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Objective To evaluate the reliability, standard error of measurement, minimum detectable change, and item-level consistency of the Transfer Assessment Instrument (TAI) version 4.0 when used to evaluate transfer quality remotely. Design Participants transferred from their wheelchair to a mat table (transfer 1), repeated this after a 10-minute delay to assess intrarater reliability (transfer 2), and repeated this 1-2 days later to assess test-retest reliability (transfer 3). Each transfer was scored in person by 4 raters and asynchronously by a remote clinician rater. Setting 2017 National Veterans Wheelchair Games. Participants Convenience sample of 44 full-time wheelchair users (N=44). Interventions Not applicable. Main Outcome Measures TAI total score, subscores (wheelchair setup, body setup, flight/landing), and item scores (15 items). Results Moderate to excellent reliability was found when scoring remotely for TAI total and subscores for intrarater (intraclass correlation coefficient (ICC(3,1)=0.687-0.854), test-retest (ICC(3,1)=0.695-0.836), and interrater reliability (ICC(3,5)=0.746-0.962). Remote rater total score and flight/landing subscore were greater (indicating higher transfer quality) compared to the average in-person raters (P=.021 and P=.005, respectively). There were no differences between transfers 1-3 in remote rater scores. Item-level percentage agreement between the remote rater and in-person exceeded the 75% cutoff for clinical utility for all items. Conclusions The TAI is a reliable outcome measure for assessing transfer technique remotely.

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

To test the hypothesis that remote learning to teach clinicians manual wheelchair skills is efficacious.A convenience sample of therapists (physical and occupational) and students were enrolled in pairs in a cohort study with pre- versus post-training comparisons. The intervention was a hybrid of self-study and hands-on practice paired with remote feedback for ten intermediate and advanced manual wheelchair skills. Participants practiced with self-selected frequency and duration, uploading a session log and video(s) to an online platform. A remote trainer provided asynchronous feedback prior to the next practice session. Capacity and confidence in completing the ten skills were evaluated using the Wheelchair Skills Test Questionnaire (WST-Q). Knowledge of wheelchair skills training and motor learning was assessed using a 62-item Knowledge Test. Secondary outcome measures included skill achievement, as confirmed by submitted video recordings, and participant feedback about the training.Across 41participants, scores were higher at follow-up compared to baseline for WST-Q capacity (73.9 ± 19.1 vs 16.8 ± 15.6,Remote learning can increase wheelchair skills capacity and confidence as well as knowledge about such training and assessment. This model should be further investigated as a delivery method for training rehabilitation professionals.NCT01807728.Implications for rehabilitationWheelchair skills training is one of the 8 steps of wheelchair provision as outlined by the World Health Organization.Wheelchair skills are not a core part of most clinical curriculums and many clinicians cite a lack of resources and uncertainty on how to implement wheelchair skills training into practice as major barriers to providing such training.Remote learning offers the benefits of structured wheelchair skills training with expert feedback on an individual's own schedule that is not afforded by one-day "bootcamp"-type courses or on-the-job training, which are how many clinicians currently learn wheelchair skills.In a sample of physical and occupational therapists and students, remote learning was effective at increasing capacity and confidence to perform manual wheelchair skills as well as knowledge of wheelchair training.

BACKGROUND Intracortical microelectrode arrays have enabled people with tetraplegia to use a brain-computer interface for reaching and grasping. In order to restore dexterous movements, it will be necessary to control individual fingers. OBJECTIVE To predict which finger a participant with hand paralysis was attempting to move using intracortical data recorded from the motor cortex. METHODS A 31-yr-old man with a C5/6 ASIA B spinal cord injury was implanted with 2 88-channel microelectrode arrays in left motor cortex. Across 3 d, the participant observed a virtual hand flex in each finger while neural firing rates were recorded. A 6-class linear discriminant analysis (LDA) classifier, with 10 × 10-fold cross-validation, was used to predict which finger movement was being performed (flexion/extension of all 5 digits and adduction/abduction of the thumb). RESULTS The mean overall classification accuracy was 67% (range: 65%-76%, chance: 17%), which occurred at an average of 560 ms (range: 420-780 ms) after movement onset. Individually, thumb flexion and thumb adduction were classified with the highest accuracies at 92% and 93%, respectively. The index, middle, ring, and little achieved an accuracy of 65%, 59%, 43%, and 56%, respectively, and, when incorrectly classified, were typically marked as an adjacent finger. The classification accuracies were reflected in a low-dimensional projection of the neural data into LDA space, where the thumb-related movements were most separable from the finger movements. CONCLUSION Classification of intention to move individual fingers was accurately predicted by intracortical recordings from a human participant with the thumb being particularly independent.

Background: Specialty palliative care (SPC) provides patient-centered care to people with serious illness and may reduce costs. Specific cost-saving functions of SPC remain unclear. Objectives: (1) To assess the effect of SPC on inpatient costs and length of stay (LOS) and (2) to evaluate differences in costs by indication and timing of SPC. Design: Case–control with in patients who received an SPC consultation and propensity matched controls. Setting: One large U.S. integrated delivery finance system. Measurements: Using administrative data, we assessed costs associated with inpatient stays, a subset of whom received an SPC consultation. Consultations were stratified by reasons based on physician discretion: goals of care, pain management, hospice evaluation, nonpain symptom management, or support. The primary outcome was total operating costs and the secondary outcome was hospital LOS. Results: In total, 1404 patients with SPC consultations associated with unique hospital encounters were matched with 2806 controls. Total operating costs were lower for patients who received an SPC consultation when the consultation was within 0 to 1 days of admission ($6,924 vs. $7,635, p = 0.002). Likewise, LOS was shorter (4.3 vs. 4.7 days, p

The shortage of physician-scientists in physical medicine and rehabilitation remains a critical problem. The Rehabilitation Medicine Scientist Training Program was developed in 1995 to provide structured career development training for aspiring rehabilitation medicine researchers. Initially funded by a 5-yr K12 grant from the National Institutes of Health National Center for Medical Rehabilitation Research, the structure was revised in 2001, continued in a stable format through three additional funding cycles (2001-2006, 2006-2012, and 2012-2016), and was again revised to a research education program (National Institutes of Health R25) model in 2019. With this change in format of the Rehabilitation Medicine Scientist Training Program, we now report the productivity of funded trainees and discuss future directions informed by the Rehabilitation Medicine Scientist Training Program's current R25 structure.

OBJECTIVE The aims of the study were to examine whether fatigue-inducing wheelchair propulsion changes neuromuscular activation and propulsion biomechanics and to determine predictor variables for susceptibility to fatigue. DESIGN This study with a quasi-experimental, one-group, pretest-posttest design investigates a population-based sample of wheelchair users with a spinal cord injury (n = 34, age: 50.8 ± 9.7 yrs, 82% males). Neuromuscular activation and propulsion biomechanics during treadmill propulsion at 25 W and 45 W were assessed before and after a protocol designed to cause fatigue. RESULTS With the induced fatigue, wheelchair users propelled with increased neuromuscular activation in the pectoralis major pars sternalis, deltoideus pars acromialis and upper trapezius (45 W, P < 0.05), and a slightly reduced push angle (25 W: 75-74 degrees, P < 0.05, 45 W: 78-76 degrees, P < 0.05). Wheelchair users susceptible to fatigue (47%) were more likely to have a complete lesion, to be injured at an older age, and had less years since injury. This group propelled in general with shorter push angle and greater maximum resultant force, had a greater anaerobic capacity, and had less neuromuscular activation. CONCLUSIONS Compensation strategies in response to fatiguing propulsion could increase the risk for shoulder injury. Predictor variables for susceptibility to fatigue inform interventions preserving shoulder health and include lesion characteristics, propulsion technique, anaerobic capacity, and neuromuscular activation. TO CLAIM CME CREDITS Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Explain a neuromuscular compensation strategy and the corresponding muscles in response to fatiguing wheelchair propulsion; (2) Recommend propulsion biomechanics associated to reduced susceptibly to fatiguing wheelchair propulsion; and (3) List examples of predictor variables of susceptibility to fatigue. LEVEL Advanced. ACCREDITATION The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Microdialysis quantifies in vivo soft-tissue biochemical concentrations via passive diffusion of interstitial molecules through a porous membrane into a dialysate. The purpose of this pilot study was to evaluate a technique to measure inflammatory cytokines associated with rotator cuff tendinopathy by inserting a microdialysis catheter into the posterior glenohumeral joint. The technique was tested in a convenience sample of six pain-free, able-bodied veterans. Complete dialysate samples were collected in two participants. Two participants' sample volumes were smaller than what was required for analysis (30 μl) and thus were diluted. Catheter failures in two participants prevented collection altogether. Three cytokine concentrations were quantified: interleukin-1 receptor antagonist, interleukin 8, and regulated on activation, normal T-cell expressed and secreted. Microdialysis is not recommended for use in the glenohumeral joint, yet quantification of glenohumeral joint cytokines could yield valuable information to better understand pathophysiology of the joint and its surrounding tissues. Another technique, such as joint lavage, may be a more attractive alternative to overcome the limitations of microdialysis in the glenohumeral joint.

Physician scientists play an important role in the translation of research findings to patient care; however, their training faces numerous challenges. Residency research track programs represent an opportunity to facilitate the training of future physician scientists in physical medicine and rehabilitation, although optimal program organization and long-term outcomes remain unknown. The Rehabilitation Medicine Scientist Training Program is a National Institutes of Health-funded program aimed at addressing the shortage of physician researchers in the field of physical medicine and rehabilitation by providing instruction, mentorship, and networking opportunities for a successful research career. While the opportunities provided through the Rehabilitation Medicine Scientist Training Program provide critical education and guidance at a national level, trainees are most successful with availability of strong local support and mentorship. The purpose of this article was to present a realistic and easily applicable structure for a physical medicine and rehabilitation residency research track that can be used in concert with the Rehabilitation Medicine Scientist Training Program.

OBJECTIVE: To determine the effectiveness of a web-based, direct-to-user transfer training program in improving transfer quality and maintaining improvements for up to one-month post-training as compared to a control group. DESIGN: Randomized control study with participants randomized to an immediate intervention (IIG) or waitlist control group (WLCG) that received the training after a 6-month delay. SETTING: Wherever the participants accessed the web-based training, likely the home environment. PARTICIPANTS: Convenience sample of full-time wheelchair users (IIG n=34, WLCG n=38 for between-group analysis, n=48 for combined within-group analysis) with spinal cord injury or disorder who were able to independently perform a lateral scoot transfer. INTERVENTIONS: Self-paced, web-based transfer training module. MAIN OUTCOME MEASURE: Transfer Assessment Instrument Questionnaire (TAI-Q) score at baseline, 1- and 6-months post-baseline (WLCG only), immediately post-training, and 1-month post-training. The TAI-Q is an 18-item self-assessment that covers several aspects of a quality transfer. RESULTS: The IIG significantly increased their baseline TAI-Q score from 6.91±0.98 to 7.79±1.12 (p

In the United States, people with serious illness often experience gaps and discontinuity in care. Gaps are frequently exacerbated by limited mobility, need for social support, and challenges managing multiple comorbidities. The Advanced Illness Care (AIC) Program provides nurse practitioner-led, home-based care for people with serious or complex chronic illnesses that specifically targets palliative care needs and coordinates with patients' primary care and specialty health care providers. We sought to investigate the effect of the AIC Program on hospital encounters [hospitalizations and emergency department (ED) visits], hospice conversion, and mortality.Retrospective nearest-neighbor matching.Patients in AIC who had ≥1 inpatient stay within the 60 days prior to AIC enrollment to fee-for-service Medicare controls at 9 hospitals within one health system.We matched on demographic characteristics and comorbidities, with exact matches for diagnosis-related group and home health enrollment. Outcomes were hospital encounters (30- and 90-day ED visits and hospitalizations), hospice conversion, and 30- and 90-day mortality.We included 110 patients enrolled in the AIC Program matched to 371 controls. AIC enrollees were mean age 77.0, 40.9% male, and 79.1% white. Compared with controls, AIC enrollees had a higher likelihood of ED visits at 30 [15.1 percentage points, confidence interval (CI) 4.9, 25.3; P = .004] and 90 days (27.8 percentage points, CI 16.0, 39.6; P.001); decreased likelihood of hospitalization at 30 days (11.4 percentage points, CI -17.7, -5.0; P.001); and a higher likelihood of converting to hospice (22.4 percentage points, CI 11.4, 33.3; P.001).The AIC Program provides care and coordination that the home-based serious illness population may not otherwise receive.By identifying and addressing care needs and gaps in care early, patients may avoid unnecessary hospitalizations and receive timely hospice services as they approach the end of life.

OBJECTIVE: To investigate the changes in total internet and mobile internet use over time and determine how demographic characteristics are related to changes in internet and mobile internet use among individuals with spinal cord injury (SCI). DESIGN: Cross-sectional analysis of multicenter cohort study. SETTING: National SCI Database. PARTICIPANTS: Persons with traumatic SCI with follow-up data collected between 2012 and 2018 (n=13,622). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Proportion of sample reporting internet use at all or through a mobile device over time and specifically in 2018. RESULTS: The proportion of internet users increased from 77.7% in 2012 to 88.1% in 2018. Older participants (p

Objective To investigate residential mobility among community-living adults with spinal cord injury (SCI) and the individual, health, and neighborhood factors associated with the propensity to relocate. Design Retrospective analysis of data from the National SCI Model Systems (SCIMS) Database collected between 2006 and 2018 and linked with the American Community Survey 5-year estimates. Setting Community. Interventions Not applicable. Participants People with traumatic SCI (N=4599) who participated in 2 waves of follow-up and had residential geographic identifiers at the census tract level. Main Outcome Measures Moving was a binary measure reflecting change in residential locations over a 5-year interval. Move distance distinguished nonmovers from local movers (different tracts within the same county) and long-distance movers (to different county or state). Move quality included 4 categories: stayed/low poverty tract, stayed/high poverty tract, moved/low poverty tract, and moved/high poverty tract. Results One in 4 people moved within a 5-year interval (n=1175). Of the movers, 55% relocated to a different census tract within the same county and 45% relocated to a different county or state. Thirty-five percent of all movers relocated to a high poverty census tract. Racial and ethnic minorities, people from low-income households, and younger adults were more likely to move, move locally, and relocate to a high poverty neighborhood. High poverty and racial/ethnic segregation in the origin neighborhood predicted an increased risk for remaining in or moving to a high poverty neighborhood. Conclusions Although people with SCI relocated at a lower rate than has been reported in the general population, moving was a frequent occurrence postinjury. People from vulnerable groups were more likely to remain in or relocate to socioeconomically disadvantaged neighborhoods, thus increasing the risk for health disparities and poorer long-term outcomes among minorities and people from low-income households. These findings inform policy makers’ considerations of housing, health care, and employment initiatives for individuals with SCI and other chronic disabilities.

Objective To determine if functional measures of ambulation can be accurately classified using clinical measures; demographics; personal, psychosocial, and environmental factors; and limb accelerations (LAs) obtained during sleep among individuals with chronic, motor incomplete spinal cord injury (SCI) in an effort to guide future, longitudinal predictions models. Design Cross-sectional, 1-5 days of data collection. Setting Community-based data collection. Participants Adults with chronic (>1 year), motor incomplete SCI (N=27). Interventions Not applicable. Main Outcome Measures Ambulatory ability based on the 10-m walk test (10MWT) or 6-minute walk test (6MWT) categorized as nonambulatory, household ambulator (0.01-0.44 m/s, 1-204 m), or community ambulator (>0.44 m/s, >204 m). A random forest model classified ambulatory ability using input features including clinical measures of strength, sensation, and spasticity; demographics; personal, psychosocial, and environmental factors including pain, environmental factors, health, social support, self-efficacy, resilience, and sleep quality; and LAs measured during sleep. Machine learning methods were used explicitly to avoid overfitting and minimize the possibility of biased results. Results The combination of LA, clinical, and demographic features resulted in the highest classification accuracies for both functional ambulation outcomes (10MWT=70.4%, 6MWT=81.5%). Adding LAs, personal, psychosocial, and environmental factors, or both increased the accuracy of classification compared with the clinical/demographic features alone. Clinical measures of strength and sensation (especially knee flexion strength), LA measures of movement smoothness, and presence of pain and comorbidities were among the most important features selected for the models. Conclusions The addition of LA and personal, psychosocial, and environmental features increased functional ambulation classification accuracy in a population with incomplete SCI for whom improved prognosis for mobility outcomes is needed. These findings provide support for future longitudinal studies that use LA; personal, psychosocial, and environmental factors; and advanced analyses to improve clinical prediction rules for functional mobility outcomes.

Objective To investigate the frequency and consequences of wheelchair repairs, looking at the relationship to usage, components, out-of-pocket costs, number of days affecting the user, and factors associated with the need for repairs or consequences. Design Survey, cross-sectional. Setting Nine spinal cord injury (SCI) Model Systems centers. Participants Wheelchair users with SCI (N=533). Interventions Not applicable. Main Outcome Measures Cost and incidence of wheelchair repairs and consequences and wheelchair usage within the past 6 months. Results A total of 310 participants (56%) reported repairs, 127 (42%) of whom experienced at least 1 adverse consequence lasting a median of 5 days (interquartile range [IQR], 2-17.3 days). Repair rates were highest for the seating system, electronics, and tires. Participants were most often stranded at home or forced to use a backup chair. Median out-of-pocket costs were $150 (IQR, $50-$620). Active users, based on type of mobility and terrain, experienced more repairs and consequences than less active users. Repairs were more common among those who were Black (odds ratio [OR], 2.42) or power wheelchair (PWC) users (OR, 1.84), whereas consequences were more common among those who were Black (OR, 2.27), PWC (OR, 2.08) or power assist users (OR, 2.76), and those who had public insurance (OR, 1.70). Conclusions Wheelchair repairs continue to affect more than 50% of wheelchair users with significant financial and personal cost. High repair rates limited participation inside and outside of the home. Consequences lasted longer than 2 weeks for many and may be minimized by a working backup chair. Disparities exist based on participant and wheelchair factors; repairs and adverse consequences appear to hit those most vulnerable with the least financial resources. Costs may be a barrier to repair completion for some individuals. This ongoing problem of high repair rates and their associated effects requires action such as higher standards, access to quicker service, and better training of users on wheelchair maintenance and repair.

Purpose Investigate the type and frequency of wheelchair repairs and resulting adverse consequences in a Veteran population. Design Convenience cross-sectional sample survey. Setting Data were collected at the 2017 National Veterans Wheelchair Games. Participants Veterans who use a wheelchair ≥ 40 h/wk (n = 60). Intervention Not applicable. Main outcome measures Repairs and associated adverse consequences, wheelchair age and usage, type of repairs completed, time elapsed between breakdowns and repairs, and who completed repairs. Results 60 participants reported 124 repairs in the previous 6 months with 88.3% of participants requiring at least one repair. Consequences were reported by 43.5% of those experiencing repairs and were most commonly secondary to repairs in the electrical system, wheelchair frame, power/control system, and wheels and casters. Travelling greater distances during the week and on weekends was associated with increased rates of repairs (p = 0.01 and p = 0.02, respectively) and consequences (p = 0.03 and p = 0.03, respectively). Power wheelchairs were more likely to require repairs than manual wheelchairs (p = 0.007). The median time to repair was 7 [0.8,30] days. Vendors completed 82.1% of the repairs. Those experiencing longer repair times were more likely to experience adverse consequences (p Conclusion A high number of repairs and resulting adverse consequences occur for wheelchair users, particularly power wheelchair users, in a sample of Veterans. Interventions to prevent breakdowns and to address repairs and adverse consequences in a time-efficient manner are needed. Implications for rehabilitation In a sample of Veterans, a high number of repairs and resulting adverse consequences occur for wheelchair users, particularly power wheelchair users. There is an important clinical opportunity to help wheelchair users avoid repairs in the first place and reduce adverse consequences after breakdowns occur by improving wheelchair quality, providing preventative chair maintenance, and repairing breakdowns in a timely and efficient manner. These interventions may prove impactful in reducing the adverse medical, functional, and social consequences of wheelchair breakdowns.

Restoring somatosensory feedback to people with limb amputations is crucial to improve prosthetic control. Multiple studies have demonstrated that peripheral nerve stimulation and targeted reinnervation can provide somatotopically relevant sensory feedback. While effective, the surgical procedures required for these techniques remain a major barrier to translatability. Here, we demonstrate in four people with upper-limb amputation that epidural spinal cord stimulation (SCS), a common clinical technique to treat pain, evoked somatosensory percepts that were perceived as emanating from the missing arm and hand. Over up to 29 days, stimulation evoked sensory percepts in consistent locations in the missing hand regardless of time since amputation or level of amputation. Evoked sensations were occasionally described as naturalistic (e.g. touch or pressure), but were often paresthesias. Increasing stimulus amplitude increased the perceived intensity linearly, without increasing area of the sensations. These results demonstrate the potential of SCS as a tool to restore somatosensation after amputations., eLife digest Even some of the most advanced prosthetic arms lack an important feature: the ability to relay information about touch or pressure to the wearer. In fact, many people prefer to use simpler prostheses whose cables and harnesses pass on information about tension. However, recent studies suggest that electrical stimulation might give prosthesis users more sensation and better control. After an amputation, the nerves that used to deliver sensory information from the hand still exist above the injury. Stimulating these nerves can help to recreate sensations in the missing limb and improve the control of the prosthesis. Still, this stimulation requires complicated surgical interventions to implant electrodes in or around the nerves. Spinal cord stimulation – a technique where a small electrical device is inserted near the spinal cord to stimulate nerves – may be an easier alternative. This approach only requires a simple outpatient procedure, and it is routinely used to treat chronic pain conditions. Now, Chandrasekaran, Nanivadekar et al. show that spinal cord stimulation can produce the feeling of sensations in a person’s missing hand or arm. In the experiments, four people who had an arm amputation underwent spinal cord stimulation over 29 days. During the stimulation, the participants reported feeling electrical buzzing, vibration, or pressure in their missing limb. Changing the strength of the electric signals delivered to the spinal cord altered the intensity of these sensations. The experiments are a step toward developing better prosthetics that restore some sensation. Further studies are now needed to determine whether spinal cord stimulation would allow people to perform sensory tasks with a prosthetic, for example handling an object that they cannot see.

Objectives To investigate the relation of gait training (GT) during inpatient rehabilitation (IPR) to outcomes of people with traumatic spinal cord injury (SCI). Design Prospective observational study using the SCIRehab database. Setting Six IPR facilities. Participants Patients with new SCI (N=1376) receiving initial rehabilitation. Interventions Patients were divided into groups consisting of those who did and did not receive GT. Patients were further subdivided based on their primary mode of mobility as measured by the FIM. Main Outcome Measures Pain rating scales, Patient Health Questionnaire Mood Subscale, Satisfaction With Life Scale, and Craig Handicap Assessment and Reporting Technique (CHART). Results Nearly 58% of all patients received GT, including 33.3% of patients who were primarily using a wheelchair 1 year after discharge from IPR. Those who used a wheelchair and received GT, received significantly less transfer and wheeled mobility training ( P P =.002), mobility ( P =.024), and occupation ( P =.003) scores were significantly worse in patients who used a wheelchair at 1 year and received GT, compared with those who used a wheelchair and did not receive GT in IPR. Older age was also a significant predictor of worse participation as measured by the CHART. Conclusions A significant percentage of individuals who are not likely to become functional ambulators are spending portions of their IPR stays performing GT, which is associated with less time allotted for other functional interventions. GT in IPR was also associated with participation deficits at 1 year for those who used a wheelchair, implying the potential consequences of opportunity costs, pain, and psychological difficulties of receiving unsuccessful GT. Clinicians should consider these data when deciding to implement GT during initial IPR.

Research Objectives To assess the sensitivity, specificity, and accuracy of selected physical examination procedures in identifying supraspinatus tears using magnetic resonance imaging (MRI) as a reference criteria in wheelchair users with chronic paraplegia. Design Cross-sectional. Setting Three SCI Model Systems (SCIMS) Centers. Participants 62 full-time manual wheelchair users with chronic paraplegia (104 shoulders; average age 41.1±11.7; average injury duration 12.5±9.9; average BMI 25.4±9.9; 19.4% female). Interventions N/A. Main Outcome Measures Presence or absence of supraspinatus tears, diagnosed by MRI[1]; physical examinations for supraspinatus pathology, including supraspinatus palpation over the greater tuberosity[2], painful arc[3], Neer's test[4], Jobe's test[5], and resisted external rotation (ER); diagnostic statistics including sensitivity, specificity, positive and negative likelihood ratios, positive and negative predictive values. A receiver operating characteristic (ROC) curve was generated to determine the area under the curve [AUC]. Results A positive Jobe's test, greater tuberosity palpation, and resisted ER produced the highest positive likelihood ratios (between 3.0 and 4.1), yet sensitivities were low (0.33-0.50). The ROC curve suggested the optimal threshold to detect a supraspinatus tear was one or more of the following positive tests: Jobe's, tendon palpation, ER, painful arc (sensitivity=0.67, specificity=0.074). The ROC curve with these four tests yielded an AUC of 0.72. When Neer's was included, the AUC was 0.70. Conclusions The findings from this study indicate no single test was best to screen for supraspinatus tears in this sample. Presence of one or more positive physical examination tests yielded the best accuracy. The low prevalence of tears among this sample could have negatively affect the power to determine sensitivity. Future studies should aim to include a larger proportion of individuals with tears to better determine sensitivity of the tests. Author(s) Disclosures The authors have nothing to disclose.

Objectives To assess in Veterans with spinal cord injury (SCI) or amputated limb (AL) the following: (1) patient demographics, medical factors, cultural and psychosocial characteristic by race; (2) wheelchair quality by race; and (3) the independent associations of patient race and the other factors with wheelchair quality. Design Cross-sectional cohort study. Setting Three Department of Veterans Affairs (VA) medical centers affiliated with academic medical centers. Participants Eligible participants were Veterans with SCI or ALs (N=516); 482 of them completed the interview. Analyses were restricted to white and African American participants. Because there was no variation in wheelchair quality among AL patients (n=42), they were excluded from all but descriptive analyses, leading to a final sample size of 421. Interventions Not applicable. Main Outcome Measure Wheelchair quality as defined by the Medicare Healthcare Common Procedure Coding System. Results We found race differences in many of our variables, but not in quality for manual (odds ratio [OR]=.67; 95% confidence interval [CI], .33–1.36) or power (OR=.82; 95% CI, .51–1.34) wheelchairs. Several factors including age (OR=.96; 95% CI, .93–.99) and income (OR=3.78; 95% CI, 1.43–9.97) were associated with wheelchair quality. There were no significant associations of cultural or psychosocial factors with wheelchair quality. Conclusions Although there were no racial differences in wheelchair quality, we found a significant association of older age and lower income with poorer wheelchair quality among Veterans. Efforts are needed to raise awareness of such disparities among VA wheelchair providers and to take steps to eliminate these disparities in prescription practice across VA sites.

Restoring somatosensory feedback to people with limb amputations is crucial for improving prosthesis acceptance and function. Epidural spinal cord stimulation is a commonly used clinical procedure that targets sensory neural pathways in the dorsal spinal cord to treat pain conditions. A similar approach could be developed as a clinically translatable means to restore somatosensation in amputees. We show that epidural stimulation of the dorsal spinal cord evoked sensory percepts, perceived as emanating from the amputated arm and hand, in four people with upper-limb amputation. After an initial caudal movement immediately following the implantation, the leads stabilized, exhibiting a median migration of

Wrist posture impacts the muscle lengths and moment arms of the extrinsic finger muscles that cross the wrist. As a result, the electromyographic (EMG) activity associated with digit movement at different wrist postures may also change. Therefore, we sought to quantify the posture-dependence of extrinsic finger muscle activity. Fine-wire bipolar electrodes were inserted in the extrinsic hand muscles of able-bodied subjects to record EMG activity during wrist and finger movements in various postures. EMG activity of all the recorded finger muscles were significantly different (p

Study design: Quasi-experimental, pretest-posttest design. Objectives: To identify acute changes in the supraspinatus and biceps tendon following fatiguing wheelchair propulsion and to associate tendon changes with risk factors associated with shoulder pain in persons with spinal cord injury (SCI). Setting: Biomechanical laboratory Swiss Paraplegic Research. Methods: A population-based sample of 50 wheelchair users with SCI at lesion level T2 or below participated. Fatigue was measured using the rate of perceived exertion and heart rate. Linear regression techniques were used to assess the association between the dependent and independent variables. Dependent variables included absolute differences in supraspinatus and biceps tendon thickness, contrast and echogenicity ratio assessed with ultrasound before and after a fatiguing wheelchair propulsion intervention. Independent variables included: susceptibility to fatigue (Yes/No), the acromio-humeral distance, sex, time since injury, activity levels and body weight. Results: A reduction in supraspinatus tendon thickness after fatiguing wheelchair propulsion (−1.39 mm; 95% CI: −2.28; −0.51) was identified after controlling for all potential confounders. Females who fatigued (n=4) displayed a greater reduction in supraspinatus tendon thickness as compared to those who did not fatigue (n=7). In contrast, higher body weight was associated with an increase in supraspinatus tendon thickness and a greater acromio-humeral distance before the intervention was associated with an increase in biceps tendon thickness. Conclusions: Acute changes in the supraspinatus and biceps tendon after fatiguing wheelchair propulsion may explain the high prevalence of tendon injuries in this population. Future research should determine the consequences of tendon changes and its relationship to tendinopathy.

Objective: Shoulder pathology is a common condition in wheelchair users that can considerably impact quality of life. Shoulder muscles are prone to fatigue, but it is unclear how fatigue affects start-up propulsion biomechanics. This study determines acute changes in start-up wheelchair propulsion biomechanics at the end of a fatiguing propulsion protocol. Design: Quasi-experimental one-group pretest-postest design. Setting: Biomechanics laboratory. Participants: Twenty-six wheelchair users with spinal cord injury (age: 35.5 ± 9.8 years, sex: 73% males and 73% with a paraplegia). Interventions: Protocol of 15 min including maximum voluntary propulsion, right- and left turns, full stops, start-up propulsion, and rests. Outcome measures: Maximum resultant force, maximum rate of rise of applied force, mean velocity, mean fraction of effective force, and mean contact time at the beginning and end of the protocol during start-up propulsion. Results: There was a significant reduction in maximum resultant force (P

OBJECTIVES To compare rates of 30‐ and 90‐day hospital readmissions and observation or emergency department (ED) returns of older adults using the University of Pittsburgh Medical Center (UPMC) Health Plan Home Transitions (HT) with those of Medicare fee‐for‐service (FFS) controls without HT. DESIGN Retrospective cohort study. SETTING Analysis of home health and hospital records from 8 UPMC hospitals in Allegheny County, Pennsylvania, from July 1, 2015, to April 30, 2017. PARTICIPANTS HT program participants (n=1,900) and controls (n=1,300). INTERVENTION HT is a care transitions program aimed at preventing readmission that identifies older adults at risk of readmission using a robust inclusion algorithm; deploys a multidisciplinary care team, including a nurse practitioner (NP), a social worker (SW), or both; and provides a multimodal service including personalized care planning, education, treatment, monitoring, and communication facilitation. MEASUREMENT We used multivariable logistic regression to determine the effects of HT on the odds of hospital readmission and observation or ED return, controlling for index admission participant characteristics and home health process measures. RESULTS The adjusted odds of 30‐day readmission was 0.31 (95% confidence interval (CI) = 0.11–0.87, P = .03) and of 90‐day readmission was 0.47 (95% CI=CI = 0.26–0.85, P = .01), for participants at medium risk of readmission in HT who received a team visit. The adjusted odds of 30‐day readmission was 0.29 (95% CI = 0.10–0.83, P = .02) for participants at high risk of readmission in HT who received a team visit. The adjusted odds of 30‐day observation or ED return was 1.90 (95% CI = 1.28–2.82, P = .001) for participants at medium risk of readmission in HT who received a team visit. CONCLUSION The HT program may be associated with lower odds of 30‐ and 90‐day hospital readmission and counterbalancing higher odds of observation or ED return. J Am Geriatr Soc 67:156–163, 2019.

Acellular biologic scaffolds derived from extracellular matrix have been investigated in preclinical and clinical studies as a regenerative medicine approach for volumetric muscle loss treatment. The present manuscript provides a review of previous studies supporting the use of extracellular matrix derived biologic scaffolds for the promotion of functional skeletal muscle tissue formation that is contractile and innervated. The manuscript also identifies key mechanisms that have been associated with ECM-mediated skeletal muscle repair, and provides hypotheses as to why there have been variable outcomes, ranging from successful to unsatisfactory, associated with ECM bioscaffold implantation in the skeletal muscle injury microenvironment.

To evaluate the immediate effects of transfer training based on the Transfer Assessment Instrument (TAI) on the upper limb biomechanics during transfers.Pre-post intervention.Biomechanics laboratory.Full-time manual wheelchair users (N=24) performed 5 transfers to a level height bench, while their natural transfer skills were scored using the TAI, and their biomechanical data were recorded.Participants with 2 or more component skill deficits were invited to return to receive personalized transfer training.TAI part 1 summary scores and biomechanical variables calculated at the shoulder, elbow, and wrist joints were compared before and immediately after transfer training.Sixteen of the 24 manual wheelchair users met the criteria for training, and 11 manual wheelchair users came back for the revisit. Their TAI part 1 summary scores improved from 6.31±.98 to 9.92±.25. They had significantly smaller elbow range of motion, shoulder resultant moment, and rates of rise of elbow and wrist resultant forces on their trailing side during transfers after training (P.05). On the leading side, shoulder maximum internal rotation and elevation angles, and shoulder resultant moments and rates of rise of shoulder resultant force and moment decreased after training (P.04).The TAI-based training showed short-term beneficial biomechanical effects on wheelchair users' upper limbs, such as better shoulder positioning and lower joint loadings. If the skills are practiced longer-term, they may help protect the upper limbs from developing pain and injuries.

In response to the growing need to train a new generation of clinician scientists, a research program was developed to train medical students in integrative, complementary, and alternative medicine (ICAM) research early in their careers. A total of 25 students (100%) successfully completed a 10-week program. Students reported significantly increased levels of knowledge in all 7 integrative, complementary, and alternative medicine topics at the conclusion of the program. All students presented their work at one or more local research symposia. In addition, the average number of quality research outputs, which included manuscripts, awards, and abstracts presented at national and international meetings, was 1.5 per student, which exceeded benchmarks based on prior program outcomes. Results from this program may be useful when planning larger or longer-term projects aimed at attracting physicians who will become our next generation of academicians, researchers, and healers.

Objective To identify changes in concentrations of inflammatory mediators in plasma and urine after traumatic spinal cord injury (SCI) and before the occurrence of a first pressure ulcer. Design Retrospective; secondary analysis of existing data. Setting Acute hospitalization and inpatient rehabilitation sites at a university medical center. Participants Individuals with a pressure ulcer and plasma samples (n=17) and individuals with a pressure ulcer and urine samples (n=15) were matched by age and plasma/urine sample days to individuals with SCI and no pressure ulcer (N=35). Interventions Not applicable. Main Outcome Measures Plasma and urine samples were assayed in patients with SCI, capturing samples within 4 days after the SCI to a week before the formation of the first pressure ulcer. The Wilcoxon signed-rank test was performed to identify changes in the inflammatory mediators between the 2 time points. Results An increase in concentration of the chemokine interferon-γ–induced protein of 10kd/CXCL10 in plasma ( P P =.01) were observed before occurrence of a first pressure ulcer (∼4d) compared with matched controls. Conclusions Altered levels of inflammatory mediators in plasma and urine may be associated with pressure ulcer development after traumatic SCI. These inflammatory mediators should be explored as possible biomarkers for identifying individuals at risk for pressure ulcer formation.

BackgroundElectrodiagnosis can reveal the nerve and muscle changes following surgical placement of an extracellular matrix (ECM) bioscaffold for treatment of volumetric muscle loss (VML).ObjectiveThe purpose of this study was to characterize nerve conduction study (NCS) and electromyography (EMG) changes following ECM bioscaffold placement in individuals with VML. The ability of presurgical NCS and EMG to be used as a tool to help identify candidates who are likely to display improvements postsurgically also was explored.DesignA longitudinal case series design was used.MethodsThe study was conducted at the McGowan Institute for Regenerative Medicine at the University of Pittsburgh. Eight individuals with a history of chronic VML participated. The intervention was surgical placement of an ECM bioscaffold at the site of VML. The strength of the affected region was measured using a handheld dynamometer, and electrophysiologic evaluation was conducted on the affected limb with standard method of NCS and EMG. All measurements were obtained the day before surgery and repeated 6 months after surgery.ResultsSeven of the 8 participants had a preoperative electrodiagnosis of incomplete mononeuropathy within the site of VML. After ECM treatment, 5 of the 8 participants showed improvements in NCS amplitude or needle EMG parameters. The presence of electrical activity within the scaffold remodeling site was concomitant with clinical improvement in muscle strength.LimitationsThis study had a small sample size, and participants served as their own controls. The electromyographers and physical therapists performing the evaluation were not blinded.ConclusionsElectrodiagnostic data provide objective evidence of physiological improvements in muscle function following ECM placement at sites of VML. Future studies are warranted to further investigate the potential of needle EMG as a predictor of successful outcomes following ECM treatment for VML.

Objective Neurofeedback (NF) trains people to volitionally modulate their cortical activity to affect a behavioral outcome. We evaluated the feasibility of using NF to improve hand function after chronic cervical-level spinal cord injury (SCI) using biologically-relevant visual feedback of motor-related brain activity and an intuitive control scheme. Approach The NF system acquired magnetoencephalography (MEG) data in real-time to provide feedback of event-related desynchronization (ERD) measured over the sensorimotor cortex during attempted hand grasping. During brain control, stronger ERD resulting from attempted grasping drove the virtual hand towards a more closed grasp, while less ERD drove the hand more open. Main results Eight individuals with partial or complete hand impairment due to chronic SCI controlled the NF to perform a grasping task that increased in difficulty as the participants achieved success. During their first NF session, participants achieved an average success rate of 63.7 ± 6.4% (chance level of 13.9%). After as few as one intervention session, four of the seven individuals evaluated for ERD changes had significantly strengthened ERD and three of the four participants with measurable grip strength prior to NF had increased grip strength. Interestingly, both individuals who participated in a longer-term study (i.e. >8 NF sessions) had improved grip strength and significantly strengthened ERD. Significance This study demonstrates that MEG-based NF training can change brain activity in individuals with hand impairment due to SCI and has the potential to induce acute changes in grip strength. Future studies will evaluate whether neuroplasticity induced with long term NF can improve hand function for those with moderate impairment.

One innovation currently influencing physical medicine and rehabilitation is brain-computer interface (BCI) technology. BCI systems used for motor control record neural activity associated with thoughts, perceptions, and motor intent; decode brain signals into commands for output devices; and perform the user's intended action through an output device. BCI systems used for sensory augmentation transduce environmental stimuli into neural signals interpretable by the central nervous system. Both types of systems have potential for reducing disability by facilitating a user's interaction with the environment. Investigational BCI systems are being used in the rehabilitation setting both as neuroprostheses to replace lost function and as potential plasticity-enhancing therapy tools aimed at accelerating neurorecovery. Populations benefitting from motor and somatosensory BCI systems include those with spinal cord injury, motor neuron disease, limb amputation, and stroke. This article discusses the basic components of BCI for rehabilitation, including recording systems and locations, signal processing and translation algorithms, and external devices controlled through BCI commands. An overview of applications in motor and sensory restoration is provided, along with ethical questions and user perspectives regarding BCI technology.

Motor output maps within primary motor cortex are widely distributed and modified by motor skill learning and neurological injury. Functions that these maps represent after spinal cord injury remain debatable. Moreover, the pattern of reorganization and whether it supports recovery of compromised motor function is not well understood. A deeper understanding of the pathophysiological mechanisms of motor dysfunction after spinal cord injury is necessary to develop and optimize repair strategies. There are three purposes for this review. The first is to synthesize available research on spontaneous reorganization with primary motor cortex following spinal cord injury. The second is to draw on existing evidence from the motor skill learning and brain injury literature to interpret the form and purpose of motor maps. The third purpose is to account for the existing research on intervention-induced reorganization of primary motor cortex following spinal cord injury. We conclude with directions for future work, emphasizing the need for multi-modal investigations that construct maps with both neuroimaging and non-invasive stimulation methods to derive a cohesive understanding of the effects of spinal cord injury on reorganization within primary motor cortex.

Background The application of rehabilitation robots has grown during the last decade. While meta-analyses have shown beneficial effects of robotic interventions for some patient groups, the evidence is less in others. We established the Advanced Robotic Therapy Integrated Centers (ARTIC) network with the goal of advancing the science and clinical practice of rehabilitation robotics. The investigators hope to exploit variations in practice to learn about current clinical application and outcomes. The aim of this paper is to introduce the ARTIC network to the clinical and research community, present the initial data set and its characteristics and compare the outcome data collected so far with data from prior studies. Methods ARTIC is a pragmatic observational study of clinical care. The database includes patients with various neurological and gait deficits who used the driven gait orthosis Lokomat® as part of their treatment. Patient characteristics, diagnosis-specific information, and indicators of impairment severity are collected. Core clinical assessments include the 10-Meter Walk Test and the Goal Attainment Scaling. Data from each Lokomat® training session are automatically collected. Results At time of analysis, the database contained data collected from 595 patients (cerebral palsy: n = 208; stroke: n = 129; spinal cord injury: n = 93; traumatic brain injury: n = 39; and various other diagnoses: n = 126). At onset, average walking speeds were slow. The training intensity increased from the first to the final therapy session and most patients achieved their goals. Conclusions The characteristics of the patients matched epidemiological data for the target populations. When patient characteristics differed from epidemiological data, this was mainly due to the selection criteria used to assess eligibility for Lokomat® training. While patients included in randomized controlled interventional trials have to fulfill many inclusion and exclusion criteria, the only selection criteria applying to patients in the ARTIC database are those required for use of the Lokomat®. We suggest that the ARTIC network offers an opportunity to investigate the clinical application and effectiveness of rehabilitation technologies for various diagnoses. Due to the standardization of assessments and the use of a common technology, this network could serve as a basis for researchers interested in specific interventional studies expanding beyond the Lokomat®.

Objectives To evaluate the relation between wheelchair breakdowns, their immediate consequences, and secondary health complications after spinal cord injury. “Immediate consequences” occur when part of a wheelchair breaks and leaves an individual stranded or injured, or causes him or her to miss medical appointments, work, or school. Design Survey, cross-sectional. Setting Spinal Cord Injury Model Systems Centers. Participants Full-time wheelchair users (N=771) with SCI from 9 Spinal Cord Injury Model Systems Centers, with data collected between 2011 and 2016. Interventions Not applicable. Main Outcome Measures Incidence of self-reported wheelchair breakdowns within the past 6 months that did or did not result in immediate consequences (ie, injury, being stranded, missing a medical appointment, or an inability to attend school/work); self-perceived health status scale; pain severity numerical rating scale; rehospitalizations; and self-reported pressure injury development within the past 12 months. Results A total of 610 participants with complete data sets were included in the analyses. When compared to those who reported no breakdowns, participants who reported 1 or more immediate consequences had worse secondary complications: higher self-perceived health status and pain scores (partial −η2=.009-.012, P Conclusions Wheelchair breakdowns that resulted in injury, being stranded, missing medical appointments, and/or an inability to attend work/school appear to have far-reaching impacts on health and secondary injury. Preventing wheelchair breakdowns, through either better maintenance or manufacturing, may be a means of decreasing secondary disability.

A large percentage of individuals with spinal cord injury (SCI) report shoulder pain that can limit independence and quality of life. The pain is likely related to the demands placed on the shoulder by transfers and propulsion. Shoulder pathology has been linked to altered scapular mechanics; however, current methods to evaluate scapular movement are invasive, require ionizing radiation, are subject to skin-based motion artifacts, or require static postures.To investigate the feasibility of applying 3-dimensional ultrasound methods, previously used to look at scapular position in static postures, to evaluate dynamic scapular movement.This study evaluated the feasibility of the novel application of a method combining 2-dimensional ultrasound and a motion capture system to determine 3-dimensional scapular position during dynamic arm elevation in the scapular plane with and without loading.Incremental increases in scapular rotations were noted for extracted angles of 30°, 45°, 60°, and 75° of humeral elevation. Group differences were evaluated between a group of 16 manual wheelchair users (MWUs) and a group of age- and gender-matched able-bodied controls. MWUs had greater scapular external rotation and baseline pathology on clinical exam. MWUs also had greater anterior tilting, with this difference further accentuated during loading. The relationship between demographics and scapular positioning was also investigated, revealing that increased age, pathology on clinical exam, years since injury, and body mass index were correlated with scapular rotations associated with impingement (internal rotation, downward rotation, and anterior tilting).Individuals with SCI, as well as other populations who are susceptible to shoulder pathology, may benefit from the application of this imaging modality to quantitatively evaluate scapular positioning and effectively target therapeutic interventions.

Background Carpal tunnel syndrome is a common and costly peripheral neuropathy. Occupations requiring repetitive, forceful motions of the hand and wrist may play a role in the development of carpal tunnel syndrome. Computer keyboarding is one such task, and has been associated with upper-extremity musculoskeletal disorder development. The purpose of this study was to determine whether continuous keyboarding can cause acute changes in the median nerve and whether these changes correlate with wrist biomechanics during keyboarding. Methods A convenience sample of 37 healthy individuals performed a 60-minute typing task. Ultrasound images were collected at baseline, after 30 and 60 min of typing, then after 30 min of rest. Kinematic data were collected during the typing task. Variables of interest were median nerve cross-sectional area, flattening ratio, and swelling ratio at the pisiform; subject characteristics (age, gender, BMI, wrist circumference, typing speed) and wrist joint angles. Findings Cross-sectional area and swelling ratio increased after 30 and 60 min of typing, and then decreased to baseline after 30 min of rest. Peak ulnar deviation contributed to changes in cross-sectional area after 30 min of typing. Interpretation Results from this study confirmed a typing task causes changes in the median nerve, and changes are influenced by level of ulnar deviation. Furthermore, changes in the median nerve are present until cessation of the activity. While it is unclear if these changes lead to long-term symptoms or nerve injury, their existence adds to the evidence of a possible link between carpal tunnel syndrome and keyboarding.

Study Design This is a focused review article. Objectives To identify important concepts in lower extremity (LE) assessment with a focus on locomotor outcomes and provide guidance on how existing outcome measurement tools may be best used to assess experimental therapies in spinal cord injury (SCI). The emphasis lies on LE outcomes in individuals with complete and incomplete SCI in Phase II-III trials. Methods This review includes a summary of topics discussed during a workshop focusing on LE function in SCI, conceptual discussion of corresponding outcome measures and additional focused literature review. Results There are a number of sensitive, accurate, and responsive outcome tools measuring both quantitative and qualitative aspects of LE function. However, in trials with individuals with very acute injuries, a baseline assessment of the primary (or secondary) LE outcome measure is often not feasible. Conclusion There is no single outcome measure to assess all individuals with SCI that can be used to monitor changes in LE function regardless of severity and level of injury. Surrogate markers have to be used to assess LE function in individuals with severe SCI. However, it is generally agreed that a direct measurement of the performance for an appropriate functional activity supersedes any surrogate marker. LE assessments have to be refined so they can be used across all time points after SCI, regardless of the level or severity of spinal injury. Sponsors Craig H. Neilsen Foundation, Spinal Cord Outcomes Partnership Endeavor.

Recent advancement in electrocorticography (ECoG)-based brain-computer interface technology has sparked a new interest in providing somatosensory feedback using ECoG electrodes, i.e., cortical surface electrodes. We conducted a 28-day study of cortical surface stimulation in an individual with arm paralysis due to brachial plexus injury to examine the sensation produced by electrical stimulation of the somatosensory cortex. A high-density ECoG grid was implanted over the somatosensory and motor cortices. Stimulation through cortical surface electrodes over the somatosensory cortex successfully elicited arm and hand sensations in our participant with chronic paralysis. There were three key findings. First, the intensity of perceived sensation increased monotonically with both pulse amplitude and pulse frequency. Second, changing pulse width changed the type of sensation based on qualitative description provided by the human participant. Third, the participant could distinguish between stimulation applied to two neighboring cortical surface electrodes, 4.5 mm center-to-center distance, for three out of seven electrode pairs tested. Taken together, we found that it was possible to modulate sensation intensity, sensation type, and evoke sensations across a range of locations from the fingers to the upper arm using different stimulation electrodes even in an individual with chronic impairment of somatosensory function. These three features are essential to provide effective somatosensory feedback for neuroprosthetic applications.

LAI, S., A. PANARESE, R. LAWRENCE, M. L. BONINGER, S. MICERA, and F. AMBROSIO. A Murine Model of Robotic Training to Evaluate Skeletal Muscle Recovery after Injury. Med. Sci. Sports Exerc., Vol. 49, No. 4, pp. 840-847, 2017. Purpose: In vivo studies have suggested that motor exercise can improve muscle regeneration after injury. Nevertheless, preclinical investigations still lack reliable tools to monitor motor performance over time and to deliver optimal training protocols to maximize force recovery. Here, we evaluated the utility of a murine robotic platform (i) to detect early impairment and longitudinal recovery after acute skeletal muscle injury and (ii) to administer varying intensity training protocols to enhance forelimb motor performance. Methods: A custom-designed robotic platform was used to train mice to perform a forelimb retraction task. After an acute injury to bilateral biceps brachii muscles, animals performed a daily training protocol in the platform at high (HL) or low (LL) loading levels over the course of 3 wk. Control animals were not trained (NT). Motor performance was assessed by quantifying force, time, submovement count, and number of movement attempts to accomplish the task. Myofiber number and cross-sectional area at the injury site were quantified histologically. Results: Two days after injury, significant differences in the time, submovement count, number of movement attempts, and exerted force were observed in all mice, as compared with baseline values. Interestingly, the recovery time of muscle force production differed significantly between intervention groups, with HL group showing a significantly accelerated recovery. Three weeks after injury, all groups showed motor performance comparable with baseline values. Accordingly, there were no differences in the number of myofibers or average cross-sectional area among groups after 3 wk. Conclusion: Our findings demonstrate the utility of our custom-designed robotic device for the quantitative assessment of skeletal muscle function in preclinical murine studies. Moreover, we demonstrate that this device may be used to apply varying levels of resistance longitudinally as a means manipulate physiological muscle responses.

Rehabilitation therapy is an important aspect of recovery after volumetric muscle loss. However, the traditional rehabilitation approach involves a period of rest and passive loading followed by gradual active loading. Extracellular matrix is a naturally occurring material consisting of structural proteins that provide mechanical strength, structural support, and functional molecules with diverse bioactive properties. There is evidence to suggest that the addition of aggressive regenerative rehabilitation protocols immediately after surgical implantation of an extracellular matrix scaffold to an area of volumetric muscle loss has significant benefits for extracellular matrix remodeling. Rehabilitation exercises likely provide the needed mechanical signals to encourage cell migration and site-specific differentiation in the temporal framework required for constructive remodeling. Herein, the authors review the literature and present an example of an aggressive rehabilitation program implemented immediately after extracellular matrix transplantation into a severely injured quadriceps muscle.

To investigate the reliability of ultrasonographic measurement of acromiohumeral distance (AHD) and the effects of shoulder positioning on AHD among manual wheelchair users (MWUs) with spinal cord injury (SCI) and an able-bodied control group.Ten MWUs with SCI and 10 able-bodied subjects participated in this study. The ultrasonographic measurements of AHD from each subject were obtained by two raters during passive and active scapular plane arm elevation in neutral, 45°, 90° with and without resistance and in a weight relief raise position. The measurements were recorded again by each rater using the same procedures after a 30-minute time interval. All raters were blinded to each other's measurements.University Laboratories and Veteran Affairs Healthcare System.Intra-rater (intraclass correlation coefficient, ICC0.83) and inter-rater (ICC0.78) reliability was excellent for both the MWUs with SCI and able-bodied groups across all arm positions except for the 45° position in the control group for one of the raters (intra-rater: ICC0.40 and inter-rater: ICC0.60). AHD significantly reduced when the shoulder was in the 90° arm elevated positions with or without resistance.Findings from our study demonstrated that ultrasonography is a reliable means to evaluate AHD in both able bodied and individuals with SCI, who are known to have significant shoulder pathology. This technique could be used to develop reference measures and to identify changes in AHD caused by interventions.

Objective To examine the additive effect of age on disability for adults with spinal cord injury (SCI). Design Prospective cohort study. Setting SCI Model Systems. Participants Individuals with SCI (median age at injury, 32y; range, 6–88y) with a discharge motor FIM score and at least 1 follow-up motor FIM score who also provided measures of other covariates (N=1660). Of the total sample, 79% were men, 72% were white, 16% had incomplete paraplegia, 33% had complete paraplegia, 30% had incomplete tetraplegia, and 21% had complete tetraplegia. Interventions Not applicable. Main Outcome Measures The primary study outcome was the motor subscale of the FIM. A mixed-models approach was used to examine the additive effect of age on disability for individuals with SCI. Results When controlling for motor FIM at discharge from rehabilitation, level and severity of injury, age at injury, sex, race, and the age × time interaction were not significant ( P =.07). Age at the time of SCI was significantly associated with motor FIM (F 1,238 =22.49, P P =.03, P =.02) and age × time-square ( P =.01, P =.006) models. Trajectory of motor FIM scores is moderated slightly by age at the time of injury. The older participants were at the time of injury, the greater the curvature and the more rapid decline were found in later years. Conclusions These findings indicate that age moderately influences disability for some individuals with SCI: the older the age at the time of injury, the greater the influence age has on disability. The findings serve as an important empirical foundation for the evaluation and development of interventions designed to augment accelerated aging experienced by individuals with SCI.

The objective of this study was to evaluate the reli- ability of using freehand three-dimensional ultrasound to mea- sure scapular rotations (internal/external, upward/downward, anterior/posterior). The scapular position in 22 healthy, nondis- abled individuals was imaged three times in four testing posi- tions of interest (arm at rest and humeral elevation in the sagittal, frontal, and scapular planes). We found substantial reliability across scanning positions and scapular rotations, with intraclass correlation coefficients ranging from 0.62 to 0.95. The highest reliability was found in the rest testing posi- tion. Our standard error of measurement was less than 2 degrees for all measurements and less than 0.5 degrees for most. Minimum detectable change ranged from 0.37 to 3.08 degrees. Our results agree with the pattern of movement found in other studies, with the scapula moving toward a more externally rotated, upwardly rotated, and posteriorly tilted posi- tion with humeral elevation. Further study is warranted to com- pare our methods to a gold standard, apply them to evaluation of dynamic movement, and determine whether they can be used to detect shoulder pathology.

Background Macrophage infiltration to the injury site during the acute response to traumatic spinal cord injury (SCI) is not uniform. Macrophage phenotype has been characterized as either proinflammatory (M1) or anti-inflammatory (M2). Results of animal studies suggest that M1 or M2 dominance at the site of injury relates to spontaneous recovery after SCI. Objective To investigate whether the phenotype of circulating macrophage precursors-monocytes (MO) is altered in the acute phase of SCI and corresponds to circulating inflammatory cytokines. Study Design A prospective observational cohort study. Setting A single academic medical center in Pennsylvania. Patients A cohort of 27 subjects with complete or incomplete traumatic SCI enrolled within 7 days after SCI injury. Methods The MO phenotype was defined within the first week after SCI by using flow cytometry and was compared with that of historic uninjured controls. Concentrations of 25 cytokines and/or chemokines were assessed by using Luminex in serial blood samples up to 2 weeks after SCI. An analysis of variance was used to determine the correlations between the phenotypes and the cytokine profiles. Results Patient subsets were identified with either M1- or M2-dominant circulating MOs distinct from the uninjured controls. The M1 dominant was associated with higher circulating levels of proinflammatory mediators interleukin (IL)12p70 and interferon gamma-induced protein 10 kDa (IP-10/CXCL10), and lower levels of anti-inflammatory cytokines IL-10, IL-15, and IL-7, whereas the M2 dominant exhibited the opposite cytokine profiles with significantly higher IL-10 and IL-7. Conclusion In the acute phase after SCI, at comparable injury severity, subgroups of patients exhibit distinct M1 or M2 MOs dominance and the phenotype is correlated with M1- or M2-specific cytokine and/or chemokine profiles. Although further studies are needed to determine how these observed phenotypic differences relate to functional recovery, our findings (1) provide the first evidence, to our knowledge, that indicates the possible individual differences in the immune responses to the comparable traumatic SCI, with potential implications for management of acute SCI and rehabilitation; and (2) may represent easily accessible biomarkers with prognostic utility.