Effect of power-assistance on upper limb biomechanical and physiological variables during a 6-minute, manual wheelchair propulsion test: a randomised, cross-over study

PURPOSE

Use of a power-assistance wheelchair could reduce the risk of musculoskeletal disorders (MSDs), however, a comprehensive biomechanical evaluation of these systems has not been carried out. This study aimed to evaluate and compare biomechanical UL propulsion variables, and physiological exercise-related variables during the use of a wheelchair with rear drive power assist device (RD-PAD) and a standard manual wheelchair (MW).

MATERIALS AND METHODS

Twenty-two adults with spinal cord injury were recruited. RD-PAD (SmartDrive system) was fitted to their own MW. An instrumented wheel was used to measure handrim forces, and gas exchange and heart rate were monitored. Participants performed repeated out and back runs for 6 min on a straight outdoor course.

RESULTS

Distance covered was significantly greater with the RD-PAD (538 ± 104 m versus 470 ± 124 m). Peak mechanical effort during the propulsion phase was significantly lower with the RD-PAD (p < 0.001). Heart rate, metabolic equivalent of task (MET), tidal volume, minute volume, oxygen consumption, and peak oxygen consumption were all significantly lower with the RD-PAD (p < 0.001).

CONCLUSIONS

The results showed that use of RD-PAD increased the distance covered by MW users and reduced the energy costs of propulsion. The biomechanical results indirectly suggest that RD-PAD may reduce the risk of MSD.Implications for RehabilitationUsing the SmartDrive system as propulsion assistance increases the travel autonomy.The SmartDrive system reduces the biomechanical constraints propelling the wheelchair on a slope and low slope.SmartDrive the system reduces the physiological solicitation related to the propulsion of wheelchair.

Assessment of the upper limb of the tetraplegic patient

The aim of our study is to describe the assessment of the upper limb in tetraplegic patients to follow his (her) neurological progression and to define the medical or surgical treatment program. We selected upper limb assessment tools and scales for tetraplegic patients described in the medical literature through a PubMed search over the last four decades. For each method, we present the implementation rules and its metrological properties, including its validity in French. We selected five clinical scales for functional evaluation of grasping, as well as four scales for evaluating the overall function of these patients. Finally, we identified three complementary precision assessment tools. The AIS (ASIA Impairment Scale) classification describes the level and the severity of the spinal cord lesion. The Giens classification is more practical for describing the upper limb in middle and low tetraplegia. Impairments can be assessed with most common generic scales and nonspecific measurement devices: range of motion, strength, sensory loss, spasticity, joint pain. Measurement of pinch and grip strength is widely used and easy to perform. The Capabilities of Upper Extremity (CUE) and the Jebsen Taylor Test are the best validated and usable scales. At a general functional level, the Spinal Cord Independence Measure (SCIM) is the most relevant scale in these patients. Motor nerve blocks, electromyography, movement analysis and echography are promising additional methods. Assessment of the upper limb of tetraplegic patients relies both on generic and specific assessment tools and scales.

Spinal cord ischemia in Scheuermann disease: A report of three cases

BACKGROUND

Neurological complications in Scheuermann's disease are rare but serious.

CASE REPORTS

We report three cases of severe neurological deficit due to medullar ischemia attributable to the compression of a radiculomedullar artery by thoracic (two cases) and lumbar (one case) disc herniations associated with Scheuermann's disease. They were not treated surgically because of the absence of direct spinal cord compression or definitive spinal cord ischemia. Those young patients still have severe neurological damage. An earlier management could have prevented them.

CONCLUSION

When doubting about any compressive sign, MRI should be performed with diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences in emergency.

Recommendations and settings of word prediction software by health-related professionals for patients with spinal cord injury: a prospective observational study

BACKGROUND

For people with cervical spinal cord injury (SCI), access to computers can be difficult, thus several devices have been developed to facilitate their use. However, text input speed remains very slow compared to users who do not have a disability, even with these devices. Several methods have been developed to increase text input speed, such as word prediction software (WPS). Health-related professionals (HRP) often recommend this type of software to people with cervical SCI. WPS can be customized using different settings. It is likely that the settings used will influence the effectiveness of the software on text input speed. However, there is currently a lack of literature regarding professional practices for the setting of WPS as well as the impact for users.

AIM

To analyze word prediction software settings used by HRP for people with cervical SCI.

DESIGN

Prospective observational study.

SETTING

Garches, France; health-related professionals who recommend Word Prediction Software.

METHODS

A questionnaire was submitted to HRP who advise tetraplegic people regarding the use of communication devices.

RESULTS

A total of 93 professionals responded to the survey. The most frequently recommended software was Skippy, a commercially available software. HRP rated the importance of the possibility to customise the settings as high. Moreover, they rated some settings as more important than others (P<0.001). However, except for the number of words displayed, each setting was configured by less than 50% of HRP. The results showed that there was a difference between the perception of the importance of some settings and data in the literature regarding the optimization of settings. Moreover, although some parameters were considered as very important, they were rarely specifically configured. Confidence in default settings and lack of information regarding optimal settings seem to be the main reasons for this discordance. This could also explain the disparate results of studies which evaluated the impact of WPS on text input speed in people with cervical SCI.

CONCLUSION

The results showed that there was a difference between the perception of the importance of some settings and data in the literature regarding the optimization of settings. Moreover, although some parameters were considered as very important, they were rarely specifically configured. Confidence in default settings and lack of information regarding optimal settings seem to be the main reasons for this discordance. This could also explain the disparate results of studies which evaluated the impact of WPS on text input speed in people with cervical SCI.

CLINICAL REHABILITATION IMPACT

Professionals tend to have confidence in default settings, despite the fact they are not always appropriate for users. It thus seems essential to develop information networks and training to disseminate the results of studies and in consequence possibly improve communication for people with cervical SCI who use such devices.

Text input speed in persons with cervical spinal cord injury

STUDY DESIGN

This is a prospective clinical study.

OBJECTIVES

The objectives of this study were to determine text input speed (TIS) in persons with cervical spinal cord injury (SCI) and to study the influence of personal characteristics and type of computer access device on TIS.

SETTING

This study was conducted in the Rehabilitation Department, Garches, France.

METHODS

People with cervical SCI were included if their level of injury was between C4 and C8 Asia A or B, and if they were computer users. In addition, able-bodied people were recruited from the hospital staff. Each participant underwent a single evaluation using their usual computer access devices. TIS was evaluated during a 10- min copying task. The relationship between the characteristics of participants with cervical SCI, type of computer access device and TIS were analyzed using a Scheirer-Ray-Hare test (nonparametric test similar to a two-way analysis of variance).

RESULTS

Thirty-five participants with cervical SCI and 21 able-bodied people were included. Median TIS of participants with cervical SCI was 11 (6; 14) words per minute (w.p.m.) and of able-bodied participants was 19 (14; 24) w.p.m. (P=0.001). Median TIS of participants with lesions at or above C5 was 12 (4; 13) w.p.m. and of those with lesions below C5 was 10 (9; 18) w.p.m. (P=0.38) [corrected]. The Scheirer-Ray-Hare test showed that only the type of computer access device significantly influenced TIS. Surprisingly, none of the person's characteristics, including the level of cervical lesion, affected TIS.

CONCLUSION

This is the first study to analyze TIS in a group of participants with cervical SCI. The results showed that only the type of computer access device influenced TIS.

Occurrence of adverse events in long-term intrathecal baclofen infusion: a 1-year follow-up study of 158 adults

OBJECTIVE

To assess the frequency and types of adverse events (AEs) related to intrathecal baclofen (ITB) therapy in adults, and associated risk factors.

DESIGN

A prospective, observational cohort study of adults followed up from January 1 to December 31, 2010.

SETTING

A neurologic rehabilitation department in a university hospital.

PARTICIPANTS

All consecutive adult subjects (N=158) receiving ITB via a pump, either implanted or followed up during the study period.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Frequency and type of AEs.

RESULTS

In 2010, 158 subjects were followed up for ITB therapy, of whom 128 were implanted before 2010 (nonsurgical subjects), and 30 underwent implantation in 2010 (surgical subjects). Of these 30 subjects, 20 were "newly implanted" and 10 were "replacements." The most frequent pathologic disorders were spinal cord injury (42%) and multiple sclerosis (28%). Twenty-eight subjects (18%) experienced a total of 38 AEs. The rate of AEs was .023 per month of ITB treatment. AEs were related to the surgical procedure in 53% of cases, to the device in 29% (predominantly catheter dysfunctions), and to adverse effects of baclofen in 18%. AEs related to the surgical incision (scar complications and collections) were more frequent in replacement than newly implanted subjects (P=.009). No significant association between occurrence of an AE and subject characteristics (age, gait capacity, spinal vs cerebral spasticity, duration of ITB therapy follow-up) was found. Nearly half of the AEs were serious, extending admission time by a mean of 16 days. No AE induced long-term morbidity or death.

CONCLUSIONS

The AE rate was relatively low in this cohort. This has to be balanced against the clinical, functional, and quality-of-life improvements, which are expected from ITB therapy.

[Spasticity: clinical and imaging features]

Spasticity, a component of the pyramidal syndrome, characterized by increased tonic stretch reflexes and hyperactive deep tendon reflexes, occurs in patients with central nervous system lesions (stroke, brain or cord injury, multiple sclerosis, cerebral motor impairment). The implementation of standard procedures (patient positioning, increased examination time, turning off certain devices before MR imaging) allows the acquisition of high quality examinations in spastic patients. Worsening spasticity in a handicaped patients is due to an irritative process (deep seated infection, fracture, syrinx...) usually detectable with imaging. Ultrasound or CT guided injections of botulinum agents provides radiologists with the opportunity to further participate in the management of spastic patients.

Rehabilitation of Balance After Stroke With Multisensorial Training: A Single-Blind Randomized Controlled Study

Objective. To compare 2 rehabilitation strategies to improve balance after stroke: (1) a multisensorial approach based on higher intensity of balance tasks and exercise during visual deprivation and (2) a conventional neurodevelopmentaltheory-based treatment (NDT) that used a general approach for sensorimotor rehabilitation. Methods . This prospective, multicenter, randomized, parallel-group study measured outcomes with blinded assessors. Sixty-eight patients able to walk without human assistance were entered from 3 to 15 months (mean, 7 months) after a first hemispheric stroke. They received 20 sessions in 4 weeks of NDT or multisensorial rehabilitation. On day 0, day 30, and day 90, assessment included the Berg Balance Scale (BBS), posturography, gait (velocity, double stance phase, climbing 10 steps, amount of walking per day), the Functional Independence Measure, and the Nottingham Health Profile. Results. All subjects improved significantly in balance and walking parameters. Regarding the main dependent variable (BBS on day 30), no difference between groups was found. Analysis of secondary outcomes suggested small differences in favor of the experimental group, but the differences are not likely to be clinically relevant. Conclusion. No evidence was found for the superiority of a multisensorial rehabilitation program in ambulatory patients with impairments beyond the time of inpatient therapy. Additional studies are recommended.

Fatigue et traumatisme crânien

Fatigue is frequent and disabling in patients with traumatic brain injury (TBI). Its mechanisms are complex and multifactorial. We performed a literature review of reports of the condition using the following key words: brain injury, depression, neuroendocrine dysfunction, and treatment. Five scales have been used to evaluate fatigue in TBI patients: the Fatigue Severity Scale, the visual analog scale (VAS) for fatigue, the Fatigue Impact Scale, the Barrow Neurological Institute (BNI) Fatigue Scale and the Cause of Fatigue (COF) Questionnaire. The BNI Fatigue Scale and the COF Questionnaire have been designed specifically for brain-injured patients. Fatigue is present in 43-73% of patients and is one of the first symptoms for 7% of them. Fatigue does not seem to be significantly related to injury severity not to time since injury. It can be related to mental effort necessary to overcome attention deficit and slowed processing ("coping hypothesis"). It can also be related to sleeping disorders and depression, although the relation between fatigue and depression are debated. Finally, fatigue can also be related to infraclinical pituitary insufficiency (growth hormone insufficiency, hypocorticism). To date, no published study of treatment of fatigue after TBI exists.

Pruritus after intrathecal baclofen withdrawal: A retrospective study

OBJECTIVES

To determine the frequency of pruritus after intrathecal baclofen (ITB) withdrawal and to study the pathophysiology of this symptom.

DESIGN

Retrospective cohort study.

SETTING

Rehabilitation department of a general hospital.

PARTICIPANTS

Patients (N=102) implanted with an ITB pump who had been followed up since 1988.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Incidence of pruritus after withdrawal. We studied the relation between pruritus and daily dose, concentration and mode of infusion of baclofen, and cause of the central nervous system lesion inducing spasticity.

RESULTS

Pruritus was observed in 10 of 23 cases of ITB withdrawal. It never occurred during the first 3 months after pump implantation. It seems likely that the segmental spinal action of baclofen is responsible for pruritus. There was no statistically significant difference between patients with ITB deprivation who did and did not experience pruritus in their daily infused dosage or in concentration and mode of infusion. Surprisingly, no pruritus was observed in patients with multiple sclerosis.

CONCLUSIONS

Pruritus is a frequent symptom after ITB withdrawal. Its occurrence is probably subsequent to chronic blocking of the liberation of substance P by baclofen at the spinal level. This symptom is a good clinical predictor of baclofen withdrawal, in contrast to an isolated increase of spasticity that may be due to drug tolerance or irritant factors. Pruritus requires investigation of a possible dysfunction of the infusion system.