim of rehabilitation following a SCI is to provide patients with the skill set, confidence and equipment to return to as full and independent a life as possible. This can only be achieved through a multidisciplinary holistic approach and a close collaboration between the patient, family and clinical teams.

With improvements in medical care, pediatric patients with spinal cord injuries with tetraplegia are living into adulthood. The goal of rehabilitation following loss of upper extremity function caused by tetraplegia is to maximize function and independence. Physiatrists must be aware of appropriate timing of referral for upper extremity surgery because it can have significant ramifications on the outcome. This article discusses the 2 most commonly used surgical strategies to restore upper extremity function: upper extremity tendon transfer and nerve grafting/transfer. Patient selection, physical examination, electrodiagnostic evaluation, and optimization of postoperative rehabilitation are important.

Objectives To update the French guidelines on the management of trauma patients with spinal cord injury or suspected spinal cord injury. Design A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Methods The committee studied twelve questions: (1) What are the indications and arrangements for spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few days in hospital? (4) What is the best way to manage these patients to improve their long-term prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® Methodology. Results The experts’ work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/−) and 12 have a low level of evidence (GRADE 2+/−). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. Conclusions There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

Background The diaphragm pacemaker (DP) has proven its utility in replacing mechanical ventilation in patients with chronic spinal cord injury (SCI) and amyotrophic lateral sclerosis (ALS). The DP improves patient quality of life and reduces morbidity and mortality and their associated health care costs. The anesthetic management of these patients and the particularities of the surgical procedure are challenging. The aim of our study is to analyze anaesthetic management and intraoperative complications in patients undergoing DP placement in our hospital. Methods We performed a chart review of patients treated between December 2007 and July 2017, recording the patients' preoperative status, anesthetic management and intraoperative complications. Results The study included 16 patients (5 pediatric) undergoing DP implantation for chronic SCI (63%), ALS (25%) and other neurologic conditions (12%). Abdominal laparoscopy was performed under general anesthesia, with intravenous (87%) or inhalational (13%) induction and maintenance using total intravenous (50%) or balanced (50%) anesthesia. Rocuronium was administered in one case to permit airway management. Complications included: hypotension (50%), difficulties in mechanical ventilation during laparoscopy (31%), pneumothorax (12.5%) and autonomic dysreflexia (6%). Conclusions DP placement under general anaesthesia is a safe intervention in both adult and paediatric patients. Complications derived from both the underlying disease and the surgical technique may appear, and must be rapidly identified and treated to obtain a satisfactory surgical outcome.

Objective To describe continuous positive airway pressure (CPAP) use for treatment of obstructive sleep apnea (OSA) in acute tetraplegia, including adherence rates and associated factors. Design Secondary analysis of CPAP data from a multinational randomized controlled trial. Setting Inpatient rehabilitation units of 11 spinal cord injury centers. Participants : People with acute, traumatic tetraplegia and OSA (N=79). Interventions Autotitrating CPAP for OSA for 3 months. Main Outcome Measures Adherence measured as mean daily hours of use. Adherent (yes/no) was defined as an average of at least 4 hours a night throughout the study. Regression analyses determined associations between baseline factors and adherence. CPAP device pressure and leak data were analyzed descriptively. Results A total of 79 participants from 10 spinal units (91% men; mean age ± SD, 46±16; 78±64d postinjury) completed the study in the treatment arm and 33% were adherent. Mean daily CPAP use ± SD was 2.9±2.3 hours. Better adherence was associated with more severe OSA (P=.04) and greater CPAP use in the first week (P Conclusion Adherence to CPAP after acute, traumatic tetraplegia is low. Early acceptance of therapy and more severe OSA predict CPAP use over 3 months. People with acute tetraplegia require less pressure to treat their OSA than the nondisabled; however, air leak is high. These findings highlight the need for further investigation of OSA treatment in acute tetraplegia.

Objective To investigate the association between insurance provider and reported assistive technology (AT) use to access computers and electronic devices 1 year after sustaining tetraplegia. Design Multicenter cross-sectional study. Setting Participants enrolled in the Spinal Cord Injury Model Systems (SCIMS) National Database. Interventions Not applicable. Participants Men and women with tetraplegia (N=498) enrolled in the SCIMS National Database were included in the analysis. Main Outcome Measures The primary study outcome was the use of AT when operating a computer or other mobile electronic device. The primary predictor was the subject’s principal health insurance provider, which was grouped into the 3 categories: government (Medicare, Medicaid, and other government), private (private insurance, private funds, and other), and workers’ compensation. Results Overall, 34.7% of participants reported using AT to access computers and electronic devices. Results of logistic regression analysis revealed sex, injury level, injury completeness, self-perceived health status, and 12-month history of pressure ulcer were all significantly associated with AT use. After adjusting for these factors, participants with workers’ compensation were more likely to report AT use than individuals with either government or private insurance. Conclusions Despite significant technological advances, AT is not readily available to the people who might benefit most from its use. Findings from the present study are the first to shed light on AT funding sources and reveal that individuals with workers’ compensation are more likely use AT than individuals with either government or private insurance. Additional work focused on AT use and functional outcomes is needed to assess the effect of barriers to use. Collectively, this work may inform insurers of the importance of having AT available for this unique population to potentially improve quality of life and participation.

Cervical spinal cord injury (cSCI) is a major public health concern in the young population as per the estimation of the annual global report, which concluded that the amount of incidence in this area ranged between 11.5 and 53.4 cases per million population. Moreover, Despite the many evaluations conducted to unveil the physiological and thermo logical complications caused to the human body after a cervical spinal cord injury, the fundamental pathophysiology about this type of injury is still inconclusive.This review attempts to provide a better understanding to the various changes caused to the body after a cSCI. It focuses on the alterations in blood circulation, energy expenditure (EE), sweating, shivering responses and consequently disruption in body temperature regulation.Various research engines such as Scopus, PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases were searched by two independent investigators. 17 studies out of 102 were included based on eligibility criteria: patients with complete and/or incomplete cSCI; minimum of 5 patients as participants; and control group of able Bodied People (AB).Following cSCI, EE decreases by 10% (p 0.05) due to reduction in lean body mass; cardiac output decrements by 27% (p 0.05) following the change in arterial blood vessel structure, and finally; thermoregulatory responses were disturbed because of the absence or decrease in vasodilation, vasoconstriction, sudomotor (autonomic activation of sweat glands) and shivering responses.The body undergoes significant thermoregulatory changes following spinal cord injury. Understanding the pathophysiology of spinal cord injury and its effect on the human body can provide us an insight to develop adequate treatment modalities that tackle the problem of thermal dysregulation in people with cSCI.

Background Three-dimensional gait analysis (3DGA) has not previously been considered by consensus panels of spinal cord experts for use in studies of patients with spinal cord damage (SCD), yet it is frequently used in other neurological populations, such as stroke and cerebral palsy. Research question How does 3DGA impairment based reporting guide individualised clinical decision-making in people with incomplete SCD? Methods Retrospective open cohort case series recruited 48 adults with incomplete SCD (traumatic or non-traumatic spinal cord dysfunction) referred to the Clinical Gait Analysis Service (CGAS), Melbourne, Australia. Three-dimensional gait data were used to identify gait impairments by the multidisciplinary clinical team. Gait patterns were classified using the plantarflexor-knee extension couple index and the Gait Profile Score (GPS). The reason for referral and the recommendations made post-3DGA were collated in decision trees to extrapolate the potential value of 3DGA in decision making for targeted intervention in this population. Results Participants with SCD generally walked at a reduced gait speed. When grouped by neurological level, the tetraplegia group had a significantly lower GPS, but no specific gait patterns emerged. Participants were primarily referred to the CGAS to direct clinical intervention decisions. The most frequent recommendation following 3DGA was the prescription of an ankle foot orthosis and in some cases, the recommendation was incongruent with the referrer’s proposed intervention. Significance 3DGA can provide specific guidance in management plans for gait of patients with incomplete SCD and may help to avoid inappropriate or unnecessary interventions. This sample of patients referred to the CGAS demonstrates its clinical utility in guiding clinicians in their decision making to target individualised intervention.

Study design observational study. Objectives Heart rate variability (HRV) studies have shown that the low-frequency (LF) domain is decreased in postural challenge of spinal cord injury (SCI). However, there are inconsistencies in the literature regarding HRV with postural challenge. We believed that asymptomatic orthostatic hypotension (OH) may contribute to the discrepancies in the literature. We also evaluated the time-domain parameters of HRV to evaluate for changes in SCI postural challenge. We looked at the association of Frequency and Time-domain HRV parameters to blood pressure (BP) and postural challenge in SCI based on groups with and without OH. Setting SCI clinic. Methods Patients from SCI clinic were enrolled and 5-minute electrocardiogram (ECG) recordings were performed before and after a postural challenge from supine to sitting position with blood pressure (BP) recordings at each time point. Between and within group analyses were performed based on tetraplegia, paraplegia, and the presence of asymptomatic OH. Results There were 6 controls and 18 SCI subjects, 4 with OH based on change in diastolic BP. After postural challenge, mean heart rate was lower in tetraplegia compared to controls in all groupings. When OH was removed from the groups, total power was consistently reduced in tetraplegia compared to paraplegia across all positions. There were both time- and frequency-domain differences observed in SCI with OH compared to SCI without. Conclusions Autonomic variability is increased in SCI with OH and can lead to misinterpretation of findings if asymptomatic OH is included in samples. Our data suggest that there are frequency- and time-domain differences in HRV variables in those with OH compared to those without. Future HRV studies should account for asymptomatic OH and include analyses of the time-domain variables in postural challenge of SCI.

Tetraplegia resulting from cervical injury is the most frequent neurologic category after spinal cord injury and causes substantial disability. The residual strength of partially paralyzed muscles is an important determinant of independence and function in tetraplegia. Small improvements in upper extremity function can make a clinically significant difference in daily activities. Major advances in rehabilitation technologies over the past 2 decades have allowed testing of robotic devices in rehabilitation of motor impairments. This literature assessment provides an overview of robotic-assisted training research for improving arm and hand functions after cervical spinal cord injury.

Individuals living with spinal cord injury or disease (SCI/D) are at increased risk for sleep-disordered breathing (SDB), with a prevalence that is three- to fourfold higher than the general population. The main features of SDB, including intermittent hypoxemia and sleep fragmentation, have been linked to adverse cardiovascular outcomes including nocturnal hypertension in patients with SCI/D. The relationship between SDB and SCI/D may be multifactorial in nature given that level and completeness of injury can affect central control of respiration and upper airway collapsibility differently, promoting central and/or obstructive types of SDB. Despite the strong association between SDB and SCI/D, access to diagnosis and management remains limited. This review explores the role of SCI/D in the pathogenesis of SDB, poor sleep quality, the barriers in diagnosing and managing SDB in SCI/D, and the alternative approaches and future directions in the treatment of SDB, such as novel pharmacologic and nonpharmacologic treatments.

Background Multiple sclerosis is a disorder of the central and peripheral nervous system of young and old adults that is characterized by muscle, coordination and vision abnormalities. Multiple sclerosis is likely due to numerous causes. Methods Recently, adolescents and adults with ophthalmological and or neurological findings have been diagnosed with biotinidase deficiency. These individuals have exhibited myelopathy, paresis and/or spastic diplegia/tetraplegia with or without optic neuropathy/vision loss. These older individuals with biotinidase deficiency were considered initially to have multiple sclerosis or similar disorders before they were determined to have biotinidase deficiency. Results If a symptomatic individual with biotinidase deficiency is treated with biotin early enough, the symptoms markedly improve or completely resolve, but if treatment is delayed, the symptoms may be irreversible. Conclusion Therefore, although biotinidase deficiency is rare relative to that of multiple sclerosis, the disorder should be included in the differential diagnosis of individuals thought to have multiple sclerosis or related disorders. Biotinidase deficiency should be considered in individuals thought to have multiple sclerosis or related disorders.

Objective To assess the feasibility of measuring ventilatory threshold (VT) in higher-level motor-complete spinal cord injury (SCI) using 4 different analysis methods based on noninvasive gas exchange. Design Observational. Setting Laboratory testing. Participants Individuals with C4-T6 motor-complete SCI (16 paraplegia, 22 tetraplegia; American Spinal Injury Association Impairment Scale A/B; 42±10 years old). Interventions Not applicable. Main Outcome VT from a graded arm cycling test to volitional exhaustion using 4 methods: ventilatory equivalents, excess CO2, V-slope, and combined method. Results VT could be identified in all individuals with paraplegia, but in only 68% of individuals with tetraplegia. Individuals without observable VT completed the graded exercise test with lower ventilatory rate, peak power output, and peak oxygen consumption (V o 2 peak) (all P V . o 2 at VT with individual methods were all correlated to peak power output (r>0.74; P o 2 peak (r>0.91; P Conclusions The assessment of VT is a feasible alternative to peak exercise testing for aerobic fitness in individuals with higher-level, motor-complete SCI, although care should be taken when interpreting VT in individuals with tetraplegia who have lower cardiorespiratory fitness and lower peak power outputs.

Objectives To specify outcomes and identify prognostic factors of neurologic and functional recovery in patients with an acute traumatic spinal cord injury (SCI) associated with cervical spinal canal stenosis (SCS), without spinal instability. Methods A retrospective study was conducted using data from a Regional Department for SCI rehabilitation in France. A description of the population characteristics, clinical data and neurological and functional outcomes of all patients treated for acute SCI due to cervical trauma associated with SCS was performed. A statistical analysis provided insights into the prognostic factors associated with the outcomes. Results Sixty-three patients (mean age 60.1 years) were hospitalized for traumatic SCI with SCS and without instability between January 2000 and December 2012. Falls were the most frequent cause of trauma (77.8%). At admission, most patients had an American Spinal Injury Association Impairment Scale (AIS) grade of C (43.3%) or D (41.7%) and the most frequent neurological levels of injury were C4 (35.7%) and C5 (28.6%). Clinical syndromes were frequently identified (78.6%), with the most frequent being the Brown-Sequard plus syndrome (BSPS) (30.9%), followed by central cord syndrome (CCS, 23.8%). Almost 80% of survivors returned to the community, 60% were able to walk and 75% recovered complete voluntary control of bladder function. Identified prognostic factors of favourable functional outcomes were higher AIS at admission, age under 60 years and presence of BSPS or CCS. Conclusion Traumatic SCI, associated with SCS results mostly in incomplete injuries, can cause various syndromes and is associated with favourable functional outcomes.

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Background: Damage to lower motor neuron causes denervation and degeneration of the muscles affected. Experimental and clinical studies of muscle denervation in lower extremities demonstrated that direct electrical stimulation (ES) of muscle can prevent denervation atrophy and restore contractility. The aim of this study was to identify possible myogenic effect of ES on denervated forearm and hand muscles in persons with spinal cord injury (SCI) and tetraplegia. Methods: This prospective interventional study with repeated measurement design included 22 patients aged 48·6 (± 15·7), 0·25 (0·1/46) years after spinal cord lesion, AIS A-D. In each patient, two electrophysiologically-confirmed denervated muscles in the hand and forearm were analyzed – one extrinsic (Extensor Carpi Ulnaris - ECU) and one intrinsic (1st Dorsal Interosseus - IOD1). Muscles were stimulated for 33 min, five times per week over a 12-weeks period. Using ultrasonography (USG), muscle thickness (MT) and pennation angle (PA) of these muscles were determined at start and end of the stimulation period. Findings: MT of IOD1 increased from 6·3 mm (± 3·2 mm) to 9·2 mm (± 2·4 mm) (p = 0·004) and the PA from 5·5° (± 3·0°) to 11° (± 2·2°) (p = 0·001). The corresponding values for the ECU were 5·5 mm (± 2·5 mm) to 7·0 mm (± 2·2 mm) (p = 0·039) and 5·5° (± 3·4°) to 9·4° (± 3·8°) (p = 0·005), respectively. The correlation of MT between baseline and completion was r = 0·58 (p = 0·037) for the ECU and r = 0·63 (p = 0·008) for the IOD1. Interpretation: 12 weeks of direct muscle stimulation increases the MT and PA of the denervated intrinsic and extrinsic hand muscles studied. Funding: Swiss Paraplegic Centre, Switzerland

Objectives: Athletes with high level spinal cord injuries (tetraplegia) are under greater thermal strain during exercise than the able-bodied. The purpose of this study was to investigate the effectiveness of pre-cooling using an ice vest and the combination of pre-cooling and cooling during play using water sprays in athletes with tetraplegia.\ud \ud Design: Counter-balanced, cross-over design.\ud \ud Methods: Eight wheelchair rugby players with tetraplegia completed a 60 min intermittent sprint protocol (ISP) on a wheelchair ergometer in 20.2 °C ± 0.2 °C and 33.0% ± 3.1% relative humidity. The ISP was conducted on three occasions; no cooling (NC), pre-cooling with an ice vest (P) and pre-cooling with an ice vest and water sprays between quarters (PW). Gastrointestinal (Tgi) temperature, mean skin temperature (Tsk) and perceptual responses were measured throughout.\ud \ud Results: At the end of pre-cooling, the change in Tgi was not significantly different between conditions (P > 0.05) but the change in Tsk was significantly greater in P and PW compared to NC (P < 0.001). The change in Tgi over the ISP was significantly lower in PW and P compared to NC (P < 0.05), whilst the change in Tsk was lower in PW compared to P and NC (P < 0.05). Cooling had no effect on performance or perceptual responses (P > 0.05).\ud \ud Conclusions: Water spraying between quarters combined with pre-cooling using an ice vest lowers thermal strain to a greater degree than pre-cooling only in athletes with tetraplegia, but has no effect on simulated wheelchair rugby performance or perceptual responses.

Summary Background People with chronic tetraplegia, due to high-cervical spinal cord injury, can regain limb movements through coordinated electrical stimulation of peripheral muscles and nerves, known as functional electrical stimulation (FES). Users typically command FES systems through other preserved, but unrelated and limited in number, volitional movements (eg, facial muscle activity, head movements, shoulder shrugs). We report the findings of an individual with traumatic high-cervical spinal cord injury who coordinated reaching and grasping movements using his own paralysed arm and hand, reanimated through implanted FES, and commanded using his own cortical signals through an intracortical brain–computer interface (iBCI). Methods We recruited a participant into the BrainGate2 clinical trial, an ongoing study that obtains safety information regarding an intracortical neural interface device, and investigates the feasibility of people with tetraplegia controlling assistive devices using their cortical signals. Surgical procedures were performed at University Hospitals Cleveland Medical Center (Cleveland, OH, USA). Study procedures and data analyses were performed at Case Western Reserve University (Cleveland, OH, USA) and the US Department of Veterans Affairs, Louis Stokes Cleveland Veterans Affairs Medical Center (Cleveland, OH, USA). The study participant was a 53-year-old man with a spinal cord injury (cervical level 4, American Spinal Injury Association Impairment Scale category A). He received two intracortical microelectrode arrays in the hand area of his motor cortex, and 4 months and 9 months later received a total of 36 implanted percutaneous electrodes in his right upper and lower arm to electrically stimulate his hand, elbow, and shoulder muscles. The participant used a motorised mobile arm support for gravitational assistance and to provide humeral abduction and adduction under cortical control. We assessed the participant's ability to cortically command his paralysed arm to perform simple single-joint arm and hand movements and functionally meaningful multi-joint movements. We compared iBCI control of his paralysed arm with that of a virtual three-dimensional arm. This study is registered with ClinicalTrials.gov, number NCT00912041. Findings The intracortical implant occurred on Dec 1, 2014, and we are continuing to study the participant. The last session included in this report was Nov 7, 2016. The point-to-point target acquisition sessions began on Oct 8, 2015 (311 days after implant). The participant successfully cortically commanded single-joint and coordinated multi-joint arm movements for point-to-point target acquisitions (80–100% accuracy), using first a virtual arm and second his own arm animated by FES. Using his paralysed arm, the participant volitionally performed self-paced reaches to drink a mug of coffee (successfully completing 11 of 12 attempts within a single session 463 days after implant) and feed himself (717 days after implant). Interpretation To our knowledge, this is the first report of a combined implanted FES+iBCI neuroprosthesis for restoring both reaching and grasping movements to people with chronic tetraplegia due to spinal cord injury, and represents a major advance, with a clear translational path, for clinically viable neuroprostheses for restoration of reaching and grasping after paralysis. Funding National Institutes of Health, Department of Veterans Affairs.

Objectives To describe long-term outcomes of neurogenic bowel dysfunction (NBD), determine changes over time in the type of bowel program, and determine changes in psychosocial outcomes associated with NBD-related factors in adults with pediatric-onset spinal cord injury (SCI). Design Longitudinal cohort survey. Follow-up occurred annually for a total of 466 interviews, with most participants (75%) contributing to at least 3 consecutive interviews. Setting Community. Participants Adults (N=131) who had sustained an SCI before the age of 19 years (men, 64.1%; tetraplegia, 58.8%; mean age ± SD, 33.4±6.1y; mean time since injury ± SD, 19.5±7.0y). Interventions Not applicable. Main Outcome Measures Type and evacuation time of bowel management programs; standardized measures assessing life satisfaction, health perception, depressive symptoms, and participation. Generalized estimating equations were formulated to determine odds of change in outcomes over time. Results At first interview, rectal suppository/enema use was most common (51%). Over time, the likelihood of using manual evacuation (odds ratio [OR]=1.077; 95% confidence interval [CI], 1.023–1.134; P =.005), oral laxatives (OR=1.052; 95% CI, 1.001–1.107; P =.047), and colostomy (OR=1.071; 95% CI, 1.001–1.147; P =.047) increased, whereas the odds of rectal suppository use decreased (OR=.933; 95% CI, .896–.973; P =.001). Bowel evacuation times were likely to decrease over time in participants using manual evacuation (OR=.499; 95% CI, .256–.974; P =.042) and digital rectal stimulation (OR=.490; 95% CI, .274–.881; P =.017), but increase for rectal suppository/enema use (OR=1.871; 95% CI, 1.264–2.771; P =.002). When the level of injury was controlled for, participants using manual evacuation and digital rectal stimulation were more likely to have increases in community participation scores ( P Conclusions Changes in type of bowel program over time may be associated with the time required to complete bowel evacuation in this relatively young adult SCI population.

Obstructive sleep apnoea (OSA) is highly prevalent in people with tetraplegia. Nasal congestion, a risk factor for OSA, is common in people with tetraplegia. The purpose of this study was to quantify objective and perceived nasal resistance and its stability over four separate days in people with tetraplegia and OSA (n=8) compared to able-bodied controls (n=6). Awake nasal resistance was quantified using gold standard choanal pressure recordings (days 1 and 4) and anterior rhinomanometry (all visits). Nasal resistance (choanal pressure) was higher in people with tetraplegia versus controls (5.3[6.5] vs. 2.1[2.4] cmH2O/L/s, p=0.02) yet perceived nasal congestion (modified Borg score) was similar (0.5[1.8] vs. 0.5[2.0], p=0.8). Nasal resistance was stable over time in both groups (CV=0.23±0.09 vs. 0.16±0.08, p=0.2). These findings are consistent with autonomic dysfunction in tetraplegia and adaptation of perception to high nasal resistance. Nasal resistance may be an important therapeutic target for OSA in this population but self-assessment cannot reliably identify those most at risk.

Persons without spinal cord injury (SCI) physiologically acclimate between seven to fourteen consecutive days of exercise in the heat. Decreased resting and exercise core temperature, decreased heart rate, increased plasma volume and increased thermal comfort during exercise are changes consistent with heat acclimation. Autonomic dysfunction after SCI impairs heat dissipation through sweating and vasodilation. The purpose of this study is to determine if seven consecutive days of exercise in the heat would result in physiologic changes consistent with heat acclimation in persons with SCI. Ten persons with SCI divided into two groups: tetraplegia (n=5) and paraplegia (n=5) exercised in 35°C using an arm ergometer at 50% Wpeak for 30min followed by 15min rest. This protocol was repeated over seven consecutive days. Heart rate (HR), skin temperature, aural temperature (Taur), rate of perceived exertion (RPE), rate of perceived thermal strain (RPTS), and plasma volume (PV) were measured throughout the protocol. There were no significant differences in resting Taur exercise Taur, mean skin temperature, HR, PV, RPE or RPTS over the 7 days for either the tetraplegic or paraplegic group. Participants with SCI did not demonstrate the ability to dissipate heat more efficiently over 7 days of exercise at 35°C. The lack of heat acclimation seen in persons with SCI has implications for the athlete and non-athlete alike. For the SCI athlete, inability to acclimate will impair performance and endurance especially in warm environments, compared to the person without SCI. For the SCI non-athlete, there is a greater risk of heat-related illness in warm environments that can negatively affect participation in outdoor activities and thus quality of life.

Objectives To determine the diagnostic accuracy of a self-report measure of traumatic brain injury (TBI) in people with spinal cord injury (SCI), and to assess the potential effect of TBI on acute and postacute outcomes. Design Incident TBI as determined by self-report was compared with systematic medical records review by physicians blinded to self-reported TBI. Setting Inpatient rehabilitation unit. Participants From 155 consecutive admissions, participants (N=105; 73% men; mean age, 45.9y; 73% white; 58% with tetraplegia) who met inclusion criteria and were admitted on the day of injury were recruited and assessed. Interventions Not applicable. Main Outcome Measure Step 2 of the Traumatic Brain Injury-4 (TBI-4) interview was used to estimate the presence and severity of TBI. Results Estimated incidence of TBI was 33% by chart review and 60% based on Step 2 of the TBI-4. Ninety-one percent of those with TBI based on chart review sustained mild injuries. At the optimal cutoff of "possible TBI," the TBI-4 had a sensitivity of 83% (95% confidence interval, 66%–93%), a specificity of 51% (95% confidence interval, 39%–64%), and a Youden Index of 0.3 (95% confidence interval, 0.2–0.5). Compared with those without TBI, those with chart review–determined TBI had nonsignificant trends toward a longer acute care length of stay and a higher functional status at rehabilitation discharge, but equivalent 1-year outcomes. Conclusions Step 2 of theTBI-4 did not meet Youden's criteria (≥0.8) for good diagnostic accuracy in the context of recent SCI. Comorbid TBIs were almost exclusively mild and not associated with poorer outcomes 1 year after SCI.

Summary Objective The purpose of this study was to analyse the effect of one year of wheelchair rugby training on thoracoabdominal mobility and its association with lung volume in adults with tetraplegia. Equipment and methods Participants (10 male adults with chronic spinal cord injury at cervical level) underwent to regular training in wheelchair rugby. At the beginning and after one year of training, lung volume and tridimensional mobility of four-chest wall compartments (superior and inferior thorax, superior and inferior abdomen) were obtained by spirometric testing and kinematic analysis, respectively. Results Seven athletes completed the study. During quiet breathing, significant improvements and linear relationships were observed for the tidal volume (16.9%), superior thorax (61.3%) and inferior thorax mobility (83.7%). During maximal breathing, significant improvements were found for the vital capacity (24.8%) and superior thorax mobility (31.5%). Besides that, there was also a significant linear relationship between the vital capacity volumes and mobility in the superior and inferior thorax and superior abdomen. These findings could support the practice of wheelchair rugby to reduce respiratory dysfunction in tetraplegics.

Constant neck flexion has been considered crucial to reducing anastomotic tension after tracheal resection. However, in rare cases, anteflexion can cause cervical cord damage, leading to acute neurological disorders such as tetraplegia. Here, we report a case of 5-year-old boy presenting with acute neurological disorder triggered by a chin-to-chest position over 4 days of deep sedation after cricotracheal resection. The radiological findings would suggest a mechanism similar to Hirayama disease, in which a shift of the dura leads to chronic muscular weakness and atrophy in young populations.

Here, we describe radiographic findings of mercury toxicity followed by a forensic necropsy in a young dog. A young female dog presented for evaluation of progressive tetraplegia over the course of two weeks. Non-ambulatory tetraplegia was noted with normal deep pain sensation and cranial nerve reaction. Radiographic examination revealed spotty metal opaque materials spreading at the subcutis of the back, radiolucent zones at the metaphyses of long bones and in the vertebral skeleton, and joint-centered radiolucency in the elbow and hip joints. The dog was not responsive to surgical treatment and died the next day. Necropsy and toxicological examination confirmed mercury toxicity-associated bony changes in this dog. This case is the first report describing the radiographic findings of bony changes associated with mercury intoxication and showed that heavy metal intoxication affects metaphyses and physes in growing animals.

Study design Cross-sectional, clinical measurement. Purpose To investigate the validity of the Duruoz Hand Index (DHI) in the assessment of hand function in patients with tetraplegia. Methods A total of 40 patients with tetraplegia participated. Patients' upper extremities were assessed on the level of ‘body function and structure’ [The American Spinal Cord Injury Association (ASIA) Impairment Scale (AIS) 2000 revised criteria, upper extremity motor score (UEMS), neurologic level of injury and visual analogue scale of hand function (VAS-HF)], ‘activity’ [DHI and Quadriplegia index of function-short form (QIF-SF)] and ‘body function and structure, activity and participation’ [Health Survey Short Form-36 (SF-36)] according to International Classification of Function. Results The DHI showed significant correlations with UEMS, AIS, QIF-SF, VAS-HF, physical functioning and physical compound summary scores of SF-36. Conclusions The DHI was found a valid method in the assessment of hand functions in patients with tetraplegia. Level of evidence Diagnostic III.

After cervical spinal cord injury, the loss of upper limb function is common. This affects an individual's ability to perform activities of daily living and participate in previous life roles. There are surgical procedures that can restore some of the upper limb function lost after cervical spinal cord injury. Tendon transfer surgery has been performed in the tetraplegic population since the early 1970s. The goals of surgery are to provide a person with tetraplegia with active elbow extension, wrist extension (if absent), and sufficient pinch and/or grip strength to perform activities of daily living without the need for adaptive equipment or orthoses. These procedures are suitable for a specific group, usually with spinal cord impairment of C4-8, with explicit components of motor and sensory loss. Comprehensive team assessments of current functioning, environment, and personal circumstances are important to ensure success of any procedure. Rehabilitation after tendon transfer surgery involves immobilization for tendon healing followed by specific, targeted therapy based on motor learning and goal-orientated training. Outcomes of tendon transfer surgery are not limited to the improvements in an individual's strength, function, and performance of activities but have much greater life affects, especially with regard to well-being, employment, and participation. This article will provide an overview of the aims of surgery, preoperative assessment, common procedures, postoperative rehabilitation strategies, and outcomes based on clinical experience and international published literature.

Objective To describe the early active rehabilitation concept developed for spasticity-correcting surgery in tetraplegia and to report the outcomes in grip ability and change of performance and satisfaction in patients' prioritized activities 1 year postoperatively. Design Retrospective case-control study. Setting Nonprofit rehabilitation unit. Participants All patients who underwent surgeries for correction of spasticity in tetraplegic hands between 2009 and 2013 in the studied unit (N=37). Interventions Spasticity-correcting upper limb surgery with early active rehabilitation to restore grip ability in tetraplegia. Main Outcome Measures Grasp and release test (GRT) and modified Canadian Occupational Performance Measure (COPM). Results All patients could accomplish the early active rehabilitation concept. The complication rate related to the treatment was low. Compared with preoperatively, all evaluated individuals experienced improvements in grasp ability and activity performance and satisfaction at 1-year follow-up. The performance in prioritized activities, as measured by the COPM, improved by 2.6 scale steps. Satisfaction with performance improved 3.0 scale steps postoperatively (n=21). The grasp ability, measured by the GRT, improved significantly, from 80 preoperatively to 111 (n=10). Conclusions The surgery, combined with the early active rehabilitation protocol, is a reliable and safe procedure. The ability to use the hand improved, and gains were maintained at least 1 year after surgery in all patients with respect to both the objective grasp ability and patients' subjective rating of their performance and satisfaction in their prioritized activities. The procedure should therefore be considered as an adjunct to other treatments of upper limb spasticity in spinal cord injury.

There are approximately 300,000 persons with spinal cord injury living in the United States, and nearly 60% of these persons have suffered tetraplegia with resultant alterations in body function, activity, and therefore participation. Restoring hand function can improve independence, and various studies have shown that persons with tetraplegia rate restoration of arm and hand function higher than bowel and bladder control, walking, or sexuality. There are conservative options to improve upper limb function in this population (eg, orthoses, neuroprostheses). Surgical interventions are also available, and 70% of surgical patients report satisfaction and improvement in various activities of daily living after surgery to restore arm and hand function. Despite these positive surgical outcomes

Objectives To quantify time from spinal cord injury to upper limb reconstructive surgery for individuals with tetraplegia; to explore influences on decision-making about surgery for persons with long-standing (>10y) tetraplegia; and to determine the applicability of our previously developed conceptual framework that described the decision-making processes for people with tetraplegia of Design Quantitative-qualitative mixed-methods study. Setting Community based in New Zealand. Participants People (N=9) living with tetraplegia for >10 years. Interventions Not applicable. Main Outcome Measures An audit of time frames between injury, assessment, and surgery for people with tetraplegia was undertaken. Interviews of people with tetraplegia were analyzed using constructivist grounded theory. Results Sixty-two percent of people with tetraplegia assessed for surgery had upper limb reconstructive surgery. Most were assessed within the first 3 years of spinal cord injury. Over half had surgery within 4 years after injury; however, 20% waited >10 years. Changes in prioritized activities, and the identification of tasks possible with surgery, were influential in the decision-making process. Participants were aware of surgery, but required a reoffer from health professionals before proceeding. The influence of peers was prominent in reinforcing the improvement in prioritized activities possible after surgery. Conclusions Findings confirmed that the previously developed conceptual framework for decision-making about upper limb reconstructive surgery was applicable for people with tetraplegia of >10 years. Similarities were seen in the influence of goals and priorities (although the nature of these might change) and information from peers (although this influence was greater for those injured longer). Repeat offers for surgery were required to allow for changes in circumstances over time.

Despite being a routine part of the early surgical management of brachial plexus injury, nerve transfers have only recently been used as a reconstructive option for those with tetraplegia. Subsequently, there is limited published literature on the rehabilitation theories and techniques for optimizing outcomes in this population. This article seeks to address this void by presenting our centers' working model for rehabilitation after nerve transfers for individuals with tetraplegia. The model is illustrated with the example of the rehabilitation process after a supinator nerve to posterior interosseous nerve transfer. This nerve transfer reconstructs wrist, finger, and thumb extension. The topics covered in the model include the following: patient selection and presurgical planning/intervention, managing the postoperative healing phase of an individual who is wheelchair dependent, maximizing motor reeducation, increasing muscle strength, and ensuring use in functional tasks. This article provides a platform for further development and collaboration to improve the outcomes of patients who undergo nerve transfers after tetraplegia.

Objective To identify key components of conventional therapy after brachioradialis (BR) to flexor pollicis longus (FPL) transfer, a common procedure to restore pinch strength, and evaluate whether any of the key components of therapy were associated with pinch strength outcomes. Design Rehabilitation protocols were surveyed in 7 spinal cord injury (SCI) centers after BR to FPL tendon transfer. Key components of therapy, including duration of immobilization, participation, and date of initiating therapy activities (mobilization, strengthening, muscle reeducation, functional activities, and home exercise), were recorded by the patient's therapist. Pinch outcomes were recorded with identical equipment at 1-year follow-up. Setting Seven SCI rehabilitation centers where the BR to FPL surgery is performed on a routine basis. Participants Thirty-eight arms from individuals with C5-7 level SCI injury who underwent BR to FPL transfer surgery (N=34). Intervention Conventional therapy according to established protocol in each center. Main Outcome Measures The frequency of specific activities and their time of initiation (relative to surgery) were expressed as means and 95% confidence intervals. Outcome measures included pinch strength and the Canadian Occupational Performance Measure (COPM). Spearman rank-order correlations determined significant relations between pinch strength and components of therapy. Results There was similarity in the key components of therapy and in the progression of activities. Early cast removal was associated with pinch force (Spearman ρ=−.40, P =.0269). Pinch force was associated with improved COPM performance (Spearman ρ=.48, P =.0048) and satisfaction (Spearman ρ=.45, P =.0083) scores. Conclusions Initiating therapy early after surgery is beneficial after BR to FPL surgery. Postoperative therapy protocols have the potential to significantly influence the outcome of tendon transfers after tetraplegia.

Objective To describe and evaluate the concept of early active rehabilitation after tendon transfer to restore grip function in tetraplegia. Design Retrospective cohort study. Setting Two nonprofit rehabilitation units in Sweden and Switzerland. Participants All patients with tetraplegia who underwent tendon transfer to restore grip ability during 2009 to 2013 (N=49). Intervention Reconstructive tendon transfer surgery with early active rehabilitation to restore grip ability in tetraplegia. Main Outcome Measures Grip and pinch strength, grip ability test, and outcome of prioritized activities. Results In the 49 surgeries performed, postoperative complications included 2 patients with bleeding and 2 infections related to the surgery. There were no reported ruptures or lengthening of transferred tendons. Within 24 hours after surgery, all 47 patients (100%) with finger flexion reconstruction succeeded to activate their finger flexion. All but 1 patient with reconstructed thumb flexion sucessfully activated their thumb flexion (n=40). Three weeks after surgery, all patients (100%) were able to perform basic activities of daily living, and instrumental activities of daily living were achieved by 74%. One year after surgery, the maximum grip strength in restored finger flexion was on average 6.9kg (range, 1.5–15kg; n=29). The maximum pinch strength in restored thumb flexion was on average 3.7kg (range, 1–20; n=29). On average, grip ability improved from 33 to 101 (n=19) according to the COPM. Prioritized activity limitations, as measured with the COPM, equated to an average of 3.5 steps (2.5 steps preoperatively to 6 steps postoperatively). Patients' perceived satisfaction with this improvement was 4 steps (increasing from 2 steps preoperatively to 6 steps postoperatively). Conclusions Grip reconstructive surgery followed by early active rehabilitation can be considered a reliable procedure that leads to substantial improvements in grip and pinch strength and activity performance among patients with tetraplegia.

Objective To describe and evaluate the rehabilitation concept after posterior deltoid to triceps transfer in patients with tetraplegia. Design Retrospective observational study. Setting Rehabilitation units. Participants Patients with tetraplegia who had posterior deltoid to triceps tendon transfer and had muscle strength measurements 1 year postsurgery from 2009 to 2013 (N=44). Interventions Posterior deltoid to triceps tendon transfer to restore elbow extension and postoperative rehabilitation. Main Outcome Measures Elbow extension range of motion and muscle strength and the modified Canadian Occupational Performance Measure (COPM). Results Surgery was performed on 53 arms. No major complications (eg tendon rupture, lengthening) were reported. Muscle strength measured 1 year after surgery was on average grade 3 (out of 5) in the 53 operated arms. The ability to extend the elbow against gravity was achieved in 62% of the arms (muscle strength of grade ≥3). In patients with a preoperative elbow extension deficit (n=14), the deficit was reduced on average from 16° to 9°. The performance of the prioritized activities as measured with the COPM improved on average 2.6 scale steps, from 3.3 to 5.9. Satisfaction with the performance improved on average 3.2 scale steps, from 2.8 to 6.0. Conclusions The posterior deltoid to triceps tendon transfer with the applied rehabilitation protocol is a safe and effective procedure. There were no tendon ruptures, and all patients were able to complete the rehabilitation protocol. The shorter restriction time after surgery allows the patient to be independent at an earlier stage of the rehabilitation and reduces hospitalization or care burden.

Hand and upper extremity function is instrumental to basic activities of daily living and level of independence in cervical spinal cord injury (SCI). Nerve transfer surgery is a novel and alternate approach for restoring function in SCI. This article discusses the biologic basis of nerve transfers in SCI, patient evaluation, management, and surgical approaches. Although the application of this technique is not new; recent case reports and case series in the literature have increased interest in this field. The challenges are to improve function, achieve maximal gains in function, avoid complications, and to primum non nocere.

Patients with high cervical complete spinal cord injuries (tetraplegia) sustain damage to the autonomic neural pathways that influence cardiovascular functioning and produce variability in the heart rate (HR) and blood pressure (BP). In non-injured individuals, an inverse relationship exists between resting autonomic control of the heart (as evidenced by HR variability (HRV)) and BP variability (BPV). This study examined the relationship between HRV, BP and BPV in individuals with tetraplegic (n=10) and paraplegic (n=10) spinal cord injuries, and a group of healthy controls (n=14). Resting HRV at baseline and 24-hour ambulatory BP measurements were collected from electrocardiogram measures of each participant. HRV was quantified using time- and frequency-domain measures. The standard deviation of the BP measurements was used as an index of BPV. Multivariate analyses of variance were performed to examine group differences for laboratory-based and 24-h dependent variables. The MANOVAs for HRV parameters (λ(14,50)=.352, p=.010, η(2)=.407) and for BP indices and HR (λ(16,48)=.318, p=.013, η(2)=.436) were significant. Furthermore, in line with existing evidence, we found that vagally mediated HRV was inversely related to BPV in healthy controls. However, this relationship did not hold for the tetraplegia group (ρ|.42|), and mixed results were found for the paraplegia group (e.g., ρ|.29| for time domain HRV, ρ|.65| for low-frequency power). These results support the conclusion that the damage to the spinal sympathetic pathways to the heart found in people with tetraplegia causes a significant disruption in baroreflex control of BP.