Locomotor training within an inpatient rehabilitation program after pediatric incomplete spinal cord injury

BACKGROUND AND PURPOSE: The outcomes of intense locomotor training after incomplete spinal cord injury (SCI) have been described in adults with acute and chronic injuries and with various levels of ambulatory function. This case report describes a comprehensive inpatient rehabilitation program with a locomotor training component in a child with a severe incomplete SCI. CASE DESCRIPTION: A 5-year-old girl injured at C4 participated in locomotor training for 5 months during inpatient rehabilitation. OUTCOMES: The patient's Functional Independence Measure for Children II (WeeFIM II) mobility score increased from 5/35 to 21/35. Her Walking Index for Spinal Cord Injury II (WISCI II) score improved from 0 to 12. The patient returned to walking in the community with assistive devices. DISCUSSION: It is feasible to include an intense locomotor training program in the clinical rehabilitation setting for a child with a severe SCI, and the outcomes were consistent with results in adults. Further investigation with experimental designs and more participants will determine the extent to which this intervention benefits the pediatric population with SCI.     

Locomotor training after human spinal cord injury: a series of case studies

Many individuals with spinal cord injury (SCI) do not regain their ability to walk, even though it is a primary goal of rehabilitation. Mammals with thoracic spinal cord transection can relearn to step with their hind limbs on a treadmill when trained with sensory input associated with stepping. If humans have similar neural mechanisms for locomotion, then providing comparable training may promote locomotor recovery after SCI. We used locomotor training designed to provide sensory information associated with locomotion to improve stepping and walking in adults after SCI. Four adults with SCIs, with a mean postinjury time of 6 months, received locomotor training. Based on the American Spinal Injury Association (ASIA) Impairment Scale and neurological classification standards, subject 1 had a T5 injury classified as ASIA A, subject 2 had a T5 injury classified as ASIA C, subject 3 had a C6 injury classified as ASIA D, and subject 4 had a T9 injury classified as ASIA D. All subjects improved their stepping on a treadmill. One subject achieved overground walking, and 2 subjects improved their overground walking. Locomotor training using the response of the human spinal cord to sensory information related to locomotion may improve the potential recovery of walking after SCI.     

Locomotor training: as a treatment of spinal cord injury and in the progression of neurologic rehabilitation

Harkema SJ, Hillyer J, Schmidt-Read M, Ardolino E, Sisto SA, Behrman AL. Locomotor training: as a treatment of spinal cord injury and in the progression of neurologic rehabilitation. Scientists, clinicians, administrators, individuals with spinal cord injury (SCI), and caregivers seek a common goal: to improve the outlook and general expectations of the adults and children living with neurologic injury. Important strides have already been accomplished; in fact, some have labeled the changes in neurologic rehabilitation a "paradigm shift." Not only do we recognize the potential of the damaged nervous system, but we also see that "recovery" can and should be valued and defined broadly. Quality-of-life measures and the individual's sense of accomplishment and well-being are now considered important factors. The ongoing challenge from research to clinical translation is the fine line between scientific uncertainty (ie, the tenet that nothing is ever proven) and the necessary burden of proof required by the clinical community. We review the current state of a specific SCI rehabilitation intervention (locomotor training), which has been shown to be efficacious although thoroughly debated, and summarize the findings from a multicenter collaboration, the Christopher and Dana Reeve Foundation's NeuroRecovery Network.     

步行训练对不完全性脊髓损伤大鼠损伤部位周围组织可塑性的影响

目的探讨步行训练对不完全性脊髓损伤大鼠损伤部位周围组织可塑性的影响。 方法将雌性SD大鼠24只分为步行训练组和对照组,每组12只,制作第10胸椎段脊髓损伤模型。步行训练组在制作脊髓损伤模型后1周开始进行步行训练,共训练9周;对照组不接受干预。制作模型后每周利用BBB评分评定后肢运动功能,8周后取材进行免疫荧光染色、Western blotting和轴突示踪分析。 结果后肢运动功能：步行训练组在伤后4周（步行训练3周）时,BBB评分较对照组出现明显改善（P<0.05）,一直持续到实验结束（伤后第10周,P<0.01）。损伤部位神经丝(NF)免疫荧光染色分析：对照组胶质瘢痕中可见许多排列比较规则、与脊髓纵轴方向一致的NF阳性纤维穿行,步行训练组除了可见少量NF阳性纤维在胶质瘢痕中穿越,还可见较多的NF阳性纤维围绕空洞边缘延伸,其NF阳性纤维数量明显高于对照组（P<0.05）。损伤部位生长相关蛋白-43（GAP-43）表达：2组损伤部位周围均可见呈红色的排列凌乱的GAP-43表达,步行训练组GAP-43+组织免疫荧光灰度值较对照组高 (P<0.05)。皮质脊髓束再生:2组损伤部位尾侧均未见生物素化葡聚糖胺（BDA）标记的纤维。 结论步行训练能明显增强脊髓损伤大鼠后肢损伤部位组织的可塑性,促进大鼠后肢运动功能恢复,但未能促进皮质脊髓束的再生。     

Lower-extremity muscle cross-sectional area after incomplete spinal cord injury

OBJECTIVES: (1) To quantify skeletal muscle size in lower-extremity muscles of people after incomplete spinal cord injury (SCI), (2) to assess differences in muscle size between involved lower limbs, (3) to determine the impact of ambulatory status (using wheelchair for community mobility vs not using a wheelchair for community mobility) on muscle size after incomplete SCI, and (4) to determine if differential atrophy occurs among individual muscles after incomplete SCI. DESIGN: Case-control study. SETTING: University research setting. PARTICIPANTS: Seventeen people with incomplete SCI and 17 age-, sex-, weight-, and height-matched noninjured controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Maximum cross-sectional area (CSA) of individual lower-extremity muscles (soleus, medial gastrocnemius, lateral gastrocnemius, tibialis anterior, quadriceps femoris, hamstrings) as assessed by magnetic resonance imaging. RESULTS: Overall, subjects with incomplete SCI had significantly smaller (24%-31%) average muscle CSA in affected lower-extremity muscles as compared with control subjects (P<.05). Mean differences were highest in the thigh muscles ( approximately 31%) compared with the lower-leg muscles ( approximately 25%). No differences were noted between the self-reported more- and less-involved limbs within the incomplete SCI group. Dichotomizing the incomplete SCI group showed significantly lower muscle CSA values in both the wheelchair (range, 21%-39%) and nonwheelchair groups (range, 24%-38%). In addition, the wheelchair group exhibited significantly greater plantarflexor muscle atrophy compared with the dorsiflexors, with maximum atrophy in the medial gastrocnemius muscle (39%). CONCLUSIONS: Our results suggest marked and differential atrophic response of the affected lower-extremity muscles that is seemingly affected by ambulatory status in people with incomplete SCI.     

Robotic-assisted, body-weight-supported treadmill training in individuals following motor incomplete spinal cord injury

BACKGROUND AND PURPOSE: Performance of therapist-assisted, body-weight-supported treadmill training (BWSTT) to enhance walking ability of people with neurological injury is an area of intense research. Its application in the clinical setting, however, is limited by the personnel and labor requirements placed on physical therapists. Recent development of motorized ("robotic") rehabilitative devices that provide assistance during stepping may improve delivery of BWSTT. CASE DESCRIPTION: This case report describes the use of a robotic device to enhance motor recovery and ambulation in 3 people following motor incomplete spinal cord injury. INTERVENTIONS: Changes in motor impairment, functional limitations, and locomotor disability were monitored weekly during robotic-assisted BWSTT and following transition to therapist-assisted BWSTT with the assistance of one therapist. OUTCOMES: Following this training, 2 patients recovered independent over-ground walking and another improved his gait speed and endurance. DISCUSSION: The use of robotic devices may assist physical therapists by providing task-specific practice of stepping in people following neurological injury.     

中西医结合治疗不完全性脊髓损伤后中枢性疼痛

目的探讨中西医结合疗法治疗不完全性脊髓损伤中枢性疼痛的治疗效果。方法采用耳压、生物反馈、电动按摩器和经皮神经电刺激仪相结合的中西医结合疗法治疗不完全性脊髓损伤中枢性疼痛患者12例,以McGill疼痛问卷(MPQ)和视觉模拟评分(VAS)于治疗前后对中枢性疼痛进行评测。结果与治疗前相比,治疗后MPQ中的PRI-S、PRI-T、NWC以及VAS有明显降低(P<0.01),PRI-A、PPI最大值降低(P<0.05)。结论中西医结合疗法对治疗脊髓损伤中枢性疼痛有一定的疗效。     

光化学法诱导猫不完全脊髓损伤动物模型的建立

目的观察光化学法诱导猫脊髓损伤后的神经行为学、运动诱发电位及形态学改变,为研究脊髓损伤后神经再生与功能重建建立动物模型。 方法将15只猫根据冷光源照射时间不同随机分为40 min组、60 min组和80 min组。手术暴露脊髓后,用35 mg/kg体重的玫瑰红静脉注射,联合应用强度为3000 klx的冷光源照射T13脊髓节段。术后21 d内连续观察动物神经行为学改变;于术后第21天检测动物的运动诱发电位,并与术前结果比较;取材观察动物脊髓组织形态学改变。 结果3组动物在手术后21 d内的神经行为学评分结果显示,损伤后动物下肢功能神经行为学评分降低,损伤程度与光照时间成正比。60 min组和80 min组动物损伤后运动诱发电位波形消失。3组动物的脊髓都有明显的缺血性坏死改变。 结论光化学法可诱导猫脊髓内产生微血栓,从而使组织发生缺血性坏死。冷光源照射60 min、80 min的动物双下肢运动功能明显受损,与其病理学改变和电生理学改变相符,用这种方法制作不完全脊髓损伤模型稳定可靠。     

Long-term body-weight-supported treadmill training for incomplete cervical spinal cord injury: a case report

[Purpose] To investigate the effects of long-term body-weight-supported treadmill training on walking ability and physical function in an elderly individual with incomplete cervical spinal cord injury. [Participant and Methods] The patient was a 68 year-old male with an incomplete spinal cord injury at the C3/C4 level, incurred when he was 56 years old. He initiated home-based body-weight-supported treadmill training using a body-weight-supported treadmill installed at his home. His walking ability was measured as the percentage of body weight load reduction, and his physical function was evaluated using manual muscle testing and measuement of the range of motion of his lower limbs. [Results] The physical function of the lower limbs was improved, maintained, or showed delayed decline until 9.5 years post-injury. [Conclusion] Long-term body-weight-supported treadmill training may improve, maintain, or at least delay the decline of the physical function of participants for several years, without causing any remarkable complications.     

胶质源性神经营养因子对大鼠脊髓不完全损伤后运动功能的保护作用

目的：探讨胶质源性神经营养因子（GDN）对大鼠脊髓损伤后运动功能恢复的影响。方法：动物分为对照组、假手术组、生理盐水（NS）组及GDNF组,改良Allen方法致脊髓不完全损伤,蛛网膜下腔分别给予NS及GDNF20μl,伤后1d ,3d,7d,10d,14d及21d评定下肢运动功能（Tarlov评分及Rivlin斜板）。结果：假手术组与对照组、假手术组自身无明显变化（P＞0．05）,NS组及GDNF组伤后运动功能明显障碍。NS组14d、GDNF组7d以后脊髓功能明显改善,10d以后GDNF组运动功能改善显著超过NS组（P＜0．01）。结论：GDNF能够救损伤脊髓运动神经元,促进不完全脊髓损伤运动功能的恢复。     

Burns after spinal cord injury

The problem of burns after spinal cord injury is described. Chart review was performed on thirty-five known cases. All burns occurred below the level of the lesion (p less than .001). Causes included bathing and showering, food and beverage, and therapeutic and environmental heating devices. We conclude that spinal cord injured patients should be educated about the risk of burn injury and the situations in which burns can occur.     

减重步行训练对不完全脊髓损伤大鼠脚桥核可塑性影响的研究

目的:探索减重步行训练对不完全脊髓损伤大鼠脚桥核可塑性的影响。方法:将雌性SD大鼠24只分为减重步行训练组、未训练组和假手术组,每组8只,用美国NYU脊髓冲击损伤仪制作大鼠T10脊髓不完全损伤模型。采用PET-CT、免疫荧光染色及BBB评分观察减重步行训练对不完全脊髓损伤(iSCI)大鼠中脑运动区(MLR)脚桥核可塑性变化和后肢运动功能的改善。结果:减重步行训练组大鼠的后肢运动功能BBB评分在造模后4周、7周两个时间点的分值均较未训练组高(P0.05)。假手术组大鼠在造模后1周、4周、7周3个时间点的BBB评分值均明显高于训练组和未训练组(P0.01)。虽然训练组18F-氟脱氧葡萄糖(18F-FDG)的标准摄取值(SUV)的平均值较未训练组增高,而且假手术组的SUV值最高,但三组SUV值的差异不具有显著性意义(P0.05)。神经元特异性核抗原(NeuN)免疫荧光染色检测显示训练组、未训练组、假手术组三组间大鼠脚桥核的神经元数量差异无显著性意义(P0.05),而脚桥核2型囊泡谷氨酸转运体(VGLUT2)的积分光密度值(IOD)比较,假手术组IOD表达最高,训练组较未训练组明显增强(P0.01)。结论:减重步行训练能够明显提高iSCI大鼠后肢运动功能及其脚桥核中谷氨酸能信号传递,而且iSCI后大鼠中脑脚桥核的整体代谢及神经元数量无明显改变。因此认为脚桥核的谷氨酸表达增强是减重步行训练使iSCI大鼠后肢步行功能改善的原因之一。减重步行训练能使脚桥核发生神经递质表达层面的可塑性变化。     

脊髓损伤后疼痛

各种文献所报道的脊髓损伤 (ｓｐｉｎａｌｃｏｒｄｉｎｊｕｒｙ ,ＳＣＩ)后疼痛的发生率差异很大 ,有报道称发生率为5 %— 70 % [1] ,也有报道认为 ,ＳＣＩ后疼痛很常见 ,其发生率一般可达到 6 5 % ,其中大约有 1/ 3属于严重疼痛[2 ] 。ＳＣＩ后疼痛会对患者的康复治疗以及日常活动造成不良影响 ,使其生活质量降低[3、4 ] 。但目前对ＳＣＩ后疼痛仍然缺乏有效的治疗措施 ,因此 ,有必要进行深入的研究。1影响ＳＣＩ后疼痛的因素在可能影响ＳＣＩ后疼痛的各种因素中[5、6 ] ,对损伤性质 (完全性或不完全性 )、损伤平面、心理状况等因素的研究…     

Employment after spinal cord injury

A predictive model for employment after spinal cord injury was developed. The study population consisted of 154 spinal cord injured persons who were treated at our hospital between 1973 and 1979, and followed for seven years after injury. Demographic, social, and injury severity data were abstracted from each subject's hospital record. Motivation to work, employment history, and sources of postinjury financial support, were assessed by a vocational rehabilitation counselor. The study population was divided into four groups: persons continuously unemployed after injury, homemakers, students, and those employed at some time during the seven-year follow-up period. Stepwise discriminant analysis was used to develop a predictive model that ultimately included seven variables: gender, motivation to work, whether the patient's last job required ambulation, race, educational level, a functional ability score, and whether the patient had children. The model correctly classified 82% of those persons who were continuously unemployed, 100% of homemakers, 63% of students, and 72% of employed subjects. Overall, 79% of subjects were classified correctly. The most important classification errors were between the unemployed and employed groups. Seventeen percent of employed patients were incorrectly classified as unemployed, and 11% of unemployed patients were incorrectly classified as employed. Although there are other determinants of postinjury vocational status, individual potential can be assessed by means of a comparatively small set of predictor variables.     

Pain after spinal cord injury

Evaluation of pain in a person with SCI should commence with a determination of the neurologic level and the completeness of injury. The pain then can be localized to one of three regions: above level, at level, or below level. The regional pain then should be categorized either as nociceptive or neuropathic and, after this, subdivided into a specific subtype. An evidence based treatment plan can be devised depending on the specific subtype, which may include physical measures, pharmacologic treatments, behavioral interventions, surgery, or an eclectic combination program. The treatment plan usually can provide some relief for any of the subtypes, although complete relief often is not possible.     

Obesity after spinal cord injury

America is in the midst of an obesity epidemic, and individuals who have spinal cord injury (SCI) are perhaps at greater risk than any other segment of the population. Recent changes in the way obesity has been defined have lulled SCI practitioners into a false sense of security about the health of their patients regarding the dangers of obesity and its sequelae. This article defines and uses a definition of obesity that is more relevant to persons who have SCI, reviews the physiology of adipose tissue, and discusses aspects of heredity and environment that contribute to obesity in SCI. The pathophysiology of obesity is discussed relative to health risks for persons who have SCI, particularly those contributing to cardiovascular disease. Prevalence of obesity and its comorbidities are discussed and management options reviewed.