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1.
PLoS One ; 14(11): e0225032, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31743353

RESUMO

OBJECTIVE: Unilateral trans-tibial amputation signifies a challenge to locomotion. Prosthetic ankle-foot units are developed to mimic the missing biological system which adapts push-off power to walking speed in some new prosthetic ankle-foot designs. The first systematic review including the two factors aims to investigate push-off power differences among Solid Ankle Cushion Heel (SACH), Energy Storage And Return (ESAR) and Powered ankle-foot units (PWR) and their relation to walking speed. DATA SOURCES: A literature search was undertaken in the Web of Science, PubMed, IEEE xplore, and Google Scholar databases. The search term included: ampu* AND prosth* AND ankle-power AND push-off AND walking. STUDY APPRAISAL AND SYNTHESIS METHODS: Studies were included if they met the following criteria: unilateral trans-tibial amputees, lower limb prosthesis, reported analysis of ankle power during walking. Data extracted from the included studies were clinical population, type of the prosthetic ankle-foot units (SACH, ESAR, PWR), walking speed, and peak ankle power. Linear regression was used to determine whether the push-off power of different prosthetic ankle-foot units varied regarding walking speed. Push-off power of the different prosthetic ankle-foot units were compared using one-way between subjects' ANOVAs with post hoc analysis, separately for slower and faster walking speeds. RESULTS: 474 publications were retrieved, 28 of which were eligible for inclusion. Correlations between walking speed and peak push-off power were found for ESAR (r = 0.568, p = 0.006) and PWR (r = 0.820, p = 0.000) but not for SACH (r = 0.267, p = 0.522). ESAR and PWR demonstrated significant differences in push-off power for slower and faster walking speeds (ESAR (p = 0.01) and PWR (p = 0.02)). CONCLUSION: Push-off power can be used as a selection criterion to differentiate ankle-foot units for prosthetic users and their bandwidth of walking speeds.

2.
J Biomech ; 94: 130-137, 2019 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-31399205

RESUMO

This study evaluated the reactive biomechanical strategies associated with both upper- and lower-body (lead and trail limbs) following the first exposures to (un)expected stepdown at comfortable (1.22 ±â€¯0.08 m/s) and fast (1.71 ±â€¯0.11 m/s) walking velocities. Eleven healthy adults completed 34 trails per walking velocity over an 8-m, custom-built track with two forceplates embedded in its center. For the expected stepdown, the track was lowered by 0-, -10- and -20-cm from the site of the second forceplate, whereas the unexpected stepdown was created by camouflaging the second forceplate (-10-cm). Two-way repeated-measurement ANOVAs detected no velocity-related effects of stepdown on kinematic and kinetic parameters during lead limb stance-phase, and on the trail limb stepping kinematics. However, analyses of significant interactions revealed greater peak flexion angles across the trunk and the trail limb joints (hip, knee and ankle) in unexpected versus expected stepdown conditions at a faster walking velocity. The -10-cm unexpected stepdown (main effect) had a greater influence on locomotor behavior compared to expected conditions due mainly to the absence of predictive adjustments, reflected by a significant decrease in peak knee flexion, contact time and vertical impulse during stance-phase. Walking faster (main effect) was associated with an increase in hip peak flexion and net anteroposterior impulse, and a decrease in contact time and vertical impulse during stepdown. The trail limb, in response, swung forward faster, generating a larger and faster recovery step. However, such reactive stepping following unexpected stepdown was yet a sparse compensation for an unstable body configuration, assessed by significantly smaller step width and anteroposterior margin-of-stability at foot-contact in the first-recovery-step compared with expected conditions. These findings depict the impact of the expectedness of stepdown onset on modulation of global dynamic postural control for a successful accommodation of (un)expected surface elevation changes in young, healthy adults.

3.
Neurorehabil Neural Repair ; 33(11): 902-910, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31455175

RESUMO

Background. Predicting functional outcomes after traumatic spinal cord injury (SCI) is essential for counseling, rehabilitation planning, and discharge. Moreover, the outcome prognosis is crucial for patient stratification when designing clinical trials. However, no valid prediction rule is currently available for bowel outcomes after a SCI. Objective. To generate a model for predicting the achievement of independent, reliable bowel management at 1 year after traumatic SCI. Methods. We performed multivariable logistic regression analyses of data for 1250 patients with traumatic SCIs that were included in the European Multicenter Study about Spinal Cord Injury. The resulting model was prospectively validated on data for 186 patients. As potential predictors, we evaluated age, sex, and variables from the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and the Spinal Cord Independence Measure (SCIM), measured within 40 days of the injury. A positive outcome at 1 year post-SCI was assessed with item 7 of the SCIM. Results. The model relied on a single predictor, the ISNCSCI total motor score-that is, the sum of muscle strengths in 5 key muscle groups in each limb. The area under the receiver operating characteristics curve (aROC) was 0.837 (95% CI: 0.815-0.859). The prospective validation confirmed high predictive power: aROC = 0.817 (95% CI: 0.754-0.881). Conclusions. We generated a valid model for predicting independent, reliable bowel management at 1 year after traumatic SCI. Its application could improve counseling, optimize patient-tailored rehabilitation planning, and become crucial for appropriate patient stratification in future clinical trials.

4.
Eur Spine J ; 28(10): 2390-2407, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31367852

RESUMO

PURPOSE: Spinal Cord Society (SCS) and Spine Trauma Study Group (STSG) established a panel tasked with reviewing management and prognosis of acute traumatic cervical central cord syndrome (ATCCS) and recommend a consensus statement for its management. METHODS: A systematic review was performed according to the PRISMA 2009 guidelines. Delphi method was used to identify key research questions and achieve consensus. PubMed, Scopus and Google Scholar were searched for corresponding keywords. The initial search retrieved 770 articles of which 37 articles dealing with management, timing of surgery, complications or prognosis of ATCCS were identified. The literature review and draft position statements were compiled and circulated to panel members. The draft was modified incorporating relevant suggestions to reach consensus. RESULTS: Out of 37 studies, 15 were regarding management strategy, ten regarding timing of surgery and 12 regarding prognosis of ATCCS. CONCLUSION: There is reasonable evidence that patients with ATCCS secondary to vertebral fracture, dislocation, traumatic disc herniation or instability have better outcomes with early surgery (< 24 h). In patients of ATCCS secondary to extension injury in stenotic cervical canal without fracture/fracture dislocation/traumatic disc herniation/instability, there is requirement of high-quality prospective randomized controlled trials to resolve controversy regarding early surgery versus conservative management and delayed surgery if recovery plateaus or if there is a neurological deterioration. Until such time decision on surgery and its timing should be left to the judgment of physician, deliberating on pros and cons relevant to the particular patient and involving the well-informed patient and relatives in decision making. These slides can be retrieved under Electronic Supplementary Material.

5.
Spinal Cord ; 57(1): 26-32, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30089891

RESUMO

STUDY DESIGN: A psychometrics study. OBJECTIVES: To determine intra and inter-observer reliability of Allen Ferguson system (AF) and sub-axial injury classification and severity scale (SLIC), two sub axial cervical spine injury (SACI) classification systems. SETTING: Online multi-national study METHODS: Clinico-radiological data of 34 random patients with traumatic SACI were distributed as power point presentations to 13 spine surgeons of the Spine Trauma Study Group of ISCoS from seven different institutions. They were advised to classify patients using AF and SLIC systems. A reference guide of the two systems had been mailed to them earlier. After 6 weeks, the same cases were re-presented to them in a different order for classification using both systems. Intra and inter-observer reliability scores were calculated and analysed with Fleiss Kappa coefficient (k value) for both the systems and Intraclass correlation coefficient(ICC) for the SLIC. RESULTS: Allen Ferguson system displayed a uniformly moderate inter and intra-observer reliability. SLIC showed slight to fair inter-observer reliability and fair to substantial intra-observer reliability. AF mechanistic types showed better inter-observer reliability than the SLIC morphological types. Within SLIC, the total SLIC had the least inter-observer agreement and the SLIC neurology had the highest intra-observer agreement. CONCLUSION: This first external reliability study shows a better reliability for AF as compared to SLIC system. Among the SLIC variables, the DLC status and the total SLIC had least agreement. Low-reliability highlights the need for improving the existing classification systems or coming out with newer ones that consider limitations of the existing ones.


Assuntos
Vértebras Cervicais/lesões , Traumatismos da Coluna Vertebral/classificação , Índices de Gravidade do Trauma , Vértebras Cervicais/diagnóstico por imagem , Humanos , Internacionalidade , Variações Dependentes do Observador , Psicometria , Reprodutibilidade dos Testes , Traumatismos da Coluna Vertebral/diagnóstico por imagem
6.
Eur J Paediatr Neurol ; 23(2): 248-253, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30579697

RESUMO

OBJECTIVE: Determining differences in neurological and functional outcome between adolescents and adults after acute traumatic spinal cord injury (SCI). DESIGN: Retrospective, multi-center case-control study. METHODS: 100 cases of patients under 18 years at accident with acute traumatic cervical SCI admitted to SCI centers participating in the European Multi-center study about SCI (EMSCI) between January 2005 and April 2016 were reviewed. According to their age at accident, age 13 to 17, patients were selected for the adolescent group. After applying in- and exclusion criteria 32 adolescents were included. Each adolescent patient was matched with two adult SCI patients for analysis. OUTCOME MEASURES: ASIA Impairment scale (AIS) grade, neurological, sensory, motor level, total motor score, and Spinal Cord Independence Measure (SCIM III) total score. RESULTS: Mean AIS conversion, neurological, motor and sensory levels as well as total motor score showed no significantly statistical difference in adolescents compared to the adult control group after follow up of 6 months. Significantly higher final SCIM scores (p < 0.05) in the adolescent group compared to adults as well as a strong trend for a higher gain in SCIM score (p < 0.061) between first and last follow up was found. CONCLUSIONS: Neurological outcome after traumatic cervical SCI is not superior in adolescents compared to adults in this cohort. Significantly higher SCIM scores indicate more functional gain for the adolescent patients after traumatic cervical SCI. Juvenile age appears to be an independent predictor for a better functional outcome.


Assuntos
Recuperação de Função Fisiológica , Traumatismos da Medula Espinal , Adolescente , Adulto , Idoso , Medula Cervical , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
7.
Neurorehabil Neural Repair ; 32(6-7): 578-589, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29869587

RESUMO

BACKGROUND: Neutralization of central nervous system neurite growth inhibitory factors, for example, Nogo-A, is a promising approach to improving recovery following spinal cord injury (SCI). In animal SCI models, intrathecal delivery of anti-Nogo-A antibodies promoted regenerative neurite growth and functional recovery. OBJECTIVE: This first-in-man study assessed the feasibility, safety, tolerability, pharmacokinetics, and preliminary efficacy of the human anti-Nogo-A antibody ATI355 following intrathecal administration in patients with acute, complete traumatic paraplegia and tetraplegia. METHODS: Patients (N = 52) started treatment 4 to 60 days postinjury. Four consecutive dose-escalation cohorts received 5 to 30 mg/2.5 mL/day continuous intrathecal ATI355 infusion over 24 hours to 28 days. Following pharmacokinetic evaluation, 2 further cohorts received a bolus regimen (6 intrathecal injections of 22.5 and 45 mg/3 mL, respectively, over 4 weeks). RESULTS: ATI355 was well tolerated up to 1-year follow-up. All patients experienced ≥1 adverse events (AEs). The 581 reported AEs were mostly mild and to be expected following acute SCI. Fifteen patients reported 16 serious AEs, none related to ATI355; one bacterial meningitis case was considered related to intrathecal administration. ATI355 serum levels showed dose-dependency, and intersubject cerebrospinal fluid levels were highly variable after infusion and bolus injection. In 1 paraplegic patient, motor scores improved by 8 points. In tetraplegic patients, mean total motor scores increased, with 3/19 gaining >10 points, and 1/19 27 points at Week 48. Conversion from complete to incomplete SCI occurred in 7/19 patients with tetraplegia. CONCLUSIONS: ATI335 was well tolerated in humans; efficacy trials using intrathecal antibody administration may be considered in acute SCI.


Assuntos
Imunoglobulina G/uso terapêutico , Regeneração Nervosa/efeitos dos fármacos , Neuritos/efeitos dos fármacos , Proteínas Nogo/imunologia , Paraplegia/tratamento farmacológico , Quadriplegia/tratamento farmacológico , Traumatismos da Medula Espinal/tratamento farmacológico , Adolescente , Adulto , Relação Dose-Resposta a Droga , Estudos de Viabilidade , Feminino , Humanos , Imunoglobulina G/administração & dosagem , Injeções Espinhais , Masculino , Pessoa de Meia-Idade , Paraplegia/etiologia , Quadriplegia/etiologia , Recuperação de Função Fisiológica/efeitos dos fármacos , Resultado do Tratamento , Adulto Jovem
8.
Artigo em Inglês | MEDLINE | ID: mdl-29479485

RESUMO

The establishment of a new technology into the mainstream of treatment, such as spinal surgery for traumatic spinal cord injury, only rarely happens after being scrutinized in trials. Usually, a new technology is widely adopted when it offers an easily identifiable advantage over other treatment choices. In the case of spinal fixation, this advantage is the omission of a prolonged immobilization. However, this does not automatically preclude that the final outcome of the treatment is better. It does not imply that associated assumptions, such as the benefit of early decompression toward neurological improvement, are true as well. They need to be established with careful studies.

10.
J Neurotrauma ; 35(6): 854-863, 2018 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-29160145

RESUMO

The Graded and Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) is a valid, reliable, and responsive outcome measure to evaluate upper limb function in individuals with tetraplegia. GRASSP generates ordinal total scores; therefore, applicability as an interval level measurement requires testing of its measurement properties. This study examined the metric characteristics with Rasch Analysis to derive interval level scales of the respective GRASSP subtests. The GRASSP was recorded within 10 days, and at 1, 3, 6, and 12 months after cervical spinal cord injury (SCI). Rasch analysis was performed for each GRASSP subscale to assess the following metric assumptions: absence of local item dependency (LID), unidimensionality, monotonicity, item and model fit, reliability, and absence of differential item functioning (DIF) for side (left and right) and examination stage. If these assumptions could not be met, adjustments were undertaken to achieve a good fit to the Rasch model. Seventy-seven individuals with cervical SCI were included (n = 154 arms). Stacking the data for the side (left and right) resulted in a total of 614 observations, which were based on the repeated measurements. With minor adjustments, the GRASSP subscales showed good reliability, item fit, and ordered response options. Local item dependencies were found in the strength and sensibility subscales. Redundancies among some measurement items allowed shortening of the subscales without reasonable loss of reliability. Absence of DIF for the examination stage supported robustness of the subscales over time. The modified GRASSP, now Version 2, subtest scores can be applied as interval level measurements, and the reduction of items within subscales allows for shorter assessment times in clinical studies without degrading metric properties.


Assuntos
Avaliação da Deficiência , Quadriplegia/fisiopatologia , Traumatismos da Medula Espinal/fisiopatologia , Adulto , Idoso , Vértebras Cervicais , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Força Muscular/fisiologia , Estudos Prospectivos , Psicometria , Quadriplegia/etiologia , Reprodutibilidade dos Testes , Traumatismos da Medula Espinal/complicações , Extremidade Superior
11.
Neurorehabil Neural Repair ; 31(9): 842-850, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28786305

RESUMO

BACKGROUND: Walking speed is assumed to be a key factor in regaining ambulation after spinal cord injury (SCI). However, from the literature it remains unclear which walking speed usually results in independent community ambulation. OBJECTIVE: The primary aim of this study was to determine at which walking speed SCI patients tend to walk in the community instead of using a wheelchair. The secondary aim was to investigate clinical conditions that favor independent ambulation in the community. METHODS: Data from SCI patients were collected retrospectively from the European Multicenter Study about Spinal Cord Injury database. We determined a cutoff walking speed at which the patients tend to walk in the community by plotting a receiver operating characteristics curve, using the Spinal Cord Independence Measure for outdoor mobility. Univariate analyses investigated which factors influence independent community ambulation. RESULTS: A walking speed of 0.59 m/s is the cutoff between patients who do and do not ambulate independently in the community, with a sensitivity of 91.6% and a specificity of 80.3%. Age, injury severity, and lower limb muscle strength have a significant influence on independent community ambulation. CONCLUSIONS: Patients with an SCI who regain a walking speed of 0.59 m/s tend to achieve a level of walking effectiveness that allows for independent community walking. Although such patients tend to be younger and less severely injured, this walking speed can be a target for locomotor training in rehabilitation and clinical trials that lead to a meaningful outcome level of community walking.


Assuntos
Transtornos dos Movimentos/etiologia , Traumatismos da Medula Espinal/complicações , Velocidade de Caminhada/fisiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia por Exercício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos dos Movimentos/diagnóstico , Transtornos dos Movimentos/reabilitação , Força Muscular/fisiologia , Curva ROC , Recuperação de Função Fisiológica/fisiologia , Características de Residência , Estudos Retrospectivos , Fatores de Tempo , Caminhada , Adulto Jovem
12.
Neurorehabil Neural Repair ; 31(5): 432-441, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28132610

RESUMO

BACKGROUND AND OBJECTIVE: The course of central and peripheral motor recovery after cervical spinal cord injury (SCI) may be investigated by electrophysiological measures. The goal of this study was to compare the 2 over the first year after injury in relation to motor gains. METHODS: Compound motor action potentials (CMAPs), motor-evoked potentials (MEPs), and F-waves were recorded from the abductor digiti minimi and CMAP and F-waves from abductor hallucis muscles in 305 patients at about 15 days, 1 month, 3 months, 6 months, and 12 months following an acute traumatic SCI. RESULTS: The MEP amplitudes and F-wave persistences were lower with more severe sensorimotor impairment. They steadily increased in most subgroups within 6 months after SCI. The amplitude of the CMAPs was low for the first 3 months in the most severely affected participants. This was also found for CMAPs from tibial nerve originating well below the cervical lesion level. Improvement in neurophysiological parameters correlated with improved upper extremity motor scores. CONCLUSION: The results point to a systematic interrelation of corticospinal transmission, spinal motoneuron excitability, and its axon function, respectively. Electrophysiological correlates of neural excitability show distinct spatial and temporal interrelations within central and peripheral motor pathways following acute cervical SCI. A strong secondary deterioration within the peripheral motor system with incomplete or no recovery depends on anatomical distance caudal to lesion and on lesion severity. Electrophysiological assessments may increase the sensitivity of interventional studies in addition to clinical measures.


Assuntos
Nervos Periféricos/fisiopatologia , Recuperação de Função Fisiológica/fisiologia , Traumatismos da Medula Espinal/fisiopatologia , Extremidade Superior/fisiopatologia , Potenciais de Ação/fisiologia , Adulto , Idoso , Avaliação da Deficiência , Eletromiografia , Europa (Continente) , Potencial Evocado Motor/fisiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Condução Nervosa/fisiologia , Exame Neurológico , Estudos Retrospectivos , Estatística como Assunto , Adulto Jovem
13.
Eur Spine J ; 26(5): 1470-1476, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-27334493

RESUMO

PURPOSE: The aim of this multicentre study was to determine whether the recently introduced AOSpine Classification and Injury Severity System has better interrater and intrarater reliability than the already existing Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries. METHODS: Clinical and radiological data of 50 consecutive patients admitted at a single centre with a diagnosis of an acute traumatic thoracolumbar spine injury were distributed to eleven attending spine surgeons from six different institutions in the form of PowerPoint presentation, who classified them according to both classifications. After time span of 6 weeks, cases were randomly rearranged and sent again to same surgeons for re-classification. Interobserver and intraobserver reliability for each component of TLICS and new AOSpine classification were evaluated using Fleiss Kappa coefficient (k value) and Spearman rank order correlation. RESULTS: Moderate interrater and intrarater reliability was seen for grading fracture type and integrity of posterior ligamentous complex (Fracture type: k = 0.43 ± 0.01 and 0.59 ± 0.16, respectively, PLC: k = 0.47 ± 0.01 and 0.55 ± 0.15, respectively), and fair to moderate reliability (k = 0.29 ± 0.01 interobserver and 0.44+/0.10 intraobserver, respectively) for total score according to TLICS. Moderate interrater (k = 0.59 ± 0.01) and substantial intrarater reliability (k = 0.68 ± 0.13) was seen for grading fracture type regardless of subtype according to AOSpine classification. Near perfect interrater and intrarater agreement was seen concerning neurological status for both the classification systems. CONCLUSIONS: Recently proposed AOSpine classification has better reliability for identifying fracture morphology than the existing TLICS. Additional studies are clearly necessary concerning the application of these classification systems across multiple physicians at different level of training and trauma centers to evaluate not only their reliability and reproducibility, but also the other attributes, especially the clinical significance of a good classification system.


Assuntos
Escala de Gravidade do Ferimento , Vértebras Lombares/lesões , Traumatismos da Coluna Vertebral/classificação , Vértebras Torácicas/lesões , Humanos , Distribuição Aleatória , Reprodutibilidade dos Testes
14.
PLoS Med ; 13(6): e1002041, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27327967

RESUMO

BACKGROUND: Neurogenic bladder dysfunction represents one of the most common and devastating sequelae of traumatic spinal cord injury (SCI). As early prediction of bladder outcomes is essential to counsel patients and to plan neurourological management, we aimed to develop and validate a model to predict urinary continence and complete bladder emptying 1 y after traumatic SCI. METHODS AND FINDINGS: Using multivariate logistic regression analysis from the data of 1,250 patients with traumatic SCI included in the European Multicenter Spinal Cord Injury study, we developed two prediction models of urinary continence and complete bladder emptying 1 y after traumatic SCI and performed an external validation in 111 patients. As predictors, we evaluated age, gender, and all variables of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) and of the Spinal Cord Independence Measure (SCIM). Urinary continence and complete bladder emptying 1 y after SCI were assessed through item 6 of SCIM. The full model relies on lower extremity motor score (LEMS), light-touch sensation in the S3 dermatome of ISNCSI, and SCIM subscale respiration and sphincter management: the area under the receiver operating characteristics curve (aROC) was 0.936 (95% confidence interval [CI]: 0.922-0.951). The simplified model is based on LEMS only: the aROC was 0.912 (95% CI: 0.895-0.930). External validation of the full and simplified models confirmed the excellent predictive power: the aROCs were 0.965 (95% CI: 0.934-0.996) and 0.972 (95% CI 0.943-0.999), respectively. This study is limited by the substantial number of patients with a missing 1-y outcome and by differences between derivation and validation cohort. CONCLUSIONS: Our study provides two simple and reliable models to predict urinary continence and complete bladder emptying 1 y after traumatic SCI. Early prediction of bladder function might optimize counselling and patient-tailored rehabilitative interventions and improve patient stratification in future clinical trials.


Assuntos
Traumatismos da Medula Espinal/complicações , Bexiga Urinaria Neurogênica/diagnóstico , Bexiga Urinaria Neurogênica/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Europa (Continente)/epidemiologia , Feminino , Humanos , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Curva ROC , Traumatismos da Medula Espinal/epidemiologia , Bexiga Urinaria Neurogênica/epidemiologia , Adulto Jovem
15.
Neurorehabil Neural Repair ; 29(9): 867-77, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25644238

RESUMO

BACKGROUND: Several novel drug- and cell-based potential therapies for spinal cord injury (SCI) have either been applied or will be considered for future clinical trials. Limitations on the number of eligible patients require trials be undertaken in a highly efficient and effective manner. However, this is particularly challenging when people living with incomplete SCI (iSCI) represent a very heterogeneous population in terms of recovery patterns and can improve spontaneously over the first year after injury. OBJECTIVE: The current study addresses 2 requirements for designing SCI trials: first, enrollment of as many eligible participants as possible; second, refined stratification of participants into homogeneous cohorts from a heterogeneous iSCI population. METHODS: This is a retrospective, longitudinal analysis of prospectively collected SCI data from the European Multicenter study about Spinal Cord Injury (EMSCI). We applied conditional inference trees to provide a prediction-based stratification algorithm that could be used to generate decision rules for the appropriate inclusion of iSCI participants to a trial. RESULTS: Based on baseline clinical assessments and a defined subsequent clinical endpoint, conditional inference trees partitioned iSCI participants into more homogeneous groups with regard to the illustrative endpoint, upper extremity motor score. Assuming a continuous endpoint, the conditional inference tree was validated both internally as well as externally, providing stable and generalizable results. CONCLUSION: The application of conditional inference trees is feasible for iSCI participants and provides easily implementable, prediction-based decision rules for inclusion and stratification. This algorithm could be utilized to model various trial endpoints and outcome thresholds.


Assuntos
Ensaios Clínicos como Assunto , Projetos de Pesquisa , Traumatismos da Medula Espinal/terapia , Algoritmos , Medula Cervical/lesões , Determinação de Ponto Final , Humanos , Estudos Longitudinais , Doenças do Sistema Nervoso/terapia , Estudos Prospectivos , Estudos Retrospectivos
16.
Neurorehabil Neural Repair ; 29(8): 755-66, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25567122

RESUMO

OBJECTIVE: To investigate the internal and external responsiveness and recovery profiles of the Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) instrument in revealing changes in upper limb function within the first year following cervical spinal cord injury (SCI). METHOD: A European prospective, longitudinal, multicenter study assessing the GRASSP at 1, 3, 6, and 12 months after cervical SCI. Subtests of GRASSP were compared to the upper extremity motor (UEMS) and light touch scores (LT) according to the International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI), the Spinal Cord Independence Measure self-care subscore (SCIM-SS), as well as a clinician-rated outcome measure (CROM) of clinical relevance. Data were analyzed for GRASSP responsiveness and recovery rate over time. RESULTS: Seventy-four participants entered the study. GRASSP subtests proved responsive (standardized response mean [SRM] ranged from 0.79 to 1.48 for strength, 0.50 to 1.03 for prehension, and 0.14 to 0.64 for sensation) between all examination time points. In comparison, UEMS and LT showed lower responsiveness (SRM UEMS ranged from 0.69 to 1.29 and SRM LT ranged from 0.30 to -0.13). All GRASSP subtests revealed significant, moderate-to-excellent correlations with UEMS, LT, and SCIM-SS at each time point, and changes in GRASSP subtests were in accordance with the CROM. GRASSP prehension and motor recovery was largest between 1 and 3 months. CONCLUSION: The GRASSP showed excellent responsiveness, detecting distinct changes in strength and prehension relating to the severity of cervical SCI. It detected clinically significant changes complimentary to the ISNCSCI and SCIM-SS assessments.


Assuntos
Força Muscular/fisiologia , Recuperação de Função Fisiológica/fisiologia , Sensação/fisiologia , Traumatismos da Medula Espinal/fisiopatologia , Extremidade Superior/fisiopatologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Medula Cervical , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Quadriplegia/etiologia , Quadriplegia/fisiopatologia , Curva ROC , Índice de Gravidade de Doença , Traumatismos da Medula Espinal/complicações , Fatores de Tempo , Adulto Jovem
17.
Neurorehabil Neural Repair ; 28(7): 632-42, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24566986

RESUMO

BACKGROUND: There is inherent heterogeneity within individuals suffering from cervical spinal cord injury (SCI), and early prediction of upper limb function and self-care is challenging. As a result, considerable uncertainty exists regarding the prediction of functional outcome following cervical SCI within 1 year of injury. OBJECTIVE: To evaluate the value of Graded Redefined Assessment of Strength, Sensibility, and Prehension (GRASSP) in predicting upper limb function and self-care outcomes in individuals with cervical SCI. METHOD: A prospective longitudinal multicenter study was performed. Data from the GRASSP, the Spinal Cord Independence Measure (SCIM III), and the American Spinal Injury Association (ASIA) Impairment Scale were recorded at 1, 6, and 12 months after cervical SCI. For prediction of functional outcome at 6 and 12 months, a logistic regression model, receiver operating characteristics (ROC), and unbiased recursive partitioning conditional inference tree (URP-CTREE) were used with 8 different predictor variables. RESULTS: Logistic regression analysis, ROC analysis, and URP-CTREE all revealed that the strength subtest within GRASSP is the strongest predictor for upper limb function and self-care outcomes. URP-CTREE provides useful information on the distribution of different outcomes in acute cervical SCI and can be used to predict cohorts with homogeneous outcomes. CONCLUSION: The GRASSP at 1 month can accurately predict upper limb function and self-care outcomes even in a heterogeneous group of individuals across a wide spectrum of neurological recovery. The application of URP-CTREE can reveal the distribution of outcome categories and, based on this, inform trial protocols with respect to outcomes analysis and patient stratification.


Assuntos
Avaliação da Deficiência , Recuperação de Função Fisiológica , Autocuidado , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/reabilitação , Extremidade Superior/fisiopatologia , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
18.
Neurorehabil Neural Repair ; 28(6): 507-15, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24477680

RESUMO

Background The reliable stratification of homogeneous subgroups and the prediction of future clinical outcomes within heterogeneous neurological disorders is a particularly challenging task. Nonetheless, it is essential for the implementation of targeted care and effective therapeutic interventions. Objective This study was designed to assess the value of a recently developed regression tool from the family of unbiased recursive partitioning methods in comparison to established statistical approaches (eg, linear and logistic regression) for predicting clinical endpoints and for prospective patients' stratification for clinical trials. Methods A retrospective, longitudinal analysis of prospectively collected neurological data from the European Multicenter study about Spinal Cord Injury (EMSCI) network was undertaken on C4-C6 cervical sensorimotor complete subjects. Predictors were based on a broad set of early (<2 weeks) clinical assessments. Endpoints were based on later clinical examinations of upper extremity motor scores and recovery of motor levels, at 6 and 12 months, respectively. Prediction accuracy for each statistical analysis was quantified by resampling techniques. Results For all settings, overlapping confidence intervals indicated similar prediction accuracy of unbiased recursive partitioning to established statistical approaches. In addition, unbiased recursive partitioning provided a direct way of identification of more homogeneous subgroups. The partitioning is carried out in a data-driven manner, independently from a priori decisions or predefined thresholds. Conclusion Unbiased recursive partitioning techniques may improve prediction of future clinical endpoints and the planning of future SCI clinical trials by providing easily implementable, data-driven rationales for early patient stratification based on simple decision rules and clinical read-outs.


Assuntos
Medula Cervical/lesões , Interpretação Estatística de Dados , /métodos , Índice de Gravidade de Doença , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/fisiopatologia , Extremidade Superior/fisiopatologia , Europa (Continente) , Humanos , Estudos Longitudinais , Prognóstico , Estudos Retrospectivos
19.
J Orthop Traumatol ; 11(3): 175-82, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20721596

RESUMO

BACKGROUND: In patients with myelomeningocele (MMC), a high number of fractures occur in the paralyzed extremities, affecting mobility and independence. The aims of this retrospective cross-sectional study are to determine the frequency of fractures in our patient cohort and to identify trends and risk factors relevant for such fractures. MATERIALS AND METHODS: Between March 1988 and June 2005, 862 patients with MMC were treated at our hospital. The medical records, surgery reports, and X-rays from these patients were evaluated. RESULTS: During the study period, 11% of the patients (n = 92) suffered one or more fractures. Risk analysis showed that patients with MMC and thoracic-level paralysis had a sixfold higher risk of fracture compared with those with sacral-level paralysis. Femoral-neck z-scores measured by dual-energy X-ray absorptiometry (DEXA) differed significantly according to the level of neurological impairment, with lower z-scores in children with a higher level of lesion. Furthermore, the rate of epiphyseal separation increased noticeably after cast immobilization. Mainly patients who could walk relatively well were affected. CONCLUSIONS: Patients with thoracic-level paralysis represent a group with high fracture risk. According to these results, fracture and epiphyseal injury in patients with MMC should be treated by plaster immobilization. The duration of immobilization should be kept to a minimum (<4 weeks) because of increased risk of secondary fractures. Alternatively, patients with refractures can be treated by surgery, when nonoperative treatment has failed.


Assuntos
Fraturas do Colo Femoral/epidemiologia , Fixação Interna de Fraturas/métodos , Imobilização/métodos , Meningomielocele/epidemiologia , Fraturas da Tíbia/epidemiologia , Adolescente , Distribuição por Idade , Análise de Variância , Placas Ósseas , Moldes Cirúrgicos , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Estudos Transversais , Feminino , Fraturas do Colo Femoral/diagnóstico por imagem , Fraturas do Colo Femoral/terapia , Seguimentos , Consolidação da Fratura/fisiologia , Humanos , Incidência , Escala de Gravidade do Ferimento , Modelos Logísticos , Extremidade Inferior/lesões , Masculino , Meningomielocele/diagnóstico , Radiografia , Estudos Retrospectivos , Medição de Risco , Distribuição por Sexo , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/terapia , Fatores de Tempo , Resultado do Tratamento
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