Rehabilitation of spinal cord injuries

Towards a Mobile Gait Analysis for Patients with a Spinal Cord Injury: A Robust Algorithm Validated for Slow Walking Speeds

Spinal cord injury (SCI) patients suffer from diverse gait deficits depending on the severity of their injury. Gait assessments can objectively track the progress during rehabilitation and support clinical decision making, but a comprehensive gait analysis requires far more complex setups and time-consuming protocols that are not feasible in the daily clinical routine. As using inertial sensors for mobile gait analysis has started to gain ground, this work aimed to develop a sensor-based gait analysis for the specific population of SCI patients that measures the spatio-temporal parameters of typical gait laboratories for day-to-day clinical applications. The proposed algorithm uses shank-mounted inertial sensors and personalized thresholds to detect steps and gait events according to the individual gait profiles. The method was validated in nine SCI patients and 17 healthy controls walking on an instrumented treadmill while wearing reflective markers for motion capture used as a gold standard. The sensor-based algorithm (i) performed similarly well for the two cohorts and (ii) is robust enough to cover the diverse gait deficits of SCI patients, from slow (0.3 m/s) to preferred walking speeds.

Advancing motor rehabilitation for adults with chronic neurological conditions through increased involvement of kinesiologists: a perspective review

Many people with neurological conditions experience challenges with movement. Although rehabilitation is often provided acutely and sub-acutely following the onset of a condition, motor deficits commonly persist in the long-term and are exacerbated by disuse and inactivity. Notably, motor rehabilitation approaches that incorporate exercise and physical activity can support gains in motor function even in the chronic stages of many neurological conditions. However, delivering motor rehabilitation on a long-term basis to people with chronic neurological conditions is a challenge within health care systems, and the onus is often placed on patients to find and pay for services. While neurological motor rehabilitation is largely the domain of physical and occupational therapists, kinesiologists may be able to complement existing care and support delivery of long-term neurological motor rehabilitation, specifically through provision of supported exercise and physical activity programs. In this perspective style review article, we discuss potential contributions of kinesiologists to advancing the field through exercise programming, focusing on community-based interventions that increase physical activity levels. We conclude with recommendations on how kinesiologists' role might be further optimized towards improving long-term outcomes for people with chronic neurological conditions, considering issues related to professional regulation and models of care.

The Canadian Occupational Performance Measure (COPM) as Routine Practice in Community-Based Rehabilitation: A Retrospective Chart Review

Objective

To investigate whether patients experienced improved functional outcomes as a result of their admission to rehabilitation and to identify whether the service provided effective, patient-centered and goal-directed rehabilitation.

Design

Retrospective chart review of admission and discharge data from patients accessing the service between 2011 and 2019.

Setting

Community-based interdisciplinary rehabilitation service.

Participants

Consecutive patients (N=612) admitted to the service.

Interventions

Routine care delivered with a median duration of 181 days and an interquartile range of 120-261 days.

Main Outcome Measures

The Canadian Occupational Performance Measure (COPM) administered on admission and discharge and an improvement ≥2 in the COPM subscales of performance and satisfaction.

Results

Of 612 participants, 96% had the COPM administered at admission (baseline) and 68% again at discharge. Performance and satisfaction were measured in 584 patients at admission, 406 at discharge, and 404 at both time points. For performance, 243 patients (60%) experienced an improvement (≥2), with an average of 2.2 points. For satisfaction, 268 patients (66%) experienced an improvement (≥2), with an average of 2.8 points. Factors influencing outcomes, differed. For each 10 year increase in patient age, the average improvement in satisfaction was 0.26 points lower (95% confidence interval, 0.07-0.45) after adjusting for sex, duration, completion, and health condition.

Conclusions

Irrespective of patient-related factors and regardless of age, sex, health condition, or discharge plan, the majority of patients reported a positive functional outcome in COPM Performance and satisfaction as a result of time spent in the community-based rehabilitation service. This service provided equitable care and patient-centered, goal-focused, and outcome-based therapy that enabled patients to improve their functional capacity.

A Pilot Study of a Sensor Enhanced Activity Management System for Promoting Home Rehabilitation Exercise Performed during the COVID-19 Pandemic: Therapist Experience, Reimbursement, and Recommendations for Implementation

Adherence to home exercise programs (HEPs) during physical rehabilitation is usually unmonitored and is thought to be low from self-reports. This article describes exploratory implementation of a Sensor Enhanced Activity Management (SEAM) system that combines HEP management software with a movement sensor for monitoring and motivating HEP adherence. The article also presents results from attempting to gain reimbursement for home use of the system with therapist oversight using Remote Physiologic Monitoring (RPM) codes. Four therapists used the system in their regular practice during the first six months of the COVID-19 pandemic. Therapists filled out surveys, kept notes, and participated in interviews. Billing and reimbursement data were obtained from the treatment facility. Exercise data from the SEAM system were used to understand HEP adherence. Patients were active for a mean of 40% (26% SD) of prescribed days and completed a mean of 25% (25% SD) of prescribed exercises. The therapists billed 23 RPM codes (USD 2353), and payers reimbursed eight of those instances (USD 649.21). The therapists reported that remote monitoring and the use of a physical movement sensor was motivating to their patients and increased adherence. Sustained technical support for therapists will likely improve implementation of new remote monitoring and treatment systems. RPM codes may enable reimbursement for review and program management activities, but, despite COVID-19 CMS waivers, organizations may have more success if these services are billed under supervision of a physician.

Recognizing Physical Activities for Spinal Cord Injury Rehabilitation Using Wearable Sensors

The research area of activity recognition is fast growing with diverse applications. However, advances in this field have not yet been used to monitor the rehabilitation of individuals with spinal cord injury. Noteworthily, relying on patient surveys to assess adherence can undermine the outcomes of rehabilitation. Therefore, this paper presents and implements a systematic activity recognition method to recognize physical activities applied by subjects during rehabilitation for spinal cord injury. In the method, raw sensor data are divided into fragments using a dynamic segmentation technique, providing higher recognition performance compared to the sliding window, which is a commonly used approach. To develop the method and build a predictive model, a machine learning approach was adopted. The proposed method was evaluated on a dataset obtained from a single wrist-worn accelerometer. The results demonstrated the effectiveness of the proposed method in recognizing all of the activities that were examined, and it achieved an overall accuracy of 96.86%.

Advanced rehabilitation technology in orthopaedics-a narrative review

INTRODUCTION

As the demand for rehabilitation in orthopaedics increases, so too has the development in advanced rehabilitation technology. However, to date, there are no review papers outlining the broad scope of advanced rehabilitation technology used within the orthopaedic population. The aim of this study is to identify, describe and summarise the evidence for efficacy for all advanced rehabilitation technologies applicable to orthopaedic practice.

METHODS

The relevant literature describing the use of advanced rehabilitation technology in orthopaedics was identified from appropriate electronic databases (PubMed and EMBASE) and a narrative review undertaken.

RESULTS

Advanced rehabilitation technologies were classified into two groups: hospital-based and home-based rehabilitation. In the hospital-based technology group, we describe the use of continuous passive motion and robotic devices (after spinal cord injury) and their effect on improving clinical outcomes. We also report on the use of electromagnetic sensor technology for measuring kinematics of upper and lower limbs during rehabilitation. In the home-based technology group, we describe the use of inertial sensors, smartphones, software applications and commercial game hardware that are relatively inexpensive, user-friendly and widely available. We outline the evidence for videoconferencing for promoting knowledge and motivation for rehabilitation as well as the emerging role of virtual reality.

CONCLUSIONS

The use of advanced rehabilitation technology in orthopaedics is promising and evidence for its efficacy is generally supportive.

Protective Effects of SIRT6 Against Inflammation, Oxidative Stress, and Cell Apoptosis in Spinal Cord Injury

Accumulating evidence supports that Sirtuin 6 (SIRT6) may play a vital role in the pathogenesis of spinal cord injury. The current study was designed to investigate the specific effects of SIRT6 on spinal cord injury (SCI). HE and Nissl staining were performed for pathological analysis in SCI rats. SIRT6 expression was detected by RT-qPCR. CCK8 assay was applied for the detection of cell viability of LPS-injured PC12 cells. TNF-a, IL-1β, IL-6, MCP-1 levels and ROS, MPO, SOD levels were assessed to evaluate inflammation and oxidative stress in spinal cord injury. Cell apoptosis were evaluated by morphological examination using AO/EB fluorescent staining methods and key proteins related to apoptosis were explored via western blot. HE staining revealed increased cavity involving the dorsal white matter and central gray matter, and Nissl staining discovered the loss of motor neurons in the ventral horn in SCI rats. SIRT6 had lower expression in SCI rats. Lipopolysaccharide (LPS) exposure induced cell apoptosis and reduced the expression of SIRT6. Mechanistically, we revealed that up-regulation of SIRT6 alleviated inflammation and oxidative stress and inhibited cell apoptosis in spinal cord injury. Together, our findings indicated that SIRT6 attenuated spinal cord injury by suppressing inflammation, oxidative stress, and cell apoptosis. This study demonstrates that SIRT6 may represent a protective effect against spinal cord injury.

A New Precision Minimally Invasive Method of Glial Scar Simulation in the Rat Spinal Cord Using Cryoapplication

According to the World Health Organization, every year worldwide up to 500,000 people suffer a spinal cord injury (SCI). Various animal biomodels are essential for searching for novel protocols and therapeutic approaches for SCI treatment. We have developed an original model of post-traumatic spinal cord glial scarring in rats through cryoapplication. With this method the low-temperature liquid nitrogen is used for the cryodestruction of the spinal cord tissue. Forty-five Sprague Dawley (SD) non-linear male rats of the Specific-pathogen-free (SPF) category were included in this experimental study. A Th13 unilateral hemilaminectomy was performed with dental burr using an operating microscope. A specifically designed cryogenic probe was applied to the spinal cord for one minute through the created bone defect. The animals were euthanized at different time points ranging from 1 to 60 days after cold-induced injury. Their Th12-L1 vertebrae with the injured spinal cord region were removed "en bloc" for histological examination. Our data demonstrate that cryoapplication producing a topical cooling around-20°C, caused a highly standardized transmural lesion of the spinal cord in the dorsoventral direction. The lesion had an "hour-glass" shape on histological sections. During the entire study period (days 1-60 of the post-trauma period), the necrotic processes and the development of the glial scar (lesion evolution) were contained in the surgically approached vertebral space (Th13). Unlike other known experimental methods of SCI simulation (compression, contusion, etc.), the proposed technique is characterized by minimal invasiveness, high precision, and reproducibility. Also, histological findings, lesion size, and postoperative clinical course varied only slightly between different animals. An original design of the cryoprobe used in the study played a primary role in the achieving of these results. The spinal cord lesion's detailed functional morphology is described at different time points (1-60 days) after the produced cryoinjury. Also, changes in the number of macrophages at distinct time points, neoangiogenesis and the formation of the glial scar's fibrous component, including morphodynamic characteristics of its evolution, are analyzed. The proposed method of cryoapplication for inducing reproducible glial scars could facilitate a better understanding of the self-recovery processes in the damaged spinal cord. It would be evidently helpful for finding innovative approaches to the SCI treatment.

Design and development of a wheelchair seating pressure relief reminder system for pressure ulcer prevention among paraplegics

Individuals with paraplegia spend their time on the wheelchair for life. Adapting to prolonged wheelchair seating for almost all activities of daily living is challenging. The loss of abilities to sense any pain or excessive seating pressure cause them to remain seated on the wheelchair without any pressure relief activities. This situation leads to secondary complications including pressure ulcer which further degrades the individual's health. To overcome this, a wheelchair seating pressure relief training system (WSETs) was developed. Optimal placement of the force sensitive resistors (FSR) as seating pressure sensors on the cushion were determined, and their responses were investigated with 5 paraplegics. Two different FSR orientations, A and B, were compared. Each paraplegic sat in resting position and then performed pressure relief activities (PRA) which included whole body push-up, left and right lean and forward lean, before returning to resting position. Orientation B, with more forward positioned FSRs, showed higher sensitivity, implying better capture of high-risk area of pressure ulcer development. The FSR sensor readings were significantly different among pressure relief activities in all subjects (p < 0.05) indicating the validity of FSR measures for the intended application. In conclusion, the WSETs system was proven suitable as a training tool for new paraplegics to habituate themselves in performing PRA.

Acute Myelopathy: Vascular and Infectious Diseases

Vascular and infectious causes are rare but important causes of spinal cord injury. High suspicion for these processes is necessary, as symptoms may progress over hours to days, resulting in delayed presentation and diagnosis and worse outcomes. History and clinical examination findings can assist with localization of the affected vascular territory and spinal level, which will assist with focusing spinal imaging. Open and/or endovascular surgical management depends on the associated vascular abnormality. Infectious myelopathy treatment consists of targeted antimicrobial therapy when possible, infectious source control, and again, close monitoring for systemic complications.

Diagnostic tests to assess balance in patients with spinal cord injury: a systematic review of their validity and reliability

Background

Sophisticated biomechanical instruments can assess balance in patients with spinal cord injury (SCI) with accuracy and precision; however, they are costly and time consuming to use. Clinical diagnostic tests to assess balance in patients with SCI are less costly and easier to use, but there is limited literature available regarding their reliability and validity.

Objectives

To review systematically articles reporting the validity and reliability of diagnostic tests used to assess balance function in patients with SCI.

Methods

We searched for articles in the English language from the earliest record to December 15, 2020, which reported validity or reliability of any clinical instrument or diagnostic test used to assess balance in patients with SCI. Articles assessing balance in paraplegic patients with causes other than SCI were excluded. Databases included MEDLINE, AMED, EMBASE, HMIC, PsycINFO, CINAHL, Scopus, and Google Scholar. The COSMIN Risk of Bias checklist was used to assess the studies included and PRISMA-DTA guidelines were applied.

Results

We included 16 articles that assessed the validity or reliability of 10 diagnostic tests. The Functional Reach Test (FRT), Berg Balance Scale (BBS), and Mini-Balance Evaluation Systems Test (Mini-BESTest) were assessed by more than 1 study, while the remaining 7 diagnostic tests including the Function in Sitting Test, T-Shirt Test, Motor Assessment Scale item 3, Sitting Balance Score, 5 Times Sit-to-Stand Test, Tinetti scale, and Sitting Balance Measure were assessed by 1 study each. The FRT has good-to-excellent test-retest reliability, excellent inter-rater reliability, and good construct, concurrent, and convergent validity. The BBS has excellent inter-rater and intra-rater reliability, high internal consistency, and good concurrent and construct validity. The Mini-BESTest has excellent test-retest reliability, excellent inter-rater reliability, high internal consistency, and good concurrent, convergent, and construct validity.

Conclusions

The FRT, BBS, and Mini-BESTest appear to be valid and reliable clinical instruments to assess balance function in patients with SCI.

Goal setting practices of occupational therapists in spinal cord injury rehabilitation in Gauteng, South Africa

INTRODUCTION

Client-centered goal setting has multiple benefits in spinal rehabilitation. However, research has shown that many occupational therapists struggle to facilitate client-centered goal setting. South Africa presents unique challenges to client-centered goal setting, but no data is available on how it is applied.

STUDY DESIGN

A qualitative research design following an appreciative inquiry stance was used.

OBJECTIVE

To explore how occupational therapists implement and envision the goal setting practices in spinal rehabilitation.

SETTING

Rehabilitation facilities in Gauteng, South Africa.

METHODS

A focus group consisting of five occupational therapists working within spinal rehabilitation was held. An appreciative inquiry stance was used to determine current successes and future ideas on how to implement goal setting in a spinal rehabilitation setting.

RESULTS

Data was analysed thematically using Braun and Clark. Themes were developed under each phase of appreciative inquiry. Discovery phase: Participants felt that current effective goal setting is therapist-directed and that client insight facilitates effective goal setting. Dream phase: Participants agreed that client-centered goal setting is the ideal. In addition, effective collaboration within the team and adequate resources were identified during the dream phase as ideals to effective goal setting practices. Design and Destination phase: Participants generated ideas on how to improve on team collaboration during goal setting and how to ensure goal setting is client-centered for effective goal setting in spinal rehabilitation to take place.

CONCLUSIONS

The study emphasizes that for effective goal setting to occur, the process must remain client-centered. Essential to this process is collaboration between both the team and family members. Adequate resources and a low therapist-patient ratio supports effective goal setting.

Urinary biomarkers indicative of recovery from spinal cord injury: A pilot study

Current assessments of recovery following spinal cord injury (SCI) focus on clinical outcome measures. These assessments bear an inherent risk of bias, emphasizing the need for more reliable prognostic biomarkers to measure SCI severity. This study evaluated fluid biomarkers as an objective tool to aid with prognosticating outcomes following SCI. Using a 1H nuclear magnetic resonance (NMR)-based quantitative metabolomics approach of urine samples, the objectives were to determine (a) if alterations in metabolic profiles reflect the extent of recovery of individual SCI patients, (b) whether changes in urine metabolites correlate to patient outcomes, and (c) whether biological pathway analysis reflects mechanisms of neural damage and repair. An inception cohort exploratory pilot study collected morning urine samples from male SCI patients (n=6) following injury and again at 6-months post-injury. A 700 MHz Bruker Avance III HD NMR spectrometer was used to acquire the metabolic signatures of urine samples, which were used to derive metabolic pathways. Multivariate statistical analyses were used to identify changes in metabolic signatures, which were correlated to clinical outcomes in the Spinal Cord Independence Measure (SCIM). Among SCI-induced metabolic changes, biomarkers which significantly correlated to patient SCIM scores included caffeine (R = -0.76, p < 0.01), 3-hydroxymandelic acid (R= -0.85, p < 0.001), L-valine (R = 0.90, p < 0.001; R = -0.64, p < 0.05), and N-methylhydantoin (R = -0.90, p < 0.001). The most affected pathway was purine metabolism. These findings indicate that urinary metabolites reflect SCI lesion severity and recovery and provide potentially prognostic biomarkers of SCI outcome in precision medicine approaches.

Acute spinal cord injury: Pathophysiology and pharmacological intervention (Review)

Spinal cord injury (SCI) is one of the most debilitating of all the traumatic conditions that afflict individuals. For a number of years, extensive studies have been conducted to clarify the molecular mechanisms of SCI. Experimental and clinical studies have indicated that two phases, primary damage and secondary damage, are involved in SCI. The initial mechanical damage is caused by local impairment of the spinal cord. In addition, the fundamental mechanisms are associated with hyperflexion, hyperextension, axial loading and rotation. By contrast, secondary injury mechanisms are led by systemic and cellular factors, which may also be initiated by the primary injury. Although significant advances in supportive care have improved clinical outcomes in recent years, a number of studies continue to explore specific pharmacological therapies to minimize SCI. The present review summarized some important pathophysiologic mechanisms that are involved in SCI and focused on several pharmacological and non‑pharmacological therapies, which have either been previously investigated or have a potential in the management of this debilitating injury in the near future.

Therapeutic repetitive Transcranial Magnetic stimulation (rTMS) for neurological dysfunction in Degenerative cervical Myelopathy: An unexplored opportunity? Findings from a systematic review

Degenerative Cervical Myelopathy (DCM) is one of the commonest causes of non-traumatic Spinal Cord Injury (SCI) leading to significant neurological impairments and reduced health-related quality of life. Guidelines recommend surgical intervention to halt disease progression in moderate-to-severe cases, and whilst many do experience neurological recovery, this is incomplete leading to lifelong disability. A James Lind Alliance (JLA) research priority setting partnership for DCM highlighted novel therapies and rehabilitation as top 10 research priority in DCM. Neurological recovery following decompressive surgery in DCM has been attributed neuroplasticity, and therapies influencing neuroplasticity are of interest. Electrical neuromodulation interventions such as repetitive Transcranial Magnetic Stimulation (rTMS), are being increasingly explored in related fields such as spinal cord injury to improve recovery and symptoms. The aim of this systematic review was to determine the role and efficacy of rTMS as a therapeutic tool in managing neurological dysfunction in DCM. We searched the databases of Medline, EMBASE, CINAHIL and Cochrane Central Register of Controlled Trials (CENTRAL). No studies were identified that had investigated the therapeutic use of rTMS in DCM. A significant number of studies had explored TMS based neurophysiological assessments indicating its role as a screening and prognostication tool in DCM. Post-operative rehabilitation interventions including TMS and non-operative management of DCM is a field which requires further investigation, as required in the AO Spine JLA DCM research priorities. rTMS is a safe neuromodulatory intervention and may have a role in enhancing recovery in DCM. Further research in these fields are required.

Traumatic spinal cord injury in southern Saudi Arabia: Patterns, time to surgery and outcomes

Introduction:

Spinal cord injury (SCI) is an unbearable neurological disorder. which has a destructive socioeconomic effect of affected individual, their families and the healthcare systems. Stressful spinal cord damages are caused by road traffic misfortunes, violence, sports or falls.

Methods:

Retrospective study of 112 spinal cord injured patient admitted to Aseer Central hospital (ACH) between the years 2016 and 2018.

Results:

The present study includes 112 cases of TSCI patients who admitted to Asser Central Hospital and surgically treated, with mean age 32.1 ± 14.12 years. Males were the mostly affected by almost 90.2%. Lower level of education is seen in 69.6% of patients; while only 30.3% of patients had university education or higher. Motor vehicle accidents (MVA) and falls are the only two causes of spinal cord injuries in this study; however, MVA was the cause of SCI in (79.5%) and 20.5% for falls.

Conclusions:

MVAs are the most source of spinal cord injuries in Southern Saudi Arabia with high male predominance. Despite the lack of significance between shorter time to surgery, and improvement in ASIA score, it was found that shorter time to surgery plays an important role in reducing the post-operative intensive care unit and ward stay, potentially reducing possible long stay related complications and eventually reducing health care cost.

Upper Extremity Overuse Injuries and Obesity After Spinal Cord Injury

Persons with spinal cord injury (SCI) are at high risk for developing neurogenic obesity due to muscle paralysis and obligatory sarcopenia, sympathetic blunting, anabolic deficiency, and blunted satiety. Persons with SCI are also at high risk for shoulder, elbow, wrist, and hand injuries, including neuromusculoskeletal pathologies and nociceptive pain, as human upper extremities are poorly designed to facilitate chronic weight-bearing activities, including manual wheelchair propulsion, transfers, self-care, and day-to-day activities. This article reviews current literature on the relationship between obesity and increased body weight with upper extremity overuse injuries, detailing pathology at the shoulders, elbows, and wrists that elicit pain and functional decline and stressing the importance of weight management to preserve function.

Robotic Locomotor Training Leads to Cardiovascular Changes in Individuals With Incomplete Spinal Cord Injury Over a 24-Week Rehabilitation Period: A Randomized Controlled Pilot Study

OBJECTIVE

To describe the effect of robotic locomotor training (RLT) and activity-based training (ABT) on cardiovascular indices during various physiological positions in individuals with spinal cord injury.

DESIGN

Randomized controlled pilot study.

SETTING

Private practice: Therapy & Beyond Centre - Walking with Brandon Foundation, Sports Science Institute of South Africa, Cape Town, South Africa.

PARTICIPANTS

Participants with chronic traumatic motor incomplete tetraplegia (N=16) who resided in the Western Cape, South Africa.

INTERVENTION

Robotic locomotor training (Ekso GT) and activity-based training over a 24-week intervention.

MAIN OUTCOME MEASURES

Brachial and ankle blood pressure, heart rate, heart rate variability, and cardiovascular efficiency during 4 physiological positions.

RESULTS

No differences between groups or over time were evident in resting systolic and diastolic blood pressure, ankle systolic pressure, ankle brachial pressure index, and heart rate variability. Standing heart rate at 24 weeks was significantly higher in the ABT group (95.58±12.61 beats/min) compared with the RLT group (75.14±14.96 beats/min) (P=.05). In the RLT group, no significant changes in heart rate variability (standard deviation R-R interval and root mean square of successive differences) was found between the standing and 6-minute walk test physiological positions throughout the intervention. Cardiovascular efficiency in the RLT group during the 6-minute walk test improved from 11.1±2.6 at baseline to 7.5±2.8 beats per meter walked at 6 weeks and was maintained from 6 to 24 weeks.

CONCLUSIONS

Large effect sizes and significant differences between groups found in this pilot study support the clinical effectiveness of RLT and ABT for changing cardiovascular indices as early as 6 weeks and up to 24 weeks of rehabilitation. RLT may be more effective than ABT in improving cardiac responses to orthostatic stress. Based on heart rate variability metrics, the stimulus of standing has comparable effects to RLT on the parasympathetic nervous system. Cardiovascular efficiency of exoskeleton walking improved, particularly over the first 6 weeks. Both the RLT and ABT interventions were limited in their effect on brachial and ankle blood pressure. A randomized controlled trial with a larger sample size is warranted to further examine these findings.

Changes to Biceps and Supraspinatus Tendons in Response to a Progressive Maximal Treadmill-Based Propulsion Aerobic Fitness Test in Manual Wheelchair Users: A Quantitative Musculoskeletal Ultrasound Study

Objective

To investigate if the completion of a recently developed treadmill-based wheelchair propulsion maximal progressive workload incremental test alters the integrity of the long head of the biceps and supraspinatus tendons using musculoskeletal ultrasound imaging biomarkers.

Method

Fifteen manual wheelchair users completed the incremental test. Ultrasound images of the long head of the biceps and supraspinatus tendons were recorded before, immediately after, and 48 hours after the completion of the test using a standardized protocol. Geometric, composition, and texture-related ultrasound biomarkers characterized tendon integrity.

Results

Participants propelled during 10.2 ± 2.9 minutes with the majority (N = 13/15) having reached at least the eighth stage of the test (speed = 0.8 m/s; slope = 3.6°). All ultrasound biomarkers characterizing tendon integrity, measured in the longitudinal and transversal planes for both tendons, were similar (p = 0.063 to 1.000) across measurement times.

Conclusion

The performance of the motorized treadmill wheelchair propulsion test to assess aerobic fitness produced no changes to ultrasound biomarkers of the biceps or supraspinatus tendons. Hence, there was no ultrasound imaging evidence of a maladaptive response due to overstimulation in these tendons immediately after and 48 hours after the performance of the test.

Design and development of 1,3,5-triazine derivatives as protective agent against spinal cord injury in rat via inhibition of NF-ĸB

Spinal cord injury (SCI) is a chronic disease causing motor and sensory loss in the affected individuals. The SCI has a huge impact on the lives of patients that makes them susceptible to life-long disability. However, the current clinical modalities are ineffective to cope the aftermath of SCI. Thus, in the present study, we aimed to develop a series of 1,3,5-triazine derivatives as a protective agent against SCI. The molecules were developed by facile synthetic route and obtained in excellent yield. The compounds were tested for their efficacy to inhibit the transcription of NF-κB in RAW 264.7 cells, where they displayed mild to potent activity. Compound 8a was identified as most potent NF-κB inhibitor among the tested analogues. The effect of compound 8a was further scrutinized against the SCI injury in rats induced by contusion injury. It has been found that compound 8a improves motor function of rats together with reduction in inflammation and edema in spinal cord of rats. It also showed to inhibit oxidative stress and inflammation in the SCI rats. In a western blot analysis, after SCI induction, compound 8a inhibited NF-κB and its upstream regulator TLR4 in a dose-dependent manner. Collectively, our study provides a novel class of agent that provide protective action against SCI.

Dynamic Segmentation for Physical Activity Recognition Using a Single Wearable Sensor

Data segmentation is an essential process in activity recognition when using machine learning techniques. Previous studies on physical activity recognition have mostly relied on the sliding window approach for segmentation. However, choosing a fixed window size for multiple activities with different durations may affect recognition accuracy, especially when the activities belong to the same category (i.e., dynamic or static). This paper presents and verifies a new method for dynamic segmentation of physical activities performed during the rehabilitation of individuals with spinal cord injuries. To adaptively segment the raw data, signal characteristics are analyzed to determine the suitable type of boundaries. Then, the algorithm identifies the time boundaries to represent the start- and endpoints of each activity. To verify the method and build a predictive model, an experiment was conducted in which data were collected using a single wrist-worn accelerometer sensor. The experimental results were compared with the sliding window approach, indicating that the proposed method outperformed the sliding window approach in terms of overall accuracy, which exceeded 5%, as well as model robustness. The results also demonstrated efficient physical activity segmentation using the proposed method, resulting in high classification performance for all activities considered.

Brake response time between male drivers with and without paraplegia: Association between sociodemographic, motor and neurological characteristics

Objective: The objective of this study was to compare the brake response time of drivers with paraplegia (who use hand control) with drivers without paraplegia (who use their feet) in a virtual driving simulator brake test. Additionally, we aimed to predict and evaluate the association of virtual brake response time with sociodemographic, motor and cognitive variables.Methods: 40 male adult drivers, with paraplegia (n = 20, mean age 38.1 ± 3.6 years) and without paraplegia (n = 20, mean age 38.0 ± 5.8 years), with valid driver licenses, had their brake response time evaluated in an automatic transmission car simulator. Non-disabled drivers were tested with conventional foot controls, while paraplegic drivers used hand controls. Drivers with paraplegia performed simple, choice and go/no-go reaction time tests as neuropsychological evaluations. Student's t-test was used to examine the differences of driving simulator brake response time between groups. Pearson coefficient verified the correlation of driving simulator brake response time with years of driving, length of disability, handgrip strength and neuropsychological tests of the paraplegic drivers. A regression model was developed to describe the mean of driving simulator brake response time using the backward elimination method for model adjustment selecting the explanatory variables.Results: Differences of simulator brake response time between groups were not statistically significant (non-paraplegic drivers = 0.90 seconds; paraplegic drivers = 0.92 seconds, p > 0.05). Years of driving significantly correlates with brake response time of paraplegic driver (r= -58, p = 0.009). Linear regression analyses indicated that years of schooling and years of driving (explanatory variables) explained 60.2% of driving simulator brake response time for the drivers with paraplegia. Driving simulator brake response time showed no difference between drivers with and without paraplegia. Years of driving and schooling were the main predictors of braking performance in drivers with paraplegia measured in a driving simulator.

Minimal Clinically Important Differences for Measures of Pain, Lung Function, Fatigue, and Functionality in Spinal Cord Injury

OBJECTIVE

The objective of this study was to determine the minimal clinically important differences (MCIDs) for the numerical pain rating scale (NPRS), peak cough flow (PCF), peak expiratory flow (PEF), fatigue severity scale (FSS), and London chest activities of daily living scale (LCADL) in patients with spinal cord injuries (SCIs) after rehabilitation.

METHODS

Inpatients with SCI from 2 rehabilitation centers participating in a daily rehabilitation program were recruited. The NPRS, PCF, PEF, FSS, and LCADL were collected at baseline and discharge. The global rating of change scale was performed at discharge. MCIDs were calculated using anchor (linear regression, mean change, and receiver operating characteristic curves) and distribution-based methods (0.5 times the baseline SD, standard error of measurement, 1.96 times standard error of measurement, and minimal detectable change) and pooled using arithmetic weighted mean.

RESULTS

Sixty inpatients with SCI (36 males; 54.5 [15.9] years) participated. On average their rehabilitation program lasted 7.3 (1.7) weeks. Pooled MCID estimates were 1.6 points for the NPRS, 69.8 L/min for the PCF, 77.4 L/min for the PEF, 1.1 points for the FSS, and 1.4 points for the LCADL.

CONCLUSION

Established MCIDs for NPRS, PCF, PEF, FSS, and LCADL will help health professionals to interpret results and guide rehabilitation interventions in patients with SCI.

IMPACT

Health professionals and researchers may now use -1.6 points for the NPRS, 69.8 L/min for the PCF, 77.4 L/min for the PEF, 1.1 points for the FSS, and 1.4 points for the LCADL to interpret if changes in pain, cough intensity, expiratory flow, fatigue and activities of daily living after rehabilitation of patients with SCI have been clinically relevant.

Macrophage migration inhibitory factor as a therapeutic target after traumatic spinal cord injury: a systematic review

PURPOSE

Macrophages play an important role in mediating damage after Spinal cord injury (SCI) by secreting macrophage migration inhibitory factor (MMIF) as a secondary injury mediator. We aimed to systematically review the role of MMIF as a therapeutic target after traumatic SCI.

METHODS

Our systematic review has been performed according to the PRISMA 2009 Checklist. A systematic search in the scientific databases was carried out for studies published before 20 February 2019 from major databases. Two researchers independently screened titles. The risk of bias of eligible articles was assessed, and data were extracted. Finally, we systematically analyzed and interpreted related data.

RESULTS

785 papers were selected for the title and abstract screening. 12 papers were included for data extraction. Eight animal studies were of high quality and the remaining two were of medium quality. One of the two human studies was of poor quality and the other was of fair quality. MMIF as a pro-inflammatory mediator can cause increased susceptibility to glutamate-related neurotoxicity, increased nitrite production, increased ERK activation, and increased COX2/PGE2 signaling pathway activation and subsequent stimulation of CCL5-related chemotaxis. Two human studies and six animal studies demonstrated that MMIF level increases after SCI. MMIF inhibition might be a potential therapeutic target in SCI by multiple different mechanisms (6/12 studies).

CONCLUSION

Most animal studies demonstrate significant neurologic improvement after administration of MMIF inhibitors, but these inhibitors have not been studied in humans yet. Further clinical trials are need to further understand MMIF inhibitor utility in acute or chronic SCI.

LEVEL OF EVIDENCE I

Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Savings of loss-of-life expectancy and lifetime medical costs from prevention of spinal cord injuries: analysis of nationwide data followed for 17 years

BACKGROUND

The objectives of this research were to determine the savings of loss-of-life expectancy (LE) and lifetime medical costs (LMC) from prevention of spinal cord injuries (SCI) in Taiwan.

METHODS

From the claims database of Taiwan National Health Insurance, we identified 6164 adult patients with newly diagnosed SCI with permanent functional disability from 2000 to 2015 and followed them until the end of 2016. We estimated survival function through the Kaplan-Meier method and extrapolated it to lifetime.

RESULTS

For the SCI cohort, the LE and loss-of-LE were 17.6 and 13.3 years, respectively, while those for SCI with coding of external causes (E-code) were 18.1 and 13.0 years, respectively. For the SCI cohort with E-code, the loss-of-LE of motor vehicle (MV)-related SCI was significantly higher than that of fall-related SCI. In young and middle-aged patients with SCI with E-code, the loss-of-LE of MV-related paraplegia was significantly higher than that of MV-related quadriplegia and fall-related SCI. With a 3% discount rate, the LMC for patients with SCI after diagnosis were US$82 772, while those for patients with SCI with E-code were US$81 473. The LMC and the cost per year for those living with quadriplegia were significantly higher than those for paraplegia in all age groups, possibly related to the higher frequencies of stroke, chronic lung disease and dementia.

CONCLUSIONS

We conclude that quadriplegia has a higher impact on medical costs than paraplegia, and MV-related SCI has a higher impact on loss-of-LE than fall-related SCI. We recommend comprehensive SCI prevention be established, including infrastructures of construction and transportation.

Metastatic spine oncology: symptom-directed management

Spinal tumors pose significant treatment challenges for the physicians treating them. Understanding the location of the tumor within the intramedullary, intradural extramedullary, or extradural (epidural) space is not only critical in determining a differential diagnosis but may also provide important information about current and future neurologic deficits. Despite significant advances in the treatment of spinal tumors over the past few decades, these patients may still experience significant symptoms related to the tumor or its treatment, such as pain, weakness, impaired sensation, and bowel and bladder dysfunction. Treatment of spinal tumors should involve a multidisciplinary team of neuro-oncologists, spine surgeons, medical and radiation oncologists, physiatrists, and pain specialists to provide comprehensive oncologic management, while optimizing the patient's functional status and quality of life.

Topical Systematic and Synthetic Literature Review Regarding Men Sexual Dysfunctions after Spinal Cord Injury

Introduction Spinal cord injury (SCI) is a life-altering event usually associated with loss of motor and sensory, as well as with bladder, bowel and sexual, functions impairment. Recovering sexual function is one of the most important function tightly coupled with the life quality. In this respect, in the related literature can be found data regarding mainly: diagnosis/evaluation issues therapeutic/assistive-rehabilitative interventions (including connected to fertility troubles) and of psychological and or educational specific counseling, kind. Materials and methods.This paper presents a current systematic (of Preferred Reporting Items for Systematic Reviews and Meta-Analyses – PRISMA – type) and synthetic literature review on sexual dysfunctions and respected available management options in male subjects with SCI, using the following search keywords/ combinations of key words: “men”, “sexual dysfunction”/ “fertility” / “erectile dysfunction”/ “ejaculatory problems” / “sexual disorder“, “spinal cord injury”, “paraplegia”/ ”tetraplegia” /“paraplegic”/ ”tetraplegic”, “management”/ “treatment”, by interrogating international renown data bases: NCBI/PubMed, NCBI/PMC, Elsevier, PEDro and respectively, ISI Web of Knowledge/Science – to check whether the selected articles are published in ISI indexed journals – considering publications from January 2009 to June 2019, written in English, open access articles and being “fair”/“high” quality on our PEDro inspired, customized quality classification of the selected papers – the basic criterion, being the weighted citations number per year. Results. We have found initially 647 articles and eventually, after accomplishing the PRISMA stages (without meta-analysis), we have selected 16 articles matching all the above mentioned quest method’s requests (see further the figure representing our PRISMA type completed flow-diagram), covering (together with knowledge acquired from extra bibliographic resources, too). Conclusions. Sexual disfunctions after SCI are complex and strongly add to the severe and multimodal disability the affected people – in the case of our work: men – experience. Therefore, they worth being fathomed and periodically reappraised. Keywords: Spinal Cord injury (SCI), men sexual dysfunctions, systematic literature review, rehabilitation,

Benefits of robotic devices in medical rehabilitation of a case with neurofibromatosis type1

The term neurofibromatosis (NF) describes a group of genetic disorders that primarily affect the cell growth of neural tissues. Three clinically and genetically distinct forms of neurofibromatosis have been described: neurofibromatosis type 1 (NF1), neurofibromatosis type 2 (NF2) and schwannomatosis. The inheritance pattern is autosomal dominant for all three types. We present the case of a 57 years old man, admitted to the Medical Rehabilitation Clinical Hospital Baile Felix, Romania, who was diagnosed with spastic tetraparesis, neurofibromatosis type 1, chronic viral hepatitis B and D, hypercholesterolemia, sarcopenia and osteoporosis. The objectives of the rehabilitation treatment were combating pain; preventing and correcting vicious postures at rest and during activity; maintaining or increasing joint mobility; increasing the mobility of the cervical and lumbar spine; decreasing spasticity; increasing strength of paralyzed muscles; improving motor control of paralyzed limbs; transfers re-education, gait re-education; improving breathing; improving ADLs; maintaining autonomy; gaining daily independence; prevention of recurrent complications and increasing the quality of life. The rehabilitation treatment was complex, performed over a period of 2 weeks and included various physiotherapy approaches, hydrokinetotherapy, massage, occupational therapy, robotic devices and virtual reality. It improved the patient's functional independence and quality of life. Innovations in information technology will refine and increase the efficiency, expertise and competence of medical rehabilitation, in order to ensure comfort for the patient and an appropriate and safe therapeutic approach. Keywords: neurofibromatosis, robotic devices, medical rehabilitation,

The effectiveness of ergo- and psychotherapy in the process of sanatorium-resort treatment of spinal patients

The aim is to explore the possibilities of improving motor and sensitive disorders to ensure the highest possible social adaptation - the expansion of self-service skills, opportunities for affordable employment, or the restoration of professional activity flax. Methods: To study the possibilities of improving the social reintegration of patients during rehabilitation in a mud resort, we observed 240 patients who had an injury to the cervical spine 24 years. Disease duration ranged before 3 years, 4-7 years, more 7 years. We studied the occupational therapy method and group psychotherapy method. All patients were divided into three representative groups: 91 patients (group 1) received a course of balneoplasty therapy in the form of mud applications on the spine and lower limbs at a temperature 42-44 0C, exposure time 20 min, placement of procedures - every other day, for a total of 12-15 procedures per treatment; on days free of mud cure, hydrokinesitherapy was performed in a pool with warm (29-32 0С) brine water, 12-15 procedures, and also apparatus physiotherapy procedures, massage and exercise therapy. In addition to the course of balneopedotherapy, 149 patients also received ergo-therapy and psychotherapy (90 people - group 2) and only occupational therapy - 59 people (group 3). Results: Improvement of post-traumatic organic neurological disorders caused by balneo-mud therapy creates a favorable basis for conducting training activities that expand patients’ functionality. The inclusion of ergotherapy in the rehabilitation process of spinal patients in a balneo-mud resort is appropriate and justified. It allows not only to expand the functionality of patients but also to reduce the time to master the essential self-care skills and consolidate them. Conclusion: The inclusion of psychotherapy in the complex of occupational therapy is desirable. It allows you to influence the psycho-emotional state of the patient and improve the effectiveness of training activities, especially in male patients. Changing the hospital and closed home atmosphere to the conditions of the resort, the possibility of broad communication, participation in various social events significantly change the psycho-emotional state of patients, increasing their activity, causing an increase in the setting for inclusion inactive life.. Keywords: ergotherapy, psychotherapy, spinal injuries, activity and participation, rehabilitation, social adaptation,

Clinical Protocol for Identifying and Managing Bladder Dysfunction during Acute Care after Traumatic Spinal Cord Injury

Bladder dysfunction is widespread following traumatic spinal cord injury (TSCI). Early diagnosis of bladder dysfunction is crucial in preventing complications, determining prognosis, and planning rehabilitation. We aim to suggest the first clinical protocol specifically designed to evaluate and manage bladder dysfunction in TSCI patients during acute care. A retrospective cohort study was conducted on 101 patients admitted for an acute TSCI between C1 and T12. Following spinal surgery, presence of voluntary anal contraction (VAC) was used as a criterion for removal of indwelling catheter and initiating trial of void (TOV). Absence of bladder dysfunction was determined from three consecutive post-void bladder scan residuals ≤200 mL without incontinence. All patients were reassessed 3 months post-injury using the Spinal Cord Independence Measure (SCIM). A total of 74.3% were diagnosed with bladder dysfunction during acute care, while 57.4% had a motor-complete TSCI. Three months later, 94.7% of them reported impaired bladder function. None of the patients discharged from acute care after a functional bladder was diagnosed reported impaired bladder function at the 3-month follow-up. A total of 95.7% patients without VAC had persisting impaired bladder function at follow-up. The proposed protocol is specifically adapted to the dynamic nature of neurogenic bladder function following TSCI. The assessment of VAC into the protocol provides major insight on the potential for reaching adequate bladder function during the subacute phase. Conducting TOV using bladder scan residuals in patients with VAC is a non-invasive and easy method to discriminate between a functional and an impaired bladder following acute TSCI.

Mesenchymal Stem Cell-Derived Exosomes: Hope for Spinal Cord Injury Repair

Spinal cord injury (SCI) is a devastating medical condition with profound social and economic impacts. Although research is ongoing, current treatment options are limited and do little to restore functionality. However, recent studies suggest that mesenchymal stem cell-derived exosomes (MSC-exosomes) may hold the key to exciting new treatment options for SCI patients. MSCs are self-renewing multipotent stem cells with multi-directional differentiation and can secrete a large number of exosomes (vesicles secreted into the extracellular environment through endocytosis, called MSC-exosomes). These MSC-exosomes play a critical role in repairing SCI through promoting angiogenesis and axonal growth, regulating inflammation and the immune response, inhibiting apoptosis, and maintaining the integrity of the blood-spinal cord barrier. Furthermore, they can be utilized to transport genetic material or drugs to target cells, and their relatively small size makes them able to permeate the blood-brain barrier. In this review, we summarize recent advances in MSC-exosome themed SCI treatments and cell-free therapies to better understand this newly emerging methodology.

(-)-Epicatechin reduces muscle waste after complete spinal cord transection in a murine model: role of ubiquitin-proteasome system

The skeletal muscle mass reduces 30-60% after spinal cord injury, this is mostly due to protein degradation through ubiquitin-proteasome system. In this work, we propose that the flavanol (-)-epicatechin, due its widespread biological effects on muscle health, can prevent muscle mass decrease after spinal cord injury. Thirty-six female Long Evans rats were randomized into 5 groups: (1) Spinal cord injury 7 days, (2) Spinal cord injury + (-)-epicatechin 7 days, (3) Spinal cord injury 30 days, (4) Spinal cord injury + (-)-epicatechin 30 days and (5) Sham (Only laminectomy). Hind limb perimeter, muscle cross section area, fiber cross section area and ubiquitin-proteasome system protein expression together with total protein ubiquitination were assessed. At 30 days Spinal cord injury group lost 49.52 ± 2.023% of muscle cross section area (-)-epicatechin treated group lost only 24.28 ± 15.45% being a significant difference. Ubiquitin-proteasome markers showed significant changes. FOXO1a increased in spinal cord injury group vs Sham (-)-epicatechin reduced this increase. In spinal cord injury group MAFbx increased significantly vs Sham but decrease in (-)-epicatechin treatment group at 30 days. At 7 and 30 days MuRF1 increased in the spinal cord injury and decreased in the (-)-epicatechin group. The global protein ubiquitination increases after spinal cord injury, epicatechin treatment induce a significant decrease in protein ubiquitination. These results suggest that (-)-epicatechin reduces the muscle waste after spinal cord injury through down regulation of the ubiquitin-proteasome system.

Multidisciplinary Outpatient Cancer Rehabilitation Can Improve Cancer Patients' Physical and Psychosocial Status-a Systematic Review

PURPOSE OF REVIEW

This systematic review aimed to determine the effects of interdisciplinary/multidisciplinary outpatient rehabilitation programmes by looking at physical, psychosocial and return to work status of adult cancer patients.

RECENT FINDINGS

There is growing evidence that emphasizes the importance of interdisciplinary/multidisciplinary rehabilitation especially in outpatient care, which addresses the complex and individual needs of cancer patients. Many studies focus on measuring the effect of individual rehabilitation interventions. Randomized controlled trials (RCTs) and before-after studies examining the effects of interdisciplinary/multidisciplinary outpatient rehabilitation programmes were included in this systematic review. The electronic literature search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and PEDro. The PICO statement was used for selection of the studies. Six randomized controlled trials and six before-after studies were included. Interdisciplinary/multidisciplinary outpatient cancer rehabilitation programmes improved physical and/or psychosocial status of cancer patients. However, non-significant changes in a variety of single physical and psychosocial measures were also common. The findings of the systematic review indicate that interdisciplinary/multidisciplinary outpatient cancer rehabilitation can improve cancer patients' physical and psychosocial status. This review is limited by the narrative approach due to the heterogeneity of outcome measures. To evaluate effects of rehabilitation, better comparable studies are necessary. Further research is needed in regard to long-term outcomes, effects on return to work status and on the associations depending on cancer type.

"Spirituality is everybody's business": an exploration of the impact of spiritual care training upon the perceptions and practice of rehabilitation professionals

PURPOSE

This study explored the impact of a brief spiritual care training program upon the perceptions and self-reported practice of rehabilitation professionals working in traumatic injury.

METHODOLOGY AND METHODS

A qualitative study. Semi-structured interviews were held with staff from a rehabilitation hospital in Sydney, Australia, between six and eight weeks after participation in spiritual care training. A thematic analysis was conducted.

RESULTS

Of the 41 rehabilitation professionals who attended the training (1 h online, 1.5 h face to face), 16 agreed to be interviewed. The majority worked in spinal cord injury and were female. Half reported holding a Christian affiliation. One overarching theme and six sub-themes were identified from the qualitative data. The overarching theme was "spirituality is everybody's business". The six sub-themes were: (i) increased awareness of the nature of spirituality, (ii) realisation of the importance of spirituality to clients, (iii) a desire to keep spirituality on the radar, (iv) identifying barriers to providing spiritual care (v) incorporating spirituality into practice, and, (vi) recognising spirituality as personally meaningful.

CONCLUSIONS

A brief spiritual care training program can impact positively upon perceptions and practice of rehabilitation professionals. Ongoing training is needed to ensure that staff retain what was learnt. IMPLICATIONS FOR REHABILITATION Brief spiritual care training can impact positively upon rehabilitation professionals' perceptions of spirituality and lead to practice change in the delivery of spiritual care across many clinical disciplines. The stories of patients and family members are powerful staff education tools in spiritual care training. Client spirituality is an under recognised resource that staff can draw upon in supporting and enhancing the rehabilitation process.

"Unknown world of wheelchairs" A mixed methods study exploring experiences of wheelchair and seating assistive technology provision for people with spinal cord injury in an Irish context

AIM

This study explores people living with spinal cord injury (SCI) experiences and perspectives of wheelchair and seating assistive technology service provision within an Irish context. There are few studies that examine the process of wheelchair and seating provision and the connection between satisfaction, performance, and participation.

METHOD

This mixed methods study explores participant experiences in two parts. Part one presents a thematic analysis of eight in-depth semi-structured interviews with wheelchair service users living with SCI. Part two presents the results content and frequency analysis of an on-line survey of wheelchair service user's experience and satisfaction with wheelchair and seating service provision from respondents with SCI (n = 117) taken from a larger national survey from respondents with various diagnoses (n = 273).

RESULTS

Findings from the interviews and survey revealed the meaning of wheelchair and seating assistive technology provision as essential to life following SCI. Barriers within the provision system such as wait times and funding were found to impede people's rights and freedom from initial assessment through to follow up, maintenance and repair.

CONCLUSIONS

The current implementation of wheelchair and seating assistive technology provision as described in this paper impacts the ability of individuals living with an SCI to participate as equal members of society. A review of wheelchair provision is essential to optimize access to services for appropriate wheelchairs.IMPLICATIONS FOR REHABILITATIONAs a basic human right, appropriate wheelchair and seating assistive technology provision facilitates people's optimal independence, health and well-being, social engagement, and participation in everyday life.The development of adequate wheelchair services should be a priority area for individuals with SCI who use wheelchair and seating assistive technology.National wheelchair and seating assistive technology provision policies in alignment with internationally developed best practice guidelines to provide equal access to services which include assessment, delivery, training, maintenance, and follow-up are essential.

Treatment of spinal cord injury with mesenchymal stem cells

Background

Spinal cord injury (SCI) is the damage to the spinal cord that can lead to temporary or permanent loss of function due to injury to the nerve. The SCI patients are often associated with poor quality of life.

Results

This review discusses the current status of mesenchymal stem cell (MSC) therapy for SCI, criteria to considering for the application of MSC therapy and novel biological therapies that can be applied together with MSCs to enhance its efficacy. Bone marrow-derived MSCs (BMSCs), umbilical cord-derived MSCs (UC-MSCs) and adipose tissue-derived MSCs (ADSCs) have been trialed for the treatment of SCI. Application of MSCs may minimize secondary injury to the spinal cord and protect the neural elements that survived the initial mechanical insult by suppressing the inflammation. Additionally, MSCs have been shown to differentiate into neuron-like cells and stimulate neural stem cell proliferation to rebuild the damaged nerve tissue.

Conclusion

These characteristics are crucial for the restoration of spinal cord function upon SCI as damaged cord has limited regenerative capacity and it is also something that cannot be achieved by pharmacological and physiotherapy interventions. New biological therapies including stem cell secretome therapy, immunotherapy and scaffolds can be combined with MSC therapy to enhance its therapeutic effects.

"I was like intoxicated with this positivity": the politics of hope amongst participants in a trial of a novel spinal cord injury rehabilitation technology in South Africa

PURPOSE

This study discussed the reports by participants in a randomised controlled trial of a novel intervention for spinal cord injury (SCI) rehabilitation in Cape Town, South Africa.

MATERIALS AND METHODS

Sixteen participants were randomised to rehabilitation involving the use of robotic locomotor training, a novel technology, or to a group receiving an activity-based intervention. All participants were interviewed before the intervention and at six months follow-up.

RESULTS

In a context in which rehabilitation services for SCI are virtually non-existent, all participants approached the study with enthusiasm and expressed gratitude for participation. They had high hopes for what the programme could achieve, with many believing, perhaps incorrectly, that the programme would help them walk independently again. While hope and enthusiasm are useful for adherence to experimental intervention studies, there is a danger, especially in poorly resourced contexts, for participants to experience considerable disappointment following false hope not being realised. This raises important ethical issues for researchers interested in the potential of new technologies to promote health in poorly resourced contexts.

CONCLUSIONS

For clinicians, the path between supporting positive emotions (which may lead to positive outcomes), and confronting unrealistic hope (which may lead to negative outcomes) may be difficult. Follow-up with participants after re-integration into their communities is important to determine long-term psychological impact.Pan African Clinical Trial Number: PACTR201608001647143IMPLICATIONS FOR REHABILITATIONIn low-resource contexts where there is a low level of access to rehabilitation services, such access in the context of a trial of a new intervention may engender hope in a group of people with spinal cord injury. This hope may increase when a new technology is used, as was the case in this study.Hope can be very helpful to people entering rehabilitation, but unrealistic hope and expectations may have negative implications in the longer term.In this study, expectations of participants centred, unrealistically, around regaining the ability to walk again, despite past experiences and medical advice suggesting otherwise.A thin line exists between supporting high expectations and confronting unrealistic hope. This conundrum is difficult for the clinician, as both inappropriate hope and undue pessimism about an intervention have the potential to cause harm.Participant follow-up after the end of any innovative trial is important, not just to monitor physical progress, but also, where necessary, to support participants through a potential period of disillusionment when they find their expectations have not been fully met.

The effectiveness of ergo- and psychotherapy in the process of sanatorium-resort treatment of spinal patients

The aim is to explore the possibilities of improving motor and sensitive disorders to ensure the highest possible social adaptation - the expansion of self-service skills, opportunities for affordable employment, or the restoration of professional activity flax. Methods: To study the possibilities of improving the social reintegration of patients during rehabilitation in a mud resort, we observed 240 patients who had an injury to the cervical spine 24 years. Disease duration ranged before 3 years, 4-7 years, more 7 years. We studied the occupational therapy method and group psychotherapy method. All patients were divided into three representative groups: 91 patients (group 1) received a course of balneoplasty therapy in the form of mud applications on the spine and lower limbs at a temperature 42-44 0C, exposure time 20 min, placement of procedures - every other day, for a total of 12-15 procedures per treatment; on days free of mud cure, hydrokinesitherapy was performed in a pool with warm (29-32 0С) brine water, 12-15 procedures, and also apparatus physiotherapy procedures, massage and exercise therapy. In addition to the course of balneopedotherapy, 149 patients also received ergo-therapy and psychotherapy (90 people - group 2) and only occupational therapy - 59 people (group 3). Results: Improvement of post-traumatic organic neurological disorders caused by balneo-mud therapy creates a favorable basis for conducting training activities that expand patients’ functionality. The inclusion of ergotherapy in the rehabilitation process of spinal patients in a balneo-mud resort is appropriate and justified. It allows not only to expand the functionality of patients but also to reduce the time to master the essential self-care skills and consolidate them. Conclusion: The inclusion of psychotherapy in the complex of occupational therapy is desirable. It allows you to influence the psycho-emotional state of the patient and improve the effectiveness of training activities, especially in male patients. Changing the hospital and closed home atmosphere to the conditions of the resort, the possibility of broad communication, participation in various social events significantly change the psycho-emotional state of patients, increasing their activity, causing an increase in the setting for inclusion inactive life.

Determining grasp selection from arm trajectories via deep learning to enable functional hand movement in tetraplegia

Background

Cervical spinal cord injury severely affects grasping ability of its survivors. Fortunately, many individuals with tetraplegia retain residual arm movements that allow them to reach for objects. We propose a wearable technology that utilizes arm movement trajectory information and deep learning methods to determine grasp selection. Furthermore, we combined this approach with neuromuscular stimulation to determine if self-driven functional hand movement could be enabled in spinal cord injury participants.

Methods

Two cervical SCI participants performed arbitrary and natural reaching movements toward target objects in three-dimensional space, which were recorded using an inertial sensor worn on their wrist. Time series classifiers were trained to recognize the trajectories using either a Dynamic Time Warping (DTW) algorithm or a Long Short-Term Memory (LSTM) recurrent neural network. As an initial proof-of-concept, we demonstrate real-time classification of the arbitrary movements using DTW only (due to its implementation simplicity), which when used in combination with a high density neuromuscular stimulation sleeve with textile electrodes, enabled participants to perform functional grasping.

Results

Participants were able to consistently perform arbitrary two-dimensional and three-dimensional arm movements which could be classified with high accuracy. Furthermore, it was found that natural reaching trajectories for two different target objects (requiring two different grasp types) were distinct and also discriminable with high accuracy. In offline comparisons, LSTM (mean accuracies 99%) performed significantly better than DTW (mean accuracies 86 and 83%) for both arbitrary and natural reaching movements, respectively. Type I and II errors occurred more frequently for DTW (up to 60 and 15%, respectively), whereas it stayed under 5% for LSTM. Also, DTW achieved online accuracy of 79%.

Conclusions

We demonstrate the feasibility of utilizing arm trajectory information to determine grasp selection using a wearable inertial sensor along with DTW and deep learning methods. Importantly, this technology can be successfully used to control neuromuscular stimulation and restore functional independence to individuals living with paralysis.

Trial registration

NCT, NCT03385005. Registered September 26, 2017.

Exploring the causes and impacts of falls among ambulators with spinal cord injury using photovoice: a mixed-methods study

OBJECTIVES

This study explored: (1) fall circumstances experienced by ambulators with spinal cord injury (SCI) over a 6-month period, (2) the impacts of falls-related injuries and fall risk and (3) their preferences/recommendations for fall prevention.

DESIGN

A sequential explanatory mixed-methods design with two phases.

SETTING

A Canadian SCI rehabilitation hospital and community setting.

PARTICIPANTS

Thirty-three ambulators with SCI participated in phase 1 and eight participants that fell in phase 1 participated in phase 2.

METHODS

In phase 1, fall circumstances were tracked using a survey that was completed each time a participant fell during the 6-month tracking period. Phase 2 involved photovoice; participants took photographs of factors that influenced their fall risk and how their fall risk impacted their work/recreational activities. Participants discussed the photographs and topics related to fall prevention in an individual interview and a focus group.

RESULTS

Of the 33 participants, 21 fell in 6 months. Falls commonly occurred in the home while participants were changing positions or walking. Most falls occurred in the morning or afternoon. In phase 2, interviews and focus group discussion revealed three themes: (1) falls are caused by bodily impairments (eg, impaired reactive response during slips and trips and weakness and altered sensation in legs/feet), (2) impacts of fall-related injuries and fall risk (eg, psychosocial effects of fall-related injuries, limiting community participation due to the risk of falling and activity-dependent concern of falling) and (3) approaches to fall prevention (eg, fall prevention strategies used, components of fall prevention and utility of professional fall prevention strategies/interventions).

CONCLUSIONS

Fall prevention interventions/strategies should focus on minimising a person's fall risk within their home as most falls occurred in the home environment. Ambulators with SCI would benefit from education and awareness about common fall circumstances that they may encounter in their daily lives.

MicroRNA339 Targeting PDXK Improves Motor Dysfunction and Promotes Neurite Growth in the Remote Cortex Subjected to Spinal Cord Transection

Spinal cord injury (SCI) is a fatal disease that can cause severe disability. Cortical reorganization subserved the recovery of spontaneous function after SCI, although the potential molecular mechanism in this remote control is largely unknown. Therefore, using proteomics analysis, RNA interference/overexpression, and CRISPR/Cas9 in vivo and in vitro, we analyzed how the molecular network functions in neurological improvement, especially in the recovery of motor function after spinal cord transection (SCT) via the remote regulation of cerebral cortex. We discovered that the overexpression of pyridoxal kinase (PDXK) in the motor cortex enhanced neuronal growth and survival and improved locomotor function in the hindlimb. In addition, PDXK was confirmed as a target of miR-339 but not miR-124. MiR-339 knockout (KO) significantly increased the neurite outgrowth and decreased cell apoptosis in cortical neurons. Moreover, miR-339 KO rats exhibited functional recovery indicated by improved Basso, Beattie, and Bresnehan (BBB) score. Furthermore, bioinformatics prediction showed that PDXK was associated with GAP43, a crucial molecule related to neurite growth and functional improvement. The current research therefore confirmed that miR-339 targeting PDXK facilitated neurological recovery in the motor cortex of SCT rats, and the underlying mechanism was associated with regulating GAP43 in the remote cortex of rats subjected to SCT. These findings may uncover a new understanding of remoting cortex control following SCI and provide a new therapeutic strategy for the recovery of SCI in future clinical trials.

Stem Cell Conditioned Medium Treatment for Canine Spinal Cord Injury: Pilot Feasibility Study

Spinal cord injury (SCI) involves nerve damage and often leads to motor, sensory and autonomic dysfunctions. In the present study, we have designed a clinical protocol to assess the feasibility of systemic delivery of allogenic canine bone marrow tissue-derived mesenchymal stem cell conditioned medium (BMMSC CM) to dogs with SCI. Four client-owned dogs with chronic SCI lasting more than six months underwent neurological and clinical evaluation, MRI imaging and blood tests before being enrolled in this study. All dogs received four intravenous infusions with canine allogenic BMMSC CM within one month. Between the infusions the dogs received comprehensive physiotherapy, which continued for three additional months. No adverse effects or complications were observed during the one, three and six months follow-up periods. Neither blood chemistry panel nor hematology profile showed any significant changes. All dogs were clinically improved as assessed using Olby locomotor scales after one, three and six months of BMMSC CM treatment. Furthermore, goniometric measurements revealed partial improvement in the range of joint motion. Bladder function improved in two disabled dogs. We conclude that multiple delivery of allogenic cell-derived conditioned medium to dogs with chronic SCI is feasible, and it might be clinically beneficial in combination with physiotherapy.

[Return to work in patients with traumatic spinal cord injury in a medical center in Mexico]

BACKGROUND AND OBJECTIVE

One of the most important outcomes regarding social reintegration after a traumatic spinal cord injury is social reinsertion; despite its huge impact, very few studies in Mexico have measured community reintegration in these patients. The objective of this study was to analyse the working situation of patients with traumatic spinal cord injury at a hospital centre in Mexico.

MATERIAL AND METHODS

Cross-sectional descriptive study. Working patients, aged 19-55 years, diagnosed with traumatic spinal cord injury at a hospital centre in Mexico were included; a telephone survey was performed.

RESULTS

Eighteen patients were included (15 men, 3 women), with a mean age of 38 years (± 10.3). The most common levels of injury were cervical and thoracic; the most common Asia Impairment Scale grades were A and E; 17 patients were included at a rehabilitation programme at discharge; the average Spinal Cord Independence Measure score was 65.22 (± 35.11). Five patients were hired after the injury in a mean period of 7 months (± 2.9). The main factors associated with occupational reintegration were young age, lower injury levels, an adequate rehabilitation programme, high Spinal Cord Independence Measure scale score, and being married or cohabiting.

CONCLUSION

This study shows the low return to work rate after a traumatic spinal cord injury, as well as the main factorsa affecting it; highlighting the importance of an adeaquate rehabilitation program with a multidisciplinary approach.

Cell Therapies for Spinal Cord Injury: Trends and Challenges of Current Clinical Trials

Cell therapies have the potential to revolutionize the treatment of spinal cord injury. Basic research has progressed significantly in recent years, with a plethora of cell types now reaching early-phase human clinical trials, offering new strategies to repair the spinal cord. However, despite initial enthusiasm for preclinical and early-phase clinical trials, there has been a notable hiatus in the translation of cell therapies to routine clinical practice. Here, we review cell therapies that have reached clinical trials for spinal cord injury, providing a snapshot of all registered human trials and a summary of all published studies. Of registered trials, the majority have used autologous cells and approximately a third have been government funded, a third industry sponsored, and a third funded by university or healthcare systems. A total of 37 cell therapy trials have been published, primarily using stem cells, although a smaller number have used Schwann cells or olfactory ensheathing cells. Significant challenges remain for cell therapy trials in this area, including achieving stringent regulatory standards, ensuring appropriately powered efficacy trials, and establishing sustainable long-term funding. However, cell therapies hold great promise for human spinal cord repair and future trials must continue to capitalize on the exciting developments emerging from preclinical studies.

Experiences with and perspectives on goal setting in spinal cord injury rehabilitation: a systematic review of qualitative studies

STUDY DESIGN

Systematic review of qualitative studies.

OBJECTIVE

To synthesise qualitative research exploring the experiences and perspectives of persons with spinal cord injury (SCI), relatives and health professionals concerning goal setting in SCI rehabilitation.

METHODS

Five electronic databases were searched. A search strategy was constructed with key concepts identified using PICo (Population, phenomena of Interest and Context). Peer reviewed studies complying with the inclusion criteria were selected. Interpretive Description methodology guided analysis and synthesis of the findings.

RESULTS

The search yielded 427 records. Of 12 full text studies assessed for eligibility, four were included describing goal setting in SCI rehabilitation from the perspective of persons with SCI and health professionals. Persons with SCI described a need for goal setting to be related to their everyday life, whereas the health professionals tended to use the hospital setting as their point of reference. Persons with SCI emphasised the importance of being self-directed and taking an active role in goal setting and rehabilitation. No studies presented the perspective of relatives.

CONCLUSIONS

This review illuminates the divergence in the understanding of goal setting between persons with SCI and health professionals. Goal setting in SCI rehabilitation often directly reflects physical functioning goals set by the health professionals, which does not prepare persons with SCI for everyday life and emotional issues. There is lack of focus on goals addressing psychosocial components such as family issues and change of roles. A shared process with goal setting relevant to persons with SCI and their everyday life is needed.

Toward a framework for developing an ICF-based documentation system in spinal cord injury-specific rehabilitation based on routine clinical practice: a case study approach

STUDY DESIGN

Case study.

OBJECTIVE

To present a framework for developing an International Classification of Functioning, Disability and Health (ICF)-based documentation system in spinal cord injury (SCI)-specific rehabilitation.

SETTING

Data collection took place at Maharaj Hospital, Thailand. The preparatory studies and analysis were performed at Swiss Paraplegic Research, Switzerland.

METHODS

Data collected from interviews and health records of four SCI cases across the continuum of care (acute, post-acute, early and late long term) were linked to ICF categories using established ICF linking rules. The resulting categories were compared with selected ICF sets (ICF Generic-30, ICF core sets for SCI and multiple sclerosis) to determine the extent of coverage. Furthermore, the context of applicable services was described systematically.

RESULTS

Less than half of the ICF categories in the defined ICF sets were covered by clinical assessment tools. Low correspondence was found predominantly in acute and late long-term phase. Least well covered were categories of activities and participations and environmental factors. The correspondence of categories increased when considering the additional ICF categories identified from patient interviews. The description of rehabilitation services provided in each case classified according to the dimensions of service provider, funding, and service delivery.

CONCLUSIONS

There is a need to promote the systematic and standardized assessment of functioning among health professionals working in the field of SCI in developing countries. This study describes basic steps toward developing a standardized ICF-based system for assessing and reporting functioning outcomes in SCI rehabilitation and across the continuum of care.