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Nedumaran L, Rebekah G, Tharion E, Tharion G. Initial Autonomic Parameters and Subsequent Short-Term Neurological Recovery after Inpatient Rehabilitation, in Traumatic Cervical Spinal Cord Injury Patients. Neurorehabil Neural Repair 2022; 36:269-273. [PMID: 35227121 DOI: 10.1177/15459683221081060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND It is unknown whether assessment of autonomic pathway integrity in newly injured traumatic cervical spinal cord injury (SCI) patients contributes to their neurological prognosis. OBJECTIVE The objective is to investigate the relationship of heart rate variability (HRV) and sympathetic skin response (SSR) at initial evaluation of American Spinal Injury Association Impairment Scale (AIS) A/B tetraplegic patients, with their short-term neurological recovery. METHODS In this prospective cohort study, short-term HRV indices and SSR to supra-lesional stimuli were computed in 24 acute traumatic cervical AIS A/B SCI patients at admission for rehabilitation. The relationship of these autonomic parameters with motor and sensory score improvement, AIS grade improvement, and time taken for recovery was tested, respectively, with Spearman's correlation coefficient test, Fisher's exact test, and Kaplan-Meier analysis. RESULTS SSR was present in 11 (45.8%) patients at initial evaluation. After rehabilitation, 5 (20.8%) patients improved from AIS A/B to AIS C (greater recovery), while the rest remained at AIS A/B (lesser recovery). Both AIS improvement and mean time for 'greater' recovery did not associate with the presence/absence of SSR. Further, HRV indices did not correlate with improvement in motor or sensory scores. CONCLUSIONS Interim neurological recovery was not related to autonomic parameters of short-term HRV indices and SSR in the AIS A/B tetraplegic patients of our study. Interestingly, about half of the patients with clinically complete SCI had evidence of preserved autonomic function. Our data add to the knowledge base of autonomic findings in cervical SCI patients and will promote research relating neurophysiological parameters and recovery.
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Affiliation(s)
- Latha Nedumaran
- Department of Physiology, 30025Christian Medical College, Vellore, TN, India
| | - Grace Rebekah
- Department of Biostatistics, 30025Christian Medical College, Vellore, TN, India
| | - Elizabeth Tharion
- Department of Physiology, 30025Christian Medical College, Vellore, TN, India
| | - George Tharion
- Department of Physical Medicine and Rehabilitation, 30025Christian Medical College, Vellore, TN, India
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Santamaria AJ, Benavides FD, Saraiva PM, Anderson KD, Khan A, Levi AD, Dietrich WD, Guest JD. Neurophysiological Changes in the First Year After Cell Transplantation in Sub-acute Complete Paraplegia. Front Neurol 2021; 11:514181. [PMID: 33536992 PMCID: PMC7848788 DOI: 10.3389/fneur.2020.514181] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/05/2020] [Indexed: 12/15/2022] Open
Abstract
Neurophysiological testing can provide quantitative information about motor, sensory, and autonomic system connectivity following spinal cord injury (SCI). The clinical examination may be insufficiently sensitive and specific to reveal evolving changes in neural circuits after severe injury. Neurophysiologic data may provide otherwise imperceptible circuit information that has rarely been acquired in biologics clinical trials in SCI. We reported a Phase 1 study of autologous purified Schwann cell suspension transplantation into the injury epicenter of participants with complete subacute thoracic SCI, observing no clinical improvements. Here, we report longitudinal electrophysiological assessments conducted during the trial. Six participants underwent neurophysiology screening pre-transplantation with three post-transplantation neurophysiological assessments, focused on the thoracoabdominal region and lower limbs, including MEPs, SSEPs, voluntarily triggered EMG, and changes in GSR. We found several notable signals not detectable by clinical exam. In all six participants, thoracoabdominal motor connectivity was detected below the clinically assigned neurological level defined by sensory preservation. Additionally, small voluntary activations of leg and foot muscles or positive lower extremity MEPs were detected in all participants. Voluntary EMG was most sensitive to detect leg motor function. The recorded MEP amplitudes and latencies indicated a more caudal thoracic level above which amplitude recovery over time was observed. In contrast, further below, amplitudes showed less improvement, and latencies were increased. Intercostal spasms observed with EMG may also indicate this thoracic “motor level.” Galvanic skin testing revealed autonomic dysfunction in the hands above the injury levels. As an open-label study, we can establish no clear link between these observations and cell transplantation. This neurophysiological characterization may be of value to detect therapeutic effects in future controlled studies.
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Affiliation(s)
- Andrea J Santamaria
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Francisco D Benavides
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Pedro M Saraiva
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Kimberly D Anderson
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Aisha Khan
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,Miller School of Medicine, The Interdisciplinary Stem Cell Institute, The University of Miami, Miami, FL, United States
| | - Allan D Levi
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - W Dalton Dietrich
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - James D Guest
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
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Santamaría AJ, Benavides FD, DiFede DL, Khan A, Pujol MV, Dietrich WD, Marttos A, Green BA, Hare JM, Guest JD. Clinical and Neurophysiological Changes after Targeted Intrathecal Injections of Bone Marrow Stem Cells in a C3 Tetraplegic Subject. J Neurotrauma 2018; 36:500-516. [PMID: 29790404 DOI: 10.1089/neu.2018.5716] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
High-level quadriplegia is a devastating condition with limited treatment options. Bone marrow derived stem cells (BMSCs) are reported to have immunomodulatory and neurotrophic effects in spinal cord injury (SCI). We report a subject with complete C2 SCI who received three anatomically targeted intrathecal infusions of BMSCs under a single-patient expanded access investigational new drug (IND). She underwent intensive physical therapy and was followed for >2 years. At end-point, her American Spinal Injury Association Impairment Scale (AIS) grade improved from A to B, and she recovered focal pressure touch sensation over several body areas. We conducted serial neurophysiological testing to monitor changes in residual connectivity. Motor, sensory, and autonomic system testing included motor evoked potentials (MEPs), somatosensory evoked potentials (SSEPs), electromyography (EMG) recordings, F waves, galvanic skin responses, and tilt-table responses. The quality and magnitude of voluntary EMG activations increased over time, but remained below the threshold of clinically obvious movement. Unexpectedly, at 14 months post-injury, deep inspiratory maneuvers triggered respiratory-like EMG bursting in the biceps and several other muscles. This finding means that connections between respiratory neurons and motor neurons were newly established, or unmasked. We also report serial analysis of MRI, International Standards for Neurological Classification of SCI (ISNCSCI), pulmonary function, pain scores, cerebrospinal fluid (CSF) cytokines, and bladder assessment. As a single case, the linkage of the clinical and neurophysiological changes to either natural history or to the BMSC infusions cannot be resolved. Nevertheless, such detailed neurophysiological assessment of high cervical SCI patients is rarely performed. Our findings indicate that electrophysiology studies are sensitive to define both residual connectivity and new plasticity.
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Affiliation(s)
- Andrea J Santamaría
- 1 The Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida
| | - Francisco D Benavides
- 1 The Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida
| | - Darcy L DiFede
- 2 Interdisciplinary Stem Cell Institute, University of Miami, Miller School of Medicine, Miami, Florida
| | - Aisha Khan
- 2 Interdisciplinary Stem Cell Institute, University of Miami, Miller School of Medicine, Miami, Florida
| | - Marietsy V Pujol
- 2 Interdisciplinary Stem Cell Institute, University of Miami, Miller School of Medicine, Miami, Florida
| | - W Dalton Dietrich
- 1 The Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida.,3 Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida
| | - Antonio Marttos
- 4 Surgical Critical Care, University of Miami, Miller School of Medicine, Miami, Florida
| | - Barth A Green
- 3 Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida
| | - Joshua M Hare
- 2 Interdisciplinary Stem Cell Institute, University of Miami, Miller School of Medicine, Miami, Florida
| | - James D Guest
- 1 The Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida.,3 Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida
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How reliable are sympathetic skin responses in subjects with spinal cord injury? Clin Auton Res 2015; 25:117-24. [DOI: 10.1007/s10286-015-0276-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 11/20/2014] [Indexed: 11/26/2022]
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Berger MJ, Hubli M, Krassioukov AV. Sympathetic skin responses and autonomic dysfunction in spinal cord injury. J Neurotrauma 2014; 31:1531-9. [PMID: 24874269 DOI: 10.1089/neu.2014.3373] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Sympathetic skin responses (SSRs), a measure of sympathetic cholinergic sudomotor function, have been used in the assessment of autonomic dysfunction in patients with spinal cord injury (SCI). This review highlights the basic mechanisms underlying SSRs as well as their application to the SCI population. We address the utility of SSRs in assessing autonomic function, the relationship between autonomic and sensorimotor impairment, and the association between SSRs and the sequelae of autonomic dysfunction in SCI, particularly autonomic dysreflexia and orthostatic hypotension. Overall, SSRs are a rapid, convenient and non-invasive method illustrating that the severity of autonomic impairment can be independent from sensorimotor impairment. We suggest that SSRs be used in conjunction with other validated autonomic tests in order to predict or document autonomic dysfunction in SCI.
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Affiliation(s)
- Michael J Berger
- 1 Division of Physical Medicine and Rehabilitation, University of British Columbia , Vancouver
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Using sympathetic skin responses in individuals with spinal cord injury as a quantitative evaluation of motor imagery abilities. Phys Ther 2012; 92:831-40. [PMID: 22403090 DOI: 10.2522/ptj.20110351] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Motor imagery (MI) ability should be evaluated in selected individuals with spinal cord injury (SCI) who can benefit from MI training in their rehabilitation program. Electrodermal activity seems to be a reliable indicator for assessing MI ability. However, individuals with SCI have a variety of autonomic dysfunctions. OBJECTIVE This study aimed to investigate electrodermal responses (EDRs) elicited by MI. DESIGN A cost-utility analysis of EDR above and below the lesion level in individuals with complete or incomplete SCI (n = 30) versus a control group of individuals who were healthy (n = 10) was used. METHOD The EDR was recorded above and below the lesion level during MI of a drinking action. Duration, latency, and amplitude of EDR were the outcome measures. RESULTS Hand and foot EDR in the control group occurred with the same pattern and similar latencies, suggesting a common efferent sympathetic pathway to sweat glands of the hand and foot mediating a sympathetic skin response. Individuals with SCI elicited responses above the lesion level. The EDR amplitude was correlated to the lesion level and autonomic dysreflexia history. No foot response was recorded in individuals with complete cervical and thoracic motor lesions. Foot response with a lower amplitude and higher latency occurred in participants with incomplete motor lesion, suggesting a link between the descending motor pathway and sympathetic function. LIMITATIONS The small sample of individuals with incomplete SCI limits the generalization of the results obtained at the foot site. CONCLUSIONS Electrodermal response above the lesion level may be a reliable index for assessing MI ability in individuals with SCI. It is a noninvasive, user-friendly method for clinicians to consider before enrolling individuals in MI training.
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West CR, Mills P, Krassioukov AV. Influence of the neurological level of spinal cord injury on cardiovascular outcomes in humans: a meta-analysis. Spinal Cord 2012; 50:484-92. [DOI: 10.1038/sc.2012.17] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Clinical neurophysiology in the prognosis and monitoring of traumatic spinal cord injury. HANDBOOK OF CLINICAL NEUROLOGY 2012; 109:63-75. [PMID: 23098706 DOI: 10.1016/b978-0-444-52137-8.00004-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Preclinical studies for the repair of spinal cord injury (SCI) and potential therapies for accessing the inherent plasticity of the central nervous system (CNS) to promote recovery of function are currently moving into the translational stage. These emerging clinical trials of therapeutic interventions for the repair of SCI require improved assessment techniques and quantitative outcome measures to supplement the American Spinal Injuries Association (ASIA) Impairment Scales. This chapter attempts to identify those electrophysiological techniques that show the most promise for provision of objective and quantitative measures of sensory, motor, and autonomic function in SCI. Reviewed are: (1) somatosensory evoked potentials, including dermatomal somatosensory evoked potentials, and the electrical perceptual threshold as tests of the dorsal (posterior) column pathway; (2) laser evoked potentials and contact heat evoked potentials as tests of the anterior spinothalamic tract; (3) motor evoked potentials in limb muscles, in response to transcranial magnetic stimulation of the motor cortex as tests of the corticospinal tract, and the application of the technique to assessment of trunk and sphincter muscles; and (4) the sympathetic skin response as a test of spinal cord access to the sympathetic chain.
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Previnaire JG, Soler JM, Leclercq V, Denys P. Severity of autonomic dysfunction in patients with complete spinal cord injury. Clin Auton Res 2011; 22:9-15. [DOI: 10.1007/s10286-011-0132-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 06/08/2011] [Indexed: 01/07/2023]
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Prévinaire JG, Mathias CJ, El Masri W, Soler JM, Leclercq V, Denys P. The isolated sympathetic spinal cord: Cardiovascular and sudomotor assessment in spinal cord injury patients: A literature survey. Ann Phys Rehabil Med 2010; 53:520-32. [PMID: 20797928 DOI: 10.1016/j.rehab.2010.06.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 06/21/2010] [Accepted: 06/29/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To present a comprehensive approach to the assessment of the severity of the autonomic lesion in spinal cord injury (SCI) patients, with regard to the level of lesion. To discuss how to assess an isolated sympathetic spinal cord that has lost supraspinal control (sympathetically complete lesion). METHOD PubMed was searched for articles related to cardiovascular (mainly cold pressor test, respiratory and postural challenges) and sudomotor (sympathetic skin responses) tests that have been used. The results of these evaluations are analysed with regard to the site of stimulation (above or below the lesion) according to three types of SCI that offer typical autonomic reactions (tetraplegics, paraplegics at T6 and at T10). RESULTS Non-invasive cardiovascular and sudomotor testing allows the assessment of the isolated sympathetic spinal cord in SCI patients. Typical responses are found in relation with the level of the sympathetic lesion. Its definition would allow comparison with the somatic motor and sensory level of lesion of SCI patients and provide additional aid to the classification of those patients. CONCLUSION For research purposes on the integrity of the spinal sympathetic pathways, a battery of test approach is probably needed, using a combination of stimuli above and below the lesion, evaluating both cardiovascular and sudomotor pathways.
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Affiliation(s)
- J G Prévinaire
- Département médullaire, centre Calvé, fondation Hopale, 62600 Berck-sur-Mer, France.
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Neuropathic bladder dysfunction in patients with motor complete and sensory incomplete spinal cord lesion. Spinal Cord 2008; 46:673-8. [DOI: 10.1038/sc.2008.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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