Reliability and repeatability of the motor and sensory examination of the international standards for neurological classification of spinal cord injury

Outcome measures in rodent models for spinal cord injury and their human correlates

Pre-clinical research is intended to inform clinical research, however, communication between these researchers is lacking. A better understanding of what can be learned from animal and human models and what cannot, is essential. This includes a better understanding of where underlying constructs in outcome measures in rodents and humans align and where they diverge to improve dialogue between human and animal researchers. The goal of this review is to promote an understanding of similarities and differences in outcome measures and encourage consideration of these differences when planning, interpreting, and communicating findings from animal or human experiments. Seven individuals with a range of expertise in human and animal research and outcome measures reviewed rat and human measures focused on sensorimotor and functional outcomes. They then discussed where measures corresponded and where they did not, based on the underlying construct the assessment is intended to measure. Key findings are that measures of impairment (such as strength) often used in clinical trials are not commonly used in rodents. Measures such as speed and distance of locomotion are commonly assessed in humans and, while not commonly assessed in rodents, can be collected through existing outcome measures. Additional findings are that animal and human outcome measures are often developed and evaluated differently, with more standardized processes applied to human outcome measures. A deeper understanding and communication of similarities and differences in outcome measures, and where differences are necessary due to interspecies differences, may improve translation from animals to humans and humans to animals.

The diagnostic and prognostic capability of artificial intelligence in spinal cord injury: A systematic review

Background

Artificial intelligence (AI) models have shown potential for diagnosing and prognosticating traumatic spinal cord injury (tSCI), but their clinical utility remains uncertain.

Method

ology: The primary aim was to evaluate the performance of AI algorithms in diagnosing and prognosticating tSCI. Subsequent systematic searching of seven databases identified studies evaluating AI models. PROBAST and TRIPOD tools were used to assess the quality and reporting of included studies (PROSPERO: CRD42023464722). Fourteen studies, comprising 20 models and 280,817 pooled imaging datasets, were included. Analysis was conducted in line with the SWiM guidelines.

Results

For prognostication, 11 studies predicted outcomes including AIS improvement (30%), mortality and ambulatory ability (20% each), and discharge or length of stay (10%). The mean AUC was 0.770 (range: 0.682-0.902), indicating moderate predictive performance. Diagnostic models utilising DTI, CT, and T2-weighted MRI with CNN-based segmentation achieved a weighted mean accuracy of 0.898 (range: 0.813-0.938), outperforming prognostic models.

Conclusion

AI demonstrates strong diagnostic accuracy (mean accuracy: 0.898) and moderate prognostic capability (mean AUC: 0.770) for tSCI. However, the lack of standardised frameworks and external validation limits clinical applicability. Future models should integrate multimodal data, including imaging, patient characteristics, and clinician judgment, to improve utility and alignment with clinical practice.

The Role of Maladaptive Plasticity in Modulating Pain Pressure Threshold Post-Spinal Cord Injury

BACKGROUND

Spinal cord injury (SCI) frequently leads to pain, leading to significant disability. Pain sensitization, a key feature of SCI, is commonly assessed via quantitative sensory testing like the Pressure Pain Threshold (PPT), though the factors influencing PPT changes remain unclear. This study hypothesizes that specific clinical and neurophysiological factors modulate PPT in SCI patients. The primary objective is to identify predictors of PPT in SCI patients.

METHODS

We conducted a cross-sectional analysis of neurophysiological, clinical, and demographic data from 102 SCI patients in an ongoing prospective cohort study called "Deficit of Inhibition as a Marker of Neuroplasticity" (DEFINE study). Multivariable regression analyses were used to evaluate demographic, clinical, and functional variables associated with PPT, the primary outcome measure.

RESULTS

The sample comprised 87.9% males with an average age of 41. Trauma was the leading cause of SCI (77.45%), predominantly affecting the cervical and thoracic levels. Pain was reported by 44% of participants, and the mean PPT was 8.3 kPa, measured bilaterally. Multivariate analysis of PPT in the left, right, and bilateral thenar regions revealed consistent trends. Significant negative associations were found between bilateral PPT and low beta EEG frequency in the central area (β = -14.94, p = 0.017), traumatic lesion etiology (β = -1.99, p = 0.038), and incomplete lesions by the American Spinal Injury Association classification (β = -1.68, p = 0.012). In contrast, positive associations were observed with age (β = 0.08, p < 0.001).

CONCLUSIONS

Our findings show that increased beta oscillations and traumatic brain injury having a lower PPT indicate that factors associated with maladaptive plasticity are associated with decreased and likely less functional PPT. On the other hand, increased motor function may help to regulate PPT in a more functional status.

Perfusion imaging metrics after acute traumatic spinal cord injury are associated with injury severity in rats and humans

Traumatic spinal cord injury (tSCI) causes an immediate loss of neurological function, and the prediction of recovery is difficult in the acute phase. In this study, we used contrast-enhanced ultrasound imaging to quantify intraspinal vascular disruption acutely after tSCI. In a rodent thoracic tSCI model, contrast-enhanced ultrasound revealed a perfusion area deficit that was positively correlated with injury severity and negatively correlated with hindlimb locomotor function at 8 weeks after injury. The spinal perfusion index was calculated by normalizing the contrast inflow at the injury center to the contrast inflow in the injury periphery. The spinal perfusion index decreased with increasing injury severity and positively correlated with hindlimb locomotor function at 8 weeks after injury. The feasibility of intraoperative contrast-enhanced ultrasound imaging was further tested in a cohort of 27 patients with acute tSCI of varying severity and including both motor-complete and motor-incomplete tSCIs. Both the perfusion area deficit and spinal perfusion index were different between motor-complete and motor-incomplete patients. Moreover, the perfusion area deficit and spinal perfusion index correlated with the injury severity at intake and exhibited a correlation with extent of functional recovery at 6 months. Our data suggest that intraoperative contrast-enhanced, ultrasound-derived metrics are correlated with injury severity and chronic functional outcome after tSCI. Larger clinical studies are required to better assess the reliability of the proposed contrast-enhanced ultrasound biomarkers and their prognostic capacity.

Incidence and etiology of traumatic spinal cord injury in Rwanda: a prospective population-based study

Background

Traumatic spinal cord injury (TSCI) is not only a life-threatening but also life changing event that happens suddenly, the effects extends beyond the TSCI survivors to include their families. In Rwanda to the best knowledge of authors, there is no published information on the epidemiology of TSCI. The aim of this study was therefore to determine the incidence rate, etiology and injury characteristics of TSCI.

Methods

All survivors of acute TSCI who met the inclusion criteria were prospectively recruited for a one-year period. The International Spinal Cord Injury Core Data Set was used to collect the minimum set of variables to facilitate worldwide comparison of epidemiological data, while the International Standards for the Neurological Classification was used to categorize TSCI according to the American Spinal Injury Association Impairment Scale (AIS). Data were collected by trained physiotherapists.

Study design

A prospective, open-ended, cohort study design.

Setting

All referral hospitals within the Republic of Rwanda.

Results

Overall, 122 adult individuals sustained a TSCI between 10th October 2019 until 9th October 2020 and all consented to take part in the study. The male-to-female ratio was 3.9:1, and the mean age was 42.5 (SD = ±14.8) years. The crude incidence rate of TSCI was 22.2 per million people (95% CI, 18.4-26.5) with significant differences in sex-adjusted rates for all age groups while men 46 years of age and older presented with the highest incidence. The leading causes of TSCI were falls (73.8%), followed by road traffic accidents (18.9%). Moreover, SCI lesions of the cervical region (n = 69) were the most common, followed by the lumbosacral region (n = 27). Fifty-one (41.8%) participants were diagnosed as complete injury, i.e., AIS A, while incomplete injury category C constituted 35 (28.7%).

Conclusion

The incidence and etiology of TSCI in Rwanda are comparable to worldwide estimates and figures. Largely, the etiology of TSCI are preventable as it is caused due to falls and road traffic accidents. There is a need to consider preventive strategies and policies on activities that predispose people to falls. Policies should focus largely on occupational health and safety in both formal and informal sectors of work.

Value of the Brain and Spinal Injury Center Score in Assessment and Prognosis of Acute Traumatic Spinal Cord Injury

The objective was to assess the severity of neurological injury in acute traumatic spinal cord injury (ATSCI) using the BASIC (Brain and Spinal Injury Center) score, to correlate with the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade at admission and at 3 months postinjury in patients managed for ATSCI at National Hospital, Abuja, and thereby validate the novel BASIC score. This was a prospective longitudinal hospital-based study involving consecutive patients diagnosed with ATSCI and managed at the National Hospital, Abuja. Sixty-five participants met the inclusion criteria. Each patient was resuscitated along the Advanced Trauma Life Support protocol, followed by history, neurological examination according to the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI), and AIS grades that were recorded. Magnetic resonance imaging scan of the injured spinal cord was done, and BASIC scores were assigned. Further management was as per the standard. Three months after injury, neurological examination was again carried out based on ISNCSCI and AIS grades assigned. Data were collected, analyzed, and correlated using Excel and SPSS version 23. Means, medians, correlation coefficients, and Fisher's exact t-tests were determined. p-Value <0.05 was considered statistically significant. Results show mean age was 39.1 ± 12.3 years. The majority (81.5%) were males, whereas 18.5% were females. The majority (67.7%) were skilled professionals, 13.8% were unskilled, and 18.5% were students. Most injuries (90.8%) were due to road traffic accidents, whereas 9.2% were due to falls. Majority (72.3%) of the patients had complete SCI (AIS grade A), whereas AIS grade E accounted for the least number (3.1%). Cervical spine injury affected 92.3% of patients, whereas 7.7% had thoracic spine injury. Most patients had BASIC 4 pattern on MRI (44.6%), whereas BASIC 1 pattern was the fewest (3.1%). Surgery was not done for 58.5% of patients, whereas 41.5% had surgical decompression and spine fusion. At 3 months postinjury, 15.4% of patients had AIS grade improvement, whereas 84.6% maintained their AIS grade. The largest AIS grade improvement was from grade B to C (6.2%), which was statistically significant (p = 0.04). BASIC score correlated moderately with admission AIS grade (p = 0.532). BASIC score also correlated moderately with AIS grade at 3 months postinjury (p = 0.546). BASIC score 4 was best at predicting poor outcome in ATSCI. In conclusion, BASIC score has a moderate correlation with AIS grade in ATSCI and can predict poor outcomes in ATSCI. BASIC score of 4 has the best discriminant value in prognosticating and represents severe SCI.

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

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.

Dysregulated neural activity between the thalamus and cerebral cortex mediates cortical reorganization in cervical spondylotic myelopathy

Neuroimaging research has revealed significant changes in brain structure and function in patients with cervical spondylotic myelopathy(CSM). The thalamus plays a crucial role in this process, although its mechanisms of action remain incompletely understood. This study aimed to investigate whether spinal cord compression leads to alterations in the functional connectivity between the thalamus and the cerebral cortex, and to determine if such changes are associated with structural and functional remodeling of the brain in patients with CSM, and to identify potential neuroimaging biomarkers for classification. The study included 40 patients with CSM and 34 healthy controls(HCs) who underwent resting-state functional magnetic resonance imaging(fMRI) and structural MRI scans. Brain structural and functional metrics were quantified using functional connectivity(FC), fractional amplitude of low-frequency fluctuations(fALFF), surface-based morphometry(SBM), and independent component analysis(ICA) based on functional and structural MRI. Patients with CSM exhibited significantly reduced fALFF in the bilateral lateral lingual gyrus, bilateral calcarine fissure, left precentral gyrus and postcentral gyrus, left middle and superior occipital gyrus, left superior marginal gyrus, left inferior parietal gyrus, and right Rolandic operculum. ICA results revealed weakened functional connectivity between the sensorimotor network (SMN) and the left and right frontoparietal network(FPN), and lateral visual network (lVN), along with decreased connectivity between lVN and rFPN, and increased connectivity between lFPN and rFPN. Patients with CSM also had decreased sulcus depth in the bilateral insula, left precentral and postcentral gyrus, and right lingual gyrus and calcarine fissure. Furthermore, cervical spondylotic myelopathy patients showed decreased functional connectivity between the left ventral posterolateral nucleus (VPL) of the thalamus and the right middle occipital gyrus (MOG). Finally,multimodal neuroimaging with support vector machine(SVM) classified patients with CSM and healthy controls with 86.00% accuracy. Our study revealed that the decrease in functional connectivity between the thalamus and cortex mediated by spinal cord compression leads to structural and functional reorganization of the cortex. Features based on neuroimaging markers have the potential to become neuroimaging biomarkers for CSM.

A future blood test for acute traumatic spinal cord injury

Acute spinal cord injury (SCI) requires prompt diagnosis and intervention to minimize the risk of permanent neurologic deficit. Presently, SCI diagnosis and interventional planning rely on magnetic resonance imaging (MRI), which is not always available or feasible for severely injured patients. Detection of disease-specific biomarkers in biofluids via liquid biopsy may provide a more accessible and objective means of evaluating patients with suspected SCI. Cell-free DNA, which has been used for diagnosing and monitoring oncologic disease, may detect damage to spinal cord neurons via tissue-specific methylation patterns. Other types of biomarkers, including proteins and RNA species, have also been found to reflect neuronal injury and may be included as part of a multi-analyte assay to improve liquid biopsy performance. The feasibility of implementing liquid biopsy into current practices of SCI management is supported by the relative ease of blood sample collection as well as recent advancements in droplet digital polymerase chain reaction technology. In this review, we detail the current landscape of biofluid biomarkers for acute SCI and propose a framework for the incorporation of a putative blood test into the clinical management of SCI.

A data-driven approach to categorize patients with traumatic spinal cord injury: cluster analysis of a multicentre database

Background

Conducting clinical trials for traumatic spinal cord injury (tSCI) presents challenges due to patient heterogeneity. Identifying clinically similar subgroups using patient demographics and baseline injury characteristics could lead to better patient-centered care and integrated care delivery.

Purpose

We sought to (1) apply an unsupervised machine learning approach of cluster analysis to identify subgroups of tSCI patients using patient demographics and injury characteristics at baseline, (2) to find clinical similarity within subgroups using etiological variables and outcome variables, and (3) to create multi-dimensional labels for categorizing patients.

Study design

Retrospective analysis using prospectively collected data from a large national multicenter SCI registry.

Methods

A method of spectral clustering was used to identify patient subgroups based on the following baseline variables collected since admission until rehabilitation: location of the injury, severity of the injury, Functional Independence Measure (FIM) motor, and demographic data (age, and body mass index). The FIM motor score, the FIM motor score change, and the total length of stay were assessed on the subgroups as outcome variables at discharge to establish the clinical similarity of the patients within derived subgroups. Furthermore, we discussed the relevance of the identified subgroups based on the etiological variables (energy and mechanism of injury) and compared them with the literature. Our study also employed a qualitative approach to systematically describe the identified subgroups, crafting multi-dimensional labels to highlight distinguishing factors and patient-focused insights.

Results

Data on 334 tSCI patients from the Rick Hansen Spinal Cord Injury Registry was analyzed. Five significantly different subgroups were identified (p-value ≤0.05) based on baseline variables. Outcome variables at discharge superimposed on these subgroups had statistically different values between them (p-value ≤0.05) and supported the notion of clinical similarity of patients within each subgroup.

Conclusion

Utilizing cluster analysis, we identified five clinically similar subgroups of tSCI patients at baseline, yielding statistically significant inter-group differences in clinical outcomes. These subgroups offer a novel, data-driven categorization of tSCI patients which aligns with their demographics and injury characteristics. As it also correlates with traditional tSCI classifications, this categorization could lead to improved personalized patient-centered care.

Assessing walking ability using a robotic gait trainer: opportunities and limitations of assist-as-needed control in spinal cord injury

BACKGROUND

Walking impairments are a common consequence of neurological disorders and are assessed with clinical scores that suffer from several limitations. Robot-assisted locomotor training is becoming an established clinical practice. Besides training, these devices could be used for assessing walking ability in a controlled environment. Here, we propose an adaptive assist-as-needed (AAN) control for a treadmill-based robotic exoskeleton, the Lokomat, that reduces the support of the device (body weight support and impedance of the robotic joints) based on the ability of the patient to follow a gait pattern displayed on screen. We hypothesize that the converged values of robotic support provide valid and reliable information about individuals' walking ability.

METHODS

Fifteen participants with spinal cord injury and twelve controls used the AAN software in the Lokomat twice within a week and were assessed using clinical scores (10MWT, TUG). We used a regression method to identify the robotic measure that could provide the most relevant information about walking ability and determined the test-retest reliability. We also checked whether this result could be extrapolated to non-ambulatory and to unimpaired subjects.

RESULTS

The AAN controller could be used in patients with different injury severity levels. A linear model based on one variable (robotic knee stiffness at terminal swing) could explain 74% of the variance in the 10MWT and 61% in the TUG in ambulatory patients and showed good relative reliability but poor absolute reliability. Adding the variable 'maximum hip flexor torque' to the model increased the explained variance above 85%. This did not extend to non-ambulatory nor to able-bodied individuals, where variables related to stance phase and to push-off phase seem more relevant.

CONCLUSIONS

The novel AAN software for the Lokomat can be used to quantify the support required by a patient while performing robotic gait training. The adaptive software might enable more challenging training conditions tuned to the ability of the individuals. While the current implementation is not ready for assessment in clinical practice, we could demonstrate that this approach is safe, and it could be integrated as assist-as-needed training, rather than as assessment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02425332.

Predicting Outdoor Walking 1 Year After Spinal Cord Injury: A Retrospective, Multisite External Validation Study

BACKGROUND AND PURPOSE

Predicting future outdoor walking ability after spinal cord injury (SCI) is important, as this is associated with community engagement and social participation. A clinical prediction rule (CPR) was derived for predicting outdoor walking 1 year after SCI. While promising, this CPR has not been validated, which is necessary to establish its clinical value. The objective of this study was to externally validate the CPR using a multisite dataset.

METHODS

This was a retrospective analysis of US SCI Model Systems data from 12 centers. L3 motor score, L5 motor score, and S1 sensory score were used as predictor variables. The dataset was split into testing and training datasets. The testing dataset was used as a holdout dataset to provide an unbiased estimate of prediction performance. The training dataset was used to determine the optimal CPR threshold through a "leave-one-site-out" cross-validation framework. The primary outcome was self-reported outdoor walking ability 1 year after SCI.

RESULTS

A total of 3721 participants' data were included. Using the optimal CPR threshold (CPR ≥ 33 threshold value), we were able to predict outdoor walking 1 year with high cross-validated accuracy and prediction performance. For the entire dataset, area under receiver operator characteristic curve was 0.900 (95% confidence interval: 0.890-0.910; P < 0.0001).

DISCUSSION AND CONCLUSIONS

The outdoor walking CPR has been externally validated. Future research should conduct a clinical outcomes and cost-benefit impact analysis for implementing this CPR. Our results support that clinicians may use this 3-variable CPR for prediction of future outdoor walking ability.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A411 ).

Neurological recovery after early versus delayed surgical decompression for acute traumatic spinal cord injury

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI). Patients with tSCI requiring surgical spinal decompression presenting to 17 centres in Europe were recruited. Depending on the timing of decompression, patients were divided into early (≤ 12 hours after injury) and late (> 12 hours and < 14 days after injury) groups. The American Spinal Injury Association neurological (ASIA) examination was performed at baseline (after injury but before decompression) and at 12 months. The primary endpoint was the change in Lower Extremity Motor Score (LEMS) from baseline to 12 months. The final analyses comprised 159 patients in the early and 135 in the late group. Patients in the early group had significantly more severe neurological impairment before surgical treatment. For unadjusted complete-case analysis, mean change in LEMS was 15.6 (95% confidence interval (CI) 12.1 to 19.0) in the early and 11.3 (95% CI 8.3 to 14.3) in the late group, with a mean between-group difference of 4.3 (95% CI -0.3 to 8.8). Using multiply imputed data adjusting for baseline LEMS, baseline ASIA Impairment Scale (AIS), and propensity score, the mean between-group difference in the change in LEMS decreased to 2.2 (95% CI -1.5 to 5.9). Compared to late surgical decompression, early surgical decompression following acute tSCI did not result in statistically significant or clinically meaningful neurological improvements 12 months after injury. These results, however, do not impact the well-established need for acute, non-surgical tSCI management. This is the first study to highlight that a combination of baseline imbalances, ceiling effects, and loss to follow-up rates may yield an overestimate of the effect of early surgical decompression in unadjusted analyses, which underpins the importance of adjusted statistical analyses in acute tSCI research.

Psychometric properties of light touch-pressure somatosensory measures in adults with neurological disorders: A systematic review

OBJECTIVES

To critically appraise the psychometric properties of light touch-pressure somatosensory assessments to provide guidance for tool selection for research or clinical purposes.

DATA SOURCES

MEDLINE, CINAHL, and PsycInfo were searched for research indexed from January 1990-November 2022. English language and human subject filters were applied. "Somatosensation", "psychometric property", and "nervous system-based health condition" search terms were combined. Grey literature and manual searches were conducted to ensure thoroughness.

REVIEW METHODS

The reliability, construct validity, and/or measurement error of light touch-pressure assessments was reviewed in adult populations with neurological disorders. Reviewers individually extracted and managed data including patient demographics, assessment characteristics, statistical methods, and psychometric properties. Methodological quality of results was evaluated using an adapted version of the COnsensus-based Standards for the selection of health Measurement INstruments checklist.

RESULTS

Thirty-three of 1938 articles were included for review. Fifteen light touch-pressure assessments demonstrated good or excellent reliability. Further, five of those 15 assessments achieved adequate validity and one of the 15 assessments achieved adequate measurement error. Over 80% of the summarized study ratings were determined to be of low or very low quality.

CONCLUSION

We recommend using electrical perceptual tests, the Semmes-Weinstein Monofilaments, the Graded and Redefined Assessment of Strength, Sensibility, and Prehension, and the Moving Touch Pressure Test given that they demonstrated good to excellent results in three psychometric properties. No other assessment achieved adequate ratings in more than two psychometric properties. This review highlights a fundamental need to develop sensory assessments that are reliable, valid, and sensitive to change.

Development of a Remote Version of the Graded Redefined Assessment of Strength, Sensation, and Prehension (GRASSP): Validity and Reliability

BACKGROUND

The Graded Redefined Assessment of Strength, Sensation, and Prehension (GRASSP V1.0) was developed in 2010 as a 3-domain assessment for upper extremity function after tetraplegia (domains: Strength, Sensibility, and Prehension). A remote version (rGRASSP) was created in response to the growing needs of the field of Telemedicine.

OBJECTIVE

The purpose of this study was to assess the psychometric properties of rGRASSP, establishing concurrent validity and inter-rater reliability.

METHODS

Individuals with tetraplegia (n = 61) completed 2 visits: 1 in-person and 1 remote. The first visit was completed in-person to administer the GRASSP, and the second visit was conducted remotely to administer the rGRASSP. The rGRASSP was scored both by the administrator of the rGRASSP (Examiner 1), and a second assessor (Examiner 2) to establish inter-rater reliability. Agreement between the in-person and remote GRASSP evaluations was assessed using the intraclass correlation coefficient (ICC) and Bland-Altman agreement plots.

RESULTS

The remote GRASSP demonstrated excellent concurrent validity with the GRASSP (left hand intraclass correlation coefficient (ICC) = .96, right ICC = .96). Concurrent validity for the domains was excellent for strength (left ICC = .96, right ICC = .95), prehension ability (left ICC = .94, right ICC = .95), and prehension performance (left ICC = .92, right ICC = .93), and moderate for sensibility (left ICC = .59, right ICC = .68). Inter-rater reliability for rGRASSP total score was high (ICC = .99), and remained high for all 4 domains. Bland-Altman plots and limits of agreements support these findings.

CONCLUSIONS

The rGRASSP shows strong concurrent validity and inter-rater reliability, providing a psychometrically sound remote assessment for the upper extremity in individuals with tetraplegia.

Derivation and Validation of a Clinical Prediction Rule for Upper Limb Functional Outcomes After Traumatic Cervical Spinal Cord Injury

IMPORTANCE

Traumatic cervical spinal cord injury (SCI) can result in debilitating paralysis. Following cervical SCI, accurate early prediction of upper limb recovery can serve an important role in guiding the appropriateness and timing of reconstructive therapies.

OBJECTIVE

To develop a clinical prediction rule to prognosticate upper limb functional recovery after cervical SCI.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study was a retrospective review of a longitudinal cohort study including patients enrolled in the National SCI model systems (SCIMS) database in US. Eligible patients were 15 years or older with tetraplegia (neurological level of injury C1-C8, American Spinal Cord Injury Association [ASIA] impairment scale [AIS] A-D), with early (within 1 month of SCI) and late (1-year follow-up) clinical examinations from 2011 to 2016. The data analysis was conducted from September 2021 to June 2022.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of dependency in eating, bladder management, transfers, and locomotion domains of functional independence measure at 1-year follow-up. Each domain ranges from 1 to 7 with a lower score indicating greater functional dependence. Composite dependency was defined as a score of 4 or higher in at least 3 chosen domains. Multivariable logistic regression was used to predict the outcome based on early neurological variables. Discrimination was quantified using C statistics, and model performance was internally validated with bootstrapping and 10-fold cross-validation. The performance of the prediction score was compared with AIS grading. Data were split into derivation (2011-2014) and temporal-validation (2015-2016) cohorts.

RESULTS

Among 2373 patients with traumatic cervical SCI, 940 had complete 1-year outcome data (237 patients [25%] aged 60 years or older; 753 men [80%]). The primary outcome was present in 118 patients (13%), which included 92 men (78%), 83 (70%) patients who were younger than 60 years, and 73 (62%) patients experiencing AIS grade A SCI. The variables significantly associated with the outcome were age (age 60 years or older: OR, 2.31; 95% CI, 1.26-4.19), sex (men: OR, 0.60; 95% CI, 0.31-1.17), light-touch sensation at C5 (OR, 0.44; 95% CI, 0.44-1.01) and C8 (OR, 036; 95% CI, 0.24-0.53) dermatomes, and motor scores of the elbow flexors (C5) (OR, 0.74; 95% CI, 0.60-0.89) and wrist extensors (C6) (OR, 0.61; 95% CI, 0.49-0.75). A multivariable model including these variables had excellent discrimination in distinguishing dependent from independent patients in the temporal-validation cohort (C statistic, 0.90; 95% CI, 0.88-0.93). A clinical prediction score (range, 0 to 45 points) was developed based on these measures, with higher scores increasing the probability of dependency. The discrimination of the prediction score was significantly higher than from AIS grading (change in AUC, 0.14; 95% CI, 0.10-0.18; P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that this prediction rule may help prognosticate upper limb function following cervical SCI. This tool can be used to set patient expectations, rehabilitation goals, and aid decision-making regarding the appropriateness and timing for upper limb reconstructive surgeries.

A phase 1/2a dose-escalation study of oligodendrocyte progenitor cells in individuals with subacute cervical spinal cord injury

OBJECTIVE

The primary objective of this study was to evaluate the safety of 3 escalating doses of oligodendrocyte progenitor cells (LCTOPC1; previously known as GRNOPC1 and AST-OPC1) administered at a single time point between 21 and 42 days postinjury to participants with subacute cervical spinal cord injuries (SCIs). The secondary objective was to evaluate changes in neurological function following administration of LCTOPC1.

METHODS

This study was designed as an open-label, dose-escalation, multicenter clinical trial. Twenty-five participants with C4-7 American Spinal Injury Association Impairment Scale grade A or B injuries received a single dose of either 2 × 106, 1 × 107, or 2 × 107 LCTOPC1 delivered via intraparenchymal injection into the spinal cord at the site of injury using a custom-designed syringe positioning device. Low-dose tacrolimus was administered until day 60. Outcome measures included adverse event (AE) monitoring and neurological function as measured by the International Standards for Neurological Classification of Spinal Cord Injury.

RESULTS

All 25 participants experienced at least one AE, with a total of 534 AEs (32 study-related vs 502 study-unrelated anticipated complications of SCI) reported at the completion of 1-year follow-up. There were 29 serious AEs reported. Two grade 3 serious AEs (CSF leak in one participant and a bacterial infection in another) were considered related to the injection procedure and to immunosuppression with tacrolimus, respectively. The CSF leakage resolved with sequelae, including self-limited altered mental status, and the infection resolved with antibiotic therapy. For all participants, MRI scans demonstrated no evidence of an enlarging mass, spinal cord damage related to the injection procedure, inflammatory lesions in the spinal cord, or masses in the ventricular system. At 1-year follow-up, 21/22 (96%) of the intention-to-treat group recovered one or more levels of neurological function on at least one side of their body, and 7/22 (32%) recovered two or more levels of neurological function on at least one side of their body.

CONCLUSIONS

LCTOPC1 can be safely administered to participants in the subacute period after cervical SCI. The injection procedure, low-dose temporary immunosuppression regimen, and LCTOPC1 were well tolerated. The safety and neurological function data support further investigation to determine the efficacy of LCTOPC1 in the treatment of SCI. Clinical trial registration no.: NCT02302157 (ClinicalTrials.gov).

Limb accelerations during sleep are related to measures of strength, sensation, and spasticity among individuals with spinal cord injury

BACKGROUND

To evaluate the relationship between measures of neuromuscular impairment and limb accelerations (LA) collected during sleep among individuals with chronic spinal cord injury (SCI) to provide evidence of construct and concurrent validity for LA as a clinically meaningful measure.

METHODS

The strength (lower extremity motor score), sensation (summed lower limb light touch scores), and spasticity (categorized lower limb Modified Ashworth Scale) were measured from 40 adults with chronic (≥ 1 year) SCI. Demographics, pain, sleep quality, and other covariate or confounding factors were measured using self-report questionnaires. Each participant then wore ActiGraph GT9X Link accelerometers on their ankles and wrist continuously for 1-5 days to measure LA from movements during sleep. Regression models with built-in feature selection were used to determine the most relevant LA features and the association to each measure of impairment.

RESULTS

LA features were related to measures of impairment with models explaining 69% and 73% of the variance (R²) in strength and sensation, respectively, and correctly classifying 81.6% (F1-score = 0.814) of the participants into spasticity categories. The most commonly selected LA features included measures of power and frequency (frequency domain), movement direction (correlation between axes), consistency between movements (relation to recent movements), and wavelet energy (signal characteristics). Rolling speed (change in angle of inclination) and movement smoothness (median crossings) were uniquely associated with strength. When LA features were included, an increase of 72% and 222% of the variance was explained for strength and sensation scores, respectively, and there was a 34% increase in spasticity classification accuracy compared to models containing only covariate features such as demographics, sleep quality, and pain.

CONCLUSION

LA features have shown evidence of having construct and concurrent validity, thus demonstrating that LA are a clinically-relevant measure related to lower limb strength, sensation, and spasticity after SCI. LA may be useful as a more detailed measure of impairment for applications such as clinical prediction models for ambulation.

The Correlation between Cervical Fusion Length and Functional Outcomes in Patients with Traumatic Spinal Cord Damage-A Registry-Based Cohort Study

This study aims to assess if there is an evident correlation between fusion length and rehabilitation success after trauma to the cervical spine that could potentially be used to predict functional outcomes. This monocentric study was conducted in the Spinal-Cord-Injury center of the Berufsgenossenschaftliches Klinikum Hamburg. Data sets of 199 patients from the Spinal-Cord-Injury center admitted between the beginning of 2003 and the end of 2018 were subjected to statistical analyses. The Spinal Cord Independence Measure II (SCIM II) difference between admission and discharge was chosen as the primary outcome variable of a multiple linear regression analysis, including several other variables. The length of fusion, SCIM at admission and the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) values at admission could be identified as significant predictors. The cervical fusion length could be identified as an independent predictor of the functional outcome within our model. This correlation most likely mediates for the range of motion as well as partly for injury severity. This is much harder to evaluate in a newly admitted rehabilitation patient than a single numerical value that represents its rehabilitative implications, such as fusion length. Together with an initial assessment of the SCIM and ISNCSCI, it provides a solid basis for outcome prediction.

Accuracy of self-reported severity and level of spinal cord injury

Study design

Observational.

Objectives

To assess accuracy of self-reported level of injury (LOI) and severity in individuals with chronic spinal cord injury (SCI) as compared with clinical examination.

Setting

An SCI Model System Hospital.

Methods

A 20-item survey evaluated demographics, physical abilities, and self-reported injury level and severity. A decision tree algorithm used responses to categorize participants into injury severity groups. Following the survey, participants underwent clinical examination to determine current injury level and severity. Participants were later asked three questions regarding S1 sparing. Chart abstraction was utilized to obtain initial injury level and severity. Injury level and severity from self-report, decision tree, clinical exam, and chart abstraction were compared.

Results

Twenty-eight individuals participated. Ninety-three percent correctly self-reported anatomical region of injury (ROI). Self-report of specific LOI matched current clinical LOI for 25% of participants, but matched initial LOI for 61%. Self-report of ASIA Impairment Scale (AIS) matched clinical AIS for 36%, but matched initial AIS for 46%. The injury severity decision tree was 75% accurate without, but 79% accurate with additional S1 questions. Self-report of deep anal pressure (DAP) was correct for 86% of participants, while self-report of voluntary anal contraction (VAC) was correct for 82%.

Conclusion

Individuals with SCI are more accurate reporting ROI than specific LOI. Self-reported injury level and severity align more closely with initial clinical examination results than current exam results. Using aggregate data from multiple questions can categorize injury severity more reliably than self-report. Using this type of decision tree may improve injury severity classification in large survey studies.

Analysis of temperaturepain sensitivity in patients with consequences of the cervical spinal cord injury

Background. The standard neurological assessment in patients with long-term consequences of spine-and-spinal cord injury and severe neurological deficit does not allow to accurately identify changes in sensitivity that determine the level, degree and nature of spinal cord injury, as well as to evaluate the minimal dynamics of these disorders with different treatment options. As a result, an objective instrumental assessment of the sensory sphere in the long-term period of spinal cord injury has not lost its relevance.The aim. To conduct an instrumental study of the temperature-pain sensitivity condition in patients with partial gross damage to the cervical spinal cord in the long-term period of the disease (type B on the ASIA scale).Methods. We examined 23 patients with consequences of vertebral fractures of the cervical spine in the late period of traumatic spinal cord disease, Grade B on the ASIA scale ASIA. The clinical analysis of sensitive disorders was performed according to ISNCSCI and ASIA scales. While studying the temperature-pain sensitivity the threshold of thermal sensitivity and the threshold of pain from hot were determined in СIV–SI dermatomes on the right and on the left using an electricesthesiometer.Results. The examined patients had hypesthesia of heat and pain sensitivity, hyperesthesia of pain sensitivity, thermoanesthesia and thermoanalgesia. The degree of changes in the temperature-pain sensitivity depended on the topographic localization of dermatomes. The more distally the study area was located from the level of damage, the more pronounced the disorders were. In 30.4 % of patients, the pain sensitivity from hot in the chain of dermatomes from CIV to SI was preserved on at least one side. The combination of thermoanesthesia with thermoanalgesia was observed in 69.6 % of cases in dermatomes with ThVII and distally.Conclusions. The instrumentally registered level of the temperature-pain sensitivity disorder did not correspond to clinically determined localization of sensory disorders. The range of discrepancy ranged from 2 to 12 dermatomes, with defining the sensitivity subclinical deficit over the area of clinical sensory disorders.

Quantitative electrophysiological assessments as predictive markers of lower limb motor recovery after spinal cord injury: a pilot study with an adaptive trial design

STUDY DESIGN

Observational, cohort study.

OBJECTIVES

(1) Determine the feasibility and relevance of assessing corticospinal, sensory, and spinal pathways early after traumatic spinal cord injury (SCI) in a rehabilitation setting. (2) Validate whether electrophysiological and magnetic resonance imaging (MRI) measures taken early after SCI could identify preserved neural pathways, which could then guide therapy.

SETTING

Intensive functional rehabilitation hospital (IFR).

METHODS

Five individuals with traumatic SCI and eight controls were recruited. The lower extremity motor score (LEMS), electrical perceptual threshold (EPT) at the S2 dermatome, soleus (SOL) H-reflex, and motor evoked potentials (MEPs) in the tibialis anterior (TA) muscle were assessed during the stay in IFR and in the chronic stage (>6 months post-SCI). Control participants were only assessed once. Feasibility criteria included the absence of adverse events, adequate experimental session duration, and complete dataset gathering. The relationship between electrophysiological data collected in IFR and LEMS in the chronic phase was studied. The admission MRI was used to calculate the maximal spinal cord compression (MSCC).

RESULTS

No adverse events occurred, but a complete dataset could not be collected for all subjects due to set-up configuration limitations and time constraints. EPT measured at IFR correlated with LEMS in the chronic phases (r = -0.67), whereas SOL H/M ratio, H latency, MEPs and MSCC did not.

CONCLUSIONS

Adjustments are necessary to implement electrophysiological assessments in an IFR setting. Combining MRI and electrophysiological measures may lead to better assessment of neuronal deficits early after SCI.

Phase 1 Safety Trial of Autologous Human Schwann Cell Transplantation in Chronic Spinal Cord Injury

A phase 1 open-label, non-randomized clinical trial was conducted to determine feasibility and safety of autologous human Schwann cell (ahSC) transplantation accompanied by rehabilitation in participants with chronic spinal cord injury (SCI). Magnetic resonance imaging (MRI) was used to screen eligible participants to estimate an individualized volume of cell suspension to be implanted. The trial incorporated standardized multi-modal rehabilitation before and after cell delivery. Participants underwent sural nerve harvest, and ahSCs were isolated and propagated in culture. The dose of culture-expanded ahSCs injected into the chronic spinal cord lesion of each individual followed a cavity-filling volume approach. Primary outcome measures for safety and trend-toward efficacy were assessed. Two participants with American Spinal Injury Association Impairment Scale (AIS) A and two participants with incomplete chronic SCI (AIS B, C) were each enrolled in cervical and thoracic SCI cohorts (n = 8 total). All participants completed the study per protocol, and no serious adverse events related to sural nerve harvest or ahSC transplantation were reported. Urinary tract infections and skin abrasions were the most common adverse events reported. One participant experienced a 4-point improvement in motor function, a 6-point improvement in sensory function, and a 1-level improvement in neurological level of injury. Follow-up MRI in the cervical (6 months) and thoracic (24 months) cohorts revealed a reduction in cyst volume after transplantation with reduced effect over time. This phase 1 trial demonstrated the feasibility and safety of ahSC transplantation combined with a multi-modal rehabilitation protocol for participants with chronic SCI.

Spinal Cord Tissue Bridges Validation Study: Predictive Relationships With Sensory Scores Following Cervical Spinal Cord Injury

Background

Using magnetic resonance imaging (MRI), widths of ventral tissue bridges demonstrated significant predictive relationships with future pinprick sensory scores, and widths of dorsal tissue bridges demonstrated significant predictive relationships with future light touch sensory scores, following spinal cord injury (SCI). These studies involved smaller participant numbers, and external validation of their findings is warranted.

Objectives

The purpose of this study was to validate these previous findings using a larger independent data set.

Methods

Widths of ventral and dorsal tissue bridges were quantified using MRI in persons post cervical level SCI (average 3.7 weeks post injury), and pinprick and light touch sensory scores were acquired at discharge from inpatient rehabilitation (average 14.3 weeks post injury). Pearson product-moments were calculated and linear regression models were created from these data.

Results

Wider ventral tissue bridges were significantly correlated with pinprick scores (r = 0.31, p < 0.001, N = 136) and wider dorsal tissue bridges were significantly correlated with light touch scores (r = 0.31, p < 0.001, N = 136) at discharge from inpatient rehabilitation.

Conclusion

This retrospective study's results provide external validation of previous findings, using a larger sample size. Following SCI, ventral tissue bridges hold significant predictive relationships with future pinprick sensory scores and dorsal tissue bridges hold significant predictive relationships with future light touch sensory scores.

Safety and efficacy of transcranial direct current stimulation in upper extremity rehabilitation after tetraplegia: protocol of a multicenter randomized, clinical trial

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.

Lateral Corticospinal Tract and Dorsal Column Damage: Predictive Relationships With Motor and Sensory Scores at Discharge From Acute Rehabilitation After Spinal Cord Injury

OBJECTIVE

To determine if lateral corticospinal tract (LCST) integrity demonstrates a significant predictive relationship with future ipsilateral lower extremity motor function (LEMS) and if dorsal column (DC) integrity demonstrates a significant predictive relationship with future light touch (LT) sensory function post spinal cord injury (SCI) at time of discharge from inpatient rehabilitation.

DESIGN

Retrospective analyses of imaging and clinical outcomes.

SETTING

University and academic hospital.

PARTICIPANTS

A total of 151 participants (N=151) with SCI.

INTERVENTIONS

Inpatient rehabilitation.

MAIN OUTCOME MEASURES

LEMS and LT scores at discharge from inpatient rehabilitation.

RESULTS

In 151 participants, right LCST spared tissue demonstrated a significant predictive relationship with right LEMS percentage recovered (β=0.56; 95% confidence interval [CI], 0.37-0.73; R=0.43; P<.001). Left LCST spared tissue demonstrated a significant predictive relationship with left LEMS percentage recovered (β=0.66; 95% CI, 0.50-0.82; R=0.51; P<.001). DC spared tissue demonstrated a significant predictive relationship with LT percentage recovered (β=0.69; 95% CI, 0.52-0.87; R=0.55; P<.001). When subgrouping the participants into motor complete vs incomplete SCI, motor relationships were no longer significant, but the sensory relationship remained significant. Those who had no voluntary motor function but recovered some also had significantly greater LCST spared tissue than those who did not recover motor function.

CONCLUSIONS

LCST demonstrated significant moderate predictive relationships with lower extremity motor function at the time of discharge from inpatient rehabilitation, in an ipsilesional manner. DC integrity demonstrated a significant moderate predictive relationship with recovered function of LT. With further development, these neuroimaging methods might be used to predict potential deficits after SCI and to provide corresponding targeted interventions.

Spinal Cord Injury: A Review of Current Management Considerations and Emerging Treatments

Traumatic spinal cord injuries can have devastating outcomes for patients. In this focused review, we discuss the epidemiology of spinal cord injuries, associated neurologic exam findings, and primary and secondary injury progression. We then delve into the emerging treatment approaches and relevance to improving outcomes. The disease is multifactorial and has many management considerations. This concise user-friendly resource can help guide clinicians caring for these patients. Also, it points to the need for continued scientific discovery and improved pharmaceutical and device innovations.

Correlation of neurological level and sweating level of injury in persons with spinal cord injury

Objective: Thermoregulatory dysfunction after spinal cord injury (SCI) impairs quality of life and predisposes persons to life-threatening sequela of heat-related illness (HRI) in conditions of high ambient temperature. SCI clinicians currently have no objective way to predict which persons are at greatest risk of HRI. Evaporative cooling via sweating is the body's most efficient mechanism of heat dissipation. The relationship between the neurological level of injury (NLOI) and the degree of sudomotor dysfunction is not well defined. This study examines the relationship between the NLOI and sweating level of injury (SwLOI). This information can assist SCI clinicians in identifying individuals with SCI who have most impaired sudomotor function and thus highest risk of HRI.Design: Observational.Setting: Human physiology laboratory.Participants: 10 persons with tetraplegia (TP), 14 with paraplegia (PP) and 10 able-bodied (AB).Intervention: Passive heat stress (1°C rise in core temperature) with sweat responses (SR) quantified with the starch iodine test.Outcome measures: The most caudal dermatomal level in which sweating was visualized was recorded as the SwLOI, which was compared to the NLOI. Minimum, maximum and median differences between NLOI and SwLOI were calculated.Results: Persons with tetraplegia demonstrated no SR. Persons with paraplegia demonstrated SR at a median of 1 level below NLOI. Able-bodied controls demonstrated sweating on all skin surface areas.Conclusions: Persons with motor complete tetraplegia lack evaporative cooling capacity through SR during passive heat stress predisposing them to HRI. Meanwhile, persons with paraplegia sweat on average 1 dermatomal level below their NLOI.

Measurement error and reliability of TMS metrics collected from biceps and triceps in individuals with chronic incomplete tetraplegia

Transcranial magnetic stimulation (TMS) is used to investigate corticomotor neurophysiology associated with functional recovery in individuals with spinal cord injury (SCI). There is insufficient evidence about test-retest measurement properties of TMS in SCI. Therefore, we investigated test-retest agreement and reliability of TMS metrics representing corticomotor excitability, output, gain, map (representation), and inhibition in individuals with cervical SCI. We collected TMS metrics from biceps and triceps muscles because of the relevance of this proximal muscle pair to the cervical SCI population. Twelve individuals with chronic C3-C6 SCI participated in two TMS sessions separated by ≥ 2 weeks. Measurement agreement was evaluated using t tests, Bland-Altman limits of agreement and relative standard error of measurement (SEM%), while reliability was investigated using intra-class correlation coefficient (ICC) and concordance correlation coefficient (CCC). We calculated the smallest detectable change for all TMS metrics. All TMS metrics except antero-posterior map coordinates and corticomotor inhibition were in agreement upon repeated measurement though limits of agreement were generally large. Measures of corticomotor excitability, output and medio-lateral map coordinates had superior agreement (SEM% < 10). Metrics representing corticomotor excitability, output, and inhibition had good-to-excellent reliability (ICC/CCC > 0.75). The smallest detectable change for TMS metrics was generally high for a single individual, but this value reduced substantially with increase in sample size. We recommend use of corticomotor excitability and recruitment curve area owing to their superior measurement properties. A modest group size (20 or above) yields more stable measurements, which may favor use of TMS metrics in group level modulation after SCI.

Reliability and validity of the international standards for neurological classification of spinal cord injury in patients with non-traumatic spinal cord lesions

STUDY DESIGN

Prospective, observational study.

OBJECTIVES

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) represent the gold standard for the assessment of patients with spinal cord injury (SCI) and their measurement properties have been evaluated in patients with traumatic lesions. Albeit the ISNCSCI are widely used also for the assessment and prognosis of patients with non-traumatic SCI, a validation of this grading system in this sample has never been performed. Therefore, the aim of this study is to evaluate the measurement properties of the ISNCSCI in a population of persons with non-traumatic SCI.

SETTING

Three Italian rehabilitation hospitals.

METHODS

The sample included 140 patients with non-traumatic SCI of different etiology, level and grade, for a total of 169 evaluations performed by two examiners. Cronbach's Alpha was used to evaluate the internal consistency of the ISNCSCI various components. The agreement between two examiners of each center in the definition of different components was used to assess the inter-rater reliability. The construct validity was evaluated through the correlation of the ISNCSCI with the Spinal Cord Independence Measure (SCIM).

RESULTS

The ISNCSCI showed substantial internal consistency, and substantial inter-rater agreement for AIS grade, cumulative motor and sensory scores. The motor scores for upper and lower extremity showed fair to moderate correlation with SCIM self-care and motility subscores, respectively. The ISNCSCI total motor score correlated with the total SCIM score.

CONCLUSIONS

Our study demonstrates that the ISNCSCI are a valid and reliable tool for the assessment of patients with non-traumatic SCI.

Revisiting the Examination of Sharp/Dull Discrimination as Clinical Measure of Spinothalamic Tract Integrity

Objective: Revisiting the sharp/dull discrimination as clinical measure of spinothalamic tract function considering the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Three clinically relevant factors were evaluated as to their impact on reliability: (1) the localization of dermatomes in relation to the sensory level, (2) the examination tool, and (3) the threshold of correct answers for grading of a preserved sharp/dull discrimination.

Design: Prospective monocentric psychometric study.

Setting: Spinal Cord Injury Center, Heidelberg University Hospital, Germany.

Participants: Convenient sample of 21 individuals with subacute spinal cord injury (age: 31–82 years) and 20 individuals without spinal cord injury (age: 24–63 years).

Assessment: All participants underwent three assessments for sharp/dull discrimination, applying five commonly used examination tools in seven dermatomes, performed by three trained examiners under conditions in accordance with ISNCSCI.

Main Outcome Measures: Assessment of interrater reliability by determining both the Fleiss kappa (κ) coefficient and the percentage agreement between raters. Data were dichotomized regarding the ISNCSCI threshold.

Results: Interrater reliability in individuals with SCI was overall substantial (κ = 0.68; CI 0.679–0.681) and moderate (κ = 0.54; CI 0.539–0.543) in dermatomes below the sensory level. All applied tools led to at least moderate reliability below the sensory level (lowest κ = 0.44; CI 0.432–0.440), with the officially endorsed safety pin achieving the highest (substantial) reliability (κ = 0.64; CI 0.638–0.646). Percentage agreement differed between non-SCI (97.3%) and formally intact above level dermatomes in SCI (89.2%).

Conclusions: Sharp/dull discrimination as a common clinical examination technique for spinothalamic tract function is a reliable assessment. Independent from the used examination tools, reliability was substantial, with the medium-sized safety pin delivering the most favorable results. Notwithstanding this, all other tools could be considered if a safety pin is not available. Regarding interrater reliability and guessing probability, a threshold of 80% correct responses for preserved sharp/dull discrimination appears to be most suitable, which is in line with current clinical approaches and ISNCSCI. The causal attribution of the identified differences in sharp/dull discrimination between clinically intact dermatomes of individuals with SCI and unaffected dermatomes of individuals without SCI requires future work.

Clinical Trial Registration Number (German Clinical Trials Register): DRKS00015334 (https://www.drks.de).

Spinal Cord Injury Clinical Classification Systems: What Is Available and a Proposed Alternative

Spinal cord injury (SCI) remains a challenging disease in terms of surgical decision-making and improving neurologic outcome. As we have now entered a new era founded on routine "big data" capture, more advanced and meaningful yet simplified SCI classification systems and outcome measurement tools would be helpful to determine the efficacy of potential therapeutics in future clinical trials and registries. The proposed classification herein focuses on gross sensorimotor, sacral function below the injured level via an easy-to-use scoring system yielding grades 1 to 4 of injury severity. Such an optimized SCI scoring system would enhance real-time analytics and offer superior outcomes modeling.

Characterizing Natural Recovery after Traumatic Spinal Cord Injury

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.

Prevalence of sleep-disordered breathing in people with tetraplegia-a systematic review and meta-analysis

STUDY DESIGN

Systematic review with meta-analysis.

OBJECTIVES

To determine the prevalence of sleep-disordered breathing (SDB) in people with tetraplegia and to identify the characteristics associated with SDB.

METHODS

A systematic literature search using Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) and grey literature sources was conducted using a combination of spinal cord injury (SCI) and SDB related terms. Articles were restricted to publication dates between 1/1/2000 and 4/9/2020 and with objectively measured SDB with an overnight sleep study. The frequency of SDB stratified by the apnoea hypopnea index (AHI) was extracted and weighted averages, using a random effects model, were calculated with 95% confidence intervals. Sub-group analyses were performed where possible.

RESULTS

Twelve articles were included in the review; of these nine were included in meta-analysis (combined sample = 630). Sample sizes and case detection methods varied. Reported SDB prevalence rates ranged from 46 to 97%. The prevalence of at least mild (AHI ≥ 5), moderate (AHI ≥ 15) and severe (AHI ≥ 30) SDB were 83% (95% CI = 73-91), 59% (46-71) and 36% (26-46), respectively. Sub-group analyses found that prevalence increased with age (p < 0.001). There were no statistically significant differences in SDB prevalence by sex (p = 0.06), complete/incomplete SCI (p = 0.06), body mass index (p = 0.07), acute/chronic SCI (p = 0.73) or high/low level of cervical SCI (p = 0.90).

CONCLUSION

Our results confirm that SDB is highly prevalent in people with tetraplegia, and prevalence increases with age. The high prevalence suggests that routine screening and subsequent treatment should be considered in both acute and community care.

The influence of conventional T2 MRI indices in predicting who will walk outside one year after spinal cord injury

CONTEXT/OBJECTIVE

Magnetic resonance imaging (MRI) indices of spinal cord damage are predictive of future motor function after spinal cord injury (SCI): hyperintensity length, midsagittal tissue bridges, and Brain and Spinal Injury Center (BASIC) scores. Whether these indices are predictive of outdoor walking after SCI is unknown. The primary purpose was to see if these MRI indices predict the ability to walk outdoors one-year after SCI. The secondary purpose was to determine if MRI indices provide additional predictive value if initial lower extremity motor scores are available.

DESIGN

Retrospective. Clinical T₂-weighted MRIs were used to quantify spinal cord damage. Three MRI indices were calculated: midsagittal ventral tissue bridges, hyperintensity length, BASIC scores.

SETTING

Academic hospital.

PARTICIPANTS

129 participants with cervical SCI.

INTERVENTIONS

Inpatient rehabilitation.

OUTCOMES MEASURES

One year after SCI, participants self-reported their outdoor walking ability.

RESULTS

Midsagittal ventral tissue bridges, hyperintensity length, and BASIC scores significantly correlated with outdoor walking ability (R = 0.34, P < 0.001; R = -0.25, P < 0.01; Rs = -0.35, P < 001, respectively). Using midsagittal ventral tissue bridges and hyperintensity length, the final adjusted R² for model 1 = 0.19. For model 2, the adjusted R² using motor scores alone = 0.81 and MRI variables were non-significant. All five participants with observable intramedullary hemorrhage reported they were unable to walk one block outdoors.

CONCLUSIONS

The MRI indices were significant predictors of outdoor walking ability, but when motor scores were available, this was the strongest predictor and neither midsagittal tissue bridges nor hyperintensity length contributed additional value. MRI indices may be a quick and convenient supplement to physical examination when motor testing is unavailable.

Intra-rater reliability and repeatability of pulse oximetry values obtained before, between sets, and after resistive exercise

BACKGROUND: Pulse oximetry measures heart rate (HR) and percent oxygen saturation (SpO2). For aerobic exercise, whereby cellular oxygen demand and delivery are elevated and maintained for extended periods, HR and SpO2 values are consistent when measured by pulse oximetry. Yet due to its intermittent nature, HR and SpO2 values from resistive exercise may exhibit lower data reliability and repeatability. OBJECTIVE: Assess intra-rater reliability and repeatability of pulse oximetry HR and SpO2 values from two identical resistive exercise protocols. METHODS: Subjects (n= 32) performed two calf press workouts on a flywheel-based ergometer as HR and SpO2 were measured before, between sets, and after exercise. Workouts entailed a 4-set 15-repetition protocol separated by 120-second rests. Intra-rater reliability was assessed with intraclass correlation coefficients (ICC). Repeatability was measured by the smallest real difference in absolute and relative terms. RESULTS: ICC and standard error of estimate results for HR ranged from 0.60–0.79 and 9.1–13.0 respectively. SpO2 ICC and standard error of estimate results ranged from 0.16–0.71 and 1.44–4.33 respectively. Between sets, smallest real difference values tended to be less for HR. CONCLUSIONS: Results demonstrate acceptable intra-rater reliability and repeatability for HR, but not SpO2 which we attribute to the exercise mode and protocol examined.

Theoretical and practical training improves knowledge of the examination guidelines of the International Standards for Neurological Classification of Spinal Cord Injury

Study design

Prospective pre–post study.

Objectives

International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) represents the most frequently used assessment to determine the level and severity of a spinal cord injury (SCI). The guidelines for ISNCSCI are complex and challenging. Knowledge of its correct execution needs to be imparted precisely. The aim of this study was to investigate whether hands-on instructional courses can increase the knowledge of the ISNCSCI examination guidelines.

Setting

European Multicenter Study about SCI.

Methods

Before and after the instructional courses, participants were asked to complete questionnaires. The set of questions covered the most important aspects of the examination guidelines. Attendees were asked to self-rate their occupation and experience in ISNCSCI.

Results

The comparison of pretest and posttest results of 164 attendees from 2014 to 2018 revealed an improvement of knowledge reflected by an increase of correct answers from 66 ± 17% before to 89 ± 11% after the course (p < 0.01). The improvement was not associated with occupation (p > 0.1). However, the correctness of pretest results differed concerning both the period of experience with ISNCSCI (p < 0.05) and the course language (p < 0.01), while the frequency of execution resulted in differences in the posttest (p = 0.01).

Conclusions

Instructional courses substantially improve knowledge of the ISNCSCI examination guidelines. Differences in knowledge present before the course leveled off after the course. Comprehensive theoretical training is strongly recommended to ensure reliability and validity of ISNCSCI examinations in clinical routine and research. Albeit being practiced in the instructional courses, the benefit of hands-on training still needs to be systematically evaluated in future studies.

Effects of Multi-Muscle Electrical Stimulation and Stand Training on Stepping for an Individual With SCI

The objective of this study was to evaluate the biomechanical, neural, and functional outcomes during a 10-min treadmill stepping trial before and after two independent interventions with neuromuscular electrical stimulation (ES) in an individual with spinal cord injury (SCI). In this longitudinal study, a 34-year-old male with sensory- and motor-complete SCI (C5/C6) underwent two consecutive interventions: 61 h of supine lower limb ES (ES-alone) followed by 51 h of ES combined with stand training (ST) using an overhead body-weight support (BWS) system (ST + ES). In post ES-alone (unloaded), compared to baseline, the majority (∼60%) of lower extremity muscles decreased their peak surface electromyography (sEMG) amplitude, while in post ST + ES (loaded), compared to post ES-alone, there was a restoration in muscle activation that endured the continuous 10-min stepping. Temporal α-motor neuron activity patterns were observed for the SCI participant. In post ST + ES, there were increases in spinal activity patterns during mid-stance at spinal levels L5–S2 for the right and left limbs. Moreover, in post ES-alone, trunk stability increased with excursions from the midline of the base-of-support (50%) to the left (44.2%; Baseline: 54.2%) and right (66.4%; baseline: 77.5%). The least amount of trunk excursion observed post ST + ES, from midline to left (43%; AB: 22%) and right (64%; AB: 64%). Overall, in post ES-alone, there were gains in trunk independence with a decrease in lower limb muscle activation, whereas in post ST + ES, there were gains in trunk independence and increased muscle activation in both bilateral trunk muscles as well as lower limb muscles during the treadmill stepping paradigm. The results of the study illustrate the importance of loading during the stimulation for neural and mechanical gains.

Association of timing of gabapentinoid use with motor recovery after spinal cord injury

OBJECTIVE

To explore the hypothesis that earlier administration of acute gabapentinoids is beneficial to motor recovery after spinal cord injury in humans.

METHODS

This is an observational study using a cohort from the European Multi-Centre Study about Spinal Cord Injury. Patient charts were reviewed to extract information regarding the administration and timing of gabapentinoid anticonvulsants. The primary outcome measure was motor scores, as measured by the International Standards for Neurological Classification of Spinal Cord Injury, collected longitudinally in the first year after injury. Sensory scores (light touch and pinprick) and functional measures (Spinal Cord Independence Measure) were secondary outcomes. Linear mixed effects regression models included a drug-by-time interaction to determine whether exposure to gabapentinoids altered recovery of muscle strength in the first year after injury.

RESULTS

A total of 201 participants were included in the study and had a median age of 46 and baseline motor score of 50. Participants were mostly men (85%) with sensory and motor complete injuries (50%). Seventy individuals (35%) were administered gabapentinoids within the first 30 days after injury, and presented with similar demographics. In the longitudinal model, the administration of gabapentinoids within 30 days after injury was associated with improved motor recovery when compared to those who did not receive gabapentinoids during this time (3.69 additional motor points from 4 to 48 weeks after injury; p = 0.03). This effect size increased as administration occurred earlier after injury (i.e., a benefit of 4.68 points when administered within 5 days).

CONCLUSIONS

This retrospective, observational study provided evidence of the beneficial effect of gabapentinoid anticonvulsants on motor recovery after spinal cord injury. More critically, it highlighted a potential time dependence, suggesting that earlier intervention is associated with better outcomes.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that gabapentinoids improve motor recovery for individuals with acute spinal cord injury.

Comparison of the 6-Min Propulsion and Arm Crank Ergometer Tests to Assess Aerobic Fitness in Manual Wheelchair Users With a Spinal Cord Injury

OBJECTIVE

The 6-Min Manual Wheelchair Propulsion Test is proposed to easily and rapidly assess aerobic fitness among long-term (≥3 mos) manual wheelchair users with spinal cord injury. However, aerobic responses to this test have not been established. This study aimed (1) to characterize aerobic responses during the 6-Min Manual Wheelchair Propulsion Test, (2) to establish parallel reliability between the 6-Min Manual Wheelchair Propulsion Test and the Maximal Arm Crank Ergometer Test, and (3) to quantify the strength of association between the total distance traveled during the 6-Min Manual Wheelchair Propulsion Test and peak oxygen consumption.

DESIGN

Twenty manual wheelchair users with a spinal cord injury completed both tests. Aerobic parameters were measured before, during, and after the tests. Main outcome measures were peak oxygen consumption and total distance traveled.

RESULTS

Progressive cardiorespiratory responses, consistent with guidelines for exercise testing, were observed during both tests. Similar peak oxygen consumption values were obtained during both tests (6-Min Manual Wheelchair Propulsion Test: 20.2 ± 4.9 ml/kg·min; Maximal Arm Crank Ergometer Test: 20.4 ± 5.0 ml/kg·min), were highly correlated (r = 0.92, P < 0.001), and had a good agreement (mean absolute difference = 0.21, 95% confidence interval = -0.70 to 1.11, P = 0.639). The peak oxygen consumption and total distance traveled (mean = 636.6 ± 56.9 m) during the 6-Min Manual Wheelchair Propulsion Test were highly correlated (r = 0.74, P < 0.001).

CONCLUSIONS

The 6-Min Manual Wheelchair Propulsion Test induces progressive aerobic responses consistent with guidelines for exercise testing and can be used to efficiently estimate aerobic fitness in manual wheelchair users with a spinal cord injury.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Explain how to administer the Six-Minute Manual Wheelchair Propulsion Test in long-term manual wheelchair users with a spinal cord injury; (2) Contrast how the workload is developed between the Six-Minute Manual Wheelchair Propulsion Test and the Maximal Arm Crank Ergometry Test and recognize how these differences may affect physiological responses; and (3) Explain why caution is advised regarding the use of the Six-Minute Manual Wheelchair Propulsion Test if aiming to estimate aerobic fitness.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Effects of hybrid-functional electrical stimulation (FES) rowing whole-body exercise on neurologic improvement in subacute spinal cord injury: secondary outcomes analysis of a randomized controlled trial

Study Design

Secondary outcome measures analysis of a randomized, controlled study.

Objective

To assess the effects of hybrid-functional electrical stimulation (FES) rowing on motor and sensory recovery in individuals with spinal cord injury (SCI) 6–18 months post-injury.

Setting

Outpatient rehabilitation network.

Methods

25 participants 6–12 months after SCI were randomly assigned to hybrid-FES rowing (n=10) or standard of care (n=15) groups. The hybrid-FES rowing group completed 6 months of rowing scheduled 3 times per week for 26 weeks at an exercise intensity of 70–85% of maximal heart rate. The standard of care group either participated in an arm ergometer exercise program (n=6) or a waitlist without an explicit exercise program (n=9). Changes in motor score and combined sensory score of the International Standards for Neurological Classification of SCI (ISNCSCI) were analyzed.

Results

Both groups demonstrated increases in motor and combined sensory scores, but no significant differences were noted between intervention groups (motor difference mean ↑1.3 (95% CI, −1.9 to 4.4), combined sensory difference mean ↓10 (−30 to 18)). There was an average of 63% adherence to the hybrid-FES rowing protocol, with no significant correlation in changes in motor or combined sensory score in the hybrid-FES rowing group with total distance or time rowed.

Conclusions

No significant effects to neurologic improvement were found with hybrid-FES rowing when compared with standard of care interventions in individuals with SCI 6–18 months post-injury.

The inter-rater reliability of the 13-point manual muscle test in people with spinal cord injury

Objective: To determine the inter-rater reliability of the 13-point manual muscle test (MMT) in two upper limb muscle groups of people with tetraplegiaSetting: The study was conducted at three spinal cord injury (SCI) units.Participants: Sixty people with complete or incomplete tetraplegia.Methods: The inter-rater reliability of the 13-point MMT was investigated. Strength of the elbow flexors and/or wrist extensors in people with tetraplegia was measured by two physiotherapists on the same day.Results: The weighted kappa coefficient (95% confidence interval) reflecting the agreement between the two strength assessments by two different assessors for the wrist extensors and elbow flexors were 0.96 (0.93 to 0.99) and 0.94 (0.89 to 0.99), respectively. Repeat measurements by different physiotherapists were within 1 of 13 points of each other 82% of the time for wrist extensors and 87% of the time for the elbow flexors.Conclusion: The 13-point MMT is a reliable measure of strength in the wrist extensors and elbow flexors of people with tetraplegia.

Multi-muscle electrical stimulation and stand training: Effects on standing

OBJECTIVE

To examine the biomechanical and neuromuscular effects of a longitudinal multi-muscle electrical stimulation (submaximal intensities) training of the lower limbs combined with/without activity-based stand training, on the recovery of stability and function for one individual with spinal cord injury (SCI).

DESIGN

Single-subject, longitudinal study.

SETTING

Neuroplasticity laboratory.

PARTICIPANT

A 34-year-old male, with sensory- and motor-complete SCI (C5/C6).

INTERVENTIONS

Two consecutive interventions: 61 hours of supine, lower-limb ES (ES-alone) and 51 hours of ES combined with stand training using an overhead body-weight support system (ST + ES).

OUTCOME MEASURES

Clinical measures, trunk stability, and muscle activity were assessed and compared across time points. Trunk Stability Limit (TSL) determined improvements in trunk independence.

RESULTS

Functional clinical values increased after both interventions, with further increases post ST + ES. Post ES-alone, trunk stability was maintained at 81% body-weight (BW) loading before failure; post ST + ES, BW loading increased to 95%. TSL values decreased post ST + ES (TSL_A/P=54.0 kg.cm, TSL_M/L=14.5 kg.cm), compared to ES-alone (TSL_A/P=8.5 kg.cm, TSL_M/L=3.9 kg.cm). Trunk muscle activity decreased post ST + ES training, compared to ES-alone.

CONCLUSION

Neuromuscular and postural trunk control dramatically improved following the multi-muscle ES of the lower limbs with stand training. Multi-muscle ES training paradigm of the lower limb, using traditional parameters, may contribute to the functional recovery of the trunk.

Inter-rater reliability of the modified Medical Research Council scale in patients with chronic incomplete spinal cord injury

OBJECTIVE

The aim of this study was to determine the inter-rater reliability of the modified Medical Research Council (MRC) scale for grading motor function in patients with chronic incomplete spinal cord injury (SCI).

METHODS

Two neurosurgical residents and 2 faculty members performed motor examinations in 6 chronic incomplete SCI patients for a total of 156 muscle groups. Examinations were performed using the modified MRC grading scale during routine clinic visits for each patient. Informed consent was obtained prior to enrollment. Patients with American Spinal Injury Association (ASIA) Impairment Scale grade A (ASIA A) injuries were excluded. Inter-rater reliability coefficients were calculated using Kendall's coefficient of concordance (W) and intraclass correlation coefficients (ICCs).

RESULTS

Sixty-four percent of the tested variables demonstrated extremely strong (W 0.71-0.9) or strong (0.51-0.7) inter-rater reliability using Kendall's coefficient of concordance and an ICC corresponding to excellent (ICC > 0.75) or fair to good (ICC 0.4-0.75) inter-rater reliability. An additional 7% showed poor inter-rater reliability (ICC < 0.4). The remaining variables tested did not reach statistical significance.

CONCLUSIONS

The inter-rater reliability of the modified MRC scale was found to be high in the majority of tested variables, but the results suggest that discrepancy among trained observers does exist. Reliability was greatest in the lower-extremity muscle groups and least in the upper-extremity muscle groups in patients with chronic incomplete SCI.

Unilateral versus bilateral lower extremity motor deficit following complex adult spinal deformity surgery: is there a difference in recovery up to 2-year follow-up?

BACKGROUND CONTEXT

Scoli-RISK-1 is a multicenter prospective cohort designed to study neurologic outcomes following complex adult spinal deformity (ASD). The effect of unilateral versus bilateral postoperative motor deficits on the likelihood of long-term recovery has not been previously studied in this population.

PURPOSE

To evaluate whether bilateral postoperative neurologic deficits have a worse recovery than unilateral deficits.

STUDY DESIGN

Secondary analysis of a prospective, multicenter, international cohort study.

METHODS

In a cohort of 272 patients, neurologic decline was defined as deterioration of the American Spinal Injury Association Lower Extremity Motor Scores (LEMS) following surgery. Patients with lower extremity neurologic decline were grouped into unilateral and bilateral cohorts. Differences in demographics, surgical variables, and patient outcome measures between the two cohorts were analyzed.

RESULTS

A total of 265 patients had LEMS completed at discharge. Unilateral decline was seen in 32 patients (12%), while 29 (11%) had bilateral symptoms. At 2 years, there was no significant difference in either median LEMS (unilateral 50.0, interquartile range [IQR] 47.5-50.0; bilateral 50.0, IQR 48.0-50.0, p=.939) or change in LEMS from baseline (unilateral 0.0, IQR -1.0 to 0.0; bilateral 0.0, IQR -1.0 to 0.0, p=.920). In both groups, approximately two-thirds of patients saw recovery to at least their preoperative baseline by 2 years postoperatively (unilateral n=15, 63%; bilateral n=14, 67%). The mean Scoliosis Research Society-22R (SRS-22R) score at 2 years was 3.7±0.6 versus 3.2±0.6 (p=.009) for unilateral and bilateral groups, respectively.

CONCLUSIONS

The prognosis for neurologic recovery of new motor deficits following complex adult spinal deformity is similar with both unilateral and bilateral weaknesses. Despite similar rates of neurologic recovery, patient reported outcomes for those with bilateral motor decline measured by SRS-22R are worse at 2 years after surgery.

Reorganization of the somatosensory pathway after subacute incomplete cervical cord injury

Objective

The main purpose of the present study was to investigate the possible somatosensory-related brain functional reorganization after traumatic spinal cord injury (SCI).

Methods

Thirteen patients with subacute incomplete cervical cord injury (ICCI) and thirteen age- and sex-matched healthy controls (HCs) were recruited. Eleven patients and all the HCs underwent both sensory task-related brain functional scanning and whole brain structural scanning on a 3.0 Tesla MRI system, and two patients underwent only structural scanning; the process of structural scanning was completed on thirteen patients, while functional scanning was only applied to eleven patients. We performed sensory task-related functional MRI (fMRI) to investigate the functional changes in the brain. In addition, voxel-based morphometry (VBM) was applied to explore whether any sensory-related brain structural changes occur in the whole brain after SCI.

Results

Compared with HCs, ICCI patients exhibited decreased activation in the left postcentral gyrus (postCG), the brainstem (midbrain and right pons) and the right cerebellar lobules IV-VI. Moreover, a significant positive association was found between the activation in the left PostCG and the activation in both the brainstem and the right cerebellar lobules IV-VI. Additionally, the decrease in gray matter volume (GMV) was detected in the left superior parietal lobule (SPL). The decrease of white matter volume (WMV) was observed in the right temporal lobe, the right occipital lobe, and the right calcarine gyrus. No structural change in the primary sensory cortex (S1), the secondary somatosensory cortex (S2) or the thalamus was detected.

Conclusion

These functional and structural findings may demonstrate the existence of an alternative pathway in the impairment of somatosensory function after SCI, which consists of the ipsilateral cerebellum, the brainstem and the contralateral postCG. It provides a new theoretical basis for the mechanism of sensory-related brain alteration in SCI patients and the rehabilitation therapy based on this pathway in the future.

•

We found that sensory-related brain reorganization may not occur in the thalamus in patients with ICCI.

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We found that brain structural reorganization did not occur in the S1 or the S2 in patients with ICCI.

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We observed that SCI can cause brain structural reorganization in non-sensory-related areas.

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We observed that an alternative pathway may exist in the impairment of somatosensory function after SCI.

Challenging questions regarding the international standards

Objective/Context To highlight questions with regards to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and provide historical perspectives to help SCI professionals gain fuller insights into the classification system. Methods Frequently asked questions to the ISNCSCI were collected and a review of literature and personal communications with International Standards committee members and Chairs were undertaken. Results Background and explanations for nine questions, detailing decision processes and challenging classification rules are presented. Conclusion While the ISNCSCI can be challenging, this background and historical explanation may provide a greater understanding and the ability to critically analyze this classification system.

Engaging cervical spinal circuitry with non-invasive spinal stimulation and buspirone to restore hand function in chronic motor complete patients

The combined effects of cervical electrical stimulation alone or in combination with the monoaminergic agonist buspirone on upper limb motor function were determined in six subjects with motor complete (AIS B) injury at C5 or above and more than one year from time of injury. Voluntary upper limb function was evaluated through measures of controlled hand contraction, handgrip force production, dexterity measures, and validated clinical assessment batteries. Repeated measure analysis of variance was used to evaluate functional metrics, EMG amplitude, and changes in mean grip strength. In aggregate, mean hand strength increased by greater than 300% with transcutaneous electrical stimulation and buspirone while a corresponding clinically significant improvement was observed in upper extremity motor scores and the action research arm test. Some functional improvements persisted for an extended period after the study interventions were discontinued. We demonstrate that, with these novel interventions, cervical spinal circuitry can be neuromodulated to improve volitional control of hand function in tetraplegic subjects. The potential impact of these findings on individuals with upper limb paralysis could be dramatic functionally, psychologically, and economically.