Reducing endocrine metabolic disease risk in adults with chronic spinal cord injury: strategic activities conducted by the Ontario-Quebec RIISC team.

PURPOSE: The Rehabilitation Interventions for Individuals with a Spinal Cord Injury in the Community (RIISC) team aimed to develop and evaluate innovative rehabilitation interventions to identify endocrine metabolic disease (EMD) risk, intending to reduce the frequency and severity of EMD related morbidity and mortality among adults living with chronic spinal cord injury or disease (SCI/D). MATERIALS AND METHODS: An interprovincial team from Ontario and Quebec reviewed available EMD literature and evidence syntheses and completed an inventory of health services, policies and practices in SCI/D care. The review outcomes were combined with expert opinion to create an EMD risk model to inform health service transformation. RESULTS: EMD risk and mortality are highly prevalent among adults with chronic SCI/D. In stark contrast, few rehabilitation interventions target EMD outcomes. The modelled solution proposes: 1) abandoning single-disease paradigms and examining a holistic perspective of the individual's EMD risk, and 2) developing and disseminating practice-based research approaches in outpatient community settings. CONCLUSIONS: RIISC model adoption could accelerate EMD care optimization, and ultimately inform the design of large-scale longitudinal pragmatic trials likely to improve health outcomes. Linking the RIISC team activities to economic evaluations and policy deliverables will strengthen the relevance and impact among policymakers, health care providers and patients.

Living with a spinal cord injury or disease (SCI/D) increases endocrine metabolic disease (EMD) risk.EMD-related outcomes include fracture; type II diabetes; and cardiovascular disease (myocardial infarction, sudden cardiac death and stroke), directly contributing to higher morbidity and mortality.Single-disease paradigms are not the ideal strategy to address multimorbidity contexts experienced in SCI/D.Practice-based research could be an alternative/adjunct to randomized control trials at generating evidence on current and emerging rehabilitation approaches.

What Is the Pathway to the Best Model of Care for Traumatic Spinal Cord Injury? Evidence-Based Guidance.

Introduction: People with traumatic spinal cord injury (tSCI) experience lifelong physical and emotional health impacts, needing specialized care that is complex to navigate. The non-standardized care pathways used by different jurisdictions to address these needs lead to care inequities and poor health outcomes. Purpose: To develop an evidence-based integrated tSCI Care Pathway, from time of injury to life in the community. Methods and Analysis: Eighty key partners engaged in planning, providing, and receiving tSCI care (1) identified existing guidelines, pathways, and care models; (2) created the tSCI Care Pathway with key elements or building blocks ("the what"), not specific recommendations ("the how") for each care stage (Acute, Rehabilitation, and Community), with elements highlighting the role of primary care and equity considerations on the pathway; (3) identified regional gaps in the tSCI Pathway and prioritized them for implementation; and (4) developed quality indicators. Outcomes: The tSCI Pathway was drafted in overarching and detailed formats. For Acute Care, building blocks focused on appropriate assessment, initial management, and transition planning; for Rehabilitation, building blocks focused on access to specialized rehabilitation and assessment and planning of community needs; for Community, building blocks focused on follow-up, mechanisms for re-access, and holistic support for persons and families; and for equity considerations, building blocks focused on those at-risk or requiring complex supports. Team-based primary care and navigation supports were seen as crucial to reduce inequities. Conclusion: This is the first comprehensive care pathway for tSCI. The Pathway is grounded in person-centred care, integrated care and services, and up-to-date clinical practice guidelines. The tSCI Care Pathway is flexible to regional realities and individual needs to ensure equitable care for all.

Properties of the surface electromyogram following traumatic spinal cord injury: a scoping review.

Traumatic spinal cord injury (SCI) disrupts spinal and supraspinal pathways, and this process is reflected in changes in surface electromyography (sEMG). sEMG is an informative complement to current clinical testing and can capture the residual motor command in great detail-including in muscles below the level of injury with seemingly absent motor activities. In this comprehensive review, we sought to describe how the sEMG properties are changed after SCI. We conducted a systematic literature search followed by a narrative review focusing on sEMG analysis techniques and signal properties post-SCI. We found that early reports were mostly focused on the qualitative analysis of sEMG patterns and evolved to semi-quantitative scores and a more detailed amplitude-based quantification. Nonetheless, recent studies are still constrained to an amplitude-based analysis of the sEMG, and there are opportunities to more broadly characterize the time- and frequency-domain properties of the signal as well as to take fuller advantage of high-density EMG techniques. We recommend the incorporation of a broader range of signal properties into the neurophysiological assessment post-SCI and the development of a greater understanding of the relation between these sEMG properties and underlying physiology. Enhanced sEMG analysis could contribute to a more complete description of the effects of SCI on upper and lower motor neuron function and their interactions, and also assist in understanding the mechanisms of change following neuromodulation or exercise therapy.

Development of Emotional Well-Being indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project.

Context: Emotional Well-Being (EWB) post-spinal cord injury or disease (SCI/D) is a critical aspect of adjustment to disability. Advancing care and assuring equity in care delivery within this rehabilitation care domain is essential. Herein, we describe the selection of EWB structure, process and outcome indicators for adults with SCI/D in the first 18 months after rehabilitation admission. Methods: A pan-Canadian Working Group completed the following tasks: (1) defined the EWB construct; (2) conducted a systematic review of available outcomes and their psychometric properties; (3) constructed a Driver diagram summarizing available evidence associated with EWB; and, (4) prepared a process map. Facilitated meetings allowed selection and review of feedback following rapid-cycle evaluations of proposed structure, process and outcome indicators. Results: The structure indicator is the proportion of staff with appropriate education and training in EWB and access to experts and resources. The process indicator is the proportion of SCI/D patients who were screened for depression and anxiety symptoms at rehabilitation admission and rehabilitation discharge. The intermediary outcome is the proportion of SCI/D patients at risk for depression or anxiety at rehabilitation discharge based on screening symptom scores. The final outcomes are: (a) proportion of individuals at risk for depression or anxiety based on screening symptom scores; and (b) proportion of individuals who received referral for EWB services or intervention. Conclusion: The proposed indicators have a low administrative burden and will ensure feasibility of screening for depression and anxiety at important transition points for individuals with SCI/D. We anticipate that the current structures have inadequate resources for at-risk individuals identified during the screening process.

Fatigue and Discomfort During Spatially Distributed Sequential Stimulation of Tibialis Anterior.

Neuromuscular electrical stimulation is conventionally applied through a single pair of electrodes over the muscle belly, denominated single electrode stimulation (SES). SES is limited by discomfort and incomplete motor-unit recruitment, restricting electrically-evoked torque and promoting premature fatigue-induced torque-decline. Sequential stimulation involving rotation of pulses between multiple pairs of electrodes has been proposed as an alternative, denominated spatially distributed sequential stimulation (SDSS). The present aim was to compare discomfort, maximal-tolerated torque, and fatigue-related outcomes between SES and SDSS of tibialis anterior. Ten healthy participants completed two experimental sessions. The self-reported discomfort at sub-maximal torque, the maximal-tolerated torque, fatigue-induced torque-decline during, and doublet-twitch torque at 10- and 100-Hz before and after, 300 intermittent (0.6-s-ON-0.6-s-OFF) isokinetic contractions were compared between SES and SDSS. SDSS stimulation improved fatigue-related outcomes, whereas increased discomfort and reduced maximal-tolerated torque. SDSS holds promise for reducing fatigue. However, limited torque production and associated discomfort may limit its utility for rehabilitation/training.

Neural and musculotendinous mechanisms underpinning age-related force reductions.

Ageing leads to substantial force production capacity reductions, which is an indicator of frailty and disability, and a mortality predictor in elders. Understanding the age-dependent neuromuscular mechanisms underlying force reductions can optimize healthcare professionals' exercise protocol choices for patients and allows researchers to investigate new interventions to mitigate these reductions. Our primary goal was to provide an updated review about the main neural and musculotendinous mechanisms underpinning age-related reductions in force capacity. Our secondary goal was to summarize how aerobic and strength training can lessen these age-related reductions. This review suggests that several steps in the force production pathway, from cortical to muscular mechanisms, are negatively affected by ageing. However, combining aerobic and strength training can attenuate these effects. Strength training (i.e. moderate to high- intensity, progressive volume, accentuated eccentric loading and fast concentric contraction velocity) can increase overall force production capacity by producing beneficial neural and musculotendinous adaptations. Additionally, aerobic training (i.e. moderate and high intensities) plays an essential role in preserving the structure and function of the neuromuscular system.

Análise da estabilidade postural e propriocepção de idosas fisicamente ativas / Analysis of postural stability and proprioception in elderly physically active women

Introdução Os limiares de sensações cutâneas e proprioceptivas são mecanismos que podem degradar durante o envelhecimento, afetando a estabilidade postural. Objetivo Verificar a estabilidade postural e a propriocepção de idosas praticantes de hidroginástica e as possíveis relações existentes entre essas variáveis. Materiais e métodos O grupo de estudo foi constituído por 25 idosas com idade média de 70,2 (dp 6,9) anos, praticantes de hidroginástica de intensidade moderada há no mínimo três meses e com duas aulas semanais. Para testar a propriocepção, utilizou-se o goniômetro analógico fixo, assentado no membro inferior preferido do sujeito. A estabilidade postural foi analisada utilizando uma plataforma de força no nível do solo. A partir dos dados de força obtidos pela plataforma, foi calculado o centro de pressão (CP). Os sujeitos foram analisados em postura bipodal, nas condições de olhos abertos (OA) e fechados (OF). Para a análise estatística, utilizaram-se a correlação de Spermann e o teste de Mann Whitney, com nível de significância de 5%. Resultados Não foi encontrada diferença estatisticamente significativa entre as condições visuais de OA e OF. A propriocepção apresentou correlação positiva (R = 0,551; p = 0,004) com a idade e com a estabilidade postural, na condição de OA e OF, apresentando maiores amplitudes e velocidades de deslocamento do CP (p < 0,05). Conclusão Os resultados encontrados sugerem que as perdas funcionais ocasionadas pela idade influenciam tanto o desempenho proprioceptivo quanto a estabilidade postural.

Introduction The thresholds for cutaneous and proprioceptive sensations are mechanisms that may be affected during aging resulting in reduced postural stability. Objective Verify proprioception and postural stability in physically active elderly women and verify the correlation between these variables. Materials and methods The study group consisted of twenty-five 70.2 ± 6.9 year-old women that practiced hydrogymnastics at moderate intensity for at least three months and two hours per week. Proprioception was tested using an analogic goniometer firmly attached to the knee joint of the preferred lower limb of the subject. The subjects needed to reproduce the knee angles that were first demonstrated passively. The difference between the angles found in each condition (passive x voluntary) was calculated. Postural stability was analyzed using a force platform at the ground level. Using the force data obtained by the force plate the center of pressure (CP) was calculated. Subjects were compared while in a bipedal posture, with their eyes opened (EO) and closed (EC). Data was analyzed using Spermann correlation and Mann-Whitney test, with a significance level of 5%. Results No statistically significant difference was found between EO and EC conditions. Proprioception revealed a positive correlation (R = 0.551; p = 0.004) with age and postural stability in the conditions of EO and EC, showing larger amplitudes and velocities of CP displacement (p < 0.05). Conclusion Our results suggested that functional losses induced by aging reduces the efficiency of the proprioception system and postural stability.

Effects of a subsequent task after sit-to-stand movement on muscle activation and initiation of movement / Efeitos da tarefa subsequente ao sentar e levantar sobre a ativação muscular e início do movimento

Muscle activation (activation time) and the beginning of movement (motor reaction time) can be changed depending on the complexity of the task. The objectives of this study were to compare the time for activation of the paraspinal and the vastus lateralis muscles, and the motor reaction time during the execution of the tasks sit-to-stand (STS) and sit-to-walk (STW), which includes the execution of the subsequent task of gait initiation. Twelve healthy young subjects participated in the study. They performed two tasks (STS and STW), five times each, randomly, separated by two minutes of rest. The kinematics of the movement were recorded using a digital electrogoniometer attached to the hip joint and muscle activation using surface electromyography in both muscles. The average of the five repetitions was calculated for each task. The beginning of the task was signaled by a luminous device, which was also used to identify the initial point for calculating the activation time and motor reaction time. Both muscles showed a longer latency for the activation time and motor reaction time during the STW task when compared with STS. Based on these results, it can be concluded that both the postural (paraspinal) and prime mover muscles (vastus lateralis) undergo change in the motor programming during the execution of the STS task when a subsequent task (gait initiation) is included. Motor programming is dependent on task complexity, where a more complex task (STW) will result in delays of movement programming and execution.

A ativação muscular (tempo para ativação) e o início do movimento (tempo de reação motor) podem ser alterados em consequência da complexidade da tarefa. Os objetivos do estudo foram comparar o tempo para ativação dos músculos paravertebral e vasto lateral e o tempo reação motor durante a execução das tarefas de sentar e levantar (SPV) e sentar e levantar com a execução da tarefa subsequente de deambular (SPVE). Doze sujeitos jovens sadios participaram do estudo. Cada sujeito executou as duas tarefas (SPV e SPVE), realizando-as em cinco repetições, com intervalo de dois minutos, sendo estas escolhidas de forma aleatória. Foram analisadas a cinemática do movimento, utilizando um eletrogoniômetro digital acoplado a articulação do quadril e a ativação muscular, utilizando eletromiografia de superfície. Posteriormente, a média das cinco repetições foi calculada. O início da tarefa foi identificado por um sinal luminoso, sendo este também utilizado na identificação do ponto inicial para o cálculo do tempo para ativação e motor. Tanto o músculo paravertebral quanto o vasto lateral, apresentaram maior latência para o tempo para ativação e motor na tarefa SPVE quando comparada a SPV. Conclui-se que tanto músculos posturais (paravertebrais) quanto os motores primários (vasto lateral) para a execução da tarefa SPV sofrem alteração na programação motora, quando uma tarefa subsequente (deambulação) é incluída. A programação motora é dependente da complexidade da tarefa a ser executada, sendo que uma tarefa mais complexa implica maiores latências para a programação e execução do movimento.

Efeito da equoterapia na estabilidade postural de portadores de esclerose múltipla: estudo preliminar / Effect of hippotherapy on the postural stability of patients with multiple sclerosis: a preliminary study / Efecto de la hipoterapia en la estabilidad postural de portadores de esclerosis múltiple: estudio preliminar

OBJETIVO: Este estudo se propôs a verificar se a estimulação por meio da equoterapia é capaz de desencadear alterações no controle postural de portadores de esclerose múltipla (EM). MÉTODO: Fizeram parte deste estudo 11 portadores de EM divididos em Grupo Intervenção (GI) e Grupo Controle (GC). O GI foi inserido num programa de hipoterapia durante 4 meses, sendo conduzidas 2 sessões semanais com duração de 50 minutos cada. A estabilidade postural foi avaliada utilizando uma plataforma de força (para calcular o deslocamento do centro de pressão (COP), durante 30 segundos, em postura ereta quasi-estática, com olhos abertos e fechados, antes e após o treinamento com equoterapia. O tratamento estatístico foi feito através do ANOVA e Post hoc de Tukey com p<0,05. RESULTADOS: A amplitude de oscilação anteroposterior reduziu significativamente no GI após a estimulação, enquanto o GC manteve um comportamento inalterado entre as avaliações. Em ambos os grupos, a estabilidade postural foi reduzida com a supressão da informação visual. CONCLUSÕES: A adaptação funcional proporcionada pela equoterapia foi capaz de melhorar a estabilidade postural dos portadores de EM. Os resultados corroboram a literatura que suporta o uso da equoterapia como uma intervenção em potencial nas desordens de controle postural em portadores de EM.

OBJECTIVE: This study intended to identify the effects of hippotherapy on the postural control of multiple sclerosis (MS) patients. METHODS: Eleven MS patients were separated into two groups: Intervention Group (IG) and Control Group (CG). Hippotherapy consisted of two 50-minute sessions each week for four months. Postural stability was evaluated before and after hippotherapy using a force plate to calculate the center of pressure (COP), when subjects stood still for 30 seconds, with eyes open and closed. Statistical analysis was performed by ANOVA and post hoc Tukey tests, p<0.05. RESULTS: Hippotherapy significantly reduced the amplitude of oscillation in the anteroposterior direction in IG while CG remained unaltered. In both groups postural stability was reduced after the suppression of visual information. CONCLUSIONS: Hippotherapy induced functional adaptations that resulted in better postural stability of subjects with MS. This study corroborates literature supporting the use of hippotherapy as a possible intervention for balance disorders in patients with MS.

OBJETIVO: El objetivo de éste estudio fue identificar los efectos de la hipoterapia sobre el control postural en pacientes con esclerosis múltiple (EM). MÉTODO: Hicieron parte de este estudio 11 portadores de EM divididos en Grupo Intervención (GI) y Grupo Control (GC). El GI fue insertado en un programa de hipoterapia durante cuatro meses, siendo realizadas dos sesiones semanales con duración de 50 minutos cada una. La estabilidad postural fue evaluada utilizando una plataforma de fuerza (para calcular el desplazamiento del centro de presión (COP), durante 30 segundos en postura erecta casi-estática, con ojos abiertos y cerrados, antes y después del entrenamiento con hipoterapia. El tratamiento estadístico fue realizado a través de ANOVA y Post hoc de Tukey con p<0,05. RESULTADOS: la amplitud de oscilación antero-posterior se redujo significativamente en el GI después de la estimulación, mientras que el GC mantuvo un comportamiento sin cambios entre las evaluaciones. En ambos grupos la estabilidad postural fue reducida con la supresión de la información visual. CONCLUSIONES: la adaptación funcional proporcionada por la hipoterapia fue capaz de mejorar la estabilidad postural de los portadores de EM. Los resultados corroboran la literatura que soporta el uso de la hipoterapia como una potencial intervención en los desordenes del control postural en portadores de EM.

Efeito da fadiga muscular sobre o controle postural durante o movimento do passe em atletas de futebol / Effect of muscle fatigue on posture control in soccer players during the short-pass movement

A fadiga muscular é caracterizada pela incapacidade na geração ou manutenção de um nível de força, afetando negativamente o desempenho esportivo. Dentre as consequências funcionais da fadiga encontra-se o decréscimo do controle postural estático e dinâmico. O objetivo do estudo foi verificar o efeito da fadiga muscular induzida por exercício de alta intensidade sobre a estabilidade postural dinâmica de atletas de futebol, durante o gesto motor característico do esporte: o passe. Participaram do estudo 27 atletas de futebol do sexo masculino, entre 14 e 16 anos, que executaram o movimento do passe sobre uma plataforma estabilométrica antes e após a realização de um protocolo de exercício de intensidade máxima em ciclo-ergômetro. Após o protocolo de fadiga, os atletas apresentaram aumento de 31 por cento na velocidade média de deslocamento do centro de pressão. Além disso, apesar de a diferença na amplitude de deslocamento do centro de pressão no sentido médio-lateral (15 por cento) não ser significante, houve um significativo aumento de 22 por cento no deslocamento ântero-posterior. Conclui-se que a fadiga muscular é capaz de promover decréscimo da estabilidade postural de jogadores de futebol durante o gesto motor do passe, o que provavelmente prejudica o desempenho esportivo dos atletas.

Muscle fatigue is characterized by the inability to generate or maintain an expected effort or force level and negatively affects sports performance. One of the functional consequences of fatigue is a decrease in static and dynamic postural stability. The objective of this study was to evaluate the effect of muscle fatigue induced by high-intensity exercise on the dynamic postural stability of soccer players during the characteristic motor action of the sport: the short-pass. Twenty-seven male soccer players aged 14 to 16 years performed the short-pass movement on a stabilometric platform before and after a high-intensity exercise protocol performed on a cycle ergometer. After the fatigue protocol, the athletes presented a 31 percent increase in the mean velocity of the center of pressure displacement. Moreover, although the difference in the center of pressure displacement amplitude in the medial-lateral direction (15 percent) was not significant, displacement increased by 22 percent in the anterior-posterior direction. It was concluded that muscle fatigue promotes a decrease of postural stability during the short-pass movement in soccer players, probably compromising the sports performance of the athletes.

Efeito de um exercício extenuante sobre o padrãoangular de pedalada: estudo preliminar / Effect of exhaustive exercise on the angular pedaling pattern:A preliminary study

Considerando aspectos biomecânicos como a cinemática, a fadiga pode ser caracterizada pela perda de eficiência em manter um padrão de movimento durante o exercício, tal como a técnica de pedalada. O propósito deste estudo preliminar foi investigar os efeitos do ciclismo extenuante, por 1h, em intensidade de 80% VO2máx sobre atécnica de pedalada. A técnica de pedalada foi avaliada por cinemática bidimensional em 4 ciclistas mountain-bike experientes. A hipótese do estudo foi de que mudanças angulares em resposta à fadiga poderiam ocorrer no tornozelo. Após o teste de consumo máximo de oxigênio, os ciclistas foram submetidos a um protocolo submáximo com intensidade de 80% VO2máx. A cada 10 minutos eles eram filmados durante 10 ciclos de pedalada. As imagens foram capturadas do membro inferior direito sendo mensurados ângulos de quadril, joelho e tornozelo. Os procedimentos estatísticos envolveram teste de Shapiro-Wilk, ANOVA e post-hoc de Tukey HSD com nível de significância de 0,05. A análise estatística mostrou diferença significante somente para o tornozelo após 40 minutos de exercício, com a amplitude de movimento aumentando de 20° no início, até 35° no final do exercício. Este resultado confirma a hipótese proposta de que o tornozelo seria a única articulação afetada. As características de movimento do tornozelo sugerem que esta articulação desempenhaum papel importante para manter a técnica de pedalada e manter a carga de trabalho sustentando o exercício.

Considering biomechanical aspects such as kinematics, fatigue can be characterized as a loss of efficiency in maintaining a movement pattern, such as pedaling technique, during exercise. The objective of this preliminary study was to investigate the effects of 1-h exhaustivecycling exercise at intensity of 80% VO2max on pedaling technique. The pedaling technique was evaluated in four skilled mountain-bike cyclists by 2D kinematics. The main hypothesis of this study was that angular changes in response to fatigue would occur mainly in the ankle joint. Afterachievement of maximal oxygen uptake (VO2max), the cyclists were submitted to a submaximal protocol at intensity corresponding to 80% VO2max for 1 h. The cyclists were filmed throughout 10 complete consecutive crank cycles at intervals of 10 min. Images were acquired from the right lower limb and the hip, knee and ankle joint angles were measured after kinematic processing. The Shapiro-Wilk test, ANOVA and post-hoc Tukey HSD test were used for statistical analysis,with the level of significance set at 0.05. Statistical analysis showed a significant difference only for ankle kinematics after 40 min of exercise, with an increase in the range of motion from 20° at the beginning of exercise to 35° at the end of exercise. This result confirms the hypothesisproposed and suggests that only the ankle joint was affected by the exercise. The characteristics of ankle movement suggest that this joint plays a compensatory role in an attempt to maintain the pedaling technique and to sustain the exercise workload.