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Masselink CE, Detterbeck A, LaBerge NB, Paleg G. RESNA and CTF position on the application of supported standing devices: Current state of the literature. Assist Technol 2024:1-18. [PMID: 39446080 DOI: 10.1080/10400435.2024.2411560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2024] [Indexed: 10/25/2024] Open
Abstract
Supported standing devices are often used to maintain a standing position by people with difficulty or inability to ambulate or stand for a period of time. Supported standing programs are first implemented by healthcare professionals with goals to impact health and function. This paper intends to update previous position on wheelchair standing devices by the Rehabilitation Engineering and Assistive Technology Association of North America, and was written in conjunction with the Clinician Task Force. The current paper expands the previous focus on wheelchair standing devices to all types of supported standing devices. A scoping review methodology found 42 studies examining outcomes of supported standing programs in the International Classification of Functioning, Disability, and Health framework in five areas of body functions, seven areas of activities and participation, and one body structure. Patterns in outcomes related to standing device type, as dynamic, or mobile, standing devices contributed to independent daily activity performance and static standing devices impacted neuromuscular capacity. Studies support engaging consistently in supported standing from nine months of age, or as soon after onset of ambulatory disability as possible, to maximize benefits. Clinical reasoning is required to apply the information in this document to unique individual cases.
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Affiliation(s)
- Cara E Masselink
- Occupational Therapy Department, Western Michigan University, Kalamazoo, Michigan, USA
| | - Ashley Detterbeck
- Clinical Education Department, Permobil Inc., Lebanon, Tennessee, USA
| | | | - Ginny Paleg
- Department of CanChild, Physical Therapy, Montgomery County Infants and Toddlers, Rockville, Maryland, USA
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Dolbow DR, Bersch I, Gorgey AS, Davis GM. The Clinical Management of Electrical Stimulation Therapies in the Rehabilitation of Individuals with Spinal Cord Injuries. J Clin Med 2024; 13:2995. [PMID: 38792536 PMCID: PMC11122106 DOI: 10.3390/jcm13102995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/09/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
Background: People with spinal cord injuries (SCIs) often have trouble remaining active because of paralysis. In the past, exercise recommendations focused on the non-paralyzed muscles in the arms, which provides limited benefits. However, recent studies show that electrical stimulation can help engage the paralyzed extremities, expanding the available muscle mass for exercise. Methods: The authors provide an evidence-based approach using expertise from diverse fields, supplemented by evidence from key studies toward the management of electrical stimulation therapies in individuals with SCIs. Literature searches were performed separately using the PubMed, Medline, and Google Scholar search engines. The keywords used for the searches included functional electrical stimulation cycling, hybrid cycling, neuromuscular electrical stimulation exercise, spinal cord injury, cardiovascular health, metabolic health, muscle strength, muscle mass, bone mass, upper limb treatment, diagnostic and prognostic use of functional electrical stimulation, tetraplegic hands, and hand deformities after SCI. The authors recently presented this information in a workshop at a major rehabilitation conference. Additional information beyond what was presented at the workshop was added for the writing of this paper. Results: Functional electrical stimulation (FES) cycling can improve aerobic fitness and reduce the risk of cardiovascular and metabolic diseases. The evidence indicates that while both FES leg cycling and neuromuscular electrical stimulation (NMES) resistance training can increase muscle strength and mass, NMES resistance training has been shown to be more effective for producing muscle hypertrophy in individual muscle groups. The response to the electrical stimulation of muscles can also help in the diagnosis and prognosis of hand dysfunction after tetraplegia. Conclusions: Electrical stimulation activities are safe and effective methods for exercise and testing for motor neuron lesions in individuals with SCIs and other paralytic or paretic conditions. They should be considered part of a comprehensive rehabilitation program in diagnosing, prognosing, and treating individuals with SCIs to improve function, physical activity, and overall health.
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Affiliation(s)
- David R. Dolbow
- Physical Therapy Program, College of Osteopathic Medicine, William Carey University, 710 William Carey Parkway, Hattiesburg, MS 39401, USA
| | - Ines Bersch
- International FES Centre®, Swiss Paraplegia Centre, CH-6207 Nottwil, Switzerland
| | - Ashraf S. Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, VA 23249, USA;
| | - Glen M. Davis
- Discipline of Exercise and Sport Sciences, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2006, Australia
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Takano M, Iida T, Hikata T. Persistent Orthostatic Hypotension Following Surgery for Adult Spinal Deformity: Prevalence, Risk Factors, and Cardiovascular Evaluation. Asian Spine J 2023; 17:685-692. [PMID: 37408295 PMCID: PMC10460655 DOI: 10.31616/asj.2022.0296] [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] [Received: 07/29/2022] [Revised: 12/05/2022] [Accepted: 12/15/2022] [Indexed: 07/07/2023] Open
Abstract
STUDY DESIGN Retrospective case-control study. PURPOSE To understand the prevalence of persistent orthostatic hypotension (POH), as well as its risk factors and cardiovascular pathology, in patients receiving surgery for the adult spinal deformity (ASD). OVERVIEW OF LITERATURE Although reports of the incidence of and risk factors for POH in different spinal disorders have recently been published, we are not aware of the comprehensive evaluation of POH following surgery for ASD. METHODS We examined medical records from a single central database for 65 patients receiving surgical treatment for ASD. Statistical comparisons were made between patients who experienced postoperative POH and those who did not, by examining patient and operative characteristics, such as age, sex, comorbidities, functional status, preoperative neurological function, vertebral fractures, three-column osteotomy, total operative time, estimated blood loss, length of stay, and radiographic parameters. The determinants of POH were assessed using multiple logistic regression. RESULTS We showed that postoperative POH was a complication of ASD surgery, with a 9% incidence rate. Patients with POH were statistically considerably more likely to require supported walkers due to partial paralysis and to have comorbidities including diabetes and neurodegenerative disease (ND). Furthermore, ND was an independent risk factor for postoperative POH (odds ratio, 4.073; 95% confidence interval, 1.094-8.362; p =0.020). Moreover, perioperative evaluation of the inferior vena cava showed that patients with postoperative POH had preoperative congestive heart failure and had hypovolemia lower postoperative diameter of the inferior vena cava than patients without POH. CONCLUSIONS Postoperative POH is a potential complication of ASD surgery. The most pertinent risk factor is having an ND. According to our study, patients who have surgery for ASD may experience alterations in their hemodynamics.
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Affiliation(s)
- Morito Takano
- Department of Orthopaedic Surgery, Spine Center, Kitasato Institute Hospital, Tokyo, Japan
| | - Tsuyoshi Iida
- Department of Orthopaedic Surgery, Spine Center, Kitasato Institute Hospital, Tokyo, Japan
| | - Tomohiro Hikata
- Department of Orthopaedic Surgery, Spine Center, Kitasato Institute Hospital, Tokyo, Japan
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Pathophysiology, Classification and Comorbidities after Traumatic Spinal Cord Injury. J Pers Med 2022; 12:jpm12071126. [PMID: 35887623 PMCID: PMC9323191 DOI: 10.3390/jpm12071126] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 12/25/2022] Open
Abstract
The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a spinal cord injury (SCI), supraspinal influences on the spinal segmental control system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, pain and dysesthesia, sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of traumatic SCI, current and emerging methods of classification, and its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue.
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Henke AM, Billington ZJ, Gater DR. Autonomic Dysfunction and Management after Spinal Cord Injury: A Narrative Review. J Pers Med 2022; 12:jpm12071110. [PMID: 35887607 PMCID: PMC9320320 DOI: 10.3390/jpm12071110] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/02/2022] [Accepted: 07/05/2022] [Indexed: 12/20/2022] Open
Abstract
The autonomic nervous system (ANS), composed of the sympathetic and parasympathetic nervous systems, acts to maintain homeostasis in the body through autonomic influences on the smooth muscle, cardiac muscles, blood vessels, glands and organs of the body. The parasympathetic nervous system interacts via the cranial and sacral segments of the central nervous system, and the sympathetic nervous system arises from the T1–L2 spinal cord segments. After a spinal cord injury (SCI), supraspinal influence on the ANS is disrupted, leading to sympathetic blunting and parasympathetic dominance resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions and uncontrolled bowel, bladder, and sexual dysfunction. Further, afferent signals to the sympathetic cord elicit unabated reflex sympathetic outflow in response to noxious stimuli below the level of SCI. This article outlines the pathophysiology of SCI on the ANS, clinical ramifications of autonomic dysfunction, and the potential long-term sequelae of these influences following SCI.
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Affiliation(s)
- Austin M. Henke
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.H.); (Z.J.B.)
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, Miami, FL 33136, USA
| | - Zackery J. Billington
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.H.); (Z.J.B.)
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, Miami, FL 33136, USA
| | - David R. Gater
- Department of Physical Medicine and Rehabilitation, University of Miami Miller School of Medicine, Miami, FL 33136, USA; (A.M.H.); (Z.J.B.)
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, Miami, FL 33136, USA
- The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Correspondence:
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McMillan DW, Astorino TA, Correa MA, Nash MS, Gater DR. Virtual Strategies for the Broad Delivery of High Intensity Exercise in Persons With Spinal Cord Injury: Ongoing Studies and Considerations for Implementation. Front Sports Act Living 2021; 3:703816. [PMID: 34423292 PMCID: PMC8377288 DOI: 10.3389/fspor.2021.703816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/08/2021] [Indexed: 11/13/2022] Open
Abstract
Spinal cord injury (SCI) results in a multitude of metabolic co-morbidities that can be managed by exercise. As in the non-injured population, manipulation of exercise intensity likely allows for fruitful optimization of exercise interventions targeting metabolic health in persons with SCI. In this population, interventions employing circuit resistance training (CRT) exhibit significant improvements in outcomes including cardiorespiratory fitness, muscular strength, and blood lipids, and recent exploration of high intensity interval training (HIIT) suggests the potential of this strategy to enhance health and fitness. However, the neurological consequences of SCI result in safety considerations and constrain exercise approaches, resulting in the need for specialized exercise practitioners. Furthermore, transportation challenges, inaccessibility of exercise facilities, and other barriers limit the translation of high intensity "real world" exercise strategies. Delivering exercise via online ("virtual") platforms overcomes certain access barriers while allowing for broad distribution of high intensity exercise despite the limited number of population-specific exercise specialists. In this review, we initially discuss the need for "real world" high intensity exercise strategies in persons with SCI. We then consider the advantages and logistics of using virtual platforms to broadly deliver high intensity exercise in this population. Safety and risk mitigation are considered first followed by identifying strategies and technologies for delivery and monitoring of virtual high intensity exercise. Throughout the review, we discuss approaches from previous and ongoing trials and conclude by giving considerations for future efforts in this area.
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Affiliation(s)
- David W. McMillan
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, United States
- Department of Physical Medicine & Rehabilitation, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - Todd A. Astorino
- Department of Kinesiology, California State University San Marcos, San Marcos, CA, United States
| | - Michael A. Correa
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, United States
| | - Mark S. Nash
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, United States
- Department of Physical Medicine & Rehabilitation, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
- Department of Neurological Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
| | - David R. Gater
- Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis, UHealth/Jackson Memorial, Miami, FL, United States
- Department of Physical Medicine & Rehabilitation, University of Miami Leonard M. Miller School of Medicine, Miami, FL, United States
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Logan A, Freeman J, Pooler J, Kent B, Gunn H, Billings S, Cork E, Marsden J. Effectiveness of non-pharmacological interventions to treat orthostatic hypotension in elderly people and people with a neurological condition: a systematic review. JBI Evid Synth 2021; 18:2556-2617. [PMID: 32773495 DOI: 10.11124/jbisrir-d-18-00005] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The objective of this review was to summarize the best available evidence regarding the effectiveness of non-pharmacological interventions to treat orthostatic hypotension (OH) in elderly people and people with a neurological condition. INTRODUCTION Orthostatic hypotension is common in elderly people and people with a neurological condition and can interfere with or limit rehabilitation. Non-pharmacological interventions to treat OH could allow for longer and earlier mobilization, which is recommended in national clinical guidelines for rehabilitation in the acute or sub-acute phase following stroke or other neurological conditions. INCLUSION CRITERIA The review considered people aged 50 years and older, and people aged 18 years and elderly people with a neurological condition. Non-pharmacological interventions to treat OH included compression garments, neuromuscular stimulation, physical counter-maneuvers, aerobic or resistance exercises, sleeping with head tilted up, increasing fluid and salt intake, and timing and size of meals. The comparator was usual care, no intervention, pharmacological interventions, or other non-pharmacological interventions. Outcome measures included systolic blood pressure, diastolic blood pressure, heart rate, cerebral blood flow, observed/perceived symptoms, duration of standing or sitting in minutes, tolerance of therapy, functional ability, and adverse events/effects. METHODS Databases for published and unpublished studies available in English up to April 2018 with no lower date limit were searched. Critical appraisal was conducted using standardized instruments from JBI. Data were extracted using standardized tools designed for quantitative studies. Where appropriate, studies were included in a meta-analysis; otherwise, data were presented in a narrative form due to heterogeneity. RESULTS Forty-three studies - a combination of randomized controlled trials (n = 13), quasi-experimental studies (n = 28), a case control study (n = 1), and a case report (n = 1) - with 1069 participants were included. Meta-analyses of three interventions (resistance exercise, electrical stimulation, and lower limb compression bandaging) showed no significant effect of these interventions. Results from individual studies indicated physical maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward improved orthostatic hypotension. Abdominal compression improved OH. Sleeping with head up in combination with pharmacological treatment was more effective than sleeping with head up alone. Eating smaller, more frequent meals was effective. Drinking 480 mL of water increased blood pressure. CONCLUSIONS The review found mixed results for the effectiveness of non-pharmacological interventions to treat OH in people aged 50 years and older, and people with a neurological condition. There are several non-pharmacological interventions that may be effective in treating OH, but not all have resulted in clinically meaningful changes in outcome. Some may not be suitable for people with moderate to severe disability; therefore, it is important for clinicians to consider the patient's abilities and impairments when considering which non-pharmacological interventions to implement.
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Affiliation(s)
- Angela Logan
- School of Health Professions, Faculty of Health, Peninsula Allied Health Centre, Plymouth University, Plymouth, UK.,Stroke and Neurology Therapy Team, Cornwall Partnership Foundation NHS Trust, Camborne Redruth Community Hospital, Cornwall, UK.,The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence
| | - Jennifer Freeman
- School of Health Professions, Faculty of Health, Peninsula Allied Health Centre, Plymouth University, Plymouth, UK.,The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence
| | - Jillian Pooler
- Faculty of Health, Peninsula Medical and Dentistry Schools, Plymouth, UK
| | - Bridie Kent
- The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence.,School of Nursing and Midwifery, Faculty of Health, Plymouth University, Plymouth, UK
| | - Hilary Gunn
- School of Health Professions, Faculty of Health, Peninsula Allied Health Centre, Plymouth University, Plymouth, UK
| | - Sarah Billings
- Stroke Rehabilitation Unit, Livewell Southwest, Mount Gould Hospital, Plymouth, UK
| | - Emma Cork
- Stroke Rehabilitation Department, Northern Devon Healthcare Trust, Northern Devon District Hospital, Barnstaple, UK
| | - Jonathan Marsden
- School of Health Professions, Faculty of Health, Peninsula Allied Health Centre, Plymouth University, Plymouth, UK.,The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence
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Ong ETE, Yeo LKP, Kaliya-Perumal AK, Oh JYL. Orthostatic Hypotension Following Cervical Spine Surgery: Prevalence and Risk Factors. Global Spine J 2020; 10:578-582. [PMID: 32677558 PMCID: PMC7359682 DOI: 10.1177/2192568219863805] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVES This study aims to determine the prevalence and risk factors for orthostatic hypotension (OH) in patients undergoing cervical spine surgery. METHODS Data was collected from records of 190 consecutive patients who underwent cervical spine procedures at our center over 24 months. Statistical comparison was made between patients who developed postoperative OH and those who did not by analyzing characteristics such as age, gender, premorbid medical comorbidities, functional status, mechanism of spinal cord injury, preoperative neurological function, surgical approach, estimated blood loss, and length of stay. RESULTS Twenty-two of 190 patients (11.6%) developed OH postoperatively. No significant differences in age, gender, medical comorbidities, or premorbid functional status were observed. Based on univariate comparisons, traumatic mechanism of injury (P = .002), poor ASIA (American Spinal Injury Association) grades (A, B, or C) (P < .001), and posterior surgical approach (P = .045) were found to significantly influence occurrence of OH. Among the significant variables, after adjusting for mechanism of injury and surgical approach, only ASIA grade was found to be an independent predictor. Having an ASIA grade of A, B, or C increased the likelihood of developing OH by approximately 5.978 times (P = .003). CONCLUSION Our study highlights that OH is not an uncommon manifestation following cervical spine surgery. Patients with poorer ASIA grades A, B, or C were more likely to have OH when compared with those with ASIA grades D or E (43.5% vs 7.2%). Hence, we suggest that postural blood pressure should be routinely monitored in this group of patients so that early intervention can be initiated.
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Affiliation(s)
| | | | - Arun-Kumar Kaliya-Perumal
- Tan Tock Seng Hospital, Singapore,Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu, India
| | - Jacob Yoong-Leong Oh
- Tan Tock Seng Hospital, Singapore,Jacob Yoong-Leong Oh, Department of Orthopaedic Surgery, Spine Division, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore.
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Sarafis ZK, Monga AK, Phillips AA, Krassioukov AV. Is Technology for Orthostatic Hypotension Ready for Primetime? PM R 2019; 10:S249-S263. [PMID: 30269810 DOI: 10.1016/j.pmrj.2018.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/04/2018] [Accepted: 04/12/2018] [Indexed: 01/29/2023]
Abstract
Spinal cord injury (SCI) often results in the devastating loss of motor, sensory, and autonomic function. After SCI, the interruption of descending sympathoexcitatory pathways disrupts supraspinal control of blood pressure (BP). A common clinical consequence of cardiovascular dysfunction after SCI is orthostatic hypotension (OH), a debilitating condition characterized by rapid profound decreases in BP when assuming an upright posture. OH can result in a diverse array of insidious and pernicious health consequences. Acute effects of OH include decreased cardiac filling, cerebral hypoperfusion, and associated presyncopal symptoms such as lightheadedness and dizziness. Over the long term, repetitive exposure to OH is associated with a drastically increased prevalence of heart attack and stroke, which are leading causes of death in those with SCI. Current recommendations for managing BP after SCI primarily include pharmacologic interventions with prolonged time to effect. Because most episodes of OH occur in less than 3 minutes, this delay in action often renders most pharmacologic interventions ineffective. New innovative technologies such as epidural and transcutaneous spinal cord stimulation are being explored to solve this problem. It might be possible to electrically stimulate sympathetic circuitry caudal to the injury and elicit rapid modulation of BP to manage OH. This review describes autonomic control of the cardiovascular system before injury, resulting cardiovascular consequences after SCI such as OH, and the clinical assessment tools for evaluating autonomic dysfunction after SCI. In addition, current approaches for clinically managing OH are outlined, and new promising interventions are described for managing this condition.
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Affiliation(s)
- Zoe K Sarafis
- ICORD-BSCC, University of British Columbia, Vancouver, BC, Canada(∗)
| | - Aaron K Monga
- ICORD-BSCC, University of British Columbia, Vancouver, BC, Canada(†)
| | - Aaron A Phillips
- Departments of Physiology and Pharmacology, Clinical Neurosciences, Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada(‡)
| | - Andrei V Krassioukov
- ICORD-BSCC; Experimental Medicine Program; Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia; GF Strong Rehabilitation Center, Vancouver Coastal Health; 818 West 10th Avenue, Vancouver, BC, Canada, V5Z1M9(§).
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Małek ŁA, Mróz A, Czajkowska A, Kosmol A, Ogonowska-Słodownik A, Molik B, Morgulec-Adamowicz N. Accuracy of Impedance Cardiography for Hemodynamic Assessment During Rest and Exercise in Wheelchair Rugby Players. RESEARCH QUARTERLY FOR EXERCISE AND SPORT 2019; 90:336-343. [PMID: 31082312 DOI: 10.1080/02701367.2019.1600651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 03/24/2019] [Indexed: 06/09/2023]
Abstract
Purpose: The aim of the study was to analyze the accuracy of impedance cardiography (ICG) for hemodynamic assessment in wheelchair rugby players during rest and exercise. Method: The study included 21 players (mean age 33.0 ± 5.4, 86% male) with posttraumatic tetraplegia. ECG, echocardiography, and gas exchange analysis during rest and exercise were used to obtain heart rate (HR), stroke volume (SV), and cardiac output (CO) for comparison with PhysioFlow®. Results: There was a good correlation between reference methods and ICG for HR, SV, CO at rest and CO at peak exercise (r = 0.69-0.77, p < .001) and a very good correlation for peak HR (r = 0.91, p < .0001). ICG overestimated SV at rest, CO at rest, and peak CO, which resulted in low intraclass correlation coefficients (ICC = 0.250 and 0.570). Conclusions: ICG can serve as a good estimate of basic hemodynamic parameters during rest and exercise in wheelchair rugby players but overestimates stroke volume and cardiac output.
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Affiliation(s)
- Łukasz A Małek
- a Józef Pilsudski University of Physical Education in Warsaw
| | - Anna Mróz
- a Józef Pilsudski University of Physical Education in Warsaw
| | - Anna Czajkowska
- a Józef Pilsudski University of Physical Education in Warsaw
| | - Andrzej Kosmol
- a Józef Pilsudski University of Physical Education in Warsaw
| | | | - Bartosz Molik
- a Józef Pilsudski University of Physical Education in Warsaw
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Momeni K, Ramanujam A, Garbarini EL, Forrest GF. Multi-muscle electrical stimulation and stand training: Effects on standing. J Spinal Cord Med 2019; 42:378-386. [PMID: 29447105 PMCID: PMC6522918 DOI: 10.1080/10790268.2018.1432311] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To examine the biomechanical and neuromuscular effects of a longitudinal multi-muscle electrical stimulation (submaximal intensities) training of the lower limbs combined with/without activity-based stand training, on the recovery of stability and function for one individual with spinal cord injury (SCI). DESIGN Single-subject, longitudinal study. SETTING Neuroplasticity laboratory. PARTICIPANT A 34-year-old male, with sensory- and motor-complete SCI (C5/C6). INTERVENTIONS Two consecutive interventions: 61 hours of supine, lower-limb ES (ES-alone) and 51 hours of ES combined with stand training using an overhead body-weight support system (ST + ES). OUTCOME MEASURES Clinical measures, trunk stability, and muscle activity were assessed and compared across time points. Trunk Stability Limit (TSL) determined improvements in trunk independence. RESULTS Functional clinical values increased after both interventions, with further increases post ST + ES. Post ES-alone, trunk stability was maintained at 81% body-weight (BW) loading before failure; post ST + ES, BW loading increased to 95%. TSL values decreased post ST + ES (TSLA/P=54.0 kg.cm, TSLM/L=14.5 kg.cm), compared to ES-alone (TSLA/P=8.5 kg.cm, TSLM/L=3.9 kg.cm). Trunk muscle activity decreased post ST + ES training, compared to ES-alone. CONCLUSION Neuromuscular and postural trunk control dramatically improved following the multi-muscle ES of the lower limbs with stand training. Multi-muscle ES training paradigm of the lower limb, using traditional parameters, may contribute to the functional recovery of the trunk.
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Affiliation(s)
- Kamyar Momeni
- Human Performance and Engineering Research, Kessler Foundation, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, New Jersey, USA
| | - Arvind Ramanujam
- Human Performance and Engineering Research, Kessler Foundation, New Jersey, USA
| | - Erica L. Garbarini
- Human Performance and Engineering Research, Kessler Foundation, New Jersey, USA
| | - Gail F. Forrest
- Human Performance and Engineering Research, Kessler Foundation, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, New Jersey, USA,Correspondence to: Gail F. Forrest, Ph.D., Human Performance and Engineering Research, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, NJ07052, USA.
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12
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Kyriakides A, Poulikakos D, Galata A, Konstantinou D, Panagiotopoulos E, Chroni E. The effect of level of injury and physical activity on heart rate variability following spinal cord injury. J Spinal Cord Med 2019; 42:212-219. [PMID: 29052467 PMCID: PMC6419680 DOI: 10.1080/10790268.2017.1383709] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE/BACKGROUND To assess frequency domain heart rate variability (HRV) parameters at rest and in response to postural autonomic provocations in individuals with spinal cord injury (SCI) and investigate the autonomic influences on the heart of different physical activities. DESIGN Cross-sectional study. METHODS Ten subjects with complete cervical SCI and fourteen subjects with complete low thoracic SCI were prospectively recruited from the community and further divided in sedentary and physically active groups, the latter defined as regular weekly 4 hour physical activity for the preceding 3 months. Sixteen healthy individuals matched for sex and age were recruited to participate in the control group. The Low Frequency (LF), High Frequency (HF) powers and the LF/HF ratio of HRV were measured from continuous electrocardiogram (ECG) recordings at rest and after sitting using a fast Fourier transformation. OUTCOME MEASURES The LF,HF, and the LF/HF ratio at rest and after sitting. RESULTS A significant decrease in all HRV parameters in patients with SCI was found compared to controls. The change in HF, LF and LF/HF following sitting maneuver was significantly greater in controls as compared with the SCI group and greater in subjects with paraplegia as compared to subjects with tetraplegia. Better HRV values and enhanced vagal activity appears to be related to the type of physical activity in active subjects with paraplegia. CONCLUSION In this cohort of subjects spectral parameters of HRV were associated with the level of the injury. Passive standing was associated with higher HRV values in subjects with paraplegia.
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Affiliation(s)
- Athanasios Kyriakides
- Spinal Cord Unit, University Hospital of Patras, Rion, Greece,Correspondence to: Athanasios Kyriakides, Spinal Cord Unit, University Hospital of Patras, Rion, Greece. ;
| | | | - Angeliki Galata
- Spinal Cord Unit, University Hospital of Patras, Rion, Greece
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13
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Restoring prolonged standing via functional electrical stimulation after spinal cord injury: A systematic review of control strategies. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2018.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Itoh M, Endo MY, Hojo T, Yoshimura M, Fukuoka Y. Characteristics of cardiovascular responses to an orthostatic challenge in trained spinal cord-injured individuals. J Physiol Anthropol 2018; 37:22. [PMID: 30268154 PMCID: PMC6162881 DOI: 10.1186/s40101-018-0182-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 09/13/2018] [Indexed: 11/22/2022] Open
Abstract
Background We investigated cardiovascular responses to an orthostatic challenge in trained spinal cord-injured (SCI) individuals compared to able-bodied (AB) individuals. Methods A total of 23 subjects participated, divided into three groups: seven were trained as spinal cord-injured (Tr-SCI) individuals, seven were able-bodied individuals trained as runners (Tr-AB), and nine were untrained able-bodied individuals (UnTr-AB). We measured the cardiovascular autonomic responses in all three groups during each 5-min head-up tilt (HUT) of 0°, 40°, and 80°. Stroke volume (SV), heart rate (HR), and cardiac output (Qc) as cardiovascular responses were measured by impedance cardiography. Changes in deoxyhemoglobin (∆[HHb]) and total hemoglobin (∆[Hbtot]) concentrations of the right medial gastrocnemius muscle were measured using near-infrared spectroscopy (NIRS). Results As the HUT increased from 0° to 80°, Tr-SCI group showed less change in SV at all HUT levels even if HR increased significantly. Mean arterial pressure (MAP) also did not significantly increase as tilting increased from 0° to 80°. Regarding peripheral vascular responses, the alterations of ∆[Hbtot] from 0° to 80° were less in Tr-SCI group compared to AB individuals. Conclusion There is a specific mechanism whereby blood pressure is maintained during a HUT in Tr-SCI group with the elicitation of peripheral vasoconstriction and the atrophy of the vascular vessels in paraplegic lower limbs, which would be associated with less change in SV in response to an orthostatic challenge.
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Affiliation(s)
- Masahiro Itoh
- Department of Physiology, Kumamoto University Graduate School of Life Sciences, 4-24-1, Kuhonji Chuou-ku, Kumamoto, 862-0976, Japan.
| | - Masako Yamaoka Endo
- Department of Exercise Science and Physiology, Faculty of Human Culture and Science, Prefectural University of Hiroshima, Hiroshima, Japan.,Laboratory of Environmental Physiology, Faculty of Environmental and Symbiotic Sciences, Prefectural University of Kumamoto, Kumamoto, Japan
| | - Tatsuya Hojo
- Laboratory of Sports Medicine, Faculty of Health and Sport Science, Doshisha University, Kyoto, Japan
| | - Miho Yoshimura
- Laboratory of Sports Medicine, Faculty of Health and Sport Science, Doshisha University, Kyoto, Japan
| | - Yoshiyuki Fukuoka
- Laboratory of Environmental Physiology, Faculty of Environmental and Symbiotic Sciences, Prefectural University of Kumamoto, Kumamoto, Japan.,Laboratory of Environmental Physiology, Faculty of Health and Sport Science, Doshisha University, Kyoto, Japan
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15
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Draghici AE, Potart D, Hollmann JL, Pera V, Fang Q, DiMarzio CA, Taylor JA, Niedre MJ, Shefelbine SJ. Near infrared spectroscopy for measuring changes in bone hemoglobin content after exercise in individuals with spinal cord injury. J Orthop Res 2018; 36:183-191. [PMID: 28561268 PMCID: PMC5711624 DOI: 10.1002/jor.23622] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 05/19/2017] [Indexed: 02/04/2023]
Abstract
Bone blood perfusion has an essential role in maintaining a healthy bone. However, current methods for measuring bone blood perfusion are expensive and highly invasive. This study presents a custom built near-infrared spectroscopy (NIRS) instrument to measure changes in bone blood perfusion. We demonstrated the efficacy of this device by monitoring oxygenated and deoxygenated hemoglobin changes in the human tibia during and after exercise in able-bodied and in individuals with spinal cord injury (SCI), a population with known impaired peripheral blood perfusion. Nine able-bodied individuals and six volunteers with SCI performed a 10 min rowing exercise (functional electrical stimulation rowing for those with SCI). With exercise, during rowing, able-bodied showed an increase in deoxygenated hemoglobin in the tibia. Post rowing, able-bodied showed an increase in total blood content, characterized by an increase in total hemoglobin content due primarily to an increase in deoxygenated hemoglobin. During rowing and post-rowing, those with SCI showed no change in total blood content in the tibia. The current study demonstrates that NIRS can non-invasively detect changes in hemoglobin concentration in the tibia. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:183-191, 2018.
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Affiliation(s)
- Adina E. Draghici
- Department of Bioengineering, Northeastern University, Boston, MA, USA
| | - Diane Potart
- Université de Technologie Compiègne, Compiègne, France
| | | | - Vivian Pera
- Department of Biomedical Engineering, Boston University, Boston, MA, USA
| | - Qianqian Fang
- Department of Bioengineering, Northeastern University, Boston, MA, USA,Department of Electrical and Computer Engineering, Northeastern University, Boston, MA, USA
| | - Charles A. DiMarzio
- Department of Electrical and Computer Engineering, Northeastern University, Boston, MA, USA
| | - J. Andrew Taylor
- Cardiovascular Research Laboratory, Spaulding Rehabilitation Hospital, Cambridge, MA, USA,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Mark J. Niedre
- Department of Bioengineering, Northeastern University, Boston, MA, USA,Department of Electrical and Computer Engineering, Northeastern University, Boston, MA, USA
| | - Sandra J. Shefelbine
- Department of Bioengineering, Northeastern University, Boston, MA, USA,Department of Mechanical and Industrial Engineering, Northeastern University, Boston, MA, USA
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16
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Wecht JM, Bauman WA. Implication of altered autonomic control for orthostatic tolerance in SCI. Auton Neurosci 2018; 209:51-58. [DOI: 10.1016/j.autneu.2017.04.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 03/16/2017] [Accepted: 04/25/2017] [Indexed: 12/22/2022]
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17
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Braz GP, Russold MF, Fornusek C, Hamzaid NA, Smith RM, Davis GM. A novel motion sensor-driven control system for FES-assisted walking after spinal cord injury: A pilot study. Med Eng Phys 2016; 38:1223-1231. [DOI: 10.1016/j.medengphy.2016.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 04/24/2016] [Accepted: 06/07/2016] [Indexed: 11/25/2022]
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18
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Braz GP, Russold MF, Fornusek C, Hamzaid NA, Smith RM, Davis GM. Cardiorespiratory and Muscle Metabolic Responses During Conventional Versus Motion Sensor-Assisted Strategies for Functional Electrical Stimulation Standing After Spinal Cord Injury. Artif Organs 2016; 39:855-62. [PMID: 26471136 DOI: 10.1111/aor.12619] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This is a case series study with the objective of comparing two motion sensor automated strategies to avert knee buckle during functional electrical stimulation (FES)-standing against a conventional hand-controlled (HC) FES approach. The research was conducted in a clinical exercise laboratory gymnasium at the University of Sydney, Australia. The automated strategies, Aut-A and Aut-B, applied fixed and variable changes of neurostimulation, respectively, in quadriceps amplitude to precisely control knee extension during standing. HC was an "on-demand" increase of stimulation amplitude to maintain stance. Finally, maximal FES amplitude (MA) was used as a control condition, whereby knee buckle was prevented by maximal isometric muscle recruitment. Four AIS-A paraplegics undertook 4 days of testing each, and each assessment day comprised three FES standing trials using the same strategy. Cardiorespiratory responses were recorded, and quadriceps muscle oxygenation was quantified using near-infrared spectroscopy. For all subjects, the longest standing times were observed during Aut-A, followed by Aut-B, and then HC and MA. The standing times of the automated strategies were superior to HC by 9-64%. Apart from a lower heart rates during standing (P = 0.034), the automation of knee extension did not promote different cardiorespiratory responses compared with HC. The standing times during MA were significantly shorter than during the automated or "on-demand" strategies (by 80-250%). In fact, the higher isometric-evoked quadriceps contraction during MA resulted in a greater oxygen demand (P < 0.0001) and wider arteriovenous oxygen extraction (P = 0.08) when compared with the other strategies. In conclusion, even though increased standing times were demonstrated using automated control of knee extension, physiological benefits compared with HC were not evident.
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Affiliation(s)
- Gustavo P Braz
- Clinical Exercise and Rehabilitation Unit, The University of Sydney, Sydney, NSW, Australia.,Discipline of Exercise and Sports Science, The University of Sydney, Sydney, NSW, Australia
| | - Michael F Russold
- Clinical Exercise and Rehabilitation Unit, The University of Sydney, Sydney, NSW, Australia
| | - Ché Fornusek
- Clinical Exercise and Rehabilitation Unit, The University of Sydney, Sydney, NSW, Australia.,Discipline of Exercise and Sports Science, The University of Sydney, Sydney, NSW, Australia
| | - Nur Azah Hamzaid
- Clinical Exercise and Rehabilitation Unit, The University of Sydney, Sydney, NSW, Australia.,Biomedical Engineering Department, Faculty of Engineering, University of Malaya, Kuala Lumpur, Malaysia
| | - Richard M Smith
- Discipline of Exercise and Sports Science, The University of Sydney, Sydney, NSW, Australia
| | - Glen M Davis
- Clinical Exercise and Rehabilitation Unit, The University of Sydney, Sydney, NSW, Australia.,Discipline of Exercise and Sports Science, The University of Sydney, Sydney, NSW, Australia.,Biomedical Engineering Department, Faculty of Engineering, University of Malaya, Kuala Lumpur, Malaysia
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19
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Paleg G, Livingstone R. Systematic review and clinical recommendations for dosage of supported home-based standing programs for adults with stroke, spinal cord injury and other neurological conditions. BMC Musculoskelet Disord 2015; 16:358. [PMID: 26576548 PMCID: PMC4650310 DOI: 10.1186/s12891-015-0813-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/12/2015] [Indexed: 11/19/2022] Open
Abstract
Background Sitting for more than 8 h a day has been shown to negatively impact health and mortality while standing is the recommended healthier alternative. Home-based standing programs are commonly recommended for adults who cannot stand and/or walk independently. The aim of this systematic review is to review effectiveness of home-based standing programs for adults with neurological conditions including stroke and spinal cord injury; and to provide dosage guidelines to address body structure and function, activity and participation outcomes. Methods Eight electronic databases were searched, including Cochrane Library databases, MEDLINE, CINAHL and EMBASE. From 376 articles, 36 studies addressing impact of a standing intervention on adults with sub-acute or chronic neurological conditions and published between 1980 and September 2015 were included. Two reviewers independently screened titles, reviewed abstracts, evaluated full-text articles and rated quality and strength of evidence. Evidence level was rated using Oxford Centre for Evidence Based Medicine Levels and quality evaluated using a domain-based risk-of-bias rating. Outcomes were divided according to ICF components, diagnoses and dosage amounts from individual studies. GRADE and the Evidence-Alert Traffic-Lighting system were used to determine strength of recommendation and adjusted in accordance with risk-of-bias rating. Results Stronger evidence supports the impact of home-based supported standing programs on range of motion and activity, primarily for individuals with stroke or spinal cord injury while mixed evidence supports impact on bone mineral density. Evidence for other outcomes and populations is weak or very weak. Conclusions Standing should occur 30 min 5 times a week for a positive impact on most outcomes while 60 min daily is suggested for mental function and bone mineral density. Electronic supplementary material The online version of this article (doi:10.1186/s12891-015-0813-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ginny Paleg
- Montgomery County Infants and Toddlers Program, Rockville, MD, USA.
| | - Roslyn Livingstone
- Sunny Hill Health Centre for Children, Vancouver, British Columbia, Canada
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20
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Magimairaj H, Hariharan R, Thumbikat P. Orthodeoxia syndrome: a rare complication of ASD in spinal cord injury. Spinal Cord Ser Cases 2015; 1:15005. [PMID: 28053709 DOI: 10.1038/scsandc.2015.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 12/18/2014] [Accepted: 01/15/2015] [Indexed: 11/09/2022] Open
Abstract
STUDY DESIGN This is a single-subject case report. OBJECTIVES The objective is to describe and discuss a rare presentation of orthodeoxia after spinal cord injury in a previously healthy adult with an asymptomatic and undiagnosed atrial septal defect. SETTING This study was conducted at the Tertiary Care Spinal Injuries Center in Sheffield, UK. METHODS An 81-year-old woman who was otherwise healthy and active sustained a polytrauma following a road traffic collision. Her injuries were managed conservatively. As a complication of epidural analgesia, she developed a complete thoracic paraplegia secondary to an epidural hematoma. She was found to have repeated episodes of severe deoxemia, without any significant postural hypotension when attempts were made to sit her up in bed. Detailed investigations were done to ascertain the cause for this deoxemia. RESULTS Echocardiography revealed an atrial septal defect; agitated saline contrast transesophageal ultrasound done in various positions revealed interatrial defect with reversal of shunting when the patient was made to sit up in bed. CONCLUSION Orthodeoxia is an uncommon finding in spinal injury patients. Detailed investigations at an early stage of rehabilitation need to be done to rule out cardiac causes after ruling out the common medical complications seen in the acute and subacute phases following spinal cord injury.
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Affiliation(s)
- H Magimairaj
- The Princess Royal Spine Injuries Center, Northern General Hospital , Sheffield, UK
| | - R Hariharan
- The Princess Royal Spine Injuries Center, Northern General Hospital , Sheffield, UK
| | - P Thumbikat
- The Princess Royal Spine Injuries Center, Northern General Hospital , Sheffield, UK
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21
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Ravensbergen HJCR, de Groot S, Post MWM, Slootman HJ, van der Woude LHV, Claydon VE. Cardiovascular function after spinal cord injury: prevalence and progression of dysfunction during inpatient rehabilitation and 5 years following discharge. Neurorehabil Neural Repair 2013; 28:219-29. [PMID: 24243916 DOI: 10.1177/1545968313504542] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Autonomic dysfunction after spinal cord injury (SCI) is an under-researched area when compared with motor and sensory dysfunction. Cardiovascular autonomic dysfunction is a particular concern, leading to impaired control of blood pressure and heart rate. OBJECTIVES (1) To determine the prevalence of hypotension in individuals with SCI during and after rehabilitation; (2) To investigate changes in cardiovascular variables during and after rehabilitation; (3) To evaluate the influence of personal and lesion characteristics on cardiovascular variables. METHODS Cardiovascular variables (resting systolic [SAP] and diastolic [DAP] arterial pressures and resting [HRrest] and peak heart rates [HRpeak]) were measured on 5 test occasions: start of inpatient rehabilitation, 3 months later, at discharge, and at 1 and 5 years after discharge. The time course and effects of personal and lesion characteristics on cardiovascular variables were studied using multilevel regression analyses. RESULTS The prevalence of hypotension was unchanged during rehabilitation and for 5 years after discharge. Odds for hypotension were highest in those with cervical and high thoracic lesions, younger individuals, and men. DAP increased during the 5 years after discharge. HRrest decreased during and after rehabilitation. SAP, DAP, HRrest, and HRpeak were lowest in those with cervical and high thoracic lesions. SAP and DAP increased with age; HRpeak decreased with age. CONCLUSIONS These longitudinal data provide normative values for blood pressure and heart rate changes with time after injury according to lesion and personal characteristics. These results can be used to guide clinical practice and place changes in cardiovascular function caused by interventions in perspective.
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22
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Weaver LC, Fleming JC, Mathias CJ, Krassioukov AV. Disordered cardiovascular control after spinal cord injury. HANDBOOK OF CLINICAL NEUROLOGY 2013; 109:213-33. [PMID: 23098715 DOI: 10.1016/b978-0-444-52137-8.00013-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Damage to the spinal cord disrupts autonomic pathways, perturbing cardiovascular homeostasis. Cardiovascular dysfunction increases with higher levels of injury and greater severity. Disordered blood pressure control after spinal cord injury (SCI) has significant ramifications as cord-injured people have an increased risk of developing heart disease and stroke; cardiovascular dysfunction is currently a leading cause of death among those with SCI. Despite the clinical significance of abnormal cardiovascular control following SCI, this problem has been generally neglected by both the clinical and research community. Both autonomic dysreflexia and orthostatic hypotension are known to prevent and delay rehabilitation, and significantly impair the overall quality of life after SCI. Starting with neurogenic shock immediately after a higher SCI, ensuing cardiovascular dysfunctions include orthostatic hypotension, autonomic dysreflexia and cardiac arrhythmias. Disordered temperature regulation accompanies these autonomic dysfunctions. This chapter reviews the human and animal studies that have furthered our understanding of the pathophysiology and mechanisms of orthostatic hypotension, autonomic dysreflexia and cardiac arrhythmias. The cardiovascular dysfunction that occurs during sexual function and exercise is elaborated. New awareness of cardiovascular dysfunction after SCI has led to progress toward inclusion of this important autonomic problem in the overall assessment of the neurological condition of cord-injured people.
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23
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Sisto SA, Lorenz DJ, Hutchinson K, Wenzel L, Harkema SJ, Krassioukov A. Cardiovascular status of individuals with incomplete spinal cord injury from 7 NeuroRecovery Network rehabilitation centers. Arch Phys Med Rehabil 2012; 93:1578-87. [PMID: 22920455 DOI: 10.1016/j.apmr.2012.04.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 02/27/2012] [Accepted: 04/19/2012] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine cardiovascular (CV) health in a large cohort of individuals with incomplete spinal cord injury (SCI). The CV health parameters of patients were compared based on American Spinal Injury Association Impairment Scale (AIS), neurologic level, sex, central cord syndrome, age, time since injury, Neuromuscular Recovery Scale, and total AIS motor score. DESIGN Cross-sectional study. SETTING Seven outpatient rehabilitation clinics. PARTICIPANTS Individuals (N=350) with incomplete AIS classification C and D were included in this analysis. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Heart rate, systolic and diastolic blood pressure during resting sitting and supine positions and after an orthostatic challenge. RESULTS CV parameters were highly variable and significantly differed based on patient position. Neurologic level (cervical, high and low thoracic) and age were most commonly associated with CV parameters where patients classified at the cervical level had the lowest resting CV parameters. After the orthostatic challenge, blood pressure was highest for the low thoracic group, and heart rate for the high thoracic group was higher. Time since SCI was negatively related to blood pressure at rest but not after orthostatic challenge. Men exhibited higher systolic blood pressure than women and lower heart rate. The prevalence of orthostatic hypotension (OH) was 21% and was related to the total motor score and resting seated blood pressures. Cervical injuries had the highest prevalence. CONCLUSIONS Resting CV parameters of blood pressure and heart rate are affected by position, age, and neurologic level. OH is more prevalent in cervical injuries, those with lower resting blood pressures and who are lower functioning. Results from this study provide reference for CV parameters for individuals with incomplete SCI. Future research is needed on the impact of exercise on CV parameters.
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Affiliation(s)
- Sue Ann Sisto
- Department of Physical Therapy, Division of Rehabilitation Sciences, Stony Brook University, Stony Brook, NY 11794-6018, USA.
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24
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Newman M, Barker K. The effect of supported standing in adults with upper motor neurone disorders: a systematic review. Clin Rehabil 2012; 26:1059-77. [DOI: 10.1177/0269215512443373] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Meredith Newman
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Karen Barker
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
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25
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Bauman WA, Korsten MA, Radulovic M, Schilero GJ, Wecht JM, Spungen AM. 31st g. Heiner sell lectureship: secondary medical consequences of spinal cord injury. Top Spinal Cord Inj Rehabil 2012; 18:354-78. [PMID: 23459498 PMCID: PMC3584784 DOI: 10.1310/sci1804-354] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Persons with spinal cord injury (SCI) have secondary medical consequences of paralysis and/or the consequences of extreme inactivity. The metabolic changes that result from reduced activity include insulin resistance with carbohydrate disorders and dyslipidemia. A higher prevalence of coronary artery calcification was found in persons with SCI than that in matched able-bodied controls. A depression in anabolic hormones, circulating testosterone and growth hormone, has been described. Adverse soft tissue body composition changes of increased adiposity and reduced skeletal muscle are appreciated. Immobilization is the cause for sublesional disuse osteoporosis with an associated increased risk of fragility fracture. Bowel dysmotility affects all segments of the gastrointestinal tract, with an interest in better defining and addressing gastroesophageal reflux disease and difficulty with evacuation. Developing and testing more effective approaches to cleanse the bowel for elective colonoscopy are being evaluated. The extent of respiratory dysfunction depends on the level and completeness of SCI. Individuals with higher spinal lesions have both restrictive and obstructive airway disease. Pharmacological approaches and expiratory muscle training are being studied as interventions to improve pulmonary function and cough strength with the objective of reducing pulmonary complications. Persons with spinal lesions above the 6th thoracic level lack both cardiac and peripheral vascular mechanisms to maintain blood pressure, and they are frequently hypotensive, with even worse hypotension with upright posture. Persistent and/or orthostatic hypotension may predispose those with SCI to cognitive impairments. The safety and efficacy of anti-hypotensive agents to normalize blood pressure in persons with higher level cord lesions is being investigated.
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Affiliation(s)
- William A Bauman
- VA RR&D National Center of Excellence for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center , Bronx, New York ; Medical Service, James J. Peters VA Medical Center , Bronx, New York ; Department of Medicine, The Mount Sinai School of Medicine , New York, New York ; Department of Rehabilitation Medicine, The Mount Sinai School of Medicine , New York, New York
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Hemodynamic effects of habituation to a week-long program of neuromuscular electrical stimulation. Med Eng Phys 2011; 34:459-65. [PMID: 21917497 DOI: 10.1016/j.medengphy.2011.08.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 08/12/2011] [Accepted: 08/12/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Neuromuscular electrical stimulation (NMES) of the calf muscles has been shown to cause instantaneous increases in venous outflow from the lower leg and could be used as an adjunct to current gold-standard compression therapies for the prevention of venous stasis and its related pathologies. However, little is known about the effects of NMES in combination with compression therapies on subject comfort, compliance and popliteal venous blood flow over the course of a week-long NMES protocol. This study aimed to assess the effects of a NMES and compression protocol for the prevention of venous stasis on the compliance, comfort and venous blood flow of healthy volunteers over the course of seven days. DESIGN Twenty-four healthy subjects were assigned to either a stimulation or control group. The stimulation group received 1.5 h of NMES daily while the control group received none. Daily measures of popliteal venous blood flow, subject compliance and comfort were recorded over 7 days. RESULTS Ejected blood flow volumes and peak velocities in the popliteal vein during NMES were sustained over a 30-min stimulation session and increased by approximately 100% over the course of seven days. Mean stimulation intensities increased progressively throughout the week, while perceived pain during NMES decreased significantly. Mean compliance to the 7-day protocol was 100%. CONCLUSION User habituation to a combined NMES and compression protocol resulted in significant increases in ejected venous volume and peak velocity over the course of 7 days. This resulted in the highest ejected venous volume reported from a single NMES induced contraction of the calf muscles to date which was twice the magnitude of values previously reported in the literature. These findings suggest that NMES based protocols applied over an extended period of days, weeks or months may provide greater hemodynamic effect for the prevention of venous stasis than previously observed during NMES sessions lasting less than a few hours.
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27
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Ogata H, Ogata T, Hoshikawa S, Uematsu A, Ogawa T, Saitou S, Kitamura T, Nakazawa K. Unusual blood pressure response during standing therapy in tetraplegic man. Clin Auton Res 2009; 20:47-50. [PMID: 19830510 DOI: 10.1007/s10286-009-0037-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Accepted: 09/21/2009] [Indexed: 11/24/2022]
Abstract
We report a case of an individual with cervical spinal cord injury who showed a unique blood pressure response during passive standing and passive walking-like leg movement, i.e., hypertension with standing and hypotension with leg movement.
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Affiliation(s)
- Hisayoshi Ogata
- Department of Rehabilitation for Movement Functions, Research Institute of National Rehabilitation Center for Persons with Disabilities, 4-1 Namiki, Tokorozawa, Saitama, 359-8555, Japan.
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28
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Krassioukov A, Eng JJ, Warburton DE, Teasell R. A systematic review of the management of orthostatic hypotension after spinal cord injury. Arch Phys Med Rehabil 2009; 90:876-85. [PMID: 19406310 DOI: 10.1016/j.apmr.2009.01.009] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 01/07/2009] [Accepted: 01/13/2009] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To review systematically the evidence for the management of orthostatic hypotension (OH) in patients with spinal cord injuries (SCIs). DATA SOURCES A key word literature search was conducted of original and review articles as well as practice guidelines using Medline, CINAHL, EMBASE, and PsycInfo, and manual searches of retrieved articles from 1950 to July 2008, to identify literature evaluating the effectiveness of currently used treatments for OH. STUDY SELECTION Included randomized controlled trials (RCTs), prospective cohort studies, case-control studies, pre-post studies, and case reports that assessed pharmacologic and nonpharmacologic intervention for the management of OH in patients with SCI. DATA EXTRACTION Two independent reviewers evaluated the quality of each study, using the Physiotherapy Evidence Database score for RCTs and the Downs and Black scale for all other studies. Study results were tabulated and levels of evidence assigned. DATA SYNTHESIS A total of 8 pharmacologic and 21 nonpharmacologic studies were identified that met the criteria. Of these 26 studies (some include both pharmacologic and nonpharmacologic interventions), only 1 pharmacologic RCT was identified (low-quality RCT producing level 2 evidence), in which midodrine was found to be effective in the management of OH after SCI. Functional electrical stimulation was one of the only nonpharmacologic interventions with some evidence (level 2) to support its utility. CONCLUSIONS Although a wide array of physical and pharmacologic measures are recommended for the management of OH in the general population, very few have been evaluated for use in SCI. Further research needs to quantify the efficacy of treatment for OH in subjects with SCI, especially of the many other pharmacologic interventions that have been shown to be effective in non-SCI conditions.
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Affiliation(s)
- Andrei Krassioukov
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.
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29
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Harkema SJ, Ferreira CK, van den Brand RJ, Krassioukov AV. Improvements in orthostatic instability with stand locomotor training in individuals with spinal cord injury. J Neurotrauma 2009; 25:1467-75. [PMID: 19118454 DOI: 10.1089/neu.2008.0572] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Prospective assessment of cardiovascular control in individuals with spinal cord injury (SCI) in response to active stand training. Cardiovascular parameters were measured at rest and in response to orthostatic challenge before and after training in individuals with clinically complete SCI. The goal of this study was to evaluate the effect of active stand training on arterial blood pressure and heart rate and changes in response to orthostatic stress in individuals with SCI. Measurements were obtained in individuals with SCI (n=8) prior to and after 40 and 80 sessions of the standing component of a locomotor training intervention (stand LT). During standing, all participants wore a harness and were suspended by an overhead, pneumatic body weight support (BWS) system over a treadmill. Trainers provided manual facilitation as necessary at the trunk and legs. All individuals were able to bear more weight on their legs after the stand LT training. Resting arterial blood pressure significantly increased in individuals with cervical SCI after 80 training sessions. At the end of the training period, resting systolic blood pressure (BP) in individuals with cervical SCI in a seated position, increased by 24% (from 84 +/- 5 to 104 +/- 7 mmHg). Furthermore, orthostatic hypotension present in response to standing prior to training (decrease in systolic BP of 24 +/- 14 mmHg) was not evident (decrease in systolic BP of 0 +/- 11 mmHg) after 80 sessions of stand LT. Hemodynamic parameters of individuals with thoracic SCI were relatively stable prior to training and not significantly different after 80 sessions of stand LT. Improvements in resting arterial blood pressure and responses to orthostatic stress in individuals with clinically complete cervical SCI occurred following intensive stand LT training. These results may be attributed to repetitive neuromuscular activation of the legs from loading and/or conditioning of cardiovascular responses from repetitively assuming an upright posture.
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Affiliation(s)
- Susan J Harkema
- Kentucky Spinal Cord Injury Research Center, Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
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Luther MS, Krewer C, Müller F, Koenig E. Comparison of orthostatic reactions of patients still unconscious within the first three months of brain injury on a tilt table with and without integrated stepping. A prospective, randomized crossover pilot trial. Clin Rehabil 2009; 22:1034-41. [PMID: 19052242 DOI: 10.1177/0269215508092821] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether passive leg movement during tilt table mobilization reduces the incidence of orthostatic dysfunction in mobilization of patients being comatose or semi-comatose early after brain injury. DESIGN Randomized crossover pilot trial using sequential testing. SETTING Neurorehabilitation hospital. SUBJECTS Nine patients still unconscious within the first three months of brain injury (5 men, 4 women; age 51 +/- 20 years). INTERVENTION Patients were subjected once to a conventional tilt table and once to a tilt table with an integrated stepping device. MAIN OUTCOME MEASURE The number of syncopes/presyncopes (orthostatic hypotension, tachypnoea, increased sweating) during interventions. RESULTS One patient had presyncopes on both devices, six patients had presyncopes on the conventional tilt table but not on the tilt table with integrated stepping, and two patients did not exhibit presyncopal symptoms on either device. There were significantly more incidents on the tilt table without than on the one with an integrated stepping device (P < 0.05) at tilts of 50 or 70 degrees respectively. CONCLUSION Patients tolerate greater degrees of head-up tilt better with simultaneous leg movement.
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Pressor response to passive walking-like exercise in spinal cord-injured humans. Clin Auton Res 2008; 19:113-22. [PMID: 19101752 DOI: 10.1007/s10286-008-0504-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Accepted: 09/22/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To examine blood pressure responses during passive walking-like exercise in the standing posture (PWE) in spinal cord-injured (SCI) humans. METHODS Twelve motor-complete SCI individuals (cervical level 6 to thoracic level 12, ASIA grade: A or B) and twelve able-bodied controls (CON) participated in this study. SCI individuals were divided into a group with injury level at or above thoracic (T) 6 (HSCI, n = 7) and a group with injury level at or below T10 (LSCI, n = 5). Subjects carried out 6-minute quiet standing and then 12-minute PWE at 1 Hz using a gait training apparatus that enables subjects to stand and move their legs passively. RESULTS Mean arterial blood pressures (MAPs) at standing in HSCI, LSCI and CON were 69 +/- 5, 83 +/- 4 and 93 +/- 2 mmHg, respectively. MAP changed significantly during PWE only in HSCI and CON, increasing to 88 +/- 4 (P < 0.001) and 98 +/- 1 mmHg (P < 0.01), respectively. The former group showed a larger increase in MAP (P < 0.001). INTERPRETATION Spinal sympathetic reflexes can be induced in a region isolated from the brainstem in response to a stimulus originating below the level of the spinal cord injury, and the magnitude of increase in blood pressure is greater in SCI individuals with lesion level at or above T6 due to loss of supraspinal control of the major sympathetic outflow. This central mechanism may be one of the reasons why greater pressor response to PWE was observed in HSCI.
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Cardiovascular response to functional electrical stimulation and dynamic tilt table therapy to improve orthostatic tolerance. J Electromyogr Kinesiol 2008; 18:900-7. [DOI: 10.1016/j.jelekin.2008.08.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 08/18/2008] [Accepted: 08/18/2008] [Indexed: 11/20/2022] Open
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Haapala S, Faghri P, Adams D. Identifying an Effective Paradigm for FES-Induced Cycle Ergometry in Individuals with Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2008. [DOI: 10.1310/sci1401-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Gillis DJ, Wouda M, Hjeltnes N. Non-pharmacological management of orthostatic hypotension after spinal cord injury: a critical review of the literature. Spinal Cord 2008; 46:652-9. [PMID: 18542098 DOI: 10.1038/sc.2008.48] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Review. OBJECTIVES Identify and describe the body of literature pertaining to non-pharmacological management of orthostatic hypotension (OH) during the early rehabilitation of persons with a spinal cord injury (SCI). SETTING Sunnaas Rehabilitation Hospital, Oslo, Norway. METHODS SEARCH STRATEGY a comprehensive search of electronic databases and cited references was undertaken. SELECTION CRITERIA case studies, parallel group trials and crossover designs using random or quasi-random assignments were considered. Participants with any level or degree of completeness of SCI and any time elapsed since injury were included. Interventions must have measured at least systolic blood pressure (BP), and have induced orthostatic stress in a controlled manner and have attempted to control OH during an orthostatic challenge. DATA COLLECTION AND ANALYSIS studies were selected, assessed and described qualitatively. Meta-analysis was deemed inappropriate. RESULTS Four distinct non-pharmacological interventions for OH were identified: application of compression and pressure to the abdominal region and/or legs, upper body exercise, functional electrical stimulation (FES) applied to the legs and biofeedback. Methodological quality varied dramatically between studies. Compression/pressure, upper body exercise and biofeedback therapies have proven inconclusive in their ability to control OH. During orthostatic challenge, FES consistently attenuates the fall in BP; however, its clinical application is less well established. CONCLUSIONS The clinical usefulness of compression/pressure, upper body exercise and biofeedback for treating OH has not been proven. FES of the legs holds the most promise.
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Affiliation(s)
- D J Gillis
- Faculty of Kinesiology and Rehabilitation Science, Katholieke Universiteit, Leuven, Belgium.
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Haapala SA, Faghri PD, Adams DJ. Leg joint power output during progressive resistance FES-LCE cycling in SCI subjects: developing an index of fatigue. J Neuroeng Rehabil 2008; 5:14. [PMID: 18439300 PMCID: PMC2396645 DOI: 10.1186/1743-0003-5-14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Accepted: 04/26/2008] [Indexed: 11/24/2022] Open
Abstract
Background The purpose of this study was to investigate the biomechanics of the hip, knee and ankle during a progressive resistance cycling protocol in an effort to detect and measure the presence of muscle fatigue. It was hypothesized that knee power output can be used as an indicator of fatigue in order to assess the cycling performance of SCI subjects. Methods Six spinal cord injured subjects (2 incomplete, 4 complete) between the ages of twenty and fifty years old and possessing either a complete or incomplete spinal cord injury at or below the fourth cervical vertebra participated in this study. Kinematic data and pedal forces were recorded during cycling at increasing levels of resistance. Ankle, knee and hip power outputs and resultant pedal force were calculated. Ergometer cadence and muscle stimulation intensity were also recorded. Results The main findings of this study were: (a) ankle and knee power outputs decreased, whereas hip power output increased with increasing resistance, (b) cadence, stimulation intensity and resultant pedal force in that combined order were significant predictors of knee power output and (c) knowing the value of these combined predictors at 10 rpm, an index of fatigue can be developed, quantitatively expressing the power capacity of the knee joint with respect to a baseline power level defined as fatigue. Conclusion An index of fatigue was successfully developed, proportionalizing knee power capacity during cycling to a predetermined value of fatigue. The fatigue index value at 0/8th kp, measured 90 seconds into active, unassisted pedaling was 1.6. This indicates initial power capacity at the knee to be 1.6 times greater than fatigue. The fatigue index decreased to 1.1 at 2/8th kp, representing approximately a 30% decrease in the knee's power capacity within a 4 minute timespan. These findings suggest that the present cycling protocol is not sufficient for a rider to gain the benefits of FES and thus raises speculation as to whether or not progressive resistance cycling is an appropriate protocol for SCI subjects.
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Affiliation(s)
- Stephenie A Haapala
- Functional Performance Laboratory, Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA.
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Luther MS, Krewer C, Müller F, Koenig E. Orthostatic circulatory disorders in early neurorehabilitation: a case report and management overview. Brain Inj 2008; 21:763-7. [PMID: 17653950 DOI: 10.1080/02699050701481639] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Orthostatic circulatory disorders are a common problem in the mobilization of patients with severe neurological diseases such as paraplegia, the vegetative state or the minimally conscious state. They create difficulties when mobilizing the patient out of bed. Although their incidence has not been clearly established and the severity and length of symptoms differ greatly, a relevant number of the patients in a rehabilitation unit is affected. Rehabilitation specialists should therefore be aware of these disorders and the therapeutic alternatives available. This case study reports on a 45-year-old patient who repeatedly suffered from orthostatic hypotension after a severe traumatic brain injury. The pathogenesis and predisposing factors of orthostatic dysfunction in severely disabled neurological patients as well as therapeutic efforts are subsequently reviewed.
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Rimaud D, Boissier C, Calmels P. Evaluation of the effects of compression stockings using venous plethysmography in persons with spinal cord injury. J Spinal Cord Med 2008; 31:202-7. [PMID: 18581669 PMCID: PMC2565483 DOI: 10.1080/10790268.2008.11760713] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND/OBJECTIVE To examine the effect of graduated compression stockings (GCS) on the properties of the venous vascular system, as characterized by venous capacitance (VC) and venous outflow (VO), in the lower extremities of individuals with spinal cord injury (SCI), according to injury level. METHODS Nine male subjects with SCI (5 with low paraplegia [LP], 4 with high paraplegia [HP]) performed 2 plethysmography tests: with and without graduated compression knee-length stockings (pressure of 21 mm/Hg). The VC, VO, and cardiovascular parameters (heart rate and blood pressure) were evaluated with and without GCS. RESULTS The VC and VO were lower in patients with HP than in those with LP. For all subjects, VC was significantly lower (-14%) with GCS than without (1.77 +/- 1.18 vs 1.53 +/- 1.09 vol%, P < 0.01). On the contrary, VO did not differ significantly when wearing or not wearing GCS. CONCLUSIONS This study demonstrated that 21-mm/Hg knee-length GCS are sufficient to prevent venous distension in individuals with SCI, even those with longstanding paraplegia, by significantly decreasing venous capacitance. This intervention may help to prevent deep vein thrombosis.
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Affiliation(s)
- Diana Rimaud
- Service de Médecine Physique et de Réadaptation, Unité de Recherche Physiologie et Physiopathologie de L'exercice et Handicap, Hôpital Bellevue, CHU Saint-Etienne, Saint-Etienne 42055 Cedex 2, France.
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Chao CY, Cheing GL. Orthostatic Hypotension for People with Spinal Cord Injuries. Hong Kong Physiother J 2008. [DOI: 10.1016/s1013-7025(09)70008-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Garstang SV, Miller-Smith SA. Autonomic Nervous System Dysfunction After Spinal Cord Injury. Phys Med Rehabil Clin N Am 2007; 18:275-96, vi-vii. [PMID: 17543773 DOI: 10.1016/j.pmr.2007.02.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The autonomic nervous system (ANS) plays a key role in the regulation of many physiologic processes, mediated by supraspinal control from centers in the central nervous system. The role of autonomic dysfunction in persons with spinal cord injuries is crucial to understand because many aspects of the altered physiology seen in these individuals are directly caused by ANS dysregulation.
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Affiliation(s)
- Susan V Garstang
- Department of Physical Medicine and Rehabilitation, UMNDJ-New Jersey Medical School, 30 Bergen Street, ADMC 101, Newark, NJ 07039, USA.
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Sidorov EV, Townson AF, Dvorak MF, Kwon BK, Steeves J, Krassioukov A. Orthostatic hypotension in the first month following acute spinal cord injury. Spinal Cord 2007; 46:65-9. [PMID: 17420772 DOI: 10.1038/sj.sc.3102064] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
STUDY DESIGN Retrospective data analysis. OBJECTIVES To determine prevalence of orthostatic hypotension (OH) in patients with spinal cord injury (SCI) during the acute rehabilitation period. SETTING Quaternary care spinal unit, Vancouver General Hospital, British Columbia, Canada. METHODS Eighty-nine patients with acute SCI stratified by neurological level (cervical, 55 (62%); upper thoracic, 12 (13%); lower thoracic, 22 (25%)), and graded by American Spinal Injury Association standards. Non-invasive measurement of systolic and diastolic blood pressure and heart rate were made at baseline and 3 min following an orthostatic challenge test administered during the first month after SCI. RESULTS Patients with cervical or upper thoracic motor complete SCI more frequently experienced OH (P<0.01). OH persisted during the first month following SCI in 74% of cervical and only 20% of upper thoracic motor complete SCI patients. CONCLUSION Patients with cervical and upper thoracic motor complete SCI are more likely to experience persistent OH than those with lower level or motor incomplete SCI during the first month of rehabilitation.
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Affiliation(s)
- E V Sidorov
- ICORD, University of British Columbia, Vancouver, British Columbia, Canada
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Claydon VE, Krassioukov AV. Orthostatic hypotension and autonomic pathways after spinal cord injury. J Neurotrauma 2007; 23:1713-25. [PMID: 17184183 DOI: 10.1089/neu.2006.23.1713] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Individuals with spinal cord injury (SCI) are prone to orthostatic hypotension (OH). We aimed to develop a simple bedside test to evaluate autonomic control following chronic SCI, and to identify those most at risk of OH and cardiovascular dysfunction. We studied 14 subjects with cervical SCI, 11 with thoracic SCI, and 17 able-bodied controls. We continuously recorded heart rate (HR; ECG) and beat-to-beat systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures (Finometer) while supine, and following the passive assumption of an upright seated position. Stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR) were calculated. Plasma catecholamines were determined. Motor and sensory loss was assessed using the American Spinal Injury Association (ASIA) impairment scale. Autonomic pathways were assessed from sympathetic skin responses (SSR). Cervical SCI subjects had lower supine HR, SAP, and noradrenaline levels than thoracic SCI and controls (p < 0.05), and lower DAP and MAP than controls (p < 0.05). When upright, HR increased in all groups (p < 0.05); SAP, DAP, and MAP increased (p < 0.01) in thoracic SCI and controls, but not in cervical SCI. Cervical SCI had larger postural falls in SV (p < 0.05) and CO, with smaller increases in TPR than the other two groups. Upright catecholamine levels were lower in cervical SCI (p < 0.05) than thoracic SCI and controls. Completeness of SCI assessed by ASIA scale did not necessarily correlate with autonomic completeness assessed by SSR. Cardiovascular control during orthostasis was impaired and OH was common in cervical SCI, but not thoracic SCI. SSR may identify those at greatest risk of orthostatic hypotension and impaired cardiovascular control. We advocate that assessments of autonomic function be included in the neurological evaluation of SCI, in addition to the ASIA assessment.
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Affiliation(s)
- Victoria E Claydon
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
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Zhao J, Wecht JM, Zhang Y, Wen X, Zeman R, Bauman WA, Cardozo C. iNOS expression in rat aorta is increased after spinal cord transection: a possible cause of orthostatic hypotension in man. Neurosci Lett 2007; 415:210-4. [PMID: 17287083 DOI: 10.1016/j.neulet.2007.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Revised: 01/09/2007] [Accepted: 01/11/2007] [Indexed: 01/22/2023]
Abstract
Orthostatic hypotension commonly occurs in persons with spinal cord injury (SCI), limiting rehabilitation and independence. Findings of increased production of nitric oxide (NO) by inducible nitric oxide synthase (iNOS) after exposure to simulated microgravity suggest that increased iNOS expression contributes to OH in persons with SCI. To test this possibility, male Wistar rats underwent surgical transection of the spinal cord (T10) or sham-SCI surgery followed by euthanasia 3, 7 or 14 days later. Expression in thoracic aortic of inducible (iNOS), endothelial (eNOS) and neuronal (nNOS) NOS was then determined. In SCI rats, expression of iNOS mRNA was decreased at 3 days, had returned to normal levels of expression at 7 days and was increased at 14 days post-SCI (1.8-fold). In contrast, levels of eNOS mRNA were increased at 3 days (1.4-fold), then declined over time reaching levels by day 14 that were reduced compared to sham-SCI (0.23-fold). There were no significant effects of SCI on nNOS expression. These findings suggest a possible role for increased iNOS expression in the pathogenesis of OH in persons with SCI.
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Affiliation(s)
- Jingbo Zhao
- Center of Excellence for the Medical Consequences of Spinal Cord Injury and Medical Service, James J. Peters VA Medical Center, Bronx, NY, USA
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Harrow JJ, Malassigné P, Nelson AL, Jensen RP, Amato M, Palacios PL. Design and evaluation of a stand-up motorized prone cart. J Spinal Cord Med 2007; 30:50-61. [PMID: 17385270 PMCID: PMC2032000 DOI: 10.1080/10790268.2007.11753914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Prone carts are used for mobility by individuals with spinal cord injury in whom seated mobility (wheelchair) is contraindicated due to ischial or sacral pressure ulcers. Currently available prone carts are uncomfortable, subjecting the user to neck and shoulder strain, and make social interaction and performing activities of daily living difficult. A better design of prone carts is needed. In addition, standing devices have shown some medical benefits. The objective was to design and evaluate an improved prone cart that facilitates standing. DESIGN Engineering development project with user feedback through questionnaire. Users selected by convenience sampling. METHODS A marketing survey was performed of nurse managers of spinal cord injury units. Then 2 prototype carts were designed and built. These carts are able to tilt up to 45 degrees and have a joystick-controlled motor for propulsion and other design features, including a workspace storage shelf and rearview mirrors. The carts were evaluated by both patients and caregivers at 2 Veteran's Administration hospitals. OUTCOME MEASURES Questionnaire of subjects, both patients and caregivers, who used the cart. FINDINGS Both patients and caregivers liked the carts and the ability to assume a nonhorizontal body angle. The major complaint about the cart was that it seemed too long when it came to making turns. CONCLUSION This prone cart design is an improvement over the standard, flat variety. However, further design changes will be necessary. This study provided valuable information that will be useful in the next-generation prone cart design project.
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Affiliation(s)
- Jeffrey J Harrow
- Patient Safety Center 118M, James J. Haley Veterans Hospital, Tampa, FL 33162-5735, USA.
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Krassioukov AV, Harkema SJ. Effect of harness application and postural changes on cardiovascular parameters of individuals with spinal cord injury. Spinal Cord 2006; 44:780-6. [PMID: 16801934 DOI: 10.1038/sj.sc.3101952] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Prospective assessment of cardiovascular parameters in individuals with spinal cord injury (SCI) in response to harness application and postural changes including orthostatic stress. OBJECTIVE To evaluate arterial blood pressure and heart rate (HR) with and without harness application during sitting, supine, and standing positions in able-bodied and SCI individuals. METHODS Measurements were obtained in all SCI research participants (n=11) before a locomotor training intervention and compared to data with able-bodied individuals (n=9). During standing, all research participants wore a harness and were suspended by an overhead, pneumatic body weight support system. RESULTS Resting arterial blood pressure and HR in individuals with cervical SCI were significantly lower during sitting than in thoracic SCI and able-bodied individuals (P<0.05). Orthostatic stress significantly decreased arterial blood pressure only in individuals with cervical SCI (P<0.05). Harness application had no effect on cardiovascular parameters in able-bodied individuals, whereas diastolic blood pressure was significantly increased in those with SCI. Orthostatic changes in cervical SCI when sitting were ameliorated by harness application. However, while standing with harness, individuals with cervical SCI still developed orthostatic hypotension. CONCLUSIONS Level of injury to the spinal cord influences baseline cardiovascular parameters. Application of harness in individuals with SCI could alter baseline cardiovascular parameters and the response to orthostatic stress. This should be carefully considered when assessing effects of therapeutic interventions using body weight support in individuals with SCI.
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Affiliation(s)
- A V Krassioukov
- International Collaboration on Repair Discoveries (ICORD), Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
Imbalance of the human haemodynamic system can provide a prognosis of syncope, dizziness or hypertension. This can be assessed by monitoring its responses to postural change. Examining variations in blood pressure (BP) is deemed an effective means to identify symptoms of this associated condition. However, conventional methods do not promote prolonged monitoring due to the discomfort caused to patients. Established correlations between BP and pulse wave transmission have shown its usefulness in clinical applications. In this study, photoplethysmography and phonocardiography were used to estimate BP changes via observed variations in delay transmission or vascular transit time (VTT) at the upper limb. Thirty-one healthy adults (21 male) were recruited to perform three test activities, namely the arm held at heart level, fully raised up and held down. Association of the three BP indices and heart rate variations with transit time changes was then computed. The results showed that observed VTT changes were related to systolic BP (R(2) = 0.820; p < 0.05), diastolic BP (R(2) = 0.517; p < 0.05), mean arterial pressure (R(2) = 0.673; p < 0.05) and heart rate (R(2) = 0.000; p > 0.05). As systolic BP had the strongest correlation, a regression equation was formulated to associate the two parameters. The non-invasive measuring nature of VTT can be more accommodating to patients, especially during continual monitoring. Moreover, it has the added advantage that the pre-ejection period is not included in its time-related derivations.
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Affiliation(s)
- Jong Yong Abdiel Foo
- Biomedical Engineering Research Centre, Nanyang Technological University, 50 Nanyang Drive, Research Techno Plaza, 6th Storey, XFrontiers Block, 637553, Singapore.
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Loeb GE, Richmond FJR, Baker LL. The BION devices: injectable interfaces with peripheral nerves and muscles. Neurosurg Focus 2006; 20:E2. [PMID: 16711659 DOI: 10.3171/foc.2006.20.5.3] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of this study was to describe a novel technology for implantable neuromuscular stimulation to treat complications of paralysis and disuse atrophy, including shoulder subluxation, hand contractures, drop foot, and osteoarthritis. The authors review the results so far of several pilot clinical studies of these muscle stimulation devices.
Methods
Miniature wireless stimulators received power and individually addressed command signals from an external radiofrequency transmission coil. One or more implants were injected through a 12-gauge hypodermic insertion tool into muscles or adjacent to motor nerves, where they provided the means to activate the muscles in any desired pattern of intensity and frequency. Randomized controlled studies in small numbers of patients are underway to identify efficacy, acceptability, best methods of practice, and any design changes that may be required to improve the technology.
Fifty patients have been enrolled in five studies; 35 patients have undergone implantation of a total of 79 BION1 devices. Comparisons with surface stimulation in patients who have suffered a stroke with shoulder subluxation and hand contractures show similar improvements in objective measures of efficacy but higher comfort levels for stimulation by implants.
Conclusions
Injected microstimulators represent a promising new class of technology for the rehabilitation of patients with upper motor neuropathies. As the technology evolves, practitioners may be able to use it to facilitate functional reanimation of paralyzed limbs.
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Affiliation(s)
- Gerald E Loeb
- Alfred Mann Institute for Biomedical Engineering and Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California 90089-1112, USA.
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Collins HL, Rodenbaugh DW, DiCarlo SE. Spinal cord injury alters cardiac electrophysiology and increases the susceptibility to ventricular arrhythmias. PROGRESS IN BRAIN RESEARCH 2006; 152:275-88. [PMID: 16198707 DOI: 10.1016/s0079-6123(05)52018-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The autonomic nervous system modulates cardiac electrophysiology and abnormalities of autonomic function are known to increase the risk of ventricular arrhythmias. The abnormal and unstable autonomic control of the cardiovascular system following spinal cord injury also is well known. For example, individuals with mid-thoracic spinal cord injury have elevated resting heart rates, increased blood pressure variability, episodic bouts of life-threatening hypertension as part of a condition termed autonomic dysreflexia, and elevated sympathetic activity above the level of the lesion. Furthermore, cardiovascular morbidity and mortality are high in individuals with spinal cord injuries due to a relatively sedentary lifestyle and higher prevalence of other cardiovascular risk factors, including obesity and diabetes. Therefore, spinal cord injury may alter cardiac electrophysiology and increase the risk for ventricular arrhythmias. In this chapter, we discuss how the autonomic changes associated with cord injury can influence cardiac electrophysiology and the susceptibility to ventricular arrhythmias.
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Affiliation(s)
- Heidi L Collins
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI 48201, USA
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Krassioukov A, Claydon VE. The clinical problems in cardiovascular control following spinal cord injury: an overview. PROGRESS IN BRAIN RESEARCH 2006; 152:223-9. [PMID: 16198703 DOI: 10.1016/s0079-6123(05)52014-4] [Citation(s) in RCA: 195] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
On a daily basis, individuals with cervical and upper thoracic spinal cord injury face the challenge of managing their unstable blood pressure, which frequently results in persistent hypotension and/or episodes of uncontrolled hypertension. This chapter will focus on the clinical issues related to abnormal cardiovascular control in individuals with spinal cord injury, which include neurogenic shock, autonomic dysreflexia and orthostatic hypotension. Blood pressure control depends upon tonic activation of sympathetic preganglionic neurons by descending input from the supraspinal structures (Calaresu and Yardley, 1988). Following spinal cord injury, these pathways are disrupted, and thus spinal circuits are solely responsible for the generation of sympathetic activity (Osborn et al., 1989; Maiorov et al., 1997). This results in a variety of cardiovascular abnormalities that have been well documented in human studies, as well as in animal models (Osborn et al., 1990; Mathias and Frankel, 1992a, b; Krassioukov and Weaver, 1995; Maiorov et al., 1997, 1998; Teasell et al., 2000). However, the recognition and management of these cardiovascular dysfunctions following spinal cord injury represent challenging clinical issues. Moreover, cardiovascular disorders in the acute and chronic stages of spinal cord injury are among the most common causes of death in individuals with spinal cord injury (DeVivo et al., 1999).
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Affiliation(s)
- Andrei Krassioukov
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC V6T 1Z4, Canada.
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Higuchi Y, Kitamura S, Kawashima N, Nakazawa K, Iwaya T, Yamasaki M. Cardiorespiratory responses during passive walking-like exercise in quadriplegics. Spinal Cord 2005; 44:480-6. [PMID: 16317423 DOI: 10.1038/sj.sc.3101875] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Cross-sectional and comparative investigation using quadriplegics (QP) and nondisabled subjects (ND). OBJECTIVE To evaluate cardiorespiratory responses during passive walking-like exercise (PWE) in QP. SETTING National Rehabilitation Center for Persons with Disabilities in Japan. METHOD The subjects were seven male QP with complete lesion (age: 27.0 +/- 5.4, injured level: C6-C7) and six male ND (age: 26.3 +/- 4.5). Cardiorespiratory responses were measured until voluntary fatigue during PWE, the rhythmical activity of paralyzed lower limbs synchronized with arm movements. RESULTS There were no significant differences in oxygen consumption (VO(2)), pulmonary ventilation (VE), heart rate (HR) and oxygen pulse (O(2) pulse) between QP and ND during PWE. ND showed increased ventilatory equivalent for oxygen (VE/VO(2) ratio) during exercise, while QP showed a significantly greater respiratory rate (RR) during exercise than ND (P < 0.05). CONCLUSION PWE elicited an increase in VO(2) with workload increment in QP similar to ND. However, higher RR suggested the intrinsic dysfunction of RR control during submaximal exercise in QP. From these results, it was thought that respiratory response would be the restriction factor of efficient oxygen transportation during PWE in QP.
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Affiliation(s)
- Y Higuchi
- Department of Physical Training for Remedial Gymnastics, Hospital, National Rehabilitation Center for Persons with Disabilities, Tokorozawa, Saitama, Japan
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Claydon VE, Steeves JD, Krassioukov A. Orthostatic hypotension following spinal cord injury: understanding clinical pathophysiology. Spinal Cord 2005; 44:341-51. [PMID: 16304564 DOI: 10.1038/sj.sc.3101855] [Citation(s) in RCA: 166] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Motor and sensory deficits are well-known consequences of spinal cord injury (SCI). During the last decade, a significant number of experimental and clinical studies have focused on the investigation of autonomic dysfunction and cardiovascular control following SCI. Numerous clinical reports have suggested that unstable blood pressure control in individuals with SCI could be responsible for their increased cardiovascular mortality. The aim of this review is to outline the incidence and pathophysiological mechanisms underlying the orthostatic hypotension that commonly occurs following SCI. We describe the clinical abnormalities of blood pressure control following SCI, with particular emphasis upon orthostatic hypotension. Possible mechanisms underlying orthostatic hypotension in SCI, such as changes in sympathetic activity, altered baroreflex function, the lack of skeletal muscle pumping activity, cardiovascular deconditioning and altered salt and water balance will be discussed. Possible alterations in cerebral autoregulation following SCI, and the impact of these changes upon cerebral perfusion are also examined. Finally, the management of orthostatic hypotension will be considered.
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Affiliation(s)
- V E Claydon
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, Canada
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