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Debenham MIB, Franz CK, Berger MJ. Neuromuscular consequences of spinal cord injury: New mechanistic insights and clinical considerations. Muscle Nerve 2024; 70:12-27. [PMID: 38477416 DOI: 10.1002/mus.28070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 03/14/2024]
Abstract
The spinal cord facilitates communication between the brain and the body, containing intrinsic systems that work with lower motor neurons (LMNs) to manage movement. Spinal cord injuries (SCIs) can lead to partial paralysis and dysfunctions in muscles below the injury. While traditionally this paralysis has been attributed to disruptions in the corticospinal tract, a growing body of work demonstrates LMN damage is a factor. Motor units, comprising the LMN and the muscle fibers with which they connect, are essential for voluntary movement. Our understanding of their changes post-SCI is still emerging, but the health of motor units is vital, especially when considering innovative SCI treatments like nerve transfer surgery. This review seeks to collate current literature on how SCI impact motor units and explore neuromuscular clinical implications and treatment avenues. SCI reduced motor unit number estimates, and surviving motor units had impaired signal transmission at the neuromuscular junction, force-generating capacity, and excitability, which have the potential to recover chronically, yet the underlaying mechanisms are unclear. Furthermore, electrodiagnostic evaluations can aid in assessing the health lower and upper motor neurons, identify suitable targets for nerve transfer surgeries, and detect patients with time sensitive injuries. Lastly, many electrodiagnostic abnormalities occur in both chronic and acute SCI, yet factors contributing to these abnormalities are unknown. Future studies are required to determine how motor units adapt following SCI and the clinical implications of these adaptations.
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Affiliation(s)
- Mathew I B Debenham
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Colin K Franz
- Biologics Laboratory, Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael J Berger
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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2
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Solinsky R, Burns K, Taylor JA, Singer W. Valsalva maneuver pressure recovery time is prolonged following spinal cord injury with correlations to autonomically-influenced secondary complications. Clin Auton Res 2024:10.1007/s10286-024-01040-5. [PMID: 38916658 DOI: 10.1007/s10286-024-01040-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 05/14/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE This work's purpose was to quantify rapid sympathetic activation in individuals with spinal cord injury (SCI), and to identify associated correlations with symptoms of orthostatic hypotension and common autonomically mediated secondary medical complications. METHODS This work was a cross-sectional study of individuals with SCI and uninjured individuals. Symptoms of orthostatic hypotension were recorded using the Composite Autonomic Symptom Score (COMPASS)-31 and Autonomic Dysfunction following SCI (ADFSCI) survey. Histories of secondary complications of SCI were gathered. Rapid sympathetic activation was assessed using pressure recovery time of Valsalva maneuver. Stepwise multiple linear regression models identified contributions to secondary medical complication burden. RESULTS In total, 48 individuals (24 with SCI, 24 uninjured) underwent testing, with symptoms of orthostatic hypotension higher in those with SCI (COMPASS-31, 3.3 versus 0.6, p < 0.01; ADFSCI, 21.2 versus. 3.2, p < 0.01). Pressure recovery time was prolonged after SCI (7.0 s versus. 1.7 s, p < 0.01), though poorly correlated with orthostatic symptom severity. Neurological level of injury after SCI influenced pressure recovery time, with higher injury levels associated with more prolonged time. Stepwise multiple linear regression models identified pressure recovery time as the primary explanation for variance in number of urinary tract infections (34%), histories of hospitalizations (12%), and cumulative secondary medical complication burden (24%). In all conditions except time for bowel program, pressure recovery time outperformed current clinical tools for assessing such risk. CONCLUSIONS SCI is associated with impaired rapid sympathetic activation, demonstrated here by prolonged pressure recovery time. Prolonged pressure recovery time after SCI predicts higher risk for autonomically mediated secondary complications, serving as a viable index for more "autonomically complete" injury.
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Affiliation(s)
- Ryan Solinsky
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN, USA.
- Spaulding Rehabilitation Hospital, Cambridge, MA, USA.
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, MA, USA.
| | - Kathryn Burns
- Spaulding Rehabilitation Hospital, Cambridge, MA, USA
| | - J Andrew Taylor
- Spaulding Rehabilitation Hospital, Cambridge, MA, USA
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, MA, USA
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Solinsky R, Burns K, Hamner JW, Singer W, Taylor JA. Characterizing preserved autonomic regulation following spinal cord injury: Methods of a novel concerted testing battery and illustrative examples of a new translationally focused data representation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.31.24308290. [PMID: 38854077 PMCID: PMC11160853 DOI: 10.1101/2024.05.31.24308290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Autonomic dysfunction is common after spinal cord injury, though differing from motor and sensory function, there are currently no established batteries of tests to comprehensively characterize these deficits. Further, while individual established autonomic tests have a long history and sound scientific background, translating these autonomic testing results to inform clinical understanding is a major barrier. Herein, we outline a battery of six laboratory autonomic tests which were carefully curated to collectively describe the ability of individuals with spinal cord injury to inhibit and recruit sympathetic activity through the injured spinal cord. Presenting normative control data in 23 uninjured individuals completing this testing battery, we further demonstrate the utility of extracting three key testing metrics for each test, comparing these control results to 11 individuals with spinal cord injury. Results demonstrate strong normality of data with testing psychometrics suggesting reliable reproducibility on repeat testing. Further, even in this preliminary sample of individuals with spinal cord injuries, clear differences begin to emerge. This illustrates the ability of this collective testing battery to characterize autonomic regulation after spinal cord injury. To aid in clinical translation, we further present a graphical representation, an autonomic phenotype, which serves as a snapshot of how normal or abnormal sympathetic inhibition and recruitment of activation may be after spinal cord injury. Utilizing these autonomic phenotypes, three example cases of individuals with spinal cord injury highlight evidence of varied degrees of autonomically complete spinal cord injury. Together, this represents a key advancement in our understanding of autonomic function after spinal cord injury.
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Burns K, Solinsky R. Autonomic impairment is not explained by neurological level of injury or motor-sensory completeness. Spinal Cord 2024:10.1038/s41393-024-00994-7. [PMID: 38609568 DOI: 10.1038/s41393-024-00994-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 03/29/2024] [Accepted: 04/08/2024] [Indexed: 04/14/2024]
Abstract
STUDY DESIGN Cross-sectional study. OBJECTIVES Determine how well common clinical assessments of level and completeness of injury are correlated with symptoms of autonomic blood pressure instability and secondary medical complications after spinal cord injury (SCI). SETTING Academic medical center, United States. METHODS Eighty-two individuals with (n = 48) and without (n = 34) SCI had symptoms of autonomic blood pressure instability quantified with the Autonomic Dysfunction Following SCI (ADFSCI) survey. Health histories quantified the secondary medical complications through number of urinary tract infections and hospitalizations in the past year, time to complete bowel program, and lifetime pressure injuries. Regression models were completed to identify strengths of associated correlations. RESULTS ADFSCI scores were significantly higher in individuals with SCI than controls. Neurological level of injury and ASIA impairment scale were both minimally correlated to symptoms of autonomic blood pressure instability, accounting for only 11.5% of variability in regression models. Secondary medical complications had similar, minimal correlations to level and motor/sensory completeness of SCI (R2 = 0.07 and R2 = 0.03 respectively). Contrasting this, symptoms of blood pressure instability on ADFSCI far outperformed the common clinical motor/sensory bedside exam, with moderately strong correlations to the ranked number of secondary medical complications after SCI (R2 = 0.31). CONCLUSION Neurological level of injury and motor/sensory completeness provided limited insights into which individuals with SCI would have blood pressure instability or secondary medical complications. Interestingly, symptoms of blood pressure instability outperform the clinical motor/sensory bedside exam, with higher correlations to secondary medical complications after SCI.
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Affiliation(s)
| | - Ryan Solinsky
- Spaulding Rehabilitation Hospital, Boston, USA.
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, USA.
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, USA.
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5
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Ji W, Nightingale TE, Zhao F, Fritz NE, Phillips AA, Sisto SA, Nash MS, Badr MS, Wecht JM, Mateika JH, Panza GS. The Clinical Relevance of Autonomic Dysfunction, Cerebral Hemodynamics, and Sleep Interactions in Individuals Living With SCI. Arch Phys Med Rehabil 2024; 105:166-176. [PMID: 37625532 DOI: 10.1016/j.apmr.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/25/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023]
Abstract
A myriad of physiological impairments is seen in individuals after a spinal cord injury (SCI). These include altered autonomic function, cerebral hemodynamics, and sleep. These physiological systems are interconnected and likely insidiously interact leading to secondary complications. These impairments negatively influence quality of life. A comprehensive review of these systems, and their interplay, may improve clinical treatment and the rehabilitation plan of individuals living with SCI. Thus, these physiological measures should receive more clinical consideration. This special communication introduces the under investigated autonomic dysfunction, cerebral hemodynamics, and sleep disorders in people with SCI to stakeholders involved in SCI rehabilitation. We also discuss the linkage between autonomic dysfunction, cerebral hemodynamics, and sleep disorders and some secondary outcomes are discussed. Recent evidence is synthesized to make clinical recommendations on the assessment and potential management of important autonomic, cerebral hemodynamics, and sleep-related dysfunction in people with SCI. Finally, a few recommendations for clinicians and researchers are provided.
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Affiliation(s)
- Wenjie Ji
- Department of Rehabilitation Science, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - Tom E Nightingale
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK; Centre for Trauma Science Research, University of Birmingham, Birmingham, UK; International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
| | - Fei Zhao
- Department of Health Care Sciences, Program of Occupational Therapy, Wayne State University, Detroit, MI; John D. Dingell VA Medical Center, Research and Development, Detroit, MI
| | - Nora E Fritz
- Department of Health Care Sciences, Program of Physical Therapy, Detroit, MI; Department of Neurology, Wayne State University, Detroit, MI
| | - Aaron A Phillips
- Department of Physiology and Pharmacology, Cardiac Sciences, Clinical Neurosciences, Biomedical Engineering, Libin Cardiovascular institute, Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, AB, Canada; RESTORE.network, University of Calgary, Calgary, AB, Canad
| | - Sue Ann Sisto
- Department of Rehabilitation Science, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - Mark S Nash
- Department of Neurological Surgery, Physical Medicine & Rehabilitation Physical Therapy, Miami, FL; Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL
| | - M Safwan Badr
- John D. Dingell VA Medical Center, Research and Development, Detroit, MI; Departments of Physiology and Internal Medicine, Wayne State University, Detroit, MI
| | - Jill M Wecht
- James J Peters VA Medical Center, Department of Spinal Cord Injury Research, Bronx, NY; Icahn School of Medicine Mount Sinai, Departments of Rehabilitation and Human Performance, and Medicine Performance, and Medicine, New York, NY
| | - Jason H Mateika
- John D. Dingell VA Medical Center, Research and Development, Detroit, MI; Departments of Physiology and Internal Medicine, Wayne State University, Detroit, MI
| | - Gino S Panza
- Department of Health Care Sciences, Program of Occupational Therapy, Wayne State University, Detroit, MI; John D. Dingell VA Medical Center, Research and Development, Detroit, MI.
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Berger MJ, Dorey T, Nouraei H, Krassioukov AV. Test-retest reliability of the Valsalva maneuver in spinal cord injury. J Spinal Cord Med 2022; 45:230-237. [PMID: 32795170 PMCID: PMC8986309 DOI: 10.1080/10790268.2020.1798134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Objective: To determine the test-retest reliability of quantitative and qualitative baroreflex sensitivity (BRS) parameters derived from the Valsalva maneuver (VM) in individuals with traumatic cervical SCI.Design: Test-retest reliability.Setting: Tertiary rehabilitation center.Participants: Fourteen participants with cervical SCI (ranging from C3-C8 neurological level).Outcome Measurements: Beat-to-beat systolic blood pressure (SBP) traces (finger photoplethysmography) were obtained during a 15-second forced expiration at two time points (7.6 ± 2.9 days between sessions) to assess VM reliability. Test-retest reliability of BRS metrics from derived from the VM (Valsalva ratio; VR, pressure recovery time; PRT, vagal baroreflex sensitivity; BRSv, adrenergic baroreflex sensitivity; BRSa1, and total recovery; TR) were assessed by intra-class correlation coefficient (ICC, with 95% confidence interval; CI) and by qualitative reproducibility (V, N, or M pattern).Results: ICCs for quantitative parameters were (CI): VR = 0.894 (0.703-0.965), TR = 0.927 (0.789-0.976), BRSa1 = 0.561 (0.149-0.911), PRT = 0.728 (0.343-0.904), BRSv = 0.243 (-0.309-0.673). Qualitatively, 12 subjects (85.7%) demonstrated reproducible VM patterns at both time points (3 "M" pattern, 8 "V" pattern and one "N" pattern).Conclusion: VR (a measure of cardiovagal function) and TR (a measure of sympathetic adrenergic function) are reliable quantitative parameters that can be derived from SBP response to VM in participants with SCI. Qualitative waveform analysis was reproducible in 12/14 participants. This provides the foundational evidence required to pursue further validity testing to establish a role for VM in the assessment of autonomic functions in SCI.
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Affiliation(s)
- Michael J Berger
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, Canada.,International Consortium on Repair Discoveries (ICORD), Vancouver, Canada
| | - Tristan Dorey
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Hirmand Nouraei
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Andrei V Krassioukov
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, Canada.,International Consortium on Repair Discoveries (ICORD), Vancouver, Canada
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7
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Taboni A, Fagoni N, Fontolliet T, Moia C, Vinetti G, Ferretti G. A closed-loop approach to the study of the baroreflex dynamics during posture changes at rest and at exercise in humans. Am J Physiol Regul Integr Comp Physiol 2021; 321:R960-R968. [PMID: 34643104 DOI: 10.1152/ajpregu.00167.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We hypothesized that during rapid uptilting at rest, due to vagal withdrawal, arterial baroreflex sensitivity (BRS) may decrease promptly and precede the operating point (OP) resetting, whereas different kinetics are expected during exercise steady state, due to lower vagal activity than at rest. To test this, eleven subjects were rapidly (<2 s) tilted from supine (S) to upright (U) and vice versa every 3 min, at rest and during steady-state 50 W pedaling. Mean arterial pressure (MAP) was measured by finger cuff (Portapres) and R-to-R interval (RRi) by electrocardiography. BRS was computed with the sequence method both during steady and unsteady states. At rest, BRS was 35.1 ms·mmHg-1 (SD = 17.1) in S and 16.7 ms·mmHg-1 (SD = 6.4) in U (P < 0.01), RRi was 901 ms (SD = 118) in S and 749 ms (SD = 98) in U (P < 0.01), and MAP was 76 mmHg (SD = 11) in S and 83 mmHg (SD = 8) in U (P < 0.01). During uptilt, BRS decreased promptly [first BRS sequence was 19.7 ms·mmHg-1 (SD = 5.0)] and was followed by an OP resetting (MAP increase without changes in RRi). At exercise, BRS and OP did not differ between supine and upright positions [BRS was 7.7 ms·mmHg-1 (SD = 3.0) and 7.7 ms·mmHg-1 (SD = 3.5), MAP was 85 mmHg (SD = 13) and 88 mmHg (SD = 10), and RRi was 622 ms (SD = 61) and 600 ms (SD = 70), respectively]. The results support the tested hypothesis. The prompt BRS decrease during uptilt at rest may be ascribed to a vagal withdrawal, similarly to what occurs at exercise onset. The OP resetting may be due to a slower control mechanism, possibly an increase in sympathetic activity.
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Affiliation(s)
- Anna Taboni
- Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergencies, University of Geneva, Geneva, Switzerland
| | - Nazzareno Fagoni
- Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergencies, University of Geneva, Geneva, Switzerland.,Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,AAT Brescia, Department of Anaesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University Hospital, Brescia, Italy
| | - Timothée Fontolliet
- Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergencies, University of Geneva, Geneva, Switzerland.,Department of Basic Neurosciences, University of Geneva, Geneva, Switzerland
| | - Christian Moia
- Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergencies, University of Geneva, Geneva, Switzerland.,Department of Basic Neurosciences, University of Geneva, Geneva, Switzerland
| | - Giovanni Vinetti
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Guido Ferretti
- Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergencies, University of Geneva, Geneva, Switzerland.,Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,Department of Basic Neurosciences, University of Geneva, Geneva, Switzerland
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8
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Wecht JM, Krassioukov AV, Alexander M, Handrakis JP, McKenna SL, Kennelly M, Trbovich M, Biering-Sorensen F, Burns S, Elliott SL, Graves D, Hamer J, Krogh K, Linsenmeyer TA, Liu N, Hagen EM, Phillips AA, Previnaire JG, Rodriguez GM, Slocum C, Wilson JR. International Standards to document Autonomic Function following SCI (ISAFSCI): Second Edition. Top Spinal Cord Inj Rehabil 2021; 27:23-49. [PMID: 34108833 DOI: 10.46292/sci2702-23] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jill M Wecht
- James J Peters VA Medical Center, Bronx, NY.,Bronx Veterans Medical Research Foundation, Bronx, NY.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrei V Krassioukov
- International Collaboration on Repair Discoveries (ICORD) and Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia.,Spinal Cord Program, GF Strong Rehabilitation Centre, University of British Columbia, Vancouver, Canada.,GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC, Canada.,President, American Spinal Injury Association (ASIA)
| | - Maralee Alexander
- Sustain Our Abilities, Birmingham, AL.,University of Alabama at Birmingham School of Medicine, Birmingham, AL.,Spaulding Rehabilitation Hospital, Charlestown, MA
| | - John P Handrakis
- James J Peters VA Medical Center, Bronx, NY.,Bronx Veterans Medical Research Foundation, Bronx, NY.,New York Institute of Technology, Department of Physical Therapy, School of Health Professions, Old Westbury, NY
| | - Stephen L McKenna
- Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA.,Department of Neurosurgery, Stanford University, Stanford, CA
| | - Michael Kennelly
- James J Peters VA Medical Center, Bronx, NY.,Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY.,International Collaboration on Repair Discoveries (ICORD) and Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia
| | - Michele Trbovich
- South Texas Veterans Health Care System, San Antonio, TX.,Department of Rehabilitation Medicine, University of Texas Health San Antonio
| | - Fin Biering-Sorensen
- Department for Spinal Cord Injuries, Copenhagen University Hospital, Rigshospitalet, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Stephen Burns
- Spinal Cord Injury Service, VA Puget Sound Health Care System, Seattle, WA.,Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA
| | - Stacy L Elliott
- International Collaboration on Repair Discoveries (ICORD) and Division of Sexual Medicine, Departments of Psychiatry and Urologic Sciences, Faculty of Medicine, University of British Columbia
| | - Daniel Graves
- College of Rehabilitation Sciences, Department of Rehabilitation Medicine, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA
| | | | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Todd A Linsenmeyer
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.,Department of Surgery ( Division of Urology), Rutgers New Jersey Medical School, Newark, NJ.,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ
| | - Nan Liu
- Department of Rehabilitation Medicine, Peking University Third Hospital, Beijing, China
| | - Ellen Merete Hagen
- National Hospital for Neurology and Neurosurgery, Queens Square, UCLH, London, UK.,Institute of Neurology, University College London, London, UK
| | - Aaron A Phillips
- Departments of Physiology and Pharmacology, Clinical Neurosciences, Cardiac Sciences, Hotchkiss Brain Institute, University of Calgary.,Cardiovascular Institute, Cumming School of Medicine, University of Calgary
| | | | - Gianna M Rodriguez
- Physical Medicine and Rehabilitation Department, Michigan Medicine, University of Michigan, Ann Arbor, MI
| | - Chloe Slocum
- Spaulding Rehabilitation Hospital, Charlestown, MA.,Harvard Medical School Department of Physical Medicine and Rehabilitation, Boston, MA
| | - James R Wilson
- Department of Physical Medicine and Rehabilitation, MetroHealth Rehabilitation Institute, Cleveland, OH.,Department of Physical Medicine and Rehabilitation, Case Western Reserve University-SOM, Cleveland, OH
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Effects of Respiratory Muscle Training on Baroreflex Sensitivity, Respiratory Function, and Serum Oxidative Stress in Acute Cervical Spinal Cord Injury. J Pers Med 2021; 11:jpm11050377. [PMID: 34062971 PMCID: PMC8147917 DOI: 10.3390/jpm11050377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/30/2021] [Accepted: 04/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background: respiratory complications are a leading cause of morbidity and mortality in individuals with spinal cord injury (SCI). We examined the effects of respiratory muscle training (RMT) in patients with acute cervical SCI. Methods: this prospective trial enrolled 44 adults with acute cervical SCI, of which twenty received RMT and twenty-four did not receive RMT. Respiratory function, cardiovascular autonomic function, and reactive oxidative species (ROS) were compared. The experimental group received 40-min high-intensity home-based RMT 7 days per week for 10 weeks. The control group received a sham intervention for a similar period. The primary outcomes were the effects of RMT on pulmonary and cardiovascular autonomic function, and ROS production in individuals with acute cervical SCI. Results: significant differences between the two groups in cardiovascular autonomic function and the heart rate response to deep breathing (p = 0.017) were found at the 6-month follow-up. After RMT, the maximal inspiratory pressure (p = 0.042) and thiobarbituric acid-reactive substances (TBARS) (p = 0.006) improved significantly, while there was no significant difference in the maximal expiratory pressure. Significant differences between the two groups in tidal volume (p = 0.005) and the rapid shallow breathing index (p = 0.031) were found at 6 months. Notably, the SF-36 (both the physical (PCS) and mental (MCS) component summaries) in the RMT group had decreased significantly at the 6-month follow-up, whereas the clinical scores did not differ significantly (p = 0.333) after RMT therapy. Conclusions: High-intensity home-based RMT can improve pulmonary function and endurance and reduce breathing difficulties in patients with respiratory muscle weakness after injury. It is recommended for rehabilitation after spinal cord injury.
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10
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Solinsky R, Draghici A, Hamner JW, Goldstein R, Taylor JA. High-intensity, whole-body exercise improves blood pressure control in individuals with spinal cord injury: A prospective randomized controlled trial. PLoS One 2021; 16:e0247576. [PMID: 33661958 PMCID: PMC7932070 DOI: 10.1371/journal.pone.0247576] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 02/08/2021] [Indexed: 11/18/2022] Open
Abstract
Blood pressure regulation following spinal cord injury (SCI) is often compromised due to impaired vascular sympathetic control, leading to increased reliance on cardiovagal baroreflex sensitivity to maintain pressure. Whole-body exercise improves cardiovagal baroreflex sensitivity in uninjured individuals, though has not been explored in those with SCI. Our objective was to determine changes in cardiovagal baroreflex sensitivity following 6 months of high-intensity, whole-body exercise in individuals with SCI compared to lower-intensity, arms only exercise, or waitlist. This randomized controlled trial recruited individuals with SCI aged 18-40 years old. Sixty-one individuals were randomized, with 38 completing at least one cardiovagal baroreflex sensitivity assessment. Whole-body exercise was performed with hybrid functional electrical stimulation rowing prescribed as two to three times per week, for 30-60 minutes with a target heart rate of >75% of maximum. The arms only exercise group performed upper body rowing exercise with the same prescription as whole-body exercise. Waitlist controls were not enrolled in any explicit training regimen. After 6 months, those in arms only exercise or waitlist crossed over to whole-body exercise. Cardiovagal baroreflex sensitivity was assessed via the neck suction technique at baseline and at three-month intervals thereafter. Intention to treat analysis with a structured equation model demonstrated no significant effect of waitlist control or arms only exercise on cardiovagal baroreflex sensitivity. Whole-body exercise significantly improved cardiovagal baroreflex sensitivity at 6 months for those initially randomized (p = 0.03), as well as those who crossed over from arms only exercise or waitlist control (p = 0.03 for each). However, amount of exercise performed and aerobic gains (VO2max) each poorly correlated with increases in cardiovagal baroreflex sensitivity (R2<0.15). In post-hoc analyses, individuals with paraplegia made significantly greater gains in baroreflex sensitivity compared to those with tetraplegia (p = 0.02), though gains within this group were again poorly correlated to gains in aerobic capacity. Clinicaltrials.gov number NCT02139436.
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Affiliation(s)
- Ryan Solinsky
- Cardiovascular Research Lab, Spaulding Rehabilitation Hospital, Cambridge, Massachusetts, United States of America
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, Massachusetts, United States of America
- Spaulding Research Institute, Boston, Massachusetts, United States of America
| | - Adina Draghici
- Cardiovascular Research Lab, Spaulding Rehabilitation Hospital, Cambridge, Massachusetts, United States of America
| | - Jason W. Hamner
- Cardiovascular Research Lab, Spaulding Rehabilitation Hospital, Cambridge, Massachusetts, United States of America
| | - Rich Goldstein
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, Massachusetts, United States of America
| | - J. Andrew Taylor
- Cardiovascular Research Lab, Spaulding Rehabilitation Hospital, Cambridge, Massachusetts, United States of America
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, Massachusetts, United States of America
- Spaulding Research Institute, Boston, Massachusetts, United States of America
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11
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Castro P, Ferreira ADS, Lopes AJ, Paula TD, Costa RMR, Cunha FA, Vigário PDS. Validity of the Polar V800 heart rate monitor for assessing cardiac autonomic control in individuals with spinal cord injury. MOTRIZ: REVISTA DE EDUCACAO FISICA 2021. [DOI: 10.1590/s1980-65742021003221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | | | | | | | - Felipe A. Cunha
- Universidade do Estado do Rio de Janeiro, Brazil; Universidade do Estado do Rio de Janeiro, Brazil
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12
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Abstract
PURPOSE OF REVIEW Autonomic hyperactivity is a relatively common consequence of severe acute brain injury and can also be seen with spinal cord and peripheral nerve disorders. This article reviews basic pathophysiologic concepts regarding autonomic hyperactivity, its various forms of clinical presentation, and practical management considerations. RECENT FINDINGS Paroxysmal sympathetic hyperactivity is most common after traumatic brain injury but can also occur after other forms of severe acute diffuse or multifocal brain injury. Formal criteria for the diagnosis and severity grading of paroxysmal sympathetic hyperactivity have now been proposed. A growing body of literature is beginning to elucidate the mechanisms underlying this disorder, but treatment remains based on observational data. Our mechanistic understanding of other distinct forms of autonomic hyperactivity, such as autonomic dysreflexia after traumatic spinal cord injury and dysautonomia after Guillain-Barré syndrome, remains rudimentary, yet clinical experience shows that their appropriate management can minimize the risk of serious complications. SUMMARY Syndromes of autonomic hyperactivity can result from injury at all levels of the neuraxis. Much more research is needed to refine our understanding of these disorders and guide optimal management decisions.
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Lucci VEM, Inskip JA, McGrath MS, Ruiz I, Lee R, Kwon BK, Claydon VE. Longitudinal Assessment of Autonomic Function during the Acute Phase of Spinal Cord Injury: Use of Low-Frequency Blood Pressure Variability as a Quantitative Measure of Autonomic Function. J Neurotrauma 2020; 38:309-321. [PMID: 32940126 DOI: 10.1089/neu.2020.7286] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
High-level spinal cord injury (SCI) can disrupt cardiovascular autonomic function. However, the evolution of cardiovascular autonomic function in the acute phase following injury is unknown. We evaluated the timing, severity, progression, and implications of cardiovascular autonomic injury following acute SCI. We tested 63 individuals with acute traumatic SCI (aged 48 ± 2 years) at five time-points: <2 weeks, and 1, 3, 6-12, and >12 months post-injury. Supine beat-to-beat systolic arterial pressure (SAP) and R-R interval (RRI) were recorded and low-frequency variability (LF SAP and LF RRI) determined. Cross-spectral analyses were used to determine baroreflex function (low frequency) and cardiorespiratory interactions (high frequency). Known electrocardiographic (ECG) markers for arrhythmia and self-reported symptoms of cardiovascular dysfunction were determined. Comparisons were made with historical data from individuals with chronic SCI and able-bodied controls. Most individuals had high-level (74%) motor/sensory incomplete (63%) lesions. All participants had decreased LF SAP at <2 weeks (2.22 ± 0.65 mm Hg2). Autonomic injury was defined as high-level SCI with LF SAP <2 mm Hg2. Two distinct groups emerged by 1 month: autonomically complete SCI with sustained low LF SAP (0.76 ± 0.17 mm Hg2) and autonomically incomplete SCI with increased LF SAP (5.46 ± 1.0 mm Hg2, p < 0.05). Autonomically complete injuries did not recover over time. Cardiovascular symptoms were prevalent and worsened with time, especially in those with autonomically complete lesions, and chronic SCI. Baroreflex function and cardiorespiratory interactions were impaired after SCI. Risk of arrhythmia increased immediately after SCI, and remained elevated throughout the acute phase. Acute SCI is associated with severe cardiovascular dysfunction. LF SAP provides a simple, non-invasive, translatable, quantitative assessment of autonomic function, and is most informative 1 month after injury.
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Affiliation(s)
- Vera-Ellen M Lucci
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.,International Collaboration on Repair and Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Jessica A Inskip
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.,International Collaboration on Repair and Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Maureen S McGrath
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.,International Collaboration on Repair and Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Ian Ruiz
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Rebekah Lee
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Brian K Kwon
- International Collaboration on Repair and Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Victoria E Claydon
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.,International Collaboration on Repair and Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
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The effect of heart rate variability on blood pressure is augmented in spinal cord injury and is unaltered by exercise training. Clin Auton Res 2020; 31:293-301. [DOI: 10.1007/s10286-020-00677-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 02/28/2020] [Indexed: 10/24/2022]
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15
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Grafting Embryonic Raphe Neurons Reestablishes Serotonergic Regulation of Sympathetic Activity to Improve Cardiovascular Function after Spinal Cord Injury. J Neurosci 2020; 40:1248-1264. [PMID: 31896670 DOI: 10.1523/jneurosci.1654-19.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/16/2022] Open
Abstract
Cardiovascular dysfunction often occurs after high-level spinal cord injury. Disrupting supraspinal vasomotor pathways affects basal hemodynamics and contributes to the development of autonomic dysreflexia (AD). Transplantation of early-stage neurons to the injured cord may reconstruct the descending projections to enhance cardiovascular performance. To determine the specific role of reestablishing serotonergic regulation of hemodynamics, we implanted serotonergic (5-HT+) neuron-enriched embryonic raphe nucleus-derived neural stem cells/progenitors (RN-NSCs) into a complete spinal cord transection lesion site in adult female rats. Grafting embryonic spinal cord-derived NSCs or injury alone served as 2 controls. Ten weeks after injury/grafting, histological analysis revealed well-survived grafts and partial integration with host tissues in the lesion site. Numerous graft-derived serotonergic axons topographically projected to the caudal autonomic regions. Neuronal tracing showed that host supraspinal vasomotor pathways regenerated into the graft, and 5-HT+ neurons within graft and host brainstem neurons were transsynaptically labeled by injecting pseudorabies virus (PRV-614) into the kidney, indicating reconnected serotonergic circuits regulating autonomic activity. Using an implanted telemeter to record cardiovascular parameters, grafting RN-NSCs restored resting mean arterial pressure to normal levels and remarkably alleviated naturally occurring and colorectal distension-induced AD. Subsequent pharmacological blockade of 5-HT2A receptors with ketanserin in RN-NSC-grafted rats reduced resting mean arterial pressure and increased heart rate in all but 2 controls. Furthermore, spinal cord retransection below RN-NSC grafts partially eliminated the recovery in AD. Collectively, these data indicate that RN-NSCs grafted into a spinal cord injury site relay supraspinal control of serotonergic regulation for sympathetic activity to improve cardiovascular function.SIGNIFICANCE STATEMENT Disruption of supraspinal vasomotor pathways results in cardiovascular dysfunction following high-level spinal cord injury. To reestablish the descending regulation of autonomic function, we transplanted serotonergic neuron enriched embryonic raphe nucleus-derived neural stem cells/progenitors into the lesion site of completely transected rat spinal cord. Consequently, grafted raphe nucleus-derived neural stem cells/progenitors acted as a neuronal relay to reconnect supraspinal center and spinal sympathetic neurons below the injury. The reconstituted serotonergic regulation of sympathetic activity led to the improvement of hemodynamic parameters and mitigated autonomic dysreflexia. Based on morphological and physiological results, this study validates the effectiveness of transplanting early-stage serotonergic neurons into the spinal cord for cardiovascular functional recovery after spinal cord injury.
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16
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Harkema SJ, Legg Ditterline B, Wang S, Aslan S, Angeli CA, Ovechkin A, Hirsch GA. Epidural Spinal Cord Stimulation Training and Sustained Recovery of Cardiovascular Function in Individuals With Chronic Cervical Spinal Cord Injury. JAMA Neurol 2019; 75:1569-1571. [PMID: 30242310 DOI: 10.1001/jamaneurol.2018.2617] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Susan J Harkema
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville.,Frazier Rehab Institute, Louisville, Kentucky.,Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, Kentucky
| | - Bonnie Legg Ditterline
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville.,Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, Kentucky
| | - Siqi Wang
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville.,Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, Kentucky
| | - Sevda Aslan
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville.,Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, Kentucky
| | - Claudia A Angeli
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville.,Frazier Rehab Institute, Louisville, Kentucky.,Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, Kentucky
| | - Alexander Ovechkin
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville.,Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, Kentucky
| | - Glenn A Hirsch
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
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17
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Aslan SC, Legg Ditterline BE, Park MC, Angeli CA, Rejc E, Chen Y, Ovechkin AV, Krassioukov A, Harkema SJ. Epidural Spinal Cord Stimulation of Lumbosacral Networks Modulates Arterial Blood Pressure in Individuals With Spinal Cord Injury-Induced Cardiovascular Deficits. Front Physiol 2018; 9:565. [PMID: 29867586 PMCID: PMC5968099 DOI: 10.3389/fphys.2018.00565] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/30/2018] [Indexed: 12/23/2022] Open
Abstract
Disruption of motor and autonomic pathways induced by spinal cord injury (SCI) often leads to persistent low arterial blood pressure and orthostatic intolerance. Spinal cord epidural stimulation (scES) has been shown to enable independent standing and voluntary movement in individuals with clinically motor complete SCI. In this study, we addressed whether scES configured to activate motor lumbosacral networks can also modulate arterial blood pressure by assessing continuous, beat-by-beat blood pressure and lower extremity electromyography during supine and standing in seven individuals with C5-T4 SCI. In three research participants with arterial hypotension, orthostatic intolerance, and low levels of circulating catecholamines (group 1), scES applied while supine and standing resulted in increased arterial blood pressure. In four research participants without evidence of arterial hypotension or orthostatic intolerance and normative circulating catecholamines (group 2), scES did not induce significant increases in arterial blood pressure. During scES, there were no significant differences in electromyographic (EMG) activity between group 1 and group 2. In group 1, during standing assisted by scES, blood pressure was maintained at 119/72 ± 7/14 mmHg (mean ± SD) compared with 70/45 ± 5/7 mmHg without scES. In group 2 there were no arterial blood pressure changes during standing with or without scES. These findings demonstrate that scES configured to facilitate motor function can acutely increase arterial blood pressure in individuals with SCI-induced cardiovascular deficits.
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Affiliation(s)
- Sevda C Aslan
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Bonnie E Legg Ditterline
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Michael C Park
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Department of Neurosurgery and Neurology, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Claudia A Angeli
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States.,Frazier Rehab Institute, Louisville, KY, United States
| | - Enrico Rejc
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Yangsheng Chen
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Alexander V Ovechkin
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Andrei Krassioukov
- Experimental Medicine Program, University of British Columbia, Vancouver, BC, Canada.,International Collaboration on Repair Discoveries, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC, Canada
| | - Susan J Harkema
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States.,Frazier Rehab Institute, Louisville, KY, United States
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