Effectiveness and efficiency of telerehabilitation on functionality after spinal cord injury: A matched case-control study.

BACKGROUND: Telerehabilitation in spinal cord injury (teleSCI) is a growing field that can improve access to care and health outcomes in patients with spinal cord injury (SCI). The clinical effectiveness of teleSCI is not known. OBJECTIVES: To compare independence in activities of daily living and mobility capacity in patients following teleSCI and matched controls undergoing traditional rehabilitation. DESIGN: Matched case-control study. SETTING: TeleSCI occurring in home setting (cases) versus traditional rehabilitation on inpatient unit (controls). PARTICIPANTS: Forty-two consecutive patients with SCI followed with teleSCI were compared to 42 historical rehabilitation inpatients (controls) matched for age, time since injury to rehabilitation admission, level of injury (paraplegia/tetraplegia), complete or incomplete injury, and etiology (traumatic/nontraumatic). The teleSCI group (n = 42) was also compared to the complete cohort of historical controls (n = 613). INTERVENTIONS: The teleSCI group followed home-based telerehabilitation (3.5 h/day, 5 days/week, 67 days average duration) and historical controls followed in-person rehabilitation. MAIN OUTCOME MEASURE(S): The Functional Independence Measure (FIM), the Spinal Cord Independence Measure (SCIM) and the Walking Index for Spinal Cord Injury (WISCI). We formally compared gains, efficiency and effectiveness. International Standards for Neurological Classification of Spinal Cord Injury and the American Spinal Injury Association Impairment Scale (AIS) were used. RESULTS: The teleSCI group (57.1% nontraumatic, 71.4% paraplegia, 73.8% incomplete, 52.4% AIS grade D) showed no significant differences compared with historical controls in AIS grades, neurological levels, duration, gains, efficiency and effectiveness in FIM, SCIM, or WISCI, although the teleSCI cohort had significantly higher admission FIM scores compared with the complete cohort of historical controls. CONCLUSIONS: TeleSCI may provide similar improvements in mobility and functional outcomes as traditional rehabilitation in medically stable patients (predominantly with paraplegia and motor incomplete SCI) when provided with appropriate support and equipment.

Tele-rehabilitation on independence in activities of daily living after stroke: A Matched Case-Control Study.

OBJECTIVES: To compare independence in activities of daily living (ADLs) in post-acute patients with stroke following tele-rehabilitation and matched in-person controls. MATERIALS AND METHODS: Matched case-control study. A total of 35 consecutive patients with stroke who followed tele-rehabilitation were compared to 35 historical in-person patients (controls) matched for age, functional independence at admission and time since injury to rehabilitation admission (<60 days). The tele-rehabilitation group was also compared to the complete cohort of historical controls (n=990). Independence in ADLs was assessed using the Functional Independence Measure (FIM) and the Barthel Index (BI). We formally compared FIM and BI gains calculated as discharge score - admission scores, efficiency measured as gains / length of stay and effectiveness defined as (discharge score-admission score)/ (maximum score-admission score). We analyzed the minimal clinically important difference (MCID) for FIM and BI. RESULTS: The groups showed no significant differences in type of stroke (ischemic or hemorrhagic), location, severity, age at injury, length of stay, body mass index, diabetes, dyslipidemia, hypertension, aphasia, neglect, affected side of the body, dominance or educational level. The groups showed no significant differences in gains, efficiency nor effectiveness either using FIM or Barthel Index. We identified significant differences in two specific BI items (feeding and transfer) in favor of the in-person group. No differences were observed in the proportion of patients who achieved MCID. CONCLUSIONS: No significant differences were seen between total ADL scores for tele-rehabilitation and in-person rehabilitation. Future research studies should analyze a combined rehabilitation approach that utilizes both models.

Clinical Prediction Rule Validation for Ambulation Outcome After Traumatic Spinal Cord Injury in a Spanish Population.

BACKGROUND: Predicting the ability to walk after traumatic spinal cord injury is of utmost importance in the clinical setting. Nevertheless, only a small fraction of predictive models are evaluated on their performance by other authors using external data. The Dutch Clinical Prediction Rule for long-term walking ability was developed and validated using neurological assessments performed within 15 days postinjury. However, in reality, this assessment is most often performed between 11 and 55 days. When considering a longer time from injury to neurological assessments, the Dutch Clinical Prediction Rule has only been externally validated for patients after non-traumatic spinal cord injury. OBJECTIVE: We aimed to validate the Dutch Clinical Prediction Rule with neurological assessment performed within 3-90 days after traumatic spinal cord injury, using (a) the Dutch Clinical Prediction Rule logistic regression coefficients (Equation 1); (b) the Dutch Clinical Prediction Rule weighted coefficients (Equation 2); and (c) the reestimated (using a Spanish population) weighted coefficients (Equation 3). METHODS: We conducted a retrospective (STROBE-compliant) study involving 298 adults with traumatic spinal cord injury admitted to a hospital between 2010 and 2019 in Spain. The Spinal Cord Independence Measure item-12 was used for walking assessment. RESULTS: Using Equation 1, the model yielded 86.2% overall classification accuracy, 94.5% sensitivity, and 83.4% specificity (area under the curve [AUC] = 0.939, 95% confidence interval [CI]: 0.915-0.965; p < .001).Using Equation 2 yielded 86.2% overall classification accuracy, 93.2% sensitivity, and 83.9% specificity (AUC = 0.9392, 95% CI: 0.914-0.964; p < .001).Using Equation 3 yielded 86.9% overall classification accuracy, 68.9% sensitivity, and 92.8% specificity (AUC = 0.939, 95% CI: 0.914-0.964; p < .001). CONCLUSIONS: This study validates the Dutch Clinical Prediction Rule in a Spanish traumatic spinal cord injury population with assessments performed up to 90 days postinjury with similar performance, using the original coefficients and including a reestimation of the coefficients.

Cross-cultural adaptation, translation, and validation of a Spanish version of the Westmead Post-traumatic Amnesia Scale for use following a traumatic brain injury.

Health professionals need linguistically and culturally correct tools with proven validity to effectively assess people in their native language. This study aimed to translate and validate the Westmead Post-traumatic Amnesia Scale (WPTAS) into a Spanish version to measure the progression and duration of post-traumatic amnesia (PTA) in Spanish-speaking populations. Seven native Spanish and English translators, 11 therapists and 15 people with a traumatic brain injury (TBI) and nine people with non-traumatic acquired brain injury participated in the forward-backward translation method to adapt the WPTAS. Participants with a TBI in PTA (n = 20), out of PTA (n = 21), and controls without cognitive impairment (n = 21) participated in the validation test phase by completing the WPTAS, Selective Reminding Test, Short Portable Metal Status Questionnaire, Digit Span, and Agitated Behaviour Scale. The translated version of the WPTAS produced consistent responses and appropriate errors (2%) among all pre-test participants. Results from the validation phase showed that participants in PTA scored significantly lower in all tests (p < .05) when compared with those out of PTA and controls. The Spanish version of the WPTAS created and tested in this study is culturally and linguistically appropriate as well as valid for use with Spanish speakers.

Multidisciplinary outpatient rehabilitation of physical and neurological sequelae and persistent symptoms of covid-19: a prospective, observational cohort study.

PURPOSE: This prospective, observational cohort study investigated the effects of multidisciplinary rehabilitation of post Covid-19 sequelae and persistent symptoms and their impact on patients' functioning and quality of life. METHODS: From 58 patients referred for neurorehabilitation, 43 were eligible for and participated in the present study. Before and after 8 weeks of rehabilitation, patients underwent physical, neuropsychological and respiratory evaluations and assessment of functional independence, impact of fatigue and quality of life. RESULTS: Forty of 43 individuals (52 ± 11.4 years, 24 male) completed the rehabilitation program. Fatigue (87.5%), dyspnea and/or shortness of breath (62.5%), and cognitive impairment (37.5%) were reported by both previously hospitalized and home-confined patients. Neurological sequelae (35.5%) were present only in hospitalized patients. After 8 weeks of rehabilitation, patients reported significant improvements in motor functional independence, upper and lower limb functionality, impact of fatigue on daily activities, respiratory muscle strength, cognitive performance, and quality of life. CONCLUSIONS: Post Covid-19 patients present with heterogeneous neurological, physical, and respiratory impairments requiring a multidisciplinary rehabilitation approach to reduce disability and improve functionality and quality of life. A comprehensive assessment of clinical profiles and responses to rehabilitation may facilitate the identification of rehabilitation candidates and help to design effective rehabilitation interventions.Implication for rehabilitationPost Covid-19 patients present multiple, heterogeneous neurological, physical and respiratory impairments that are observed in both previously hospitalized and home-confined patients.Eight weeks of multidisciplinary rehabilitation may significantly reduce disability and improve functionality and quality of life.A comprehensive assessment of their clinical profile and response to rehabilitation may facilitate the identification of rehabilitation candidates and help to design more effective rehabilitation interventions.

Effects of different vibration frequencies on spinal cord reflex circuits and thermoalgesic perception.

OBJECTIVES: We studied the effect of different vibration frequencies on spinal cord excitability and heat pain perception. We hypothesized that the effects of vibration on spinal cord reflexes, and, also those on heat pain perception, depend on vibration frequency. METHODS: In 9 healthy subjects, we applied vibration over the tibialis anterior muscle at three different frequencies (50, 150, or 250 Hz) on spinal cord reflex excitably, tested with the H reflex and the T wave in the soleus muscle, as well as on sensory and pain perception, tested by measuring warm perception (WT) and heat pain perception thresholds, (HPT) in sites rostral and caudal to vibration. Exams were carried out before, during, and after vibration. RESULTS: The amplitude of the H reflex and T wave significantly decreased during vibration in comparison to baseline. Low frequencies (50 and 150Hz) induced greater reflex suppression than high frequency (250Hz). No significant changes were observed on WT and HPT. CONCLUSIONS: The effects of vibratory stimulation can be summarized as frequency-related suppression of the spinal cord excitability without an effect on warm and heat pain perception. The present results may help to design vibration-related interventions intended to diminish spinal cord reflex excitability in spastic patients.

What's going on following acute covid-19? Clinical characteristics of patients in an out-patient rehabilitation program.

BACKGROUND: Coronavirus disease 2019 (COVID-19) patients present long-lasting physical and neuropsychological impairment, which may require rehabilitation. OBJECTIVES: The current cross-sectional study characterizes post COVID-19 sequelae and persistent symptoms in patients in an outpatient rehabilitation program. METHODS: Thirty patients [16 post-ICU and 14 non-ICU; median age = 54(43.8-62) years; 19 men] presenting sequelae and/or persistent symptoms (>3 months after acute COVID-19) were selected of 41 patients referred for neurorehabilitation. Patients underwent physical, neuropsychological and respiratory evaluation and assessment of impact of fatigue and quality of life. RESULTS: The main reasons for referral to rehabilitation were: fatigue (86.6%), dyspnea (66.7%), subjective cognitive impairment (46.7%) and neurological sequelae (33.3%). Post-ICU patient presented sequelae of critical illness myopathy and polyneuropathy, stroke and encephalopathy and lower forced vital capacity compared to non-ICU patients. Cognitive impairment was found in 63.3% of patients, with a similar profile in both sub-groups. Increased physical fatigue, anxiety and depression and low quality of life were prevalent irrespective of acute COVID-19 severity. CONCLUSIONS: The variability of post COVID-19 physical and neuropsychological impairment requires a complex screening process both in ICU and non-ICU patients. The high impact of persistent symptoms on daily life activities and quality of life, regardless of acute infection severity, indicate need for rehabilitation.

Espasticidad en la patología neurológica. Actualización sobre mecanismos fisiopatológicos, avances en el diagnóstico y tratamiento / Spasticity in neurological pathologies. An update on the pathophysiological mechanisms, advances in diagnosis and treatment

INTRODUCCIÓN: La espasticidad es un signo clínico frecuente en personas con enfermedades neurológicas que afecta a la movilidad y causa graves complicaciones: dolor, limitación articular, contracturas y úlceras por presión, que conllevan una afectación significativa de la funcionalidad del individuo y de su calidad de vida. OBJETIVO: Revisar la integración, la descripción y la interpretación crítica de la evidencia científica más reciente sobre la variabilidad clínica de la espasticidad y los síntomas asociados, los distintos mecanismos fisiopatológicos y su relevancia en el abordaje diagnóstico y terapéutico. DESARROLLO: Se realizó una búsqueda de las publicaciones científicas sobre los distintos aspectos de la espasticidad agrupados en dos categorías magistrales: patologías cerebral y medular; y se revisaron aspectos epidemiológicos, clínicos y fisiopatológicos, el diagnóstico clínico e instrumental, y el abordaje fisioterapéutico, farmacológico y quirúrgico de la espasticidad en cada grupo de patologías. CONCLUSIÓN: La espasticidad se relaciona con lesiones estructurales y cambios neuroplásticos maladaptativos que determinan una importante variabilidad en su expresión clínica. Aunque su diagnóstico presenta importantes limitaciones, el uso de herramientas de diagnóstico clínico y neurofisiológico encaminadas al abordaje diferencial en las patologías neurológicas de origen cerebral y medular podría optimizar la eficacia de las terapias de la espasticidad

INTRODUCTION: Spasticity is a frequent clinical sign in people with neurological diseases that affects mobility and causes serious complications: pain, joint limitation, muscular contractions and bed sores, which have a significant effect on the individual's functionality and quality of life. AIM: To review the integration, description and critical interpretation of the most recent scientific evidence on the clinical variability of spasticity and associated symptoms, the different pathophysiological mechanisms and their relevance in the diagnostic and therapeutic approach. DEVELOPMENT: A search was conducted in the scientific publications on the different aspects of spasticity grouped into two main categories: cerebral and spinal cord pathologies. The epidemiological, clinical and pathophysiological aspects, clinical and instrumental diagnoses, and the physiotherapeutic, pharmacological and surgical approach to spasticity in each group of pathologies were all reviewed. CONCLUSION: Spasticity is related to structural lesions and maladaptive neuroplastic changes that determine an important variability in its clinical expression. Although its diagnosis presents important limitations, the use of clinical and neurophysiological diagnostic tools aimed at achieving different approaches in cases of neurological pathologies originating in the brain and in the spinal cord could optimise the effectiveness of spasticity therapies

Noninvasive Brain Stimulation and Noninvasive Peripheral Stimulation for Neglect Syndrome Following Acquired Brain Injury.

OBJECTIVE: Hemispatial neglect is a frequent condition usually following nondominant hemispheric brain injury. It strongly affects rehabilitation strategies and everyday life activities. It is associated with behavioral and cognitive disability with a strong impact on patient's life. METHODS: We reviewed the published literature on the use of noninvasive brain stimulation, including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), and of noninvasive peripheral muscle stimulation, as therapeutic strategies for rehabilitation of neglect after acquired brain injury, such as in stroke or in traumatic injuries. The studies were grouped as controlled or uncontrolled studies in each stimulation techniques. RESULTS: Thirty-four studies were identified and 16 on rTMS, 10 on tDCS, and 8 on vibration. All studies were conducted in adult patients who suffered a stroke, except for one that was conducted in a patient suffering traumatic acquired brain injury and another that was conducted in a patient with brain tumor. In spite of significant variability in treatment protocols, patients' features and assessment of neglect, improvement was reported in almost all studies with no side-effects. CONCLUSIONS: Noninvasive brain stimulation and neuromuscular vibration are promising therapeutic neuromodulatory approaches for neglect. Further randomized-controlled studies are needed to corroborate their effectiveness as separate and combined techniques.

Occupational performance and multisensory stimulation during post-traumatic amnesia: An observational and randomized controlled trial protocol.

BACKGROUND.: Occupational performance (OP) and interventions during post-traumatic amnesia (PTA) following traumatic brain injury are poorly understood. PURPOSE.: This study aims to describe a study protocol to (a) track person factors of OP throughout PTA and (b) assess the feasibility of a randomized controlled trial (RCT) protocol comparing an occupation-based multisensory stimulation and environmental enrichment intervention with usual care during PTA. METHOD.: A prospective observational study will be conducted with an embedded Phase II RCT with 30 participants in PTA. Participants will be randomly assigned to group and regularly assessed on PTA and OP measures. Feasibility aspects will be recorded in a logbook. All measures will be repeated at PTA resolution and 1 month later, with a follow-up questionnaire completed at 6 months postinjury. FINDINGS.: Observational data will be analyzed using correlations. Feasibility will be examined descriptively, and group comparisons will be conducted to determine effect size. IMPLICATIONS.: Results will provide a broader understanding of OP during PTA and inform future trials.

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

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

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

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

Placebo-controlled study of rTMS combined with Lokomat® gait training for treatment in subjects with motor incomplete spinal cord injury.

High-frequency rTMS combined with gait training improves lower extremity motor score (LEMS) and gait velocity in SCI subjects who are able to walk over ground. The aim of this study was to optimize the functional outcome in early phases of gait rehabilitation in SCI using rTMS as an additional treatment to physical therapy. The present study included 31 motor incomplete SCI subjects randomized to receive real or sham rTMS, just before Lokomat gait training (15 subjects for real, 16 for sham rTMS). rTMS consisted of one daily session for 20 days over vertex (at 20 Hz). The subjects were evaluated using modified Ashworth scale (MAS) for spasticity, upper and lower extremity motor score (UEMS and LEMS, respectively), ten meters walking test (10MWT) and Walking Index for SCI (WISCI-II) for gait at baseline, after last rTMS session, and during follow-up. UEMS and LEMS improved significantly after last session in both groups and during follow-up period. The improvement was greater in real than in sham rTMS group. At follow-up, 71.4 % of the subjects after real rTMS and 40 % of the subjects after sham rTMS could perform 10MWT without significant differences in gait velocity, cadence, step length and WISCI-II between both groups. We conclude that 20 sessions of daily high-frequency rTMS combined with Lokomat gait training can lead to clinical improvement of gait in motor incomplete SCI. Such combined treatment improved motor strength in lower extremity in incomplete SCI subjects and in upper extremity in those with cervical SCI.

Transcranial direct current stimulation is not effective in the motor strength and gait recovery following motor incomplete spinal cord injury during Lokomat(®) gait training.

OBJECTIVE/HYPOTHESIS: Transcranial direct current stimulation (tDCS) is a potential tool to improve motor recovery in patients with neurological disorders. Safety and efficacy of this procedure for lower extremity motor strengthe and gait function in motor incomplete spinal cord injury (SCI) have not yet been addressed. The aim of this study is to optimize the functional outcome in early phases of gait rehabilitation assisted by Lokomat(®) in motor incomplete SCI patients using tDCS as an additional treatment to physical therapy. METHODS: We performed in a SCI unit a single-centre randomized, double-blind, sham-controlled study to investigate safety and efficacy of anodal tDCS of over leg motor cortex in motor incomplete SCI patients. Twenty-four SCI patients received either daily sessions of anodal tDCS (n=12) at 2mA for 20min to the vertex (leg motor cortex) during twenty days or sham tDCS (n=12). Motor deficit was assessed by the lower extremity motor score (LEMS) and for gait function: ten meter walking test (10MWT) and Walking Index for SCI (WISCI II) at baseline, after last tDCS session (after 4 weeks of stimulation), and after 8 weeks (from baseline) for follow-up. RESULTS: No side effects were detected during either tDCS or sham. In both groups, there was a significant improvement in LEMS (p<0.03), which did not significantly differ when comparing anodal and sham tDCS groups. During follow-up, in both group 5 of 12 patients could perform gait, without significant differences in gait velocity, cadence, step length and WISCI-II between both groups. CONCLUSION: Combination twenty sessions of daily tDCS to the leg motor cortex and Lokomat(®) gait training appear to be safe in motor incomplete SCI patients. There was an expected improvement in both LEMS and gait scales however, did not differ between patients treated with anodal or sham tDCS.

Influence of spinal cord lesion level and severity on H-reflex excitability and recovery curve.

INTRODUCTION: Changes in spinal reflexes can result from alterations in the spinal cord and descending pathways. We studied whether H-reflex excitability and its recovery depend on the level and/or severity of spinal cord injury (SCI). METHODS: The soleus Hmax and Mmax responses and the H-reflex recovery curve (HRC) at interstimulus intervals (ISIs) ranging from 50 to 1,000 ms were recorded in 38 SCI individuals and 18 healthy subjects. RESULTS: Amplitude of Mmax correlated with level and severity of lesion (smaller amplitude correlated with more severe SCI or with more caudal lesion). Hmax/Mmax correlated only with age in the SCI group. HRC was increased significantly in complete SCI at ISIs < 500 ms and in incomplete SCI at ISIs > 200 ms with respect to healthy subjects. CONCLUSIONS: The changes in spinal reflexes as measured by the H-reflex and its recovery curve after SCI depend on the severity, but not on the level of the lesion.

Effects of high-frequency repetitive transcranial magnetic stimulation on motor and gait improvement in incomplete spinal cord injury patients.

OBJECTIVE: Incomplete spinal cord injury (SCI) patients have the potential to regain some ambulatory function, and optimal reorganization of remaining circuits can contribute to this recovery. We hypothesized that repetitive transcranial magnetic stimulation (rTMS) may promote active recovery of motor function during gait rehabilitation. METHODS: A total of 17 incomplete SCI patients were randomized to receive active rTMS or sham stimulation coupled with rehabilitation therapy; 3 patients who began in the sham group crossed over to the active rTMS group after a washout period of more than 3 weeks. Active rTMS consisted of 15 daily sessions over the leg motor area (at 20 Hz). We compared lower-extremity motor score (LEMS), 10-m walking test for walking speed, timed up and go, Walking Index for SCI Scale, Modified Ashworth Scale, and Spinal Cord Injury Spasticity Evaluation Tool at baseline, after the last session, and 2 weeks later in the active rTMS and sham stimulation groups. RESULTS: A significant improvement was observed after the last rTMS session in the active group for LEMS, walking speed, and spasticity. Improvement in walking speed was maintained during the follow-up period. Sham stimulation did not induce any improvement in LEMS, gait assessment, and spasticity after the last session and neither during follow-up. CONCLUSION: In incomplete SCI, 15 daily sessions of high-frequency rTMS can improve motor score, walking speed, and spasticity in the lower limbs. The study provides evidence for the therapeutic potential of rTMS in the lower extremities in SCI rehabilitation.

Recovery of assisted overground stepping in a patient with chronic motor complete spinal cord injury: a case report.

BACKGROUND: Clinical studies have shown that after incomplete spinal cord lesions at the thoracic level, patients can develop functional gait patterns through gait training. To date, however, training has been ineffective in producing gait in patients with clinically motor complete spinal cord lesions. OBJECTIVE: Here we report a patient with chronic motor complete spinal cord injury who regained locomotor function with assistance after intensive gait rehabilitation treatment. METHODS: A fifteen year old female patient had sustained motor complete spinal cord injury (T6, AIS B) 2 years earlier, with severe bilateral extensor spasticity, and ineffective previous gait training with robotic systems. The therapy consisted of two months of gait training with a robotic system combined with bilateral functional electrical stimulation (FES) of the peroneal nerve, and one month of gait training with a special walker and FES of the left leg and occasionally on the right leg, due to flexor reflex could sometimes be initiated by the patient in the right leg without electrical stimulation. Neurophysiological studies and ten metres test were done. RESULTS: At the end of training, the patient was able to cover a distance of 200 metres without FES with a walker and assistance from a physiotherapist, who pulled the walker with each step to help her to accomplish effective overground stepping. Motor and somatosensory evoked potentials were absent in the lower limbs. CONCLUSION: Even after a motor complete lesion with some preservation of sensory pathways, the spinal cord may be able to retain some of its locomotor function through intensive gait rehabilitation.

Gait training in human spinal cord injury using electromechanical systems: effect of device type and patient characteristics.

OBJECTIVE: To report the clinical improvements in spinal cord injury (SCI) patients associated with intensive gait training using electromechanical systems according to patient characteristics. DESIGN: Prospective longitudinal study. SETTING: Inpatient SCI rehabilitation center. PARTICIPANTS: Adults with SCI (n=130). INTERVENTION: Patients received locomotor training with 2 different electromechanical devices, 5 days per week for 8 weeks. MAIN OUTCOME MEASURES: Lower-extremity motor score, Walking Index for Spinal Cord Injury, and 10-meter walking test data were collected at the baseline, midpoint, and end of the program. Patients were stratified according to the American Spinal Injury Association (ASIA) category, time since injury, and injury etiology. A subgroup of traumatic ASIA grade C and D patients were compared with data obtained from the European Multicenter Study about Human Spinal Cord Injury (EM-SCI). RESULTS: One hundred and five patients completed the program. Significant gains in lower-limb motor function and gait were observed for both types of electromechanical device systems, to a similar degree. The greatest rate of improvement was shown in the motor incomplete SCI patients, and for patients <6 months postinjury. The positive response associated with training was not affected by injury etiology, age, sex, or lesion level. The trajectory of improvement was significantly enhanced relative to patients receiving the conventional standard of care without electromechanical systems (EM-SCI). CONCLUSIONS: The use of electromechanical systems for intensive gait training in SCI is associated with a marked improvement in lower-limb motor function and gait across a diverse range of patients and is most evident in motor incomplete patients, and for patients who begin the regimen early in the recovery process.

Decrease of spasticity with muscle vibration in patients with spinal cord injury.

OBJECTIVE: Spasticity is common after spinal cord injury (SCI). Exaggerated tendon jerks, clonus, and spasms are key features of spasticity that result from hyperexcitability of the stretch reflex circuit. Here we studied the effects of vibration on the rectus femoris muscle (RF) on clinical and electrophysiological measures of spasticity in the leg. METHODS: Nineteen SCI patients with spasticity and nine healthy subjects were studied at baseline and under stimulation (vibration at 50 Hz during 10 min on the thigh). Neurophysiological studies included evaluation of the soleus T wave and Hmax/Mmax ratio. Clinical measurements of spasticity were the score in the Modified Ashworth Scale (MAS), range of motion (ROM), and duration and frequency of clonus. RESULTS: Patients with incomplete SCI (iSCI) presented higher number of cycles and longer duration of clonus than patients with complete SCI (cSCI). The Hmax/Mmax ratio and T wave amplitude at baseline were significantly larger in iSCI patients than in cSCI or healthy subjects. During vibration, we found a significant reduction of MAS and duration of clonus, and an increase in ROM, in all patients as a group. The Hmax/Mmax ratio and the T wave amplitude decreased significantly in both, patients and controls. CONCLUSIONS: Prolonged vibration on proximal lower extremity muscles decreased limb spasticity in patients with spinal cord injury, regardless of whether the lesion is complete or incomplete. SIGNIFICANCE: Muscle vibration may be useful for physical therapy, by facilitating passive and active movements of the extremities in spastic SCI patients.

Reduction of spasticity with repetitive transcranial magnetic stimulation in patients with spinal cord injury.

OBJECTIVE: Spasticity with increased tone and spasms is frequent in patients after spinal cord injury (SCI). Damage to descending corticospinal pathways that normally exert spinal segmental control is thought to play an important causal role in spasticity. The authors examined whether the modulation of excitability of the primary motor cortex with high-frequency repetitive transcranial magnetic stimulation (rTMS) could modify lower limb spasticity in patients with incomplete SCI. METHODS: Patients were assessed by the Modified Ashworth Scale, Visual Analogue Scale, and the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) and neurophysiologically with measures of corticospinal and segmental excitability by the H(max)/M(max), T reflex, and withdrawal reflex. Fifteen patients received 5 days of daily sessions of active (n = 14) or sham (n = 7) rTMS to the leg motor area (20 trains of 40 pulses at 20 Hz and an intensity of 90% of resting motor threshold for the biceps brachii muscle). RESULT: A significant clinical improvement in lower limb spasticity was observed in patients following active rTMS but not after sham stimulation.This improvement lasted for at least 1 week following the intervention. Neurophysiological studies did not change. CONCLUSIONS: High-frequency rTMS over the leg motor area can improve aspects of spasticity in patients with incomplete SCI.