[Predictors of upper limbs' function in patients with cervical tetraplegia]

Patients with traumatic cervical injury of the spinal cord show clinical symptoms of tetraplegia. Furthermore, the motor function of the upper limbs is a key function for such patients, because it has a significant impact on the quality of life. One of the components of the definition of rehabilitation potential is the identification of the possible functions' ceiling and compliance of the patient's current condition with known model characteristics.

OBJECTIVE

The aim of the study is to determine the predictors of upper limb functional motor activity in patients in the late period after spinal cord injury (SCI).

MATERIAL AND METHODS

The study included 190 patients with SCI: 151 men and 49 women. The mean age of patients was 30.0±12.9 years, the age of SCI - 1.9 [0.60; 5.40] years, in 93% of cases SCI was traumatic. Patients were classified using the ASIA International Neurological Standard. Upper limb function was evaluated using a short version of the Van Lushot Test (VLT). Stimulation electroneuromyography (SENMG) from the median and ulnar nerves was performed. The distribution at the motor level (ML) was as follows: C4-C6 - 117 patients; C7-D1 - 73 patients; depending on the severity of injury (SI): type A and B - 132 patients; upper limb motor score (ASIAarm) was 25.0±12.2, on VLT - 38.3±20.9. The factor loading of 10 factors was evaluated simultaneously in a linear discriminant analysis, the cut-off point was 20 and 40 scores on VLT (25 and 50% on the International Classification of Functioning, Disability and Health without the domain «balance»).

RESULTS

According to SENMG, denervation changes were detected in 15% of median and in 23% of ulnar nerves. The rank significance for the VLT threshold of 20 scores was: ASIA_arm - 100, functional tenodesis (FT) - 91, ML - 73, SI - 18; the classification tree had one branching at the ASIA_arm point of 17.3 score. The rank significance for the threshold of 40 scores was: ASIA_arm - 100, ML - 59, SI - 50, FT - 28, M response from the median nerve - 5; the classification tree had one branching at the ASIA_arm point of 26.9 score. The results of multivariate linear regression analysis confirmed the highest factor loading of ML predictor, motor score for upper limb (ASIA_arm) in both cases (R=0.67, R₂=0.45, F=38.0, p=0.00 and R=0.69, R₂=0.47; F=42.0, p=0.00, respectively).

CONCLUSION

In the late period after a spinal injury the leading predicative value for functional motor activity has the motor score of ASIA for the upper limb. The ASIA score more than 27 scores is the prediction of moderate and mild impairments, and less than 17 - severe impairments.

[Patient-centered approach using COPM, GAS scores in medical rehabilitation of patients with tetraplegia after spinal cord injury]

OBJECTIVE

To study the efficacy of the patient- and task-oriented approach and specific therapeutic exercises (TE) for the arms in patients after spinal cord injury at the cervical level.

MATERIAL AND METHODS

The study included 119 patients with a history of spinal injury of more than one year. They were divided into three demographically comparable groups. Group 1 patients (control) received standard of care: TE, physiotherapeutic treatment, social adaptation (SA), and massage; Group 2-standard of care and specific TE for the arms as part of the SA; Group 3-the same as Group 2 combined with the patient- and task-oriented approach (patient-selected activities were trained). Outcomes were assessed at the beginning (T₁), end (T₂), and at 1 year (T₃) after a 30-day medical rehabilitation course.

RESULTS

No statistically significant differences between the groups in demographic, neurological (ISCSCI score), motor (FIMm, VLT scores), psychological parameters (depression, anxiety), quality of life (WHOQOL-BREF score) before the medical rehabilitation (T₁) were observed. At the end of the medical rehabilitation course (T₂), the increase in functional scores was 6.0±5.4 points of FIMm score, 6.0±4.6 points of VLT score in group 1; 8.0±7.6 points of FIMm score, 7.0±7.1 points of VLT score in group 2; 9.0±6.9 points of FIMm score, 8.0±7.6 points of VLT in group 3. Significant differences were found between groups 1 and 2 and 3 on the domains of «finger I» (13.6±9.64 points vs. 15.2±9.40 and 15.3±9.21 points respectively), «fingers II-V» (9.4±6.76 points vs. 11.3±6.41 and 11.6±6.76 points respectively) of VLT score; between groups 3 and 1 on the domains «self-care» (25.9±9.67 points vs. 23.1±9.8 points), «transfer» (11.7±6.21 points vs. 10.6±6.1 points) of the FIMm score, and also the group 3 patients had a higher quality of life by 3.0±1.8 points. At delayed follow-up (T₃-T₂), no changes of the FIMm and VLT scores were detected within groups. In group 3, 69% of problems were identified in self-care (COPM); subjective assessment of functional improvement for COPM (T₂-T₁) was as follows: «performance» 4.7±1.27 points, «satisfaction» 3.8±1.63 points; for GAS the T-score at the end of rehabilitation was 1.3±0.55 points, and the greatest significance of change was noted for COPM under «performance» (ES=0.73), with the correlation coefficient between FIMm and COPM being 0.55 and 0.63 for «performance» and «satisfaction» domains, respectively.

CONCLUSION

Patient- and task-oriented approach implemented by using COPM questionnaire and GAS score together with specific TE for arms is an effective method of motor medical rehabilitation of patients with posttraumatic cervical tetraplegia. This approach improves their quality of life, while parameters of subjective scores (COPM, GAS) have the same sensitivity in comparison with the conventional motor scores (FIMm, VLT).

[Upper limb motor and functional recovery in patients with tetraplegia]

OBJECTIVE

To study the recovery of the upper limb motor function and functional independence in patients with cervical spinal cord injury.

MATERIAL AND METHODS

The study included 49 patients with subacute tetraplegia, mean age 33±14.8 years, 42 men and 7 women, admitted to the Preodolenie Rehabilitation Center. The follow-up was up to 2 years. The clinical and functional states were assessed after 3, 6, 12 and more than 12 months after spinal injury, using the ASIA neurological standard scale, the motor subscale of Functional Independence Scale (FIM) and short form of Van Lieshout Test (VLT). All patients received continuous rehabilitation courses that included physiotherapy, occupational therapy, social support, psychological rehabilitation.

RESULTS

Upper limb motor recovery occurred in the first 6 months after spinal cord injury at 5±3.9 points (ASIA), while in 49% patients motor level decreased by one segment of the spinal cord, in 8% patients completeness of spinal cord injury improved. The improvement of functional independence was found during the first 12 months: according to FIM, in the period of 3-6 months by 18±11.1 points, in the period of 6-12 months by 8±8.1 points; according to VLT in the period of 3-6 months by 19±14.4 points, in the period of 6-12 months by 5.6±6.02 points.

CONCLUSIONS

Upper limb motor recovery mostly occurs in the first 6 months while the functional independence improvement lasts during the first 12 months after a spinal cord injury.

[Comparative analysis of functional independence predictors in patients with cervical tetraplegia]

Purpose of the study was to investigate clinical predictors of functional independence in patients with cervical tetraplegia at different periods after a spinal cord injury (SCI).

MATERIAL AND METHODS

190 patients (151 men and 39 women) with an SCI from 3 months to 6 years old were included in a retrospective study. The average age was 27 years. The examination was carried out using the international standard for neurological classification of spinal cord injury (ASIA) with the definition of motor score ASIA for the upper extremity (ASIA _{upper extremity}), neurological (NL) and motor levels (ML), and the completeness of spinal cord injury (AIS). Functional assessment was performed using the FIM motor subscale. The study of neuromuscular conduction of the median nerves - according to stimulation electroneuromyography (SENMG). The degree of functional independence was assessed as a severe disability with FIM less than 42 points, mild and moderate - FIM 42 points or more.

RESULTS

Using logistic regression analysis, it was found that in the first 6 months after SCI, the main predictors are ASIA_{upper extremity} (AUC=0.84; X²=3.32; p=0.06) and NL (AUC=0.80; X²=2.96; p=0.09). When observed in the first 12 months, ASIA_{upper extremity} (AUC=0.86) remains the leading predictor. Moreover, pronounced functional limitations can be predicted using predictors of ASIA_{upper extremity} in 84.4% and completeness of injury (AIS) in 81.2% of cases, moderate and mild limitations - ASIA_{upper extremity} in 81.4%, NL in 86.0% and functional tenodesis (FT) in 100% of cases. In the long-term period (more than 12 months), the exceptional predictive power of the predictor ASIA_{upper extremity} (AUC=0.92) is noted both in the prediction of severe (82.5%) cases and moderate and mild functional disorders (91.8% of cases). In addition, in the SCI long-term period, the predictor AIS plays a significant role in severe disorders (in 82.5% of cases), and NL (88.2%) and FT (100%) - in moderate and mild disorders. The boundaries between functional groups according to functional independence in groups of 12 months and more than 12 months after SMT are presented: ASIA_{upper extremity} 22.4 and 22.6 points, ML more than 6.5 and the presence of FT with a ML of more than 5.6, respectively. At the same time, the results of SENMG showed low predictive significance.

CONCLUSION

Motor score ASIA_{upper extremity} is a leading predictor in all periods after SCI, while completeness of spinal cord injury (AIS) more accurately predicts pronounced functional limitations, and ML and FT predict moderate functional limitations. The FT, a neurological level of C6 and higher, a motor score ASIA _{upper extremity} of more than 22 points are criteria for achieving moderate functional independence.

[Funtional tenodesis as a predictor of functional outcome in patients with cervical tetraplegia]

AIM

To determine the value of functional tenodesis (FT) of the hand as a predictor of the degree of disability in patients with cervical tetraplegia (CT) at different periods after a spinal injury.

MATERIAL AND METHODS

We examined 190 patients (79% - men) with CT (92.5% of cases of traumatic origin) at the age of 27 [21.0; 36.0] years with a neurological level of C_ІІІ-D_І, and a share of complete motor damage (A - B according to AIS) 70%. The examination included determination of neurological, motor levels and completeness of spinal cord injury (according to ISNSCI), assessment of functional independence (FIM motor domain), FT of the hand, and the severity of contractures of the joints of the hand. Using logit-regression analysis, creation of contingency tables, ROC analysis, depending on the timing of spinal injury, 4 classification models were studied: Disease duration less than 6 months, assessment of the functional outcome 6 months after spinal injury (model A); disease duration less than 6 months, assessment after 12 months (model B); disease duration less than 12 months, assessment after 12 months (model C); disease duration more than 12 months, evaluation after more than 12 months (model D, primary one).

RESULTS

FT developed in the first 6 months after spinal injury in 12 (24%) patients, in 6-12 months - in 15 patients (20%), in more than 12 months - in 1 (less than 1%) patient. The incidence of joint contractures of the hand in group A (20%) and C (24%) did not have a statistical difference (χ²=0.22; p=0.64). Hand contractures in the first 6 months were observed in 20% of patients, in the first 12 months - in 24%, more than 12 months after spinal injury - in 28% of patients. In model A, the FT sensitivity was 80%, specificity was 64%, AUC - 0.65; in model B - 85%, 36%, 0.36, respectively; in model C (log-regression χ²=19.1; p was not determined) - 69%, 100%, 0.59, respectively; in model D (log-regression χ²=55.3; p was not determined) - 65%, 100%, 0.71, respectively.

CONCLUSION

FT and contracture of the joints of the hand form during the first year after the debut of CT. As a predictor of a pronounced limitation of self-care, the sensitivity of FT in the first 6 months after spinal injury was 80-85%, in the later period, the specificity of FT was 100%, and sensitivity was 65-69%; in general, the predictive power of FT was low (AUC 0.36-0.71) and increased with the assessment of the functional outcome in the period of more than 12 months after the injury.

[Orthostatic hypotension in patients with posttraumatic cervical myelopathy]

AIM

To define the mechanism of formation of orthostatic hypotension in patients with traumatic tetraplegia.

MATERIAL AND METHODS

The study included 64 patients with chronic (more 6 month) and subacute (less 6 month) tetraplegia; the period of observation was about 30 days after admission to the rehabilitation center. Changes in the state of the autonomic nervous systems (heart rate variability at rest and head-up tilt test, sinus arrhythmia) were studied.

RESULTS

In the first 6 months, all patients, and after 6-12 months, one third of the patients experienced orthostatic hypotension, which was accompanied by lower values of the normalized sympatovagal index (LF_n/HF_n) 0.35 (0.260; 0.650) and expiratory-inspiratory coefficient (RR_max/RR_min) 1.09 (1.040; 1200). An increase in expiratory-inspiratory coefficient as a result of physical rehabilitation up to 1.16 (1.120; 1.24) was noted only in patients less than 6 months after injury.

CONCLUSION

Both sympathetic and parasympathetic parts of the autonomic nervous system are involved in the formation of orthostatic hypotension syndrome in patients with spinal tetraplegia.