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The aim of this study was to evaluate the use of ultrasound imaging (USI) as a diagnostic tool to assess muscle function after a spinal cord injury (SCI). Ultrasound videos of the gastrocnemius medialis muscle were recorded both at rest and during attempted maximum voluntary contraction (MVC) for fifteen participants with a SCI and fifteen able-bodied controls. Measurements were repeated at monthly intervals for participants in the SCI group during their inpatient stay. Differences in muscle echogenicity and thickness were detected between both able-bodied and SCI groups and subgroups of SCI participants, suggesting USI can detect and monitor changes in muscle structure which are characteristic of atrophy. Decreased muscle movement in the SCI groups was also detected during attempted MVC. The ability of USI to distinguish between different levels of function demonstrates the potential of USI as a quantitative tool to assess muscles.

Summary Fibular response to disuse has been described in cross-sectional but not longitudinal studies. This study assessed fibular bone changes in people with spinal cord injury. Fibular bone loss was less than in the tibia and was not correlated together. This might explain low fibular fracture incidents in these patients. Purpose Cross-sectional studies suggest that the fibula responds differently to loading and disuse compared to the tibia. Whilst tibial bone changes following spinal cord injury (SCI) have been established in longitudinal studies, fibular changes remain unexplored. Methods Fibular and tibial bone parameters were assessed in 13 individuals with SCI (aged 16–76 years). Peripheral quantitative computed tomography scans were acquired at 4%, 38% and 66% distal–proximal tibia length at 5 weeks and 12 months post-injury. Changes in 4% site total bone mineral content (BMC), total cross-sectional area (CSA) and bone mineral density (BMD), and 38% and 66% sites total BMC, total CSA, cortical BMD and cortical CSA were assessed using paired T-tests. Relationships between bone loss in the two bones at equivalent sites were assessed using paired T-tests and correlation. Results At the 4% site, fibular total BMC and BMD losses were less than tibial losses (− 6.9 ± 5.1% and − 6.6 ± 6.0% vs − 14.8 ± 12.4% and − 14.4 ± 12.4%, p = 0.02 and p = 0.03, respectively). Similarly, at the 66% site, fibular BMC losses were less than those in the tibia (− 2.0 ± 2.6% vs − 4.3 ± 3.6%, p = 0.03), but there was no difference at 38% (− 1.8 ± 3.5% vs − 3.8 ± 2.1%, p = 0.1). No correlation was observed for BMC changes between the two bones (all p > 0.25). Conclusion These results support cross-sectional evidence of smaller disuse-related bone loss in the fibula compared to the tibia. These results may in part explain lower incidence of fibula fractures in individuals with chronic SCI. The lack of association between losses in the two bones might point to different underlying mechanisms.

Study design Economic modelling analysis. Objectives To determine lifetime direct and indirect costs from initial hospitalisation of all expected new traumatic and non-traumatic spinal cord injuries (SCI) over 12 months. Setting United Kingdom (UK). Methods Incidence-based approach to assessing costs from a societal perspective, including immediate and ongoing health, rehabilitation and long-term care directly attributable to SCI, as well as aids and adaptations, unpaid informal care and participation in employment. The model accounts for differences in injury severity, gender, age at onset and life expectancy. Results Lifetime costs for an expected 1270 new cases of SCI per annum conservatively estimated as £1.43 billion (2016 prices). This equates to a mean £1.12 million (median £0.72 million) per SCI case, ranging from £0.47 million (median £0.40 million) for an AIS grade D injury to £1.87 million (median £1.95 million) for tetraplegia AIS A–C grade injuries. Seventy-one percent of lifetime costs potentially are paid by the public purse with remaining costs due to reduced employment and carer time. Conclusions Despite the magnitude of costs, and being comparable with international estimates, this first analysis of SCI costs in the UK is likely to be conservative. Findings are particularly sensitive to the level and costs of long-term home and residential care. The analysis demonstrates how modelling can be used to highlight economic impacts of SCI rapidly to policymakers, illustrate how changes in future patterns of injury influence costs and help inform future economic evaluations of actions to prevent and/or reduce the impact of SCIs.

An international multi-centred, double-blinded, randomised sham-controlled trial (eWALK).To determine the effect of 12 weeks of transcutaneous spinal stimulation (TSS) combined with locomotor training on walking ability in people with spinal cord injury (SCI).Dedicated SCI research centres in Australia, Spain, USA and Scotland.Fifty community-dwelling individuals with chronic SCI will be recruited. Participants will be eligible if they have bilateral motor levels between T1 and T11, a reproducible lower limb muscle contraction in at least one muscle group, and a Walking Index for SCI II (WISCI II) between 1 and 6. Eligible participants will be randomised to one of two groups, either the active stimulation group or the sham stimulation group. Participants allocated to the stimulation group will receive TSS combined with locomotor training for three 30-min sessions a week for 12 weeks. The locomotor sessions will include walking on a treadmill and overground. Participants allocated to the sham stimulation group will receive the same locomotor training combined with sham stimulation. The primary outcome will be walking ability with stimulation using the WISCI II. Secondary outcomes will record sensation, strength, spasticity, bowel function and quality of life.ANZCTR.org.au identifier ACTRN12620001241921.

Osteoporosis is a long-term consequence of spinal cord injury (SCI) that leads to a high risk of fragility fractures. The fracture rate in people with SCI is twice that of the general population. At least 50% of these fractures are associated with clinical complications such as infections. This review article presents key features of osteoporosis after SCI, starting with its aetiology, a description of temporal and spatial changes in the long bones and the subsequent fragility fractures. It then describes the physical and pharmacological approaches that have been used to attenuate the bone loss. Bone loss after SCI has been found to be highly site-specific and characterised by large inter-variability and site-specific changes. The assessment of the available interventions is limited by the quality of the studies and the lack of information on their effect on fractures, but this evaluation suggests that current approaches do not appear to be effective. More studies are required to identify factors influencing rate and magnitude of bone loss following SCI. In addition, it is important to test these interventions at the sites that are most prone to fracture, using detailed imaging techniques, and to associate bone changes with fracture risk. In summary, bone loss following SCI presents a substantial clinical problem. Identification of at-risk individuals and development of more effective interventions are urgently required to reduce this burden.

Brain–computer interface (BCI) controlled functional electrical stimulation (FES) is a novel technique for volitional control of FES using a signal derived from the brain. The intuitive nature of BCI-FES has promoted its use to control FES-based assistive device to augment an imagined movement. Researchers are now exploring extensively the use of the BCI-FES as a neurorehabilitation system based on the fact that it necessitates active participation and establishes temporal association between efferent information, from cortical activation due to attempted movement and afferent information due to peripheral stimulation. The research literature mainly focuses on people with stroke for BCI-FES rehabilitation whilst people with spinal cord injury (SCI) have been considered good candidates for BCI-FES as an assistive device. This chapter discusses application of BCI-FES as neurorehabilitative system for the hand function in people with SCI, and highlights issues related to altered sensorimotor cortical activity as a result of the injury. Based on experimental results this chapter also introduces a concept of researcher-therapist-caregiver knowledge transfer and introduces a concept of caregiver and patient self-managed BCI-FES for home-based rehabilitation.

We report excellent neurological improvement in a patient with C6/C7 dislocation following a high speed road traffic accident. This case in particular is unusual because the patient was the recipient of an organ transplant during childhood and was therefore on long term immunosuppressant medication at the time of injury. In this report we reflect on the role of steroid use in traumatic spinal cord injury and put our case within the context of current evidence and this unusual clinical scenario.

Background Neurofeedback (NFB) is a neuromodulatory technique that enables voluntary modulation of brain activity in order to treat neurological condition, such as central neuropathic pain (CNP). A distinctive feature of this technique is that it actively involves participants in the therapy. In this feasibility study, we present results of participant self-managed NFB treatment of CNP. Methods Fifteen chronic spinal cord injured (SCI) participants (13M, 2F), with chronic CNP equal or greater than 4 on the Visual Numeric Scale, took part in the study. After initial training in hospital (up to 4 sessions), they practiced NF at home, on average 2–3 times a week, over a period of several weeks (min 4, max 20). The NFB protocol consisted of upregulating the alpha (9–12 Hz) and downregulating the theta (4–8 Hz) and the higher beta band (20–30 Hz) power from electrode location C4, for 30 min. The output measures were pain before and after NFB, EEG before and during NFB and pain questionnaires. We analyzed EEG results and show NFB strategies based on the Power Spectrum Density of each single participant. Results Twelve participants achieved statistically significant reduction in pain and in eight participants this reduction was clinically significant (larger than 30%). The most successfully regulated frequency band during NFB was alpha. However, most participants upregulated their individual alpha band, that had an average dominant frequency at αp = 7.6 ± 0.8 Hz (median 8 Hz) that is lower than the average of the general population, which is around 10 Hz. Ten out of fifteen participants significantly upregulated their individual alpha power (αp ± 2 Hz) as compared to 4 participants who upregulated the power in the fixed alpha band (8–12 Hz). Eight out of the twelve participants who achieved a significant reduction of pain, significantly upregulated their individual alpha band power. There was a significantly larger increase in alpha power (p < 0.0001) and decrease of theta power (p < 0.04) in participant specific rather than in fixed frequency bands. Conclusion Neurofeedback is a neuromodulatory technique that gives participants control over their pain and can be self-administered at home. Regulation of individual frequency band was related to a significant reduction in pain.

Available online 23 May 2018 Objectives To create a classifier based on electroencephalography (EEG) to identify spinal cord injured (SCI) participants at risk of developing central neuropathic pain (CNP) by comparing them with patients who had already developed pain and with able bodied controls. Methods Multichannel EEG was recorded in the relaxed eyes opened and eyes closed states in 10 able bodied participants and 31 subacute SCI participants (11 with CNP, 10 without NP and 10 who later developed pain within 6 months of the EEG recording). Up to nine EEG band power features were classified using linear and non-linear classifiers. Results Three classifiers (artificial neural networks ANN, support vector machine SVM and linear discriminant analysis LDA) achieved similar average performances, higher than 85% on a full set of features identifying patients at risk of developing pain and achieved comparably high performance classifying between other groups. With only 10 channels, LDA and ANN achieved 86% and 83% accuracy respectively, identifying patients at risk of developing CNP. Conclusion Transferable learning classifier can detect patients at risk of developing CNP. EEG markers of pain appear before its physical symptoms. Simple and complex classifiers have comparable performance. Significance Identify patients to receive prophylaxic treatment of CNP. This work was partially supported by the Higher Committee for Education Development

Study design: A retrospective cohort study. Objectives: To review demographic trends in traumatic spinal cord injury (TSCI) and non-traumatic spinal cord injury (NTSCI). Setting: The Queen Elizabeth National Spinal Injuries Unit (QENSIU), sole provider of treatment for TSCI in Scotland; a devolved region of the UK National Health Service. Methods: A retrospective review of the QENSIU database was performed between 1994 and 2013. This database includes demographic and clinical data from all new TSCI patients in Scotland, as well as patients with severe NTSCI. Results: Over this 20-year period there were 1638 new cases of TSCI in Scotland; 75.2% occurring in males. TSCI incidence increased non-significantly (13.3 per million population to 17.0), while there were significant increases in mean age at time of TSCI (44.1–52.6 years), the proportion of TSCIs caused by falls (41–60%), the proportion of TSCIs resulting in an American Spinal Injury Association Impairment Scale score of C and D on admission (19.7–28.6% and 34.5–39.5%, respectively) and the proportion of cervical TSCIs (58.4–66.3%). The increase in cervical TSCI was specifically due to an increase in C1–C4 lesions (21.7–31.2%). NTSCI patients (n=292) were 5 years older at injury, more likely to be female (68.1% male) and had a range of diagnoses. Conclusion: This study supports the suggestion that demographic profiles in SCI are subject to change. In this population, of particular concern is the increasing number of older patients and those with high level tetraplegia, due to their increased care needs. Prevention programmes, treatment pathways and service provision need to be adjusted for optimum impact, improved outcome and long-term care for their target population.

Background Disuse osteoporosis occurs in response to long-term immobilization. Spinal cord injury (SCI) leads to a form of disuse osteoporosis that only affects the paralyzed limbs. High rates of bone resorption after injury are evident from decreases in bone mineral content (BMC), which in the past have been attributed in the main to loss of trabecular bone in the epiphyses and cortical thinning in the shaft through endocortical resorption. Methods Patients with motor-complete SCI recruited from the Queen Elizabeth National Spinal Injuries Unit (Glasgow, UK) were scanned within 5 weeks of injury (baseline) using peripheral Quantitative Computed Tomography (pQCT). Unilateral scans of the tibia, femur and radius provided separate estimates of trabecular and cortical bone parameters in the epiphyses and diaphyses, respectively. Using repeat pQCT scans at 4, 8 and 12 months post-injury, changes in BMC, bone mineral density (BMD) and cross-sectional area (CSA) of the bone were quantified. Results Twenty-six subjects (5 female, 21 male) with SCI (12 paraplegic, 14 tetraplegic), ranging from 16 to 76 years old, were enrolled onto the study. Repeated-measures analyses showed a significant effect of time since injury on key bone parameters at the epiphyses of the tibia and femur (BMC, total BMD, trabecular BMD) and their diaphyses (BMC, cortical BMD, cortical CSA). There was no significant effect of gender or age on key outcome measures, but there was a tendency for the female subjects to experience greater decreases in cortical BMD. The decreases in cortical BMD in the tibia and femur were found to be statistically significant in both men and women. Conclusions By carrying out repeat pQCT scans at four-monthly intervals, this study provides a uniquely detailed description of the cortical bone changes that occur alongside trabecular bone changes in the first year of complete SCI. Significant decreases in BMD were recorded in both the cortical and trabecular bone compartments of the tibia and femur throughout the first year of injury. This study provides evidence for the need for targeted early intervention to preserve bone mass within this patient group.

It is widely believed that cortical changes are a consequence of long standing neuropathic pain (NP). In this paper we demonstrate that NP in people with subacute spinal cord injury (SCI) has characteristic electroencephalographic (EEG) markers which precede the onset of pain. EEG was recorded in a relaxed state and during motor imagination tasks in 10 able bodied participants and 31 subacute SCI participants (11 with NP, 10 without NP and 10 who developed pain within 6 months of EEG recording). All 20 SCI participants initially without NP were tested for mechanically induced allodynia but only one person, who later developed pain, reported an unpleasant sensation. The EEG reactivity to opening eyes was reduced in the alpha band and absent in the theta and beta bands in participants who later developed pain, and it was reduced in participants who already had pain. Alpha band power was reduced at BA7 in both the relaxed state and during motor imagination in participants who either had or later developed pain compared to participants without pain. All SCI groups had reduced dominant alpha frequency and beta band power at BA7.\ud \ud Electroencephalographic reactivity to eyes opening, and reduced spontaneous and induced alpha activity over the parietal cortex were predictors of future NP as well as markers of existing NP.\ud \ud Clinical Trial Registration Number: NCT02178917\ud \ud Perspectives: We demonstrate that brain activity in subacute SCI contains both early markers and predictors of NP, which may manifest before sensory discomfort. These markers and predictors may complement known sensory phenotypes of NP. They may exist in other patient groups suffering from NP of central origin.

Background: The high risk of fracture associated with chronic spinal cord injury (SCI) is attributed to extensive disuse-related bone loss in previously weight-bearing long bones. Changes in bone mineral density (BMD) after SCI have been documented extensively for the epiphyses of the tibia and femur, fracture-prone sites in this patient group. Less attention has been given to patterns of cortical bone loss in the diaphyses, but variability in BMD distributions throughout the long bones may contribute to some patients’ increased susceptibility to shaft fractures in chronic SCI. Aim: A cross-sectional study was carried out to determine whether BMD distributions along the tibia differ between individuals with chronic SCI and healthy able-bodied (AB) controls, in both the trabecular and cortical bone compartments. The effects of time post-injury and gender on BMD distribution were also explored. Methods: Individuals with chronic (≥ 6 months post-injury) motor-complete SCI were recruited from the Queen Elizabeth National Spinal Injuries Unit (Glasgow, UK). AB control subjects were recruited to achieve similar age and gender profiles for the SCI and control groups. Multi-slice pQCT (XCT3000, Stratec) was performed along the length of the tibia (2mm thickness, 0.5mm voxel size), at 1% intervals in the epiphyses and 5% intervals in the diaphysis (34 slices in total). These were used to reconstruct full 3-D subject-specific models (Mimics, Materialise) of BMD distribution, by interpolating between slices. Subjects with chronic SCI were subdivided into ‘early’ (

Spinal cord injury caused by stab wounds (SCISW) results from a partial or complete transection of the cord, and presents opportunities for interventional research. It is recognized that there is low incidence, but little is known about the natural history or the patient's suitability for long-term clinical outcome studies. This study aims to provide population-based evidence of the demographics of SCISW, and highlight the issues regarding the potential for future research. The database of the Queen Elizabeth National Spinal Injuries Unit (QENSIU), the sole center for treating SCI in Scotland, was reviewed between 1994 and 2013 to ascertain the incidence, demographics, functional recovery, and mortality rates for new SCISW. During this 20 year period, 35 patients with SCISW were admitted (97.1% male, mean age 30.0 years); 31.4% had a cervical injury, 60.0% had a thoracic injury, and 8.6% had a lumbar injury. All had a neurological examination, with 42.9% diagnosed as motor complete on admission and 77.1% discharged as motor incomplete. A total of 70.4% of patients with an American Spinal Injury Association Impairment Scale (AIS) level of A to C on admission had an improved AIS level on discharge. Nine (25.7%) patients have died since discharge, with mean life expectancy for these patients being 9.1 years after injury (20-65 years of age). Patients had higher levels of comorbidities, substance abuse, secondary events, and poor compliance compared with the general SCI population, which may have contributed to the high mortality rate observed post-discharge. The low incidence, heterogeneous nature, spontaneous recovery rate, and problematic follow-up makes those with penetrating stab injuries of the spinal cord a challenging patient group for SCI research.

After spinal cord injury (SCI), bone loss in the paralysed limbs progresses at variable rates. Decreases in bone mineral density (BMD) in the first year range from 1% (slow) to 40% (rapid). In chronic SCI, fragility fractures commonly occur around the knee, with significant associated morbidity. Osteoporosis treatments await full evaluation in SCI, but should be initiated early and targeted towards patients exhibiting rapid bone loss. The potential to predict rapid bone loss from a single bone scan within weeks of a SCI was investigated using statistical shape modelling (SSM) of bone morphology, hypothesis: baseline bone shape predicts bone loss at 12-months post-injury at fracture-prone sites. In this retrospective cohort study 25 SCI patients (median age, 33 years) were scanned at the distal femur and proximal tibia using peripheral Quantitative Computed Tomography at

The disuse-related bone loss that results from immobilisation following injury shares characteristics with osteoporosis in post-menopausal women and the aged, with decreases in bone mineral density leading to weakening of the bone and increased risk of fracture. The aim of this study was to use the finite element method to: (i) calculate the mechanical response of the tibia under mechanical load and (ii) estimate of the risk of fracture; comparing between two groups, an able-bodied group and spinal cord injury patients group suffering from varying degrees of bone loss. The tibiae of eight male subjects with chronic spinal cord injury and those of four able-bodied age-matched controls were scanned using multi-slice peripheral quantitative computed tomography. Images were used to develop full three-dimensional models of the tibiae in Mimics (Materialise) and exported into Abaqus (Simulia) for calculation of stress distribution and fracture risk in response to specified loading conditions – compression, bending and torsion. The percentage of elements that exceeded a calculated value of the ultimate stress provided an estimate of the risk of fracture for each subject, which differed between spinal cord injury subjects and their controls. The differences in bone mineral density distribution along the tibia in different subjects resulted in different regions of the bone being at high risk of fracture under set loading conditions, illustrating the benefit of creating individual material distribution models. A predictive tool can be developed based on these models, to enable clinicians to estimate the amount of loading that can be safely allowed onto the skeletal frame of individual patients who suffer from extensive musculoskeletal degeneration (including spinal cord injury, multiple sclerosis and the ageing population). The ultimate aim is to reduce fracture occurrence in these vulnerable groups.

Damage to the spinal cord compromises motor function and sensation below the level of injury, resulting in paralysis and progressive secondary health complications. Inactivity and reduced energy requirements result in reduced cardiopulmonary fitness and an increased risk of coronary heart disease and cardiovascular complications. These risks may be minimized through regular physical activity. It is proposed that such activity should begin at the earliest possible time point after injury, before extensive neuromuscular degeneration has occurred. Robotic-assisted tilt-table therapy may be used during early-stage spinal cord injury (SCI) to facilitate stepping training, before orthostatic stability has been achieved. This study investigates whether such a stimulus may be used to maintain pulmonary and coronary health by describing the acute responses of patients with early-stage (

Background: We are investigating the potential of robotics-assisted treadmill technology as a mode of exercise in people with spinal cord injury (SCI). People with incomplete SCI can actively contribute to this form of exercise, but in the clinical setting they often walk passively in the system. It is not known whether in doing so they are meeting the recommended guidelines for increasing cardiopulmonary fitness. Objective: The aims of this study were twofold: to characterise the intensity of passive walking during robotics-assisted treadmill exercise (RATE) in incomplete SCI; and to determine if this intensity meets the recommended guidelines for cardiopulmonary training in this population. Methods: 10 subjects with incomplete SCI twice performed an exercise test on a robotics-assisted treadmill. The test comprised a period of passive walking and a ramp phase to the limit of tolerance. Oxygen uptake (VO$_2$) and heart rate (HR) were continuously measured. Results: VO$_2$ during passive exercise was on average 1.4 times higher than resting VO$_2$(VO$_{2R}$), but this was only 29% of peak VO$_2$(VO$_{2peak}$) (range 16-43%). Relative to rest, passive VO$_2$(VO$_{2P}$) was only 12% of VO$_2$(VO$_{2peak}$). HR did not increase from rest to passive walking (81 ± 10 bpm to 81 ± 13 bpm respectively). The HR associated with passive walking was on average 50% of peak HR (HR$_{peak}$) (161 ± 13 bpm). Test-retest reliability was moderate for VO$_{2R}$ (R=0.62) and resting HR (HR$_{R}$) (R=0.68), high for VO$_{2P}$ (R=0.81), passive HR (HR$_{P}$) (R=0.87) and HR$_{peak}$ (R=0.88), and very high (R=0.95) for VO$_{2peak}$. Only HR$_{P}$ differed significantly between tests (p=0.029). Conclusions: The intensity of passive walking during RATE is low and is insufficient to increase cardiopulmonary fitness in people with SCI. Subjects must actively contribute to the exercise in order to achieve the recommended training intensity.

Objective: (i) to compare cardiopulmonary performance parameters obtained from incremental exercise tests (IETs) performed using a robotics-assisted treadmill and an arm crank ergometer; (ii) to investigate test-retest reliability during both modes of exercise. Design: Each participant performed two IETs to the limit of tolerance on both a robotics-assisted treadmill and an arm crank ergometer. Setting: A Spinal Injuries Unit in the United Kingdom. Participants: 10 people with an incomplete spinal cord injury (SCI). Interventions: Not applicable. Main Outcome Measures: Peak oxygen uptake (dO$_{2peak}$), the gas exchange threshold (GET), peak heart rate (HR$_{peak}$) and peak lactate (Lactate$_{peak}$) were obtained for each mode of assessment. The mean responses and test-retest reliability of the main outcome measures were determined and compared between modes of assessment. Results: dO$_{2peak}$ was 16% higher (p= 0.016) and the dO$_2$ at the GET was 40% higher (p =0.007) during the robotics-assisted treadmill exercise (RATE) IET. There was a trend for HR$_{peak}$ to be higher during arm crank ergometry (ACE) (p=0.058). Lactate$_{peak}$ was 46% higher (p=0.006) during the ACE IET. During robotics-assisted exercise, the test-retest reliability was very high for dO$_{2peak}$ (r=0.95), high for the GET (r=0.75) and HR$_{peak}$ (r=0.88), and moderate for Lactate$_{peak}$ (r=0.58). For ACE, the test-retest reliability was very high for dO$_{2peak}$ (r=0.93), high for HR$_{peak}$ (r =0.81) and Lactate$_{peak}$ (r=0.78), and low for the GET (r=0.16). Conclusions: The results suggest that, when compared with ACE, RATE can be a highly effective stressor of the cardiopulmonary system, and may be a more appropriate mode of assessment to determine and monitor cardiopulmonary fitness in people with incomplete SCI.