Characterizing Natural Recovery of People With Initial Motor Complete Tetraplegia

ObjectiveTo determine the differences in neurologic recovery in persons with initial cervical American Spinal Cord Injury Association Impairment Scale (AIS) grades A and B over time.DesignRetrospective analysis of data from people with traumatic cervical spinal cord injury (SCI) enrolled in the National Spinal Cord Injury Model Systems (SCIMS) database from 2011-2019.SettingSCIMS centers.ParticipantsIndividuals (N=187) with traumatic cervical (C1-C7 motor level) SCI admitted with initial AIS grade A and B injuries within 30 days of injury, age 16 years or older, upper extremity motor score (UEMS) ≤20 on both sides, and complete neurologic data at admission and follow-up between 6 months and 2 years.InterventionsNot applicable.Main Outcome MeasuresConversion in AIS grades, UEMS and lower extremity motor scores (LEMS), and sensory scores.ResultsMean time to initial and follow-up examinations were 16.1±7.3 days and 377.5±93.4 days, respectively. Conversion from an initial cervical AIS grades A and B to motor incomplete status was 13.4% and 50.0%, respectively. The mean UEMS change for people with initial AIS grades A and B did not differ (7.8±6.5 and 8.8±6.1; P=.307), but people with AIS grade B experienced significantly higher means of LEMS change (2.3±7.4 and 8.8±13.9 (P≤.001). The increased rate of conversion to motor incomplete status from initial AIS grade B appears to be the primary driving factor of increased overall motor recovery. Individuals with initial AIS grade B had greater improvement in sensory scores.ConclusionsWhile UEMS recovery is similar in persons with initial AIS grades A and B, the rate of conversion to motor incomplete status, LEMS, and sensory recovery are significantly different. This information is important for clinical as well as research considerations.     

Late neurologic recovery after traumatic spinal cord injury

OBJECTIVE: To present Model Spinal Cord Injury System (MSCIS) data on late neurologic recovery after 1 year after spinal cord injury (SCI). DESIGN: Longitudinal study of neurologic status as determined by annual evaluations at 1 and 5 years postinjury. SETTING: MSCIS centers contributing data on people with traumatic SCI to the National Spinal Cord Injury Statistical Center database. PARTICIPANTS: People with traumatic SCI (N=987) admitted to an MSCIS between 1988 and 1997 with 1- and 5-year follow-up examinations. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: American Spinal Injury Association (ASIA) Impairment Scale (AIS) classification, motor index scores (MIS), motor level, and neurologic level of injury (NLI), measured and compared for changes over time. RESULTS: The majority of subjects (94.4%) who had a neurologically complete injury at 1 year remained complete at 5 years postinjury, with 3.5% improving to AIS grade B, and up to 1.05% each improving to AIS grades C and D. There was a statistically significant change noted for MIS. There were no significant changes for the motor level and NLI over 4 years; however, approximately 20% of subjects improved their motor level and NLI. People with complete and incomplete injuries had similar improvements in motor level, but subjects with an incomplete injury had a greater chance of improvement in NLI and MIS. CONCLUSIONS: There was a small degree of neurologic recovery (between 1 and 5 y postinjury) after a traumatic SCI. Late conversion, between 1 and 5 years, from a neurologically complete to an incomplete injury occurred in 5.6% of cases, but in only up to 2.1% was there a conversion from motor complete to motor incomplete status. Limitations of this study included changes in the ASIA classification during the study and in the intra- and interrater reliability typically seen in longitudinal studies of the ASIA standards. Functional changes were not studied. Knowledge of the degree of late recovery may help in analyzing newer interventions to enhance recovery.     

A new instrument for outcome assessment in rehabilitation medicine: Spinal cord injury ability realization measurement index

OBJECTIVES: To introduce a new measure of disability weighted for the neurologic deficit in patients with spinal cord lesions and to examine the effect on the instrument of being in rehabilitation. DESIGN: Development of instrument and preliminary comparative before-after study. SETTING: Spinal department in a rehabilitation hospital in Israel. PARTICIPANTS: Seventy-nine patients with spinal cord lesions. INTERVENTIONS: Patients were repeatedly assessed during rehabilitation with the American Spinal Injury Association Impairment Scale (AIS) to measure neurologic motor impairment and with the Spinal Cord Independence Measure (SCIM-II) to measure disability. Scores of the 2 assessments were combined to create the Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI). MAIN OUTCOME MEASURES: A preliminary formula for the calculation of SCI-ARMI using the individual patients' SCIM-II and AIS motor scores and changes in SCI-ARMI values through rehabilitation. RESULTS: The highest observed SCIM-II scores at patients' AIS level correlated highly with the AIS motor scores (r=.96, P<.01). A regression performed for this linear relationship resulted in a preliminary SCI-ARMI formula. The calculated SCI-ARMI values improved during rehabilitation irrespective of patient age, gender, lesion level, or lesion severity (P<.001). CONCLUSIONS: The preliminary version of the SCI-ARMI can be used to assess quantitatively changes in functional ability, isolating them from the effect of neurologic changes.     

Relationship Between ASIA Examination and Functional Outcomes in the NeuroRecovery Network Locomotor Training Program

Buehner JJ, Forrest GF, Schmidt-Read M, White S, Tansey K, Basso DM. Relationship between ASIA examination and functional outcomes in the NeuroRecovery Network Locomotor Training Program.ObjectiveTo determine the effects of locomotor training on: (1) the International Standards for Neurological Classification of Spinal Cord Injury examination; (2) locomotion (gait speed, distance); (3) balance; and (4) functional gait speed stratifications after chronic incomplete spinal cord injury (SCI).DesignProspective observational cohort.SettingOutpatient rehabilitation centers in the NeuroRecovery Network (NRN).ParticipantsIndividuals (n=225) with American Spinal Injury Association Impairment Scale (AIS) grade C or D chronic motor incomplete SCI having completed locomotor training in the NRN.InterventionThe NRN Locomotor Training Program consists of manual-facilitated body weight–supported standing and stepping on a treadmill and overground.Main Outcome MeasuresAIS classification, lower extremity pin prick, light touch and motor scores, ten-meter walk and six-minute walk tests, and the Berg Balance Scale.ResultsSignificant gains occurred in lower extremity motor scores but not in sensory scores, and these were only weakly related to gait speed and distance. Final Berg Balance Scale scores and initial lower extremity motor scores were positively related. Although 70% of subjects showed significantly improved gait speed after locomotor training, only 8% showed AIS category conversion.ConclusionsLocomotor training improves gait speed to levels sufficient for independent in-home or community ambulation after chronic motor incomplete SCI. Changes in lower extremity motor and sensory scores do not capture the full extent of functional recovery, nor predict responsiveness to locomotor training. Functional classification based on gait speed may provide an effective measure of treatment efficacy or functional improvement after incomplete SCI.     

Gait training in human spinal cord injury using electromechanical systems: effect of device type and patient characteristics

Benito-Penalva J, Edwards DJ, Opisso E, Cortes M, Lopez-Blazquez R, Murillo N, Costa U, Tormos JM, Vidal-Samsó J, Valls-Solé J, European Multicenter Study about Human Spinal Cord Injury Study Group, Medina J. Gait training in human spinal cord injury using electromechanical systems: effect of device type and patient characteristics.ObjectiveTo report the clinical improvements in spinal cord injury (SCI) patients associated with intensive gait training using electromechanical systems according to patient characteristics.DesignProspective longitudinal study.SettingInpatient SCI rehabilitation center.ParticipantsAdults with SCI (n=130).InterventionPatients received locomotor training with 2 different electromechanical devices, 5 days per week for 8 weeks.Main Outcome MeasuresLower-extremity motor score, Walking Index for Spinal Cord Injury, and 10-meter walking test data were collected at the baseline, midpoint, and end of the program. Patients were stratified according to the American Spinal Injury Association (ASIA) category, time since injury, and injury etiology. A subgroup of traumatic ASIA grade C and D patients were compared with data obtained from the European Multicenter Study about Human Spinal Cord Injury (EM-SCI).ResultsOne hundred and five patients completed the program. Significant gains in lower-limb motor function and gait were observed for both types of electromechanical device systems, to a similar degree. The greatest rate of improvement was shown in the motor incomplete SCI patients, and for patients <6 months postinjury. The positive response associated with training was not affected by injury etiology, age, sex, or lesion level. The trajectory of improvement was significantly enhanced relative to patients receiving the conventional standard of care without electromechanical systems (EM-SCI).ConclusionsThe use of electromechanical systems for intensive gait training in SCI is associated with a marked improvement in lower-limb motor function and gait across a diverse range of patients and is most evident in motor incomplete patients, and for patients who begin the regimen early in the recovery process.     

A Concordance Table to Convert FIM Basic Mobility and Self-Care Scale Scores to SCI-FI/AT Scores

ObjectiveTo estimate Spinal Cord Injury Functional Index Assistive Technology (SCI-FI/AT) scores from FIM motor items.DesignSecondary data analysis.SettingFourteen Spinal Cord Injury Model Systems (SCIMS) programs.ParticipantsPersons with traumatic spinal cord injury (SCI) discharged from inpatient rehabilitation at 14 SCIMS programs (N=1237).InterventionsNot applicable.Main Outcome MeasuresFIM motor items were matched to SCI-FI/AT domains and summary scores for each measure were developed. The kernel-based method was employed to develop a concordance table to estimate SCI-FI/AT domain summary scores from content-matched FIM motor item summary scores. We conducted analyses to compare agreement between actual SCI-FI/AT summary scores (actual SCI-FI/AT_S) and estimated SCI-FI/AT summary scores (est-SCI-FI/AT_S) for the total sample and for participants with different SCI injury categories.ResultsNine FIM items matched SCI-FI/AT basic mobility and self-care domain content. Pearson correlations for actual and est-SCI-FI/AT_S scores (0.79) were adequate for using concordance linking methods. Intraclass correlation coefficient values (0.79; 95% confidence interval, 0.77-0.81) indicated moderate reliability. t tests revealed no significant differences between actual and est-SCI-FI/AT_S scores in the total sample. For almost 60% of the sample, actual and est-SCI-FI/AT_S score differences were <5 points (half of a SD). Greater differences between actual and est-SCI-FI/AT_S scores were noted for persons with tetraplegia American Spinal Injury Association Impairment Scales (AISs) A, B, and C.ConclusionsDespite differences between the FIM and SCI-FI/AT assessments, we developed a concordance table to estimate self-care and basic mobility SCI-FI/AT scores from content-matched FIM motor item scores. This concordance table allows researchers to merge FIM data with SCI-FI/AT data to analyze SCI functional outcomes at the group level. However, owing to greater differences between actual and estimated scores, the concordance table should be used with caution to interpret scores for those with cervical-level injuries AISs A, B, C.     

Interrater reliability of the international standards for neurological classification of spinal cord injury in youths with chronic spinal cord injury

Mulcahey MJ, Gaughan JP, Chafetz RS, Vogel LC, Samdani AF, Betz RR. Interrater reliability of the International Standards for Neurological Classification of Spinal Cord Injury in youths with chronic spinal cord injury.

Objectives

To evaluate the interrater reliability of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) in children with chronic spinal cord injury (SCI), and to define the lower age limit at which the examinations have clinical utility.

Design

Repeated measures, multicenter reliability study.

Setting

Two U.S. pediatric specialty hospitals with recognized SCI programs.

Participants

Children (N=236) with chronic SCI.

Interventions

Subjects underwent 4 examinations by 2 raters: sensory tests (pin prick [PP] and light touch [LT]), a motor test, and a test of anal sensation (AS) and anal contraction (AC).

Main Outcome Measures

A 2-way general linear model analysis of variance was used for analysis. Intraclass correlation coefficients (ICCs) and 95% confidence intervals were calculated for PP, LT, motor, AS, and AC.

Results

No child younger than 6 years completed the examination. When examined as a function of age, interrater reliability for motor, PP, LT, AS, and AC was moderate (ICC=.89) to high (ICC=.99). There was poor reliability for AS (ICC=.49) in subjects with complete injuries but moderate reliability for all other variables. There was moderate to high reliability for classification of type (tetraplegia/paraplegia) and severity (complete/incomplete) of injury across age groups.

Conclusions

The ISNCSCI does not have utility for children younger than 6 years. For children older than 6 years, interrater reliability of PP, LT, and motor examinations is high.     

Longitudinal patterns of functional recovery in patients with incomplete spinal cord injury receiving activity-based rehabilitation

Lorenz DJ, Datta S, Harkema SJ. Longitudinal patterns of functional recovery in patients with incomplete spinal cord injury receiving activity-based rehabilitation.ObjectiveTo model the progression of 3 functional outcome measures from patients with incomplete spinal cord injury (SCI) receiving standardized locomotor training.DesignObservational cohort.SettingThe NeuroRecovery Network (NRN), a specialized network of treatment centers providing standardized, activity-based therapy for SCI patients.ParticipantsPatients (N=337) with incomplete SCI (grade C or D on the International Standards for Neurological Classification of Spinal Cord Injury scale) who were enrolled in the NRN between February 2008 and March 2011.InterventionAll enrolled patients received standardized locomotor training sessions, as established by NRN protocol, and were evaluated monthly for progress.Main Outcome MeasuresBerg Balance Scale, 6-minute walk test, and 10-meter walk test. Progression over time was analyzed via the fitting of linear mixed effects models.ResultsThere was significant improvement on each outcome measure and significant attenuation of improvement over time. Patients varied significantly across groups defined by recovery status and American Spinal Injury Association Impairment Scale (AIS) grade at enrollment with respect to baseline performance and rates of change over time. Time since SCI was a significant determinant of the rate of recovery for all measures.ConclusionsLocomotor training, as implemented in the NRN, results in significant improvement in functional outcome measures as treatment sessions accumulate. Variability in patterns of recovery over time suggest that time since SCI and patient functional status at enrollment, as measured by the Neuromuscular Recovery Scale, are important predictors of performance and recovery as measured by the targeted outcome measures.     

Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the national spinal cord injury database

Marino RJ, Burns S, Graves DE, Leiby BE, Kirshblum S, Lammertse DP. Upper- and lower-extremity motor recovery after traumatic cervical spinal cord injury: an update from the National Spinal Cord Injury Database.

Objective

To present upper- (UEMS) and lower-extremity motor score (LEMS) recovery, American Spinal Injury Association Impairment Scale (AIS) change, and motor level change in persons with traumatic tetraplegia from the Spinal Cord Injury Model Systems (SCIMS).

Design

Longitudinal cohort; follow-up to 1 year.

Setting

U.S. SCIMS.

Participants

Subjects (N=1436; age>15y) with tetraplegia with at least 2 examinations, the first within 7 days of injury. Subjects were 80% men injured by vehicular collisions (44%), falls (30%), sports (12%), and violence (11%).

Interventions

Not applicable.

Main Outcome Measures

Change in AIS, UEMS, LEMS, and motor levels.

Results

From a baseline of 7 days or less, 22% of subjects with AIS grade A converted to AIS grade B or better by rehabilitation discharge; and 30%, by 1 year, with 8% to AIS grade C and 7.1% to grade D. Conversion from complete to motor incomplete was not related to timing of the initial examination (P=.54) or initial neurologic level (P=.96). For AIS grade B, 34% remained motor complete, 30% became AIS grade C, and 37% became grade D by 1 year. Although 82.5% of those with AIS grade C improved to AIS grades D and E, mean 1-year UEMS score was only 35 points. UEMS scores in patients with AIS grade A increased a mean of 9 to 11 points, except for C1 to C3 and C8 to T1 motor levels (gain, 2–3 points). Motor level was unchanged or ascended in 35% and improved 1 level in 42%, 2 levels in 14%, and more than 2 levels in 9%. Motor zone of partial preservation of 2 segments or more was associated with gain of 2 or more motor levels, with a relative risk of 5.0 (95% confidence interval, 3.2–7.8; P<.001).

Conclusions

More patients with cervical complete spinal cord injury may be converting to AIS grade D compared with earlier reports. Motor level recovery in those with AIS grade A and UEMS recovery in those with AIS grade C injuries are potential outcomes for acute clinical trials.     

Neurologic recovery after traumatic spinal cord injury: data from the Model Spinal Cord Injury Systems

OBJECTIVE: To present data on neurologic recovery gathered by the Model Spinal Cord Injury (SCI) Systems over a 10-year period. DESIGN: Case series. SETTING: Twenty-one Model SCI Systems. PATIENTS: A total of 3,585 individuals with traumatic SCI admitted between January 1, 1988 and December 31, 1997. MAIN OUTCOME MEASURES: Neurologic impairment category; Frankel grade; American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade; motor score. RESULTS: SCI caused by violence is more likely than SCI from nonviolent etiologies to result in a complete injury. Changes in severity of injury were similar using the older Frankel scale and the newer ASIA Impairment Scale. Individuals who were motor-complete with extended zones of sensory preservation but without sacral sparing were less likely to convert to motor-incomplete status than those with sacral sparing (13.3% vs 53.6%; p < .001). Motor score improvements at 1 year were related to severity of injury, with greater increases for better AIS grades except grade D, because of ceiling effects. Individuals with AIS grade B injuries have a mixed prognosis. CONCLUSION: Neurologic recovery after SCI is influenced by etiology and severity of injury. Multicenter studies on prognostic features such as preserved pin sensation in grade B injuries may identify subgroups with similar recovery patterns. Identification of such groups would facilitate clinical trials for neurologic recovery in acute SCI.     

Cardiovascular Status of Individuals With Incomplete Spinal Cord Injury From 7 NeuroRecovery Network Rehabilitation Centers

Sisto SA, Lorenz DJ, Hutchinson K, Wenzel L, Harkema SJ, Krassioukov A. Cardiovascular status of individuals with incomplete spinal cord injury from 7 NeuroRecovery Network rehabilitation centers.ObjectiveTo examine cardiovascular (CV) health in a large cohort of individuals with incomplete spinal cord injury (SCI). The CV health parameters of patients were compared based on American Spinal Injury Association Impairment Scale (AIS), neurologic level, sex, central cord syndrome, age, time since injury, Neuromuscular Recovery Scale, and total AIS motor score.DesignCross-sectional study.SettingSeven outpatient rehabilitation clinics.ParticipantsIndividuals (N=350) with incomplete AIS classification C and D were included in this analysis.InterventionsNot applicable.Main Outcome MeasuresHeart rate, systolic and diastolic blood pressure during resting sitting and supine positions and after an orthostatic challenge.ResultsCV parameters were highly variable and significantly differed based on patient position. Neurologic level (cervical, high and low thoracic) and age were most commonly associated with CV parameters where patients classified at the cervical level had the lowest resting CV parameters. After the orthostatic challenge, blood pressure was highest for the low thoracic group, and heart rate for the high thoracic group was higher. Time since SCI was negatively related to blood pressure at rest but not after orthostatic challenge. Men exhibited higher systolic blood pressure than women and lower heart rate. The prevalence of orthostatic hypotension (OH) was 21% and was related to the total motor score and resting seated blood pressures. Cervical injuries had the highest prevalence.ConclusionsResting CV parameters of blood pressure and heart rate are affected by position, age, and neurologic level. OH is more prevalent in cervical injuries, those with lower resting blood pressures and who are lower functioning. Results from this study provide reference for CV parameters for individuals with incomplete SCI. Future research is needed on the impact of exercise on CV parameters.     

Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury

Behrman AL, Ardolino E, VanHiel LR, Kern M, Atkinson D, Lorenz DJ, Harkema SJ. Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury.ObjectiveTo develop a scale (Neuromuscular Recovery Scale [NRS]) for classification of functional motor recovery after spinal cord injury (SCI) based on preinjury movement patterns that would reduce variability of the populations' level of function within each class, because assessment of functional improvement after SCI is problematic as a result of high variability of the populations' level of function and the insensitivity to change within the available outcome measures.DesignProspective observational cohort with longitudinal follow-up.SettingSeven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).ParticipantsIndividuals (N=95) with American Spinal Injury Association Impairment Scale (AIS) grade C or AIS grade D having received at least 20 locomotor training treatment sessions in the NRN.InterventionsIntensive locomotor training including stepping on a treadmill with partial body weight support and manual facilitation and translation of skills into home and community activities.Main Outcome MeasuresBerg Balance Scale, six-minute walk test, and ten-meter walk test.ResultsIndividuals classified within each of the 4 phases of the NRS were functionally discrete, as shown by significant differences in the mean values of balance, gait speed, and walking endurance, and the variability of these measurements was significantly reduced by NRS classification. The magnitude of improvements in these outcomes was also significantly different among phase groups.ConclusionsAssessment with the NRS provides a classification for functional motor recovery without compensation, which reduces variability in performance and improvements for individuals with injuries classified as AIS grades C and D.     

Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury

OBJECTIVE: To compare neurologic, medical, and functional outcomes of patients with acute spinal cord injury (SCI) undergoing early (<24 h and 24-72 h) and late (>72 h) surgical spine intervention versus those treated nonsurgically. DESIGN: Retrospective case series comparing outcomes by surgical and nonsurgical groups during acute care, rehabilitation, and at 1-year follow-up. SETTING: Multicenter National Spinal Cord Injury Database. PARTICIPANTS: Consecutive patients with acute, nonpenetrating, traumatic SCI from 1995 to 2000, admitted in the first 24 hours after injury. Surgical spinal intervention was likely secondary to nature of injury and the need for spinal stabilization. Interventions Not applicable. MAIN OUTCOME MEASURES: Changes in neurologic outcomes (motor and sensory levels, motor index score, American Spinal Injury Association [ASIA] Impairment Scale [AIS]), medical complications (pneumonia and atelectasis, deep vein thrombosis and pulmonary embolism, pressure ulcers, autonomic dysreflexia, rehospitalization), and functional outcomes (acute and rehabilitation length of stay [LOS], hospital charges, FIM instrument score, FIM motor efficiency scores). RESULTS: Subjects in the early surgery group were more likely ( P <.05) to be women, have paraplegia, and have SCI caused by motor vehicle collisions. The nonsurgical group was more likely ( P <.05) to have an older mean age and more incomplete injuries. ASIA motor index improvements (from admission to 1-y follow-up) were more likely ( P <.05) in the nonsurgical groups, as compared with the surgical groups. Those with late surgery had significantly ( P <.05) increased acute care and total LOS and hospital charges along with higher incidence of pneumonia and atelectasis. No differences between groups were found for changes in neurologic levels, AIS grade, or FIM motor efficiency. CONCLUSIONS: ASIA motor index improvements were noted in the nonsurgery group, though likely related to increased incompleteness of injuries within this group. Early versus late spinal surgery was associated with shorter LOS and reduced pulmonary complications, however, no differences in neurologic or functional improvements were noted between early or late surgical groups.     

Falls During Inpatient Rehabilitation After Spinal Cord Injury: Characterization,Clock-Hour Visualization,and Time to Event Predictors

ObjectivesTo (1) determine fall characteristics (eg, cause, location, witnesses) of inpatients with spinal cord injury (SCI) and whether they were different for ambulatory persons vs wheelchair users; (2) visualize the total number of daily falls per clock-hour for different inpatients’ features (eg, cause of injury, age); (3) compare clinical and demographic characteristics of inpatients who experienced a first fall event vs inpatients who did not experience such event; and (4) identify first fall event predictors.DesignRetrospective observational cohort study.SettingInstitution for inpatient neurologic rehabilitation.ParticipantsPersons with SCI (N=1294) admitted to a rehabilitation facility between 2005 and 2022.InterventionsNot applicable.Main Outcome MeasuresFunctional independence measure (FIM), Hospital Anxiety and Depression Scale (HADS), American Spinal Injury Association Impairment Scale (AIS), and Spinal Cord Independence Measure (SCIM) at admission. Kaplan-Meier survival curves and Cox proportional hazards models were used.ResultsA total of 502 fall events were experienced by 369 ambulatory inpatients (19.8%) and wheelchair users (80.2%) in 63.9% of cases being alone, with cause, situation, and location significantly different in both groups. Clock-hour visualizations revealed an absolute peak at 12 AM (complete or incomplete injuries, with paraplegia or tetraplegia) but a relative peak at 9 AM mainly including incomplete patients with paraplegia. Of the (n=1294) included patients, 16.8% experienced at least 1 fall. Fallen patients reported higher levels of HADS depression, lower total SCIM, and longer time since injury to admission, with no differences in age, sex, educational level, FIM (quasi-significant), and AIS grade. Multivariable Cox proportional hazards identified time since injury to admission and AIS grade D as significant predictors of first fall event.ConclusionsFalls identification, characterization, and clock-hour visualization can support decisions for mitigation strategies specifically addressed to inpatients with SCI. Fall predictors were identified as a first step for future research.     

Recovery of Sensory and Supraspinal Control of Leg Movement in People With Chronic Paraplegia: A Case Series

Objective

To report on unexpected findings in 4 patients with chronic paraplegia who underwent the laparoscopic implantation of neuroprosthesis procedure in the pelvic lumbosacral nerves.

Design

Observational case series.

Setting

Tertiary referral unit specialized in advanced gynecological surgery and neuropelveology.

Participants

Three patients with incomplete American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade B (n=2) and AIS grade C (n=1) spinal cord injury (SCI) and 1 patient with flaccid complete chronic SCI (AIS grade A) (n=1).

Intervention

Functional electrical stimulation (FES)-assisted locomotor training and continuous low-frequency pelvic-lumbosacral neuromodulation.

Main Outcome Measures

Change in ASIA Lower Extremity Motor Scores, ASIA sensory scores for light touch and pinprick sensation, and Walking Index for Spinal Cord Injury scores.

Results

All 4 patients developed progressive recovery of some sensory and voluntary motor functions below the lesions. Three are currently capable of voluntary weight-bearing standing and walking a few meters with a walker without FES. The first patient with the longest follow-up is even capable of electrically assisted standing/walking with 2 crutches without braces or assistance for a distance of about 900 meters, and of weight-bearing standing and walking for 30 meters with a walker without stimulation.

Conclusions

We report unexpected sensory and locomotor recovery in 4 people with paraplegia with SCI. Our findings suggest that FES-assisted locomotor training with continuous low-frequency pelvic nerve stimulation in patients with SCI may induce changes that affect the central pattern generator and allow supra- and infraspinal inputs to engage residual spinal pathways.     

Effects of gender on neurologic and functional recovery after spinal cord injury

OBJECTIVE: To assess gender differences in neurologic and functional outcome measures in persons with spinal cord injury (SCI). DESIGN: Case series. SETTINGS: Model Spinal Cord Injury Systems (MSCIS) throughout the United States. PARTICIPANTS: People (N=14,433) admitted to an MSCIS within 30 days of injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Improvement in American Spinal Injury Association (ASIA) motor index score, ASIA Impairment Scale, level of injury, and FIM instrument scores after SCI. RESULTS: When examining subjects grouped by severity of injury, changes in ASIA motor index total scores, from system admission to 1-year anniversary, were significantly greater for women than men with either complete ( P =.035) or incomplete ( P =.031) injuries. Functional comparison of men and women, using the FIM motor subscale, revealed that men had higher FIM motor scores at rehabilitation discharge among those with motor-complete injuries, except for those with C1-4 and C6 neurologic levels. Women with motor-incomplete high tetraplegia (C1-4 levels) had higher discharge FIM motor scores than did similarly afflicted men. There were no significant differences in FIM motor scores among men and women with other levels of motor incomplete SCI. CONCLUSIONS: Gender differences in SCI were seen in several areas. Women may have more natural neurologic recovery than men; however, for a given level and degree of neurologic injury, men tend to do better functionally than women at time of discharge from rehabilitation. Future prospective study of the effects of estrogen on neurologic recovery and the effects of gender on functional potential are recommended.     

Prevalence and Determinants of Pain in Spinal Cord Injury During Initial Inpatient Rehabilitation: Data From the Dutch Spinal Cord Injury Database

ObjectiveTo describe the prevalence and characteristics of spinal cord injury (SCI)-related pain during initial inpatient rehabilitation and to investigate relationships with demographic and lesion characteristics.DesignCohort during inpatient rehabilitation.SettingEight specialized SCI rehabilitation centers in the Netherlands.ParticipantsPatients with newly acquired SCI admitted for inpatient rehabilitation between November 2013 and August 2019 (N=1432).InterventionsNot applicable.Main Outcome MeasuresPresence of pain at admission and discharge. Logistic regression analyses were used to study the prevalence of pain related to sex, age, etiology, completeness, and level of injury.ResultsData from 1432 patients were available. Of these patients 64.6% were male, mean age was 56.8 years, 59.9% had a nontraumatic SCI, 63.9% were classified as American Spinal Cord Injury Association Impairment Scale (AIS) D and 56.5% had paraplegia. Prevalence of pain was 61.2% at admission (40.6% nociceptive pain [NocP], 30.2% neuropathic pain [NeuP], 5.4% other pain) and 51.5% at discharge (26.0% NocP, 31.4% NeuP, 5.7% other pain). Having NocP at admission was associated with traumatic SCI. AIS B had a lower risk of NocP than AIS D at admission. Having NocP at discharge was associated with female sex and traumatic SCI. AIS C had a lower risk of NocP at discharge than AIS D. Having NeuP at admission was associated with female sex. Having NeuP at discharge was associated with female sex, age younger than 65 years vs age older than 75 years and tetraplegia.ConclusionsSCI-related pain is highly prevalent during inpatient rehabilitation. Prevalence of NocP decreased during inpatient rehabilitation, and prevalence of NeuP stayed the same. Different patient and lesion characteristics were related to the presence of SCI-related pain. Healthcare professionals should be aware of these differences in screening patients on presence and development of pain during inpatient rehabilitation.     

PREVALENCE OF DISCOMPLETE SENSORIMOTOR SPINAL CORD INJURY AS EVIDENCED BY NEUROPHYSIOLOGICAL METHODS: A CROSS-SECTIONAL STUDY

ObjectivesTo assess the prevalence of residual trans-lesion connectivity in persons with chronic clinically complete spinal cord injury (discompleteness) by neurophysiological methods.ParticipantsA total of 23 adults with chronic sensorimotor complete spinal cord injury, identified through regional registries the regional spinal cord registry of Östergötland, Sweden.MethodsDiagnosis of clinically complete spinal cord injury was verified by standardized neurological examination. Then, a neurophysiological examination was performed, comprising electroneurography, electromyography, sympathetic skin response and evoked potentials (sensory, laser and motor). Based on this assessment, a composite outcome measure, indicating either strong, possible or no evidence of discomplete spinal cord injury, was formed.ResultsStrong neurophysiological evidence of discomplete spinal cord injury was found in 17% (4/23) of participants. If also accepting “possible evidence”, the discomplete group comprised 39% (9/23). The remaining 61% showed no neurophysiological evidence of discompleteness. However, if also counting reports of subjective sensation elicited during neurophysiological testing in the absence of objective findings, 52% (12/23) showed indication of discomplete spinal cord injury.CONCLUSIONEvidence of discomplete spinal cord injury can be demonstrated using standard neurophysiological techniques in a substantial subset of individuals with clinically complete spinal cord injury. This study adds to the evidence base indicating the potential of various modes of cross-lesional sensorimotor functional restoration in some cases of chronic clinically complete spinal cord injury.LAY ABSTRACTSpinal cord injuries are usually classed as complete or incomplete. A complete injury implies that no residual function exists below the neurological level of injury. This status is determined by standardized neurological examination and is thought to correlate with spinal cord function in each individual with spinal cord injuries. However, studies have indicated that, in some people with complete spinal cord injury, there may be residual function that is not detected by such testing. The aim of the current study was to examine whether residual function, which is not detected by such testing, exists, and, if so, how common it is among people with complete spinal cord injuries (based on clinical testing) in a chronic stage (>2 years since injury). A battery of neurophysiological tests was used. Signs of “subclinical” residual function were found in 17–39% of 23 participants. This finding may lead to improvements in rehabilitative outcomes for people with complete spinal cord injury.Key words: somatosensory evoked potentials, motor evoked potentials, electromyography, sympathetic skin response, laser evoked potentials, spinal cord injury, complete, discomplete

Spinal cord injury (SCI) causes sensorimotor deficits at and below the neurological level of injury (NLI), including paralysis and altered or lost sensory function. Autonomic functions are usually also impaired to some extent, affecting respiratory, circulatory, bladder, bowel and sexual functions (1). In addition, complications such as excessive spasticity and neuropathic pain are common (2, 3) and associated with decreased quality of life (4). There is no known unambiguous correlation between the degree of neurological deficits and the presence of such complications.Currently, no methods are available in clinical routine practice for repairing SCI. However, as the concept of neuroplasticity has gained acceptance (5, 6), interest in exploring therapeutic neuro-modulation has increased.SCI is classified as complete or incomplete, using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) (7), which is based entirely on clinical sensorimotor examination. Based on the clinical assessment, SCI is sub-classified into 5 levels of varying residual infra-lesion neurological function; American Spinal Injury Association Impairment Scale (AIS) A–E (where A is complete functional transection, and E is complete restitution of infra-lesional sensory and voluntary motor function). In some individuals with SCI of grade AIS A, there exists a “zone of partial preservation” (ZPP), defined as the most caudal segment with some sensory function, determined by pin-prick and light touch testing below NLI, without sacral preservation of sensory and voluntary motor function (7, 8).A high prevalence (30–78%) of residual anatomical continuity was noted in post-mortem studies on clinically complete traumatic SCI (9, 10). It is likely that such anatomical continuity corresponds to a functional but subclinical neurological connectivity across the injury site in some cases. However, other pathways for such connectivity have also been proposed, e.g. the sympathetic trunk and/or the vagus nerve (11–14).For residual subclinical trans-lesion connectivity, the term discomplete spinal cord injury (dSCI) was proposed (15). Various methods for detection of this phenomenon have since been used, and both motor and sensory discompleteness have been proposed.For assessment of motor dSCI, electromyography (EMG) was the first method used (16). EMG recordings below the NLI can also be combined with transcranial magnetic stimulation (TMS) of the brain motor cortex (17, 18) to find signs of subclinical trans-lesion motor conduction.Sensory dSCI has been studied using somatosensoryevoked potentials (SEP, 17–19), consisting of somatosensory peripheral stimulation (typically electrical nerve stimulation) under simultaneous registration of activity in the somatosensory cortex, using scalp electrodes. Functional magnetic resonance imaging (fMRI) appears to have a higher sensitivity for detecting remaining sensory connectivity in patients with clinically complete SCI (25–54% (19–21)), compared with SEP (13–25% (22, 23)):In one study (23), 8/12 (67%) people with SCI and neuropathic pain perceived a change in perception below the NLI using adjuvant-enhanced thermal stimulation, compared with 0/12 (0%) for the group without neuropathic pain. Thus, a correlation was postulated between sensory dSCI and neuropathic pain after SCI.In summary, evidence for the concept of dSCI has accumulated. However, most of these studies have been small, and methods and quality of control conditions have varied. The current study aimed to determine the prevalence of motor and/or sensory dSCI among persons with chronic clinically complete SCI, by strict application of current clinical diagnostic criteria, and use of multiple, standardized neurophysiological methods.     

Predicting walking at discharge from inpatient rehabilitation after a traumatic spinal cord injury

OBJECTIVE: To investigate how injury level and American Spinal Injury Association Impairment Scale (AIS) grade at rehabilitation admission are related to walking at discharge after traumatic spinal cord injury (SCI). DESIGN: Retrospective study. SETTING: Comprehensive rehabilitation hospital. PARTICIPANTS: A total of 343 adult inpatients with traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: FIM instrument walking rating of 3 (moderate assistance) or higher at discharge. RESULTS: Significantly more subjects admitted with AIS grade C (28.3%) than AIS grade A or B injuries (0.9%) walked at discharge. Significantly more subjects admitted with AIS grade D (67.2%) than AIS grade C (28.3%) injuries walked at discharge. Level of injury did not significantly affect walking after AIS grade C or D injuries. Being 50 years or older had a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries. CONCLUSIONS: Admission AIS grades give information about walking for treatment and discharge planning during acute inpatient rehabilitation, including the following: (1) patients admitted with AIS grade C injuries should not be considered functionally complete when predicting walking (FIM score > or = 3; no more than moderate assistance) at discharge, (2) level of injury does not affect walking for those with AIS grade C or D injuries, and (3) being 50 years or older has a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries.     

The impact of sacral sensory sparing in motor complete spinal cord injury

Kirshblum S, Botticello A, Lammertse DP, Marino RJ, Chiodo AE, Jha A. The impact of sacral sensory sparing in motor complete spinal cord injury.

Objective

To determine the effect of sensory sparing in motor complete persons with spinal cord injury (SCI) on completion of rehabilitation on neurologic, functional, and social outcomes reported at 1 year.

Design

Secondary analysis of longitudinal data collected by using prospective survey-based methods.

Setting

Data submitted to the National SCI Statistical Center Database.

Participants

Of persons (N=4106) enrolled in the model system with a motor complete injury (American Spinal Injury Association Impairment Scale [AIS] grade A or B) at the time of discharge between 1997 and 2007, a total of 2331 (56.8%) completed a 1-year follow-up interview (Form II) and 1284 (31.3%) had complete data for neurologic (eg, AIS grade, injury level) variables at 1 year.

Interventions

Not applicable.

Main Outcome Measures

AIS grade (A vs B) at 1 year, bladder management, hospitalizations, perceived health status, motor FIM items, Satisfaction With Life Scale, depressive symptoms, and social participation.

Results

Compared with persons with AIS grade A at discharge, persons with AIS grade B were less likely to require indwelling catheterization and be hospitalized and more likely to perceive better health, report greater functional independence (ie, self-care, sphincter control, mobility, locomotion), and report social participation in the first year postinjury. A greater portion of individuals with AIS grade B at discharge had improved neurologic recovery at 1 year postinjury than those with AIS grade A. Significant AIS group differences in 1-year outcomes related to physical health were maintained after excluding persons who improved to motor incomplete status for only bladder management and change in perceived health status. This recognition of differences between persons with motor complete injuries (AIS grade A vs B) has important ramifications for the field of SCI rehabilitation and research.