Abstract 19: Cortical reorganization of hand motor function to primary sensory cortex in hemiparetic patients with a primary motor cortex infarct.

Objective: To demonstrate cortical reorganization in hemiparetic patients with a primary motor cortex (M1) infarct using functional magnetic resonance imaging (fMRI). Design: The hand motor function of 2 hemiparetic stroke patients and 20 control subjects was evaluated by fMRI. Setting: Academic medical center. Participants: 2 hemiparetic patients and 20 control subjects with no history of neurologic disease. Interventions: fMRI was performed using the blood oxygen level-dependent technique at 1.5T. For the motor task paradigm, hand grasp-release movements were performed at a frequency of 1Hz for stimulation, guided with a metronome, over a repeated cycle of 15 seconds of control and 15 seconds of stimulus. Each task paradigm of alternating control-stimulus (30s) was repeated 3 times. Main Outcome Measures: fMRI data were analyzed using SPM-99 software running under the Matlab environment. The images were then smoothed with an 8mm isotropic gaussian kernel. Statistical parametric maps were obtained and voxels were considered significant at P<.001, uncorrected, with the additional requirement of a cluster size of 5 voxels. Results: The contralateral primary sensorimotor cortex was activated by the hand movements of control subjects and of the unaffected side of the 2 patients. Only the contralateral (infarct side) primary sensory cortex (S1) was activated by the affected hand movements of the 2 patients, a result that was not observed in control subjects or the unaffected hand of stroke patients. Conclusions: We believe that the hand motor function of the infarcted M1 of these patients was reorganized into S1. It seems that cortical reorganization took place in patients with an M1 infarct.     

Poster 18: A method for quantitative analysis of central nervous system motor output during voluntary movements

Objective: To assess methods used to reduce surface electromyographic data during voluntary movements. Design: Retrospective analysis of surface electromyograms recorded from healthy subjects and subjects with spinal cord injury (SCI) using the Brain Motor Control Assessment protocol. Setting: Regional referral center for SCI. Participants: 9 subjects with SCI who had American Spinal Injury Association Impairment Scale classes C and D injuries and were drawn from another study; and 15 healthy subjects. Intervention: Supported treadmill ambulation training was provided to the subjects with SCI as a part of a separate efficacy study and was used to demonstrate analysis method sensitivity to changes in motor control. Main Outcome Measures: Surface electromyographic responses to voluntary maneuvers from 10 muscles in the lower limbs. They were used to calculate the inner product of vectors of each muscle’s average activity. Results: The electromyographic responses of intact subjects to voluntary maneuvers were consistent. Response vector similarity of SCI patients’ data set to prototype response vector was consistent. The magnitude of the response vector varied within a reliable range. Conclusions: This method of analysis shows the potential to differentiate between subjects with healthy and with damaged central nervous system movement control. It also appears that this method has the sensitivity to differentiate among subjects with SCI and changes in motor control over time, and to characterize those changes with respect to responses recorded in healthy subjects.     

Abstract 12: Small heat shock protein gene therapy to protect damaged spinal cord from secondary injury.

Objective: To test the hypothesis that overexpression of small heat shock protein (Hsp27) after spinal cord lesion protects neural cells from secondary injury. Design: Gene therapy study on animal models. Setting: Academic research center. Animals: Rats. Interventions: Not applicable. Main Outcome Measures: Clone human Hsp27 complementary deoxyribonucleic acid into a neural tropic recombinant herpes simples and adeno-associated virus hybrid vector; prepare amplicons carrying Hsp27 and green fluorescent protein (GFP) genes; induce rat spinal cord injury by weight-drop apparatus (10g, 25mm); microinject the injured and uninjured spinal cords with Hsp27 amplicons with GFP amplicons and saline as a control; observe the spinal cord target gene expressions, histology reaction, and neuron survival; and perform immunohistochemistry studies as well as apoptosis assay. Results: Hours after injection, obvious target gene expression was observed. The expression peaked at 48 hours and was quite constant, lasting >8 weeks. The expression area was mainly around the site of injection. No obvious local inflammatory reaction induced any amplicons. Protective signs of neural tissue were observed in the Hsp27 group. 2 weeks after the contusion, about 30% more neurons survived around the lesion area in the Hsp27 therapy group than in the controls. Many Hsp27 labeled axon-like processes were found around the lesion site. There were fewer cells with apoptosis markers around the injury area in the Hsp27 group. The differences showed statistical significance. Conclusion: Hsp27 gene therapy may limit secondary injury in the rat spinal lesion model. Further studies on the underlying mechanisms and functional outcomes are suggested.     

Article 9: Sensitivity of H-reflex in detecting response to complex-continuous mode of intrathecal baclofen delivery

Objective: To determine sensitivity of H-reflex in assessing spinal cord responsiveness before and after programming complex-continuous mode of intrathecal baclofen (ITB) delivery. Design: Prospective, consecutive sample. Setting: Traumatic Brain Injury Model Systems inpatient rehabilitation center. Participants: 7 patients with dysfunctional spasticity due to acquired brain injury underwent serial soleus H-reflex recordings before and 4 hours after the ITB delivery mode was changed from simple- to complex-continuous. Intervention: 25- to 125-μg ITB boluses during complex-continuous mode. Main Outcome Measures: The ratio between maximum H-reflex and maximum M wave (H/M). Results: Initial simple-continuous dose ranged from 150 to 490μg/d with the corresponding H/M ratios from 33% to 82%. After bolus administration, the H/M ratio decreased in 5 subjects from 10% to 60% in a dose-dependent manner. Corresponding change in mean Ashworth Scale score (n=3) was <0.7. In the remaining 2 subjects, only minimal change in H/M occurred; malfunctioning pumps were later found. Conclusions: Our results indicate that the H-reflex is a sensitive technique for monitoring spinal cord responsiveness to complex-continuous mode of ITB delivery. H-reflex recordings may be useful for ensuring proper pump function, especially when clinical spasticity is decreased due to simple-continuous ITB delivery and, therefore, less detectable by clinical evaluation.     

Article 11: Aerobic exercise improves work capacity and functional mobility in spinal cord injury above T6

Objective: To determine if adults with low-cervical and high-thoracic spinal cord injury (SCI) significantly improve work capacity and functional mobility after a structured aerobic exercise. Design: Pre- and posttest interventional trial. Setting: Exercise laboratory. Participants: 6 subjects (4 men, 2 women; mean age ± SD, 37.7±12.1y; mean weight, 74.1±21.2kg; mean time since injury, 5.9±5.6y) with motor complete SCI between C7 and T5 completed the intervention. Interventions: Subjects performed arm crank ergometry at 70% of peak power output for 30min/d, 3d/wk for 10 weeks. Main Outcome Measures: Peak oxygen consumption (Vo₂peak), peak power output, and 12-minute wheelchair propulsion (12WCP). Results: Vo₂peak significantly increased, from 10.8±3.6mL·kg⁻¹·min⁻¹ to 12.6±4.2mL·kg⁻¹·min⁻¹ (P<.05) after the intervention, while peak power output and 12WPC increased from 40.8±15.3W to 54.2±18.9W and 1260±344ft to 1358±312ft, respectively (P<.005). Conclusions: Structured aerobic exercise can significantly improve work capacity and functional mobility in persons with motor complete SCI between C7 and T5.     

Poster 27: Pressure ulcer history and spinal cord injury

Objective: To identify risk and protective factors associated with a history of recurrent pressure ulcers after spinal cord injury (SCI). Design: Cross-sectional. Setting: Large southeastern US specialty hospital. Participants: 826 nonambulatory adults with traumatic SCI of at least 5 years in duration. Interventions: Not applicable. Main Outcome Measures: Outcomes included current pressure ulcers, pressure ulcers within the past years, days adversely impacted by pressure ulcers, pressure ulcer surgeries, and pressure ulcer history (recurrent vs nonrecurrent). Results: 69% failed to report recurrent pressure ulcers, whereas 13% reported a clear pattern of recurring pressure ulcers of 1 or more per year (18% could not be classified). Logistic regression identified several general protective behaviors for recurrent pressure ulcers (eg, lifestyle, exercise, diet), none of which included those generally recommended during inpatient rehabilitation to prevent pressure ulcers (eg, skin checks, weight shifts). Fewer risk behaviors were associated with pressure ulcer history, although several proxy variables were related to pressure ulcer history. Conclusions: Pressure ulcer history is a more viable measure of pressure ulcer outcomes than measures taken at a single point in time (current), over a brief period of time (eg, 1y), or those relying on critical events occurring at any time since SCI onset (ie, surgeries to repair pressure ulcers). A general healthy lifestyle appears to be strongly associated with an absence of recurrent pressure ulcers, whereas the efficacy of specific prevention behaviors was not demonstrated.     

Article 10: Effect of cognitive retraining on reorganization of attention network in patients with traumatic brain injury

Objective: To identify the areas of reorganization in the neural network for attention after cognitive retraining in the patients with traumatic brain injury (TBI) using functional MRI (fMRI). Design: Controlled clinical trials. Setting: Department of physical medicine and rehabilitation in general hospital. Participants: Ten TBI patients and 12 healthy volunteers participated. Interventions: Patients had received computer-assisted cognitive retraining to practice diverse attention skills for 3 to 4 weeks. Main Outcome Measures: fMRI was performed on a 3T ISOL Forte scanner with single-shot echoplanar imaging sequences before and after the intervention using a modified Posner paradigm as an activation task. Data were analyzed using Statistical Parametric Mapping 99. Results: The accuracy was lower and reaction time was slower in the patient group (P<.001). fMRI results showed more activation in the right prefrontal and less activation in the cingulate, occipitotemporal, and cerebellar regions in the patients than in the normal group. After cognitive retraining, reaction time improved significantly (P<.05). fMRI analysis showed a decrease in activation of the bilateral frontal and an increase in activation of the medial frontal areas after cognitive retraining. Conclusion: The effect of cognitive retraining was accompanied by reorganization of attention networks in frontal areas.     

Abstract 15: H-reflex latencies and sensory and motor nerve action potential latencies among diabetic patients seen at the outpatient service of a tertiary hospital: a correlative study.

Objective: To determine the correlation between the H-reflex latencies and the sensory and motor nerve action potential latencies in detecting diabetic neuropathy. Design: Prospective, cross-sectional. Setting: Outpatient departments of neurology and rehabilitation medicine in a tertiary hospital. Participants: 41 subjects with diabetes. Interventions: Not applicable. Main Outcome Measures: H-reflex latencies of the tibial nerve and nerve conduction studies (median motor and sensory, peroneal motor, sural sensory latencies) of the upper and lower extremity of each patient. Results: The correlation between the nerve action potential latencies and the H-reflex latencies was studied using the canonical correlation analysis method. The computed canonical correlation coefficient was .8379 (P=.0001). Conclusions: The findings suggest that there is a strong correlation between H-reflex latencies and sensory and motor nerve action potential latencies among patients with diabetic neuropathy. Based on this study, use of H-reflex latencies is a promising alternative electrophysiologic technique in the investigation of peripheral neuropathy among patients with diabetes mellitus.     

Poster 13: Validation of the assessment of motor and process skills among older adults in the community

Objective: To assess the validity of the Assessment of Motor and Process Skills (AMPS), an occupational therapy tool, for epidemiologic research. Design: Population-based sample. Setting: Northern New York City. Participants: 217 elders aged ≥70 years were recruited from Medicare beneficiary files. Interventions: Not applicable. Main Outcome Measures: The AMPS composite motor and cognitive process scores. Results: In this sample of nondemented older people (32% men; mean age, 78.5±5.6y; two thirds minorities), motor scores correlated highly with gait speed (.53), grip strength (.34), and tandem stand time (.36) (P<.001). Process scores were significantly lower in people with mild cognitive impairment relative to those with normal cognition (P<.001). Correlations between process scores and physical indicators, and motor scores and cognitive performance, were much lower, indicating discriminant validity. 25% of participants scored in the impaired range in motor skills, 10% in process skills, and 7.5% in both. Self-reported deficits were related to both motor and process scores. Conclusions: The AMPS appears to be a valid tool for epidemiologic research.     

Poster 31: Community-acquired pneumonia in veterans with spinal cord injury

Objective: To describe the characteristics of community-acquired pneumonia (CAP) in persons with spinal cord injury (SCI) and how management is related to outcomes. Design: Cross-sectional retrospective review of administrative and clinical data. Setting: Department of Veterans Affairs (VA) facilities, and for substudy, 3 VA SCI centers (October 1998-September 2000). Participants: Veterans with SCI: 260 inpatients with CAP; in the substudy, 41 inpatients and outpatients with CAP from 3 sites. Interventions: Not applicable. Main Outcome Measures: Percentage of patients with an etiologic diagnosis, mortality rate, mean length of stay (LOS), and number and types of procedures and treatments. Results: Of the 260 inpatients with SCI identified from administrative data with CAP, only 24% had an etiologic diagnosis. Etiologic diagnosis was not associated with mortality after adjusting for several factors (OR=1.38; CI, 0.45-4.20), however, it was associated with an increase in LOS (P=.024). For the substudy, almost 75% of the 41 patients were hospitalized (mean LOS=16.3d) and 3 patients died. Most received chest radiographs (85%), but up to 54% did not receive other tests standard for management of CAP during the first day of care (eg, blood cultures, CHEM 7). Of the 16 patients with sputum cultures, an organism was identified in 44% through microbiology testing. Over 90% received antibiotics within 24 hours of admission. Conclusions: Many patients do not receive the minimum recommended testing. Empiric treatment appears to have been the predominant type of management used in this population. Further research to assess the relationship between clinical characteristics and management with patient outcomes is     

Article 8: Hemilens-induced constrained visual processing improves contralesional visual, perceptual, and motor functioning for patients with lateralized brain injury

Objective: To evaluate whether vision, constrained by contact lenses to force processing of neglected hemispace, improves visual neglect and lateralized visuoperceptual and motor functions. Design: Pre- versus posttreatment measures of visual and motor functions analyzed with parametric and nonparametric statistical techniques. Setting: Postacute head injury rehabilitation day treatment program. Participants: 7 patients demonstrating hemineglect during paper and pencil activities. Intervention: Use of contact lenses designed to block visual input to the spared visual hemispace. Main Outcome Measures: Judgment of line orientation, grip strength, finger oscillation speed, line bisection, Trail-Making Test Part A, Wechsler Adult Intelligence Scale-III block design, letter cancellation, visual form discrimination. Results: A statistically significant number of patients demonstrated improved performances for 4 measures and statistically significant magnitude of improvement was demonstrated on 6 measures, with trends for significant magnitude of improvement for 3 other measures. Conclusion: Contact lens-induced constrained visual processing appears to have a potential specific benefit for the amelioration of both unilateral neglect-related visuoperceptual processing deficits and for lateralized motor deficits.     

Poster 19: Time course of recovery of skeletal muscles after botulinum toxin type a injection in juvenile rats: a 6-month follow-up

Objectives: To document the time course of recovery of the targeted muscle after botulinum toxin type A (BTX) injection. Design: Basic science study using a rat model. Setting: University medical center research laboratory. Animals: Twenty-four 1-month old Sprague-Dawley rats. Intervention: BTX-A was injected into the left gastrocnemius muscle of 24 rats (6U/kg of body weight). Equal volume of saline was injected into the right gastrocnemius muscle (control). Main Outcome Measures: Muscle mass, motor evoked action potentials (latency, amplitude), and muscle force generation (single twitch, tetanus) were evaluated at different follow-up intervals. Results: In the BTX group, muscle mass was reduced by 31.5% of the control side within 2 weeks of injection and recovered to 92% at 6 months. Latency was prolonged to 144.9% at 3 days and recovered to 101% at 6 months. Amplitude, single twitch, and tetanus were significantly reduced at 1 week, but recovered to >94% at 6 months. Conclusions: BTX injection at 6U/kg of body weight effectively decreased muscle mass and muscle electrophysiologic parameters with peak onset 1 to 2 weeks after injection and with >90% functional recovery at 6 months.     

Abstract 9: Maximal bladder capacity as the predictor of response to desmopressin on nocturnal enuresis in patients with spinal cord injuries.

Objectives: To evaluate the efficacy of intranasal desmopressin inhalation on nocturnal enuresis in patients with spinal cord injury (SCI) and to investigate the validity of maximal bladder capacity as the predictor of response to intranasal desmopressin inhalation. Design: Before and after interventional trial. Setting: University-affiliated hospital. Participants: 22 adults SCI with nocturnal enuresis were divided into 2 groups: the large bladder capacity group (bladder capacity, >250mL; n=11) and the small bladder capacity group (bladder capacity, <250mL; n=11). Intervention: All participants were treated with intranasal desmopressin, 10μg daily at bedtime for 4 weeks. Main Outcome Measures: Total volume of daily nocturnal incontinence and serum electrolytes. Maximal bladder capacities were measured by urodynamic evaluation. Results: After intranasal desmopressin inhalation, mean volume of nocturnal incontinence decreased significantly in the large bladder capacity group (P<.05), but not in the small bladder capacity group (P>.05). The mean maximal bladder capacity of responders was larger than that of nonresponders (P<.05). Neither hyponatremia nor serum electrolytes abnormalities occurred. Conclusions: Intranasal desmopressin inhalation is safe and effective in symptomatic management of neurogenic bladder dysfunction in selected patients with SCI. Maximal bladder capacity is a valuable predictor of response to desmopressin.     

Article 14: Effect of a wheelchair-mounted robotic arm on functional outcomes in persons with spinal cord injury

Objective: To determine the effect of a wheelchair-mounted robotic arm (WMRA) on function in persons with spinal cord injury (SCI). Design: Participants enrolled in the 2-week protocol. Setting: Veterans Affairs medical centers in Houston and Pittsburgh. Participants: 11 men (mean age, 42±12y) with cervical SCI (C3-4 to C6-7). All used power wheelchairs with joystick controls. Intervention: Training took place for 6 hours over 3 days. Subjects practiced activities of daily (ADL) tasks for 14 hours over 7 days. Tasks were timed and subjects were classified functionally as dependent (0), needs assistance (1), or independent (2). After 2 weeks, they were reevaluated for functional improvement with the WMRA. Main Outcome Measures: Number and time to complete tasks were calculated. Results: Mean ADL scores (independence) at reevaluation were significantly higher (P<.02) than at baseline. Average ADL performance times decreased from 226 to 171 seconds, a statistically significant reduction in time (P<.0001). Data revealed significant differences in subjects’ functional independence and time to complete tasks with the WMRA in 7 activities (P<.05). Conclusions: The WMRA has the potential to enable persons with SCI to perform functional tasks that would otherwise be impossible for them. However, design problems (ie, added wheelchair width when WMRA is installed) interfered with maximum utilization and satisfaction.     

Poster 31: Value of a fitness program after completion of rehabilitation therapy poststroke

Objective: To assess the value of a fitness program after completion of formal stroke rehabilitation. Design: Randomized, controlled, prospective study. Setting: Community wellness center. Participants: 39 subjects with stroke randomly assigned to immediate (n=20) versus deferred treatment (n=19). Interventions: The immediate group (IG) was enrolled in a 12-week exercise program. The deferred group (DG) was deferred from the exercise program for 12 weeks. Main Outcome Measures: Fugl-Meyer motor and balance subscores, 2- and 6-minute timed walk tests, FIM™ instrument, number of falls, number of hospitalizations, Mini-Mental State Examination, Beck Depression Scale, Community Integration Questionnaire, and Burke Handicap Scores were obtained at baseline and at 12 weeks postenrollment. Results: Preliminary analysis showed that the change in Fugl-Meyer motor score from baseline to 12 weeks was the only significant outcome variable (IG score ± SEM, 5.3±1.5 vs DG score, −1.7±2.1; P=.01). Subject dropouts differed significantly between the 2 groups (1 in IG, 6 in DG; χ²=4.0, P=.04). Conclusions: Structured exercise after completion of formal stroke rehabilitation has a significant effect on impairment. Subject dropouts in the DG indicated the strength of patient demand for a structured exercise program.     

Poster 7: Shoulder impingement syndrome: clinical indicators and short-term predictors of disability

Objective: To identify the best indicators of the current disability of patients with shoulder impingement syndrome (SIS) and the strongest predictors of 3-month SIS-related disability. Design: Prospective cohort study. Setting: Movement analysis laboratory. Participants: 41 subjects with SIS. Interventions: Evaluations at baseline and at 3 months. Main Outcome Measures: Personal, occupational, and impairment variables and the Shoulder Pain and Disability Index (SPADI). Cross-sectional explicative and 3-month predictive regression models of the level of disability (SPADI score) were developed using multivariate analyses. Results: Strength deficits in shoulder abduction-lateral rotation, pain during muscle strength testing, painful arc in abduction, scapular anterior tilting asymmetry, gender, and age explained 91% of the variance of the SPADI at baseline. The SPADI score at baseline, perceived work capacity, acromiohumeral distance at 90° of abduction, acromiohumeral distance difference between shoulders at 110° of flexion, difference between active and passive range of motion in abduction, and the presence of SIS on the dominant side predicted 86% of the variance of the SPADI at 3 months. Conclusions: Variables that best explain the current disability level and predictors of short-term level of disability should be considered in SIS treatment planning as well as for establishing prognosis.     

Poster 9: Motivating, game-based stroke rehabilitation: a pilot study

Objective: To determine the efficacy and reactions of stroke patient to a game-based rehabilitation modality for more affected upper limbs. Design: Case series. Setting: Outpatient rehabilitation clinic. Participants: 4 persons with stroke (3 men; mean age, 60.0±4.9y; age range, 56-66y; mean time since stroke, 84.3mo; range, 10-264mo). Interventions: Each patient received thirteen 30-minute training sessions using the gaming device. Each session required participation in electronic table tennis using the more affected hand as the joystick, thus forcing use of the more affected limb. Instantaneous kinesthetic and force feedback was available via participation. Main Outcome Measures: Wolf Motor Function Test (WMFT) and patient interviews before and after intervention. Results: After the intervention, patients exhibited decreased median time to complete WMFT tasks (−5.3s), decreased mean time to perform WMFT tasks (−19.7s), and improved performance ratings as assessed by an objective rater. Interviews revealed high satisfaction and motivation; they also revealed that motor improvement had a high carryover to valued activities. Conclusions: This approach appears to be an efficacious, motivating, and enjoyable modality deserving of additional research. A larger, multicenter trial is planned.