Shoulder EMG during depression raise in men with spinal cord injury: the influence of lesion level

BACKGROUND & OBJECTIVE: The depression-style raise maneuver is commonly performed by persons with spinal cord injury (SCI) to relieve skin pressures and avoid skin ulceration. The demands of this critical activity, however, are not fully documented for individuals with higher spinal cord lesions. The purpose of this investigation was to determine the influence of SCI lesion level on shoulder muscle activity during a depression raise maneuver. EXPERIMENTAL DESIGN: Sample of convenience, group comparison. METHODS: Fine-wire intramuscular electrodes recorded electromyographic (EMG) activity from 12 shoulder muscles in 57 men with SCI while they performed depression raises (C6 tetraplegia, n = 10; C7 tetraplegia, n = 18; high paraplegia, n = 16; low paraplegia, n = 13). EMG intensity was normalized to a manual muscle test (MMT) effort. RESULTS: For persons with paraplegia and C7 tetraplegia, dominant EMG activity was recorded from latissimus dorsi, sternal pectoralis major, and triceps muscles (31%-69% MMT). Tetraplegic groups had significantly greater anterior deltoid activity (C6 = 53%, C7 = 22% MMT) than that recorded in paraplegic groups (high paraplegia = 10%, low paraplegia = 3% MMT). Participants with tetraplegia also had increased infraspinatus activity (C6 = 50%, C7 = 32% MMT) compared with participants with low paraplegia (7% MMT). All other muscles had low or very low EMG activity during the depression raise. CONCLUSIONS: Persons with tetraplegia lack normal strength of the primary muscles used by participants with paraplegia for the depression raise (ie, latissimus dorsi, sternal pectoralis major, and triceps muscles). Although increased anterior deltoid activation assisted with elbow extension, it potentially contributes to glenohumeral joint impingement. Alternate methods of pressure relief should be considered for persons with tetraplegia.     

Shoulder Muscular Demand During Lever-Activated Vs Pushrim Wheelchair Propulsion In Persons With Spinal Cord Injury

Background/Objective: The high demand on the upper limbs during manual wheelchair (WC) use contributes to a high prevalence of shoulder pathology in people with spinal cord injury (SCI). Leveractivated (LEVER) WCs have been presented as a less demanding alternative mode of manual WC propulsion. The objective of this study was to evaluate the shoulder muscle electromyographic activity and propulsion characteristics in manual WC users with SCI propelling a standard pushrim (ST) and LEVER WC design.

Methods: Twenty men with complete injuries (ASIA A or B) and tetraplegia (C6, n = 5; C7, n = 7) or paraplegia (n = 8) secondary to SCI propelled STand LEVER WCs at 3 propulsion conditions on a stationary ergometer: self-selected free, self-selected fast, and simulated graded resistance. Average velocity, cycle distance, and cadence; median and peak electromyographic intensity; and duration of electromyography of anterior deltoid, pectoralis major, supraspinatus, and infraspinatus muscles were compared between LEVER and ST WC propulsion .

Results: Sign ificant decreases in pectoralis major and supraspinatus activity were recorded during LEVER compared with ST WC propulsion. However, anterior deltoid and infraspinatus intensities tended to increase during LEVER WC propulsion. Participants with tetraplegia had similar or greater anterior deltoid, pectoralis major, and infraspinatus activity for both ST and LEVER WC propulsion compared with the men with paraplegia.

Conclusions: Use of the LEVER WC reduced and shifted the shoulder muscular demands in individuals with paraplegia and tetraplegia. Further studies are needed to determine the impact of LEVER WC propulsion on long-term shoulder function.     

Nutrient Intake and Body Habitus After Spinal Cord Injury: An Analysis by Sex and Level of Injury

Background/Objectives: To examine nutrient intake and body mass index (BMI) in the spinal cord injury (SCI) population according to level of injury and sex.

Design: Cross-sectional study conducted at 2 SCI treatment centers.

Participants/Methods: Seventy-three community-dwelling individuals with C5-T12 ASIA Impairment Scale (AIS) A or B SCI. Subjects were divided into 4 groups: male tetraplegia (N = 24), male paraplegia (N = 37), female tetraplegia (N = 1), and female paraplegia (N = 11). Mean age was 38 years; 84% were male; 34% were white, 41 % were African American, and 25% were Hispanic. Participants completed a 4-day food log examining habitual diet. Dietary composition was analyzed using Food Processor II v 7.6 software.

Results: Excluding the 1 woman with tetraplegia, total calorie intake for the other 3 groups was below observed values for the general population. The female paraplegia group tended to have a lower total calorie intake than the other groups, although macronutrient intake was within the recommended range. The male tetraplegia group, male paraplegia group, and the 1 woman with tetraplegia all had higher than recommended fat intake. Intake of several vitamins, minerals, and macronutrients did not meet recommended levels or were excessively low, whereas sodium and alcohol intake were elevated. Using adjusted BMI tables, 74.0% of individuals with SCI were overweight or obese.

Conclusions: Women with paraplegia tended to maintain healthier diets, reflected by lower caloric and fat intakes, fewer key nutrients falling outside recommended guidelines, and less overweight or obesity. Individuals with tetraplegia tended to take in more calories and had higher BMIs, and using adjusted BMI, the majority of the population was overweight or obese. The majority of people with SCI would benefit from nutritional counseling to prevent emerging secondary conditions as the population with SCI ages.     

The Relationships Among Serum Lipid Levels,Adiposity, And Depressive Symptomatology In Persons Aging With Spinal Cord Injury

Abstract

Background: Cardiovascular disease (CVD) appears to occur prematurely in persons with spinal cord injury (SCI). Stress may play a significant role in the development of CVD. Depression is the most common form of stress complicating the care of persons with SCI.

Methods: In 188 persons with SCI, 46% with tetraplegia and 54% with paraplegia, the relationship between depression and the serum lipid profile was studied. Depression was measured by the Older Adult Health and Mood Questionnaire (OAHMQ) for persons with disability. Total cholesterol, high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol and triglycerides were measured; body mass index (BMI) was computed and percent body fat was determined by dual-energy x-ray absorptiometry (DXA).

Results: Depression and level of SCI were found to have significant interactive effects on serum lipid levels. Serum total and LDL cholesterol, as well as triglycerides, were all higher among persons with paraplegia who were depressed compared to those who were not depressed. This was not found in persons with tetraplegia. Inverse relationships were evident between serum triglycerides and HDL cholesterol levels. Persons with paraplegia who were depressed had significantly more adiposity than those not depressed. BMI correlated directly with serum triglycerides and indirectly with serum HDL cholesterol.

Conclusion: Depression appears to be a strong determinant of adverse lipid profiles in patients with paraplegia. The association between depression and adiposity in these patients compounds the risk for cardiovascular disease.     

Mobile Arm Supports: Evidence-Based Benefits and Criteria for Use

Background/Objective: To collect data from therapists regarding criteria for use and activities that individuals with C4-C5 tetraplegia can perform using a mobile arm support (MAS) that they otherwise could not. Reasons for nonuse, equipment design limitations, and therapist training needs were also studied. Methods: A modified Delphi approach was used to conduct an e-mail survey for which the response to each question was analyzed and used to formulate the subsequent question.

Setting: Rehabilitation centers.

Participants: Eighteen occupational therapists (most affiliated with 1 of the federally designated Model Spinal Cord Injury Systems) with extensive experience in the treatment of individuals with spinal cord injury (SCI).

Results: The key physical prerequisite for successful use of the MAS was at least minimal strength of the deltoid and biceps muscles; 92% of respondents indicated that they would fit an MAS for motivated patients having very weak (< 2/5) biceps and deltoid muscles. According to the therapists, 100% (n = 30) of their clients were able to perform at least 1 activity using a MAS that they were unable to perform without the device. These activities included (in descending frequency) eating, page turning, driving a power wheelchair, brushing teeth, keyboarding, writing, name signing, drawing, painting, scratching nose, playing board games, accessing electronic devices, drinking, and grooming. Equipment design limitations included increased wheelchair width and problems managing the arms while reclining.

Conclusions: Mobile arm supports allow persons with C4-C5 tetraplegia to engage in activities that they otherwise cannot perform with their arms.     

Lipid Profiles of Persons With Paraplegia and Tetraplegia: Sex Differences

Abstract

Background/Objective: To examine the lipoprotein profiles of men and women with paraplegia and tetraplegia. Impairment of the sympathetic nervous system (dependent on the level of injury) and the extent of physical capacity and activity were correlated with the lipid profile in men with spinal cord injury (SCI). Sex-related differences of the lipoprotein profiles could be found in nondisabled and premenopausal women with SCI mainly because of the different effects of sexual hormones.

Methods: Lipoprotein profiles of 112 participants with SCI (32 premenopausal women, 80 men) were analyzed and correlated to sex, lesion level, and physical performance capacity.

Results: Women with tetraplegia or paraplegia showed significantly higher levels of high-density lipoprotein and lower ratios of total cholesterol to high-density lipoprotein-cholesterol compared with men with corresponding lesion levels, without a difference in peak oxygen consumption. Concentrations of very-low-density lipoproteins were lower in women with paraplegia than in men with paraplegia, no differences were found in total cholesterol, low-density lipoprotein-cholesterol, and triglycerides. Sexindependent elevations in total cholesterol and low-density lipoprotein-cholesterol were associated with paraplegia, and sex-independent elevations in triglyceride levels were associated with tetraplegia.

Conclusions: Persons with SCI showed sex-related differences in their lipoprotein profiles. Independent of physical fitness, the lipoprotein profile of premenopausal women with SCI did not exhibit the adverse lipoprotein characteristics observed in men with SCI, probably because of the influence of sexual hormones independent of lesion level.     

Reliability and Repeatability of the Motor and Sensory Examination of the International Standards for Neurological Classification of Spinal Cord Injury

Abstract

Objective: To determine the reliability and repeatability of the motor and sensory examination of the International Standards for Classification of Spinal Cord Injury (SCI) in trained examiners.

Participants/Methods: Sixteen examiners (8 physicians, 8 physical therapists) with clinical SCI experience and 16 patients participated in a reliability study in preparation for a clinical trial involving individuals with acute SCI. After a training session on the standards, each examiner evaluated 3 patients for motor, light touch (LT), and pin prick (PP). The following day, 15 examiners reevaluated one patient. Interrater reliability was determined using intraclass correlation coefficients (1-way, random effects model). Intrarater reliability was determined using a 2-way random effects model. Repeatability was determined using the method of Bland and Altman.

Results: Patients were classified as complete tetraplegia (n = 5), incomplete tetraplegia (n = 5), complete paraplegia (n = 5), and incomplete paraplegia (n = 1). Overall, inter-rater reliability was high: motor = 0.97, LT = 0.96, PP = 0.88. Repeatability values were small in patients with complete SCI (motor < 2 points, sensory < 7 points) but large for patients with incomplete SCI. Intra-rater reliability values were > 0.98 for patients with complete SCI.

Conclusions: The summed scores for motor, LT, and PP in subjects with complete SCI have high interrater reliability and small repeatability values. These measures are appropriately reliable for use in clinical trials involving serial neurological examinations with multiple examiners. Further research in subjects with incomplete SCI is needed to determine whether repeatability is acceptably small.     

The impact of level of injury on patterns of cognitive dysfunction in individuals with spinal cord injury

Context: While it is well recognized that physical and physiological changes are more prominent in individuals with higher neurologic levels of spinal cord injury (SCI), the impact of level of lesion on cognition is less clear.

Design: Cross-sectional, 3-group.

Setting: Non-profit rehabilitation research foundation.

Participants: 59 individuals with SCI (30 with tetraplegia, 29 with paraplegia) and 30 age-matched healthy controls (HC).

Interventions: None.

Outcome Measures: Neuropsychological tests in the domains of attention, working memory, processing speed, executive control, and learning and memory.

Results: Results indicated significantly lower test performance in individuals with paraplegia on new learning and memory testing compared to HC. In contrast, compared to HC the group with tetraplegia, showed a significantly impaired performance on a processing speed task, and both the tetraplegia and the paraplegia groups were similarly impaired on a verbal fluency measure. SCI groups did not differ on any cognitive measure.

Conclusion: Individuals with SCI may display different patterns of cognitive performance based on their level of injury.     

Effect of fore-aft seat position on shoulder demands during wheelchair propulsion: part 2. An electromyographic analysis

BACKGROUND/OBJECTIVES: Shoulder pain is common in persons with complete spinal cord injury. Adjustment of the wheelchair-user interface has been thought to reduce shoulder demands. The purpose of this study was to quantify the effect of seat fore-aft position on shoulder muscle activity during wheelchair propulsion. METHODS: Shoulder electromyography (EMG) was recorded while 13 men with paraplegia propelled a wheelchair in the following 2 seat positions: (a) shoulder joint center aligned with the wheel axle (anterior) and (b) shoulder joint center 8 cm posterior to the wheel axle (posterior) in 3 test conditions (free, fast, and graded). Duration of EMG activity and median and peak intensities were compared. RESULTS: During free propulsion, the median EMG intensity of all muscles was similar between anterior and posterior seat positions. The major propulsive muscles (pectoralis major and anterior deltoid) demonstrated significant reductions in their median and peak intensities in the posterior seat position. Pectoralis major median intensity was significantly reduced in the posterior position during fast (52% vs 66% maximal muscle test [MMT]) and graded (41 % vs 49% MMT) conditions, and peak intensity was significantly reduced in the free condition (29% vs 52% MMT) and the fast condition (103% vs 150% MMT). Anterior deltoid intensity was significantly reduced in the posterior position during fast propulsion only (26% vs 31% MMT). For all muscles, EMG duration was similar between positions in all test conditions. CONCLUSIONS: Reduction in the intensity of the primary push phase muscles (pectoralis major and anterior deltoid) during high-demand activities of fast and graded propulsion may reduce the potential for shoulder muscle fatigue and injuries.     

Comparison of Lung Volume Measurements In Individuals With Spinal Cord Injury By Two Different Methods

Abstract

Background/Objective: Few detailed studies have been performed among subjects with spinal cord injury (SCI) using whole body plethysmography for measurement of static lung volumes. Because abdominal gas volumes and respiratory patterns among subjects with varying Ieveis of SCI may differ significantly from able-bodied individuals, methodological concerns related to this technique could conceivably Iead to inaccuracies in lung volume measurements. The purpose of this study was to compare lung volume parameters obtained by whole body plethysmography with those determined by the commonly used nitrogen washaut technique among individuals with SCI.

Participants: Twenty-nine clinically stable men, 14 with chronic tetraplegia (injury C4-C7) and 15 with paraplegia (injury below T5) participated in the study.

Methods: Lung volumes were obtained using whole body plethysmography and the open-circuit nitrogen washout technique. Within both study groups, data were evaluated by the paired Student’st test and by determination of correlation coefficients.

Results: No statistically significant differences for any lung volume parameter were found within either group. ln subjects with tetraplegia on paraplegia, respectively, strong correlation coefficients were found for measurements of totallung capacity (.8 6 and .97), functional residual capacity (.87 and .96), and residual volume (.77 and .85).

Conclusion: These findings indicate that body plethysmography is a valid technique for determining lung volumes among subjects with SCI. Because airway resistance measurements can also be obtained du ring same study sessions for assessment of airway caliber and bronchial responsiveness, body plethysmography is a useful tool for examining multiple aspects of pulmonary physiology in this population.     

Compensatory Movement Patterns Are Based on Abnormal Activity of the Biceps Brachii and Posterior Deltoid Muscles in Patients with Symptomatic Rotator Cuff Tears

BackgroundAbnormal movement patterns due to compensatory mechanisms have been reported in patients with rotator cuff tears. The long head of the biceps tendon may especially be overactive and a source of pain and could induce abnormal muscle activation in these patients. It is still unknown why some patients with a rotator cuff tear develop complaints and others do not.Questions/purposes(1) Which shoulder muscles show a different activation pattern on electromyography (EMG) while performing the Functional Impairment Test-Hand and Neck/Shoulder/Arm (FIT-HaNSA) in patients with a symptomatic rotator cuff tear compared with age-matched controls with an intact rotator cuff? (2) Which shoulder muscles are coactivated on EMG while performing the FIT-HaNSA?MethodsThis comparative study included two groups of people aged 50 years and older: a group of patients with chronic symptomatic rotator cuff tears (confirmed by MRI or ultrasound with the exclusion of Patte stage 3 and massive rotator cuff tears) and a control group of volunteers without shoulder conditions. Starting January 2019, 12 patients with a chronic rotator cuff tear were consecutively recruited at the outpatient orthopaedic clinic. Eleven age-matched controls (randomly recruited by posters in the hospital) were included after assuring the absence of shoulder complaints and an intact rotator cuff on ultrasound imaging. The upper limb was examined using the FIT-HaNSA (score: 0 [worst] to 300 seconds [best]), shoulder-specific instruments, health-related quality of life, and EMG recordings of 10 shoulder girdle muscles while performing a tailored FIT-HaNSA.ResultsEMG (normalized root mean square amplitudes) revealed hyperactivity of the posterior deltoid and biceps brachii muscles during the upward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 111% ± 6% versus 102% ± 10%, mean difference -9 [95% confidence interval -17 to -1]; p = 0.03; biceps brachii: 118% ± 7% versus 111% ± 6%, mean difference -7 [95% CI -13 to 0]; p = 0.04), and there was decreased activity during the downward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 89% ± 6% versus 98% ± 10%, mean difference 9 [95% CI 1 to 17]; p = 0.03; biceps brachii: 82% ± 7% versus 89% ± 6%, mean difference 7 [95% CI 0 to 14]; p = 0.03). The posterior deltoid functioned less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than in the control group.ConclusionPatients with a symptomatic rotator cuff tear show compensatory movement patterns based on abnormal activity of the biceps brachii and posterior deltoid muscles when compared with age-matched controls. The posterior deltoid functions less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than the control group.Clinical RelevanceThis study supports the potential benefit of addressing the long head biceps tendon in the treatment of patients with a symptomatic rotator cuff tear. Moreover, clinicians might use these findings for conservative treatment; the posterior deltoid can be specifically trained to help compensate for the deficient rotator cuff.     

Lifetime Care Needs of Individuals with Multiple Sclerosis

Abstract

Due to the high incidence of lifelong infections in persons with spinal cord injury (SCI), the authors examined level of injury-relateifimmune characteristics in a cohort of subjects with chronic SCI. Since the sympathetic nervous system and the endocrine system are known to be modulators of immune function, one possible explanation for heightened incidence of infections includes dysregulation of sympathetic outflow tracts in individuals with tetraplegia or high paraplegia. Natural killer cell cytotoxicity (NKCC) and bactericidal function of circulating neutrophils were assayed in a group of 10 individuals with chronic complete cervical SCI, a group of 8 individuals with paraplegia with injuries below the main sympathetic outflow (T-1 0 and below) and a group of 18 age- and sex-matched controls. In addition, a psychiatric assessment of depression was performed as well as assays of pituitary and adrenal functions. Analyses revealed no significant differences in immune function between all subjects with SCI combined and their matched controls. Further analyses stratifying based on presence or absence of sympathetic dysregulation revealed significantly impaired phagocytic ability and a trend toward reduced NKCC in the group with tetraplegia compared with their controls. Hormonal assays showed that dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DS) were higher in individuals with tetraplegia than controls, but no such differences were observed in individuals with paraplegia compared with their controls. The results of this study suggest that individuals sustaining complete cervical SCI experience alterations in immune function, while those with lesions at or below T-10 do not. These findings of level of injury related immune alteration could not be explained by mood differences. This paper is a review of previously published work and the authors? current thinking regarding increased acquisition of infections in this population.     

Physiotherapy Secretion Removal Techniques in People With Spinal Cord Injury: A Systematic Review

Abstract

Objective: To address whether secretion removal techniques increase airway clearance in people with chronic spinal cord injury (SCI).

Data Sources and Study Selection: MEDLINE/PubMed, CINAHL, EMBASE, and PsyclNFO were searched from inception to May 2009 for population keywords (spinal cord injury, paraplegia, tetraplegia, quadriplegia) paired with secretion removal-related interventions and outcomes. Inclusion criteria for articles were a research study, irrespective of design, that examined secretion removal in people with chronic SCI published in English.

Review Methods: Two reviewers determined whether articles met the inclusion criteria, abstracted information, and performed a quality assessment using PEDro or Downs and Black criteria. Studies were then given a level of evidence based on a modified Sackett scale.

Results: Of 2,416 abstracts and titles retrieved, 24 met the inclusion criteria. Subjects were young (mean, 31 years) and 84% were male. Most evidence was level 4 or 5 and only 2 studies were randomized controlled trials. Three reports described outcomes for secretion removal techniques in addition to cough, whereas most articles examined the immediate effects of various components of cough. Studies examining insufflation combined with manual assisted cough provided the most consistent, high-level evidence. Compelling recent evidence supports the use of respiratory muscle training or electrical stimulation of the expiratory muscles to facilitate airway clearance in people with SCI.

Conclusion: Evidence supporting the use of secretion removal techniques in SCI, while positive, is limited and mostly of low level. Treatments that increase respiratory muscle force show promise as effective airway clearance techniques.     

The International Standards for Neurological Classification of Spinal Cord Injury: Intra-Rater Agreement of Total Motor and Sensory Scores in the Pediatric Population

Background: The International Standards for Neurological Classification of Spinal Cord Injury (ISCSCI) is the gold standard for evaluating and classifying the neurological consequence of spinal cord injury (SCI). Objective: To determine the within-rater agreement for total scores of light touch (LT), pin prick (PP), and total motor (TM) in children and youth.

Design: Part of a larger cross-sectional study to determine the intra-rater reliability of the standards when applied to children and youth.

Participants/Methods: A total of 187 subjects participated in 2 repeated examinations performed by the same rater. A total of 7 raters participated in this study. Intraclass correlations coefficients (ICCs), with 95% Cl were calculated to determine agreement between the 2 examinations for LT, PP, and TM.

Results: With the exception of subjects younger than 6 years, agreement on repeated total PP, LT, and TM scores were good to excellent, as shown by ICC values of 0.92 or higher. Although agreement was high for the youngest age group for LT (ICC = 0.920), PP (ICC = 0.957), and TM (ICC = 0.971), all of the lower 95% Cl values fell well below 0.66, indicating poor precision. All subgroups had good to high agreement for total PP, LT, and TM scores, as indicated by ICC values of 0.87 and higher. There were lower 95% Cl (LCI) values for the 6- to 11-year-old group with incomplete paraplegia due to the low number of subjects in that subgroup (N = 4). The LCI values were poor for PP for the subgroups with 6- to 11-year-olds with incomplete tetraplegia (LCI = 0.675) and the 12- to 15-year-old group with incomplete paraplegia (LCI = 0.707) and for TM for 16- to 21-year-old group with complete paraplegia (LCI = 0.706).

Conclusions: In children as young as 6 years, within-rater agreement on LT, PP, and TM exceeded recommended values for clinical measures. With the exception of 6- to 11-year-olds with incomplete injuries, type of injury and severity of injury were not factors in agreement. Although more work is needed to define the lower age limit in which the ISCSCI have utility, these data represent growing evidence supporting the use of the ISCSCI when evaluating the neurological consequence of SCI in children.     

Five-Year Longitudinal Bone Evaluations In Individuals With Chronic Complete Spinal Cord Injury

Background/Objectives:Knowledge of spinal cord injury (SCI) bone changes has been derived primarilythrough cross-sectional studies, many of which are controvertible. Longitudinal studies are sparse, and longtermlongitudinal chronic studies are unavailable. The objective of this study was to provide a clearerperception of chronic longitudinal bone variations in people with complete SCI.

Methods:Bone status of 31 individuals with chronic, complete SCI was assessed twice using dual-energy xrayabsorptiometry at an average interval of 5.06 ± 0.9 years. Because the sample of women was small (4),the primary analyses of change and comparisons of those with paraplegia vs tetraplegia were confined to themale participants.

Results: Spine Z-scores showed a significant increase (P < 0.0001 ). The average Z-scores, initial and followup,were within the normal range. Hip Z-scores also showed a significant increase (P < 0.0001 ), and hipbone mineral density (BMD) increased in 48% of the participants. Knee BMD and lower extremity total bonemineral showed significant decreases (P < 0.003 and P < 0.02, respectively), but increases were seen in 33% and 26% at the respective sites. Individuals with tetraplegia had significantly lower values across all regions(P < 0.0001 ), and changes were significantly different compared with paraplegia (P < 0.0001 ). Bone valuesand changes in men vs women, despite the small sample of women, showed highly significant differences(P < 0.003?0.002).

Conclusion:Chronic effects of complete SCI do not exclusively result in continued loss of BMD or a staticstate of lowered BMD; gain in BMD may occur. The nature and magnitude of the effects of complete SCI on BMD vary by site, with sex and level of injury, which has implications for treatment and its assessment.     

The effect of level of injury and physical activity on heart rate variability following spinal cord injury

Objective/Background: To assess frequency domain heart rate variability (HRV) parameters at rest and in response to postural autonomic provocations in individuals with spinal cord injury (SCI) and investigate the autonomic influences on the heart of different physical activities.

Design: Cross-sectional study.

Methods: Ten subjects with complete cervical SCI and fourteen subjects with complete low thoracic SCI were prospectively recruited from the community and further divided in sedentary and physically active groups, the latter defined as regular weekly 4 hour physical activity for the preceding 3 months. Sixteen healthy individuals matched for sex and age were recruited to participate in the control group. The Low Frequency (LF), High Frequency (HF) powers and the LF/HF ratio of HRV were measured from continuous electrocardiogram (ECG) recordings at rest and after sitting using a fast Fourier transformation.

Outcome measures: The LF,HF, and the LF/HF ratio at rest and after sitting.

Results: A significant decrease in all HRV parameters in patients with SCI was found compared to controls. The change in HF, LF and LF/HF following sitting maneuver was significantly greater in controls as compared with the SCI group and greater in subjects with paraplegia as compared to subjects with tetraplegia. Better HRV values and enhanced vagal activity appears to be related to the type of physical activity in active subjects with paraplegia.

Conclusion: In this cohort of subjects spectral parameters of HRV were associated with the level of the injury. Passive standing was associated with higher HRV values in subjects with paraplegia.     

Transcranial direct current stimulation (tDCS) paired with massed practice training to promote adaptive plasticity and motor recovery in chronic incomplete tetraplegia: A pilot study

Objective: Our goal was to determine if pairing transcranial direct current stimulation (tDCS) with rehabilitation for two weeks could augment adaptive plasticity offered by these residual pathways to elicit longer-lasting improvements in motor function in incomplete spinal cord injury (iSCI).

Design: Longitudinal, randomized, controlled, double-blinded cohort study.

Setting: Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Participants: Eight male subjects with chronic incomplete motor tetraplegia.

Interventions: Massed practice (MP) training with or without tDCS for 2 hrs, 5 times a week.

Outcome Measures: We assessed neurophysiologic and functional outcomes before, after and three months following intervention. Neurophysiologic measures were collected with transcranial magnetic stimulation (TMS). TMS measures included excitability, representational volume, area and distribution of a weaker and stronger muscle motor map. Functional assessments included a manual muscle test (MMT), upper extremity motor score (UEMS), action research arm test (ARAT) and nine hole peg test (NHPT).

Results: We observed that subjects receiving training paired with tDCS had more increased strength of weak proximal (15% vs 10%), wrist (22% vs 10%) and hand (39% vs. 16%) muscles immediately and three months after intervention compared to the sham group. Our observed changes in muscle strength were related to decreases in strong muscle map volume (r=0.851), reduced weak muscle excitability (r=0.808), a more focused weak muscle motor map (r=0.675) and movement of weak muscle motor map (r=0.935).

Conclusion: Overall, our results encourage the establishment of larger clinical trials to confirm the potential benefit of pairing tDCS with training to improve the effectiveness of rehabilitation interventions for individuals with SCI.

Trial Registration: NCT01539109     

C-Reactive Protein and Erythrocyte Sedimentation Rate in Patients With Heterotopic Ossification After Spinal Cord Injury

Abstract

Background/Objective: Formation of heterotopic ossification (HO) in soft tissue afterspinal cord injury (SCI) is associated with various degrees of inflammation. Recent studies have shown that inhibition of inflammatory reaction with nonsteroidal anti-inflammatory drugs is an effective prevention of HO after SCI. The goal of this study was to monitor the activity of the most widely used indicators of acute inflammation-namely, erythrocyte Sedimentation rate (ESR) and C-reactive protein (CRP)-in patients with HO.

Methods: In a retrospective study, the results of 37 patie nts with HO were evaluated. There were 25 patients with tetraplegia and 12 with paraplegia. The age (mean ± SD) of the patients was 2 8 ± 8 years (range = 19-46 years). The patients were admitted to the rehabilitation center 2 to 5 weeks after SCI. HO was confirmed by bone scintigraphy. Blood samples were obtained from the patients at the time of diagnosis of HO and du ring the therapy. ESR was measured with the Westergren method, and serum CRP was determined by enzyme-linked immunosorbent assay.

Results: In the acute stage of HO, both tests were e levated in all patients. ln the later stages when clinical signs and symptoms of inflammat ion were resolving, both tests showed a gradual decline. When clinical sig ns and symptoms of inflammation (fever, acute soft tissue swelling, and erythema) were not present, the concentration of CRP was normal in 91 .2% of patients, whereas only 1 7 .6% of patients had normal ESR. Mean serum concentrations of CRP were 8.9 ±5.6 mg/L in the inflammatory phase and 0.9 ± 0.6 mg/L in the noninflammatory phase.

Conclusion: The data indicate that serum CRP is a useful and more specific test than is ESR for monitaring the inflammatory activity of HO after SCI. The normalization of CRP was seen during the first 3 to 4 weeks of etidronate therapy, indicating a resolution of acute-phase inflammatory reaction.     

Gastric Dysmotility After Abdominal Surgery in Persons With Cervical Spinal Cord Injury: A Case Series

Abstract

Background: Spinal cord injury (SCI) has been found to affect the physiology of the gastrointestinal tract. Changes in gastric motility occur in tetraplegia because of dissociation of antral and duodenal motility. Among individuals with high-level tetraplegia, antral quiescence has been hypothesized as a manifestation of autonomic dysreflexia after surgery. This case series shows the issues with gastric hypomotility after gastrointestinal surgery in tetraplegic patients with tetraplegia, including management strategies.

Objective: To report 3 patients with complete high cervical SCI who developed gastroparesis after abdominal surgery and discuss the effect of autonomic dysfunction on gastric motility.

Methods: Retrospective chart review of 3 cases.

Results: Gastroparesis occurred after abdominal surgery in 3 patients with C4 American Spinal Injury Association (ASIA) A tetraplegia and seemed to be a sign of autonomic hyperreflexia caused by postoperative pain. Management was challenging because it consisted of balancing of appropriate pain medication and dealing with absorption issues and dysmotility. Often gastric motility agents were not effective in improving gastric emptying. However, increased use of pain medication improved gastric emptying, which supports the hypothesis that this issue represents gastric dysfunction from autonomic hyperreflexia.

Conclusions: In persons with complete cervical SCI who have undergone abdominal surgery, postoperative gastroparesis can be a manifestation of pain. This may occur as the excessive sympathetic response from autonomic hyperreflexia inhibits distal antral activity. Thus, treatment of postoperative gastroparesis should focus on improved pain control to decrease excessive splanchnic sympathetic output and circulating norepinephrine.