Functional neuromuscular stimulation in spinal cord injury

With recent advances in clinical medicine and biomedical engineering, functional neuromuscular stimulation (FNS) can now be added to the psychiatric armamentarium to decrease the debilitating effects of traumatic spinal cord injury. In this article, the components of FNS systems and their evolution in design are presented. The clinical implications of FNS are discussed with respect to upper and lower extremities and bladder applications, and perspectives on future developments and directions are reviewed.     

Functional neuromuscular stimulation for standing after spinal cord injury

A study was undertaken to determine if functional neuromuscular stimulation could be used to obtain standing in patients with traumatic spinal cord injury. Twenty-five subjects were selected during the study, and standing was accomplished in 21 using bilateral quadriceps stimulation with the hips in hyperextension. Four subjects elected not to continue participation to the point of standing. Stimulation parameters were 0 to 120V pulse amplitude, frequency 13Hz or 20Hz, and pulse width of 0.4msec. Confirmation of standing with support of 95% of the body weight by the legs was verified by quantitative measurements with a dual-scale force platform or a biomechanics force platform. Subjects initially selected had injury levels between C7 and T11 and ranged in age from 22 to 47 years, with duration of injury from one to 13 years. The subjects had complete lesions, with no active motor function below the last normal level, and absent sensation or partial sparing of sensation with vague perception of pinprick, but no position sense. Six subjects stood at home and 15 stood only in the laboratory. This five-year experience indicates that paraplegic individuals may obtain standing with functional neuromuscular stimulation.     

Neurotransmitters in spinal cord injury.

The authors report the distribution of acetylcholinesterase activity and catecholamine fluorescence in the intact and completely transected rat spinal cord. The catecholamine terminals were scarce in the posterior horn and abundant in the intermediale and anterior horn regions. In the thoracic region, intense amine fluorescence was seen in the intermediolateral cell column. Spinal transection resulted in the enhancement of fluorescence above the lesion and disappearance below the lesion within seven days. The cholinesterase activity in the controls was found mostly in the anterior horn region and the tip of the posterior horn. Following transection, there was no significant change in the distribution of this enzyme. These changes correlated with the appearance of spasticity.     

Neonatal spinal cord injury.

In this review of the prognosis of patients having neonatal spinal cord injury, findings in 3 patients and 11 case histories from the literature are evaluated as to obstetric complications, clinical and pathologic examinations, and follow-up data from 2 to 12 years, or until death of the child. Eight of the 14 patients died: 4 at less than 3 months of age, 3 between 3 months and 1 year of age, and 1 at 3 1/2 years of age. Six children survived for more than 2 years for follow-up examination. Survival is dependent on the level of the lesion, with cervical lesions being almost incompatible with life. The quality of survival for those with levels of C8-T1 and below depends on the child's multiple medical complications.     

Sexual function and infertility following spinal cord injury

Changes in sexual function and fertility frequently occur following spinal cord injury (SCI). This article presents an overview of human sexual response and the changes that occur in that response following SCI. This article addresses the issues of childbearing for women with SCI, erectile function for men with SCI, and the issues of fertility and parenting for men and women with SCI.     

Preserved cardiac function after chronic spinal cord injury

OBJECTIVE: To assess the effect of chronic deconditioning on cardiac dimensions and function in subjects with high-level spinal cord injury (SCI), who represent a human in-vivo model of extreme inactivity. DESIGN: Cross-sectional study. SETTING: University medical center. PARTICIPANTS: Seven men with tetraplegia and 7 able-bodied controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Echocardiographic measurements of resting cardiac dimensions, systolic function, and global and long-axis diastolic function. RESULTS: Left ventricular mass index was significantly lower in the subjects with SCI than in the controls (90.8+/-26 g/m(2) vs 122+/-28.9 g/m(2); P=.05). In addition, dimensions of left ventricle, left atrium, and vena cava inferior were all significantly reduced in the subjects with SCI compared with controls (P<.05). There were no differences between the groups for any of the parameters reflecting systolic and global and long-axis diastolic function. CONCLUSIONS: Tetraplegia is associated with a reduction in cardiac mass and dimensions. Resting diastolic and systolic function is not altered with continued exposure to inactivity, however, which suggests a remodeling of the heart as a physiologic adaptive process.     

Rehabilitation in spinal cord disorders. 3. Comprehensive management of spinal cord injury

This self-directed learning module highlights advances in the management of the person with a spinal cord deficit. Traumatic spinal cord injury is being used as the model, but the principles apply to all patients with spinal cord deficits. This article is part of the chapter on rehabilitation of spinal cord disorders for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. Specifically, this section contains information regarding prehospital care, acute assessment and management, primary rehabilitation by systems, sexuality and psychosocial issues, management of pain and spasticity, functional goals, the role of functional electrical stimulation, and long-term follow-up.     

脊髓损伤后膀胱功能的量表评定

本文介绍一种脊髓损伤后膀胱功能的评定量表 ,该量表根据患者不同的膀胱功能状态和不同的膀胱排空方式 ,将膀胱功能分为5个等级 ,能体现脊髓损伤后膀胱功能改善的细微变化 ,内容科学、简便实用 ,有临床应用价值。     

Pain assessment in spinal cord injury.

Pain management is a serious problem for individuals with spinal cord injury (SCI). Recent developments in pain assessment indicate that multiaxial approaches, assessing medical, psychosocial, and behavioral/functional dimensions, are necessary to measure adequately the impact of chronic pain. The application of this multiaxial system to persons with SCI and chronic pain is presented. A review of the literature indicates that the psychometric properties and test utility for most pain measures have not been established for persons with SCI. The assessment task is further confounded by the functional limitations and psychosocial impairments that may accompany SCI. Recommendations are made for adapting established pain measures for use with SCI individuals. The choice of assessment tools for these patients is guided by the multidimensional nature of the pain experience, functional limitations, and the goals of treatment.     

Fatigue after spinal cord injury.

OBJECTIVES: To identify variables increasing fatigue following spinal cord injury (SCI) and their functional consequences. METHODS: A search of the Medline and Reedoc databases with the keywords SCI, fatigue, intrinsic muscular fatigue, chronic fatigue, aging, training, electrostimulation, quality of life and the same words in French. RESULTS: Two kinds of fatigue are identified following SCI. Intrinsic fatigue in muscles totally or partially paralysed at the level of or below the spinal cord lesion; this peripheral fatigue is due to denervation, total or partial loss of motoneurons, or histological and metabolical changes in muscle; it is well-defined by electrophysiological technology; spasticity and spasms have little influence on its development; it is reversible in part with long term electrostimulation, but at this time, electroneuroprosthetic techniques do not reduce the excessive energetic cost to stand up and walk. Chronic fatigue appears in the long term following SCI; it is linked with aging, physiological, and psychological deconditioning; some data point to chronic fatigue after SCI similar to post-polio syndrome and chronic fatigue syndrome, which may explain the central nature of the fatigue; training programs could be useful in delaying this chronic fatigue and as a consequence, increasing the latent quality of life. CONCLUSION: Muscular intrinsic fatigue after SCI is always of a peripherical nature in muscles partially or totally paralysed. Chronic fatigue during aging greatly decreases quality of life. Both intrinsic and chronic fatigue could be anticipated by electrostimulation technique on the one hand and long term training on the other.     

Employment after spinal cord injury.

The purpose of this study was to compare preinjury and postinjury employment rates in a diverse sample of persons with spinal cord injuries. Several employment variables were compared in individuals grouped into cohorts based on injury level, chronologic age, age at injury, time since injury, and years of education. The study sample (N = 286) was highly educated (mean = 14.2 years of education) and was an average of 18.6 years postinjury. Forty-eight percent of the participants were working at the time of the study, and 75% had worked at some time since injury. Only 12% of the persons who were employed at the time of injury returned to the same job after injury. Several noteworthy findings among the groups were: (1) participants with paraplegia were more likely than those with quadriplegia to return to their preinjury jobs; (2) employment rates were dramatically lower in the 51- to 60-year group; (3) more than 85% of persons in the cohorts who were at least 21 years postinjury had worked at some time since injury; (4) younger age at injury was associated with higher current employment rates; and (5) nearly 95% of all participants with 16 or more years of education had worked at some point since injury. The study results reaffirmed the need for comprehensive rehabilitation, identified the need for retraining several years after injury, and pointed to the role of higher education in producing high employment rates.     

Renal function in spinal cord injury: a preliminary report

To investigate the effect of current bladder management techniques on renal function in spinal cord injury (SCI), we followed 99 patients by frequent examinations, excretory urograms, and iothalamate short renal clearances. Fifty-eight percent of the subjects emptied their bladders by catheter-free methods (bladder retrained), 32% by intermittent self-catheterization, and 10% by indwelling urethral catheters. All remained clinically well, but more and earlier excretory urogram abnormalities occurred in the intermittent self-catheterization group. Twenty-one percent of the intermittent self-catheterization group but only 5% of the bladder retrained group had excretory urogram abnormalities. Declines of more than 10% in short renal clearance values were noted in 30% of intermittent self-catheterization patients and in 15% of bladder retrained patients. Our preliminary data support the need for close surveillance and follow-up after SCI rehabilitation, even in patients appearing clinically well. These data also suggest that renal function can be preserved with current bladder management methods, with bladder retraining having a slight edge over intermittent self-catheterization.     

Increased aerobic fitness after neuromuscular electrical stimulation training in adults with spinal cord injury

Carty A, McCormack K, Coughlan GF, Crowe L, Caulfield B. Increased aerobic fitness after neuromuscular electrical stimulation training in adults with spinal cord injury.ObjectivesTo evaluate the efficacy of a novel neuromuscular electrical stimulation (NMES) system for improving aerobic fitness in individuals with spinal cord injury (SCI). It was hypothesized that training with this NMES system would increase peak oxygen consumption (Vo₂peak) and peak heart rate (HRpeak) in a sedentary adult SCI population.DesignProspective cohort study.SettingAll testing took place at a university human performance laboratory.ParticipantsVolunteer participants with SCI (N=16; T4-11 American Spinal Injury Association Impairment Scale grades A and B) were recruited from the national SCI outpatient and outreach service databases. All completed the training program, but results from 2 participants were excluded because posttraining tests were invalid. Therefore, 14 participants (11 men, 3 women) completed the program and testing.InterventionsFour electrodes (175cm²) were placed bilaterally on the quadriceps and hamstrings muscle groups, and subtetanic contractions were elicited using an NMES device. Training was undertaken unsupervised at home for 1 hour, 5d/wk for 8 weeks.Main Outcome MeasuresAn incremental treadmill wheelchair propulsion exercise test with simultaneous cardiopulmonary gas exchange analysis was used to determine Vo₂peak and HRpeak.ResultsA statistically significant increase in Vo₂peak (P=.001) and HRpeak (P=.032) between baseline and follow-up was observed.ConclusionsThis novel form of NMES is an effective method of improving aerobic fitness in an SCI population. Results are comparable to those with current functional electrical stimulation exercise systems.     

Relation of disability costs to function: spinal cord injury

OBJECTIVE: This study evaluated the validity of the Functional Independence Measure (FIM instrument) in predicting (1) the number of minutes of daily assistance provided, (2) the cost of durable goods currently used, and (3) the number of paid helper hours provided daily to persons with spinal cord injury living in the community. DESIGN: A cross-sectional study. SUBJECTS: One hundred nine persons with spinal cord injury who were a median 6 years postdischarge from initial medical rehabilitation. RESULTS: A significant inverse linear relationship was observed between FIM scores and the square root values of the three cost-related measures. The FIM-18 and the FIM motor scores were the best single predictors of the square root of minutes of assistance (paid and/or unpaid) per day, explaining 85% of variance. The FIM motor measure was the best single predictor of square root of cost of durable goods, explaining 29% of variance. The Self-Care, FIM motor, and FIM-18 scores equally predicted square root of hours of paid help per day, explaining 58% of variance. CONCLUSION: The findings indicate FIM-related scores predict the amount of assistance needed and certain costs for persons with spinal cord injury disability.     

Pulmonary function testing in spinal cord injury: effects of abdominal muscle stimulation.

The purpose of this study was to assess the effects of applying transcutaneous electrical stimulation to paralyzed abdominal muscles during pulmonary function testing (PFT) of individuals with spinal cord injury (SCI). Ten male subjects with anatomical level of SCI between C5-T7 were studied. Subjects performed PFTs with and without electrical stimulation delivered to the abdominal muscles. Subjects with the lowest percentage of predicted expiratory volumes and flows demonstrated the greatest improvement when electrical stimulation was delivered during forced expiration. The overall increases seen in percent of predicted for the study sample were 23 percent for forced vital capacity (FVC), 16 percent for forced expiratory flow in 1 s (FEV1), and 22 percent for peak expiratory flow rate (PEF). Contractions of paralyzed expiratory muscles in response to electrical stimulation during the performance of PFT maneuvers can significantly improve FVC, FEV1, and PEF in some individuals with SCI.     

脊髓损伤前后肠道功能的变化

目的：研究脊髓损伤前后肠道功能的变化。方法：采用面对问卷调查方式对70例脊髓损伤患者进行有关肠道功能的问卷调查。结果：脊髓损伤前后患者在肠道症状、排便频率及耗时、排便成功率、依赖程度、辅助手段等方面有高度显著性差异。结论：脊髓损伤后肠道功能改变有较高的发生率，应积极开展肠道管理。     

Rehabilitation in spinal cord injury

Caring for the new quadriplegic is an immense undertaking involving multiple health care professionals who must function as a team. The physician in charge must understand rehabilitation principles and be able to communicate with all members of the team caring for the patient. Rehabilitation principles, if considered early, can greatly decrease the length of stay of the patient and allow him to maximize his potential for recovery. A basic knowledge of physicial and occupational therapy in paraplegia and quadriplegia in the acute stage as well as functional expectations in the long term have been presented.