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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

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.

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.

Microstimulation in the somatosensory cortex can evoke artificial tactile percepts and can be incorporated into bidirectional brain–computer interfaces (BCIs) to restore function after injury or disease. However, little is known about how stimulation parameters themselves affect perception. Here, we stimulated through microelectrode arrays implanted in the somatosensory cortex of two human participants with cervical spinal cord injury and varied the stimulus amplitude, frequency, and train duration. Increasing the amplitude and train duration increased the perceived intensity on all tested electrodes. Surprisingly, we found that increasing the frequency evoked more intense percepts on some electrodes but evoked less-intense percepts on other electrodes. These different frequency–intensity relationships were divided into three groups, which also evoked distinct percept qualities at different stimulus frequencies. Neighboring electrode sites were more likely to belong to the same group. These results support the idea that stimulation frequency directly controls tactile perception and that these different percepts may be related to the organization of somatosensory cortex, which will facilitate principled development of stimulation strategies for bidirectional BCIs.

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.

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

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.

PURPOSE Many medical schools require scholarly research projects. However, outcomes data from these initiatives are scarce. The authors studied the impact of the Scholarly Research Project (SRP), a four-year longitudinal requirement for all students at the University of Pittsburgh School of Medicine (UPSOM), on research productivity and residency match. METHOD The authors conducted a longitudinal study of non-dual-degree UPSOM graduates in 2006 (n = 121, non-SRP participants) versus 2008 (n = 118), 2010 (n = 106), and 2012 (n = 132), all SRP participants. The authors used PubMed for publication data, National Resident Matching Program for residency match results, and Blue Ridge Institute for Medical Research for National Institutes of Health funding rank for residency-affiliated academic institutions. RESULTS Research productivity of students increased for those completing the SRP, measured as a greater proportion of students with publications (27.3% in 2006 vs. 45.8% in 2008, 55.7% in 2010, and 54.5% in 2012; P < .001) and first-authorship (9.9% in 2006 vs. 26.3% in 2008, 33.0% in 2010, and 35.6% in 2012; P < .001). Across years, there was a significantly greater proportion of students with peer-reviewed publications matched in higher-ranked residency programs (57.0% with publications in the top 10%, 52.7% in the top 10%-25%, 32.4% in the top 25%-50%, 41.2% in the bottom 50%, and 45.2% in unranked programs; P = .018). CONCLUSIONS Longitudinal research experiences for medical students may be one effective tool in fostering student publications and interest in extending training in a research-focused medical center.

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.

Using proper technique is important for minimizing upper limb kinetics during wheelchair transfers. The objective of the study was to 1) evaluate the transfer techniques used during toilet transfers and 2) determine the impact of technique on upper limb joint loading for two different toilet configurations.Twenty-six manual wheelchair users (23 men and 3 women) performed transfers in a side and front wheelchair-toilet orientation while their habitual transfer techniques were evaluated using the Transfer Assessment Instrument. A motion analysis system and force sensors were used to record biomechanical data during the transfers.More than 20% of the participants failed to complete five transfer skills in the side setup compared to three skills in the front setup. Higher quality skills overall were associated with lower peak forces and moments in both toilet configurations (-0.68 r -0.40, p 0.05). In the side setup, participants who properly placed their hands in a stable position and used proper leading handgrips had lower shoulder resultant joint forces and moments than participants who did not perform these skills correctly (p ≤ 0.04). In the front setup, positioning the wheelchair within three inches of the transfer target was associated with reduced peak trailing forces and moments across all three upper limb joints (p = 0.02).Transfer skills training, making toilet seats level with the wheelchair seat, positioning the wheelchair closer to the toilet and mounting grab bars in a more ideal location for persons who do sitting pivot transfers may facilitate better quality toilet transfers.

Brain-computer interface (BCI) controlled prosthetic arms are being developed to restore function to people with upper-limb paralysis. This work provides an opportunity to analyze human cortical activity during complex tasks. Previously we observed that BCI control became more difficult during interactions with objects, although we did not quantify the neural origins of this phenomena. Here, we investigated how motor cortical activity changed in the presence of an object independently of the kinematics that were being generated using intracortical recordings from two people with tetraplegia. After identifying a population-wide increase in neural firing rates that corresponded with the hand being near an object, we developed an online scaling feature in the BCI system that operated without knowledge of the task. Online scaling increased the ability of two subjects to control the robotic arm when reaching to grasp and transport objects. This work suggests that neural representations of the environment, in this case the presence of an object, are strongly and consistently represented in motor cortex but can be accounted for to improve BCI performance.

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.

Motor commands for the arm and hand generally arise from the contralateral motor cortex, where most of the relevant corticospinal tract originates. However, the ipsilateral motor cortex shows activity related to arm movement despite the lack of direct connections. The extent to which the activity related to ipsilateral movement is independent from that related to contralateral movement is unclear based on conflicting conclusions in prior work. Here we investigate bilateral arm and hand movement tasks completed by two human subjects with intracortical microelectrode arrays implanted in the left hand and arm area of the motor cortex. Neural activity was recorded while they attempted to perform arm and hand movements in a virtual environment. This enabled us to quantify the strength and independence of motor cortical activity related to continuous movements of each arm. We also investigated the subjects’ ability to control both arms through a brain–computer interface. Through a number of experiments, we found that ipsilateral arm movement was represented independently of, but more weakly than, contralateral arm movement. However, the representation of grasping was correlated between the two hands. This difference between hand and arm representation was unexpected and poses new questions about the different ways the motor cortex controls the hands and arms.

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.

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.

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.

Objective Brain-computer interface (BCI) technology aims to provide individuals with paralysis a means to restore function. Electrocorticography (ECoG) uses disc electrodes placed on either the surface of the dura or the cortex to record field potential activity. ECoG has been proposed as a viable neural recording modality for BCI systems, potentially providing stable, long-term recordings of cortical activity with high spatial and temporal resolution. Previously we have demonstrated that a subject with spinal cord injury (SCI) could control an ECoG-based BCI system with up to three degrees of freedom (Wang et al 2013 PLoS One). Here, we expand upon these findings by including brain-control results from two additional subjects with upper-limb paralysis due to amyotrophic lateral sclerosis and brachial plexus injury, and investigate the potential of motor and somatosensory cortical areas to enable BCI control. Approach Individuals were implanted with high-density ECoG electrode grids over sensorimotor cortical areas for less than 30 d. Subjects were trained to control a BCI by employing a somatotopic control strategy where high-gamma activity from attempted arm and hand movements drove the velocity of a cursor. Main results Participants were capable of generating robust cortical modulation that was differentiable across attempted arm and hand movements of their paralyzed limb. Furthermore, all subjects were capable of voluntarily modulating this activity to control movement of a computer cursor with up to three degrees of freedom using the somatotopic control strategy. Additionally, for those subjects with electrode coverage of somatosensory cortex, we found that somatosensory cortex was capable of supporting ECoG-based BCI control. Significance These results demonstrate the feasibility of ECoG-based BCI systems for individuals with paralysis as well as highlight some of the key challenges that must be overcome before such systems are translated to the clinical realm. ClinicalTrials.gov Identifier: NCT01393444.

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.

Objectives To refine the Transfer Assessment Instrument (TAI 2.0), develop a training program for the TAI, and analyze the basic psychometric properties of the TAI 3.0, including reliability, standard error of measurement (SEM), minimal detectable change (MDC), and construct validity. Design Repeated measures. Setting A winter sports clinic for disabled veterans. Participants Wheelchair users (N=41) who perform sitting-pivot or standing-pivot transfers. Intervention Not applicable. Main Outcome Measures TAI version 3.0, intraclass correlation coefficients, SEMs, and MDCs for reliable measurement of raters' responses. Spearman correlation coefficient, 1-way analysis of variance, and independent t tests to evaluate construct validity. Results TAI 3.0 had acceptable to high levels of reliability (range, .74–.88). The SEMs for part 1, part 2, and final scores ranged from .45 to .75. The MDC was 1.5 points on the 10-point scale for the final score. There were weak correlations (ρ range, −.13 to .25; P >.11) between TAI final scores and subjects' characteristics (eg, sex, body mass index, age, type of disability, length of wheelchair use, grip and elbow strength, sitting balance). Conclusions With comprehensive training, the refined TAI 3.0 yields high reliability among raters of different clinical backgrounds and experience. TAI 3.0 was unbiased toward certain physical characteristics that may influence transfer. TAI fills a void in the field by providing a quantitative measurement of transfers and a tool that can be used to detect problems and guide transfer training.

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.

To analyze and evaluate the efficacy of evacuation plans described by individuals with spinal cord injury (SCI).Descriptive study from a convenience sample.Outpatient population center in Pittsburgh, PA, USA.Twenty-one individuals with SCI who previously indicated that they had a plan of evacuation from either their homes, places of work, or towns/cities were contacted via telephone and asked to describe their evacuation plans. The number of critical elements (scale of 0-10 with 10 indicating a more thorough plan) and assistive technology (AT) devices were recorded.The number of critical elements (scale of 0-10 with 10 indicating a more thorough plan) and AT devices were recorded.Median home and town/city evacuation scores were both 3.00 (ranges: 1.0-4.0 and 0.0-8.0, respectively). Median evacuation scores of individuals with paraplegia were higher in home (P = 0.05, r = 0.44) and town/city (P = 0.045, r = 0.63) than individuals with tetraplegia. Median evacuation scores of subjects who were employed were higher in home (P = 0.036, r = 0.47) and town/city (P = 0.064, r = 0.59) than unemployed.Low scores indicate that individuals with SCI who believe that they have plans are not adequately prepared for an emergency evacuation. Interventions are needed to improve evacuation readiness and lack of preparedness in a catastrophe should be considered by emergency personnel when responding.

Objectives To describe the development of a strict education protocol to implement the clinical practice guideline "Preservation of Upper Limb Function Following Spinal Cord Injury" into a clinical setting, and evaluate the effect of the protocol on transfer quality. Design Randomized controlled trial. Setting Acute Model Spinal Cord Injury Systems rehabilitation facility and community. Participants Volunteer sample of full-time wheelchair users (N=70) with new spinal cord injuries randomized (1:1) to an intervention and standard-of-care group. Intervention The intervention group was educated on transfer skills with a structured protocol implemented by a physical and occupational therapist who were extensively educated on the clinical practice guidelines and current transfer research. The standard-of-care group received standard therapy services. Main Outcome Measures Comparison of transfer quality evaluated by the Transfer Assessment Instrument at 4 time points during first year after injury. Results No significant differences were found between study groups. Secondary analysis based on type of transfer performed found that participants in the intervention group who performed assisted sitting pivot transfers performed higher-quality transfers (mean ± SE: 9.43±.55) compared with the standard-of-care group (mean ± SE: 7.81±.46) ( P =.026) at 1 year after discharge. Also, participants who performed a dependent transfer had a higher average score across all 4 time points (mean ± SE: 9.14±.34) compared with the standard-of-care group (mean ± SE: 8.09±.29) ( P =.019). Conclusions For participants who perform assisted or dependent transfers, use of an evidenced-based, structured education program during acute inpatient rehabilitation has the potential to significantly improve the quality of transfers. Further follow-up testing is necessary with a larger sample size to determine the long-term effects.

Hosseini SM, Oyster ML, Kirby RL, Harrington AL, Boninger ML. Manual wheelchair skills capacity predicts quality of life and community integration in persons with spinal cord injury. Objectives To determine wheelchair (WC) skills success rates for manual WC users with spinal cord injury (SCI), to determine subject characteristics associated with the lowest success rates of WC skills, and to characterize the relationship between WC skills and measures of community integration and quality of life (QOL). Design Cross-sectional multisite study. Setting Six Spinal Cord Injury Model Systems (SCIMS) centers. Participants Individuals with SCI (N=214) who were at least 11 months postinjury, treated at an SCIMS center, and who used a manual WC as their primary means of mobility. Intervention Not applicable. Main Outcome Measures Wheelchair Skills Test (WST) and questionnaires of demographics and characteristics, QOL, and community participation. Results Of the 31 skills in the WST assessed, success rates ranged from 19.6% to 100%. Eight skills had success rates of ≤75%: folding/unfolding the WC (71.5%), ascending (19.6%) and descending (47.2%) a 15-cm curb, ascending (23.2%) and descending (26.5%) stairs, transferring from ground to WC (40.6%), turning 180° in wheelie position (55.2%), and holding a 30-second stationary wheelie (59.9%). Male sex, paraplegia, employed status, lower education, younger age at injury, and white race were among the participant characteristics bivariately associated with higher success rates of several WC skills. After controlling for covariates, higher success rates of several WC skills and a higher total WST score predicted better self-perceived health, higher life satisfaction, and more community participation. Conclusions For people with SCI who use a manual WC as their primary means of mobility, their ability to perform manual WC skills is associated with higher community participation and life satisfaction. Factors contributing to low success rates need to be investigated, and interventions to improve these rates are needed.

To examine (1) differences in quality-of-life scores for groups based on transitions in locomotion status at 1, 5, and 10 years postdischarge in a sample of people with spinal cord injury (SCI); and (2) whether demographic factors and transitions in locomotion status can predict quality-of-life measures at these time points.Retrospective case study of the National SCI Database.Model SCI Systems Centers.Individuals with SCI (N=10,190) from 21 SCI Model Systems Centers, identified through the National SCI Model Systems Centers database between the years 1985 and 2012. Subjects had FIM (locomotion mode) data at discharge and at least 1 of the following: 1, 5, or 10 years postdischarge.Not applicable.FIM-locomotion mode; Severity of Depression Scale; Satisfaction With Life Scale; and Craig Handicap Assessment and Reporting Technique.Participants who transitioned from ambulation to wheelchair use reported lower participation and life satisfaction, and higher depression levels (P.05) than those who maintained their ambulatory status. Participants who transitioned from ambulation to wheelchair use reported higher depression levels (P.05) and no difference for participation (P.05) or life satisfaction (P.05) compared with those who transitioned from wheelchair to ambulation. Demographic factors and locomotion transitions predicted quality-of-life scores at all time points (P.05).The results of this study indicate that transitioning from ambulation to wheelchair use can negatively impact psychosocial health 10 years after SCI. Clinicians should be aware of this when deciding on ambulation training. Further work to characterize who may be at risk for these transitions is needed.

OBJECTIVE The objectives of this work were to investigate how wheelchair transfers influence acute changes in ultrasound markers for biceps and supraspinatus tendon degeneration and to determine how such changes correlate with transfer technique and demographic characteristics. DESIGN Participants underwent quantitative ultrasound examinations for markers of biceps and supraspinatus tendon degeneration (tendon width, echogenicity, variance, and contrast) before and after a stressful repeated-transfers protocol. The Transfer Assessment Instrument was completed for each participant to identify transfer skills. Linear regression tested whether demographics and transfer skills correlated with ultrasound measures. RESULTS Sixty-two wheelchair users with spinal cord injury were included (39 with paraplegia and 23 with tetraplegia). Biceps tendon width increased after repeated transfers (P < 0.001). Participants with greater body weight experienced greater increases in biceps width after transfers (β = 0.109, P < 0.05). Skills evaluating body position relative to the target surface and safe and stable hand and arm positions affected changes in biceps and supraspinatus width and echogenicity (P < 0.05). CONCLUSIONS Repeated transfers caused measurable changes in biceps tendon width in a subset of participants. Changes in biceps and supraspinatus ultrasound measures were related to body weight and performance of specific transfer skills. Further testing is needed to confirm whether the clinical meaning of the observed relationships and whether using certain transfer skills and reducing body weight can attenuate the development of tendinopathy.

Intracortical microstimulation of the somatosensory cortex offers the potential for creating a sensory neuroprosthesis to restore tactile sensation. Whereas animal studies have suggested that both cutaneous and proprioceptive percepts can be evoked using this approach, the perceptual quality of the stimuli cannot be measured in these experiments. We show that microstimulation within the hand area of the somatosensory cortex of a person with long-term spinal cord injury evokes tactile sensations perceived as originating from locations on the hand and that cortical stimulation sites are organized according to expected somatotopic principles. Many of these percepts exhibit naturalistic characteristics (including feelings of pressure), can be evoked at low stimulation amplitudes, and remain stable for months. Further, modulating the stimulus amplitude grades the perceptual intensity of the stimuli, suggesting that intracortical microstimulation could be used to convey information about the contact location and pressure necessary to perform dexterous hand movements associated with object manipulation.

Objective To understand the role of cultural and psychosocial factors in the outcomes of veteran wheelchair users with spinal cord injury (SCI) to help clinicians identify unique factors faced by their patients and help researchers identify target variables for interventions to reduce disparities in outcomes. Design Cross-sectional cohort study. Setting Three urban Veterans Affairs medical centers affiliated with academic medical centers. Participants Of the patients (N=516) who were eligible to participate, 482 completed the interview and 439 had SCI. Because of small numbers in other race groups, analyses were restricted to white and African American participants, resulting in a final sample of 422. Intervention Not applicable. Main Outcome Measures Quality of life (QOL, Veterans RAND 12-Item Health Survey); satisfaction (Client Satisfaction Questionnaire); and participation (Craig Handicap Assessment and Reporting Technique Short Form). Results African American Veterans reported poorer physical QOL but better mental QOL than did white Veterans. No other significant race differences were found in unadjusted analyses. Multivariable analyses showed that psychosocial factors were predominantly associated with patients' QOL outcomes and satisfaction with service, but demographic and medical factors were predominantly associated with participation outcomes. Interaction analyses showed that there was a stronger negative association between anxiety and mental QOL for African Americans than for whites, and a positive association between higher self-esteem and social integration for whites but not African Americans. Conclusions Findings suggest that attempts to improve the outcomes of Veterans with SCI should focus on a tailored approach that emphasizes patients' demographic, medical, and psychosocial assets (eg, building their sense of self-esteem or increasing their feelings of mastery), while providing services targeted to their specific limitations (eg, reducing depression and anxiety).

To determine if the presence of pneumonia and pressure ulcers are associated in individuals with an acute spinal cord injury during acute care and rehabilitation hospitalizations.Retrospective, secondary analyses of data obtained from the Spinal Cord Injury Model Systems enrolled from 1993 until 2006 Setting: Acute care hospitalization and inpatient rehabilitation facilities Participants: A cohort of individuals hospitalized in acute care (n = 3,098) and inpatient rehabilitation (n = 1,768) was included in the analysis. Frequencies of pressure ulcer formation and episodes of pneumonia were noted in both settings.Not applicable.Pressure ulcer formation and diagnosis of pneumonia Results: The development of pressure ulcers, including stage I, was 20.3% acute care and 21.1% during in inpatient rehabilitation. Multivariate logistic regression analyses revealed a significant association of pneumonia with occurrence of pressure ulcers (P ≤ 0.001, OR = 2.3 and 2.2 respectively), the American Spinal Injury Association Impairment Scale grades (P 0.001), and utilization of mechanical ventilation (P 0.01) in both settings.A higher presence of pressure ulcers was found in individuals with pneumonia, after adjusting for injury severity, age, sex, and utilization of mechanical ventilation. Impaired inflammatory response and decreased mobility in individuals with pneumonia may predispose these individuals to develop pressure ulcers. Surveillance and preventive measures for pressure ulcers should be rigorous in individuals with SCI and pneumonia.

Objective To investigate the frequency and types of wheelchair repairs and associated adverse consequences. Design Convenience cross-sectional sample survey. Setting Nine Spinal Cord Injury Model Systems Centers. Participants People with spinal cord injury who use a wheelchair >40h/wk (N=591). Interventions Not applicable. Main Outcome Measures Number of repairs needed and resulting adverse consequences, number and types of repairs completed, and location where main repair was completed in the previous 6 months. Results There were 591 participants responded to the survey, 63.8% (377/591) of them needed ≥1 repair; of these, 27.6% (104/377) experienced ≥1 adverse consequence, including 18.2% (69/377) individuals who were stranded. Of those who needed repairs, 6.9% did not have them completed (26/377). Repairs completed on the wheels and casters were the most frequent repair to manual wheelchairs, whereas repairs to the electrical and power and control systems were the most frequent type of repair on power wheelchairs. Forty percent (79/201) of manual wheelchair users reported completing repairs at home themselves compared with 14% (21/150) of power wheelchair users. Twelve percent of the variance in the odds of facing an adverse consequence because of a wheelchair breakdown can be described as a function of occupation, funding source, and type of wheelchair. Conclusions Wheelchair repairs are highly prevalent. There are differences in types of repairs and who completes the repairs based on the type of wheelchair. Wheelchair breakdowns result in adverse consequences for users, and there is a deficit between repairs needed and those completed, highlighting the need for interventions that address these problems.

To describe the wheelchair skills capacity and performance of experienced manual wheelchair users with spinal cord injury (SCI) and to assess measurement properties of the Wheelchair Skills Test (WST) and Wheelchair Skills Test Questionnaire (WST-Q).Cross-sectional descriptive study involving within-subject comparisons.Four Spinal Cord Injury Model Systems centers.Manual wheelchair users with SCI (N=117).Not applicable.WST and WST-Q version 4.2 as well as measures for Confidence, Basic Mobility, Independence, Ability to Participate, Satisfaction, and Pain Interference.The median (interquartile range) values for WST capacity, WST-Q capacity, and WST-Q performance were 81.0% (69.0%-90.0%), 88.0% (77.0%-97.0%), and 76.0% (66.3%-84.0%). The total WST capacity scores correlated significantly with the total WST-Q capacity scores (r=.76; P.01) and WST-Q performance scores (r=.55; P.01). The total WST-Q capacity and WST-Q performance scores were correlated significantly (r=.63; P.001). Success rates were75% for 10 of the 32 (31%) individual skills on the WST and 6 of the 32 (19%) individual skills on the WST-Q. Regression models for the total WST and WST-Q measures identified statistically significant predictors including age, sex, body mass index, and/or level of injury. The WST and WST-Q measures correlated significantly with the Confidence, Basic Mobility, Independence, or Pain Interference measures.Many people with SCI are unable to or do not perform some of the wheelchair skills that would allow them to participate more fully. More wheelchair skills training may enhance participation and quality of life of adults with SCI. The WST and WST-Q exhibit good content, construct, and concurrent validity.

This paper demonstrates a synergy-based brain-machine interface that uses low-dimensional command signals to control a high dimensional virtual hand. First, temporal postural synergies were extracted from the angular velocities of finger joints of five healthy subjects when they performed hand movements that were similar to activities of daily living. Two synergies inspired from the extracted synergies, namely, two-finger pinch and whole-hand grasp, were used in real-time brain control, where a virtual hand with 10 degrees of freedom was controlled to grasp or pinch virtual objects. These two synergies were controlled by electrocorticographic (ECoG) signals recorded from two electrodes of an electrode array that spanned motor and speech areas of an individual with intractable epilepsy, thus demonstrating closed loop control of a synergy-based brain-machine interface.

Riggins MS, Kankipati P, Oyster ML, Cooper RA, Boninger ML. The relationship between quality of life and change in mobility 1 year postinjury in individuals with spinal cord injury. Objective To examine quality-of-life (QOL) factors and change in mobility in individuals with traumatic spinal cord injury (SCI) 1 year after injury. Design Retrospective case study of National SCI Database data. Setting SCI Model Systems (SCIMS) sites (N=18). Participants Subjects (N=1826; age >18y) who presented to an SCIMS site after traumatic SCI between June 2004 and July 2009 and returned for 1-year follow-up. All subjects had FIM mobility data for both assessments. Interventions Not applicable. Main Outcome Measures Assessment of impairment based on Lower-Extremity Motor Score. Assessment of QOL based on Craig Handicap Assessment and Reporting Technique, Patient Health Questionnaire, Satisfaction With Life Scale, Self-perceived Health Status, and pain severity scores. Results Of the sample, 55 individuals transitioned from walking to wheelchair use within 1 year of discharge. This group had the highest number of individuals from minority groups (52.8%) and the lowest employment rate (7.3%). Compared with individuals who transitioned from wheelchair use to walking or maintained wheelchair use or ambulation, the walking-to-wheelchair transition group had significantly lower QOL scores ( P P P Conclusions Individuals with SCI who transitioned from walking at discharge to wheelchair use within 1 year had low QOL factors, including high pain and depression scores. Rehabilitation professionals should consider encouraging marginal ambulators to work toward functional independence from a wheelchair, rather than primary ambulation during acute inpatient rehabilitation.

Norweg A, Jette AM, Houlihan B, Ni P, Boninger ML. Patterns, predictors, and associated benefits of driving a modified vehicle after spinal cord injury: findings from the National Spinal Cord Injury Model Systems. Objectives To investigate the patterns, predictors, and benefits associated with driving a modified vehicle for people with spinal cord injuries (SCIs). Design Cross-sectional retrospective survey design. Settings Sixteen Model SCI Systems (MSCISs) throughout the United States. Participants People (N=3726) post-SCI from the National MSCIS Database. Interventions Not applicable. Main Outcome Measures Driving, employment, and community reintegration post-SCI. Results The study found that 36.5% of the sample drove a modified vehicle after SCI. Significant predictors of driving a modified vehicle post-SCI included married at injury, younger age at injury, associate's degree or higher before injury, paraplegia, a longer time since the injury, non-Hispanic race, white race, male sex, and using a wheelchair for more than 40 hours a week after the injury (accounting for 37% of the variance). Higher activity of daily living independence (in total motor function) at hospital discharge also increased the odds of driving. Driving increased the odds of being employed at follow-up by almost 2 times compared with not driving postinjury (odds ratio, 1.85). Drivers tended to have higher community reintegration scores, especially for community mobility and total community reintegration. Driving was also associated with small health-related quality-of-life gains, including less depression and pain interference and better life satisfaction, general health status, and transportation availability scores. Conclusions The associated benefits of driving and the relatively low percentage of drivers post-SCI in the sample provide evidence for the need to increase rehabilitation and assistive technology services and resources in the United States devoted to facilitating driving after SCI.

McClure LA, Boninger ML, Oyster ML, Roach MJ, Nagy J, Nemunaitis G. Emergency evacuation readiness of full-time wheelchair users with spinal cord injury. Objectives To determine the percentage of full-time wheelchair users with spinal cord injuries who felt they could evacuate from various locations, and the percentage who have a plan for evacuation. Study results will help clinicians and emergency officials understand needs related to evacuation preparedness. Design Convenience sample survey. Setting Six Spinal Cord Injury Model System centers, part of the national database funded through the Department of Education, National Institute on Disability and Rehabilitation Research. Participants People (N=487) with spinal cord injuries who use a wheelchair more than 40 hours a week. Interventions Not applicable. Main Outcome Measures The percentage of wheelchair users who felt they would be able to safely evacuate, had a plan for safe evacuation, or reported a need for assistive technology and human assistance to evacuate from various locations in the event of an emergency. Results The highest percentage of participants felt they would be able to safely evacuate and had a plan for work evacuation. The lowest percentage of participants reported they could evacuate from their city/town in the event of an emergency and had a plan to evacuate their city/town in the event of a natural disaster. A large difference exists between the percentage of participants who felt they could evacuate and those who have a plan for evacuation. Conclusions A large discrepancy exists between the perception that one can evacuate and actually having a plan. The perception that one can evacuate without a plan or the use of assistive technology is an area of concern that must be further addressed by educators. Education must emphasize the need to have a defined evacuation plan and effective utilization of assistive technology.

McClure LA, Boninger ML, Ozawa H, Koontz A. Reliability and validity analysis of the Transfer Assessment Instrument. Objectives To describe the development and evaluate the reliability and validity of a newly created outcome measure, the Transfer Assessment Instrument (TAI), to assess the quality of transfers performed by full-time wheelchair users. Design Repeated measures. Setting 2009 National Veterans Wheelchair Games in Spokane, WA. Participants A convenience sample of full-time wheelchair users (N=40) who perform sitting pivot or standing pivot transfers. Interventions Not applicable. Main Outcome Measures Intraclass correlation coefficients (ICCs) for reliability and Spearman correlation coefficients for concurrent validity between the TAI and a global assessment scale (0–100 visual analog scale [VAS]). Results No adverse events occurred during testing. Intrarater ICCs for 3 raters ranged between .35 and .89, and the interrater ICC was .642. Correlations between the TAI and a global assessment VAS ranged between .19 ( P =.285) and .69 ( P >.000). Item analyses of the tool found a wide range of results, from weak to good reliability. Evaluators found the TAI to be safe and able to be completed in a short time. Conclusions The TAI is a safe, quick outcome measure that uses equipment typically found in a clinical setting and does not ask participants to perform new skills. Reliability and validity testing found the TAI to have acceptable interrater and a wide range of intrarater reliability. Future work indicates the need for continued refinement including removal or modification of items found to have low reliability, improved education for clinicians, and further reliability and validity analysis with a more diverse subject population. The TAI has the potential to fill a void in assessment of transfers.