Comparison of the effects of body-weight-supported treadmill training and tilt-table standing on spasticity in individuals with chronic spinal cord injury

Abstract

Objective

Determine the effects of body-weight-supported treadmill training (BWSTT) and tilt-table standing (TTS) on clinically assessed and self-reported spasticity, motor neuron excitability, and related constructs in individuals with chronic spinal cord injury (SCI).

Design

Random cross-over.

Methods

Seven individuals with chronic SCI and spasticity performed thrice-weekly BWSTT for 4 weeks and thrice-weekly TTS for 4 weeks, separated by a 4-week wash-out. Clinical (Modified Ashworth Scale, Spinal Cord Assessment Tool for Spinal reflexes) and self-report (Spinal Cord Injury Spasticity Evaluation Tool, Penn Spasm Frequency Scale) assessments of spasticity, quality of life (Quality of Life Index Spinal Cord Injury Version – III), functional mobility (FIM Motor Subscale), plus soleus H-reflex were measured at baseline, after the first training session and within 2 days of completing each training condition.

Results

In comparison with TTS, a single session of BWSTT had greater beneficial effects for muscle tone (effect size (ES) = 0.69), flexor spasms (ES = 0.57), and the H/M ratio (ES = 0.50). Similarly, flexor spasms (ES = 0.79), clonus (ES = 0.66), and self-reported mobility (ES = 1.27) tended to benefit more from 4 weeks of BWSTT than of TTS. Participation in BWSTT also appeared to be favorable for quality of life (ES = 0.50). In contrast, extensor spasms were reduced to a greater degree with TTS (ES = 0.68 for single session; ES = 1.32 after 4 weeks).

Conclusion

While both BWSTT and TTS may provide specific benefits with respect to spasticity characteristics, data from this pilot study suggest that BWSTT may result in a broader range of positive outcomes.     

Spinal Cord Injury Providers’ Perceptions Of Barriers To Implementing Selected Clinical Practice Guideline Recommendations

Abstract

Background/Objective: Twelve focus groups were conducted at 6 Department of Veterans Affairs (DVA) Spinal Cord Injury (SCI) Centers. The purpose of these focus groups was to identify provider-perceived barriers to implementing selected recommendations of two clinical practice guidelines (CPGs)-Prevention of Thromboembolism in Spinal Cord Injury and Management of Neurogenic Bowel in Adults With Spinal Cord Injury-at their sites.

Methods: A total of 75 SCI direct-care staff (including physicians, nurses, dieticians, rehabilitation therapists, psychologists, and social workers) participated in the focus groups, which were conducted by trained focus group facilitators. Woolfs framework was used to classify perceived barriers into 1 of 4 categories: (a) lack of knowledge, (b) lack of agreement, (c) lack of ability, or (d) lack of systematic reminders for implementation. The "lack of ability" category was further expanded to reflect which specific aspect of the environment was seen as the obstacle: (a) patient, (b) provider, (c) SCI unit, (d) hospital or medical center, or (e) non-Veterans Affairs (VA) hospital setting.

Results: Providers disagreed with the recommendation to reinstitute prophylaxis in patients with nona cute SCI to prevent deep vein thrombosis and identified a number of system-level problems with providing appropriate prophylaxis. Providers identified patient reluctance to changing their bowel programs and difficulties in documenting changes in the patients' bowel program as obstacles to implementing the neurogenic bowel CPG.

Conclusion: Based on this feedback, interventions were developed to address provider-perceived barriers. These interventions were implemented at 6 Veterans Affairs SCI Centers.

J Spinal Cord Med. 2003;26:48-58     

Antispasmodic medications may be associated with reduced recovery during inpatient rehabilitation after traumatic spinal cord injury

Objective: To determine whether antispasmodic medications are associated with neurological and functional outcomes during the first year after traumatic spinal cord injury (SCI).

Design/Methods: Retrospective analysis of prospectively collected data from six inpatient SCI rehabilitation centers. Baseline-adjusted outcomes at discharge and one-year follow-up were compared using analysis of covariance between patients who received antispasmodic medication on at least 5 days during inpatient rehabilitation and patients who did not.

Outcome measures: Rasch-transformed motor subscore of the Functional Independence Measure (FIM); International Standards for Neurological Classification of Spinal Cord Injury motor scores, grade, and level.

Results: Of 1,259 patients, 59.8%, 35.4%, and 4.8% were injured at the cervical, thoracic, and lumbosacral levels, respectively. 65.6% had motor complete injury. Rasch-transformed motor FIM score at admission averaged 23.3 (95% confidence interval (CI) 22.4–24.2). Total motor score averaged 39.2 (95% CI 37.8–40.6). 685 patients (54.4%) received one or more antispasmodic medications on at least 5 days. After controlling for demographic and injury variables at admission, Rasch-transformed motor FIM scores at discharge were significantly lower (P?=?0.018) in patients receiving antispasmodic medications than in those who did not. This trend persisted in secondary analyses for cervical, thoracic, and lumbosacral subgroups. Multivariate regression showed that receiving antispasmodic medication significantly contributed to discharge motor FIM outcome. At one-year follow-up, no outcomes significantly differed between patients ON or OFF antispasmodics.

Conclusions: Antispasmodic medications may be associated with decreased functional recovery at discharge from inpatient traumatic SCI rehabilitation. Randomized prospective studies are needed to directly evaluate the effects of antispasmodic medication on recovery.     

Reliability of S3 pressure sensation and voluntary hip adduction/toe flexion and agreement with deep anal pressure and voluntary anal contraction in classifying persons with traumatic spinal cord injury

Context/Objective: The sacral examination components of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), namely deep anal pressure (DAP) and voluntary anal sphincter contraction (VAC), are often difficult to perform. We evaluated whether pressure sensation at the S3 dermatome (S3P), and voluntary hip adductor or toe flexor contraction (VHTC) are tenable alternatives. Here we report test–retest reliability and agreement of these components at 1 month after spinal cord injury (SCI), and impact of disagreement on American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades.

Design: Longitudinal cohort. ISNCSCI examination, S3P and VHTC conducted at 1-month post-injury; retest of the sacral exam, S3P and VHTC within 3 days. Follow-up examinations performed at 3, 6, and 12 months.

Setting: Five Spinal Cord Injury Model System Centers.

Participants: Subjects with acute traumatic SCI, neurological levels T12 and above, AIS grades A–C.

Interventions: None.

Outcome Measures: ISNCSCI exam, AIS grades.

Results: Fifty-one subjects had 1-month data, and 39 had at least one follow-up examination. Test–retest reliability indicated perfect agreement (kappa?=?1.0) for all data except S3P (kappa?=?0.96). The agreement was almost perfect between S3P and DAP (kappa?=?0.84) and between VHTC and VAC (kappa?=?0.81). VHTC and VAC differed more often with neurologic levels below T10, possibly due to root escape in conus medullaris injuries.

Conclusion: S3P and VHTC show promise as alternatives to DAP and VAC for determining sacral sparing in persons with neurologic levels T10 and above. Reliability and agreement should be evaluated at earlier timepoints and in children with SCI.     

The Spinal Cord Injury Spasticity Evaluation Tool: A Persian adaptation and validation study

Objective: To adapt the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) into the Persian language (SCI-SETp) and to examine the reliability and validity of the SCI-SETp in patients with spinal cord injury (SCI).

Design: A cross-sectional and prospective cohort validation study.

Setting: University Neurological Physiotherapy Clinic.

Participants: Adult patients with SCI.

Main Outcome Measures: SCI-SET.

Results: There was no missing data. No floor or ceiling effect was observed. Cronbach's α coefficient was 0.862. Factor analysis suggested 1 factor structure (Eigenvalue?=?8.49) explained 24.27% of the total variance. The ICC_agreement for test-retest reliability was 0.84. The standard error of measurement and the smallest detectable change was 0.30 and 0.82, respectively. The divergent relationships demonstrated the SCI-SETp uniqueness construct.

Conclusion: The results support the reliability and validity of the SCI-SETp for assessing the impact of spasticity on daily life of patients with SCI.     

International standards to document remaining autonomic function after spinal cord injury

Abstract

This is the first guideline describing the International Standards to document remaining Autonomic Function after Spinal Cord Injury (ISAFSCI). This guideline should be used as an adjunct to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) including the ASIA Impairment Scale (AIS), which documents the neurological examination of individuals with SCI. The Autonomic Standards Assessment Form is recommended to be completed during the evaluation of individuals with SCI, but is not a part of the ISNCSCI. A web-based training course (Autonomic Standards Training E Program (ASTeP)) is available to assist clinicians with understanding autonomic dysfunctions following SCI and with completion of the Autonomic Standards Assessment Form (www.ASIAlearningcenter.com).     

Lower extremity functional electrical stimulation cycling promotes physical and functional recovery in chronic spinal cord injury

Abstract

Objective

To examine the effect of long-term lower extremity functional electrical stimulation (FES) cycling on the physical integrity and functional recovery in people with chronic spinal cord injury (SCI).

Design

Retrospective cohort, mean follow-up 29.1 months, and cross-sectional evaluation.

Setting

Washington University Spinal Cord Injury Neurorehabilitation Center, referral center.

Participants

Twenty-five people with chronic SCI who received FES during cycling were matched by age, gender, injury level, and severity, and duration of injury to 20 people with SCI who received range of motion and stretching.

Intervention

Lower extremity FES during cycling as part of an activity-based restorative treatment regimen.

Main outcome measure

Change in neurological function: motor, sensory, and combined motor–sensory scores (CMSS) assessed by the American Spinal Injury Association Impairment scale. Response was defined as ≥1 point improvement.

Results

FES was associated with an 80% CMSS responder rate compared to 40% in controls. An average 9.6 CMSS point loss among controls was offset by an average 20-point gain among FES subjects. Quadriceps muscle mass was on average 36% higher and intra/inter-muscular fat 44% lower, in the FES group. Hamstring and quadriceps muscle strength was 30 and 35% greater, respectively, in the FES group. Quality of life and daily function measures were significantly higher in FES group.

Conclusion

FES during cycling in chronic SCI may provide substantial physical integrity benefits, including enhanced neurological and functional performance, increased muscle size and force-generation potential, reduced spasticity, and improved quality of life.     

Aps Funded Research Projects

Abstract

Objectives: Determine the unique effects of age across a variety of outcome domains following spinal cord injury (SCI).

Design: Cross-sectional; 61 32 individuals with traumatic onset SCI in the National Spinal Cord Injury Statistical Center (NSCISC) database.

Outcome Measures: Functional Independence Measure (FIM) , Sat isfaction With Life Scale (SWLS) , the Craig Hand icap Assessment and Reporting Technique (CHART), and the Short Form-12 (SF-12).

Results: Older age was most consistently associated with decreased self-reported outcomes across most domains assessed. More specifically, a significant linear decline with age was found for functional independence (FIM) , overall life satisfaction (SWLS) , perceived physical health (SF-12 physical health), and overall handicap (CHART-total score), particularly in the areas of physical independence, mobility, occupational functioning, and social integration (CHART subscales). However, regression analyses, controlling for numerous demographic and medical characteristics, indicated that the amount of unique variance that could be specifically attributed to age was relatively small. Age was unrelated to self-reported mental health (S F-1 2 mental health subscale) and economic functioning (CHART -economic self-sufficiency subscale). Pain interference in day-to-day activities (ie, a single item from SF-12) significantly increased with age.

Spinal Cord Med. 2003;26:37-44     

Poster Presentations

Objective: To evaluate age-related variation in mobility independence among community-living wheelchair users with spinal cord injury (SCI).

Design: Community Survey (2011–2013) as part of the Swiss Spinal Cord Injury Cohort Study.

Setting: Community.

Participants: Individuals aged 16 years or older with traumatic or non-traumatic SCI permanently residing in Switzerland and using a wheelchair for moving around moderate distances (10–100?m).

Interventions: Not applicable.

Outcome Measures: Mobility-related items of the Spinal Cord Independence Measure-Self Report were matched to the three principal domains “changing basic body position,” “transferring oneself” and “moving around.” Binary outcomes (“independence” vs. “no independence”) were created for every domain and analyzed using multivariable logistic regression (adjusted for sex, socioeconomic factors, SCI characteristics, and health conditions).

Results: Regression analyses (N?=?949; 27% women; median age 51, interquartile range 41–61) showed a decline in the odds of independence (odds ratio; 95% confidence interval) with increasing age for “changing basic body position” (age 16–30 (reference), 31–45 (0.99; 0.53–1.83), 46–60 (0.64; 0.33–1.21), 61–75 (0.45; 0.22–0.92), 76+ (0.18; 0.07–0.44); P?Conclusions: Mobility independence was negatively associated with age in wheelchair users with SCI. Future longitudinal analyses are required to gain further insights into the causal factors for the age-related decline.     

Intensive Gait Treatment Using a Robot Suit Hybrid Assistive Limb in Acute Spinal Cord Infarction: Report of Two Cases

Context: Spinal cord infarction (SCI) causes gait disturbance because of paresis, spasticity, and sensory disturbance of the lower limbs. There is no effective medical treatment for SCI, and conventional rehabilitation alone is the main approach to helping individuals work toward independent walking. The aim of this study was to evaluate the effect of gait treatment using the Hybrid Assistive Limb (HAL) on acute SCI.

Findings: A 61-year-old female and a 62-year-old male with incomplete paraplegia participated in this study. Our study participants received gait treatment with HAL 3–4 times per week, with a total of 7–8 sessions (20 min), in addition to conventional physical therapy. The American Spinal Injury Association Impairment Scale, Lower Extremity Motor Score (LEMS), Modified Ashworth Scale (MAS), the Walking Index for Spinal Cord Injury (WISCI II), comfortable gait speed (CGS), stride, cadence, Barthel Index (BI), Functional Independence Measure (FIM), modified Rankin Scale (mRS), joint angles, and adverse effects were assessed prior to HAL treatment and post-HAL treatment. HAL facilitated intensive gait treatment in people during the acute phase after SCI. Improvements in LEMS, WISCI II, CGS, stride, cadence, BI, FIM, mRS, and joint angles were observed in both study participants. Furthermore, decreased spasticity in the gastrocnemius muscle was found in one participant as assessed by MAS.

Conclusion: Gait treatment using HAL may be beneficial for paraplegic, non-ambulatory individuals with acute SCI. HAL may be useful for intensive gait treatment without increasing spasticity.     

A brief fall prevention intervention for manual wheelchair users with spinal cord injuries: A pilot study

Objective: To conduct a pilot study of an intervention to decrease fall incidence and concerns about falling among individuals living with Spinal Cord Injury who use manual wheelchairs full-time.

Design: Pre/post. After a baseline assessment, a structured intervention was implemented. The assessment protocol was repeated 12 weeks after the baseline assessment.

Setting: Research laboratory and community.

Participants: 18 individuals living with SCI who use a manual wheelchair full-time with an average age of 35.78?±?13.89 years, lived with SCI for 17.06?±?14.6 years; 61.1% were female.

Intervention: A 1:1, 45 minute, in-person intervention focused on factors associated with falls and concerns about falling: transfers skills and seated postural control.

Outcome measures: Participants reported fall incidence and completed the Spinal Cord Injury Fall Concerns Scale, Community Participation Indicators and the World Health Organization Quality of Life – short version (WHOQOL-BREF). Transfer quality was assessed with the Transfer Assessment Instrument (TAI) and seated postural control with the Function In Seating Test (FIST).

Results: Recruitment, assessment and delivery of the intervention were successfully completed. After exposure to the intervention, fall incidence significantly decreased, (P?=?0.047, d_{z ?}=?0.507) and FIST scores improved (P?=?0.035, d_z? =?0.54). Significant improvements were also found in the WHOQOL-BREF Physical (P?=?0.05, d_{z ?}=?1.566) and Psychological (P?=?0.040, d_{z ?}=?0.760) domains.

Conclusion: The feasibility of the structured intervention was established and the intervention has the potential to reduce fall incidence and improve quality of life among individuals living with SCI who use a wheelchair. Appropriately powered randomized controlled trials of the program are warranted.     

Muscle spasticity associated with reduced whole-leg perfusion in persons with spinal cord injury

Abstract

Objective

To determine the association between peripheral blood flow and spasticity in individuals with spinal cord injury (SCI).

Design

A cross-sectional study with measurements of muscle spasticity and whole-limb blood flow in individuals with SCI.

Setting

University of Texas at Austin and Brain & Spine Recovery Center, Austin, TX, USA.

Participants

Eighteen individuals (14 males and 4 females) with SCI were classified into high (N = 7), low (N = 6), and no (N = 5) spasticity groups according to the spasticity levels determined by the modified Ashworth scale scores.

Interventions

Whole-limb blood flow was measured in the femoral and brachial arteries using Doppler ultrasound and was normalized to lean limb mass obtained with dual-energy X-ray absorptiometry.

Outcome measures

Limb blood flow and muscle spasticity.

Results

Age, time post-SCI, and the American Spinal Injury Association impairment scale motor and sensory scores were not different among groups with different muscle spasticity. Femoral artery blood flow normalized to lean leg mass was different (P = 0.001) across the three spasticity groups (high 78.9 ± 16.7, low 98.3 ± 39.8, no 142.5 ± 24.3 ml/minute/kg). Total leg muscle spasticity scores were significantly and negatively correlated with femoral artery blood flow (r = ?0.59, P < 0.01). There was no significant difference in brachial artery blood flow among the groups.

Conclusions

Whole-leg blood flow was lower in individuals with greater spasticity scores. These results suggest that a reduction in lower-limb perfusion may play a role, at least in part, in the pathogenesis leading to muscle spasticity after 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.     

Reference for the 2011 revision of the international standards for neurological classification of spinal cord injury

Abstract

The latest revision of the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) was available in booklet format in June 2011, and is published in this issue of the Journal of Spinal Cord Medicine. The ISNCSCI were initially developed in 1982 to provide guidelines for the consistent classification of the neurological level and extent of the injury to achieve reliable data for clinical care and research studies. This revision was generated from the Standards Committee of the American Spinal Injury Association in collaboration with the International Spinal Cord Society's Education Committee. This article details and explains the updates and serves as a reference for these revisions and clarifications.     

Comparison of Rehabilitation Outcomes in Violent Versus Non-violent Traumatic SCI

Abstract

This paper represents the results of a cohort study comparing functional outcomes of individuals with violent and non-violent traumatic spinal cord injury (SCI) following inpatient rehabilitation. Twenty-seven consecutive patients with a diagnosis of traumatic SCI of violent etiology (gunshot wound, stabbing or assault) and 27 patients with non-violent etiology (motor vehicle accident and falls) were matched for neurological level of injury and classification. Demographic comparison of violent versus non-violent groups revealed mean age 30 versus 39, gender 93 percent versus 78 percent male, race 89 percent versus 59 percent non-white, 74 percent versus 41 percent unmarried and 56 percent versus 22 percent unemployed, respectively. Violent and non-violent traumatic SCI groups had similar lengths of stay, admission and discharge functional independent measures (FIM), FIM improvement, payor sources, hospital charges and discharge to home rates. Despite the differences noted in the demographics of violent and non-violent traumatic SCI, these two matched groups achieved similar functional outcomes and discharge disposition following inpatient rehabilitation. (J Spinal Cord Med 1998;21:32-36)     

Reliability of the sit-up test in individuals with spinal cord injury

Abstract

Objective

To determine the day-to-day reliability of blood pressure responses during a sit-up test in individuals with a traumatic spinal cord injury (SCI).

Design

Within-subject, repeated measures design.

Setting

Community outpatient assessments at a research laboratory at the University of British Columbia.

Participants

Five men and three women with traumatic SCI (age: 31 ± 6 years; C4-T11; American Spinal Injury Association Impairment Scale A-B; 1–17 years post-injury).

Outcome measure

Maximum change in systolic (ΔSBP) and diastolic (ΔDBP) blood pressure upon passively moving from a supine to seated position.

Results

The average values for ΔSBP were –11 ± 13 mmHg (range –38 to 3 mmHg) for visit 1, and ?12 ± 8 mmHg (range ?26 to ?1 mmHg) for visit 2. The average values for ΔDBP were ?9 ± 8 mmHg (range -21 to 0 mmHg) for visit 1, and –13 ± 8 mmHg (range –29 to –3 mmHg) for visit 2. The ΔSBP demonstrated substantial reliability with an intraclass correlation coefficient of 0.79 (P = 0.006; 95% CI 0.250–0.953), while the ΔDBP demonstrated almost perfect reliability with an intraclass correlation coefficient of 0.92 (P < 0.001; 95% CI 0.645–0.983). The smallest detectable differences in ΔSBP and ΔDBP were 7 mmHg and 6 mmHg, respectively.

Conclusion

Blood pressure responses to the sit-up test are reliable in individuals with SCI, which supports its implementation as a practical bedside assessment for orthostatic hypotension in this at risk population.