Training with FES-assisted cycling in a subject with spinal cord injury: Psychological, physical and physiological considerations.

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 5.80 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.

Development of Functional Electrical Stimulation Rowing: The Rowstim Series.

Potentially, functional electrical stimulation (FES)-assisted exercise may have an important therapeutic role in reducing comorbidities associated with spinal cord injury (SCI). Here, we present an overview of these secondary life-threatening conditions, discuss the rationale behind the development of a hybrid exercise called FES rowing, and describe our experience in developing FES rowing technology. FES rowing and sculling are unique forms of adaptive rowing for those with SCI. The paralyzed leg musculature is activated by multiple channels of electrical pulses delivered via self-adhesive electrodes attached to the skin. The stimulated muscle contractions are synchronized with voluntary rowing movements of the upper limbs. A range of steady-state FES rowing exercise intensities have been demonstrated from 15.2 ± 1.8 mL/kg/min in tetraplegia to 22.9 ±7.1 mL/kg/min in paraplegia. We expect that such high levels may help some to achieve significant reductions in the risks to their health, particularly where a dose-response relationship exists as is the case for cardiovascular disease and Type II diabetes. Furthermore, preliminary results suggest that cyclical forces more than 1.5 times body weight are imposed on the leg long bones which may help to reduce the risk of fragility fractures. We have demonstrated the feasibility of FES rowing on land and water using adapted rowing technology that includes; a fixed stretcher indoor ergometer (adapted Concept 2, Model E), a floating stretcher indoor ergometer (adapted Concept 2 Dynamic), a turbine powered water rowing tank, a custom hydraulic sculling simulator and a single scull (adapted Alden 16). This has involved volunteers with paraplegia and tetraplegia with SCI ranging from C4 to T12 AIS A using at least 4-channels of surface electrical stimulation. FES rowers, with SCI, have competed alongside non-SCI rowers over the Olympic distance of 2000 m at the British Indoor Rowing Championships in 2004, 2005, and 2006 and the World Indoor Rowing Championships in 2006 (CRASH-B's) in Boston, MA, USA. The best 2000 m FES rowing performance to date has been achieved by a 23-year-old male, Tom Aggar T12 AIS A, in 10 min 28 s. Moreover, two of our FES rowers with complete paraplegia have gone on to successfully compete in the Adaptive Rowing arms-only category (AM1x) at the World Rowing Championships and Paralympic Games.

Motor imagery in spinal cord injured people is modulated by somatotopic coding, perspective taking, and post-lesional chronic pain.

Motor imagery (MI) allows one to mentally represent an action without necessarily performing it. Importantly, however, MI is profoundly influenced by the ability to actually execute actions, as demonstrated by the impairment of this ability as a consequence of lesions in motor cortices, limb amputations, movement limiting chronic pain, and spinal cord injury. Understanding MI and its deficits in patients with motor limitations is fundamentally important as development of some brain-computer interfaces and daily life strategies for coping with motor disorders are based on this ability. We explored MI in a large sample of patients with spinal cord injury (SCI) using a comprehensive battery of questionnaires to assess the ability to imagine actions from a first-person or a third-person perspective and also imagine the proprioceptive components of actions. Moreover, we correlated MI skills with personality measures and clinical variables such as the level and completeness of the lesion and the presence of chronic pain. We found that the MI deficits (1) concerned the body parts affected by deafferentation and deefferentation, (2) were present in first- but not in third-person perspectives, and (3) were more altered in the presence of chronic pain. MI is thus closely related to bodily perceptions and representations. Every attempt to devise tools and trainings aimed at improving autonomy needs to consider the cognitive changes due to the body-brain disconnection.

Reversed cortical over-activity during movement imagination following neurofeedback treatment for central neuropathic pain.

OBJECTIVE: One of the brain signatures of the central neuropathic pain (CNP) is the theta band over-activity of wider cortical structures, during imagination of movement. The objective of the study was to investigate whether this over-activity is reversible following the neurofeedback treatment of CNP. METHODS: Five paraplegic patients with pain in their legs underwent from twenty to forty neurofeedback sessions that significantly reduced their pain. In order to assess their dynamic cortical activity they were asked to imagine movements of all limbs a week before the first and a week after the last neurofeedback session. Using time-frequency analysis we compared EEG activity during imagination of movement before and after the therapy and further compared it with EEG signals of ten paraplegic patients with no pain and a control group of ten able-bodied people. RESULTS: Neurofeedback treatment resulted in reduced CNP and a wide spread reduction of cortical activity during imagination of movement. The reduction was significant in the alpha and beta band but was largest in the theta band. As a result cortical activity became similar to the activity of other two groups with no pain. CONCLUSIONS: Reduction of CNP is accompanied by reduced cortical over-activity during movement imagination. SIGNIFICANCE: Understanding causes and consequences mechanism through which CNP affects cortical activity.

[Impacts on fine movement of upper extremity with flaccid paralysis in stroke treated with acupuncture combined with motor imagery].

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.

The influence of central neuropathic pain in paraplegic patients on performance of a motor imagery based Brain Computer Interface.

OBJECTIVE: The aim of this study was to test how the presence of central neuropathic pain (CNP) influences the performance of a motor imagery based Brain Computer Interface (BCI). METHODS: In this electroencephalography (EEG) based study, we tested BCI classification accuracy and analysed event related desynchronisation (ERD) in 3 groups of volunteers during imagined movements of their arms and legs. The groups comprised of nine able-bodied people, ten paraplegic patients with CNP (lower abdomen and legs) and nine paraplegic patients without CNP. We tested two types of classifiers: a 3 channel bipolar montage and classifiers based on common spatial patterns (CSPs), with varying number of channels and CSPs. RESULTS: Paraplegic patients with CNP achieved higher classification accuracy and had stronger ERD than paraplegic patients with no pain for all classifier configurations. Highest 2-class classification accuracy was achieved for CSP classifier covering wider cortical area: 82±7% for patients with CNP, 82±4% for able-bodied and 78±5% for patients with no pain. CONCLUSION: Presence of CNP improves BCI classification accuracy due to stronger and more distinct ERD. SIGNIFICANCE: Results of the study show that CNP is an important confounding factor influencing the performance of motor imagery based BCI based on ERD.

Human Instruments: Accessible Musical Instruments for People with Varied Physical Ability.

There are few ways in which persons, who do not have the use of their hands or arms, are able make music or control complex computer systems. Music as an expressive output is key to the full development of the human mind. Human Instruments is dedicated to the development and production of accessible musical instruments playable at a professional level, as well as computer control interfaces. We are currently user-testing three new, uniquely accessible devices, for their effectiveness in expressive music creation. Preliminary results are compelling.

Spiritual well-being as predictor of quality of life for adults with paraplegia.

PURPOSE: The promotion of quality of life (QOL) and healthy development across the person's life span can result in long and meaningful lives. The purpose of this study was to examine relationships between spiritual well-being (SWB), depression, and QOL for adults with paraplegia. DESIGN: A descriptive correlational design was used for this study. METHODS: A purposive sample of 75 participants completed the Ellison's SWB Scale, the Center for Epidemiologic Studies-Depression Scale, and a QOL scale. FINDINGS: Quality of life was significantly associated with SWB (r = .47, p = .01), and depression (r = -.59, p = .01), 43% of the variance in QOL was explained by age, gender, length of stay, SWB, and depression (F[5,69] = 10.45, p < .001). CONCLUSIONS: Participants with a strong sense of purpose or meaning in life were more likely to experience a higher QOL. CLINICAL RELEVANCE: Rehabilitation nurses can help guide patients to the discovery of what brings purpose and meaning to their lives.

Complex motor representations may not be preserved after complete spinal cord injury.

When using motor imagery to improve rehabilitation after spinal cord injury it is assumed that the motor representations are preserved and that task specific physical training is not necessary. Here I tested this hypothesis by examining P.W. who has a complete spinal cord injury due to an accident. However, P.W. was an elite wheelchair athlete, hence, has experienced a high load of physical training in general. During functional magnetic resonance imaging (fMRI), P.W. imagined wheelchair slalom (a complex motor task P.W. can perform) and stair walking (a complex motor task P.W. no longer can perform). A control group of neurologically intact participants were also included. The results showed that only for the task (wheelchair slalom) P.W. currently could physically perform was the pre-motor cortex recruited. For stair walking P.W. recruited inferior frontal cortex and parietal cortex. The results were confirmed with the control group showing similar pattern but for the opposite tasks. The conclusions from this study are that complex motor representations may not be preserved after a complete spinal cord injury and motor imagery is dependent on the current ability to perform the task physically.

Brain simulation of action may be grounded in physical experience.

An intriguing quality of our brain is that when actions are imagined, corresponding brain regions are recruited as when the actions are actually performed. It has been hypothesized that the similarity between real and simulated actions depends on the nature of motor representations. Here we tested this hypothesis by examining S.D., who never used her legs but is an elite wheel chair athlete. Controls recruited motor brain regions during imagery of stair walking and frontal regions during imagery of wheel chair slalom. S.D. showed the opposite pattern. Thus, brain simulation of actions may be grounded in specific physical experiences.

The hypnotic diagnostic interview for hysterical disorders, pediatric form.

This article reports on the use of hypnosis to facilitate the diagnostic process in two cases of pediatric hysterical reactions. The Hypnotic Diagnostic Interview for Hysterical Disorders (HDIHD), an interview tool, specifically designed for these cases, is reported. The first case was an adolescent male with motor Conversion Disorder manifested as paralysis of his lower limbs. The second was a preadolescent girl with sensory Conversion Disorder manifested as reduction of visual field in her right eye. Freudian conceptualization of hysterical reactions was employed as the conceptual basis in the formulation of these cases. This orientation posits hysterical phenomena a psychological defense employed by individuals exposed to traumatic experiences in order to effectuate a defense from intolerable affective material. The emotionally overwhelming material converts into physical reactivity free of the traumatic consequences by keeping the intolerable images and emotions deeply repressed within the subconscious. As the focus on these cases was diagnostic, treatment efforts were avoided. As it turned out, environmental interventions, based on the obtained information from the hypnotic interviews, extinguished the symptoms. The children were symptom free at follow-up.

[The erect walking of the soul or: the dignity of a broken life]. / Der aufrechte Gang der Seele oder: Von der Würde des Fragments.

Getting the diagnosis of "paraplegia" means an extremely deep cut into someone's life. Suddenly everything is changed. Questions are arising: Why me? What is the meaning behind this? Pastoral care accompanies patients and their families during these hard weeks and months. There is time for people and their pain. It is not about offering easy solutions but about helping people to find their own language to express their inner experience and hopefully in the end, to find their own way with the disability. There is hope that something new can arise from the fragments of one's former life.

Walking performance, medical outcomes and patient training in FES of innervated muscles for ambulation by thoracic-level complete paraplegics.

OBJECTIVE: To discuss functional electric stimulation (FES) gait training of upper motoneuron spinal cord injured complete paraplegics considering ambulation performance, physiologic and metabolic responses as well as psychologic outcome, while providing myologic insight into ambulation via FES when training starts many years post-injury. METHODS: Transcutaneous FES using the Parastep stimulation system, gait training methods with and without major emphasis on muscle reinforcement, cardiovascular and respiratory conditioning. Examination of myofiber tissues and correlation of normal muscles histology versus innervated muscles of upper motor neuron and of denervated muscles of lower motor neuron paraplegics. RESULTS: Published works in literature reviewed in this paper report average walking distance of 440 m/walk when major muscle reinforcement and preconditioning cardiovascular and respiratory systems precedes gait training, versus average 115 m/walk when undergoing direct gait training. Medical, metabolic and psychologic outcomes, as reported in several works, point to benefits of FES walking, including 60% increase in blood flow to lower extremities. Myofiber tissues of patients with upper motor neuron paralysis compare well with those of normal tissue even many years post-injury, while adipose tissue substitute muscle fibers in patients with lower motor neuron lesions. DISCUSSION: Transcutaneous FES allows considerably longer walking distances and speed at the end of training when training involves an extensive pre-conditioning program than with direct gait training. Medical and psychologic benefits are observed, especially concerning blood flow to the lower extremities. Myofiber examinations provide myologic understanding of effectiveness of FES many years post-injury.

Lower extremity paralysis in a male preadolescent.

A 12-year-old boy presented to the emergency department with bilateral lower leg sensory loss and inability to walk. The initial work-up revealed no significant abnormalities on physical examination other than bilateral paralysis and no laboratory abnormalities. The inpatient work-up included neurologic, psychiatric, and psycho-logic evaluations. The patient was diagnosed with a conversion disorder, and treatment included relaxation exercises and guided imagery as well as antidepressants. Upon discharge, the patient was walking without assistance. Follow-up therapy was initiated for stress and behavior management. No further episodes have occurred. Diagnosis, therapy options, and outcomes of conversion disorder are further discussed as they relate to treatment by general pediatricians.

[Scuba diving -- a therapeutic option for patients with paraplegia]. / Tauchen als therapeutische Option bei Patienten mit Querschnittsyndrom.

OBJECTIVE: Spasticity is often a handicap in paraplegics and interferes with quality of life. Medical therapeutic options (e.g. baclofen, tizanidin) lead to drowsiness, fatigue and loss in activity. On the other hand paraplegics are increasingly active in daily life and leisure (paralympics). Neurorehabilitation is effective in reduction of spasticity, gaining motor function and enhancing quality of life. Hippotherapy (Lechner et al 2003) and aquatic rehabilitation are additive methods. Already 15 years ago Madorsky et al pointed out SCUBA diving as a positive neurorehabilitation procedure. The study group around Stanghelle reported also beneficial aspects on spasticity of patients with spinal cord injuries. These references inspired to introduce a prospective study. METHODS: After obtaining an ethic votum and evaluation assessment for diving permission 6 volunteers with paraplegia entered the pilot study. Medication was kept stable throughout the study time. Supervised by diving instructors and a diving trained doctor the volunteers dived to a platform in the depth of 7.2 meters. The daily diving time was exactly 30 minutes. Stabilized on the platform physiotherapeutic assessment took place in different positions to reduce spasticity. Ashworth Scale and spasm frequency scale were noted daily and at beginning and end of the study the WHO Quality of life Test had to be completed. For objective reasons a locomat training happened before, within a week after and 4 weeks after the study week. RESULTS: All patients did the daily dives without any difficulties. The statistics included the assessment of day 1 versus day 7 of 5 patients and showed a significant reduction of Modified Ashwoth Scale (p=0.04). Quality of life showed an improvement. CONCLUSION: The improvement rationale can only be supposed. A correlation to the ambient pressure suggests itself. Therefore deeper depths should increase the good spasticity results or manage to achieve those faster. Many questions remain, so further studies are necessary to ascertain the ideal standard options.

On the application of cannabis in paediatrics and epileptology.

An initial report on the therapeutic application of delta 9-THC (THC) (Dronabinol, Marinol) in 8 children resp. adolescents suffering from the following conditions, is given: neurodegenerative disease, mitochondriopathy, posthypoxic state, epilepsy, posttraumatic reaction. THC effected reduced spasticity, improved dystonia, increased initiative (with low dose), increased interest in the surroundings, and anticonvulsive action. The doses ranged from 0.04 to 0.12 mg/kg body weight a day. The medication was given as an oily solution orally in 7 patients, via percutaneous gastroenterostomy tube in one patient. At higher doses disinhibition and increased restlessness were observed. In several cases treatment was discontinued and in none of them discontinuing resulted in any problems. The possibility that THC-induced effects on ion channels and transmitters may explain its therapeutic activity seen in epileptic patients is discussed.

A personal user's view of functional electrical stimulation cycling.

Two years of functional electrical stimulation cycling (FESC) as a researcher and subject have given me an insight into the direction that future FESC should take as well as providing me with significant health benefits and an enjoyable and functional ability to cycle. If FESC is to benefit spinal cord injured persons (SCIPs), researchers must turn their attention to making the activity convenient and enjoyable. What follows is a personal view and will be less scientifically rigorous than other presentations but hopefully still of value. It calls upon my experience as a general medical practitioner with a special interest in the value of exercise, a human powered vehicle enthusiast, an amateur FES researcher, but most importantly, an SCIP and FES cyclist.

Life-saving treatments and disabilities. Are all QALYs created equal?

OBJECTIVES: Decision-makers and the general public are often reluctant to adopt policy recommendations based exclusively upon cost-utility analyses. One possible reason explored here is that patients' previous health state before experiencing the onset of an acute life-threatening illness may influence the value of saving those patients' lives. METHODS: We surveyed members of the general public to see the relative importance of saving patients' lives when some patients could be returned to perfect health and others would live the remainder of their years with paraplegia. Among this latter group, some were described as having pre-existing paraplegia. Others were described as having as having the onset of paraplegia. The relative importance of saving each of these lives was measured using the person trade-off method. RESULTS: Six hundred five subjects completed questionnaires, and 250 met pre-established consistency criteria and were included in the final analysis. Overall, subjects placed equal importance on saving the lives of people with pre-existing paraplegia versus those who could be returned to perfect health because they did not have pre-existing paraplegia. In contrast, respondents gave lower priority to patients who would experience the onset of paraplegia after having their lives saved, especially if their paraplegia was avoidable with an alternative treatment. CONCLUSION: People do not think that all quality-adjusted life-years are created equal. Instead, the value that people place on treatment programs depends on patients' state of health before developing life-threatening illnesses, and on whether alternative treatments are available that provide better health outcomes for the patients. These results may explain, in part, public discomfort over basing health care priorities on cost-utility analysis.