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Metelmann M, Baum P, Pelz J. Autonome Diagnostik bei der Amyotrophen
Lateralsklerose. KLIN NEUROPHYSIOL 2023. [DOI: 10.1055/a-2018-3174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
ZusammenfassungBei der Amyotrophen Lateralsklerose (ALS) handelt sich um eine neurodegenerative
Multisystemerkrankung. Diese äußert sich neben den motorischen
Defiziten mit nicht-motorischen Symptomen. Hierzu zählen auch autonome
Störungen, die von veränderter Schweißsekretion
über Tachykardie bis zu gastrointestinalen Symptomen reichen. Autonome
Störungen können mit verschiedenen Methoden, wie
Selbsterhebungsfragebögen, Messung der Herzfrequenzvariabilität,
QTc-Intervallmessung, Erhebung der sudomotorischen Funktion und Sonographie des
Nervus vagus erfasst werden, die in diesem Artikel dargestellt werden. Die
bislang bei der ALS eingesetzten Methoden der autonomen Diagnostik ergeben zum
Teil deutlich divergierende Ergebnisse über die Aktivität des
Sympathikus im Krankheitsverlauf. Relevante autonome Störungen scheinen
zumeist erst im fortgeschrittenen Krankheitsstadium aufzutreten, wobei
multizentrische Studien mit longitudinalem Ansatz ausstehen.
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Affiliation(s)
- Moritz Metelmann
- Department of Neurology,Universitätsklinikum Leipzig, Leipzig,
Germany
| | - Petra Baum
- Klinik für Neurologie , Universitätsklinikum Leipzig,
Leipzig, Germany
| | - Johann Pelz
- Department of Neurology,Universitätsklinikum Leipzig, Leipzig,
Germany
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Nedumaran L, Rebekah G, Tharion E, Tharion G. Initial Autonomic Parameters and Subsequent Short-Term Neurological Recovery after Inpatient Rehabilitation, in Traumatic Cervical Spinal Cord Injury Patients. Neurorehabil Neural Repair 2022; 36:269-273. [PMID: 35227121 DOI: 10.1177/15459683221081060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND It is unknown whether assessment of autonomic pathway integrity in newly injured traumatic cervical spinal cord injury (SCI) patients contributes to their neurological prognosis. OBJECTIVE The objective is to investigate the relationship of heart rate variability (HRV) and sympathetic skin response (SSR) at initial evaluation of American Spinal Injury Association Impairment Scale (AIS) A/B tetraplegic patients, with their short-term neurological recovery. METHODS In this prospective cohort study, short-term HRV indices and SSR to supra-lesional stimuli were computed in 24 acute traumatic cervical AIS A/B SCI patients at admission for rehabilitation. The relationship of these autonomic parameters with motor and sensory score improvement, AIS grade improvement, and time taken for recovery was tested, respectively, with Spearman's correlation coefficient test, Fisher's exact test, and Kaplan-Meier analysis. RESULTS SSR was present in 11 (45.8%) patients at initial evaluation. After rehabilitation, 5 (20.8%) patients improved from AIS A/B to AIS C (greater recovery), while the rest remained at AIS A/B (lesser recovery). Both AIS improvement and mean time for 'greater' recovery did not associate with the presence/absence of SSR. Further, HRV indices did not correlate with improvement in motor or sensory scores. CONCLUSIONS Interim neurological recovery was not related to autonomic parameters of short-term HRV indices and SSR in the AIS A/B tetraplegic patients of our study. Interestingly, about half of the patients with clinically complete SCI had evidence of preserved autonomic function. Our data add to the knowledge base of autonomic findings in cervical SCI patients and will promote research relating neurophysiological parameters and recovery.
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Affiliation(s)
- Latha Nedumaran
- Department of Physiology, 30025Christian Medical College, Vellore, TN, India
| | - Grace Rebekah
- Department of Biostatistics, 30025Christian Medical College, Vellore, TN, India
| | - Elizabeth Tharion
- Department of Physiology, 30025Christian Medical College, Vellore, TN, India
| | - George Tharion
- Department of Physical Medicine and Rehabilitation, 30025Christian Medical College, Vellore, TN, India
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Cardiovascular Autonomic Dysfunction in Spinal Cord Injury: Epidemiology, Diagnosis, and Management. Semin Neurol 2020; 40:550-559. [PMID: 32906175 DOI: 10.1055/s-0040-1713885] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Spinal cord injury (SCI) disrupts autonomic circuits and impairs synchronistic functioning of the autonomic nervous system, leading to inadequate cardiovascular regulation. Individuals with SCI, particularly at or above the sixth thoracic vertebral level (T6), often have impaired regulation of sympathetic vasoconstriction of the peripheral vasculature and the splanchnic circulation, and diminished control of heart rate and cardiac output. In addition, impaired descending sympathetic control results in changes in circulating levels of plasma catecholamines, which can have a profound effect on cardiovascular function. Although individuals with lesions below T6 often have normal resting blood pressures, there is evidence of increases in resting heart rate and inadequate cardiovascular response to autonomic provocations such as the head-up tilt and cold face tests. This manuscript reviews the prevalence of cardiovascular disorders given the level, duration and severity of SCI, the clinical presentation, diagnostic workup, short- and long-term consequences, and empirical evidence supporting management strategies to treat cardiovascular dysfunction following a SCI.
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Mneimneh F, Moussalem C, Ghaddar N, Ghali K, Omeis I. Experimental study on the effectiveness of the PCM cooling vest in persons with paraplegia of varying levels. J Therm Biol 2020; 91:102634. [PMID: 32716876 DOI: 10.1016/j.jtherbio.2020.102634] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/23/2020] [Accepted: 05/27/2020] [Indexed: 11/17/2022]
Abstract
Persons with paraplegia (PA) from thoracic spinal cord injury (T1-T12) are prone to thermal stress during exercise due to impaired thermoregulation. This study evaluates the effectiveness of phase change material (PCM) cooling vests on persons with PA of different levels of injury during exercise in hot exposure. Sixteen participants were recruited and divided to three groups based on injury level; high-thoracic T1-T3, mid-thoracic T4-T8, and low thoracic T9-T12 to perform a 30-min arm-crank exercise at a 30 °C room condition. Two types of PCM vests at melting temperature of 20 °C were tested: i) V1 with PCM covering the trunk of 3.4 kg overall vest mass and ii) V2 with PCM covering chest and upper back of 2.17 kg overall vest mass. High thoracic and low-thoracic groups performed NV and V1 tests; whereas, mid-thoracic group performed NV, V1, and V2 tests. Heart rate, core, and skin temperatures were monitored during 15-min preconditioning, 30-min exercise, and 15-min recovery. In addition, thermal comfort, sensation, skin wettedness, and perceived exertion were recorded during exercise only. The main findings were that the effectiveness of the cooling vest was dependent on injury level and portion of sensate skin of trunk covered by the PCM packets. Rise in core temperature (ΔTcr) was reduced significantly for the low-thoracic group during exercise and recovery (ΔTcr=0.41°C, 0.26°C for NV and V1; respectively, p<0.05). For the mid-thoracic group, both V1 (p = 0.001) and V2 (p = 0.008) were effective in reducing ΔTcr compared to the NV test at the end of the recovery period (0.74°C,0.42°C,0.56°C, for NV, V1 and V2; respectively). For the high-thoracic group, V1 was not effective in reducing core temperature (p>0.05). For the mid-thoracic group, V2 at 36% lower mass significantly improved thermal comfort (p = 0.0004) compared to the NV test and was as effective compared to V1 in reducing core temperature.
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Affiliation(s)
- Farah Mneimneh
- Mechanical Engineering Department, American University of Beirut, P.O. Box 11-0236, Beirut, 1107-2020, Lebanon
| | - Charbel Moussalem
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, P.O. Box: 11-0236, Riad El Solh Beirut, 1107 2020, Beirut, Lebanon
| | - Nesreen Ghaddar
- Mechanical Engineering Department, American University of Beirut, P.O. Box 11-0236, Beirut, 1107-2020, Lebanon.
| | - Kamel Ghali
- Mechanical Engineering Department, American University of Beirut, P.O. Box 11-0236, Beirut, 1107-2020, Lebanon
| | - Ibrahim Omeis
- Division of Neurosurgery, Department of Surgery, American University of Beirut Medical Center, P.O. Box: 11-0236, Riad El Solh Beirut, 1107 2020, Beirut, Lebanon
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Suresh S, Duerstock BS. Automated Detection of Symptomatic Autonomic Dysreflexia Through Multimodal Sensing. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2020; 8:2800108. [PMID: 32082953 PMCID: PMC7028437 DOI: 10.1109/jtehm.2019.2955947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/08/2019] [Accepted: 11/17/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Autonomic Dysreflexia (AD) is a potentially life-threatening syndrome which occurs in individuals with higher level spinal cord injuries (SCI). AD is caused by triggers which can lead to rapid escalation of pathophysiological responses and if the trigger is not removed, AD can be fatal. There is currently no objective, non-invasive and accurate monitoring system available to automatically detect the onset of AD symptoms in real time in a non-clinical setting. Technology or Method: We developed a user-independent method of symptomatic AD detection in real time with a wearable physiological telemetry system (PTS) and a machine learning model using data from eleven participants with SCI. RESULTS The PTS could detect onset of AD symptoms with an average accuracy of 94.10% and a false negative rate of 4.89%. CONCLUSIONS The PTS can detect the onset of the symptoms AD with high sensitivity and specificity to assist people with SCIs in preventing the occurrence of AD. It would enable persons with high level SCIs to be more independent and pursue vocational activities while granting continuous medical oversight. Clinical Impact: The PTS could serve as a supplementary tool to current solutions to detect the onset of AD and prepare individuals who are newly injured to be better prepared for AD episodes. Moreover, it could be translated into a system to encourage individuals to practice better healthcare management to prevent future occurrences.
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Affiliation(s)
- Shruthi Suresh
- Weldon School of Biomedical EngineeringPurdue UniversityWest LafayetteIN47907USA
| | - Bradley S. Duerstock
- Weldon School of Biomedical EngineeringPurdue UniversityWest LafayetteIN47907USA
- School of Industrial EngineeringPurdue UniversityWest LafayetteIN47907USA
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Abstract
OBJECTIVE To examine differences in heart rate (HR) responses during international wheelchair rugby competition between athletes with and without a cervical spinal cord injury (SCI) and across standardized sport classifications. DESIGN Observational study. SETTING The 2015 Parapan American Games wheelchair rugby competition. PARTICIPANTS Forty-three male athletes (31 ± 8 years) with a cervical SCI (n = 32) or tetraequivalent impairment (non-SCI, n = 11). MAIN OUTCOME MEASURES Average and peak HR (HRavg and HRpeak, respectively). To characterize HR responses in accordance with an athletes' International Wheelchair Rugby Federation (IWRF) classification, we separated athletes into 3 groups: group I (IWRF classification 0.5-1.5, n = 15); group II (IWRF classification 2.0, n = 15); and group III (IWRF classification 2.5-3.5, n = 13). RESULTS Athletes with SCI had lower HRavg (111 ± 14 bpm vs 155 ± 13 bpm) and HRpeak (133 ± 12 bpm vs 178 ± 13 bpm) compared with non-SCI (both P < 0.001). Average HR was higher in group III than in I (136 ± 25 bpm vs 115 ± 20 bpm, P = 0.045); however, SCI athletes showed no difference in HRavg or HRpeak between groups. Within group III, SCI athletes had lower HRavg (115 ± 6 bpm vs 160 ± 8 bpm) and HRpeak (135 ± 11 bpm vs 183 ± 11 bpm) than non-SCI athletes (both P < 0.001). CONCLUSIONS This study is the first to demonstrate attenuated HR responses during competition in SCI compared with non-SCI athletes, likely due to injury to spinal autonomic pathways. Among athletes with SCI, IWRF classification was not related to differences in HR. Specific assessment of autonomic function after SCI may be able to predict HR during competition and consideration of autonomic impairments may improve the classification process.
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Application of electrophysiological measures in spinal cord injury clinical trials: a narrative review. Spinal Cord 2019; 57:909-923. [PMID: 31337870 DOI: 10.1038/s41393-019-0331-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 01/05/2023]
Abstract
STUDY DESIGN Narrative review. OBJECTIVES To discuss how electrophysiology may contribute to future clinical trials in spinal cord injury (SCI) in terms of: (1) improvement of SCI diagnosis, patient stratification and determination of exclusion criteria; (2) the assessment of adverse events; and (3) detection of therapeutic effects following an intervention. METHODS An international expert panel for electrophysiological measures in SCI searched and discussed the literature focused on the topic. RESULTS Electrophysiology represents a valid method to detect, track, and quantify readouts of nerve functions including signal conduction, e.g., evoked potentials testing long spinal tracts, and neural processing, e.g., reflex testing. Furthermore, electrophysiological measures can predict functional outcomes and thereby guide rehabilitation programs and therapeutic interventions for clinical studies. CONCLUSION Objective and quantitative measures of sensory, motor, and autonomic function based on electrophysiological techniques are promising tools to inform and improve future SCI trials. Complementing clinical outcome measures, electrophysiological recordings can improve the SCI diagnosis and patient stratification, as well as the detection of both beneficial and adverse events. Specifically composed electrophysiological measures can be used to characterize the topography and completeness of SCI and reveal neuronal integrity below the lesion, a prerequisite for the success of any interventional trial. Further validation of electrophysiological tools with regard to their validity, reliability, and sensitivity are needed in order to become routinely applied in clinical SCI trials.
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Horiuchi M, Fukuoka Y. Absence of cardiovascular drift during prolonged arm-crank exercise in individuals with spinal cord injury. Spinal Cord 2019; 57:942-952. [DOI: 10.1038/s41393-019-0301-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/15/2019] [Accepted: 05/18/2019] [Indexed: 11/09/2022]
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Krassioukov AV, Currie KD, Hubli M, Nightingale TE, Alrashidi AA, Ramer L, Eng JJ, Ginis KAM, MacDonald MJ, Hicks A, Ditor D, Oh P, Verrier MC, Craven BC. Effects of exercise interventions on cardiovascular health in individuals with chronic, motor complete spinal cord injury: protocol for a randomised controlled trial [Cardiovascular Health/Outcomes: Improvements Created by Exercise and education in SCI (CHOICES) Study]. BMJ Open 2019; 9:e023540. [PMID: 30612110 PMCID: PMC6326283 DOI: 10.1136/bmjopen-2018-023540] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Recent studies demonstrate that cardiovascular diseases and associated complications are the leading cause of morbidity and mortality in individuals with spinal cord injury (SCI). Abnormal arterial stiffness, defined by a carotid-to-femoral pulse wave velocity (cfPWV) ≥10 m/s, is a recognised risk factor for heart disease in individuals with SCI. There is a paucity of studies assessing the efficacy of conventional training modalities on arterial stiffness and other cardiovascular outcomes in this population. Therefore, this study aims to compare the efficacy of arm cycle ergometry training (ACET) and body weight-supported treadmill training (BWSTT) on reducing arterial stiffness in individuals with chronic motor complete, high-level (above the sixth thoracic segment) SCI. METHODS AND ANALYSIS This is a multicentre, randomised, controlled, clinical trial. Eligible participants will be randomly assigned (1:1) into either ACET or BWSTT groups. Sixty participants with chronic (>1 year) SCI will be recruited from three sites in Canada (Vancouver, Toronto and Hamilton). Participants in each group will exercise three times per week up to 30 min and 60 min for ACET and BWSTT, respectively, over the period of 6 months. The primary outcome measure will be change in arterial stiffness (cfPWV) from baseline. Secondary outcome measures will include comprehensive assessments of: (1) cardiovascular parameters, (2) autonomic function, (3) body composition, (4) blood haematological and metabolic profiles, (5) cardiorespiratory fitness and (6) quality of life (QOL) and physical activity outcomes. Outcome measures will be assessed at baseline, 3 months, 6 months and 12 months (only QOL and physical activity outcomes). Statistical analyses will apply linear-mixed modelling to determine the training (time), group (ACET vs BWSTT) and interaction (time × group) effects on all outcomes. ETHICS AND DISSEMINATION Ethical approval was obtained from all three participating sites. Primary and secondary outcome data will be submitted for publication in peer-reviewed journals and widely disseminated. TRIAL REGISTRATION NUMBER NCT01718977; Pre-results. TRIAL STATUS Recruitment for this study began on January 2013 and the first participant was randomized on April 2013. Recruitment stopped on October 2018.
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Affiliation(s)
- Andrei V Krassioukov
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
- GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Katharine D Currie
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Kinesiology, Michigan State University, East Lansing, Michigan, USA
| | - Michèle Hubli
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
- Balgrist University Hospital, University of Zurich, Zurich, Swaziland
| | - Tom E Nightingale
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Abdullah A Alrashidi
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Medicine, Experimental Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Physical Therapy Department, King Fahd Medical City, Riyadh, Saudi Arabia
| | - Leanne Ramer
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
- Biomedical Physiology and Kinesiology, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Janice J Eng
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
- GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, British Columbia, Canada
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kathleen A Martin Ginis
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
- Southern Medical Program, School of Health & Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
| | | | - Audrey Hicks
- Spinal Cord Injury Centre, McMaster University, Hamilton, Ontario, Canada
| | - Dave Ditor
- Department of Kinesiology, Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Paul Oh
- Department of Medicine University Health Network, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Molly C Verrier
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Beverly Catharine Craven
- Department of Medicine University Health Network, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
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Badry R, Gamal RM, Hassanien MM, El Hamed MA, Hammam N, El Fawal BM. Sympathetic skin response in patients with systemic sclerosis and rheumatoid arthritis. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2018; 54:38. [PMID: 30546249 PMCID: PMC6267634 DOI: 10.1186/s41983-018-0044-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 11/18/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Sympathetic skin response (SSR) is a technique to assess the sympathetic cholinergic pathways. Sympathetic dysfunction may participate in the development of pain, which is the major complaint in patients with systemic sclerosis (SSc) and rheumatoid arthritis (RA). OBJECTIVES In this study, we aimed to assess the autonomic dysfunction in patients with (SSc) and (RA) using SSR as a simple neurophysiologic test. METHODS Palmar SSR to median nerve electrical stimulation was recorded in 21 patients with SSc, 39 patients with RA, and in 60 healthy age and sex-matched control subjects. RESULTS Palmar SSR to median nerve stimulation (of SSc patients and RA patients) shows significantly delayed latency and reduced amplitude in comparison to the control group. SSR of SSc patients has significantly delayed latency and reduced amplitude when compared to RA patients. Moreover, six SSc patients have delayed SSR in spite of the absence of manifestations of polyneuropathy. CONCLUSIONS Patients with SSc and RA have features of autonomic dysfunction with more affection of SSc patients.
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Affiliation(s)
- Reda Badry
- Department of Neurology and Psychiatry, Assiut University Hospital, Post Box: 711526, Assiut, Egypt
| | - Rania M. Gamal
- Rheumatology and Rehabilitation Department, Assiut University Hospital, Assiut, Egypt
| | - Manal M. Hassanien
- Rheumatology and Rehabilitation Department, Assiut University Hospital, Assiut, Egypt
| | - Mohamed Abd El Hamed
- Department of Neurology and Psychiatry, Assiut University Hospital, Post Box: 711526, Assiut, Egypt
| | - Nevin Hammam
- Rheumatology and Rehabilitation Department, Assiut University Hospital, Assiut, Egypt
| | - Bastawy M. El Fawal
- Department of Neurology and Psychiatry, Aswan University Hospital, Aswan, Egypt
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Walter M, Krassioukov AV. Autonomic Nervous System in Paralympic Athletes with Spinal Cord Injury. Phys Med Rehabil Clin N Am 2018; 29:245-266. [PMID: 29627087 DOI: 10.1016/j.pmr.2018.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Individuals sustaining a spinal cord injury (SCI) frequently suffer from sensorimotor and autonomic impairment. Damage to the autonomic nervous system results in cardiovascular, respiratory, bladder, bowel, and sexual dysfunctions, as well as temperature dysregulation. These complications not only impede quality of life, but also affect athletic performance of individuals with SCI. This article summarizes existing evidence on how damage to the spinal cord affects the autonomic nervous system and impacts the performance in athletes with SCI. Also discussed are frequently used performance-enhancing strategies, with a special focus on their legal aspect and implication on the athletes' health.
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Affiliation(s)
- Matthias Walter
- Faculty of Medicine, International Collaboration on Repair Discoveries (ICORD), University of British Columbia, 818 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada
| | - Andrei V Krassioukov
- Division of Physical Medicine and Rehabilitation, Department of Medicine, International Collaboration on Repair Discoveries (ICORD), Blusson Spinal Cord Centre, University of British Columbia, GF Strong Rehabilitation Centre, Vancouver Coastal Health, 818 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada.
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Brown R, Burton AR, Macefield VG. Autonomic dysreflexia: Somatosympathetic and viscerosympathetic vasoconstrictor responses to innocuous and noxious sensory stimulation below lesion in human spinal cord injury. Auton Neurosci 2018; 209:71-78. [DOI: 10.1016/j.autneu.2017.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 06/24/2017] [Accepted: 07/11/2017] [Indexed: 11/17/2022]
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Nicotra A, Young TM, Asahina M, Mathias CJ. The Effect of Different Physiological Stimuli on Skin Vasomotor Reflexes above and below the Lesion in Human Chronic Spinal Cord Injury. Neurorehabil Neural Repair 2016; 19:325-31. [PMID: 16263964 DOI: 10.1177/1545968305281210] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective. Spinal cord injury (SCI) results in disruption of descending tonic activation of sympathetic circuits in the spinal cord. The authors determined whether different stimuli that increase sympathetic activity induced cutaneous vasoconstriction (skin vasomotor reflex, SkVR) above and below the level of lesion in subjects with clinically complete SCI. Methods. Baseline skin blood flow (SkBF) and SkVR reduction rate in the pulp of the finger and great toe was measured by laser Doppler probes in chronic complete SCI and in controls. Results. In the finger, baseline SkBF was similar in SCI and controls. The SkVR was elicited by all stimuli in controls but was significantly diminished to gasp, mental arithmetic, tactile stimulation, cutaneous cold, and deep breathing in high SCI compared to controls. In the toe, baseline SkBF was less stable in both controls and SCI. SkVR trends were identified in controls, and responses were not present or greatly reduced in high and low SCI. Conclusions. Measurements of skin vasomotor reflexes to physiological stimuli may be a noninvasive method to evaluate the extent of sympathetic adrenergic pathways in chronic SCI. This is of clinical relevance in monitoring recovery of sympathetic adrenergic function either spontaneously or following repair interventions.
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Affiliation(s)
- Alessia Nicotra
- Neurovascular Medicine Unit, Faculty of Medicine, Imperial College London at St Mary's Hospital, UK.
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Currie KD, West CR, Hubli M, Gee CM, Krassioukov AV. Peak heart rates and sympathetic function in tetraplegic nonathletes and athletes. Med Sci Sports Exerc 2016; 47:1259-64. [PMID: 25211366 DOI: 10.1249/mss.0000000000000514] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE To examine differences in peak heart rate (HR) and measures of sympathetic function between nonathletes and athletes with chronic, motor-complete, cervical spinal cord injury (SCI). METHODS Eight nonathletic men with SCI (C4-C7; age 47 ± 9 yr, with injury duration of 16 ± 9 yr) and 13 athletic men with SCI (C5-C8; age 37 ± 8 yr, with injury duration of 16 ± 6 yr) participated in the study. Measures of sympathetic function included palmar sympathetic skin responses (SSR) to median nerve stimulation, and systolic (SBP) and diastolic (DBP) blood pressure responses to a passive sit-up test. Peak HR responses were assessed during a maximal exercise test. RESULTS Compared to the athletic group, the nonathletic group exhibited lower peak HR (102 ± 34 vs 161 ± 20 bpm, P < 0.001) and average SSR scores (0.13 ± 0.35 vs 2.41 ± 1.97, P = 0.008), along with greater reductions in SBP and DBP in response to passive sit-up (SBP: -22 ± 10 vs -9 ± 12 mm Hg, P = 0.019; DBP: -18 ± 8 mm Hg vs -4 ± 9 mm Hg, P = 0.003). On the basis of the criteria for orthostatic hypotension (OH) (drop in SBP ≥ 20 mm Hg or DBP ≥ 10 mm Hg), 88% and 23% of nonathletes and athletes had OH. CONCLUSIONS Attenuated peak HR in nonathletic individuals with tetraplegia may be secondary to impairments in sympathetic function including absent SSR and OH. Furthermore, the degree of preserved sympathetic function documented in tetraplegic athletes may suggest a predisposition to engage in high-performance sports. Collectively, our findings provide novel insight into the importance of the sympathetic nervous system for exercise performance.
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Affiliation(s)
- Katharine D Currie
- 1International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, CANADA; 2Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, CANADA; 3G. F. Strong Rehabilitation Centre, Vancouver, British Columbia, CANADA
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15
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West CR, Krassioukov AV. Autonomic cardiovascular control and sports classification in Paralympic athletes with spinal cord injury. Disabil Rehabil 2016; 39:127-134. [DOI: 10.3109/09638288.2015.1118161] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Christopher R. West
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Andrei V. Krassioukov
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada
- G. F. Strong Rehab Centre, Vancouver, BC, Canada
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Boosting in Elite Athletes with Spinal Cord Injury: A Critical Review of Physiology and Testing Procedures. Sports Med 2015; 45:1133-42. [DOI: 10.1007/s40279-015-0340-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Krassioukov A, West C. The role of autonomic function on sport performance in athletes with spinal cord injury. PM R 2015; 6:S58-65. [PMID: 25134753 DOI: 10.1016/j.pmrj.2014.05.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 05/05/2014] [Accepted: 05/21/2014] [Indexed: 11/17/2022]
Abstract
Devastating paralysis, autonomic dysfunction, and abnormal cardiovascular control present significant hemodynamic challenges to individuals with spinal cord injury (SCI), especially during exercise. In general, resting arterial pressure after SCI is lower than with able-bodied individuals and is commonly associated with persistent orthostatic intolerance along with transient episodes of life-threatening hypertension, known as "autonomic dysreflexia." During exercise, the loss of central and reflexive cardiovascular control attenuates maximal heart rate and impairs blood pressure regulation and blood redistribution, which ultimately reduces venous return, stroke volume, and cardiac output. Thermoregulation also is severely compromised in high-lesion SCI, a problem that is compounded when competing in hot and humid conditions. There is some evidence that enhancing venous return via lower body positive pressure or abdominal binding improves exercise performance, as do cooling strategies. Athletes with SCI also have been documented to self-induce autonomic dysreflexia before competition with a view of increasing blood pressure and improving their performance, a technique known as "boosting." For health safety reasons, boosting is officially banned by the International Paralympics Committee. This article addresses the complex issue of how the autonomic nervous system affects sports performance in athletes with SCI, with a specific focus on the potential debilitating effects of deranged cardiovascular control.
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Affiliation(s)
- Andrei Krassioukov
- International Collaboration on Repair Discoveries, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, British Columbia, Canada∗; International Collaboration on Repair Discoveries, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada(†).
| | - Christopher West
- International Collaboration on Repair Discoveries, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, British Columbia, Canada∗
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18
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Sweating on the palm and sole: physiological and clinical relevance. Clin Auton Res 2015; 25:153-9. [DOI: 10.1007/s10286-015-0282-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 12/11/2014] [Indexed: 01/23/2023]
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West CR, Wong SC, Krassioukov AV. Autonomic cardiovascular control in Paralympic athletes with spinal cord injury. Med Sci Sports Exerc 2014; 46:60-8. [PMID: 23739527 DOI: 10.1249/mss.0b013e31829e46f3] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Disruption of autonomic control after spinal cord injury (SCI) results in life-threatening cardiovascular dysfunctions and impaired endurance performance; hence, an improved ability to recognize those at risk of autonomic disturbances is of critical clinical and sporting importance. PURPOSE The objective of this study is to assess the effect of neurological level, along with motor, sensory, and autonomic completeness of injury, on cardiovascular control in Paralympic athletes with SCI. METHODS Fifty-two highly trained male Paralympic athletes (age, 34.8 ± 7.1 yr) from 14 countries with chronic SCI (C2-L2) completed three experimental trials. During trial 1, motor and sensory functions were assessed according to the American Spinal Injury Association Impairment Scale. During trial 2, autonomic function was assessed via sympathetic skin responses (SSR). During trial 3, cardiovascular control was assessed via the beat-by-beat blood pressure response to orthostatic challenge. RESULTS Athletes with cervical SCI exhibited the lowest seated blood pressure and the most severe orthostatic hypotension (P < 0.025). There were no differences in cardiovascular function between athletes with different American Spinal Injury Association Impairment Scale grades (P > 0.96). Conversely, those with the lowest SSR scores exhibited the lowest seated blood pressure and the most severe orthostatic hypotension (P < 0.002). Linear regression demonstrated that the combined model of neurological level and autonomic completeness of SCI explained the most variance in all blood pressure indices. CONCLUSION We demonstrate for the first time that neurological level and SSR score provide the optimal combination of assessments to identify those at risk of abnormal cardiovascular control. We advocate the use of autonomic testing in the clinical and sporting classification of SCI athletes.
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Affiliation(s)
- Christopher R West
- 1International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, CANADA; 2Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, BC, CANADA; and 3GF Strong Rehabilitation Centre, Vancouver, BC, CANADA
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West CR, Gee CM, Voss C, Hubli M, Currie KD, Schmid J, Krassioukov AV. Cardiovascular control, autonomic function, and elite endurance performance in spinal cord injury. Scand J Med Sci Sports 2014; 25:476-85. [DOI: 10.1111/sms.12308] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 12/17/2022]
Affiliation(s)
- C. R. West
- International Collaboration on Repair Discoveries (ICORD); Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - C. M. Gee
- International Collaboration on Repair Discoveries (ICORD); Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - C. Voss
- Centre for Hip Health and Mobility; Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - M. Hubli
- International Collaboration on Repair Discoveries (ICORD); Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - K. D. Currie
- International Collaboration on Repair Discoveries (ICORD); Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
| | - J. Schmid
- Paracycling Classification; International Cycling Union; Aigle Switzerland
| | - A. V. Krassioukov
- International Collaboration on Repair Discoveries (ICORD); Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
- Division of Physical Medicine and Rehabilitation; Faculty of Medicine; University of British Columbia; Vancouver British Columbia Canada
- GF Strong Rehabilitation Centre; Vancouver Health Authority; Vancouver British Columbia Canada
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Berger MJ, Hubli M, Krassioukov AV. Sympathetic skin responses and autonomic dysfunction in spinal cord injury. J Neurotrauma 2014; 31:1531-9. [PMID: 24874269 DOI: 10.1089/neu.2014.3373] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Sympathetic skin responses (SSRs), a measure of sympathetic cholinergic sudomotor function, have been used in the assessment of autonomic dysfunction in patients with spinal cord injury (SCI). This review highlights the basic mechanisms underlying SSRs as well as their application to the SCI population. We address the utility of SSRs in assessing autonomic function, the relationship between autonomic and sensorimotor impairment, and the association between SSRs and the sequelae of autonomic dysfunction in SCI, particularly autonomic dysreflexia and orthostatic hypotension. Overall, SSRs are a rapid, convenient and non-invasive method illustrating that the severity of autonomic impairment can be independent from sensorimotor impairment. We suggest that SSRs be used in conjunction with other validated autonomic tests in order to predict or document autonomic dysfunction in SCI.
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Affiliation(s)
- Michael J Berger
- 1 Division of Physical Medicine and Rehabilitation, University of British Columbia , Vancouver
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Kumru H, Schubert M, Benito J, Opisso E, Vidal J. Reappearance of sympathetic skin response below a thoracic level-9 complete spinal cord injury. Auton Neurosci 2013; 181:90-3. [PMID: 24359880 DOI: 10.1016/j.autneu.2013.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 10/24/2013] [Accepted: 11/29/2013] [Indexed: 10/25/2022]
Abstract
Reappearance of sympathetic skin response (SSR) below lesion is reported in a patient with a complete thoracic-9 spinal cord injury 6 months following injury. SSR was elicited by electrical stimulation of supraorbital nerve (SON) and pudendal nerve (PN). SON stimulation induced SSRs only in the hand. SSRs were initially absent below the level of SCI but reappeared only with PN stimulation. This case suggests that 6 months following a complete lesion, the isolated spinal cord can generate a SSR. Possible underlying mechanisms and implications for autonomic plasticity below spinal lesion are discussed in view of the literature.
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Affiliation(s)
- Hatice Kumru
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, 08916 Badalona, Barcelona, Spain; Univ Autonoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Spain; Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain.
| | - Martin Schubert
- Spinal Cord Injury Center, University Hospital Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Jesus Benito
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, 08916 Badalona, Barcelona, Spain; Univ Autonoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Spain; Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Eloy Opisso
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, 08916 Badalona, Barcelona, Spain; Univ Autonoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Spain; Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Joan Vidal
- Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, 08916 Badalona, Barcelona, Spain; Univ Autonoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Spain; Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, Spain
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West CR, Bellantoni A, Krassioukov AV. Cardiovascular function in individuals with incomplete spinal cord injury: a systematic review. Top Spinal Cord Inj Rehabil 2013; 19:267-78. [PMID: 24244092 DOI: 10.1310/sci1904-267] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is a clear relationship between the neurological level of spinal cord injury (SCI) and cardiovascular function; however, the relationship between completeness of injury and cardiovascular function is less straightforward. Traditionally completeness of injury has referred to neurological (motor/sensory) completeness. Recently, a number of studies have started to investigate autonomic completeness of injury. OBJECTIVE To investigate the relationships between cardiovascular function and neurological and autonomic completeness of injury. METHODS A literature search was conducted in November 2012 through MEDLINE, Embase, and CINAHL. Twenty-one studies were included in this review. RESULTS In acute SCI, there is no clear consensus about whether resting heart rate (HR), blood pressure (BP), or prevalence of BP abnormalities differs between neurologically complete and incomplete SCI. In chronic SCI, there is limited evidence that there is less prevalence of autonomic dysreflexia and improved heart rate variability in response to provocation in neurologically incomplete SCI; however, resting HR and BP appear similar between neurologically complete and incomplete SCI. There is growing evidence that BP and HR at rest and during orthostasis is enhanced in autonomically incomplete SCI. Numerous studies report that neurological completeness does not agree with autonomic completeness of injury. CONCLUSIONS For acute SCI, there is no clear consensus whether cardiovascular function differs between complete and incomplete. For chronic SCI, the studies to date suggest that autonomic completeness of SCI is more strongly related to cardiovascular function than neurological completeness of injury. Thus, clinicians and scientists should account for autonomic completeness of injury when assessing cardiovascular function in SCI.
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Affiliation(s)
- Christopher R West
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia , Vancouver, British Columbia , Canada
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Emad R, Zafarghasempour M, Roshanzamir S. Sympathetic skin response in incomplete spinal cord injury with urinary incontinence. Ann Indian Acad Neurol 2013; 16:234-8. [PMID: 23956572 PMCID: PMC3724082 DOI: 10.4103/0972-2327.112479] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 02/23/2012] [Accepted: 07/01/2012] [Indexed: 11/24/2022] Open
Abstract
Objectives: Sympathetic skin response (SSR) is a test for evaluation of the sympathetic sweat gland pathways, and it has been used to study the central sympathetic pathways in spinal cord injury (SCI). This study aimed to assess the autonomic pathways according to normal or abnormal SSR in urinary incontinence patients due to incomplete spinal cord injury. Materials and Methods: Suprapubic, palmar, and plantar SSR to the peripheral nerve electrical stimulation were recorded in 16 urinary incontinence patients with incomplete spinal cord injury at various neurological levels and in 30 healthy control subjects. Results: All the recordings of SSR from the incomplete SCI patients with urinary incontinence as compared with their counterparts in the control group showed significantly reduced amplitudes with more prominent reduction in the suprapubic area recording site (P value < 0.0004). SSR with significantly prolonged latencies were recorded from palm and plantar areas in response to suprapubic area and tibial N stimuli, respectively (P value < 0.02). In this study, a significantly higher stimulus intensity (P value < 0.01) was needed to elicit SSR in the cases compared with the control group. Conclusion: This study showed abnormal SSR in urinary incontinence patients due to incomplete SCI. In addition, for the first time we have described recording of abnormal SSR from the suprapubic area as another way to show bladder sympathetic system involvement.
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Affiliation(s)
- Reza Emad
- Department of Physical Medicine and Rehabilitation, Shahid Faghihi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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25
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Collet C, Di Rienzo F, El Hoyek N, Guillot A. Autonomic nervous system correlates in movement observation and motor imagery. Front Hum Neurosci 2013; 7:415. [PMID: 23908623 PMCID: PMC3726866 DOI: 10.3389/fnhum.2013.00415] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 07/11/2013] [Indexed: 11/13/2022] Open
Abstract
The purpose of the current article is to provide a comprehensive overview of the literature offering a better understanding of the autonomic nervous system (ANS) correlates in motor imagery (MI) and movement observation. These are two high brain functions involving sensori-motor coupling, mediated by memory systems. How observing or mentally rehearsing a movement affect ANS activity has not been extensively investigated. The links between cognitive functions and ANS responses are not so obvious. We will first describe the organization of the ANS whose main purposes are controlling vital functions by maintaining the homeostasis of the organism and providing adaptive responses when changes occur either in the external or internal milieu. We will then review how scientific knowledge evolved, thus integrating recent findings related to ANS functioning, and show how these are linked to mental functions. In turn, we will describe how movement observation or MI may elicit physiological responses at the peripheral level of the autonomic effectors, thus eliciting autonomic correlates to cognitive activity. Key features of this paper are to draw a step-by step progression from the understanding of ANS physiology to its relationships with high mental processes such as movement observation or MI. We will further provide evidence that mental processes are co-programmed both at the somatic and autonomic levels of the central nervous system (CNS). We will thus detail how peripheral physiological responses may be analyzed to provide objective evidence that MI is actually performed. The main perspective is thus to consider that, during movement observation and MI, ANS activity is an objective witness of mental processes.
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Affiliation(s)
- C Collet
- Mental processes and Motor Performance Laboratory, EA 647 CRIS, University of Lyon - Claude Bernard University Lyon 1 Villeurbanne Cedex, France
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WEST CHRISTOPHERR, ROMER LEEM, KRASSIOUKOV ANDREI. Autonomic Function and Exercise Performance in Elite Athletes with Cervical Spinal Cord Injury. Med Sci Sports Exerc 2013; 45:261-7. [DOI: 10.1249/mss.0b013e31826f5099] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Marchal-Crespo L, Zimmermann R, Lambercy O, Edelmann J, Fluet MC, Wolf M, Gassert R, Riener R. Motor execution detection based on autonomic nervous system responses. Physiol Meas 2012; 34:35-51. [PMID: 23248174 DOI: 10.1088/0967-3334/34/1/35] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Triggered assistance has been shown to be a successful robotic strategy for provoking motor plasticity, probably because it requires neurologic patients' active participation to initiate a movement involving their impaired limb. Triggered assistance, however, requires sufficient residual motor control to activate the trigger and, thus, is not applicable to individuals with severe neurologic injuries. In these situations, brain and body-computer interfaces have emerged as promising solutions to control robotic devices. In this paper, we investigate the feasibility of a body-machine interface to detect motion execution only monitoring the autonomic nervous system (ANS) response. Four physiological signals were measured (blood pressure, breathing rate, skin conductance response and heart rate) during an isometric pinching task and used to train a classifier based on hidden Markov models. We performed an experiment with six healthy subjects to test the effectiveness of the classifier to detect rest and active pinching periods. The results showed that the movement execution can be accurately classified based only on peripheral autonomic signals, with an accuracy level of 84.5%, sensitivity of 83.8% and specificity of 85.2%. These results are encouraging to perform further research on the use of the ANS response in body-machine interfaces.
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Affiliation(s)
- Laura Marchal-Crespo
- Sensory-Motor Systems Laboratory, Institute of Robotics and Intelligent Systems, ETH Zurich, 8006 Zurich, Switzerland.
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28
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The Sir Ludwig Guttmann Lecture 2012: the contribution of Stoke Mandeville Hospital to spinal cord injuries. Spinal Cord 2012; 50:790-6. [DOI: 10.1038/sc.2012.109] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Macefield VG, Burton AR, Brown R. Somatosympathetic Vasoconstrictor Reflexes in Human Spinal Cord Injury: Responses to Innocuous and Noxious Sensory Stimulation below Lesion. Front Physiol 2012; 3:215. [PMID: 22737131 PMCID: PMC3382416 DOI: 10.3389/fphys.2012.00215] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Accepted: 05/30/2012] [Indexed: 11/13/2022] Open
Abstract
It is known that the sudden increases in blood pressure associated with autonomic dysreflexia in people with spinal cord injury (SCI) are due to a spinally mediated reflex activation of sympathetic vasoconstrictor neurons supplying skeletal muscle and the gut. Apart from visceral inputs, such as those originating from a distended bladder, there is a prevailing opinion that autonomic dysreflexia can be triggered by noxious stimulation below the lesion. However, do noxious inputs really cause an increase in blood pressure in SCI? Using microelectrodes inserted into a peripheral nerve to record sympathetic nerve activity we had previously shown that selective stimulation of small-diameter afferents in muscle or skin, induced by bolus injection of hypertonic saline into the tibialis anterior muscle or the overlying skin, evokes a sustained increase in muscle sympathetic nerve activity and blood pressure and a transient increase in skin sympathetic nerve activity and decrease in skin blood flow in able-bodied subjects. We postulated that these sympathetic responses would be exaggerated in SCI, with a purely noxious stimulus causing long-lasting increases in blood pressure and long-lasting decreases in skin blood flow. Surprisingly, though, we found that intramuscular or subcutaneous injection of hypertonic saline into the leg caused negligible changes in these parameters. Conversely, weak electrical stimulation over the abdominal wall, which in able-bodied subjects is not painful and activates large-diameter cutaneous afferents, caused a marked increase in blood pressure in SCI but not in able-bodied subjects. This suggests that it is activation of large-diameter somatic afferents, not small-diameter afferents, that triggers increases in sympathetic outflow in SCI. Whether the responses to activation of large-diameter afferents reflect plastic changes in the spinal cord in SCI is unknown.
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Affiliation(s)
- Vaughan G Macefield
- School of Medicine, University of Western Sydney and Neuroscience Research Australia Sydney, NSW, Australia
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30
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Using sympathetic skin responses in individuals with spinal cord injury as a quantitative evaluation of motor imagery abilities. Phys Ther 2012; 92:831-40. [PMID: 22403090 DOI: 10.2522/ptj.20110351] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Motor imagery (MI) ability should be evaluated in selected individuals with spinal cord injury (SCI) who can benefit from MI training in their rehabilitation program. Electrodermal activity seems to be a reliable indicator for assessing MI ability. However, individuals with SCI have a variety of autonomic dysfunctions. OBJECTIVE This study aimed to investigate electrodermal responses (EDRs) elicited by MI. DESIGN A cost-utility analysis of EDR above and below the lesion level in individuals with complete or incomplete SCI (n = 30) versus a control group of individuals who were healthy (n = 10) was used. METHOD The EDR was recorded above and below the lesion level during MI of a drinking action. Duration, latency, and amplitude of EDR were the outcome measures. RESULTS Hand and foot EDR in the control group occurred with the same pattern and similar latencies, suggesting a common efferent sympathetic pathway to sweat glands of the hand and foot mediating a sympathetic skin response. Individuals with SCI elicited responses above the lesion level. The EDR amplitude was correlated to the lesion level and autonomic dysreflexia history. No foot response was recorded in individuals with complete cervical and thoracic motor lesions. Foot response with a lower amplitude and higher latency occurred in participants with incomplete motor lesion, suggesting a link between the descending motor pathway and sympathetic function. LIMITATIONS The small sample of individuals with incomplete SCI limits the generalization of the results obtained at the foot site. CONCLUSIONS Electrodermal response above the lesion level may be a reliable index for assessing MI ability in individuals with SCI. It is a noninvasive, user-friendly method for clinicians to consider before enrolling individuals in MI training.
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Ravensbergen HJC, Walsh ML, Krassioukov AV, Claydon VE. Electrocardiogram-based predictors for arrhythmia after spinal cord injury. Clin Auton Res 2012; 22:265-73. [PMID: 22562253 DOI: 10.1007/s10286-012-0166-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 04/16/2012] [Indexed: 01/28/2023]
Abstract
PURPOSE Individuals with spinal cord injury (SCI) have an increased risk of cardiac arrhythmias, particularly during autonomic dysreflexia (acute hypertensive episodes). This may be partly due to impaired autonomic control of the heart after SCI. The interval between the peak and end of the T-wave of the electrocardiograph (ECG) provides an index of transmural dispersion of repolarisation, a factor underlying the development of ventricular arrhythmias. Another ECG-based risk factor for ventricular arrhythmias is variability in the QT segment, the QT variability index (QTVI). Similarly, P-wave variability may be correlated with risk for atrial arrhythmias. We aimed to: (1) determine whether there are abnormalities in these parameters at rest in those with SCI; (2) determine correlations between these ECG parameters and severity of autonomic impairment after SCI. METHODS ECG intervals were determined using customised software from a 15 min ECG recording (lead II) in 28 SCI subjects and 27 controls. Autonomic severity of SCI was determined from sympathetic skin responses, low frequency systolic blood pressure variability, and plasma noradrenaline levels. RESULTS T(peak)-T(end) variability and QTVI were increased in those with autonomically complete SCI compared to controls. P-wave variability was increased in SCI individuals compared to controls, and was negatively correlated with plasma noradrenaline. CONCLUSION The higher T(peak)-T(end) variability, QTVI and P-wave variability in individuals with SCI could be markers of severity of injury to cardiac autonomic (sympathetic) pathways after SCI, and may represent new risk assessment parameters for predisposition to cardiac arrhythmias in this population.
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Affiliation(s)
- H J C Ravensbergen
- Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
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West CR, Mills P, Krassioukov AV. Influence of the neurological level of spinal cord injury on cardiovascular outcomes in humans: a meta-analysis. Spinal Cord 2012; 50:484-92. [DOI: 10.1038/sc.2012.17] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Clinical neurophysiology in the prognosis and monitoring of traumatic spinal cord injury. HANDBOOK OF CLINICAL NEUROLOGY 2012; 109:63-75. [PMID: 23098706 DOI: 10.1016/b978-0-444-52137-8.00004-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Preclinical studies for the repair of spinal cord injury (SCI) and potential therapies for accessing the inherent plasticity of the central nervous system (CNS) to promote recovery of function are currently moving into the translational stage. These emerging clinical trials of therapeutic interventions for the repair of SCI require improved assessment techniques and quantitative outcome measures to supplement the American Spinal Injuries Association (ASIA) Impairment Scales. This chapter attempts to identify those electrophysiological techniques that show the most promise for provision of objective and quantitative measures of sensory, motor, and autonomic function in SCI. Reviewed are: (1) somatosensory evoked potentials, including dermatomal somatosensory evoked potentials, and the electrical perceptual threshold as tests of the dorsal (posterior) column pathway; (2) laser evoked potentials and contact heat evoked potentials as tests of the anterior spinothalamic tract; (3) motor evoked potentials in limb muscles, in response to transcranial magnetic stimulation of the motor cortex as tests of the corticospinal tract, and the application of the technique to assessment of trunk and sphincter muscles; and (4) the sympathetic skin response as a test of spinal cord access to the sympathetic chain.
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Previnaire JG, Soler JM, Leclercq V, Denys P. Severity of autonomic dysfunction in patients with complete spinal cord injury. Clin Auton Res 2011; 22:9-15. [DOI: 10.1007/s10286-011-0132-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 06/08/2011] [Indexed: 01/07/2023]
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Desmarais A, Descarreaux M, Houle S, Piché M. Tuning the gain of somato-sympathetic reflexes by stimulation of the thoracic spine in humans. Neurosci Lett 2011; 490:107-11. [DOI: 10.1016/j.neulet.2010.12.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 11/23/2010] [Accepted: 12/15/2010] [Indexed: 10/18/2022]
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Prévinaire JG, Mathias CJ, El Masri W, Soler JM, Leclercq V, Denys P. The isolated sympathetic spinal cord: Cardiovascular and sudomotor assessment in spinal cord injury patients: A literature survey. Ann Phys Rehabil Med 2010; 53:520-32. [PMID: 20797928 DOI: 10.1016/j.rehab.2010.06.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Revised: 06/21/2010] [Accepted: 06/29/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To present a comprehensive approach to the assessment of the severity of the autonomic lesion in spinal cord injury (SCI) patients, with regard to the level of lesion. To discuss how to assess an isolated sympathetic spinal cord that has lost supraspinal control (sympathetically complete lesion). METHOD PubMed was searched for articles related to cardiovascular (mainly cold pressor test, respiratory and postural challenges) and sudomotor (sympathetic skin responses) tests that have been used. The results of these evaluations are analysed with regard to the site of stimulation (above or below the lesion) according to three types of SCI that offer typical autonomic reactions (tetraplegics, paraplegics at T6 and at T10). RESULTS Non-invasive cardiovascular and sudomotor testing allows the assessment of the isolated sympathetic spinal cord in SCI patients. Typical responses are found in relation with the level of the sympathetic lesion. Its definition would allow comparison with the somatic motor and sensory level of lesion of SCI patients and provide additional aid to the classification of those patients. CONCLUSION For research purposes on the integrity of the spinal sympathetic pathways, a battery of test approach is probably needed, using a combination of stimuli above and below the lesion, evaluating both cardiovascular and sudomotor pathways.
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Affiliation(s)
- J G Prévinaire
- Département médullaire, centre Calvé, fondation Hopale, 62600 Berck-sur-Mer, France.
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Brown R, Burton A, Macefield VG. Input–output relationships of a somatosympathetic reflex in human spinal injury. Clin Auton Res 2009; 19:213-20. [DOI: 10.1007/s10286-009-0010-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 03/13/2009] [Indexed: 05/25/2023]
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Abstract
Electrophysiological measures can provide information that complements clinical assessments such as the American Spinal Injury Association sensory and motor scores in the evaluation of outcomes after spinal cord injury (SCI). The authors review and summarize the literature regarding tests that are most relevant to the study of SCI recovery--in particular, motor evoked potentials and somatosensory evoked potentials (SSEPs). In addition, they discuss the role of other tests, including F-wave nerve conductance tests and electromyography, sympathetic skin response, and the Hoffman reflex (H-reflex) test as well as the promise of dermatomal SSEPs and the electrical perceptual threshold test, newer quantitative tests of sensory function. It has been shown that motor evoked potential amplitudes improve with SCI recovery but latencies do not. Somatosensory evoked potentials are predictive of ambulatory capacity and hand function. Hoffman reflexes are present during spinal shock despite the loss of tendon reflexes, but their amplitudes increase with time after injury. Further, H-reflex modulation is reflective of changes in spinal excitability. While these tests have produced data that is congruent with clinical evaluations, they have yet to surpass clinical evaluations in predicting outcomes. Continuing research using these methodologies should yield a better understanding of the mechanisms behind SCI recovery and thus provide potentially greater predictive and evaluative power.
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Affiliation(s)
- James Xie
- Neural Plasticity and Outcomes Research Laboratories, Veterans' Affairs Palo Alto Health Care System, Stanford, California, USA
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Kumru H, Vidal J, Perez M, Schestatsky P, Valls-Solé J. Sympathetic Skin Responses Evoked by Different Stimuli Modalities in Spinal Cord Injury Patients. Neurorehabil Neural Repair 2009; 23:553-8. [DOI: 10.1177/1545968308328721] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. By using a combination of physiological and electrical peripheral nerve stimuli, the authors aimed to characterize the expected dysfunction of the circuits responsible for sympathetic skin response (SSR) in persons with spinal cord injury (SCI). Methods. The authors examined SSR induced in the hand and foot in 50 SCI patients and 15 age-matched and gender-matched healthy volunteers. SSR was induced by deep inhalation, unexpected acoustic stimuli, brisk hand muscle contraction, and median and peroneal nerve electrical stimulation (PNS). Results. SSRs to any stimulus modality were absent in hand and foot in patients with complete SCI above the T4 level. They were present in the hand and absent in the foot in complete SCI patients at levels between T4 and T11 for all stimuli modalities except PNS. The elicitability of SSR was lower with peroneal nerve stimulation than the other stimuli in hand and foot. The mean latency difference between SSRs of the hand and foot was significantly longer in patients than in controls, regardless of stimulus modality. The amplitude of SSR was larger in volunteers than in patients. Conclusion . SSR to various stimuli confirms the importance of supraspinal centers and the integrity of sympathetic descending pathways. Simultaneous recording of the SSR in the hands and feet provides information about the degree of sympathetic impairment possibly in the efferent pathway. To monitor spontaneous recovery or the efficacy of a drug or biological therapeutic intervention, changes in the latency delay between the hand and foot may be valuable.
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Affiliation(s)
- Hatice Kumru
- Department of Neurology and Neurorehabilitation, Instituto Guttmann, Badalona, Barcelona, Spain,
| | - Joan Vidal
- Department of Neurology and Neurorehabilitation, Instituto Guttmann, Badalona, Barcelona, Spain
| | - Maria Perez
- Department of Neurology and Neurorehabilitation, Instituto Guttmann, Badalona, Barcelona, Spain
| | - Pedro Schestatsky
- Service of Neurology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil, Unitat d'EMG, Servei de Neurologia, Hospital Clinic, Barcelona, Spain
| | - Josep Valls-Solé
- Unitat d'EMG, Servei de Neurologia, Hospital Clinic, Barcelona, Spain
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Previnaire JG, Soler JM, El Masri W, Denys P. Assessment of the sympathetic level of lesion in patients with spinal cord injury. Spinal Cord 2008; 47:122-7. [DOI: 10.1038/sc.2008.87] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Inskip JA, Ramer LM, Ramer MS, Krassioukov AV. Autonomic assessment of animals with spinal cord injury: tools, techniques and translation. Spinal Cord 2008; 47:2-35. [DOI: 10.1038/sc.2008.61] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Brown R, Engel S, Wallin BG, Elam M, Macefield V. Assessing the integrity of sympathetic pathways in spinal cord injury. Auton Neurosci 2007; 134:61-8. [PMID: 17321221 DOI: 10.1016/j.autneu.2007.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 09/29/2006] [Indexed: 11/24/2022]
Abstract
STUDY DESIGN Measurement of cutaneous sympathetic reflexes and hemodynamic responses to brief electrical stimuli applied above (forehead) and below (abdominal wall) a spinal lesion. OBJECTIVE To assess the validity of using cutaneous vasoconstriction as a sensitive indicator of increases in sympathetic activity in spinal cord injury. SETTING Prince of Wales Medical Research Institute, Australia. SUBJECTS Twenty spinal cord injured subjects with injuries ranging from C3-T11 and nine able-bodied controls. METHOD Cutaneous electrical stimulation was applied to the forehead and abdominal wall to subjects at unexpected times. Sudomotor and vasomotor responses, as well as continuous arterial pressure, heart rate and respiration were monitored. RESULTS Sudomotor (electrodermal) responses to forehead stimulation were scarce in spinal cord injured subjects, whereas cutaneous vasoconstrictor responses (photoelectric pulse plethysmography) provided a sensitive indicator of any remaining central control of sympathetic function below the lesion. Electrical stimulation applied to the abdominal wall evoked vasoconstrictor reflexes below the lesion in the majority of spinal cord injured subjects, whereas only a limited number of electrodermal responses were observed. That these cutaneous vasoconstrictor responses could reflect parallel increases in muscle and splanchnic vasoconstrictor activity was indicated by the increases in blood pressure; patients lacking vasoconstrictor responses rarely showed stimulus-induced blood pressure increases. CONCLUSION Our findings show that skin vasomotor responses to somatosensory stimulation provide a more sensitive tool than electrodermal responses for evaluation of sympathetic function below a spinal cord lesion. STATEMENT OF ETHICS: We certify that all applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during the course of this research, and all experiments were conducted with the understanding and consent of each subject.
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Affiliation(s)
- Rachael Brown
- Spinal Injuries Research Centre, Prince of Wales Medical Research Institute, Sydney, NSW 2031, Australia.
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Claydon VE, Krassioukov AV. Orthostatic hypotension and autonomic pathways after spinal cord injury. J Neurotrauma 2007; 23:1713-25. [PMID: 17184183 DOI: 10.1089/neu.2006.23.1713] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Individuals with spinal cord injury (SCI) are prone to orthostatic hypotension (OH). We aimed to develop a simple bedside test to evaluate autonomic control following chronic SCI, and to identify those most at risk of OH and cardiovascular dysfunction. We studied 14 subjects with cervical SCI, 11 with thoracic SCI, and 17 able-bodied controls. We continuously recorded heart rate (HR; ECG) and beat-to-beat systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures (Finometer) while supine, and following the passive assumption of an upright seated position. Stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR) were calculated. Plasma catecholamines were determined. Motor and sensory loss was assessed using the American Spinal Injury Association (ASIA) impairment scale. Autonomic pathways were assessed from sympathetic skin responses (SSR). Cervical SCI subjects had lower supine HR, SAP, and noradrenaline levels than thoracic SCI and controls (p < 0.05), and lower DAP and MAP than controls (p < 0.05). When upright, HR increased in all groups (p < 0.05); SAP, DAP, and MAP increased (p < 0.01) in thoracic SCI and controls, but not in cervical SCI. Cervical SCI had larger postural falls in SV (p < 0.05) and CO, with smaller increases in TPR than the other two groups. Upright catecholamine levels were lower in cervical SCI (p < 0.05) than thoracic SCI and controls. Completeness of SCI assessed by ASIA scale did not necessarily correlate with autonomic completeness assessed by SSR. Cardiovascular control during orthostasis was impaired and OH was common in cervical SCI, but not thoracic SCI. SSR may identify those at greatest risk of orthostatic hypotension and impaired cardiovascular control. We advocate that assessments of autonomic function be included in the neurological evaluation of SCI, in addition to the ASIA assessment.
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Affiliation(s)
- Victoria E Claydon
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
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Steeves JD, Lammertse D, Curt A, Fawcett JW, Tuszynski MH, Ditunno JF, Ellaway PH, Fehlings MG, Guest JD, Kleitman N, Bartlett PF, Blight AR, Dietz V, Dobkin BH, Grossman R, Short D, Nakamura M, Coleman WP, Gaviria M, Privat A. Guidelines for the conduct of clinical trials for spinal cord injury (SCI) as developed by the ICCP panel: clinical trial outcome measures. Spinal Cord 2006; 45:206-21. [PMID: 17179972 DOI: 10.1038/sj.sc.3102008] [Citation(s) in RCA: 331] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
An international panel reviewed the methodology for clinical trials of spinal cord injury (SCI), and provided recommendations for the valid conduct of future trials. This is the second of four papers. It examines clinical trial end points that have been used previously, reviews alternative outcome tools and identifies unmet needs for demonstrating the efficacy of an experimental intervention after SCI. The panel focused on outcome measures that are relevant to clinical trials of experimental cell-based and pharmaceutical drug treatments. Outcome measures are of three main classes: (1) those that provide an anatomical or neurological assessment for the connectivity of the spinal cord, (2) those that categorize a subject's functional ability to engage in activities of daily living, and (3) those that measure an individual's quality of life (QoL). The American Spinal Injury Association impairment scale forms the standard basis for measuring neurologic outcomes. Various electrophysiological measures and imaging tools are in development, which may provide more precise information on functional changes following treatment and/or the therapeutic action of experimental agents. When compared to appropriate controls, an improved functional outcome, in response to an experimental treatment, is the necessary goal of a clinical trial program. Several new functional outcome tools are being developed for measuring an individual's ability to engage in activities of daily living. Such clinical end points will need to be incorporated into Phase 2 and Phase 3 trials. QoL measures often do not correlate tightly with the above outcome tools, but may need to form part of Phase 3 trial measures.
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Affiliation(s)
- J D Steeves
- ICORD, University of British Columbia (UBC) and Vancouver Coastal Health (VCH) Research Institute, Vancouver, BC, Canada
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Claydon VE, Hol AT, Eng JJ, Krassioukov AV. Cardiovascular responses and postexercise hypotension after arm cycling exercise in subjects with spinal cord injury. Arch Phys Med Rehabil 2006; 87:1106-14. [PMID: 16876557 DOI: 10.1016/j.apmr.2006.05.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Revised: 05/05/2006] [Accepted: 05/11/2006] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine postexercise hypotension and contributing factors in subjects with spinal cord injury (SCI). DESIGN Prospective clinical research study. SETTING Rehabilitation center. PARTICIPANTS Subjects with chronic cervical-level (n=19) and thoracic-level (n=8) SCI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Subjects underwent graded arm-cycling with electrocardiogram and oxygen uptake monitoring to exhaustion. Heart rates and blood pressures were measured before and after exercising. Injury to motor and sensory pathways was determined by American Spinal Injury Association grade, and to autonomic pathways by sympathetic skin responses (SSRs) (n=16). RESULTS Resting blood pressures and heart rates were lower in cervical than thoracic SCI (mean arterial pressure [MAP]: cervical, 76.6+/-2 mmHg; thoracic, 93.5+/-3 mmHg; P<.001). Following exercise, heart rate responses were greater in thoracic than cervical SCI; MAP increased in thoracic SCI (8.4+/-5 mmHg) and markedly decreased in cervical SCI (-9.3+/-2 mmHg) (P<.001). No subject had significant electrocardiographic abnormalities at rest or during exercise. There were correlations between SSR and heart rate and blood pressure responses to exercise; the correlation between the SSR and blood pressure response was due to an interaction between the heart rate and blood pressure responses. CONCLUSIONS Abnormal cardiovascular responses to exercise and transient postexercise hypotension were common in cervical, but not thoracic SCI. This may be partly related to loss of descending sympathetic nervous control of the heart and vasculature following high SCI.
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Affiliation(s)
- Victoria E Claydon
- International Collaboration On Repair Discoveries, University of British Columbia, Vancouver, Canada
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Pan SL, Wang YH, Hou WH, Wang CM, Huang TS. Reduced Sympathetic Skin Response in the Isolated Spinal Cord of Subjects With Spinal Cord Injury. Arch Phys Med Rehabil 2006; 87:1201-6. [PMID: 16935055 DOI: 10.1016/j.apmr.2006.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Accepted: 05/31/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To compare the excitability of the sympathetic skin response (SSR) between subjects with spinal cord injury (SCI) and healthy controls with intact supraspinal connection. DESIGN Cross-sectional survey. SETTING Referral center. PARTICIPANTS A total of 37 men with traumatic neurologically complete SCI (26 with tetraplegia, 11 with paraplegia) and history of autonomic dysreflexia were included. Twenty age-matched healthy male controls were recruited as the control group. Subjects with SCI were at the mean age +/- standard deviation of 36.5+/-11.0 years (range, 20.1-61.3 y) and the mean injury duration was 11.3+/-9.3 years (range, 1.0-38.1 y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The SSR tests were grouped into 3 test sets according the stimulation and recording sites: (1) right supraorbital nerve stimulation with left hand recording (SH set); (2) right supraorbital nerve stimulation and left foot recording (SF set); and (3) right posterior tibial nerve stimulation and left foot recording (TF set). RESULTS In patients with tetraplegia (n=26), none showed positive SSR in the SH or the SF set, and only 5 (19.2%) showed a positive SSR in the TF set. In subjects with paraplegia (n=11), the positive response rates of SSR were 72.7% for the SH set, 0% for the SF set, and 9.1% for the TF set. Electric stimulation at high intensity (100 mA for 1 ms) was required to elicit SSR for the TF set in the patients with SCI. The SSR amplitudes in the SH and TF sets were smaller in subjects with SCI than those in controls (SH set, P=.004; TF set, P<.001). The SSR latency in the SH set was longer in patients with SCI (P=.04), whereas the SSR latency in the TF set tended to be shorter in subjects with SCI (P=.09). CONCLUSIONS The excitability of SSR was reduced in an isolated spinal cord. This suggests that excitability of sympathetic sudomotor response in subjects with an isolated spinal cord is lower than in healthy controls.
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Affiliation(s)
- Shin-Liang Pan
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
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Nicotra A, Critchley HD, Mathias CJ, Dolan RJ. Emotional and autonomic consequences of spinal cord injury explored using functional brain imaging. Brain 2006; 129:718-28. [PMID: 16330503 PMCID: PMC2633768 DOI: 10.1093/brain/awh699] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
In health, emotions are integrated with autonomic bodily responses. Emotional stimuli elicit changes in somatic (including autonomic) bodily states, which feedback to influence the expression of emotional feelings. In patients with spinal cord injury (SCI), this integration of emotion and bodily arousal is partially disrupted, impairing both efferent generation of sympathetic responses and afferent sensory feedback of visceral state via the spinal cord. A number of theoretical accounts of emotion predict emotional deficits in SCI patients, particularly at the level of emotional feelings, yet evidence for such a deficit is equivocal. We used functional MRI (fMRI) and a basic emotional learning paradigm to investigate the expression of emotion-related brain activity consequent upon SCI. We scanned seven SCI patients and seven healthy controls during an aversive fear conditioning task. Subjects viewed randomized presentations of four angry faces. One of the faces (CS + arm) was associated with delivery of electrical shock to the upper arm on 50% of trials. This shock was painful to all subjects. A face of the same gender acted as a 'safe' control stimulus (CS - arm). In both control subjects and SCI patients, painful cutaneous stimulation of the arm evoked enhanced activity within components of a central pain matrix, including dorsal anterior cingulate, right insula and medial temporal lobe. However, SCI patients differed from controls in conditioning-related brain activity. SCI patients showed a relative enhancement of activity within dorsal anterior cingulate, periaqueductal grey matter (PAG) and superior temporal gyrus. Conversely, SCI patients showed relative attenuation of activity in subgenual cingulate, ventromedial prefrontal and posterior cingulate cortices to threat of painful arm stimulation (CS + arm > CS - arm). Our findings provide evidence for differences in emotion-related brain activity in SCI patients. We suggest that the observed functional abnormalities including enhanced anterior cingulate and PAG reflect central sensitization of the pain matrix, while decreased subgenual cingulate activity may represent a substrate underlying affective vulnerability in SCI patients consequent upon perturbation of autonomic control and afferent visceral representation. Together these observations may account for motivational and affective sequelae of SCI in some individuals.
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Affiliation(s)
- Alessia Nicotra
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, and Institute of Neurology, UCL, London, UK.
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Claydon VE, Elliott SL, Sheel AW, Krassioukov A. Cardiovascular responses to vibrostimulation for sperm retrieval in men with spinal cord injury. J Spinal Cord Med 2006; 29:207-16. [PMID: 16859224 PMCID: PMC1864810 DOI: 10.1080/10790268.2006.11753876] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Cardiovascular abnormalities and arrhythmias are common in individuals with spinal cord injury (SCI) who are undergoing vibrostimulation for sperm retrieval. The study aimed to examine cardiovascular control in men with SCI undergoing this procedure. METHODS Individuals with chronic cervical (n=8; age: 33.1 +/- 1.9 years) and upper thoracic SCI (n=5; age: 35.2 +/- 2.9 years) volunteered for vibrostimulation, with continuous blood pressure (Finometer) and electrocardiographic monitoring. Patients were characterized further by sympathetic skin responses (SSR) to assess descending autonomic spinal pathways and American Spinal Injury Association (ASIA) scores to assess motor and sensory pathways. RESULTS All but one subject with cervical SCI were ASIA A or B and were negative for SSR in the hands and feet. All subjects with upper thoracic SCI were ASIA A or B and were positive for SSR in the hands. Systolic blood pressure was lower in men with cervical injury at rest. Vibrostimulation induced an increase in systolic blood pressure >20 mmHg in all patients with cervical SCI (range = 125/65 - 280/152; median = 167/143 mmHg) and in 2 thoracic subjects (151/104 and 170/121 mmHg). During ejaculation, 6 cervical and 3 thoracic subjects developed arrhythmias (5 with bradycardia, 6 with premature atrial contractions, 4 with ventricular excitation, 1 with junctional rhythm, and 1 with heart block). CONCLUSION The vibrostimulation procedure induced electrocardiographic abnormalities and autonomic dysreflexia in subjects with either cervical or high thoracic SCI.
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Affiliation(s)
| | - Stacy Lorraine Elliott
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia (UBC)
- Department of Psychiatry, UBC
- Department of Urology, UBC
- Vancouver Sperm Retrieval Clinic and Sexual Health Rehabilitation Service and the GF Strong Rehabilitation Centre, Vancouver General Hospital; Vancouver, British Columbia, Canada
| | - Andrew William Sheel
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia (UBC)
- School of Human Kinetics, UBC
| | - Andrei Krassioukov
- International Collaboration On Repair Discoveries (ICORD), University of British Columbia (UBC)
- Division of Physical Medicine and Rehabilitation, UBC
- School of Rehabilitation, UBC
- Vancouver Sperm Retrieval Clinic and Sexual Health Rehabilitation Service and the GF Strong Rehabilitation Centre, Vancouver General Hospital; Vancouver, British Columbia, Canada
- Please address correspondence to Dr. Andrei Krassioukov, MD, PhD, International Collaboration On Repair Discoveries (ICORD), 6270 University Boulevard, University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z4; phone: 604.822.2673; fax: 604.822.2924 (e-mail: )
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