Ultrasonographic Median Nerve Changes After Repeated Wheelchair Transfers in Persons With Paraplegia: Relationship With Subject Characteristics and Transfer Skills

Longitudinal Median Nerve Ultrasound Changes in Individuals With Spinal Cord Injury and an Age- and Sex-Matched Nondisabled Cohort

Objectives

To assess the natural history for development of carpal tunnel syndrome (CTS) in persons with acute spinal cord injury (SCI) at 1 year postdischarge from initial rehabilitation and to assess baseline median nerve (MN) cross-sectional area (CSA) above/below 10 mm2 correlates with any longitudinal changes in quantitative ultrasound (US) of the MN.

Design

A prospective cohort study of persons with acute SCI evaluated for CTS using quantitative US and compared to a group without SCI (non-SCI).

Setting

Academic medical center.

Participants

N=69 total (N=34 SCI, N=35 non-SCI). The average age in both groups was 28 and the SCI group included 30 males and 2 females and the non-SCI group included 30 males and 3 females.

Interventions

Not applicable.

Main Outcome Measures

The primary outcome was the change in quantitative US parameters of the MN, including CSA and grayscale, from baseline to 1-year follow-up in those with SCI and those without SCI. CTS symptomatology and physical exam sum score and US measures for dominant and nondominant arms were considered secondary outcomes.

Results

The SCI had darker nerves at baseline (P=.036, nondominant), greater CTS symptoms at follow-up (P≤.036, bilateral), and no differences in all change scores (all P≥.056). Individuals with smaller nerves at baseline had larger increases in nerve size (P=.029, nondominant) vs those with larger nerves. Change in CTS symptoms CSA (nondominant) and nerve echogenicity (dominant) were inversely associated with their respective baseline values (all P≤.045).

Conclusions

We observed few differences between the SCI group and the non-SCI control group and between those with smaller vs larger MN. In general, MN pathology changes (CTS symptoms and US variables) over 1 year were more common in the nondominant arm and appear to be a function of MN pathology at enrollment. Individuals with SCI may experience increased CTS symptoms as soon as 1 year after injury.

Shoulder Tendon Adaptations Following a Graded Exercise Test to Exhaustion in Highly Trained Wheelchair Rugby Athletes With Different Impairments

Objective

This study aimed to identify acute changes in biceps and supraspinatus tendon characteristics before and after a graded exercise test to exhaustion (GXT) in highly trained wheelchair rugby (WR) athletes. A secondary aspect was to define chronic tendon adaptations related to the impairment of the athlete and the occupation of the tendon within the subacromial space (occupation ratio).

Methods

Twelve WR athletes with different impairments (age = 32 ± 6 years; body mass = 67.2 ± 11.2 kg; 9.0 ± 3.6 years competing) volunteered for this study. Performance Corrected Wheelchair Users Shoulder Pain Index was used to quantify shoulder pain. Quantitative Ultrasound Protocols (QUS) were used to define supraspinatus and biceps tendon thickness, echogenicity, and echogenicity ratio of both dominant and non-dominant shoulder before and after the GXT including 22 ± 3.1 min submaximal propulsion and 10.2 ± 1.7 min maximal propulsion on a treadmill. Furthermore, the acromio-humeral distance (AHD) defined from ultrasound (US) images was used to calculate the occupation ratios.

Results

A mixed-effect multilevel analysis that included shoulder as grouping variable, demonstrated a significant reduction in the echogenicity of the biceps following GXT whilst controlling for impairment [spinal cord injury (SCI) and non-SCI] and the occupation ratio (β = −9.01, SEβ = 2.72, p = 0.001, 95% CI = [−14.34; −3.68]). This points toward fluid inflow into the tendon that may be related to overload and acute inflammation. In addition, persons with a SCI (n = 8) had a thicker supraspinatus tendon in comparison to persons with non-SCI (n = 3) which may be related to chronic tendon adaptations (β = −0.53 mm, SEβ = 0.26, p = 0.038, 95% CI = [−1.04; −0.03]). Finally, a greater occupation ratio was associated with signs of tendinopathy (i.e., greater biceps and supraspinatus tendon thickness, and lower supraspinatus echogenicity and echogenicity ratio).

Conclusion

Acute biceps tendon adaptations in response to the GXT in highly trained WR athletes were evident with chronic adaptations in the supraspinatus tendon being related to the impairment of the athlete. Ultrasound can be used to monitor tendon adaptations in WR athletes for medical diagnosis to assist the scheduling and type of training.

Increased Risk of Carpal Tunnel Syndrome in People With Spinal Cord Injury: A Nationwide Longitudinal Follow-Up Study

OBJECTIVE

To investigate the long-term risk of carpal tunnel syndrome (CTS) in people with spinal cord injury (SCI).

DESIGN

Retrospective cohort study.

SETTING

Taiwan's Longitudinal Health Insurance Database 2005, containing data about 1 million people randomly sampled from among those registered in the National Health Insurance Program as of 2005.

PARTICIPANTS

The SCI group consisted of 1681 subjects with SCI, and the comparison group comprised 6724 propensity score-matched subjects without SCI (N=8405). The variables included in propensity-score matching were age, sex, comorbid conditions, and socioeconomic status.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The occurrence of newly diagnosed CTS, defined by at least 1 hospital discharge or 2 outpatient visits with a diagnosis of CTS.

RESULTS

The incidence density of CTS in the SCI group was 7.55 per 1000 person-years (95% confidence interval [CI], 6.03-9.33), and in the comparison group, 4.61 per 1000 person-years (95% CI, 4.08-5.19). The hazard ratio (HR) of CTS for the SCI group was therefore 1.59 (95% CI, 1.24-2.03). Additionally, the HR of CTS for the cervical-SCI subgroup, 1.90 (95% CI, 1.21-2.97) was considerably higher than that of its noncervical counterpart, 1.47 (95% CI, 1.09-1.98).

CONCLUSIONS

People with both cervical and noncervical SCI have an increased risk of developing CTS, as compared with those without SCI. Moreover, the CTS risk appears to be higher for individuals with cervical SCI than their noncervical SCI counterparts.

Peripheral nerve decompression in the upper limb in spinal cord injury: experiences at the National Spinal Injuries Centre, UK

STUDY DESIGN

Retrospective cohort study of consecutive upper limb peripheral nerve decompressions in SCI patients. All procedures were performed at a single National Spinal Injuries Centre between 2015 and 2019.

OBJECTIVES

Entrapment neuropathies in the upper limb are underdiagnosed and undertreated in patients with spinal cord injury (SCI). This cohort study represents the first published outcomes of upper limb peripheral nerve decompression in patients with SCI.

SETTING

National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire, UK.

METHODS

Data collected from electronic medical records included patient demographics, procedures performed, length of inpatient stay, nerve conduction studies, and patient satisfaction. Patients were also contacted by telephone to complete a questionnaire that included patient satisfaction, the NHS 'Friends & Family Test' and validated patient-reported outcome measures (PROMs).

RESULTS

Thirty-four decompression procedures (24 carpal tunnel, 10 cubital tunnel) were performed in 24 patients (14 with paraplegia, 10 tetraplegia). 71% of patients had pre-operative nerve conduction studies: 71% of these were graded as severe. Mean length of stay was 14 nights. 91% of patients were satisfied with their procedure at clinic follow-up. Mean Boston Carpal Tunnel Questionnaire (BCTQ) symptom scores were reduced from 3.7 to 1.3 pre- vs. post-operatively (p < 0.001). Patient Reported Ulnar Nerve Evaluation (PRUNE) scores reduced from 49.4 to 23.0 (p = 0.01).

CONCLUSION

In our experience, SCI patients tend to present with severe upper limb nerve entrapment syndromes. Operative management is well tolerated with low risk of complications and can result in marked improvements in symptoms and function.

Effectiveness of a Web-Based Direct-to-User Transfer Training Program: A Randomized Controlled Trial

OBJECTIVE

To determine the effectiveness of a web-based, direct-to-user transfer training program in improving transfer quality and maintaining improvements for up to 1 month after training as compared with a control group.

DESIGN

Randomized controlled trial with participants randomized to an immediate intervention group (IIG) or waitlist control group (WLCG) that received the training after a 6-month delay.

SETTING

Wherever the participants accessed the web-based training, likely the home environment.

PARTICIPANTS

Convenience sample of full-time wheelchair users (N=72; IIG, n=34; WLCG, n=38 for between-group analysis, n=48 for combined within-group analysis) with spinal cord injury or disorder who were able to independently perform a lateral scoot transfer.

INTERVENTIONS

Self-paced, web-based transfer training module.

MAIN OUTCOME MEASURES

Transfer Assessment Instrument Questionnaire (TAI-Q) score at baseline, 1 month, and 6 months postbaseline (WLCG only), immediately posttraining, and 1 month posttraining. The TAI-Q is an 18-item self-assessment that covers several aspects of a quality transfer.

RESULTS

The IIG significantly increased particpants' baseline TAI-Q score from 6.91±0.98 to 7.79±1.12 (P<.001) by 1 month posttraining. The WLCG also increased from baseline to the 1-month postbaseline assessment (from 6.52±1.13 to 7.00±1.09; P=.014), potentially from learning effects secondary to self-assessment with the TAI-Q. The extent of change over time did not differ significantly between the IIG and WLCG from baseline to 1 month (P=.169). However, significant improvements in TAI-Q scores were still evident after the training for the WLCG (P<.001). Those with a lower pretraining TAI-Q score and more shoulder pain were most likely to benefit from the training.

CONCLUSIONS

Repeated TAI-Q self-assessments likely contributed to improved transfer quality, with web-based training having an additive effect. Wheelchair users are likely to benefit from transfer training and self-assessment of transfer quality in their home environments. This has the potential to decrease injury risk while avoiding barriers to in-person training.

Intra- and Interrater Reliability of Remote Assessment of Transfers by Wheelchair Users Using the Transfer Assessment Instrument (Version 4.0)

OBJECTIVE

To evaluate the reliability, standard error of measurement, minimum detectable change, and item-level consistency of the Transfer Assessment Instrument (TAI) version 4.0 when used to evaluate transfer quality remotely.

DESIGN

Participants transferred from their wheelchair to a mat table (transfer 1), repeated this after a 10-minute delay to assess intrarater reliability (transfer 2), and repeated this 1-2 days later to assess test-retest reliability (transfer 3). Each transfer was scored in person by 4 raters and asynchronously by a remote clinician rater.

SETTING

2017 National Veterans Wheelchair Games.

PARTICIPANTS

Convenience sample of 44 full-time wheelchair users (N=44).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

TAI total score, subscores (wheelchair setup, body setup, flight/landing), and item scores (15 items).

RESULTS

Moderate to excellent reliability was found when scoring remotely for TAI total and subscores for intrarater (intraclass correlation coefficient (ICC(3,1)=0.687-0.854), test-retest (ICC(3,1)=0.695-0.836), and interrater reliability (ICC(3,5)=0.746-0.962). Remote rater total score and flight/landing subscore were greater (indicating higher transfer quality) compared to the average in-person raters (P=.021 and P=.005, respectively). There were no differences between transfers 1-3 in remote rater scores. Item-level percentage agreement between the remote rater and in-person exceeded the 75% cutoff for clinical utility for all items.

CONCLUSIONS

The TAI is a reliable outcome measure for assessing transfer technique remotely.

A systematic review of the methodology of sonographic assessment of upper limb activities-associated carpal tunnel syndrome

BACKGROUND

Various upper limb activities were speculated to be associated with the development of carpal tunnel syndrome (CTS). Nonetheless, there are currently no standardization on the uses of parameters in CTS assessments, nor are there any conclusive findings regarding the usefulness of various sonographic measurements in studies of different upper limb activities. In this review, we intend to evaluate the methodology of assessing CTS induced by upper limb activities with ultrasonographic technique and provide corresponding suggestions.

METHODS

Clinical studies on the association between upper limb activities and prevalence of CTS using ultrasonography were recruited in a database research on the basis of a procedural selection criteria and reviewed. The following qualitative items were extracted: characteristics of studies, scanning methods, selection of sonographic parameters, and related article findings.

RESULTS

Eleven studies were qualified for this review. Three studies were computer keyboard typing related, five studies were electronic device related, and three studies were wheelchair-related. All sampled articles included cross-sectional area (CSA) at the pisiform level. The swelling ratio (SR) and flattening ratio (FR) at the hamate level are also used in most studies in addition to the CSA at the pisiform level. The effectiveness of such parameters is subjected to various confounding factors such as age, weight, body mass index, and wrist anthropometrics, suggesting CSA and SR with sufficient levels had significant values as sonographic parameters. Values of parameters were found affecting symptomatic signs and hand dominance.

CONCLUSION

Ultrasound scan is a suitable tool to assess the relationship between upper limb activity and CTS. CSA at the pisiform level and SR and the FR at the hamate levels are generally suitable in upper limb-associated CTS investigations. Specific study designs are required to eliminate different confounding factors accordingly.

Case-Control Study of Ultrasound Evaluation of Acute Median Nerve Response to Upper Extremity Circuit Training in Spinal Cord Injury

OBJECTIVE

Individuals with spinal cord injury (SCI) often present signs and symptoms of median nerve (MN) pathology. Preclinical signs identification of MN pathology might facilitate early intervention to prevent or delay carpal tunnel syndrome in SCI. We assessed if ultrasound parameters changed in response to upper extremity (UE) circuit training exercise in individuals with paraplegia and able-bodied individuals.

DESIGN

Case-control study.

PARTICIPANTS

Adults (N=32) with paraplegia (n=16) and age- and sex-matched able-bodied controls (n=16).

INTERVENTION

Circuit training exercise.

MAIN OUTCOME MEASURES

MN ultrasound evaluation at the pisiform and radius before and after UE exercise. Ultrasound parameters included cross-sectional area (CSA), and gray scale (GS). Data presented as mean ± SD.

RESULTS

Pre-exercise CSAs were larger in SCI at the radius (12.0±2.9 vs 9.0±2.1; P=.003), but not the pisiform (9.8±3.1 vs 9.1±1.7; P=.431). There were no statistical differences in MN response to exercise between groups (all P≥.293). Across participants, CSA changes were inversely associated with their pre-exercise values at the pisiform (r=-0.648; P<.001) and the radius (r=-0.366; P=.043). Participants with pre-exercise CSA values ≥10.00 mm² at the pisiform responded to exercise with decreases in CSA (mean change ± SD, -2.0±1.5; P=.002) and GS (-2.8±6.2; P=.029). Participants with pre-exercise CSA ≤9.99 mm² at the pisiform responded to exercise with no change in CSA (mean change ± SD, 0.7±2.5; P=.002) and increased GS (3.2±7.2; P=.029).

CONCLUSIONS

CSA exercise response was more strongly related to pre-exercise MN values than presence or absence of SCI.

Effects of grab bars and backrests on independent wheelchair transfer performance and technique

OBJECTIVE

For individuals who rely on wheeled mobility devices for primary mobility, the ability to transfer independently greatly enhances participation in activities within and outside of the home. Nonlevel transfers are challenging and inevitable as not all surfaces in all settings can be made level with an individual's seat to floor height. The purpose of this study was to investigate the effects of two transfer aids, grab bars, and backrests, on the performance and quality of nonlevel transfers.

METHODS

This study employed a repeated-measures design with transfer setup as the independent variable. Sixty-eight (53 men and 15 women) wheeled mobility device users performed level and nonlevel transfers to a bare surface, a surface with grab bars present, a surface with grab bars, and a backrest present. For each condition, participants were asked to transfer as high and as low as they could go while still performing an independent and safe transfer. The transfer assessment instrument was used to evaluate the quality of their transfer technique.

RESULTS

Participants were able to transfer an absolute height up to 2.5 cm (1″) higher and lower when grab bars or grab bars and a backrest were present on the surface (p < 0.042) and 2.3 cm (~1″) higher relative to their wheelchair level seat high when grab bars were present on the surface (p < .001). Transfer technique significantly improved for both uphill and downhill transfers with the presence of grab bars and a backrest as shown by the transfer assessment instrument scores (p < 0.046).

CONCLUSIONS

The presence of grab bars and a backrest on transfer surfaces may help mobility device users to achieve higher and lower absolute transfer heights and facilitate better transfer technique.

Reliability and Validity of the Revised Transfer Assessment Instrument

Background: Proper transfer technique is associated with improved biomechanics and decreased pain and pathology. However, many users do not use proper technique, and appropriate assessment and training are needed to address these deficits. The transfer assessment instrument (TAI) 4.0 was designed to meet those needs and improve on past versions by removing the need for clinician training, shortening administration time, and simplifying question content. Objectives: Evaluate the psychometric properties of the TAI 4.0. Methods: A convenience sample of full-time wheelchair users was scored on multiple transfers by four raters to assess interrater, intrarater, and test-retest reliability and concurrent validity of the TAI 4.0. Each user also was scored using a visual analog scale (VAS). Results: For 44 participants, the mean TAI 4.0 and VAS across all transfers were 7.58 ± 1.12 and 7.44 ± 1.78, respectively, and scores were significantly correlated (r = 0.52-0.7). VAS scores were more strongly influenced by the flight/landing and body setup phases of the transfer. There were no significant associations between TAI 4.0 score and demographics. Intraclass correlation coefficients (ICC) ranged from 0.80 to 0.85 for interrater reliability, 0.60 to 0.76 for intrarater reliability, and 0.55 to 0.76 for test-retest reliability. The minimum detectable change (MDC) for the total score ranged from 1.02 to 1.30. Conclusion: The TAI 4.0 provides reliable and valid quantitative assessment of an individual's transfer without the need for comprehensive training, as is the case with the TAI 3.0. The tool can be completed in 3 minutes (average) in a clinical setting with only a ruler and goniometer.

Effect of technique and transfer board use on the performance of wheelchair transfers

Transferring to and from the wheelchair seat is a necessary skill for many wheelchair users who wish to be independent of their everyday life. The performance of wheelchair transfers has been associated with the risk of falling and developing upper limb injuries. Both present a risk to the independence of the individual. Previous studies on wheelchair transfers have focused mainly on the analysis of sitting transfers performed by individuals with spinal cord injury, which only represent a small portion of the wider wheelchair users’ population. The purpose of this study is to investigate the effect of different transferring techniques (sitting, standing) and transfer board use on the ground reaction forces under the hands during transfer performance and transfer quality measured using the transfer assessment instrument (TAI). Sitting transfers displayed generally higher peak and mean reaction forces underneath both leading and trailing hands compared with the other techniques, but the difference was only significant between sitting and standing transfers. Standing transfers had significantly lower TAI scores compared with sitting transfer, potentially indicating a decreased level of safety associated with their performance. Transfer boards were only partially effective in reducing the weight born by the upper limbs and they caused only a minor reduction in the overall TAI score in comparison to sitting transfers.

Ultrasound-Guided Steroid Injection of the Pisotriquetral Joint: A Multidisciplinary Effort

From the perspective of a multidisciplinary team, the authors describe the first reported use of ultrasound guidance for steroid injection into the pisotriquetral joint to relieve wrist pain of a person with spinal cord injury undergoing acute inpatient rehabilitation. Musculoskeletal ultrasound guidance was used to improve the accuracy of a corticosteroid injection of the pisotriquetral joint and the basal thumb in a 70-year-old man with paraplegia experiencing multifocal degenerative wrist pain. There was no bleeding or bruising after the injections, and the patient reported complete pain resolution 1 wk after the injections, which continued for over 1 yr. A multidisciplinary team was key in diagnosis, selection of treatment, and evaluation of treatment effect. Corticosteroid injection of the pisotriquetral joint under ultrasound guidance can be used as a treatment modality for managing wrist pain stemming from that joint. Further investigation and studies evaluating the use of ultrasound versus other imaging modalities for injection of the wrist are indicated.