RESUMO
OBJECTIVE: Spinal cord ischemia (SCI) with paraplegia or paraparesis is a devastating complication of complex aortic repair (CAR). Treatment includes cerebrospinal fluid drainage, maintenance of hemoglobin concentration (>10 g/L), and elevating mean arterial blood pressure. Animal and human case series have reported improvements in SCI outcomes with hyperbaric oxygen therapy (HBOT). We reviewed our center's experience with HBOT as a rescue treatment for spinal cord ischemia post-CAR in addition to standard treatment. METHODS: A retrospective review of the University Health Network's Hyperbaric Medicine Unit treatment database identified HBOT sessions for patients with SCI post-CAR between January 2013 and June 2021. Mean estimates of overall motor function scores were determined for postoperative, pre-HBOT, post-HBOT (within 4 hours of the final HBOT session), and at the final assessment (last available in-hospital evaluation) using a linear mixed model. A subgroup analysis compared the mean estimates of overall motor function scores between improvement and non-improvement groups at given timepoints. Improvement of motor function was defined as either a ≥2 point increase in overall muscle function score in patients with paraparesis or an upward change in motor deficit categorization (para/monoplegia, paraparesis, and no deficit). Subgroup analysis was performed by stratifying by improvement or non-improvement of motor function from pre-HBOT to final evaluation. RESULTS: Thirty patients were treated for SCI. Pre-HBOT, the motor deficit categorization was 10 paraplegia, three monoplegia, 16 paraparesis, and one unable to assess. At the final assessment, 14 patients demonstrated variable degrees of motor function improvement; eight patients demonstrated full motor function recovery. Seven of the 10 patients with paraplegia remained paraplegic despite HBOT. The estimated mean of overall muscle function score for pre-HBOT was 16.6 ± 2.9 (95% confidence interval [CI], 10.9-22.3) and for final assessment was 23.4 ± 2.9 (95% CI, 17.7-29.1). The estimated mean difference between pre-HBOT and final assessment overall muscle function score was 6.7 ± 3.1 (95% CI, 0.6-16.1). The estimated mean difference of the overall muscle function score between pre-HBOT and final assessment for the improved group was 16.6 ± 3.5 (95% CI, 7.5-25.7) vs -4.9 ± 4.2 (95% CI, -16.0 to 6.2) for the non-improved group. CONCLUSIONS: HBOT, in addition to standard treatment, may potentially improve recovery in spinal cord function following SCI post-CAR. However, the potential benefits of HBOT are not equally distributed among subgroups.
Assuntos
Aneurisma da Aorta Torácica , Oxigenoterapia Hiperbárica , Isquemia do Cordão Espinal , Humanos , Aneurisma da Aorta Torácica/cirurgia , Hemiplegia/complicações , Hemiplegia/terapia , Paraparesia/etiologia , Paraplegia/diagnóstico , Paraplegia/etiologia , Paraplegia/terapia , Medula Espinal , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/terapia , Resultado do TratamentoRESUMO
Spinal cord injury causes temporary or permanent loss of motor, sensory, or autonomic functions, leading to long-term impairments that are not only confined to physical attributes but also restrict individuals' participation in major domains of life. Around 60%-80% of individuals with spinal cord injuries depend on a wheelchair for mobility. Numerous studies have reported yoga's beneficial role in alleviating spinal cord injury symptoms; however, a validated wheelchair-based yoga module was unavailable. Thus, the present study aimed to develop and validate a wheelchair-based yoga module that comprises a printed protocol for individuals with paraplegia. The study was conducted in four phases: The first three phases were the steps for the formulation of a wheelchair-based yoga module, and in the last phase the content validity of the designed module was determined by a panel of 10 experts, who were asked to rate the preliminary module for its necessity and relevance using a Likert scale. A total of 17 yoga practices with high content validity were included in the final wheelchair-based yoga module, and 10 practices with lower content validity were excluded from the designed module. Data analysis revealed the mean content validation index of the designed module to be 0.81. This study concludes that the formulated wheelchair-based yoga module is valid for individuals with paraplegia. However, future studies need to be conducted to determine the protocol's feasibility and effectiveness.
Assuntos
Traumatismos da Medula Espinal , Cadeiras de Rodas , Yoga , Humanos , Paraplegia/terapia , Paraplegia/etiologia , Traumatismos da Medula Espinal/terapia , Traumatismos da Medula Espinal/complicações , Cadeiras de Rodas/efeitos adversosRESUMO
BACKGROUND: With an increase in the global popularity of coffee, caffeine is one of the most consumed ingredients of modern times. However, the consumption of massive amounts of caffeine can lead to severe hypokalemia. CASE PRESENTATION: A 29-year-old man without a specific past medical history was admitted to our hospital with recurrent episodes of sudden and severe lower-extremity weakness. Laboratory tests revealed low serum potassium concentration (2.6-2.9 mmol/L) and low urine osmolality (100-130 mOsm/kgH2O) in three such prior episodes. Urinary potassium/urinary creatinine ratio was 12 and 16 mmol/gCr, respectively. The patient was not under medication with laxatives, diuretics, or herbal remedies. Through an in-depth interview, we found that the patient consumed large amounts of caffeine-containing beverages daily, which included > 15 cups of coffee, soda, and various kinds of tea. After the cessation of coffee intake and concomitant intravenous potassium replacement, the symptoms rapidly resolved, and the serum potassium level normalized. CONCLUSIONS: An increased intracellular shift of potassium and increased loss of potassium in urine due to the diuretic action have been suggested to be the causes of caffeine-induced hypokalemia. In cases of recurring hypokalemia of unknown cause, high caffeine intake should be considered.
Assuntos
Cafeína/efeitos adversos , Café , Dietoterapia/métodos , Hidratação/métodos , Hipopotassemia , Paraplegia , Potássio , Adulto , Café/efeitos adversos , Café/química , Café/metabolismo , Diuréticos/efeitos adversos , Comportamento de Ingestão de Líquido , Humanos , Hipopotassemia/diagnóstico , Hipopotassemia/etiologia , Hipopotassemia/fisiopatologia , Masculino , Debilidade Muscular/sangue , Debilidade Muscular/diagnóstico , Debilidade Muscular/etiologia , Concentração Osmolar , Paraplegia/sangue , Paraplegia/etiologia , Paraplegia/fisiopatologia , Paraplegia/terapia , Potássio/administração & dosagem , Potássio/sangue , Potássio/urina , Recidiva , Resultado do Tratamento , Urinálise/métodosRESUMO
Neuropathic pain following spinal cord injury involves plastic changes along the whole neuroaxis. Current neuroimaging studies have identified grey matter volume (GMV) and resting-state functional connectivity changes of pain processing regions related to neuropathic pain intensity in spinal cord injury subjects. However, the relationship between the underlying neural processes and pain extent, a complementary characteristic of neuropathic pain, is unknown. We therefore aimed to reveal the neural markers of widespread neuropathic pain in spinal cord injury subjects and hypothesized that those with greater pain extent will show higher GMV and stronger connectivity within pain related regions. Thus, 29 chronic paraplegic subjects and 25 healthy controls underwent clinical and electrophysiological examinations combined with neuroimaging. Paraplegics were demarcated based on neuropathic pain and were thoroughly matched demographically. Our findings indicate that (a) spinal cord injury subjects with neuropathic pain display stronger connectivity between prefrontal cortices and regions involved with sensory integration and multimodal processing, (b) greater neuropathic pain extent, is associated with stronger connectivity between the posterior insular cortex and thalamic sub-regions which partake in the lateral pain system and (c) greater intensity of neuropathic pain is related to stronger connectivity of regions involved with multimodal integration and the affective-motivational component of pain. Overall, this study provides neuroimaging evidence that the pain phenotype of spinal cord injury subjects is related to the underlying function of their resting brain.
Assuntos
Córtex Cerebral/fisiopatologia , Conectoma , Potenciais Evocados/fisiologia , Rede Nervosa/fisiopatologia , Neuralgia/fisiopatologia , Nociceptividade/fisiologia , Paraplegia/fisiopatologia , Traumatismos da Medula Espinal/fisiopatologia , Tálamo/fisiopatologia , Adulto , Idoso , Córtex Cerebral/diagnóstico por imagem , Doença Crônica , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Rede Nervosa/diagnóstico por imagem , Neuralgia/diagnóstico por imagem , Paraplegia/diagnóstico por imagem , Paraplegia/etiologia , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/diagnóstico por imagem , Tálamo/diagnóstico por imagemRESUMO
BACKGROUND Spinal hematomas can be post-traumatic, iatrogenic, or spontaneous. A spontaneous spinal hematoma is a rare finding, but one with very serious clinical implications. There are some risk factors linked to its occurrence, e.g. arteriovenous malformations, lumbar puncture, coagulopathy, neoplasms, or therapeutic anticoagulation. At present, only a few cases of spontaneous spinal hematoma (SSH) associated with new oral anticoagulants (NOACs) have been described, three of which were linked with rivaroxaban. CASE REPORT We report the case of an 82-year-old Caucasian woman with persistent atrial fibrillation treated with rivaroxaban, who presented to the Urology Department with acute-onset back pain which was thought to be due to urolithiasis. No kidney stones were found, but her creatinine serum level was elevated, so she was transferred to our clinic for further treatment. During hospitalization she quickly developed paraplegia with urine and stool retention. MRI was performed, and demonstrated an acute epidural hemorrhage in her thoracic and lumbar spine. The neurosurgeons disqualified this patient from surgical intervention due to the extent of the hematoma and its location. The patient was referred to the Neurology Department for treatment and rehabilitation, but, to the best of our knowledge, she did not recover her motor function. CONCLUSIONS Although rivaroxaban has been shown to be more effective than warfarin in stroke prevention in patients with atrial fibrillation, physicians must remember that its use also carries the risk of major bleeding. SSH occurrence should be taken into account in a patient taking NOACs who develops paraplegia, even if there is no history of trauma prior to admission.
Assuntos
Anticoagulantes/efeitos adversos , Hematoma Epidural Espinal/induzido quimicamente , Paraplegia/etiologia , Rivaroxabana/efeitos adversos , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Feminino , Hematoma Epidural Espinal/diagnóstico por imagem , Humanos , Vértebras Lombares/diagnóstico por imagem , Imageamento por Ressonância Magnética , Rivaroxabana/administração & dosagem , Vértebras Torácicas/diagnóstico por imagemRESUMO
BACKGROUND: Participation in physical and therapeutic activities is usually severely restricted after a spinal cord injury (SCI). Reasons for this are the associated loss of voluntary motor function, inefficient temperature regulation of the affected extremities, and early muscle fatigue. Hydrotherapy or swim training offer an inherent weight relief, reduce spasticity and improve coordination, muscle strength and fitness. METHODS: We present a new hybrid exercise modality that combines functional electrical stimulation (FES) of the knee extensors and transcutaneous spinal cord stimulation (tSCS) with paraplegic front crawl swimming. tSCS is used to stimulate the afferent fibers of the L2-S2 posterior roots for spasticity reduction. By activating the tSCS, the trunk musculature is recruited at a motor level. This shall improve trunk stability and straighten the upper body. Within this feasibility study, two complete SCI subjects (both ASIA scale A, lesion level Th5/6), who have been proficient front crawl swimmers, conducted a 10-week swim training with stimulation support. In an additional assessment swim session nine months after the training, the knee extension, hip extension, and trunk roll angles where measured using waterproof inertial measurement units (IMUs) and compared for different swimming conditions (no stimulation, tSCS, FES, FES plus tSCS). RESULTS: For both subjects, a training effect over the 10-week swim training was observed in terms of measured lap times (16 m pool) for all swimming conditions. Swimming supported by FES reduced lap times by 15.4% and 8.7% on average for Subject A and Subject B, respectively. Adding tSCS support yielded even greater mean decreases of 19.3% and 20.9% for Subjects A and B, respectively. Additionally, both subjects individually reported that swimming with tSCS for 30-45 minutes eliminated spasticity in the lower extremities for up to 4 hours beyond the duration of the session. Comparing the median as well as the interquartile range of all different settings, the IMU-based motion analysis revealed that FES as well as FES+tSCS improve knee extension in both subjects, while hip extension was only increased in one subject. Trunk roll angles were similar for all swimming conditions. tSCS had no influence on the knee and hip joint angles. Both subjects reported that stimulation-assisted swimming is comfortable, enjoyable, and they would like to use such a device for recreational training and rehabilitation in the future. CONCLUSIONS: Stimulation-assisted swimming seems to be a promising new form of hybrid exercise for SCI people. It is safe to use with reusable silicone electrodes and can be performed independently by experienced paraplegic swimmers except for transfer to water. The study results indicate that swimming speed can be increased by the proposed methods and spasticity can be reduced by prolonged swim sessions with tSCS and FES. The combination of stimulation with hydrotherapy might be a promising therapy for neurologic rehabilitation in incomplete SCI, stroke or multiples sclerosis patients. Therefore, further studies shall incorporate other neurologic disorders and investigate the potential benefits of FES and tSCS therapy in the water for gait and balance.
Assuntos
Terapia por Estimulação Elétrica/métodos , Terapia por Exercício/métodos , Paraplegia/reabilitação , Traumatismos da Medula Espinal/reabilitação , Natação/fisiologia , Adulto , Terapia por Estimulação Elétrica/instrumentação , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Espasticidade Muscular/etiologia , Espasticidade Muscular/reabilitação , Paraplegia/etiologia , Projetos Piloto , Traumatismos da Medula Espinal/complicaçõesRESUMO
Spinal cord ischemia (SCI) is a rare presenting symptom of acute complicated type B aortic dissection, occurring in approximately 3% of patients . We present a case report of a patient with this presentation who had observed resolution of his paraplegia symptoms immediately after placement of a thoracic stent graft under local anesthesia. The temporal association between true lumen flow restoration and paraplegia resolution intraoperatively is a novel finding. We feel that this case report may provide support for recognized cord perfusion theory , as well as contribute to the understanding of the time frame associated with SCI and reversibility of paraplegia.
Assuntos
Anestesia Local , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Extremidade Inferior/inervação , Paraplegia/etiologia , Isquemia do Cordão Espinal/etiologia , Doença Aguda , Idoso , Dissecção Aórtica/complicações , Dissecção Aórtica/diagnóstico por imagem , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/diagnóstico por imagem , Procedimentos Endovasculares/efeitos adversos , Humanos , Masculino , Paraplegia/diagnóstico , Paraplegia/fisiopatologia , Recuperação de Função Fisiológica , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/fisiopatologia , Resultado do TratamentoRESUMO
STUDY DESIGN: Randomized controlled trial. OBJECTIVE: To determine the effects of advanced weight-bearing mat exercises (AWMEs) with/without functional electrical stimulation (FES) of the quadriceps and gastrocnemius muscles on the ability of wheelchair-dependent people with spinal cord injury (SCI) to transfer and attain independence in activities of daily living (ADLs). SETTING: An outpatient clinic, Iran. METHODS: People with traumatic chronic paraplegia (N = 16) were randomly allocated to three groups. The exercise group (EX; N = 5) performed AWMEs of quadruped unilateral reaching and tall-kneeling for 24 weeks (3 days/week). Sessions were increased from 10 min to 54 min over the 24-week period. The exercise-FES group (EX + FES; N = 5) performed AWMEs simultaneously with FES of the quadriceps and gastrocnemius muscles. The control group performed no exercise and no FES (N = 6). The primary outcomes were the total Spinal Cord Independence Measure-III (SCIM-III) to reflect independence with ADL, and the sum of the four SCIM-III transfer items to reflect ability to transfer. There were six other outcomes. RESULTS: The mean (95% CI) between-group differences of the four transfer items of the SCIM-III for the EX vs. control group was 1.8 points (0.2-3.4), and for the EX + FES vs. control group was 2 points (0.4-3.6). The equivalent differences for the total SCIM-III scores were 2.7 points (-0.6-6.0) and 4.1 points (0.8-7.4), respectively. There were no significant between-group differences for any other outcomes. CONCLUSIONS: Advanced weight-bearing mat exercises improve the ability of wheelchair-dependent people with SCI to transfer and attain independence in ADL.
Assuntos
Atividades Cotidianas , Terapia por Estimulação Elétrica/métodos , Terapia por Exercício/métodos , Músculo Esquelético , Avaliação de Resultados em Cuidados de Saúde , Paraplegia/reabilitação , Traumatismos da Medula Espinal/reabilitação , Suporte de Carga , Adulto , Terapia Combinada , Feminino , Humanos , Masculino , Limitação da Mobilidade , Músculo Esquelético/fisiopatologia , Paraplegia/etiologia , Traumatismos da Medula Espinal/complicações , Suporte de Carga/fisiologia , Cadeiras de RodasRESUMO
CONTEXT: People with spinal cord injury (SCI) experience the effects of a sedentary lifestyle very early on. Literature data suggest that programs using FES-assisted cycling would contribute to reduce the consequences of physical inactivity. The objective was to assess the feasibility of 12-month training on a FES-assisted bike of a subject with paraplegia for 21 years, T3, Asia Impairment Scale (AIS) A. An evaluation of morbidity, self-esteem, satisfaction, quality of life and duration of pedaling was performed. The impact on pain, cardiorespiratory function, body composition and bone metabolism were also assessed. FINDINGS: The acceptability score of the training constraints increased from 51 to 59/65 and satisfaction was high around 8/10. The pedaling duration increased from 1' to 26' on the recumbent bike and from 1' to 15' on open terrain. No significant changes were found with BMD and cardiorespiratory measures during exercise tests. SF 36 showed significant improvement of more than 10% and the Rosenberg Self Esteem score rapidly improved from 36 to 39/40. At the end of the training, the patient reached the objective of the Cybathlon 2016 by covering 750 m in less than 8 minutes, at an average speed of 5.80â km/hr. CONCLUSION/CLINICAL RELEVANCE: A person with high and complete level of SCI for more than 20 years can undertake this type of challenge if the prerequisites are met; this training is without danger if the safety precautions are respected; the challenge of participating in a competition had a powerful impact on JP's self-esteem and perceived quality of life.
Assuntos
Ciclismo , Terapia por Estimulação Elétrica , Terapia por Exercício , Paraplegia/reabilitação , Traumatismos da Medula Espinal/reabilitação , Ciclismo/fisiologia , Ciclismo/psicologia , Terapia Combinada , Terapia por Estimulação Elétrica/normas , Terapia por Exercício/normas , Humanos , Masculino , Pessoa de Meia-Idade , Paraplegia/etiologia , Paraplegia/fisiopatologia , Paraplegia/psicologia , Qualidade de Vida , Autoimagem , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/fisiopatologia , Traumatismos da Medula Espinal/psicologiaRESUMO
BACKGROUND: Spinal epidural hematoma (SEH) is an uncommon but serious emergency condition rare cases of spontaneously or following a minor traumatic event without bony injury. OBJECTIVE: We report the rare case of SEH associated with traditional massage initially presenting with delayed lower paraplegia. CASE REPORT: A 20-year-old man presented with bilateral lower extremity weakness and numbness 3â¯h prior to presentation. 3â¯days prior he was given a layperson Thai massage by a friend. Magnetic resonance imaging revealed a spinal epidural lesion suspicious for hematoma extending from C6 to T2 levels. Emergent surgical intervention for cord decompression was performed. An epidural hematoma with cord compression at C6-T2 levels was identified intraoperatively. No evidence of abnormal vascular flow or AV malformations was identified. Similar to chiropractic manipulation, massage may be associated with spinal trauma. CONCLUSION: Emergency physicians must maintain a high index of suspicion for spinal epidural hematomas in patients with a history of massage or chiropractic manipulation with neurologic complaints, because delays in diagnosis may worsen clinical outcome.
Assuntos
Hematoma Epidural Espinal/diagnóstico por imagem , Massagem/efeitos adversos , Paraplegia/etiologia , Compressão da Medula Espinal/cirurgia , Descompressão Cirúrgica , Hematoma Epidural Espinal/complicações , Hematoma Epidural Espinal/etiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Compressão da Medula Espinal/etiologia , Adulto JovemRESUMO
CONTEXT: Thyrotoxic periodic paralysis (TPP) is a relatively common complication seen in Asian hyperthyroid patients. However, it is a rare occurrence to find a TPP case comprised of acute hypercapnic respiratory failure in patients with painless thyroiditis. PATIENT: A 29-year-old Chinese man presented with flaccid paralysis of all four limbs and he was brought to emergency room. Severe hypokalemia was found on admission. Although treatment had been initiated with potassium chloride supplementation, he went on to develop acute hypercapnic respiratory failure likely due to muscle fatigue. The patient was intubated for mechanical ventilatory support. Once his serum potassium levels were normalized, he was able to be weaned off ventilator support. Thyroid function tests showed elevated free thyroxine concentration and low thyroid-stimulating hormone concentration. He underwent a thyroid uptake scan with 131I which revealed decreased uptake rate of thyroid area. Based on the patient's clinical presentation and associated findings, we diagnosed him with TPP due to painless thyroiditis. We have reviewed TPP cases caused by painless thyroiditis and TPP cases associated with acute hypercapnic respiratory failure. CONCLUSION: It is important to note that potentially fatal complications such as acute hypercapnic respiratory failure might occur in acute attacks of TPP even in cases of TPP due to painless thyroiditis.
Assuntos
Hipercapnia/complicações , Paralisia Periódica Hipopotassêmica/complicações , Insuficiência Respiratória/complicações , Tireoidite/complicações , Adulto , Povo Asiático , Humanos , Hipercapnia/diagnóstico , Hipercapnia/etnologia , Hipopotassemia/etnologia , Hipopotassemia/etiologia , Paralisia Periódica Hipopotassêmica/diagnóstico , Paralisia Periódica Hipopotassêmica/etnologia , Masculino , Paraplegia/etnologia , Paraplegia/etiologia , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/etnologia , Tireoidite/diagnóstico , Tireoidite/etnologiaRESUMO
Vegetarian and vegan diets are gaining popularity in the United States. Although appropriately planned vegetarian diets, including vegan diets, are healthful and nutritionally adequate and may provide health benefits in the prevention and treatment of certain diseases, not all families are aware of the nutritional supplements that may be required for their children. We describe a case of a 2-year-old previously healthy child consuming a vegan diet who presented to the pediatric emergency department with an acute inability to move her legs. Ionized calcium was found to be 0.89 mmol/L, and symptoms completely resolved within 2 hours of calcium gluconate infusion.
Assuntos
Gluconato de Cálcio/uso terapêutico , Dieta Vegetariana/efeitos adversos , Hipocalcemia/complicações , Paraplegia/etiologia , Doença Aguda , Cálcio/sangue , Pré-Escolar , Feminino , Humanos , Hipocalcemia/tratamento farmacológicoRESUMO
BACKGROUND: Neurological adverse events with spinal cord ischemia (SCI) remain one of the most feared complications in patients undergoing thoracic endovascular aortic repair (TEVAR). These patients can develop irreversible paraplegia with lifelong consequences with physical and psychological agony. CASE PRESENTATION: We herein present a patient who developed SCI with bilateral lower leg paraplegia on the third postoperative day following TEVAR. Spinal catheter was inserted for spinal fluid drainage. A hyperbaric oxygen therapy was initiated for 90 minutes for 2 days, which was followed by therapeutic hypothermia for 24 hours with a target temperature of 33°C. The patient exhibited significant neurological recovery following these treatments, and he ultimately regained full neurological function without spinal deficit. DISCUSSION: This represents the first reported case of full neurological recovery of a patient who developed complete SCI following TEVAR procedure. The neurological recovery was due in part to immediate therapeutic hypothermia and hyperbaric oxygen therapy which reversed the spinal ischemia.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Oxigenoterapia Hiperbárica , Hipotermia Induzida , Isquemia do Cordão Espinal/terapia , Idoso , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aortografia/métodos , Terapia Combinada , Angiografia por Tomografia Computadorizada , Humanos , Masculino , Paraplegia/etiologia , Paraplegia/fisiopatologia , Paraplegia/terapia , Recuperação de Função Fisiológica , Fluxo Sanguíneo Regional , Isquemia do Cordão Espinal/diagnóstico por imagem , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Resultado do TratamentoRESUMO
BACKGROUND: Functional neuromuscular stimulation, lower limb orthosis, powered lower limb exoskeleton, and hybrid neuroprosthesis (HNP) technologies can restore stepping in individuals with paraplegia due to spinal cord injury (SCI). However, a self-contained muscle-driven controllable exoskeleton approach based on an implanted neural stimulator to restore walking has not been previously demonstrated, which could potentially result in system use outside the laboratory and viable for long term use or clinical testing. In this work, we designed and evaluated an untethered muscle-driven controllable exoskeleton to restore stepping in three individuals with paralysis from SCI. METHODS: The self-contained HNP combined neural stimulation to activate the paralyzed muscles and generate joint torques for limb movements with a controllable lower limb exoskeleton to stabilize and support the user. An onboard controller processed exoskeleton sensor signals, determined appropriate exoskeletal constraints and stimulation commands for a finite state machine (FSM), and transmitted data over Bluetooth to an off-board computer for real-time monitoring and data recording. The FSM coordinated stimulation and exoskeletal constraints to enable functions, selected with a wireless finger switch user interface, for standing up, standing, stepping, or sitting down. In the stepping function, the FSM used a sensor-based gait event detector to determine transitions between gait phases of double stance, early swing, late swing, and weight acceptance. RESULTS: The HNP restored stepping in three individuals with motor complete paralysis due to SCI. The controller appropriately coordinated stimulation and exoskeletal constraints using the sensor-based FSM for subjects with different stimulation systems. The average range of motion at hip and knee joints during walking were 8.5°-20.8° and 14.0°-43.6°, respectively. Walking speeds varied from 0.03 to 0.06 m/s, and cadences from 10 to 20 steps/min. CONCLUSIONS: A self-contained muscle-driven exoskeleton was a feasible intervention to restore stepping in individuals with paraplegia due to SCI. The untethered hybrid system was capable of adjusting to different individuals' needs to appropriately coordinate exoskeletal constraints with muscle activation using a sensor-driven FSM for stepping. Further improvements for out-of-the-laboratory use should include implantation of plantar flexor muscles to improve walking speed and power assist as needed at the hips and knees to maintain walking as muscles fatigue.
Assuntos
Terapia por Estimulação Elétrica/instrumentação , Exoesqueleto Energizado , Paraplegia/reabilitação , Traumatismos da Medula Espinal/reabilitação , Adulto , Feminino , Humanos , Extremidade Inferior/fisiopatologia , Masculino , Paraplegia/etiologia , Traumatismos da Medula Espinal/complicações , Caminhada/fisiologiaRESUMO
We report a case of chronic traumatic paraplegia in which epidural electrical stimulation (EES) of the lumbosacral spinal cord enabled (1) volitional control of task-specific muscle activity, (2) volitional control of rhythmic muscle activity to produce steplike movements while side-lying, (3) independent standing, and (4) while in a vertical position with body weight partially supported, voluntary control of steplike movements and rhythmic muscle activity. This is the first time that the application of EES enabled all of these tasks in the same patient within the first 2 weeks (8 stimulation sessions total) of EES therapy.
Assuntos
Terapia por Estimulação Elétrica/métodos , Músculo Esquelético/fisiopatologia , Paraplegia , Traumatismos da Medula Espinal , Medula Espinal/fisiopatologia , Adulto , Eletromiografia/métodos , Humanos , Masculino , Paraplegia/diagnóstico , Paraplegia/etiologia , Paraplegia/fisiopatologia , Postura/fisiologia , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/fisiopatologia , Traumatismos da Medula Espinal/terapia , Análise e Desempenho de Tarefas , Resultado do Tratamento , Caminhada/fisiologiaRESUMO
BACKGROUND: Assessments of function in persons with spinal cord injury (SCI) often utilize pre-defined constructs and measures without consideration of patient context, including how patients define function and what matters to them. OBJECTIVES/HYPOTHESIS: We utilized photovoice to understand how individuals define function, facilitators and barriers to function, and adaptations to support functioning. METHODS: Veterans with SCI were provided with cameras and guidelines to take photographs of things that: (1) help with functioning, (2) are barriers to function, and (3) represent adaptations used to support functioning. Interviews to discuss photographs followed and were audio-recorded, transcribed, and analyzed using grounded-thematic coding. Nvivo 8 was used to store and organize data. RESULTS: Participants (n = 9) were male (89%), Caucasian (67%), had paraplegia (75%), averaged 64 years of age, and were injured, on average, for 22 years. Function was described in several ways: the concept of 'normalcy,' aspects of daily living, and ability to be independent. Facilitators included: helpful tools, physical therapy/therapists, transportation, and caregivers. Barriers included: wheelchair-related issues and interior/exterior barriers both in the community and in the hospital. Examples of adaptations included: traditional examples like ramps, and also creative examples like the use of rubber bands on a can to help with grip. CONCLUSION(S): Patient-perspectives elicited in-depth information that expanded the common definition of function by highlighting the concept of "normality," facilitators and barriers to function, and adaptations to optimize function. These insights emphasize function within a patient-context, emphasizing a holistic definition of function that can be used to develop personalized, patient-driven care plans.
Assuntos
Atividades Cotidianas , Atitude , Pessoas com Deficiência , Vida Independente , Paraplegia , Traumatismos da Medula Espinal , Veteranos , Adulto , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Planejamento Ambiental , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Militares , Paraplegia/etiologia , Autonomia Pessoal , Tecnologia Assistiva , Traumatismos da Medula Espinal/complicações , Cadeiras de RodasRESUMO
PURPOSE: We report on a 72-year-old male patient who developed a nontraumatic spinal subdural hematoma (SSDH) during rivaroxaban therapy, a relatively new orally administered direct factor Xa inhibitor. CASE DESCRIPTION: The patient sustained a sudden onset of interscapular pain, followed by gait impairment and paraplegia. Magnetic resonance imaging (MRI) of the spine demonstrated SSDH from T6 to T8. Laboratory tests revealed a high rivaroxaban level, associated with a major hemorrhagic risk. Surgery was, therefore, performed the following morning, after normalization of coagulation parameters. CONCLUSION: Determining the time of safe surgery remains challenging when hemorrhagic complications happen with direct factor Xa inhibitor, especially when neurological prognosis is engaged. Spinal subdural hematoma has not previously been reported following rivaroxaban therapy.
Assuntos
Inibidores do Fator Xa/uso terapêutico , Hematoma Subdural Espinal/induzido quimicamente , Rivaroxabana/uso terapêutico , Doenças da Medula Espinal/induzido quimicamente , Idoso , Humanos , Imageamento por Ressonância Magnética , Masculino , Paraplegia/etiologiaRESUMO
CASE PRESENTATION: A man with chronic paraplegia sustained a distal femur fracture following an unrelated fall while enrolled in a study examining musculoskeletal changes after 6 months of cycling with functional electrical stimulation (FES). After healing, he restarted and completed the study. MANAGEMENT AND OUTCOME: Study measures included areal bone mineral density, trabecular bone microarchitecture, cortical bone macroarchitecture, serum bone formation/resorption markers, and muscle volume. The patient made small gains in bone- and muscle-related measures. Bone markers had not returned to baseline prior to restarting cycling, which may have impacted results. DISCUSSION: This case shows that cycling with FES may be safely resumed after distal femur fracture.
Assuntos
Ciclismo , Osso e Ossos , Terapia por Estimulação Elétrica , Estimulação Elétrica , Fraturas Ósseas , Paraplegia/terapia , Traumatismos da Medula Espinal/terapia , Densidade Óssea , Osso e Ossos/metabolismo , Contraindicações , Fêmur/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Paraplegia/etiologia , Traumatismos da Medula Espinal/complicaçõesRESUMO
OBJECTIVE: To explore the impacts on the fine movement of upper extremity with flaccid paralysis in stroke treated with acupuncture and motor imagery. METHODS: Sixty-two cases of flaccid paralysis of upper extremity in stroke were randomized into an observation group (30 cases) and a control group (32 cases). In the control group, the conventional western medication and the passive movement of the extremity were applied. Additionally, the penetrating needling technique was used at the head points [penetrating needling from Baihui (GV 20) to Taiyang (EX-HN 5)] and the local affected extremity [penetrating needling from Jianyu (LI 15) to Binao (LI1 14), from Quchi (LI 11) to Shaohai (HT 3), from Waiguan (TE 5) to Neiguan (PC 6), etc]. The needles were retained for 30 min. In the observation group, on the basic treatment as the control group, during the needle retaining, the motor imagery therapy was supplemented. The treatment was given once a day, 5 treatments a week, for 4 weeks totally in the either group. The scores in the action research arm test (ARAT) and the modified Fugl-Meyer assessment (FMA) were recorded at the moment of enrollment, in 2 and 4 weeks of treatment, in the 6th and 8th weeks, as well as after 90 days separately. RESULTS: (1) ARAT score: since the 2nd week, ARAT scores in the observation group were all improved significantly as compared with those in the control group at the each time points (all P<0. 05). In the observation group, the scores were improved significantly in the pair comparison at the time points (all P<0. 05). In the control group, the score in the 2nd week was not different significantly as compared with that before treatment (P>0. 05), but the scores at the rest time points were improved significantly in the pair comparison (all P<0. 05); (2) FMA score: in the 2nd week and on the 90th day, FMA score in the observation group was higher significantly than those in the control group (both P < 0. 05). In the observation group, the scores were all improved significantly in the pair comparison at the time points (all P<0. 05). In the control group, except that in comparison between the 90th day and the 8th week (P>0. 05), the results were all P<0. 05 at the rest time points. CONCLUSION: The early intervention of the combined therapy of acupuncture and motor imagery effectively promotes the recovery of the coordination function and the fine movement of upper extremity, especially the improvements of the fine movement in stroke at flaccid paralysis stage. The efficacy is better than the single acupuncture treatment.
Assuntos
Terapia por Acupuntura , Imagens, Psicoterapia , Paraplegia/terapia , Acidente Vascular Cerebral/complicações , Extremidade Superior/fisiopatologia , Adulto , Idoso , Terapia Combinada , Feminino , Humanos , Imaginação , Masculino , Pessoa de Meia-Idade , Atividade Motora , Paraplegia/etiologia , Paraplegia/fisiopatologia , Paraplegia/psicologia , Acidente Vascular Cerebral/terapiaRESUMO
BACKGROUND: Direct brain control of overground walking in those with paraplegia due to spinal cord injury (SCI) has not been achieved. Invasive brain-computer interfaces (BCIs) may provide a permanent solution to this problem by directly linking the brain to lower extremity prostheses. To justify the pursuit of such invasive systems, the feasibility of BCI controlled overground walking should first be established in a noninvasive manner. To accomplish this goal, we developed an electroencephalogram (EEG)-based BCI to control a functional electrical stimulation (FES) system for overground walking and assessed its performance in an individual with paraplegia due to SCI. METHODS: An individual with SCI (T6 AIS B) was recruited for the study and was trained to operate an EEG-based BCI system using an attempted walking/idling control strategy. He also underwent muscle reconditioning to facilitate standing and overground walking with a commercial FES system. Subsequently, the BCI and FES systems were integrated and the participant engaged in several real-time walking tests using the BCI-FES system. This was done in both a suspended, off-the-ground condition, and an overground walking condition. BCI states, gyroscope, laser distance meter, and video recording data were used to assess the BCI performance. RESULTS: During the course of 19 weeks, the participant performed 30 real-time, BCI-FES controlled overground walking tests, and demonstrated the ability to purposefully operate the BCI-FES system by following verbal cues. Based on the comparison between the ground truth and decoded BCI states, he achieved information transfer rates >3 bit/s and correlations >0.9. No adverse events directly related to the study were observed. CONCLUSION: This proof-of-concept study demonstrates for the first time that restoring brain-controlled overground walking after paraplegia due to SCI is feasible. Further studies are warranted to establish the generalizability of these results in a population of individuals with paraplegia due to SCI. If this noninvasive system is successfully tested in population studies, the pursuit of permanent, invasive BCI walking prostheses may be justified. In addition, a simplified version of the current system may be explored as a noninvasive neurorehabilitative therapy in those with incomplete motor SCI.