Spasticity Management after Spinal Cord Injury: The Here and Now

Enhancing Spinal Cord Injury Care: Using Wearable Technologies for Physical Activity, Sleep, and Cardiovascular Health

Wearable devices have the potential to advance health care by enabling real-time monitoring of biobehavioral data and facilitating the management of an individual's health conditions. Individuals living with spinal cord injury (SCI) have impaired motor function, which results in deconditioning and worsening cardiovascular health outcomes. Wearable devices may promote physical activity and allow the monitoring of secondary complications associated with SCI, potentially improving motor function, sleep, and cardiovascular health. However, several challenges remain to optimize the application of wearable technologies within this population. One is striking a balance between research-grade and consumer-grade devices in terms of cost, accessibility, and validity. Additionally, limited literature supports the validity and use of wearable technology in monitoring cardio-autonomic and sleep outcomes for individuals with SCI. Future directions include conducting performance evaluations of wearable devices to precisely capture the additional variation in movement and physiological parameters seen in those with SCI. Moreover, efforts to make the devices small, lightweight, and inexpensive for consumer ease of use may affect those with severe motor impairments. Overcoming these challenges holds the potential for wearable devices to help individuals living with SCI receive timely feedback to manage their health conditions and help clinicians gather comprehensive patient health information to aid in diagnosis and treatment.

PAK1 inhibition with Romidepsin attenuates H-reflex hyperexcitability after spinal cord injury

Hyperreflexia associated with spasticity is a prevalent neurological condition characterized by excessive and exaggerated reflex responses to stimuli. Hyperreflexia can be caused by several diseases including multiple sclerosis, stroke and spinal cord injury (SCI). Although we have previously identified the contribution of the RAC1-PAK1 pathway underlying spinal hyperreflexia with SCI-induced spasticity, a feasible druggable target has not been validated. To assess the utility of targeting PAK1 to attenuate H-reflex hyperexcitability, we administered Romidepsin, a clinically available PAK1 inhibitor, in Thy1-YFP reporter mice. We performed longitudinal EMG studies with a study design that allowed us to assess pathological H-reflex changes and drug intervention effects over time, before and after contusive SCI. As expected, our results show a significant loss of rate-dependent depression - an indication of hyperreflexia and spasticity - 1 month following SCI as compared with baseline, uninjured controls (or before injury). Romidepsin treatment reduced signs of hyperreflexia in comparison with control cohorts and in pre- and post-drug intervention in SCI animals. Neuroanatomical study further confirmed drug response, as romidepsin treatment also reduced the presence of SCI-induced dendritic spine dysgenesis on α-motor neurons. Taken together, our findings extend previous work demonstrating the utility of targeting PAK1 activity in SCI-induced spasticity and support the novel use of romidepsin as an effective tool for managing spasticity. KEY POINTS: PAK1 plays a role in contributing to the development of spinal cord injury (SCI)-induced spasticity by contributing to dendritic spine dysgenesis. In this study, we explored the preclinical utility of inhibiting PAK1 to reduce spasticity and dendritic spine dysgenesis in an SCI mouse model. Romidepsin is a PAK1 inhibitor approved in the US in 2009 for the treatment of cutaneous T-cell lymphoma. Here we show that romidepsin treatment after SCI reduced SCI-induced H-reflex hyperexcitability and abnormal α-motor neuron spine morphology. This study provides compelling evidence that romidepsin may be a promising therapeutic approach for attenuating SCI-induced spasticity.

The net contribution of rehabilitation to improvement in performance in patients with spinal cord lesions in five countries

CONTEXT

Change in ability realization reflects the main contribution of rehabilitation to improvement in the performance of daily activities in patients with spinal cord lesions (SCL).

OBJECTIVE

To assess the net effect of rehabilitation of patients with SCL and compare it between countries.

METHODS

We calculated the Spinal Cord Ability Realization Measurement Index (SCI-ARMI) and its change from admission to rehabilitation to discharge, for inpatients admitted to SCL units in five countries, between 2016 and 2019. We used chi-square tests, analysis of variance (ANOVA), McNemar's test, Pearson's correlations, and analysis of covariance (ANCOVA) to compare countries and patient groups and assess the relationships of various factors with SCI-ARMI gain during rehabilitation.

RESULTS

The study included 218 inpatients (67% males, age 52 ± 17). In Brazil, Israel, Italy, Portugal, and Turkiye, respectively, SCI-ARMI gain was 2 (SD = 15), 19 (SD = 17), 31 (SD = 23), 13 (SD = 15), and 16 (SD = 12). Yet, after controlling for admission SCI-ARMI and the time from SCL onset to the examination, the effect of the country on ability realization gain was found non-significant (P = 0.086).

CONCLUSION

The study confirmed that rehabilitation makes a net contribution to improvement in performance in patients with SCL, beyond the contribution of neurological recovery. After controlling for affecting factors, this contribution was quite similar in the participating units from different countries.

Construct Validity of the Gait Deviation Index for People With Incomplete Spinal Cord Injury (GDI-SCI)

BACKGROUND

The Gait Deviation Index for Spinal Cord Injury (SCI-GDI) was recently proposed as a dimensionless multivariate kinematic measure based on 21 gait features derived from 3-dimensional kinematic data which quantifies gait impairment of adult population with incomplete spinal cord injury (iSCI) relative to the normative gait of a healthy group. Nevertheless, no validity studies of the SCI-GDI have been published to date.

OBJECTIVE

To assess the construct validity of the SCI-GDI in adult population following iSCI. Methods. SCI-GDI data were obtained from a sample of 50 healthy volunteers and 35 adults with iSCI. iSCI group was also assessed with the following measures: 10-Meter Walk Test (10MWT) at both self-selected (SS) and maximum speeds, Timed Up and Go Test (TUGT), SS and maximum levels of the Walking Index for Spinal Cord Injury (WISCI) II, mobility items of the Spinal Cord Independence Measure III (SCIM IIIIOMob), Lower Extremity Motor Score (LEMS), and Modified Ashworth Scale (MAS). Spearman's correlation coefficient was used to investigate the relationship with the SCI-GDI.

RESULTS

SCI-GDI shows strong correlation with the 10MWT (r ≥ -.716) and good correlation with LEMS (r = .638), TUGT (r = -.582), SS WISCI II levels (r = .521), and SCIM IIIIOMob (r = .501). No significant correlations were found with maximum WISCI II levels and MAS (P > .006).

CONCLUSIONS

Construct validity of the SCI-GDI was demonstrated with the 10MWT, TUGT, LEMS, SCIM IIIIOMob, and SS WISCI II levels for independently walking adults with iSCI. Future work will include assessing the psychometric characteristics with a more heterogeneous sample, also considering the pediatric population.

Research progress on the application of transcranial magnetic stimulation in spinal cord injury rehabilitation: a narrative review

Traumatic or non-traumatic spinal cord injury (SCI) can lead to severe disability and complications. The incidence of SCI is high, and the rehabilitation cycle is long, which increases the economic burden on patients and the health care system. However, there is no practical method of SCI treatment. Recently, transcranial magnetic stimulation (TMS), a non-invasive brain stimulation technique, has been shown to induce changes in plasticity in specific areas of the brain by regulating the activity of neurons in the stimulation site and its functionally connected networks. TMS is a new potential method for the rehabilitation of SCI and its complications. In addition, TMS can detect the activity of neural circuits in the central nervous system and supplement the physiological evaluation of SCI severity. This review describes the pathophysiology of SCI as well as the basic principles and classification of TMS. We mainly focused on the latest research progress of TMS in the physiological evaluation of SCI as well as the treatment of motor dysfunction, neuropathic pain, spasticity, neurogenic bladder, respiratory dysfunction, and other complications. This review provides new ideas and future directions for SCI assessment and treatment.

Nutrition Education to Reduce Metabolic Dysfunction for Spinal Cord Injury: A Module-Based Nutrition Education Guide for Healthcare Providers and Consumers

Spinal cord injury (SCI) results in a high prevalence of neurogenic obesity and metabolic dysfunction. The increased risk for neurogenic obesity and metabolic dysfunction is mainly due to the loss of energy balance because of significantly reduced energy expenditure following SCI. Consequently, excessive energy intake (positive energy balance) leads to adipose tissue accumulation at a rapid rate, resulting in neurogenic obesity, systemic inflammation, and metabolic dysfunction. The purpose of this article is to review the existing literature on nutrition, dietary intake, and nutrition education in persons with SCI as it relates to metabolic dysfunction. The review will highlight the poor dietary intakes of persons with SCI according to authoritative guidelines and the need for nutrition education for health care professionals and consumers. Nutrition education topics are presented in a module-based format with supporting literature. The authors emphasize the role of a diet consisting of low-energy, nutrient-dense, anti-inflammatory foods consistent with the Dietary Guidelines for Americans' MyPlate to effectively achieve energy balance and reduce the risk for neurogenic obesity and metabolic dysfunction in individuals with SCI.

Pathophysiology, Classification and Comorbidities after Traumatic Spinal Cord Injury

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.