A Prediction Model for Determining Over Ground Walking Speed After Locomotor Training in Persons With Motor Incomplete Spinal Cord Injury

Background/Objective: To develop and test a clinically relevant model for predicting the recovery of over ground walking speed after 36 sessions of progressive body weight-supported treadmill training (BWSTT) in individuals with motor incomplete spinal cord injury (SCI).

Design: A retrospective review and stepwise regression analysis of a SCI clinical outcomes data set.

Setting: Outpatient SCI laboratory.

Subjects: Thirty individuals with a motor incomplete SCI who had participated in locomotor training with BWSTT. Eight individuals with similar diagnoses were used to prospectively test the prediction model.

Main Outcome Measures: Over ground walking speed was assessed using the 10-m walking test.

Methods: The locomotor training program consisted of 36 sessions of sequential comprehensive training comprised of robotic assisted BWSTT, followed by manual assisted BWSTT, and over ground walking. The dose of locomotor training was standardized throughout the protocol.

Results: Clinical characteristics with predictive value for walking speed were time from injury onset, the presence or absence of voluntary bowel and bladder voiding, a functional spasticity assessment, and over ground walking speed before locomotor training. The model identified that these characteristics accounted for 78.3% of the variability in the actual final over ground walking speed after 36 sessions of locomotor training. The model was successful in prospectively predicting over ground walking speed in the 8 test participants within 4.15 ± 2.22 cm/s in their recovered walking speed.

Conclusions: This prediction model can identify individuals who are most likely to experience success using locomotor training by determining an expected magnitude of training effect, thereby allowing individualized decisions regarding the use of this intensive approach to rehabilitation.     

A Prediction Model for Determining Over Ground Walking Speed After Locomotor Training in Persons With Motor Incomplete Spinal Cord Injury

Background/Objective:     

Locomotor Training and Muscle Function After Incomplete Spinal Cord Injury: Case Series

Abstract

Background/Objective: To determine whether 9 weeks of locomotor training (LT) results in changes in muscle strength and alterations in muscle size and activation after chronic incomplete spinal cord injury (SCI). Study Design: Longitudinal prospective case series.

Methods: Five individuals with chronic incomplete SCI completed 9 weeks of LT. Peak isometric torque, torque developed within the initial 200 milliseconds of contraction (Torque₂₀₀), average rate of torque development (ARTD), and voluntary activation deficits were determined using isokinetic dynamometry for the knee-extensor (KE) and plantar-flexor (PF) muscle groups before and after LT. Maximum muscle crosssectional area (CSA) was measured prior to and after LT.

Results: Locomotor training resulted in improved peak torque production in all participants, with the largest increases in the more-involved PF (43.9% ± 20.0%), followed by the more-involved KE (21.1% ± 12.3%). Even larger improvements were realized in Torque200 and ARTD (indices of explosive torque), after LT. In particular, the largest improvements were realized in the Torque200 measures of the PF muscle group. Improvements in torque production were associated with enhanced voluntary activation in both the KE and ankle PF muscles and an increase in the maximal CSA of the ankle PF muscles.

Conclusion: Nine weeks of LT resulted in positive alterations in the KE and PF muscle groups that included an increase in muscle size, improved voluntary activation, and an improved ability to generate both peak and explosive torque about the knee and ankle joints.     

The Effect of Body Weight-Supported Treadmill Training on Muscle Morphology in an Individual With Chronic,Motor- Complete Spinal Cord Injury: A Case Study

Abstract

Objective: The purpose of this pilot study was to examine the effects of 4 months of thrice-weekly body weight-supported treadmill training (BWSTT) on skeletal muscle morphology in a woman (age 27 y) with chronic, motor-complete (ASIA B) spinal cord injury (SCI).

Methods: The participant performed passive thrice-weekly BWSTT for 4 months (48 total sessions) with manual assistance from therapists. Muscle biopsies of the vastus lateralis were taken prior to the beginning of the training program as well as following the completion of 4 months of training. Histochemical analysis was utilized to evaluate changes in muscle fiber size and type following training.

Results: At baseline, vastus lateralis muscle biopsies showed evidence of fiber atrophy and fiber type redistribution typical of persons with SCI, with mean fiber areas (and % distributions) of type I, type I la and type llx fibers being 3474nm2 (1.3%), 3146nm2 (30.8%) and 1284^im2 (68.0%), respectively. Following training, there were increases in treadmill walking speed (pre: 1.0km/h; post: 2.5km/h) and distance walked/session (pre: 500m; post: 1875m). Vastus lateralis mean fiber area increased by 27.1% and type I fiber % distribution increased to 24.6%, whereas type I la and type llx fiber % distributions both decreased following training.

Conclusion: These data indicate that 4 months of thrice-weekly BWSTT improved muscle morphology in an individual with chronic, motor-complete SCI.     

Acute Cardiorespiratory and Metabolic Responses During Exoskeleton-Assisted Walking Overground Among Persons with Chronic Spinal Cord Injury

Background:

Lower extremity robotic exoskeleton technology is being developed with the promise of affording people with spinal cord injury (SCI) the opportunity to stand and walk. The mobility benefits of exoskeleton-assisted walking can be realized immediately, however the cardiorespiratory and metabolic benefits of this technology have not been thoroughly investigated.

Objective:

The purpose of this pilot study was to evaluate the acute cardiorespiratory and metabolic responses associated with exoskeleton-assisted walking overground and to determine the degree to which these responses change at differing walking speeds.

Methods:

Five subjects (4 male, 1 female) with chronic SCI (AIS A) volunteered for the study. Expired gases were collected during maximal graded exercise testing and two, 6-minute bouts of exoskeleton-assisted walking overground. Outcome measures included peak oxygen consumption (V̇O_2peak), average oxygen consumption (V̇O_2avg), peak heart rate (HR_peak), walking economy, metabolic equivalent of tasks for SCI (METs_sci), walk speed, and walk distance.

Results:

Significant differences were observed between walk-1 and walk-2 for walk speed, total walk distance, V̇O_2avg, and METs_sci. Exoskeleton-assisted walking resulted in %V̇O_2peak range of 51.5% to 63.2%. The metabolic cost of exoskeleton-assisted walking ranged from 3.5 to 4.3 METs_sci.

Conclusion:

Persons with motor-complete SCI may be limited in their capacity to perform physical exercise to the extent needed to improve health and fitness. Based on preliminary data, cardiorespiratory and metabolic demands of exoskeleton-assisted walking are consistent with activities performed at a moderate intensity.     

Augmentation of Voluntary Locomotor Activity by Transcutaneous Spinal Cord Stimulation in Motor‐Incomplete Spinal Cord‐Injured Individuals

The level of sustainable excitability within lumbar spinal cord circuitries is one of the factors determining the functional outcome of locomotor therapy after motor‐incomplete spinal cord injury. Here, we present initial data using noninvasive transcutaneous lumbar spinal cord stimulation (tSCS) to modulate this central state of excitability during voluntary treadmill stepping in three motor‐incomplete spinal cord‐injured individuals. Stimulation was applied at 30 Hz with an intensity that generated tingling sensations in the lower limb dermatomes, yet without producing muscle reflex activity. This stimulation changed muscle activation, gait kinematics, and the amount of manual assistance required from the therapists to maintain stepping with some interindividual differences. The effect on motor outputs during treadmill‐stepping was essentially augmentative and step‐phase dependent despite the invariant tonic stimulation. The most consistent modification was found in the gait kinematics, with the hip flexion during swing increased by 11.3° ± 5.6° across all subjects. This preliminary work suggests that tSCS provides for a background increase in activation of the lumbar spinal locomotor circuitry that has partially lost its descending drive. Voluntary inputs and step‐related feedback build upon the stimulation‐induced increased state of excitability in the generation of locomotor activity. Thus, tSCS essentially works as an electrical neuroprosthesis augmenting remaining motor control.     

Treatment Of Major Depression In Individuals With Spinal Cord Injury

Abstract

Objective: This study evaluated the effects of treating major depression in individuals with spinal cord injury (SCI), focusing on the degree of improvement and correlated changes that could be expected in 6 months of treatment.

Design: Apretreatment–posttreatment designwas used. Random assignment to a nontreatment group could not be implemented ethically. Therefore, this study compared participants who declined treatment to persons who accepted treatment over a 24–month period.

Setting and Participants: Participants were outpatients of a large urban rehabilitation center in southern California. Twenty–eight participants who accepted treatment were assigned to a treatment group; 15 individuals who declined treatment were assigned to a nontreatment group. The age of the participants ranged from 20 to 7 4 years. Varying Ieveis of SCI dysfunction were represented. lnterventio1,1s: A 6–month combination of psychotherapy and antidepressant medication.

Outcome Measures: Adepression inventory, a community activities checklist, and a life satisfaction scale.

Results: A significant (P < 0.001) 57% reduction in depressive symptoms occurred in the treatment group, whereas there was no significant change in the nontreatment group. At theend of 6 months, 30% of participantshad no depression, 42%had minor depression, and 297% still had major depression, butto a lesser degree.Community activities increased significantly over the treatment period, as did life satisfaction.

Conclusion: The results suggest that depression is treatable in this population, although 6 months may not be sufficient to reach maximum benefit in all cases. This study further identified obstacles that limited the ability to randomize participants into treatment arms and made it difficult to deliver services to all those in need. Complications related to SCI, such as difficulties in transportation, likely restriet the ability to implement needed services to many individuals with SCI.     

Trunk Function and Ischial Pressure Offloading in Individuals with Spinal Cord Injury

Objective: To determine if there is a relationship between trunk function and offloading of the ischial tuberosities in individuals with Spinal Cord Injury (SCI).

Design: Prospective cross-sectional evaluation.

Setting: Sub-acute rehabilitation hospital.

Participants: Fifteen non-ambulatory participants with complete or incomplete traumatic and non-traumatic SCI, American Spinal Injury Association Impairment Scale (AIS), Classification A-D.

Outcome Measures: Isometric trunk strength using a hand held dynamometer, the ability to reach using the multidirectional reach test and offloading times of the ischial tuberosities using a customized pressure mat.

Results: Participants who were able to engage in the multidirectional reach test were defined as “Reachers”, whereas individuals who were unable to engage in the multidirectional reach test were defined as “Non-Reachers”. Trunk strength was significantly higher in Reachers compared with Non-Reachers (P < 0.05). Offloading times over the left and right ischial tuberosities were lower in Non-Reachers when compared with Reachers, however the results were statistically significant only for offloading over the right ischial tuberosity (P < 0.05). There was no correlation between trunk strength and pressure offloading times for both groups.

Conclusions: Regardless of an individual's ability to engage in a reaching task, participants with spinal cord injury spent more time offloading the left ischial tuberosity compared with the right ischial tuberosity. The study highlights the need to identify factors that may contribute to offloading behavior in individuals with spinal cord injury who lack sufficient trunk strength.     

The Effect Of Dietary Intervention On Lipid Profiles In Individuals With Spinal Cord Injury

Abstract

Objective: The purpose of this study was to evaluate the effects of a simple dietary intervention for individuals with chronic spinal cord injury(SCI)and moderately elevated total cholesterol.

Methods: Baseline and follow–up serum lipid values were obtained on 222 persons with SCI. Eighty–six individuals with total cholesterol>200mg∕dL were referred for dietary consultation (group 1). The remainder with values <200 mg∕dL and no consultation served as controls(group 2).

Results: At average follow–up of 16 months, group 1 demonstrated significant declines in total cholesterol and low–density lipoproteincholesterol (LdL–C), whereas group 2 demonstrated significant increases in total cholesterol. Triglyceride levels followed similar butnonsignificant patterns. There were no significant changes in high–density lipoprotein cholesterol for either group. In group 1,17’7’o had clinically significant reductions in total cholesterol to <200 mg∕dL and 21 ’7’o had reductions of LdL–C from >135 mg∕dL to <135 mg∕dl.

Conclusions: Dietary intervention should be an initial treatment for those with SCI and moderately elevated total cholesterol, with the expectation that approximately 20% will respond favorably.     

脊髓损伤后大鼠后肢运动功能恢复的评分标准比较

目的：比较脊髓损伤（SCI）后大鼠后肢运动功能恢复的不同评分标准的优劣。方法：40只SD成熟雌性大鼠随机分为：正常组（Normal组）、急性脊髓中度损伤组（SCI组）及对照组（CON组），其中SCI组采用改良的Allen打击法，CON组仅行T10椎板切除术。术后1、2、3、4、6周观察大鼠后肢神经功能恢复的情况，并记录结果。评价标准分别为：斜板试验评分、改良Tarlov评分及BBB评分。结果：SCI组与CON组比较，斜板试验临界角度在1-6周时，均有所减小（P〈0．05），尤以第1周时减少更甚（P〈0．01）；改良Tarlov评分第1、2、3、4周时，分值间的差别非常明显（P〈0．01）第6周时，未见变化（P〉0．05）：而BBB评分各时间点的区分程度非常明显（P〈0．01）。结论：BBB评分对SCI模型运动功能评价具有明显优势，可作为今后研究的标准评分法。     

纳洛酮加脊髓腹侧减压术治疗胸腰椎骨折合并脊髓损伤

作者采用纳洛酮加脊髓腹侧减压术治疗胸腰椎骨折合并脊髓损伤65例,结果见单纯脊髓腹侧减压术肢体肌力恢复到Ⅲ级以上者9例,小剂量纳洛酮加脊髓腹侧减压术肢体肌力恢复到Ⅲ级以上者14例;大剂量纳洛酮加脊髓腹侧减压术肢体肌力恢复到Ⅲ级以上者18例。临床结果显示纳洛酮通过改善脊髓微循环和增加脊髓血流量,具有促进脊髓功能恢复的作用。纳洛酮加脊髓腹侧减压治疗脊髓损伤优于单纯脊髓腹侧减压术。     

颈椎病与急性颈脊髓损伤

从1980年10月到1994年1月我们收治41例无颈椎骨折脱位的急性颈脊髓损伤,同时在X线、CT及MRI皆有颈椎病的改变.分两组治疗方法比较,手术组皆在颅骨牵引下进行颈椎前路减压、钩椎关节增生部刮除、取自体髂骨或异体骨作椎间植骨融合术.非手术组行颅骨牵引、脱水、皮质激素、神经营养药物、中药及激光血疗,以及早期康复脊髓功能.随访1～9年4个月,平均5年1个月.手术组优14例、显效4例、差3例.非手术组优5例、显效7例、差8例.治愈显效率:前者为85.5%,后者为60%.手术组优于非手术组,P<0.05,有显著意义.治愈显效者皆在不同时间内恢复原来工作,无任何并发症.治疗的关键是选择适当的病例及严格的手术指征,熟练手术方法的技巧及术前术后的精心护理.本文对发病机理、诊治及命名亦进行了初步探讨.     

急性脊柱脊髓损伤早期并发症及防治

目的：分析急性脊柱脊髓损伤的伤情、合并伤和并发症,提出早期治疗原则。方法：对1352例急性脊柱脊髓损伤病例进行回顾性分析。结果：脊髓完全性损伤875例,不完全性损伤477例,合并症有肺部感染、泌尿系感染、褥疮等,合并伤有颅脑损伤、四肢骨盆骨折、血气胸等。保守治疗包括大剂量甲基强的松龙冲击疗法、高压氧治疗、脱水剂、神经营养药物等;对存在脊柱不稳、脱位和脊髓压迫者,进行减压内固定手术。合并伤均给予专科处理。结论：及时正确的早期处理,重视处理合并伤,预防脊髓继发性损伤和并发症的发生,重视早期康复指导是提高救治水平的关键。     

bFGF对大鼠脊髓损伤后神经细胞凋亡的影响

目的 :探讨大鼠脊髓损伤后应用碱性成纤维细胞生长因子 (basicfibroblastgrowthfactor ,bFGF)对脊髓损伤区细胞凋亡的影响。方法 :利用Allen氏WD(weightdrop ,WD)技术 ,以 10 g× 2 .5cm致伤力造成SD大白鼠T8脊髓损伤模型 ,并于损伤平面以下蛛网膜下腔置细塑料导管。bFGF治疗组 (A组 )分别于术后即刻 1、2、4、8、12、2 4及 48h经导管注入bFGF溶液 2 0 μl(含bFGF10 0 u) ,以后每周经导管注入 2 0 μlbFGF ;对照组 (B组 )则在同时间注入等量生理盐水。损伤后 1、3、7、14、2 8d对脊髓损伤区进行细胞凋亡的检测 (TUNEL) ,采用计算机图像分析技术进行定量分析。结果 :A、B两组中均发现凋亡细胞 ,B组细胞凋亡率大于A组。结论 :bFGF能抑制脊髓损伤后脊髓损伤区的细胞凋亡。     

Low-Frequency Fatigue in Individuals With Spinal Cord Injury

Abstract

Background/Objective: This study examined magnitude and recovery of low-frequency fatigue (LFF) in the quadriceps after electrically stimulated contractions in spinal cord-injured (SCI) and able-bodied subjects.

Subjects: Nine SCI (ASIA A-C, levels C5-T9, injured 13.6 ± 12.2 years) and 9 sedentary able-bodied subjects completed this study.

Methods: Fatigue was evoked in 1 thigh, and the nonfatigued leg served as a control. The fatigue test for able-bodied subjects lasted 15 minutes. For SCI, stimulation was adjusted so that the relative drop in force was matched to the able-bodied group. Force was assessed at 20 (P20) and 100 Hz (PI 00), and the ratio of P20/P100 was used to evaluate LFF in thighs immediately after, at 10, 20, and 60 minutes, and at 2, 4, 6, and 24 hours after a fatigue test.

Results: The magnitude of LFF (up to 1 hour after fatigue) was not different between able-bodied and patients with SCI. However, recovery of LFF over 24 hours was greater in able-bodied compared with patients with SCI in both the experimental (P < 0.001) and control legs (P < 0.001). The able-bodied group showed a gradual recovery of LFF over time in the experimental leg, whereas the SCI group did not.

Conclusions: These results show that individuals with SCI are more susceptible to LFF than able-bodied subjects. In SCI, simply assessing LFF produced considerable LFF and accounted for a substantial portion of the response. We propose that muscle injury is causing the dramatic LFF in SCI, and future studies are needed to test whether “fatigue” in SCI is actually confounded by the effects of muscle injury.     

大鼠急性脊髓损伤后细胞凋亡的时空分布特点

目的：研究急性脊髓损伤后神经细胞凋亡的分布特别及其意义。方法：Wistar雌性大白鼠54只，使用改良Alien法制作急性脊髓损伤模型，分别于术后l、4、8、24、72h、7、14及2ld处死取材(每时间点n=6)。应用HE染色及凋亡细胞原位末端标记法(TUNEL)对脊髓组织进行标记。结果：损伤后4h，在损伤段及邻近段可见末端标记的阳性神经细胞，损伤段灰质中阳性细胞数24h达高峰，72h白质中阳性胶质细胞数量达高峰。相邻节段阳性细胞数量在72h达高峰。灰质中神经元及胶质细胞均有阳性表达，但以胶质细胞为主。结论：脊髓损伤后神经细胞凋亡是继发损伤期的重要病理变化，并有其时相和空间分布特点.     

汉防己甲素治疗急性脊髓损伤的实验研究

目的探讨汉防已甲素对完全性急性脊髓损伤的保护作用及意义.方法21只中国家犬随机分成2组,用Allen WD法致脊髓完全损伤.A组为对照组;B组汉防已甲素治疗组.观察各组伤后1、2、3个月神经功能、皮层体感诱发电位、神经元数量、神经元截面积和尼氏体密度恢复情况.结果B组上述各项指标均明显优于同时期A组(P≤0.001),差异有显著性意义.结论汉防已甲素能改善脊髓微循环,减轻Ca2 的局部聚集,阻断脊髓组织继发性损伤,对脊髓损伤有保护作用,能促进神经功能早期、较好的恢复.     

复位内固定治疗脊柱骨折脱位合并脊髓损伤

本文报告1989年3月至1990年1月外院转入我院53例脊柱骨折脱位合并脊髓损伤患者,其中50例曾行手术治疗。结果,复位:向后成角平均20.5°,37例有成角,占70％;椎体移位平均0.5cm,47例有移位,移位率88％。固定:53例中仍存有内固定者18例,有11例内固定失败,占61％。减压:27例做核磁检查,有椎管狭窄脊髓受压者19例占70.4％。我院1981～1989年对32例新鲜脊柱骨折脱位进行复位内固定术。结果,复位:完全复位24例(75％),大部复位6例(19％),部分复位2例(6％)。内固定:无改变29例,3例失败,占9％。通过对比分析,提出充分复位、减压及有效内固定的重要性。     

Incidence,Etiology, and Risk Factors for Fever Following Acute Spinal Cord Injury

Abstract

Objective: To identify the incidence, etiology, and risk factors for fevers in individuals with traumatic spinal cord injury (SCI).

Design: A retrospective review of the medical records of consecutive adult traumatic SCI patients over a 2- year period was performed.

Setting: The study was performed at a tertiary care, Level I trauma center.

Participants: Consecutive adult traumatic SCI admissions to acute care (n = 48) and rehabilitation (n = 40) were included in the study.

Main Outcome Measures: Incidence, etiology, mean maximum temperature elevation, and duration of fevers (temperature >99.9 F) were measured.

Results: The incidence of fever was 60.4% and 50% (acute care and rehabilitation, respectively). Total number of fevers was 58 and 66, acute and rehabilitation, respectively. Respiratory and urinary tract were the most common identifiable fever etiologies. Unidentified fever etiologies were numerous in both the acute and rehabilitation groups, representing 66% and 56% of cases, respectively. Significant differences (P < 0.05) were found between identified vs unidentified fever etiology groups for mean maximal temperature (102.5°F vs 101.1°F on acute and 101.5°F vs 100.7°F on rehabilitation), duration of fever (10.3 days vs 2.2 on acute and 2.8 days vs 1.3 on rehabilitation), fevers above 101.4°F (75% vs 29% on acute and 40% vs 8% on rehabilitation), cause of injury (gunshot wound on acute care) and completeness of injury (American Spinal Injury Association classification A on rehabilitation).

Conclusions: This study suggests that fevers occur commonly in patients with SCI, with respiratory and genitourinary system etiologies most commonly identified. Unidentified etiologies were common and were associated with lower temperature elevation and shorter fever duration. Injury etiology and completeness of injury may comprise additional risk factors. These factors should be taken into account when initiating cost- efficient fever workup in individuals with SCI.