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Arora T, Liu J, Mohan A, Li X, O'laughlin K, Bennett T, Nemunaitis G, Bethoux F, Pundik S, Forrest G, Kirshblum S, Kilgore K, Bryden A, Kristi Henzel M, Wang X, Baker K, Brihmat N, Bayram M, Plow EB. Corticospinal inhibition investigated in relation to upper extremity motor function in cervical spinal cord injury. Clin Neurophysiol 2024; 161:188-197. [PMID: 38520799 DOI: 10.1016/j.clinph.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 12/29/2023] [Accepted: 02/22/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVE Corticospinal inhibitory mechanisms are relevant to functional recovery but remain poorly understood after spinal cord injury (SCI). Post-injury characteristics of contralateral silent period (CSP), a measure of corticospinal inhibition evaluated using transcranial magnetic stimulation (TMS), is inconsistent in literature. We envisioned that investigating CSP across muscles with varying degrees of weakness may be a reasonable approach to resolve inconsistencies and elucidate the relevance of corticospinal inhibition for upper extremity function following SCI. METHODS We studied 27 adults with chronic C1-C8 SCI (age 48.8 ± 16.1 years, 3 females) and 16 able-bodied participants (age 33.2 ± 11.8 years, 9 females). CSP characteristics were assessed across biceps (muscle power = 3-5) and triceps (muscle power = 1-3) representing stronger and weaker muscles, respectively. We assessed functional abilities using the Capabilities of the Upper Extremity Test (CUE-T). RESULTS Participants with chronic SCI had prolonged CSPs for biceps but delayed and diminished CSPs for triceps compared to able-bodied participants. Early-onset CSPs for biceps and longer, deeper CSPs for triceps correlated with better CUE-T scores. CONCLUSIONS Corticospinal inhibition is pronounced for stronger biceps but diminished for weaker triceps muscle in SCI indicating innervation relative to the level of injury matters in the study of CSP. SIGNIFICANCE Nevertheless, corticospinal inhibition or CSP holds relevance for upper extremity function following SCI.
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Affiliation(s)
- Tarun Arora
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, OH, USA; Department of Neurology, Division of Clinical Neuroscience, Oslo University Hospital, Norway
| | - Jia Liu
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, OH, USA
| | - Akhil Mohan
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, OH, USA
| | - Xin Li
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, OH, USA
| | - Kyle O'laughlin
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, OH, USA
| | - Teale Bennett
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, OH, USA
| | - Gregory Nemunaitis
- Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic Foundation, OH, USA
| | - Francois Bethoux
- Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic Foundation, OH, USA
| | - Svetlana Pundik
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio, USA; Department of Neurology, Case Western Reserve University School of Medicine, Cleveland OH, USA
| | - Gail Forrest
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Tim and Caroline Reynolds Center for Spinal Stimulation, Kessler Foundation, West Orange, New Jersey, USA
| | - Steven Kirshblum
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Tim and Caroline Reynolds Center for Spinal Stimulation, Kessler Foundation, West Orange, New Jersey, USA; Kessler Institute for Rehabilitation, West Orange, New Jersey, USA; Kessler Foundation, West Orange, New Jersey, USA
| | - Kevin Kilgore
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio, USA; Department of Physical Medicine and Rehabilitation, MetroHealth Center for Rehabilitation Research, OH, USA; Institute for Functional Restoration, Case Western Reserve University, Cleveland, OH, USA
| | - Anne Bryden
- Department of Physical Medicine and Rehabilitation, MetroHealth Center for Rehabilitation Research, OH, USA; Institute for Functional Restoration, Case Western Reserve University, Cleveland, OH, USA
| | - M Kristi Henzel
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Ohio, USA; Department of Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, Cleveland OH, USA
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, OH, USA
| | - Kelsey Baker
- Department of Neuroscience, School of Medicine, University of Texas RioGrande Valley, RioGrande Valley, TX, USA
| | - Nabila Brihmat
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Tim and Caroline Reynolds Center for Spinal Stimulation, Kessler Foundation, West Orange, New Jersey, USA
| | - Mehmed Bayram
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA; Tim and Caroline Reynolds Center for Spinal Stimulation, Kessler Foundation, West Orange, New Jersey, USA
| | - Ela B Plow
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, OH, USA; Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic Foundation, OH, USA; Cleveland Clinic Rehabilitation Hospitals, Cleveland, OH, USA.
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Sangari S, Chen B, Hobbs S, Olson A, Anschel A, Kim K, Chen D, Kessler A, Heinemann AW, Oudega M, Kwon BK, Kirshblum S, Guest JD, Perez MA. Reply to "Letter on Spasticity Predicts Motor Recovery in Motor Complete Spinal Cord Injury". Ann Neurol 2024; 95:1011-1012. [PMID: 38501331 DOI: 10.1002/ana.26908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/26/2024] [Indexed: 03/20/2024]
Affiliation(s)
| | - Bing Chen
- Shirley Ryan AbilityLab, Chicago, IL, USA
| | - Sara Hobbs
- Shirley Ryan AbilityLab, Chicago, IL, USA
| | | | - Alan Anschel
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - Ki Kim
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - David Chen
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - Allison Kessler
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - Allen W Heinemann
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
| | - Martin Oudega
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
- Edward Hines Jr VA Hospital, Hines, IL, USA
- Department of Neuroscience, Northwestern University, Chicago, IL, USA
| | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - James D Guest
- The Miami Project to Cure Paralysis, University of Miami, Coral Gables, FL, USA
| | - Monica A Perez
- Shirley Ryan AbilityLab, Chicago, IL, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
- Edward Hines Jr VA Hospital, Hines, IL, USA
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Engel-Haber E, Snider B, Botticello A, Eren F, Kirshblum S. Clinical Subsets of Central Cord Syndrome: Is it a Distinct Entity from Other Forms of Incomplete Tetraplegia for Research? J Neurotrauma 2024. [PMID: 38581474 DOI: 10.1089/neu.2023.0613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2024] Open
Abstract
Central cord syndrome (CCS) is the most prevalent and debated incomplete spinal cord injury (SCI) syndrome, with its hallmark feature being more pronounced weakness of the upper extremities compared to the lower extremities. Varying definitions encapsulate multiple clinical features under the single umbrella term of CCS, complicating evaluation of its frequency, prognosis discussions, and outcomes research. Oftentimes, people with CCS are excluded from research protocols, as it is thought to have a favorable prognosis, but the vague nature of CCS raises doubts about the validity of this practice. The objective of this study was to categorize CCS into specific subsets with clear quantifiable differences, to assess whether this would enhance the ability to determine if individuals with CCS or its subsets exhibit distinct neurological and functional outcomes relative to others with incomplete tetraplegia. This study retrospectively reviewed individuals with new motor incomplete tetraplegia from traumatic SCI who enrolled in the Spinal Cord Injury Model Systems (SCIMS) database from 2010 to 2020. Through an assessment of the prevailing criteria for CCS, coupled with data analysis, we used two key criteria, including the severity of distal upper extremity weakness (i.e., hands and fingers) and extent of symmetry, to delineate three CCS subsets: Full CCS, Unilateral CCS, and Borderline CCS. Of the 1,490 participants in our sample, 17.5% had Full, 25.6% Unilateral, and 9% Borderline CCS, together encompassing more than 50% of motor incomplete tetraplegia cases. Despite the increased sensitivity and specificity of these subsets compared to existing quantifiable criteria, substantial variability in clinical presentation was still observed. Overall, individuals meeting CCS subset criteria showed a higher likelihood of AIS D grade compared to those with motor incomplete tetraplegia without CCS, from admission to the 1-year follow-up. The upper extremity motor score (UEMS) for those with CCS was lower on admission, a difference that diminished by discharge, while their lower extremity motor score (LEMS) consistently remained higher compared to those without CCS. However, these neurological distinctions did not result in significant functional differences, as lower and upper extremity functional outcomes at discharge were mostly similar to those with motor incomplete tetraplegia, with some significant differences observed within those with AIS D grade. The AIS grade seems to remain the foremost determinant influencing neurological and functional outcomes, rather than the diagnosis of CCS. We recommend that future studies consider incorporating motor incomplete tetraplegia into their inclusion/exclusion criteria, instead of relying on criteria specific to CCS. While there remains clinical value in characterizing an injury pattern as CCS and perhaps using the different subsets to better characterize the impairments, it does not appear to be a useful research criterion.
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Affiliation(s)
- Einat Engel-Haber
- Rutgers New Jersey Medical School, 12286, Physical Medicine and Rehabilitation, 183 South Orange Avenue, Suite F 1555, Newark, New Jersey, United States, 07101
- Kessler Foundation, 158368, 1199 Pleasant Valley Way, West Orange, New Jersey, United States, 07052;
| | - Brittany Snider
- Rutgers New Jersey Medical School, 12286, Physical Medicine & Rehabilitation, Newark, New Jersey, United States
- Kessler Foundation, 158368, West Orange, New Jersey, United States
- Kessler Institute for Rehabilitation, 21326, West Orange, New Jersey, United States;
| | - Amanda Botticello
- Rutgers New Jersey Medical School, Physical Medicine and Rehabilitation, Newark, New Jersey, United States
- Kessler Foundation, West Orange, New Jersey, United States;
| | - Fatma Eren
- East Carolina University, 3627, Department of Internal Medicine, Greenville, North Carolina, United States;
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, 21326, West Orange, New Jersey, United States, 07052-1419;
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4
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Hejrati N, Srikandarajah N, Alvi MA, Quddusi A, Tetreault LA, Guest JD, Marco RAW, Kirshblum S, Martin AR, Strantzas S, Arnold PM, Basu S, Evaniew N, Kwon BK, Skelly AC, Fehlings MG. The Management of Intraoperative Spinal Cord Injury - A Scoping Review. Global Spine J 2024; 14:150S-165S. [PMID: 38526924 DOI: 10.1177/21925682231196505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Scoping Review. OBJECTIVE To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). METHODS MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. RESULTS Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. CONCLUSION There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae.
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Affiliation(s)
- Nader Hejrati
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Cantonal Hospital St.Gallen, St.Gallen, Switzerland
| | - Nisaharan Srikandarajah
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - James D Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Rex A W Marco
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Allan R Martin
- Department of Neurological Surgery, University of California Davis, Davis, CA, USA
| | - Samuel Strantzas
- Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | | | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | | | - Michael G Fehlings
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
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5
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Fehlings MG, Tetreault LA, Hachem L, Evaniew N, Ganau M, McKenna SL, Neal CJ, Nagoshi N, Rahimi-Movaghar V, Aarabi B, Hofstetter CP, Wengel VT, Nakashima H, Martin AR, Kirshblum S, Rodrigues Pinto R, Marco RAW, Wilson JR, Kahn DE, Newcombe VFJ, Zipser CM, Douglas S, Kurpad SN, Lu Y, Saigal R, Samadani U, Arnold PM, Hawryluk GWJ, Skelly AC, Kwon BK. An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery. Global Spine J 2024; 14:174S-186S. [PMID: 38526922 DOI: 10.1177/21925682231181883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Clinical practice guideline development. OBJECTIVES Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI). METHODS A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. RESULTS The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence. CONCLUSIONS It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.
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Affiliation(s)
- Michael G Fehlings
- Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - Laureen Hachem
- Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Nathan Evaniew
- Department of Surgery, Orthopaedic Surgery, McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mario Ganau
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Chris J Neal
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Valerie Ter Wengel
- Department of Neurosurgery, Amsterdam UMC VUMC Site, Amsterdam, Netherlands
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Allan R Martin
- Department of Neurological Surgery, University of California-Davis, Sacramento, CA, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Ricardo Rodrigues Pinto
- Spinal Unit (UVM), Centro Hospitalar Universitário de Santo António, Hospital CUF Trindade, Porto, Portugal
| | - Rex A W Marco
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Jefferson R Wilson
- Department of Surgery, Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
| | - David E Kahn
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Virginia F J Newcombe
- Department of Medicine, University Division of Anaesthesia and PACE, University of Cambridge, Cambridge, UK
| | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Sam Douglas
- Praxis Spinal Cord Institute, Vancouver, BC, Canada
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Yi Lu
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Rajiv Saigal
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Uzma Samadani
- Department of Surgery, Minneapolis Veterans Affairs, Minneapolis, MN, USA
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | | | | | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
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Srikandarajah N, Hejrati N, Alvi MA, Quddusi A, Tetreault LA, Evaniew N, Skelly AC, Douglas S, Rahimi-Movaghar V, Arnold PM, Kirshblum S, Kwon BK, Fehlings MG. Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury in the Setting of Spine Surgery: A Proposed Care Pathway. Global Spine J 2024; 14:166S-173S. [PMID: 38526925 DOI: 10.1177/21925682231217980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN This study is a mixed methods approach. OBJECTIVES Intraoperative spinal cord injury (ISCI) is a challenging complication in spine surgery. Intra-operative neuromonitoring (IONM) has been developed to detect changes in neural function. We report on the first multidisciplinary, international effort through AO Spine and the Praxis Spinal Cord Institute to develop a comprehensive guideline and care pathway for the prevention, diagnosis, and management of ISCI. METHODS Three literature reviews were registered on PROSPERO (CRD 42022298841) and performed according to PRISMA guidelines: (1) Definitions, frequency, and risk factors for ISCI, (2) Meta-analysis of the accuracy of IONM for diagnosis of ISCI, (3) Reported management approaches for ISCI and related events. The results were presented in a consensus session to decide the definition of IONM and recommendation of its use in high-risk cases. Based on a literature review of management strategies for ISCI, an intra-operative checklist and overall care pathway was developed by the study team. RESULTS An operational definition and high-risk patient categories for ISCI were established. The reported incidence of deficits was documented to be higher in intramedullary tumour spine surgery. Multimodality IONM has a high sensitivity and specificity. A guideline recommendation of IONM to be employed for high-risk spine cases was made. The different sections of the intraoperative checklist include surgery, anaesthetic and neurophysiology. The care pathway includes steps (1) initial clinical assessment, (2) pre-operative planning, (3) surgical/anaesthetic planning, (4) intra-operative management, and (5) post-operative management. CONCLUSIONS This is the first evidence based comprehensive guideline and care pathway for ISCI using the GRADE methodology. This will facilitate a reduction in the incidence of ISCI and improved outcomes from this complication. We welcome the wide implementation and validation of these guidelines and care pathways in prospective, multicentre studies.
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Affiliation(s)
- Nisaharan Srikandarajah
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Nader Hejrati
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | | | - Nathan Evaniew
- McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada
| | | | - Sam Douglas
- Praxis Spinal Cord Institute, Vancouver, BC, Canada
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
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7
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Fehlings MG, Alvi MA, Evaniew N, Tetreault LA, Martin AR, McKenna SL, Rahimi-Movaghar V, Ha Y, Kirshblum S, Hejrati N, Srikandarajah N, Quddusi A, Moghaddamjou A, Malvea A, Pinto RR, Marco RAW, Newcombe VFJ, Basu S, Strantzas S, Zipser CM, Douglas S, Laufer I, Chou D, Saigal R, Arnold PM, Hawryluk GWJ, Skelly AC, Kwon BK. A Clinical Practice Guideline for Prevention, Diagnosis and Management of Intraoperative Spinal Cord Injury: Recommendations for Use of Intraoperative Neuromonitoring and for the Use of Preoperative and Intraoperative Protocols for Patients Undergoing Spine Surgery. Global Spine J 2024; 14:212S-222S. [PMID: 38526921 DOI: 10.1177/21925682231202343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
STUDY DESIGN Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. OBJECTIVE The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. METHODS All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. RESULTS Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at "high risk" for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. CONCLUSION We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.
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Affiliation(s)
- Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Nathan Evaniew
- Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | | | - Allan R Martin
- Department of Neurological Surgery, University of California, Davis, Davis, CA, USA
| | | | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Yoon Ha
- Department of Neurosurgery, College of Medicine, Yonsei University, Seoul, Korea
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Nader Hejrati
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Nisaharan Srikandarajah
- Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ali Moghaddamjou
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Anahita Malvea
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ricardo Rodrigues Pinto
- Spinal Unit (UVM), Centro Hospitalar Universitário de Santo António, Hospital CUF Trindade, Porto, Portugal
| | - Rex A W Marco
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Virginia F J Newcombe
- Department of Medicine, University Division of Anaesthesia and PACE, University of Cambridge, Cambridge, UK
| | | | - Samuel Strantzas
- Division of Neurosurgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Sam Douglas
- Praxis Spinal Cord Institute, Vancouver, BC, Canada
| | - Ilya Laufer
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Dean Chou
- Department of Neurosurgery, Columbia University, New York, NY, USA
| | - Rajiv Saigal
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Paul M Arnold
- Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Cleveland Clinic Akron GeneralHospital, Akron, OH, USA
| | | | - Brian K Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
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8
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Schuld C, Kirshblum S, Tansey K, Rupp R. The revised zone of partial preservation (ZPP) in the 2019 International Standards for Neurological Classification of Spinal Cord Injury: ZPP applicability in incomplete injuries. Spinal Cord 2024; 62:79-87. [PMID: 38191920 PMCID: PMC10853064 DOI: 10.1038/s41393-023-00950-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 11/17/2023] [Accepted: 12/13/2023] [Indexed: 01/10/2024]
Abstract
STUDY DESIGN Consensus process. OBJECTIVES To provide a reference for the Zone(s) of Partial Preservation (ZPP) in the 2019 International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and analyze the initial impact of applicability of the revised ZPPs. Revisions include the use of ZPPs in selected incomplete injuries (in addition to prior use in sensorimotor complete injuries). Specifically, the revised motor ZPPs are applicable bilaterally in injuries with absent voluntary anal contraction (VAC) and the revised sensory ZPP for a given side is applicable if deep anal pressure (DAP), light touch and pin prick sensation in S4-5 are absent on that side. SETTING Committee with 16 ISNCSCI experts and datasets from the European Multicenter Study about Spinal Cord Injury (EMSCI). METHODS Occurrence frequencies of applicable ZPPs were determined in an EMSCI cohort consisting of two ISNCSCI examinations from 665 individuals with traumatic SCI. RESULTS Motor ZPPs were derived in 35.2% of all datasets of incomplete injuries, while sensory ZPPs are much less frequent (1.0%). Motor ZPPs are applicable in all American Spinal Injury Association Impairment Scale (AIS) B datasets (mean ZPP length: 0.9 ± 1.0 segments), in 55.4% of all AIS C datasets (ZPP length: 11.8 ± 8.2 segments) and in 9.9% of the AIS D datasets (ZPP length: 15.4 ± 7.9 segments). CONCLUSIONS The revised ZPP allows for determining motor ZPPs in approximately 1/3 of all incomplete injuries. The broadened applicability enables the use of ZPPs beyond complete injuries for complementary description of residual functions in more individuals. SPONSORSHIP N/A.
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Affiliation(s)
- Christian Schuld
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ, USA
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Keith Tansey
- Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, MS, USA
- Spinal Cord Injury Clinic, Jackson VA Medical Center, Jackson, MS, USA
- Departments of Neurosurgery and Neurobiology and Anatomical Sciences, University of Mississippi Medical Center, Jackson, MS, USA
| | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118, Heidelberg, Germany.
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9
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Morrison D, Pinpin C, Lee A, Sison C, Chory A, Gregersen PK, Forrest G, Kirshblum S, Harkema SJ, Boakye M, Harrop JS, Bryce TN, Schwab JM, Kwon BK, Stein AB, Bank MA, Bloom O. Profiling Immunological Phenotypes in Individuals During the First Year After Traumatic Spinal Cord Injury: A Longitudinal Analysis. J Neurotrauma 2023; 40:2621-2637. [PMID: 37221869 PMCID: PMC10722895 DOI: 10.1089/neu.2022.0500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Abstract Individuals with SCI are severely affected by immune system changes, resulting in increased risk of infections and persistent systemic inflammation. While recent data support that immunological changes after SCI differ in the acute and chronic phases of living with SCI, only limited immunological phenotyping in humans is available. To characterize dynamic molecular and cellular immune phenotypes over the first year, we assess RNA (bulk-RNA sequencing), protein, and flow cytometry (FACS) profiles of blood samples from 12 individuals with SCI at 0-3 days and at 3, 6, and 12 months post injury (MPI) compared to 23 uninjured individuals (controls). We identified 967 differentially expressed (DE) genes in individuals with SCI (FDR <0.001) compared to controls. Within the first 6 MPI we detected a reduced expression of NK cell genes, consistent with reduced frequencies of CD56bright, CD56dim NK cells present at 12 MPI. Over 6MPI, we observed increased and prolonged expression of genes associated with inflammation (e.g. HMGB1, Toll-like receptor signaling) and expanded frequencies of monocytes acutely. Canonical T-cell related DE genes (e.g. FOXP3, TCF7, CD4) were upregulated during the first 6 MPI and increased frequencies of activated T cells at 3-12 MPI. Neurological injury severity was reflected in distinct whole blood gene expression profiles at any time after SCI, verifying a persistent 'neurogenic' imprint. Overall, 2876 DE genes emerge when comparing motor complete to motor incomplete SCI (ANOVA, FDR <0.05), including those related to neutrophils, inflammation, and infection. In summary, we identify a dynamic immunological phenotype in humans, including molecular and cellular changes which may provide potential targets to reduce inflammation, improve immunity, or serve as candidate biomarkers of injury severity.
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Affiliation(s)
- Debra Morrison
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Camille Pinpin
- Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
| | - Annette Lee
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
| | - Cristina Sison
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
| | - Ashley Chory
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Peter K. Gregersen
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
| | - Gail Forrest
- Tim and Caroline Reynolds Center for Spinal Stimulation, Center for Mobility and Human Engineering Research, West Orange, New Jersey, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Steven Kirshblum
- Tim and Caroline Reynolds Center for Spinal Stimulation, Center for Mobility and Human Engineering Research, West Orange, New Jersey, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Institute for Rehabilitation. West Orange, New Jersey, USA
| | - Susan J. Harkema
- Kentucky Spinal Injury Research Center, School of Medicine, University of Louisville, Louisville, Kentucky, USA
- Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Maxwell Boakye
- Kentucky Spinal Injury Research Center, School of Medicine, University of Louisville, Louisville, Kentucky, USA
- Department of Neurosurgery, School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - James S. Harrop
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Thomas N. Bryce
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - Jan M. Schwab
- The Belford Center for Spinal Cord Injury, Spinal Cord Division, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
- Department of Neurology, Spinal Cord Division, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Brian K. Kwon
- International Collaboration on Repair Discoveries (ICORD), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Adam B. Stein
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
| | - Matthew A. Bank
- Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
- North Shore University Hospital, Manhasset, New York, USA
| | - Ona Bloom
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, New York, USA
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10
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Magnuson FS, Christensen P, Krassioukov A, Rodriguez G, Emmanuel A, Kirshblum S, Krogh K. Neurogenic Bowel Dysfunction in Patients with Spinal Cord Injury and Multiple Sclerosis-An Updated and Simplified Treatment Algorithm. J Clin Med 2023; 12:6971. [PMID: 38002586 PMCID: PMC10672578 DOI: 10.3390/jcm12226971] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
Neurogenic bowel dysfunction (NBD) is a common condition in individuals with spinal cord injury (SCI) or multiple sclerosis (MS). It usually entails constipation, difficult evacuation of the rectum, and fecal incontinence (FI); often in combination. It is highly burdensome for affected patients and is correlated with poor quality of life. The current treatment algorithm, or treatment pyramid, does not completely correspond to actual clinical practice, and the known and classical pyramid contains both treatments still in their experimental stage as well as several treatments which are not available at all treatment centers. Thus, an updated treatment algorithm is called upon, and the authors of this paper therefore propose a simplified version of the treatment pyramid, aiming to guide clinicians in treating NBD.
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Affiliation(s)
- Fredrika S. Magnuson
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Peter Christensen
- Department of Surgery, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Andrei Krassioukov
- International Collaboration of Repair Discoveries (ICORD), Department of Medicine, Division of Physical Medicine and Rehabilitation, The University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Gianna Rodriguez
- Physical Medicine and Rehabilitation, Spinal Cord Injury Medicine, University of Michigan Health, Ann Arbor, MI 48108, USA
| | - Anton Emmanuel
- GI Physiology Unit, University College London Hospital, London WC1E 6DB, UK
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ 07052, USA;
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, 8200 Aarhus, Denmark
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11
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Engel-Haber E, Snider B, Kirshblum S. Central cord syndrome definitions, variations and limitations. Spinal Cord 2023; 61:579-586. [PMID: 37015975 DOI: 10.1038/s41393-023-00894-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/06/2023]
Abstract
Central cord syndrome (CCS) is the most common, yet most controversial, among the different spinal cord injury (SCI) incomplete syndromes. Since its original description in 1954, many variations have been described while maintaining the core characteristic of disproportionate weakness in the upper extremities compared to the lower extremities. Several definitions have been proposed in an attempt to quantify this difference, including a widely accepted criterion of ≥10 motor points in favor of the lower extremities. Nevertheless, recent reports have recommended revisiting the terminology and criteria of CCS as existing definitions do not capture the entire essence of the syndrome. Due to methodological differences, the full extent of CCS is not known, and a large variation in prevalence has been described. This review classifies the different definitions of CCS and describes some inherent limitations, highlighting the need for universal quantifiable criteria.
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Affiliation(s)
- Einat Engel-Haber
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA.
- Kessler Foundation, West Orange, NJ, USA.
| | - Brittany Snider
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
- Kessler Foundation, West Orange, NJ, USA
- Kessler Institute for Rehabilitation, West Orange, NJ, USA
| | - Steven Kirshblum
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
- Kessler Foundation, West Orange, NJ, USA
- Kessler Institute for Rehabilitation, West Orange, NJ, USA
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12
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Kelly-Hedrik M, Abd-El-Barr MM, Aarabi B, Curt A, Howley SP, Harrop JS, Kirshblum S, Neal CJ, Noonan V, Park C, Ugiliweneza B, Tator C, Toups EG, Fehlings MG, Williamson T, Guest JD. Importance of Prospective Registries and Clinical Research Networks in the Evolution of Spinal Cord Injury Care. J Neurotrauma 2023; 40:1834-1848. [PMID: 36576020 DOI: 10.1089/neu.2022.0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Only 100 years ago, traumatic spinal cord injury (SCI) was commonly lethal. Today, most people who sustain SCI survive with continual efforts to improve their quality of life and neurological outcomes. SCI epidemiology is changing as preventative interventions reduce injuries in younger individuals, and there is an increased incidence of incomplete injuries in aging populations. Early treatment has become more intensive with decompressive surgery and proactive interventions to improve spinal cord perfusion. Accurate data, including specialized outcome measures, are crucial to understanding the impact of epidemiological and treatment trends. Dedicated SCI clinical research and data networks and registries have been established in the United States, Canada, Europe, and several other countries. We review four registry networks: the North American Clinical Trials Network (NACTN) SCI Registry, the National Spinal Cord Injury Model Systems (SCIMS) Database, the Rick Hansen SCI Registry (RHSCIR), and the European Multi-Center Study about Spinal Cord Injury (EMSCI). We compare the registries' focuses, data platforms, advanced analytics use, and impacts. We also describe how registries' data can be combined with electronic health records (EHRs) or shared using federated analysis to protect registrants' identities. These registries have identified changes in epidemiology, recovery patterns, complication incidence, and the impact of practice changes such as early decompression. They've also revealed latent disease-modifying factors, helped develop clinical trial stratification models, and served as matched control groups in clinical trials. Advancing SCI clinical science for personalized medicine requires advanced analytical techniques, including machine learning, counterfactual analysis, and the creation of digital twins. Registries and other data sources help drive innovation in SCI clinical science.
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Affiliation(s)
| | | | - Bizhan Aarabi
- University of Maryland School of Medicine, Maryland, USA
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Susan P Howley
- Christopher & Dana Reeve Foundation, Short Hills, New Jersey, USA
| | - James S Harrop
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven Kirshblum
- Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - Christopher J Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Vanessa Noonan
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
| | - Christine Park
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Charles Tator
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth G Toups
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Theresa Williamson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James D Guest
- Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami, Miami, USA
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13
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Hartsgrove C, DeLauter G, Kirshblum S. Sustained Impact of a Virtual Disability Education Curriculum With Fourth-Year Medical Students in a Mandatory Physical Medicine and Rehabilitation Clerkship. Am J Phys Med Rehabil 2023; 102:780-786. [PMID: 36753447 DOI: 10.1097/phm.0000000000002201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVE The aim of the study was to measure the short- and long-term impact of a virtual disability education curriculum associated with a 2-wk mandatory physical medicine and rehabilitation clerkship for fourth-year medical students. DESIGN A prospective pre-post intervention survey-based study measuring the impact of a virtual disability education series at 1-wk and 6-mo time points after a mandatory physical medicine and rehabilitation clerkship including 8 hrs of virtual didactics with an emphasis on physical disabilities. The surveys assessed the overall virtual curriculum, perceived benefit of a virtual encounter, and the long-term applicability of the information learned from the clerkship. RESULTS The physical medicine and rehabilitation clerkship was effective in improving medical students' perceived comfort and clinical knowledge regarding treatment of persons with disabilities ( P < 0.01). There were no statistical differences at the 6-mo time point, indicating sustained benefit and integration of knowledge in the long term ( P > 0.05). In addition, 84% of students reported using the information in clinical experiences at 6 mos. CONCLUSIONS The physical medicine and rehabilitation clerkship including a virtual disability education curriculum improved long-term perceived medical student comfort and knowledge of treating persons with disabilities, with a focus on those with physical disabilities. Virtual encounters with persons with disabilities are viable and impactful avenues to provide this education.
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Affiliation(s)
- Caitlin Hartsgrove
- From the Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey (CH, SK); Rutgers New Jersey Medical School, Newark, New Jersey (CH, SK); Kessler Institute for Rehabilitation, West Orange, New Jersey (CH, SK); and Select Medical, Mechanicsburg, Pennsylvania (GD)
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14
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Sangari S, Chen B, Grover F, Salsabili H, Sheth M, Gohil K, Hobbs S, Olson A, Eisner-Janowicz I, Anschel A, Kim K, Chen D, Kessler A, Heinemann AW, Oudega M, Kwon BK, Kirshblum S, Guest JD, Perez MA. Spasticity Predicts Motor Recovery for Patients with Subacute Motor Complete Spinal Cord Injury. Ann Neurol 2023; 95:71-86. [PMID: 37606612 DOI: 10.1002/ana.26772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/25/2023] [Accepted: 08/17/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVE A motor complete spinal cord injury (SCI) results in the loss of voluntary motor control below the point of injury. Some of these patients can regain partial motor function through inpatient rehabilitation; however, there is currently no biomarker to easily identify which patients have this potential. Evidence indicates that spasticity could be that marker. Patients with motor complete SCI who exhibit spasticity show preservation of descending motor pathways, the pathways necessary for motor signals to be carried from the brain to the target muscle. We hypothesized that the presence of spasticity predicts motor recovery after subacute motor complete SCI. METHODS Spasticity (Modified Ashworth Scale and pendulum test) and descending connectivity (motor evoked potentials) were tested in the rectus femoris muscle in patients with subacute motor complete (n = 36) and motor incomplete (n = 30) SCI. Motor recovery was assessed by using the International Standards for Neurological Classification of Spinal Cord Injury and the American Spinal Injury Association Impairment Scale (AIS). All measurements were taken at admission and discharge from inpatient rehabilitation. RESULTS We found that motor complete SCI patients with spasticity improved in motor scores and showed AIS conversion to either motor or sensory incomplete. Conversely, patients without spasticity showed no changes in motor scores and AIS conversion. In incomplete SCI patients, motor scores improved and AIS conversion occurred regardless of spasticity. INTERPRETATION These findings suggest that spasticity represents an easy-to-use clinical outcome that might help to predict motor recovery after severe SCI. This knowledge can improve inpatient rehabilitation effectiveness for motor complete SCI patients. ANN NEUROL 2023.
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Affiliation(s)
| | - Bing Chen
- Shirley Ryan AbilityLab, Chicago, Illinois, USA
| | | | | | | | | | - Sara Hobbs
- Shirley Ryan AbilityLab, Chicago, Illinois, USA
| | | | | | - Alan Anschel
- Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
| | - Ki Kim
- Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
| | - David Chen
- Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
| | - Allison Kessler
- Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
| | - Allen W Heinemann
- Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
| | - Martin Oudega
- Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, USA
- Edward Hines Jr. VA Hospital, Hines, Illinois, USA
- Department of Neuroscience, Northwestern University, Chicago, Illinois, USA
| | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - James D Guest
- The Miami Project to Cure Paralysis, University of Miami, Miami, Florida, USA
| | - Monica A Perez
- Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, USA
- Edward Hines Jr. VA Hospital, Hines, Illinois, USA
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15
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Zhang F, Carnahan J, Ravi M, Bheemreddy A, Kirshblum S, Forrest GF. Combining Spinal Cord Transcutaneous Stimulation with Activity-based Training to Improve Upper Extremity Function Following Cervical Spinal Cord Injury . Annu Int Conf IEEE Eng Med Biol Soc 2023; 2023:1-4. [PMID: 38082735 DOI: 10.1109/embc40787.2023.10340976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Recovery of upper extremity (UE) function is the top priority following cervical spinal cord injury (SCI); even partial function restoration would greatly improve the quality of their life and thus remains an important goal in SCI rehabilitation. Current clinical therapies focus on promoting neuroplasticity by performing task-specific activities with high intensity and high repetition. Repetitive training, paired with functional electrical, somatosensory, or transcranial magnetic stimulation, has been evaluated to augment functional recovery in chronic SCI, but improvements were modest. Evidence has demonstrated that the non-invasive spinal cord transcutaneous stimulation (scTS) can increase the excitability of spinal circuits and facilitate the weak or silent descending drive for restoration of sensorimotor function. Currently, we are conducting a multicenter randomized clinical trial to investigate the efficacy and potential mechanisms of scTS combined with activity-based training (ABT) to facilitate UE function recovery in individuals with tetraplegia. The preliminary outcomes from our four individuals with complete and incomplete injury demonstrated that the combination of scTS and ABT led to immediate and sustained (for up to 1-month follow-up) UE function recovery. Notably, one individual with motor complete injury showed a 5-fold improvement in UE function quantified by the Graded Redefined Assessment of Strength, Sensibility, and Prehension following scTS+ABT, as compared to receiving ABT alone. These functional gains were also reflected in the increased spinal excitability by measuring the scTS-evoked muscle response of UE motor pools, suggesting physiological evidence of reorganization of the non-functional, but surviving spinal networks after spinal transcutaneous stimulation.Clinical Relevance-This study offered the preliminary efficacy of combining scTS and ABT to facilitate UE function recovery following cervical SCI.
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16
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Androwis GJ, Engler A, AlRabadi S, Rana S, Snider B, Kirshblum S, Yue GH. Motor Control Changes after Utilizing Upper Extremity Myoelectric Powered Wearable Orthotics in Persons with Acute SCI. Annu Int Conf IEEE Eng Med Biol Soc 2023; 2023:1-4. [PMID: 38083205 DOI: 10.1109/embc40787.2023.10340685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Following spinal cord injury (SCI), upper extremity (UE) weakness may impede one's ability to carry out activities of daily living (ADLs). Such a limitation drastically lowers a person's level of independence. Additionally, therapy and the field of assistive technology continue to place a strong premium on the restoration of UE motor function in patients with SCI. The main objective of this study was to assess the benefits of an UE myoelectric-powered wearable orthosis (MPWO) produced by MyoMo, Inc. (Boston, MA) on improving UE motor function in order to enhance ADLs and quality of life in individuals with subacute SCI. A 43-year-old man with subacute incomplete SCI (iSCI), American Spinal Injury Association (ASIA) Impairment Scale (AIS) C grade received 18 sessions (over a period of six weeks) of UE mobility therapy utilizing the MPWO. The MPWO was used to enhance active range of motion (AROM) of the hand and elbow, and associated muscle activations. After training with the MPWO, hand and elbow AROM and muscle activations were enhanced. These preliminary findings imply that UE-MPWO device-assisted rehabilitation may increase participants' UE activities, leading to improved function.Clinical Relevance- These preliminary findings from a person with iSCI in the subacute phase indicate that training with UE-MPWO assistive devices may enhance UE use during ADLs for people with muscle weakness but still having some residual voluntary muscle activation ability.
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17
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McNamara S, Hon B, Kirshblum S. Restless leg syndrome in spinal cord injury: case report. Spinal Cord Ser Cases 2023; 9:19. [PMID: 37137889 PMCID: PMC10156660 DOI: 10.1038/s41394-023-00576-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/05/2023] Open
Abstract
CASE DESCRIPTION Restless leg syndrome (RLS) is a condition infrequently reported in spinal cord injury that causes an uncomfortable sensation in the legs and an urge to move them. We report a case involving a 63-year-old man with incomplete paraplegia with an onset of RLS four years post injury. FINDINGS Based upon history, pramipexole was prescribed for the presumptive diagnosis of RLS, with good effect. Initial workup revealed an anemia (hemoglobin of 9.3 gram/deciliter (g/dl)) and iron deficiency (ferritin of 10 microgram/liter (μg/L)), necessitating further evaluation. CONCLUSION Due to the complexities in diagnosing RLS in patients with SCI, it is important to be cognizant of symptoms and to consider this diagnosis to initiate the appropriate work-up for an etiology, of which iron deficiency anemia is common.
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Affiliation(s)
- Shane McNamara
- Rutgers New Jersey Medical School, Department of Physical Medicine and Rehabilitation, Newark, NJ, USA.
| | - Beverly Hon
- Rutgers New Jersey Medical School, Department of Physical Medicine and Rehabilitation, Newark, NJ, USA
- Spinal Cord Injury & Disorders Department, Veteran Administration New Jersey Healthcare System, East Orange, NJ, USA
| | - Steven Kirshblum
- Rutgers New Jersey Medical School, Department of Physical Medicine and Rehabilitation, Newark, NJ, USA
- Kessler Institute for Rehabilitation, West Orange, New Jersey. Kessler Foundation, West Orange, NJ, USA
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18
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Boakye M, Ball T, Dietz N, Sharma M, Angeli C, Rejc E, Kirshblum S, Forrest G, Arnold FW, Harkema S. Spinal cord epidural stimulation for motor and autonomic function recovery after chronic spinal cord injury: A case series and technical note. Surg Neurol Int 2023; 14:87. [PMID: 37025529 PMCID: PMC10070319 DOI: 10.25259/sni_1074_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/14/2023] [Indexed: 03/19/2023] Open
Abstract
Background:
Traumatic spinal cord injury (tSCI) is a debilitating condition, leading to chronic morbidity and mortality. In recent peer-reviewed studies, spinal cord epidural stimulation (scES) enabled voluntary movement and return of over-ground walking in a small number of patients with motor complete SCI. Using the most extensive case series (n = 25) for chronic SCI, the present report describes our motor and cardiovascular and functional outcomes, surgical and training complication rates, quality of life (QOL) improvements, and patient satisfaction results after scES.
Methods:
This prospective study occurred at the University of Louisville from 2009 to 2020. scES interventions began 2–3 weeks after surgical implantation of the scES device. Perioperative complications were recorded as well as long-term complications during training and device related events. QOL outcomes and patient satisfaction were evaluated using the impairment domains model and a global patient satisfaction scale, respectively.
Results:
Twenty-five patients (80% male, mean age of 30.9 ± 9.4 years) with chronic motor complete tSCI underwent scES using an epidural paddle electrode and internal pulse generator. The interval from SCI to scES implantation was 5.9 ± 3.4 years. Two participants (8%) developed infections, and three additional patients required washouts (12%). All participants achieved voluntary movement after implantation. A total of 17 research participants (85%) reported that the procedure either met (n = 9) or exceeded (n = 8) their expectations, and 100% would undergo the operation again.
Conclusion:
scES in this series was safe and achieved numerous benefits on motor and cardiovascular regulation and improved patient-reported QOL in multiple domains, with a high degree of patient satisfaction. The multiple previously unreported benefits beyond improvements in motor function render scES a promising option for improving QOL after motor complete SCI. Further studies may quantify these other benefits and clarify scES’s role in SCI patients.
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Affiliation(s)
- Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Tyler Ball
- Department of Neurosurgery, Vanderbilt University, Nashville,
| | - Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Claudia Angeli
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Enrico Rejc
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Steven Kirshblum
- Department of Physical Medicine Rehabilitation, Rutgers, Newark, New Jersey,
| | - Gail Forrest
- Department of Physical Medicine Rehabilitation, Rutgers, Newark, New Jersey,
| | - Forest W. Arnold
- Department of Infectious Diseases, University of Louisville, Louisville, United States
| | - Susan Harkema
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
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19
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Androwis G, Engler A, Al-Rabadi S, Chmielewska N, Rana S, Kirshblum S, Yue G. Myoelectric Powered Wearable Orthotics Improvements on Upper Extremity Function in Persons with SCI. Arch Phys Med Rehabil 2023. [DOI: 10.1016/j.apmr.2022.12.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
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20
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Lopez J, Forrest GF, Engel-Haber E, Snider B, Momeni K, Ravi M, Kirshblum S. Transcutaneous spinal stimulation in patients with intrathecal baclofen pump delivery system: A preliminary safety study. Front Neurosci 2022; 16:1075293. [PMID: 36620445 PMCID: PMC9811171 DOI: 10.3389/fnins.2022.1075293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Objective To determine the effect of transcutaneous spinal stimulation (TSS) on an implanted intrathecal baclofen (ITB) pump in persons with traumatic spinal cord injury (SCI). Design Prospective clinical trial. Participants Five individuals with chronic traumatic SCI, >18 years of age, and an anteriorly implanted Medtronic SynchroMed™ II ITB pump delivery system. Intervention Transcutaneous spinal stimulation trials with cathode at T11/12, with pump interrogation before, during and after stimulation. Results There was no evidence of any effect of the TSS in regards to disruption of the ITB pump delivery mechanism. Communication interference with the interrogator to the pump occurred often during stimulation for log transmission most likely secondary to the electromagnetic interference from the stimulation. One individual had elevated blood pressure at the end of the trial, suspected to be unrelated to the spinal stimulation. Conclusion Based upon this pilot study, further TSS studies including persons with an implanted Medtronic SynchroMed™ II ITB pump can be considered when stimulating at the low thoracic spine, although communication with the programmer during the stimulation may be affected.
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Affiliation(s)
- John Lopez
- Kessler Institute for Rehabilitation, West Orange, NJ, United States,New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States,*Correspondence: John Lopez,
| | - Gail F. Forrest
- New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States,Kessler Foundation, West Orange, NJ, United States
| | - Einat Engel-Haber
- New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States,Kessler Foundation, West Orange, NJ, United States
| | - Brittany Snider
- Kessler Institute for Rehabilitation, West Orange, NJ, United States,New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States,Kessler Foundation, West Orange, NJ, United States
| | - Kam Momeni
- Koneksa Health, New York, NY, United States
| | | | - Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ, United States,New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States,Kessler Foundation, West Orange, NJ, United States
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21
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Engel-Haber E, Botticello A, Snider B, Kirshblum S. Incomplete Spinal Cord Syndromes: Current Incidence and Quantifiable Criteria for Classification. J Neurotrauma 2022; 39:1687-1696. [PMID: 35708116 DOI: 10.1089/neu.2022.0196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The demographics of acute traumatic spinal cord injury (SCI) have changed over the last few decades, with a significant increase in age at the time of injury, a higher percentage of injuries caused by falls, and incomplete tetraplegia becoming the most common type of neurological impairment. Incomplete SCI syndromes, most specifically central cord syndrome (CCS), anterior cord syndrome (ACS) and Brown-Sequard syndrome (BSS), constitute a substantial proportion of incomplete tetraplegia and SCI overall. Nevertheless, the updated incidence of these syndromes is not well known, and their estimates vary considerably, largely because of methodological inconsistencies across previous studies. A retrospective analysis of individuals with new traumatic SCI enrolled in the Spinal Cord Injury Model Systems database between January 2011 and May 2020 was performed. Using newly proposed computable definitions for ACS and BSS, as well as an existing quantitative definition of CCS, we determined the current incidence and neurological characteristics of each syndrome. Within the population of individuals with a traumatic SCI, including all levels and severity of injuries (N = 3639), CCS, ACS, and BSS accounted for 14%, 6.5%, and 2%, respectively. Of the 1649 individuals with incomplete tetraplegia in our cohort, CCS was the most common syndrome (30%), followed by ACS (10%) and BSS (3%). Using quantifiable definitions, these three syndromes now account for ∼22% and ∼44% of cases of traumatic SCI and incomplete tetraplegia, respectively, with CCS having increased over the last decade. This updated information and proposed calculable criteria for these syndromes allow for a greater understanding of the incidence and characteristics of these syndromes and enable greater study in the future.
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Affiliation(s)
- Einat Engel-Haber
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Kessler Foundation, West Orange, New Jersey, USA
| | - Amanda Botticello
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Kessler Foundation, West Orange, New Jersey, USA
| | - Brittany Snider
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Kessler Foundation, West Orange, New Jersey, USA.,Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
| | - Steven Kirshblum
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Kessler Foundation, West Orange, New Jersey, USA.,Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
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22
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Arora T, Desai N, Kirshblum S, Chen R. Utility of transcranial magnetic stimulation in the assessment of spinal cord injury: Current status and future directions. Front Rehabil Sci 2022; 3:1005111. [PMID: 36275924 PMCID: PMC9581184 DOI: 10.3389/fresc.2022.1005111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/16/2022] [Indexed: 11/06/2022]
Abstract
Comprehensive assessment following traumatic spinal cord injury (SCI) is needed to improve prognostication, advance the understanding of the neurophysiology and better targeting of clinical interventions. The International Standards for Neurological Classification of Spinal Cord Injury is the most common clinical examination recommended for use after a SCI. In addition, there are over 30 clinical assessment tools spanning across different domains of the International Classification of Functioning, Disability, and Health that have been validated and recommended for use in SCI. Most of these tools are subjective in nature, have limited value in predicting neurologic recovery, and do not provide insights into neurophysiological mechanisms. Transcranial magnetic stimulation (TMS) is a non-invasive neurophysiology technique that can supplement the clinical assessment in the domain of body structure and function during acute and chronic stages of SCI. TMS offers a better insight into neurophysiology and help in better detection of residual corticomotor connectivity following SCI compared to clinical assessment alone. TMS-based motor evoked potential and silent period duration allow study of excitatory and inhibitory mechanisms following SCI. Changes in muscle representations in form of displacement of TMS-based motor map center of gravity or changes in the map area can capture neuroplastic changes resulting from SCI or following rehabilitation. Paired-pulse TMS measures help understand the compensatory reorganization of the cortical circuits following SCI. In combination with peripheral stimulation, TMS can be used to study central motor conduction time and modulation of spinal reflexes, which can be used for advanced diagnostic and treatment purposes. To strengthen the utility of TMS in SCI assessment, future studies will need to standardize the assessment protocols, address population-specific concerns, and establish the psychometric properties of TMS-based measurements in the SCI population.
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Affiliation(s)
- Tarun Arora
- Krembil Research Institute, University Health Network, Toronto, ON, Canada,Correspondence: Tarun Arora Robert Chen
| | - Naaz Desai
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Steven Kirshblum
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, United States,Kessler Institute for Rehabilitation, West Orange, NJ, United States,Kessler Foundation, West Orange, NJ, United States,Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Robert Chen
- Krembil Research Institute, University Health Network, Toronto, ON, Canada,Edmond J. Safra Program in Parkinson’s Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, ON, Canada,Division of Neurology, University of Toronto, Toronto, ON, Canada,Correspondence: Tarun Arora Robert Chen
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23
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Hsieh S, Donovan J, Fyffe D, McKay O, Kirshblum S. Effect of Adding a Wheelchair Immersion Program to a Physical Medicine and Rehabilitation Clerkship on Emotions, Behavior, and Attitude: A Prospective Pilot Study. Am J Phys Med Rehabil 2022; 101:782-788. [PMID: 35034065 DOI: 10.1097/phm.0000000000001952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT People with disabilities encounter significant barriers in health care and report that healthcare providers often lack an understanding in caring for them. Currently, there is limited disability awareness training in medical school curricula. This mixed-methods pilot study examined the effects of integrating a short wheelchair immersion program in a physical medicine and rehabilitation clerkship, versus the clerkship alone, on attitudes toward people with disabilities, comfort in treating people with disabilities, knowledge of wheelchair etiquette, and understanding of wheelchair-associated challenges. The standard training group underwent the physical medicine and rehabilitation clerkship, consisting of a 2-wk clinical rotation and didactic program. The intervention group additionally underwent a newly developed 1-hr wheelchair program where they simulated mobility and some activities of daily living as a "wheelchair user" and "caregiver." Quantitative analysis demonstrated that all students who completed the clerkship had significantly improved attitudes toward and comfort in treating people with disabilities, knowledge of wheelchair etiquette, and understanding of wheelchair-associated challenges, whereas students in the wheelchair immersion program had a greater change in understanding wheelchair-associated challenges. Qualitative analysis revealed that the intervention resulted in positive attitudinal changes. These findings suggest that integrating a brief wheelchair immersion program with a physical medicine and rehabilitation clerkship may enhance disability awareness training in medical school curricula.
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Affiliation(s)
- Shelly Hsieh
- From the Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey (SH, JD, DF, OM, SK); Kessler Institute for Rehabilitation, West Orange, New Jersey (SH, JD, SK); Burke Rehabilitation Hospital, White Plains, New York (SH); Montefiore Medical Center, Bronx, New York (SH); Kessler Foundation, West Orange, New Jersey (JD, DF, SK); and Roper Rehabilitation Hospital, Charleston, North Carolina (JD)
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24
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Eren F, DeLuca R, Kirshblum S. Frequency of turning in bed at home in persons with chronic spinal cord injury. J Spinal Cord Med 2022; 45:390-394. [PMID: 32808913 PMCID: PMC9135412 DOI: 10.1080/10790268.2020.1800965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Objective: To determine the routine turning frequency of persons with chronic spinal cord injury (SCI) in bed at night in their home environment.Design: An online questionnaire consisting of 22 questions.Setting: Free standing SCI rehabilitation facility.Participants: Persons between ages 18-75 with a traumatic SCI for ≥3 months, and living at home.Interventions: None.Outcome measures: Questionnaire-based evaluation of turning frequency of persons with SCI.Results: 86 subjects (70 men) with traumatic SCI completed the survey; 66.3% with tetraplegia and 41.9% with a neurological complete SCI. Almost every participant (96%) recalled being counseled on the importance of turning in bed at night upon discharge from their rehabilitation facility with 48.4% recalling the frequency recommended as every 2 h. At present, 25.6% of subjects reported turning every 2 h, 15.1% every 3 h, 15.1% every 4 h, 3.5% every 6 h, and 40.7% of respondents stated that they do not turn regularly at night.Conclusion: Although frequently recommended for repositioning at night in bed every two hours for persons with chronic SCI, especially for those at risk for pressure injuries, only 25.6% of individuals report turning at this frequency and 40.7% report not turning at night time regularly. The reasons for limited turning may be multi-factorial, however, this finding may serve as a call to practitioners to best determine the most appropriate turning frequency that can meet compliance of the individual with SCI, as well as maintain skin protection in the chronic period after injury.
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Affiliation(s)
- Fatma Eren
- Kessler Foundation, West Orange, New Jersey, USA,Department of PM&R, Rutgers New Jersey Medical School, Newark, New Jersey, USA,Correspondence to: Fatma Eren, 1199 Pleasant Valley Way, West Orange, New Jersey07052, USA; Ph: 973-243-6916. Supplemental data for this article can be accessed on the publisher’s website. https://doi.org/10.1080/10790268.2020.1800965
| | - Robert DeLuca
- Kessler Institution for Rehabilitation, West Orange, New Jersey, USA
| | - Steven Kirshblum
- Kessler Foundation, West Orange, New Jersey, USA,Department of PM&R, Rutgers New Jersey Medical School, Newark, New Jersey, USA,Kessler Institution for Rehabilitation, West Orange, New Jersey, USA
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25
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Bushi S, Kirshblum S, Ezepue T, Ma R. Perceived Benefits of a Cadaver-Based Ultrasound Procedure Workshop for Physical Medicine and Rehabilitation Trainees. Am J Phys Med Rehabil 2022; 101:e18-e21. [PMID: 34091463 DOI: 10.1097/phm.0000000000001814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Ultrasound-guided musculoskeletal and spasticity injections have become common procedures in physical medicine and rehabilitation practices, but there are currently no guidelines for teaching these procedures in residency and fellowship training programs. As part of a quality improvement initiative, the authors aimed to assess the educational value of a hands-on cadaver-based workshop for enhancing these skills in residents and fellows. Twenty-seven physical medicine and rehabilitation trainees in a single institution were asked to complete surveys before and after the workshop to assess self-perceived benefits. After the workshop, the overwhelming majority felt improvement in their overall knowledge of ultrasound-guided musculoskeletal (93%) and spasticity (78%) procedures. In addition, the workshop improved the level of comfort of trainees both in planning (70%) and performing (59%) the procedures independently. Improving these skills is especially important considering most trainees plan to incorporate ultrasound-guided musculoskeletal (81%) and spasticity (74%) procedures into their future practices. The framework for this workshop can serve as a template for other programs to incorporate into their own training.
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Affiliation(s)
- Sharon Bushi
- From the Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey (SB, SK, RM); Kessler Institute for Rehabilitation, West Orange, New Jersey (SB); Kessler Foundation, East Hanover, New Jersey (SK); New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey (TE); and Department of Physical Medicine and Rehabilitation, VA Health System, East Orange, New Jersey (RM)
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26
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Arora T, O’Laughlin K, Potter-Baker K, Kirshblum S, Kilgore K, Forrest GF, Bryden AM, Wang X, Henzel MK, Li M, Perlic K, Richmond MA, Pundik S, Bethoux F, Frost F, Plow EB. Safety and efficacy of transcranial direct current stimulation in upper extremity rehabilitation after tetraplegia: protocol of a multicenter randomized, clinical trial. Spinal Cord 2022; 60:774-778. [PMID: 35246620 PMCID: PMC8896974 DOI: 10.1038/s41393-022-00768-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 01/22/2023]
Abstract
STUDY DESIGN A multisite, randomized, controlled, double-blinded phase I/II clinical trial. OBJECTIVE The purpose of this clinical trial is to evaluate the safety, feasibility and efficacy of pairing noninvasive transcranial direct current stimulation (tDCS) with rehabilitation to promote paretic upper extremity recovery and functional independence in persons living with chronic cervical spinal cord injury (SCI). SETTING Four-site trial conducted across Cleveland Clinic, Louis Stokes Veterans Affairs Medical Center of Cleveland and MetroHealth Rehabilitation Rehabilitation Institute of Ohio, and Kessler Foundation of New Jersey. METHODS Forty-four adults (age ≥18 years) with tetraplegia following cervical SCI that occurred ≥1-year ago will participate. Participants will be randomly assigned to receive anodal tDCS or sham tDCS given in combination with upper extremity rehabilitation for 15 sessions each over 3-5 weeks. Assessments will be made twice at baseline separated by at least a 3-week interval, once at end-of-intervention, and once at 3-month follow-up. PRIMARY OUTCOME MEASURE(S) Primary outcome measure is upper extremity motor impairment assessed using the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) scale. Functional abilities will be assessed using Capabilities of Upper Extremity-Test (CUE-T), while functional independence and participation restrictions will be evaluated using the self-care domain of Spinal Cord Independent Measure (SCIM), and Canadian Occupational Performance Measure (COPM). SECONDARY OUTCOME MEASURES Treatment-associated change in corticospinal excitability and output will also be studied using transcranial magnetic stimulation (TMS) and safety (reports of adverse events) and feasibility (attrition, adherence etc.) will also be evaluated. TRIAL REGISTRATION ClincalTrials.gov identifier NCT03892746. This clinical trial is being performed at four sites within the United States: Cleveland Clinic (lead site), Louis Stokes Cleveland Veterans Affairs Medical Center (VAMC) and MetroHealth Rehabilitation Institute in Ohio, and Kessler Foundation in New Jersey. The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick MD 21702-5014 is the awarding and administering acquisition office.
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Affiliation(s)
- Tarun Arora
- grid.239578.20000 0001 0675 4725Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH USA
| | - Kyle O’Laughlin
- grid.239578.20000 0001 0675 4725Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH USA
| | - Kelsey Potter-Baker
- Department of Neuroscience, School of Medicine, University of Texas RioGrande Valley, RioGrande Valley, TX USA
| | - Steven Kirshblum
- grid.419761.c0000 0004 0412 2179Kessler Foundation, West Orange, NJ USA ,grid.415191.90000 0000 9146 3393Kessler Institute for Rehabilitation, West Orange, NJ USA ,grid.430387.b0000 0004 1936 8796Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ USA
| | - Kevin Kilgore
- grid.430779.e0000 0000 8614 884XDepartment of Physical Medicine and Rehabilitation, MetroHealth System, Cleveland, OH USA ,grid.67105.350000 0001 2164 3847Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH USA ,grid.410349.b0000 0004 5912 6484Louis Stokes Veterans Affairs (VA) Medical Center, Cleveland, OH USA
| | - Gail F. Forrest
- grid.419761.c0000 0004 0412 2179Kessler Foundation, West Orange, NJ USA ,grid.430387.b0000 0004 1936 8796Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ USA
| | - Anne M. Bryden
- grid.430779.e0000 0000 8614 884XDepartment of Physical Medicine and Rehabilitation, MetroHealth System, Cleveland, OH USA ,grid.67105.350000 0001 2164 3847Institute for Functional Restoration, Case Western Reserve University, Cleveland, OH USA
| | - Xiaofeng Wang
- grid.239578.20000 0001 0675 4725Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH USA
| | - M. Kristi Henzel
- grid.410349.b0000 0004 5912 6484Louis Stokes Veterans Affairs (VA) Medical Center, Cleveland, OH USA ,grid.67105.350000 0001 2164 3847Department of Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Manshi Li
- grid.239578.20000 0001 0675 4725Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH USA
| | - Kaitlin Perlic
- grid.239578.20000 0001 0675 4725Therapy Services, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH USA
| | - Mary Ann Richmond
- grid.410349.b0000 0004 5912 6484Louis Stokes Veterans Affairs (VA) Medical Center, Cleveland, OH USA ,grid.67105.350000 0001 2164 3847Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Svetlana Pundik
- grid.410349.b0000 0004 5912 6484Louis Stokes Veterans Affairs (VA) Medical Center, Cleveland, OH USA ,grid.67105.350000 0001 2164 3847Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Francois Bethoux
- grid.239578.20000 0001 0675 4725Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH USA
| | - Frederick Frost
- grid.239578.20000 0001 0675 4725Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH USA
| | - Ela B. Plow
- grid.239578.20000 0001 0675 4725Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH USA ,grid.239578.20000 0001 0675 4725Department of Physical Medicine and Rehabilitation, Neurological Institute, Cleveland Clinic Foundation, Cleveland, OH USA
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Kirshblum S, Schmidt Read M, Rupp R. Classification challenges of the 2019 revised International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Spinal Cord 2022; 60:11-17. [PMID: 34088981 PMCID: PMC8737267 DOI: 10.1038/s41393-021-00648-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective review of ISNCSCI datasets. OBJECTIVES To discuss the correct classification of ISNCSCI datasets considered as challenging. SETTING International expert collaboration. METHODS The International Standards Committee of the American Spinal Injury Association (ASIA) receives challenging case scenarios regarding the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI). Among those cases received, sample cases representing different categories of typical classification difficulties were identified by members of the International Standards committee. RESULTS From the cases received, five sample cases were identified as representative for publication. These cases are related to the correct classification in the presence of non-SCI related conditions, the determination of motor zones of partial preservation in regions with no myotomes to test, the classification of the ASIA Impairment Scale in patients with substantial motor function below the motor level but no sacral sparing, the inclusion of non-key muscle functions in the classification of sensory incomplete individuals, and the correct classification of individuals with an amputation. CONCLUSION Presenting cases with challenging classifications, along with responses and explanations, will serve spinal cord injury professionals to better understand and utilize the ISNCSCI classification. As the ISNCSCI endorsed by ASIA and the International Spinal Cord Society (ISCoS) evolves over time, such resources are important to clarify inquiries from the spinal cord injury community and to understand the rationale for revisions.
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Affiliation(s)
- Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ, USA
- Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany.
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Maltser S, Trovato E, Fusco HN, Sison CP, Ambrose AF, Herrera J, Murphy S, Kirshblum S, Bartels MN, Bagay L, Oh-Park M, Stein AB, Cuccurullo S, Nori P, Donovan J, Dams-O’Connor K, Amorapanth P, Barbuto SA, Bloom O, Escalon MX. Challenges and Lessons Learned for Acute Inpatient Rehabilitation of Persons With COVID-19: Clinical Presentation, Assessment, Needs, and Services Utilization. Am J Phys Med Rehabil 2021; 100:1115-1123. [PMID: 34793372 PMCID: PMC8594401 DOI: 10.1097/phm.0000000000001887] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to present: (1) physiatric care delivery amid the SARS-CoV-2 pandemic, (2) challenges, (3) data from the first cohort of post-COVID-19 inpatient rehabilitation facility patients, and (4) lessons learned by a research consortium of New York and New Jersey rehabilitation institutions. DESIGN For this clinical descriptive retrospective study, data were extracted from post-COVID-19 patient records treated at a research consortium of New York and New Jersey rehabilitation inpatient rehabilitation facilities (May 1-June 30, 2020) to characterize admission criteria, physical space, precautions, bed numbers, staffing, employee wellness, leadership, and family communication. For comparison, data from the Uniform Data System and eRehabData databases were analyzed. The research consortium of New York and New Jersey rehabilitation members discussed experiences and lessons learned. RESULTS The COVID-19 patients (N = 320) were treated during the study period. Most patients were male, average age of 61.9 yrs, and 40.9% were White. The average acute care length of stay before inpatient rehabilitation facility admission was 24.5 days; mean length of stay at inpatient rehabilitation facilities was 15.2 days. The rehabilitation research consortium of New York and New Jersey rehabilitation institutions reported a greater proportion of COVID-19 patients discharged to home compared with prepandemic data. Some institutions reported higher changes in functional scores during rehabilitation admission, compared with prepandemic data. CONCLUSIONS The COVID-19 pandemic acutely affected patient care and overall institutional operations. The research consortium of New York and New Jersey rehabilitation institutions responded dynamically to bed expansions/contractions, staff deployment, and innovations that facilitated safe and effective patient care.
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Hartsgrove C, Guevarra-Fernandez J, Kendall J, Delauter G, Kirshblum S. Measuring Discharge Outcomes, Length of Stay, and Functional ADL Score During COVID-19 in Inpatient Rehabilitation Hospitals. Arch Phys Med Rehabil 2021; 102:2291-2299. [PMID: 34303669 PMCID: PMC8299148 DOI: 10.1016/j.apmr.2021.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To measure discharge disposition, length of stay (LOS), and functional activities of daily living (ADL) scores for patients admitted to acute inpatient rehabilitation hospitals (IRHs) during the coronavirus disease 2019 (COVID-19) pandemic and to compare these parameters with a period prior to the pandemic. DESIGN Retrospective cohort study via systematic retrospective chart review of consecutive patients admitted to IRHs from January 1-February 19, 2020 (pre-COVID-19T), and COVID-19 time period/patients admitted from April 1, 2020-May 9, 2020 (COVID-19T). SETTING System of 3 IRHs in the Northeastern United States. PARTICIPANTS Pre-COVID-19T, n=739; COVID-19T, n=335, of whom n=139 were positive for COVID-19 (COVID+) and n=196 were negative (COVID-) (N=1074). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Discharge disposition, LOS, and functional ADL scores. RESULTS COVID-19T patients were younger (P=.03) and less likely to be White (P=.03). These patients also had a higher case mix index (CMI; P<.01), longer acute care LOS (P<.01), and longer IRH LOS (P<.01). Patients who were COVID+ (during COVID-19T) were less likely to be White (P<.01), had lower CMI (P<.01), had higher admission and discharge functional ADL scores (P=.02, P<.01), and had longer acute care LOS compared with those who were COVID- (P<.01). There were no differences in discharge outcomes between pre-COVID-19T and COVID-19T cohorts (P=.75), including when stratified for COVID-19 status (P=.74). Functional ADL scores on admission and discharge were lower in COVID-19T than in pre-COVID-19T (P=.01), including when stratified for COVID-19 status though not significant (P=.06). CONCLUSIONS There were no differences in discharge outcomes for any group. IRH LOS was significantly increased during the pandemic, but there were no statistically significant differences between the COVID+ and COVID- cohorts within COVID-19T. Functional ADL scores were significantly lower during COVID-19T, but COVID status was not a significant predictor. This suggests that COVID+ status was not a barrier to discharge or functional outcomes. This supports the importance of IRHs to restore function and discharge patients to home, even with a more medically complex COVID-19 pandemic population.
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Affiliation(s)
- Caitlin Hartsgrove
- From the Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ; Rutgers New Jersey Medical School, Newark, NJ; Kessler Institute for Rehabilitation, West Orange, NJ.
| | | | - Jamila Kendall
- From the Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ; Rutgers New Jersey Medical School, Newark, NJ; Kessler Institute for Rehabilitation, West Orange, NJ
| | | | - Steven Kirshblum
- From the Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ; Rutgers New Jersey Medical School, Newark, NJ; Kessler Institute for Rehabilitation, West Orange, NJ
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Androwis GJ, Engler A, Rana S, Kirshblum S, Yue GH. The Rehabilitation Effects of Myoelectric Powered Wearable Orthotics on Improving Upper Extremity Function in Persons with SCI. Annu Int Conf IEEE Eng Med Biol Soc 2021; 2021:4944-4948. [PMID: 34892317 DOI: 10.1109/embc46164.2021.9630972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Upper extremity (UE) weakness and/or paralysis following spinal cord injury (SCI) can lead to a limited capacity to perform activities of daily living (ADL). Such disability significantly reduces an individual's level of independence. Further, restoration of UE motor function in people with SCI remains a high priority in rehabilitation and the field of assistive technology. The overall goal of this study was to evaluate the effects of a myoelectric-powered wearable orthosis (MPWO) manufactured by MyoMo, Inc. (Boston, MA) for UE movement assistance on ameliorating UE motor function in order to improve ADL and quality of life in people with SCI. Two male participants with chronic incomplete SCI (iSCI), a 75- and a 31-year-old with AIS D and B, respectively, underwent 18 sessions (over 6 weeks) of UE movement rehabilitation using the MPWO. Handgrip strength, active range of motion (AROM) of the hand, response time to initiate a movement, and muscles activations were examined before and after the rehabilitation training using the MPWO. The response time to initiate UE movements decreased, and handgrip strength and AROM improved after training with the MPWO. These preliminary data suggest that rehabilitation with the use of the UE-MPWO device could enhance the participants' UE activities that led to improved function.Clinical Relevance- These preliminary results from two individuals with iSCI suggest that training with UE-MPWO assistive devices may improve UE utilization during ADL for individuals with muscle weakness or paralysis but still possessing residual voluntary muscle activation capabilities.
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Androwis GJ, Engler A, Rana S, Kirshblum S, Yue G. Upper Extremity Functional Improvements in Persons with SCI Resulted from Daily Utilization of Myoelectric Powered Wearable Orthotics. Annu Int Conf IEEE Eng Med Biol Soc 2021; 2021:4949-4952. [PMID: 34892318 DOI: 10.1109/embc46164.2021.9629938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Spinal cord injury (SCI) is a medically complex and life-disrupting condition. It is estimated that 17,700 new traumatic SCI cases are reported each year in the United States. Approximately half of those cases, involves paralysis, sensory loss, and impaired motor control in the upper extremity (UE) and lower extremities. Such impairments could affect the person's independence as well as their family members and caregiver. The limitation at the UE can significantly limit the general activities of daily living (ADL). The purpose of this paper is to determine the daily utilization effects on changing the handgrip AROM and handgrip forces before and after providing upper extremity in-clinic rehabilitation along with at-home utilization using an UE myoelectric powered wearable orthosis (UE-MPWO) in a person with incomplete spinal cord injury (iSCI). This device helps restore function to the weakened or paralyzed UE muscles. We demonstrate that the handgrip AROM and handgrip force improved after 6-weeks of training with the UE-MPWO. The overall goal of this study was to evaluate the effects of UE-MPWO (MyoPro) when utilized for in-clinic rehabilitation combined with at-home daily use in improving UE movement and function of people with iSCI.Clinical Relevance- The results of in-clinic rehabilitation combined with at-home daily utilization suggest that this UE-MPWO may improve UE function. The examined UE-MPWO could represent a relatively good example as a rehabilitation and assistive tool for persons with iSCI.
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Abstract
Objective: The current diagnostic criteria of autonomic dysreflexia (AD) is based solely on systolic blood pressure (SBP) increases from baseline without regard to changes in diastolic blood pressure (DBP). During urodynamics in persons with SCI at or above the sixth thoracic level (T6), we evaluated diastolic blood pressure (DBP) changes related with AD episodes.Design: Retrospective review of blood pressures recorded during urodynamics.Setting: Outpatient SCI urology program in a free standing rehabilitation center.Participants: Persons with spinal cord injury at or above the T6 level.Interventions: Urodynamic procedures performed between August 2018 to January 2019, as well as their prior testing for up to 10 years.Outcome Measures: Systolic and diastolic blood pressures were recorded during the procedure and episodes of AD defined as SBP >20 mmHg above baseline.Results: Seventy individuals accounting for 282 urodynamic tests were reviewed. AD occurred in 43.3% (122/282) of all urodynamics tests. The mean maximum SBP and DBP increase from baseline for those with AD were 35.5 ± 10.9 mmHg and 19.0±9.4 mmHg, respectively. There was a concomitant rise of DBP >10 mmHg with a SBP rise of >20 mmHg in 76.2% (93/122) of urodynamic tests. An elevation of DBP >10 mmHg was recorded in 23.8% (38/160) of urodynamics that did not have AD by the SBP definition.Conclusion: DBP increments of >10 mmHg with concurrent SBP increases of >20 mmHg occurs in the majority of AD episodes. Given the significance of cardiovascular complications in chronic SCI, further work is warranted to determine the significance of DBP elevations for defining AD.
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Affiliation(s)
- Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA,Kessler Foundation, West Orange, New Jersey, USA,Correspondence to: Steven Kirshblum, 1199 Pleasant Valley Way, West Orange, New Jersey07052, USA; Ph: 973-243-6916.
| | - Fatma Eren
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA,Kessler Foundation, West Orange, New Jersey, USA
| | - Ryan Solinsky
- Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathryn Gibbs
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Katharine Tam
- VA St. Louis Health Care System, St. Louis, Missouri, USA
| | - Robert DeLuca
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
| | - Todd Linsenmeyer
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA,Kessler Foundation, West Orange, New Jersey, USA
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Aspinall P, Harrison L, Scheuren P, Cragg JJ, Ferguson AR, Guest JD, Hsieh J, Jones L, Kirshblum S, Lammertse D, Kwon BK, Kramer JLK. A Systematic Review of Safety Reporting in Acute Spinal Cord Injury Clinical Trials: Challenges and Recommendations. J Neurotrauma 2021; 38:2047-2054. [PMID: 33899507 DOI: 10.1089/neu.2020.7540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Accurate safety information in published clinical trials guides the assessment of risk-benefit, as well as the design of future clinical trials. Comprehensive reporting of adverse events, toxicity, and discontinuations from acute spinal cord injury clinical trials is an essential step in this process. Here, we sought to assess the degree of "satisfactoriness" of reporting in past clinical trials in spinal cord injury. A review of citations from MEDLINE and EMBASE identified eligible clinical trials in acute (within 30 days) spinal cord injury. English language studies, published between 1980 and 2020, with sensory, motor, or autonomic neurological assessments as the primary outcome measure were eligible for inclusion. Criteria were then established to qualify the safety reporting as satisfactory (i.e., distinguished severe/life-threatening events), partially satisfactory, or unsatisfactory (i.e., only mentioned in general statements, or reported but without distinguishing severe events). A total of 40 trials were included. Satisfactory reporting for clinical adverse events was observed in 30% of trials; partially satisfactory was achieved by 10% of the trials, and the remaining 60% were unsatisfactory. The majority of trials were determined to be unsatisfactory for the reporting of laboratory-defined toxicity (82.5%); only 17.5% were satisfactory. Discontinuations were satisfactorily reported for the majority of trials (80%), with the remaining partially satisfactory (5%) or unsatisfactory (15%). Reporting of safety in clinical trials for acute spinal cord injury is suboptimal. Due to the complexities of acute spinal cord injury (e.g., polytrauma, multiple systems affected), tailored and specific standards for tracking adverse events and safety reporting should be established.
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Affiliation(s)
- Paul Aspinall
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Liam Harrison
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Paulina Scheuren
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jacquelyn J Cragg
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Adam R Ferguson
- Data Science, Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, California, USA
- San Francisco Veteran's Affairs Healthcare System, San Francisco, California, USA
| | - James D Guest
- Department of Neurological Surgery, University of Miami and the Miami Project to Cure Paralysis, Miami, Florida, USA
| | | | - Linda Jones
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Steven Kirshblum
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
| | | | - Brian K Kwon
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - John L K Kramer
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada
- Hugill Center for Anesthesiology, University of British Columbia, Vancouver, British Columbia, Canada
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Krassioukov A, Linsenmeyer TA, Beck LA, Elliott S, Gorman P, Kirshblum S, Vogel L, Wecht J, Clay S. [Formula: see text] [Formula: see text] [Formula: see text] [Formula: see text]Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows. J Spinal Cord Med 2021; 44:631-683. [PMID: 34270391 PMCID: PMC8288133 DOI: 10.1080/10790268.2021.1925058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Andrei Krassioukov
- University of British Columbia, Vancouver, British Columbia, BC
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, BC, Canada
| | - Todd A Linsenmeyer
- Kessler Institute for Rehabilitation, West Orange, NJ
- Rutgers University Medical School, Newark, NJ
| | | | - Stacy Elliott
- University of British Columbia, Vancouver, British Columbia, BC
| | | | - Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ
- Rutgers University Medical School, Newark, NJ
| | | | - Jill Wecht
- Icahn School of Medicine at Mt Sinai, New York, NY
| | - Sarah Clay
- Richard L. Roudebush VA Medical Center, Indianapolis, IN
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35
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Sangari S, Kirshblum S, Guest JD, Oudega M, Perez MA. Distinct patterns of spasticity and corticospinal connectivity following complete spinal cord injury. J Physiol 2021; 599:4441-4454. [PMID: 34107068 DOI: 10.1113/jp281862] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/01/2021] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Damage to corticospinal axons have implications for the development of spasticity following spinal cord injury (SCI). Here, we examined to which extent residual corticospinal connections and spasticity are present in muscles below the injury (quadriceps femoris and soleus) in humans with motor complete thoracic SCI. We found three distinct sub-groups of people: participants with spasticity and corticospinal responses in the quadriceps femoris and soleus, participants with spasticity and corticospinal responses in the quadriceps femoris only, and participants with no spasticity or corticospinal responses in either muscle. Spasticity and corticospinal responses were present in the quadriceps but never only in the soleus muscle, suggesting a proximal to distal gradient of symptoms of hyperreflexia. These results suggest that concomitant patterns of residual corticospinal connectivity and spasticity exist in humans with motor complete SCI and that a clinical exam of spasticity might be a good predictor of residual corticospinal connectivity. ABSTRACT The loss of corticospinal axons has implications for the development of spasticity following spinal cord injury (SCI). However, the extent to which residual corticospinal connections and spasticity are present across muscles below the injury remains unknown. To address this question, we tested spasticity using the Modified Ashworth Scale and transmission in the corticospinal pathway by examining motor evoked potentials elicited by transcranial magnetic stimulation over the leg motor cortex (cortical MEPs) and by direct activation of corticospinal axons by electrical stimulation over the thoracic spine (thoracic MEPs), in the quadriceps femoris and soleus muscles, in 30 individuals with motor complete thoracic SCI. Cortical MEPs were also conditioned by thoracic electrical stimulation at intervals allowing their summation or collision. We found three distinct sub-groups of participants: 47% showed spasticity in the quadriceps femoris and soleus muscle, 30% showed spasticity in the quadriceps femoris muscle only, and 23% showed no spasticity in either muscle. While cortical MEPs were present only in the quadriceps in participants with spasticity, thoracic MEPs were present in both muscles when spasticity was present. Thoracic electrical stimulation facilitated and suppressed cortical MEPs, showing that both forms of stimulation activated similar corticospinal axons. Cortical and thoracic MEPs correlated with the degree of spasticity in both muscles. These results provide the first evidence that related patterns of residual corticospinal connectivity and spasticity exist in muscles below the injury after motor complete thoracic SCI and highlight that a clinical exam of spasticity can predict residual corticospinal connectivity after severe paralysis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sina Sangari
- Shirley Ryan AbilityLab, Chicago, Illinois, 60611.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, 60611
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - James D Guest
- The Miami Project to Cure Paralysis, University of Miami, Miami, 33136
| | - Martin Oudega
- Shirley Ryan AbilityLab, Chicago, Illinois, 60611.,Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, 60611.,Edward Hines Jr. VA Hospital, Hines, Illinois, 60141
| | - Monica A Perez
- Shirley Ryan AbilityLab, Chicago, Illinois, 60611.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, 60611.,Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, 60611.,Edward Hines Jr. VA Hospital, Hines, Illinois, 60141
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36
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Rupp R, Biering-Sørensen F, Burns SP, Graves DE, Guest J, Jones L, Read MS, Rodriguez GM, Schuld C, Tansey-Md KE, Walden K, Kirshblum S. International Standards for Neurological Classification of Spinal Cord Injury: Revised 2019. Top Spinal Cord Inj Rehabil 2021; 27:1-22. [PMID: 34108832 DOI: 10.46292/sci2702-1] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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37
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Field-Fote EC, Furbish CL, Tripp NE, Zanca JM, Dyson-Hudson T, Kirshblum S, Heinemann AW, Chen D, Felix ER, Worobey L, Schmidt-Read M, Marino RJ, Hayat MJ. Characterizing the Experience of Spasticity after Spinal Cord Injury: A National Survey Project of the Spinal Cord Injury Model Systems Centers. Arch Phys Med Rehabil 2021; 103:764-772.e2. [PMID: 34015348 DOI: 10.1016/j.apmr.2021.03.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/14/2021] [Accepted: 03/23/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To characterize the qualities that individuals with spinal cord injury (SCI) associate with their experience of spasticity and to describe the relationship between spasticity and perceived quality of life and the perceived value of spasticity management approaches. DESIGN Online cross-sectional survey. SETTING Multicenter collaboration among 6 Spinal Cord Injury Model Systems hospitals in the United States. PARTICIPANTS Individuals with SCI (N=1076). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Qualities of Spasticity Questionnaire, modified Spinal Cord Injury-Spasticity Evaluation Tool (mSCI-SET), and the modified Patient-Reported Impact of Spasticity Measure (mPRISM). RESULTS Respondents indicated that spasms most often occurred in response to movement-related triggering events. However, spontaneous spasms (ie, no triggering event) were also reported to be among the most common types. Frequency of spasms appears to decline with age. The highest frequency of spasms was reported by 56% of respondents aged <25 years and by only 28% of those >55 years. Stiffness associated with spasticity was reported to be more common than spasms (legs, 65% vs 54%; trunk, 33% vs 18%; arms, 26% vs 15%). Respondents reported negative effects of spasticity more commonly than positive effects. Based on their association with negative scores on the mSCI-SET and the mPRISM, the 5 most problematic experiences reported were stiffness all day, interference with sleep, painful spasms, perceived link between spasticity and pain, and intensification of pain before a spasm. Respondents indicated spasticity was improved more by stretching (48%) and exercise (45%) than by antispasmodics (38%). CONCLUSIONS The experience of spasticity after SCI is complex and multidimensional, with consequences that affect mobility, sleep, comfort, and quality of life. Stiffness, rather than spasms, appears to be the most problematic characteristic of spasticity. Physical therapeutic interventions to treat spasticity warrant in-depth investigation.
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Affiliation(s)
- Edelle C Field-Fote
- Crawford Research Institute, Shepherd Center, Atlanta, GA; Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA; Program in Applied Physiology, Georgia Institute of Technology, Atlanta, GA.
| | | | - Natalie E Tripp
- School of Public Health, Georgia State University, Atlanta, GA
| | | | | | - Steven Kirshblum
- Kessler Foundation, West Orange, NJ; Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, NJ
| | - Allen W Heinemann
- Shirley Ryan AbilityLab, Chicago, IL; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | - Lynn Worobey
- Departments of Physical Medicine and Rehabilitation, Bioengineering and Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | | | - Ralph J Marino
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadephia, PA
| | - Matthew J Hayat
- School of Public Health, Georgia State University, Atlanta, GA
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Gilbert C, Hsieh S, Donovan J, Dyson-Hudson T, Cabarle M, Granger S, Kirshblum S. Effect of an interventional educational wheelchair program on medical students' understanding of manual wheelchair use. PM R 2021; 13:1350-1356. [PMID: 33956395 DOI: 10.1002/pmrj.12628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/02/2020] [Accepted: 04/05/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is limited literature exploring the benefits of interactive wheelchair educational programs in medical student curricula. OBJECTIVE To identify the effect of an educational interactive wheelchair program on medical students' understanding of wheelchair use. Researchers hypothesized that the program would increase understanding. DESIGN Repeated-measures survey study with postintervention comparison. SETTING Inpatient acute rehabilitation center. PARTICIPANTS Out of 123 eligible fourth-year medical students on a mandatory physical medicine and rehabilitation clerkship, 79 students participated. INTERVENTION All participants underwent a 2-hour educational wheelchair program consisting of (1) a disability lecture; (2) a video on the importance of proper wheelchair type and fit, wheelchair prescription, as well as recreational wheelchair use; and (3) an interactive wheelchair experience. MAIN OUTCOME MEASURES Pre- and postsurvey Likert scale questions measured medical students' understanding of four main areas: (1) impact of manual wheelchair use, (2) challenges of manual wheelchair use, (3) manual wheelchair skills, and (4) wheelchair etiquette. RESULTS A two-tailed sign test demonstrated a highly significant increase from pre- to postsurvey scores in each survey section (P < .001). Presurvey and postsurvey mean scores for impact of manual wheelchair use, challenges of manual wheelchair use, manual wheelchair skills, and wheelchair etiquette survey sections were 3.9 and 4.4, 3.1 and 4.4, 2.4 and 4.4, and 2.5 and 4.0, respectively. CONCLUSIONS This study demonstrates that an interactive educational wheelchair program effectively increases medical students' understanding of manual wheelchair use. The addition of an educational interactive wheelchair program to medical student curricula is recommended to improve medical students' understanding of manual wheelchair use and its impact on users.
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Affiliation(s)
- Courtney Gilbert
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
| | - Shelly Hsieh
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
| | - Jayne Donovan
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
| | - Trevor Dyson-Hudson
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Kessler Foundation, West Orange, New Jersey, USA
| | - Mary Cabarle
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
| | - Syndi Granger
- Kessler Institute for Rehabilitation, West Orange, New Jersey, USA
| | - Steven Kirshblum
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA.,Kessler Institute for Rehabilitation, West Orange, New Jersey, USA.,Kessler Foundation, West Orange, New Jersey, USA
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Abstract
The predominant tool used to predict outcomes after traumatic spinal cord injury (SCI) is the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), in association with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). These measures have evolved based on analyses of large amounts of longitudinal neurological recovery data published in numerous separate studies. This article reviews and synthesizes published data on neurological recovery from multiple sources, only utilizing data in which the sacral sparing definition was applied for determination of completeness. Conversion from a complete to incomplete injury is more common in tetraplegia than paraplegia. The majority of AIS conversion and motor recovery occurs within the first 6-9 months, with the most rapid rate of motor recovery occurring in the first three months after injury. Motor score changes, as well as recovery of motor levels, are described with the initial strength of muscles as well as the levels of the motor zone of partial preservation influencing the prognosis. Total motor recovery is greater for patients with initial AIS B than AIS A, and greater after initial AIS C than with motor complete injuries. Older age has a negative impact on neurological and functional recovery after SCI; however, the specific age (whether >50 or >65 years) and underlying reasons for this impact are unclear. Penetrating injury is more likely to lead to a classification of a neurological complete injury compared with blunt trauma and reduces the likelihood of AIS conversion at one year. There are insufficient data to support gender having a major effect on neurological recovery after SCI.
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Affiliation(s)
- Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, New Jersy, USA
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - Brittany Snider
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Fatma Eren
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
- Kessler Foundation, West Orange, New Jersey, USA
| | - James Guest
- Neurological Surgery, Miller School of Medicine, Miami, Florida, USA
- The Miami Project to Cure Paralysis, Miami, Florida, USA
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Boakye M, Ugiliweneza B, Madrigal F, Mesbah S, Ovechkin A, Angeli C, Bloom O, Wecht JW, Ditterline B, Harel NY, Kirshblum S, Forrest G, Wu S, Harkema S, Guest J. Clinical Trial Designs for Neuromodulation in Chronic Spinal Cord Injury Using Epidural Stimulation. Neuromodulation 2021; 24:405-415. [PMID: 33794042 DOI: 10.1111/ner.13381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/11/2021] [Accepted: 02/09/2021] [Indexed: 12/17/2022]
Abstract
STUDY DESIGN This is a narrative review focused on specific challenges related to adequate controls that arise in neuromodulation clinical trials involving perceptible stimulation and physiological effects of stimulation activation. OBJECTIVES 1) To present the strengths and limitations of available clinical trial research designs for the testing of epidural stimulation to improve recovery after spinal cord injury. 2) To describe how studies can control for the placebo effects that arise due to surgical implantation, the physical presence of the battery, generator, control interfaces, and rehabilitative activity aimed to promote use-dependent plasticity. 3) To mitigate Hawthorne effects that may occur in clinical trials with intensive supervised participation, including rehabilitation. MATERIALS AND METHODS Focused literature review of neuromodulation clinical trials with integration to the specific context of epidural stimulation for persons with chronic spinal cord injury. CONCLUSIONS Standard of care control groups fail to control for the multiple effects of knowledge of having undergone surgical procedures, having implanted stimulation systems, and being observed in a clinical trial. The irreducible effects that have been identified as "placebo" require sham controls or comparison groups in which both are implanted with potentially active devices and undergo similar rehabilitative training.
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Affiliation(s)
- Maxwell Boakye
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Department of Health Management and Systems Sciences, University of Louisville, Louisville, KY, USA
| | - Fabian Madrigal
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Samineh Mesbah
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Alexander Ovechkin
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Claudia Angeli
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Department of Bioengineering, University of Louisville, Louisville, KY, USA.,Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, USA
| | - Ona Bloom
- Feinstein Institute for Medical Research, Manhasset, NY, USA.,Department of Molecular Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA.,Department of Physical Medicine and Rehabilitation, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA.,James J Peters VA Medical Center, Bronx, NY, USA
| | - Jill W Wecht
- James J Peters VA Medical Center, Bronx, NY, USA.,The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bonnie Ditterline
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Noam Y Harel
- James J Peters VA Medical Center, Bronx, NY, USA.,The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NY, USA.,Human Performance and Engineering Research, Kessler Foundation, West Orange, NJ, USA
| | - Gail Forrest
- Human Performance and Engineering Research, Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Samuel Wu
- Department of Biostatistics, CTSI Data Coordinating Center, University of Florida, Gainesville, FL, USA
| | - Susan Harkema
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, USA
| | - James Guest
- Neurological Surgery, and the Miami Project to Cure Paralysis, Miller School of Medicine, Miami, FL, USA
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Guest JD, Kirshblum S. Commentary on "The Influence of Timing of Surgical Decompression for Acute Spinal Cord Injury: A Pooled Analysis of Individual Patient Data". Neurospine 2021; 18:17-19. [PMID: 33819932 PMCID: PMC8021831 DOI: 10.14245/ns.2142234.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
| | - Steven Kirshblum
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
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Donovan J, Forrest G, Linsenmeyer T, Kirshblum S. Spinal Cord Stimulation After Spinal Cord Injury: Promising Multisystem Effects. Curr Phys Med Rehabil Rep 2021. [DOI: 10.1007/s40141-020-00304-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Zhang F, Momeni K, Ramanujam A, Ravi M, Carnahan J, Kirshblum S, Forrest GF. Cervical Spinal Cord Transcutaneous Stimulation Improves Upper Extremity and Hand Function in People With Complete Tetraplegia: A Case Study. IEEE Trans Neural Syst Rehabil Eng 2021; 28:3167-3174. [PMID: 33382659 DOI: 10.1109/tnsre.2020.3048592] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Recovery of the upper extremity (UE) and hand function is considered the highest priority for people with tetraplegia, because these functions closely integrate with their activities of daily living. Spinal cord transcutaneous stimulation (scTS) has great potential to facilitate functional restoration of paralyzed limbs by neuro-modulating the excitability of the spinal network. Recently, this approach has been demonstrated effective in improving UE function in people with motor complete and incomplete cervical SCI. However, the research thus far is limited by the lack of a comprehensive assessment of functional improvement and neurological recovery throughout the intervention. The goal of this study was to investigate whether scTS can also facilitate UE functional restoration in an individual with motor and sensory complete tetraplegia. A 38-year-old male with a C5 level, ASIA Impairment Scale-A SCI (15 years post-injury, left hand dominant pre- and post-injury), received 18 sessions (60 minutes/session) of scTS combined with task-specific hand training over the course of 8 weeks. The total score of the Graded Redefined Assessment of Strength, Sensibility, and Prehension significantly improved from 72/232 to 96/232 at post-intervention, and maintained ranging from 82/232 to 86/232 during the three months follow-up without any further treatment. The bilateral handgrip force improved by 283.4% (left) and 30.7% (right), respectively at post-intervention. These strength gains were sustained at 233.5% -250% (left) and 11.5%-73.1% (right) during the follow-up evaluation visits. Neuromuscular Recovery Scale demonstrated dramatic and long-lasting improvements following the completion of the intervention. Changes of spinal motor evoked potentials from pre- to post-intervention indicated an increased level of spinal network excitability. The present data offer preliminary evidence that the novel scTS intervention combined with hand training can enhance UE functional use in people with motor and sensory complete SCI.
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Krassioukov A, Linsenmeyer TA, Beck LA, Elliott S, Gorman P, Kirshblum S, Vogel L, Wecht J, Clay S. Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows: Management of Blood Pressure, Sweating, and Temperature Dysfunction. Top Spinal Cord Inj Rehabil 2021; 27:225-290. [PMID: 34108837 PMCID: PMC8152175 DOI: 10.46292/sci2702-225] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | | | | | - Stacy Elliott
- University of British Columbia, Vancouver, British Columbia, CA
| | | | | | | | - Jill Wecht
- Icahn School of Medicine at Mt Sinai, New York, NY
| | - Sarah Clay
- Richard L. Roudebush VA Medical Center, Indianapolis, IN
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Enam N, Veerubhotla A, Ehrenberg N, Kirshblum S, Nolan KJ, Pilkar R. Augmented-reality guided treadmill training as a modality to improve functional mobility post-stroke: A proof-of-concept case series. Top Stroke Rehabil 2020; 28:624-630. [PMID: 33342389 DOI: 10.1080/10749357.2020.1864987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: To provide a proof-of-concept for a novel stroke-gait-specific augmented reality (AR)-guided treadmill intervention by evaluating its effect on temporospatial and functional outcomes of mobility.Methods: Two females with hemiplegia post stroke were recruited for participation in a 4-week intervention, and a single healthy control was recruited for baseline comparisons. The stroke-intervention (SI) participant (aged 54-years), completed 12 sessions of AR-guided treadmill intervention. The stroke-control (SC) participant (aged 59-years) completed 12 sessions of conventional treadmill intervention. Temporospatial and functional mobility were assessed pre-intervention, post-intervention, and at 1-month follow-up. Physical ACtivity Enjoyment Scale (PACES) was administered post-intervention.Results: The SI participant showed clinically meaningful improvements in functional outcomes post-intervention and at 1-month follow-up (Berg balance score (BBS): +6 and +10 points; Dynamic Gait Index (DGI): +2 at post-intervention only; walking speed: +0.19 and +0.24 m/s; 6-minute walk test (6MWT): +51.9 and +38.9) respectively. The SC showed clinically meaningful improvements in BBS (+3 and +3) and walking speed (+0.06 at post-intervention). The PACES scores showed that the SI participant had a significantly higher (23 points) enjoyment level during the intervention compared to the SC participant. The SI participant was more asymmetric compared to the SC participant at pre and post-intervention visits.Conclusions: The SI participant showed greater improvement in functional assessments compared to the SC participant post intervention. The AR-guided approach may have added benefits compared to traditional treadmill training, while providing better customization, patient enjoyment, and engagement. Further investigation with a larger sample is warranted.
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Affiliation(s)
- Nabela Enam
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Akhila Veerubhotla
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers - New Jersey Medical School, Newark, NJ, USA
| | - Naphtaly Ehrenberg
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, USA
| | - Steven Kirshblum
- Department of Physical Medicine and Rehabilitation, Rutgers - New Jersey Medical School, Newark, NJ, USA.,Center for Spinal Stimulation Research, Kessler Foundation, West Orange, NJ, USA.,Spinal Cord Rehabilitation, Kessler Institute for Rehabilitation, West Orange, NJ, USA
| | - Karen J Nolan
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers - New Jersey Medical School, Newark, NJ, USA
| | - Rakesh Pilkar
- Center for Mobility and Rehabilitation Engineering Research, Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers - New Jersey Medical School, Newark, NJ, USA
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Androwis G, Gant KL, Sheridan A, Attanasio A, Dasgupta M, Engler A, Dietrich WD, Kirshblum S. The Effectiveness of Brain-Computer Interface-Based Electromagnetic Field Treatment in Persons with SCI. Arch Phys Med Rehabil 2020. [DOI: 10.1016/j.apmr.2020.09.324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Engel-Haber E, Zeilig G, Haber S, Worobey L, Kirshblum S. The effect of age and injury severity on clinical prediction rules for ambulation among individuals with spinal cord injury. Spine J 2020; 20:1666-1675. [PMID: 32502654 DOI: 10.1016/j.spinee.2020.05.551] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/22/2020] [Accepted: 05/22/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT While several models for predicting independent ambulation early after traumatic spinal cord injury (SCI) based upon age and specific motor and sensory level findings have been published and validated, their accuracy, especially in individual American Spinal Injury Association [ASIA] Impairment Scale (AIS) classifications, has been questioned. Further, although age is widely used in prediction rules, its role and possible modifications have not been adequately evaluated until now. PURPOSE To evaluate the predictive accuracy of existing clinical prediction rules for independent ambulation among individuals at spinal cord injury model systems (SCIMS) Centers as well as the effect of modifying the age parameter from a cutoff of 65 years to 50 years. STUDY DESIGN Retrospective analysis of a longitudinal database. PATIENT SAMPLE Adult individuals with traumatic SCI. OUTCOME MEASURES The FIM locomotor score was used to assess independent walking ability at the 1-year follow-up. METHODS In all, 639 patients were enrolled in the SCIMS database between 2011 and 2015, with complete neurological examination data within 15 days following the injury and a follow-up assessment with functional independence measure (FIM) at 1-year post injury. Two previously validated logistic regression models were evaluated for their ability to predict independent walking at 1-year post injury with participants in the SCIMS database. Area under the receiver operating curve (AUC) was calculated for the individual AIS categories and for different age groups. Prediction accuracy was also calculated for a new modified LR model (with cut-off age of 50). RESULTS Overall AUC for each of the previous prediction models was found to be consistent with previous reports (0.919 and 0.904). AUCs for grouped AIS levels (A+D, B+C) were consistent with prior reports, moreover, prediction for individual AIS grades continued to reveal lower values. AUCs by different age categories showed a decline in prognostication accuracy with an increase in age, with statistically significant improvement of AUC when age-cut off was reduced to 50. CONCLUSIONS We confirmed previous results that former prediction models achieve strong prognostic accuracy by combining AIS subgroups, yet prognostication of the separate AIS groups is less accurate. Further, prognostication of persons with AIS B+C, for whom a clinical prediction model has arguably greater clinical utility, is less accurate than those with AIS A+D. Our findings emphasize that age is an important factor in prognosticating ambulation following SCI. Prediction accuracy declines for older individuals compared with younger ones. To improve prediction of independent ambulation, the age of 50 years may be a better cutoff instead of age of 65.
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Affiliation(s)
- Einat Engel-Haber
- Department of Neurological Rehabilitation, The Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Gabi Zeilig
- Department of Neurological Rehabilitation, The Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Simi Haber
- Department of Mathematics, Bar-Ilan University, Ramat-Gan, Israel
| | - Lynn Worobey
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange NJ, USA; Rutgers New Jersey Medical School, Newark, NJ, USA
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Kirshblum S, Botticello A, Benedetto J, Donovan J, Marino R, Hsieh S, Wagaman N. A Comparison of Diagnostic Stability of the ASIA Impairment Scale Versus Frankel Classification Systems for Traumatic Spinal Cord Injury. Arch Phys Med Rehabil 2020; 101:1556-1562. [DOI: 10.1016/j.apmr.2020.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 04/20/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
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Spungen AM, Bauman WA, Biswas K, Jones KM, Snodgrass AJ, Goetz LL, Gorman PH, Kirshblum S, Sabharwal S, White KT, Asselin PK, Morin KG, Cirnigliaro CM, Huang GD. The design of a randomized control trial of exoskeletal-assisted walking in the home and community on quality of life in persons with chronic spinal cord injury. Contemp Clin Trials 2020; 96:106102. [PMID: 32800962 DOI: 10.1016/j.cct.2020.106102] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 02/06/2023]
Abstract
There are more than 300,000 estimated cases of spinal cord injury (SCI) in the United States, and approximately 27,000 of these are Veterans. Immobilization from SCI results in adverse secondary medical conditions and reduced quality of life. Veterans with SCI who have completed rehabilitation after injury and are unable to ambulate receive a wheelchair as standard of care. Powered exoskeletons are a technology that offers an alternative form of limited mobility by enabling over-ground walking through an external framework for support and computer-controlled motorized hip and knee joints. Few studies have reported the safety and efficacy for use of these devices in the home and community environments, and none evaluated their impact on patient-centered outcomes through a randomized clinical trial (RCT). Absence of reported RCTs for powered exoskeletons may be due to a range of challenges, including designing, statistically powering, and conducting such a trial within an appropriate experimental framework. An RCT for the study of exoskeletal-assisted walking in the home and community environments also requires the need to address key factors such as: avoiding selection bias, participant recruitment and retention, training, and safety concerns, particularly in the home environment. These points are described here in the context of a national, multisite Department of Veterans Affairs Cooperative Studies Program-sponsored trial. The rationale and methods for the study design were focused on providing a template for future studies that use powered exoskeletons or other strategies for walking and mobility in people with immobilization due to SCI.
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Affiliation(s)
- Ann M Spungen
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY 10468, United States of America; Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States of America; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States of America.
| | - William A Bauman
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY 10468, United States of America; Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States of America; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States of America.
| | - Kousick Biswas
- Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point, MD 21902, United States of America.
| | - Karen M Jones
- Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point, MD 21902, United States of America.
| | - Amanda J Snodgrass
- VA Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM 87106, United States of America; University of New Mexico, College of Pharmacy, Albuquerque, NM 87106, United States of America.
| | - Lance L Goetz
- Hunter Holmes McGuire VA Medical Center, Richmond, VA 23249, United States of America; Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA 23298, United States of America.
| | - Peter H Gorman
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, United States of America; VA Maryland Healthcare System, Baltimore, MD 21201, United States of America.
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, West Orange, NJ 07052, United States of America; Rutgers New Jersey Medical School, Newark, NJ 07103, United States of America; Kessler Foundation, West Orange, NJ 07052, United States of America.
| | - Sunil Sabharwal
- VA Boston Health Care System, Boston, MA 02130, United States of America; Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA 02115, United States of America.
| | - Kevin T White
- James A Haley Veterans' Hospital, Tampa, FL 33612, United States of America; University of South Florida, Tampa, FL 33612, United States of America.
| | - Pierre K Asselin
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY 10468, United States of America; Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States of America.
| | - Kel G Morin
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY 10468, United States of America.
| | - Christopher M Cirnigliaro
- National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters VA Medical Center, Bronx, NY 10468, United States of America.
| | - Grant D Huang
- Cooperative Studies Program Central Office, VA Office of Research and Development, Washington, DC 20420, United States of America.
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