Mean kurtosis-Curve (MK-Curve) correction improves the test-retest reproducibility of diffusion kurtosis imaging at 3 T.

Diffusion kurtosis imaging (DKI) is applied to gain insights into the microstructural organization of brain tissues. However, the reproducibility of DKI outside brain white matter, particularly in combination with advanced estimation to remedy its noise sensitivity, remains poorly characterized. Therefore, in this study, we investigated the variability and reliability of DKI metrics while correcting implausible values with a fit method called mean kurtosis (MK)-Curve. A total of 10 volunteers (four women; age: 41.4 ± 9.6 years) were included and underwent two MRI examinations of the brain. The images were acquired on a clinical 3-T scanner and included a T1-weighted image and a diffusion sequence with multiple diffusion weightings suitable for DKI. Region of interest analysis of common kurtosis and tensor metrics derived with the MK-Curve DKI fit was performed, including intraclass correlation (ICC) and Bland-Altman (BA) plot statistics. A p value of less than 0.05 was considered statistically significant. The analyses showed good to excellent agreement of both kurtosis tensor- and diffusion tensor-derived MK-Curve-corrected metrics (ICC values: 0.77-0.98 and 0.87-0.98, respectively), with the exception of two DKI-derived metrics (axial kurtosis in the cortex: ICC = 0.68, and radial kurtosis in deep gray matter: ICC = 0.544). Non-MK-Curve-corrected kurtosis tensor-derived metrics ranged from 0.01 to 0.52 and diffusion tensor-derived metrics from 0.06 to 0.66, indicating poor to moderate reliability. No structural bias was observed in the BA plots for any of the diffusion metrics. In conclusion, MK-Curve-corrected DKI metrics of the human brain can be reliably acquired in white and gray matter at 3 T and DKI metrics have good to excellent agreement in a test-retest setting.

S1 Guidelines on Bone Impairment in Spinal Cord Injury.

During the acute and chronic phase of spinal cord injury (SCI) bone turnover and structure are affected. Bone mineral density of lower limbs is decreased up to 28%-50% below that of age-matched peers at 12-18 mo post injury. Coexisting secondary etiologies of osteoporosis may be present, and during ageing additional loss of bone occurs. All these compose a complex canvas of bone impairment after spinal cord injury and make the therapeutical approach challenging. The risk of fragility fractures is increased after the 2nd decade post SCI affecting the functionality and quality of life of individuals with SCI. Diagnostic flaws, lack of a ranking system to categorize the degree of bone impairment similar to the one of World Health Organization, and evidence-based clinical guidelines for management in SCI requires interdisciplinary cooperation and appropriate planning of future research and interventions. Spinal Cord Section of Hellenic Society of Physical Rehabilitation Medicine convened an expert panel working group on bone and spinal cord injury at the Pan-Hellenic Congress 2018 of PRM in Athens Greece, to establish an evidence-based position statement for bone loss in individuals with SCI of traumatic or non-traumatic etiology. This was reviewed by an International Task Force and used to create S1 Guidelines. This first version S1 guideline will work towards to provide help with prophylactic basic osteoporosis therapy diagnostic and therapeutic decisions in acute and chronic phase and rehabilitation countermeasures against osteoporosis related with spinal cord injury.

Osteoporosis in the lower extremities in chronic spinal cord injury.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To investigate the effect of chronic motor complete spinal cord injury (SCI) and sex on bone densitometry parameters of the hip, femoral neck, tibial epiphysis, and diaphysis and on long bone fractures. SETTING: SCI rehabilitation center. METHODS: Women and men with long-term (≥7 years) motor complete SCI were compared with able-bodied women and men. Dual-energy X-ray absorptiometry was used to assess bone densitometry parameters at the hip and femoral neck, whereas peripheral quantitative computed tomography was used for the tibial epiphysis and diaphysis. RESULTS: The data of 18 women and 25 men with SCI with a mean age of 54.7 ± 12.4 and 53.5 ± 8.6 years, respectively, were analyzed. As reference groups, 74 able-bodied women and 46 men with a mean age of 51.0 ± 13.1 and 50.9 ± 11.2 years were evaluated. Most bone densitometry values were significantly (p ≤ 0.033) lower in the SCI compared with the reference groups, including total bone mineral density at the distal tibial epiphysis (-58.0% in SCI women and -53.6% in SCI men). Fracture rates per 100 patient-years were 3.17 and 2.66 in women and men with SCI compared with 0.85 and 0.21 in able-bodied women and men, respectively. CONCLUSIONS: Compared with able-bodied women and men, individuals with chronic motor complete SCI showed considerably lower bone densitometry values and a higher historical fracture rate. These findings support the need for preventative and therapeutic strategies against bone loss in individuals with SCI.

Nutritional blood parameters and nutritional risk screening in patients with spinal cord injury and deep pressure ulcer-a retrospective chart analysis.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To describe (i) the nutritional blood parameters (NBP) and the nutritional risk screening (NRS) in patients with spinal cord injury (SCI) and pressure ulcers (PU) III and IV according to the EPUAP classification, and (ii) the relationship between both NBP and NRS. SETTING: SCI acute care and rehabilitation clinic in Switzerland. METHODS: The NBPs were measured upon the admission of patients treated for PU III and IV between 11/2011 and 12/2014. Descriptive analyses and group comparisons were done. RESULTS: A total of 170 patients, including 42 (25%) women, 19 (12%) people with paraplegia and 104 (61%) people with traumatic SCI, were admitted and analyzed. Pathologic blood values and NBP were found for c-reactive protein (83%), vitamin D (73%), protein (41%), erythrocyte sedimentation rate (ESR) (41%), albumin (34%), hemoglobin (34%), zinc (29%), folic acid (22%), transferrin (15.3%), and copper (1.2%). Overall, the NRS was >3 in 39% of the patients, wherefrom 28% in patients with PU III and 44% with PU IV (p=0.07). No statistical significant differences were found between patients with PU III and IV in terms of NBP and NRS. CONCLUSIONS: We found abnormal values in NBP and in NRS in a significant number of patients with SCI and PU of both III and IV. Both laboratory examinations and nutritional assessments at admission can help to detect and correct the nutritional deficits in patients at risk. Neither the grade of the PUs, nor the NBP or the NRS can replace one another.

Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso Bionics.

STUDY DESIGN: Prospective quasi-experimental study, pre- and post-design. OBJECTIVES: Assess safety, feasibility, training characteristics and changes in gait function for persons with spinal cord injury (SCI) using the robotic exoskeletons from Ekso Bionics. SETTING: Nine European rehabilitation centres. METHODS: Robotic exoskeleton gait training, three times weekly over 8 weeks. Time upright, time walking and steps in the device (training characteristics) were recorded longitudinally. Gait and neurological function were measured by 10 Metre Walk Test (10 MWT), Timed Up and Go (TUG), Berg Balance Scale (BBS), Walking Index for Spinal Cord Injury (WISCI) II and Lower Extremity Motor Score (LEMS). RESULTS: Fifty-two participants completed the training protocol. Median age: 35.8 years (IQR 27.5-52.5), men/women: N = 36/16, neurological level of injury: C1-L2 and severity: AIS A-D (American Spinal Injury Association Impairment Scale). Time since injury (TSI) < 1 year, N = 25; > 1 year, N = 27. No serious adverse events occurred. Three participants dropped out following ankle swelling (overuse injury). Four participants sustained a Category II pressure ulcer at contact points with the device but completed the study and skin normalized. Training characteristics increased significantly for all subgroups. The number of participants with TSI < 1 year and gait function increased from 20 to 56% (P = 0.004) and 10MWT, TUG, BBS and LEMS results improved (P < 0.05). The number of participants with TSI > 1 year and gait function, increased from 41 to 44% and TUG and BBS results improved (P < 0.05). CONCLUSIONS: Exoskeleton training was generally safe and feasible in a heterogeneous sample of persons with SCI. Results indicate potential benefits on gait function and balance.

Biophysical skin properties of grade 1 pressure ulcers and unaffected skin in spinal cord injured and able-bodied persons in the unloaded sacral region.

AIM OF THE STUDY: To examine biophysical skin properties in the sacral region in spinal cord injury (SCI) patients suffering from a grade 1 pressure ulcer (PU) defined as non-blanchable erythema (SCI/PU), SCI patients in the post-acute phase (SCI/PA) and able-bodied participants (CON). Also, for SCI/PU patients, both the affected skin and healthy skin close to the PU were examined. STUDY DESIGN: An experimental controlled study with a convenience sample. SETTING: A Swiss acute care and rehabilitation clinic specializing in SCIs. MATERIALS AND METHODS: We determined hydration, redness, elasticity and perfusion of the unloaded skin in the sacral region of 6 SCI/PU patients (affected and healthy skin), 20 SCI/PA patients and 10 able-bodied controls. These measures were made by two trained examiners after the patients were lying in the supine position. RESULTS: The affected skin of SCI/PU patients showed elevated redness: median 595.5 arbitrary units (AU) (quartiles 440.4; 631.6) and perfusion: 263.0 AU (104.1; 659.4), both significantly increased compared to the healthy skin in SCI/PA patients and CON (p < 0.001). Similarly, healthy skin of SCI/PA patients showed elevated redness (p = 0.016) and perfusion (p < 0.001) compared to CON. On the other hand, differences in redness and perfusion between the affected and unaffected skin in SCI/PU patients were not significant. The results for skin hydration and skin elasticity were similar in all groups. CONCLUSIONS: Skin perfusion and redness were significantly increased in grade 1 PUs and for healthy skin in both SCI/PA patients and CON participants; thus, these are important in understanding the pathophysiology of PUs and skin in SCI.

Functional Electrical Stimulation in Spinal Cord Injury: Clinical Evidence Versus Daily Practice.

Functional electrical stimulation (FES) has clinical evidence in the rehabilitation of patients with spinal cord injury as indicated by several studies. Both inpatients and outpatients benefit from the therapeutic effect of the FES. The application areas are multifaceted and can be customized on the need for patients. This is represented by the individuality of the programmability of the stimulators and the variety of stimulation schedules that are based on the knowledge about the effects of FES on structural and functional level. Nevertheless, looking into daily clinical practice, the use of FES is rather poor. Expenditure of time, complexity of technical equipment, and compliance and acceptance of therapists and patients should be taken into account as limiting factors.

Challenges to measure hydration, redness, elasticity and perfusion in the unloaded sacral region of healthy persons after supine position.

AIM OF THE STUDY: To combine measurement methods of biophysical skin properties in a clinical setting and to measure baseline values in the unloaded sacral region of healthy persons after lying 30 min in supine position. METHODS: Hydration (Corneometer® CM 825), redness (Mexameter® MX 18), elasticity (Cutometer® MPA 580) and perfusion (PeriFlux System 5000) of the skin in the sacral region of 10 healthy participants (median age: 26.9 years) were measured consecutively in the laying position by two trained examiners. RESULTS: The assessment duration for all four parameters lasted about 15 min. Intra-class correlation coefficients were overall moderate to strong (hydration r = 0.594, redness r = 0.817, elasticity r = 0.719, perfusion r = 0.591). Hydration (median 27.7 arbitrary units (AU)) mainly indicated dry skin conditions. Redness (median 158.5 AU) was low. Elasticity (median 0.880 AU) showed similar values as in the neck region. Perfusion (median 17.1 AU) showed values in the range of results reported in the literature. CONCLUSION: Biophysical skin properties in the sacral region after supine position can be measured within periods of 15 min. The results provide baseline data for the skin of healthy persons as well as insights into skin-physiological variations. But it remains challenging to optimize measurement procedures and test protocols when transferring preclinical tests in a clinical application.

Prostate volume in male patients with spinal cord injury: a question of nerves?

OBJECTIVE: To assess the influence of standardized complete surgical deafferentation of the lower urinary tract by sacral deafferentation (SDAF) and sacral anterior root stimulation (SARS) on prostate volume in men with spinal cord injury (SCI). PATIENTS AND METHODS: In a prospective study, the prostate volume of men with SCI who underwent SDAF/SARS was measured using transrectal ultrasonography. The prostate volumes of these men were compared with those of men with complete SCI but who did not undergo SDAF/SARS, those of men with incomplete SCI, and those of a historical sample of able-bodied men. RESULTS: The median [25th;75th percentile] prostate volume of men who underwent SDAF/SARS (20.0 [14.0; 29.0]) and of men with complete SCI who did not undergo SDAF/SARS (20.0 [16.5; 29.0]) was significantly smaller than in the reference group (25.0 [5.0; 84.0]). The mean prostate volume was associated with age in the reference group (r = 0.185; P < 0.001) and in men with incomplete SCI (r = 0.284; P = 0.031), but not in men with complete SCI, irrespective of SDAF/SARS. CONCLUSIONS: The prostate volume of men with complete SCI was significantly smaller than that of able-bodied men. Our data imply that sustained central innervation of the prostate plays an important role in prostate growth.

Clinical usefulness of ultrasound assessment of detrusor wall thickness in patients with neurogenic lower urinary tract dysfunction due to spinal cord injury: urodynamics made easy?

PURPOSE: To evaluate the clinical usefulness of sonographic measurement of detrusor wall thickness (DWT) for the prediction of risk factors in patients with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI). METHODS: In a prospective study, 60 consecutive patients with NLUTD due to SCI presenting for routine urodynamic assessment at a specialized SCI center underwent additional measurement of DWT at varying bladder volumes. Results of urodynamic testing were classified into favorable and unfavorable. DWT at maximum capacity was used to calculate a possible cutoff value for favorable urodynamic results. RESULTS: Urodynamic results were favorable in 48 patients and unfavorable in 12 patients. A DWT of 0.97 mm or less can safely (sensitivity 91.7 %, specificity 63.0 %) be used as a cutoff point for the absence of risk factors for renal damage. CONCLUSION: According to our results, DWT may be useful as an additional risk assessment for renal damage in patients with NLUTD due to SCI. However, as other parameters required for bladder management, especially detrusor overactivity, cannot be evaluated by this technique, it cannot replace urodynamic testing.

Metabolic profile of complete spinal cord injury in pons and cerebellum: A 3T 1H MRS study.

The aim of this exploratory study was the assessment of the metabolic profiles of persons with complete spinal cord injury (SCI) in three region-of-interests (pons, cerebellar vermis, and cerebellar hemisphere), with magnetic resonance spectroscopy, and their correlations to clinical scores. Group differences and association between metabolic and clinical scores were examined. Fifteen people with chronic SCI (cSCI), five people with subacute SCI (sSCI) and fourteen healthy controls were included. Group comparison between cSCI and HC showed lower total N-acetyl-aspartate (tNAA) in the pons (p = 0.04) and higher glutathione (GSH) in the cerebellar vermis (p = 0.02). Choline levels in the cerebellar hemisphere were different between cSCI and HC (p = 0.02) and sSCI and HC (p = 0.02). A correlation was reported for choline containing compounds (tCho) to clinical scores in the pons (rho = - 0.55, p = 0.01). tNAA to total creatine (tNAA/tCr ratio) correlated to clinical scores in the cerebellar vermis (rho = 0.61, p = 0.004) and GSH correlated to the independence score in the cerebellar hemisphere (rho = 0.56, p = 0.01). The correlation of tNAA, tCr, tCho and GSH to clinical scores might be indicators on how well the CNS copes with the post-traumatic remodeling and might be further examined as outcome markers.

Functional connectivity and amplitude of low-frequency fluctuations changes in people with complete subacute and chronic spinal cord injury.

After spinal cord injury (SCI), reorganization processes and changes in brain connectivity occur. Besides the sensorimotor cortex, the subcortical areas are strongly involved in motion and executive control. This exploratory study focusses on the cerebellum and vermis. Resting-state functional magnetic resonance imaging (fMRI) was performed. Between-group differences were computed using analysis of covariance and post-hoc tests for the seed-based connectivity measure with vermis and cerebellum as regions of interest. Twenty participants with complete SCI (five subacute SCI, 15 with chronic SCI) and 14 healthy controls (HC) were included. Functional connectivity (FC) was lower in all subjects with SCI compared with HC in vermis IX, right superior frontal gyrus (pFDR = 0.008) and right lateral occipital cortex (pFDR = 0.036). In addition, functional connectivity was lower in participants with chronic SCI compared with subacute SCI in bilateral cerebellar crus I, left precentral- and middle frontal gyrus (pFDR = 0.001). Furthermore, higher amplitude of low-frequency fluctuations (ALFF) was found in the left thalamus in individuals with subacute SCI (pFDR = 0.002). Reduced FC in SCI indicates adaptation with associated deficit in sensory and motor function. The increased ALFF in subacute SCI might reflect reorganization processes in the subacute phase.

Impact of propofol on electrocardiographic alterations during intravascular application of bupivacaine--a study in piglets.

BACKGROUND: Intravascular application of a small dose of local anesthetics (LA) with epinephrine as well as larger doses of LA under sevoflurane anesthesia results in increase in T-wave amplitude in the electrocardiogram (ECG). The aim of this study was to elucidate whether propofol anesthesia affects these ECG alterations or not. METHODS: Thirty neonatal pigs were randomized into two groups. Group 1 was anesthetized with sevoflurane, group 2 with sevoflurane plus continuous propofol infusion (10 mg·kg(-1)·h(-1)). A test dose of 0.2 ml·kg(-1) bupivacaine 0.125% + epinephrine 1 : 200,000 was injected intravenously. Arterial pressure was monitored. ECG was analyzed for changes in T-wave amplitude (positive if ≥25% baseline) and heart rate. In another setting, bupivacaine 0.125% was intravenous infused at a rate of 4 mg·kg(-1)·min(-1). ECG was analyzed for alteration in T-wave amplitude and heart rate at 1.25, 2.5, and 5 mg·kg(-1) bupivacaine infused. RESULTS: T-wave elevation after the administration of an epinephrine containing LA test dose was similar between the two groups. Increase in heart rate caused by the test dose were significantly higher in group 2 (P = 0.008). During continuous bupivacaine administration, T-wave elevation occurred in 40% and 71% (group 1 and 2) at 1.25 mg·kg(-1), in 80% and 100% at 2.5 mg·kg(-1), and in 93% and 86% at 5 mg·kg(-1) bupivacaine infused. CONCLUSION: Continuous propofol infusion does not suppress the ECG signs of a systemically administered epinephrine containing LA test dose nor does it suppress the ECG signs caused by high doses of intravenous applied bupivacaine.

A clinical study on the effect in horses during medetomidine-isoflurane anaesthesia, of butorphanol constant rate infusion on isoflurane requirements, on cardiopulmonary function and on recovery characteristics.

OBJECTIVE: To test if the addition of butorphanol by constant rate infusion (CRI) to medetomidine-isoflurane anaesthesia reduced isoflurane requirements, and influenced cardiopulmonary function and/or recovery characteristics. STUDY DESIGN: Prospective blinded randomised clinical trial. ANIMALS: 61 horses undergoing elective surgery. METHODS: Horses were sedated with intravenous (i.v.) medetomidine (7 µg kg(-1)); anaesthesia was induced with i.v. ketamine (2.2 mg kg(-1)) and diazepam (0.02 mg kg(-1)) and maintained with isoflurane and a CRI of medetomidine (3.5 µg kg(-1) hour(-1)). Group MB (n = 31) received butorphanol CRI (25 µg kg(-1) i.v. bolus then 25 µg kg(-1) hour(-1)); Group M (n = 30) an equal volume of saline. Artificial ventilation maintained end-tidal CO2 in the normal range. Horses received lactated Ringer's solution 5 mL kg(-1) hour(-1), dobutamine <1.25 µg kg(-1) minute(-1) and colloids if required. Inspired and exhaled gases, heart rate and mean arterial blood pressure (MAP) were monitored continuously; pH and arterial blood gases were measured every 30 minutes. Recovery was timed and scored. Data were analyzed using two way repeated measures anova, independent t-tests or Mann-Whitney Rank Sum test (p < 0.05). RESULTS: There was no difference between groups with respect to anaesthesia duration, end-tidal isoflurane (MB: mean 1.06 ± SD 0.11, M: 1.05 ± 0.1%), MAP (MB: 88 ± 9, M: 87 ± 7 mmHg), heart rate (MB: 33 ± 6, M: 35 ± 8 beats minute(-1)), pH, PaO2 (MB: 19.2 ± 6.6, M: 18.2 ± 6.6 kPa) or PaCO2. Recovery times and quality did not differ between groups, but the time to extubation was significantly longer in group MB (26.9 ± 10.9 minutes) than in group M (20.4 ± 9.4 minutes). CONCLUSION AND CLINICAL RELEVANCE: Butorphanol CRI at the dose used does not decrease isoflurane requirements in horses anaesthetised with medetomidine-isoflurane and has no influence on cardiopulmonary function or recovery.

Exercise Capacity, Functioning and Quality of Life 12 Weeks after Traumatic Thoracic Spinal Cord Injury.

BACKGROUND: A spinal cord injury (SCI) leads to patho-physiological changes that can affect physical and psychological performance. The aim of this observational study was to evaluate the relationship between exercise capacity, functioning and quality of life in patients 12 weeks after traumatic paraplegia participating in early rehabilitation. MATERIAL AND METHODS: 13 patients participated in this study and performed cardio-pulmonary exercise testing (CPET) on an arm-crank ergometer to determine peak exercise capacity (VO2peak). Data from the spinal cord independence measure (SCIM) were used to assess different areas of functioning. The 12-item short form survey (SF12) questionnaire was applied to measure quality of life. Spearman correlations were used to relate VO2peak with SCIM data and results from the SF12 questionnaire. RESULTS: VO2peak ranged between 12.6 and 28.1 ml/kg/min. A significant relationship was found between VO2peak and the physical component of the SF12 questionnaire, whereas no correlations were found with either SCIM sub or total score, or with the mental component or the total score of the SF12 questionnaire. CONCLUSIONS: 1. Patients with traumatic paraplegia showed fair to average exercise capacity after 12 weeks of early rehabilitation. 2. A significant relationship between VO2peak and subjectively rated physical fitness exists at this time point. 3. The implementation of an individual fitness program tailored to the patients' needs based on CPET results is highly recommended in order to improve functioning and quality of life.

Tracheal fluid leakage in benchtop trials: comparison of static versus dynamic ventilation model with and without lubrication.

PURPOSE: Longitudinal folds in tracheal tube (TT) cuffs cause leakage of pooled secretions past the tube cuff, and the most common in vitro method to test the efficacy of a new tube is a benchtop model using an artificial rigid trachea. This study compared the potential of a static and dynamic ventilation benchtop model and cuff lubrication in testing the tracheal sealing properties of a given TT cuff. METHODS: Static trial Six brands of 7.5 mm internal diameter (ID) cuffed TT (n = 8) with high volume-low pressure cuffs were inflated in an artificial trachea (18 mm ID) without and with lubrication. Dynamic trial The same tube cuffs, without lubrication, were subjected to positive pressure ventilation (PPV) + positive end-expiratory pressure (PEEP) of 5cmH(2)O or to PPV alone (without PEEP) or to PEEP alone (without PPV). Clear water (5 ml) was placed above the tube cuff, and fluid leakage (ml) was measured up to 60 min. RESULTS: Gel lubrication, PEEP alone and PPV + PEEP completely prevented fluid leakage across the tube cuffs in all six TT brands tested within 60 min when compared to the static unlubricated model (0% leak versus 100% leak; P < 0.01). Fluid leakage in the static unlubricated model and the PPV group was 1.38-4.76 ml and 0.23-4.47 ml, respectively. CONCLUSION: Gel lubrication, PEEP alone, and PPV + PEEP in the benchtop model had a much stronger protective effect than PPV alone on fluid leakage. Studies testing the fluid sealing efficiency of tube cuffs might be more conclusive in a static benchtop model without lubrication than in a dynamic model.

Bone steady-state is established at reduced bone strength after spinal cord injury: a longitudinal study using peripheral quantitative computed tomography (pQCT).

Spinal cord injury (SCI) is associated with a marked and rapid sublesional bone loss. So far, reports about the time course of adaptive changes in bone mass and structure in people with chronic and complete SCI are conflicting. Both, a continuous decline of bone parameters throughout the chronic phase of immobilisation as well as stabilisation of bone status on a low level have been documented. In our recently published cross-sectional study we suggested that subjects with a complete SCI reach a new bone steady-state in the paralysed limbs after extensive bone loss was complete. In addition, we described a time loss curve for each measured bone mineral density and geometry parameter and calculated its individual time to reach steady-state (tsteady-state). The aim of the present study was to test the findings of our cross-sectional study in a longitudinal design. Thirty-nine male subjects of the original cross-sectional study with complete SCI and paralysis duration between 0.9 and 34 years were included. Two follow-up pQCT measurements at 15 and 30 months after baseline measurement were performed at the distal epiphyses and mid shafts of the femur, tibia and radius. From the epiphyseal scans, bone mass, trabecular and total BMD were calculated. From the shaft scans, bone mass and cortical BMD, total and cortical cross-sectional areas and cortical thickness were determined. Repeated measures ANOVAs were performed with bone data at baseline, after 15 months and 30 months. Analyses were performed including only subjects with a lesion duration > or =t(steady-state) for each particular bone parameter. Bone parameters of tibial and femoral epi- and diaphyses were found to show no statistically significant differences between the three time points. Relative changes in bone parameters were small and ranged from -1.72% to +0.51% in the femur and from -1.67% to +0.42% in the tibia within 30 months of monitoring. Our data confirm the temporal limitation of the bone loss after complete SCI with stabilisation of BMD and geometric properties on a lower level-a finding of clinical importance considering the treatment strategies of bone loss after SCI with respect to lesion duration.

High-volume FES-cycling partially reverses bone loss in people with chronic spinal cord injury.

Spinal cord injury (SCI) leads to severe bone loss in the paralysed limbs and to a resulting increased fracture risk thereof. Since long bone fractures can lead to comorbidities and a reduction in quality of life, it is important to improve bone strength in people with chronic SCI. In this prospective longitudinal cohort study, we investigated whether functional electrical stimulation (FES) induced high-volume cycle training can partially reverse the loss of bone substance in the legs after chronic complete SCI. Eleven participants with motor-sensory complete SCI (mean age 41.9+/-7.5 years; 11.0+/-7.1 years post injury) were recruited. After an initial phase of 14+/-7 weeks of FES muscle conditioning, participants performed on average 3.7+/-0.6 FES-cycling sessions per week, of 58+/-5 min each, over 12 months at each individual's highest power output. Bone and muscle parameters were investigated in the legs by means of peripheral quantitative computed tomography before the muscle conditioning (t1), and after six (t2) and 12 months (t3) of high-volume FES-cycle training. After 12 months of FES-cycling, trabecular and total bone mineral density (BMD) as well as total cross-sectional area in the distal femoral epiphysis increased significantly by 14.4+/-21.1%, 7.0+/-10.8% and 1.2+/-1.5%, respectively. Bone parameters in the femoral shaft showed small but significant decreases, with a reduction of 0.4+/-0.4% in cortical BMD, 1.8+/-3.0% in bone mineral content, and 1.5+/-2.1% in cortical thickness. These decreases mainly occurred between t1 and t2. No significant changes were found in any of the measured bone parameters in the tibia. Muscle CSA at the thigh increased significantly by 35.5+/-18.3%, while fat CSA at the shank decreased by 16.7+/-12.3%. Our results indicate that high-volume FES-cycle training leads to site-specific skeletal changes in the paralysed limbs, with an increase in bone parameters at the actively loaded distal femur but not the passively loaded tibia. Thus, we conclude that high-volume FES-induced cycle training has clinical relevance as it can partially reverse bone loss and thus may reduce fracture risk at this fracture prone site.

Exoskeleton gait training after spinal cord injury: An exploratory study on secondary health conditions.

OBJECTIVE: To explore changes in pain, spasticity, range of motion, activities of daily living, bowel and lower urinary tract function and quality of life of individuals with spinal cord injury following robotic exoskeleton gait training. DESIGN: Prospective, observational, open-label multicentre study. METHODS: Three training sessions per week for 8 weeks using an Ekso™ GT robotic exoskeleton (EKSO Bionics). Included were individuals with recent (<1 year) or chronic (>1 year) injury, paraplegia and tetraplegia, complete and incomplete injury, men and women. RESULTS: Fifty-two participants completed the training protocol. Pain was reported by 52% of participants during the week prior to training and 17% during training, but no change occurred longitudinally. Spasticity decreased after a training session compared with before the training session (p <0.001), but not longitudinally. Chronically injured participants increased Spinal Cord Independence Measure (SCIM III) from 73 to 74 (p = 0.008) and improved life satisfaction (p = 0.036) over 8 weeks of training. Recently injured participants increased SCIM III from 62 to 70 (p < 0.001), but no significant change occurred in life satisfaction. Range of motion, bowel and lower urinary function did not change over time. CONCLUSION: Training seemed not to provoke new pain. Spasticity decreased after a single training session. SCIM III and quality of life increased longitudinally for subsets of participants.