Conception and implementation of an MRI-compatible device to elicit the bulbocavernosus reflex for an open spinal cord study.

OBJECTIVE: Functional MRI (fMRI) can be employed to assess neuronal activity in the central nervous system. However, investigating the spinal cord using fMRI poses several technical difficulties. Enhancing the fMRI signal intensity in the spinal cord can improve the visualization and analysis of different neural pathways, particularly those involved in bladder function. The bulbocavernosus reflex (BCR) is an excellent method for evaluating the integrity of the sacral spinal cord. Instead of stimulating the glans penis or clitoris, the BCR can be simulated comfortably by tapping the suprapubic region. In this study, we explain the necessity and development of a device to elicit the simulated BCR (sBCR) via suprapubic tapping while conducting an fMRI scan. METHODS: The device was successfully tested on a group of 20 healthy individuals. Two stimulation task block protocols were administered (empty vs. full bladder). Each block consisted of 40 s of suprapubic tapping followed by 40 s of rest, and the entire sequence was repeated four times. RESULTS: Our device can reliably and consistently elicit sBCR noninvasively as demonstrated by electromyographic recording of pelvic muscles and anal winking. Participants did note mild to moderate discomfort and urge to void during the full bladder task. CONCLUSION: Our device demonstrates an efficacious approach to elicit sBCR within an MRI bore to assess sacral spinal cord functional activity without generating any significant motion artifacts. SIGNIFICANCE: This device can explore the mechanisms and processes controlling urinary, digestive, or sexual function within this region in humans.

Evaluating the impact of using a wound-specific oral nutritional supplement to support wound healing in a rehabilitation setting.

Chronic wounds adversely affect patient quality of life, increase the risk of mortality, and impose high costs on healthcare systems. Since protein-energy malnutrition or specific nutrient deficiencies can delay wound healing, nutritionally focused care is a key strategy to help prevent or treat the occurrence of non-healing wounds. The objective of our study of inpatients in a rehabilitation hospital was to quantify the effect of daily wound-specific oral nutritional supplementation (WS-ONS) on healing chronic wounds. Using electronic medical records, we conducted a retrospective analysis of patients with chronic wounds. We identified records for (a) a treatment group who received standard wound care + usual hospital diet + daily WS-ONS for ≥14 days, and (b) a control group who received standard wound care + a usual hospital diet. We collected data for demographics, nutritional status, and wound-relevant health characteristics. We examined weekly measurements of wound number and sizes (surface area for superficial wounds or volume for non-superficial wounds). There were 341 patients identified, 114 with 322 wounds in the treatment group and 227 patients with 420 wounds in the control group. We found that rehabilitation inpatients who were given nutritional support had larger wounds and lower functional independence on admission. At discharge, wound area reduction (percent) was nearly two-fold better in patients who were given daily WS-ONS + usual hospital diet compared to those who consumed usual diet only (61.1% vs 34.5%). Overall, weekly wound improvement (lowered wound area or wound volume) was more likely in the WS-ONS group than in the Control group, particularly from the start of care to week 2. Inpatients with largest wounds and lowest functional independence on admission were most likely to be given WS-ONS, an indication that caregivers recognised the need for supplementation. Week-to-week improvement in wound size was more likely in patients who received WS-ONS than in those who did not. Specifically, wound areas and wound volumes were significantly lower at discharge among patients who were given specialised nutritional support. More research in this field is needed to improve care and reduce healthcare costs.

The Effect of Early Infection on the Rate of Volitional Voiding after Spinal Cord Injury: A Potential Modifiable Risk Factor for Bladder Outcomes.

PURPOSE: Recently, it has been observed that early infections after spinal cord injury (SCI) are associated with decreased long-term motor and sensory recovery. We investigate the effects of early infection after SCI on long-term bladder function. MATERIALS AND METHODS: We assessed data for the years 1995 to 2006 using the National Spinal Cord Injury Database. Postoperative wound infections and pneumonia were used to classify infections during the acute inpatient and rehabilitation periods. The effect of early infections on volitional voiding status at 1-year followup was assessed. Age, gender and neurological status at rehabilitation discharge (level of injury, American Spinal Injury Association Impairment Scale [AIS] and bilateral lower extremity motor scores) were included in multivariate logistic regression modeling to control for confounding. RESULTS: Of the 3,561 persons studied, 1,233 (34.6%) had an early infection. Those with an infection during early recovery were less likely to void than their noninfected counterparts if in the AIS A (0.3% vs 1.9%, p=0.010), AIS B (3.8% vs 10.5%, p=0.018) and AIS C (29.1% vs 37.3%, p=0.071) classification, while those with less complete injuries (AIS D) did not appear to be affected (62.6% vs 65.4%, p=0.456). Similar findings were found when stratifying by lower extremity motor scores and persisted on multivariate analysis, where early infection decreased the odds of volitional voiding at 1-year followup (OR=0.79, p=0.042). CONCLUSIONS: Infections during the early recovery period may modify volitional voiding at 1-year followup by 20% or more. Future investigations to confirm our findings and potentially evaluate mitigation strategies are warranted.

Comparing outcomes of mechanical ventilation with high vs. moderate tidal volumes in tracheostomized patients with spinal cord injury in acute inpatient rehabilitation setting: a retrospective cohort study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The primary objective of this study was to evaluate safety and efficacy of higher tidal volumes (HVt) compared to moderate Vt (MVt) in people with spinal cord injury (SCI) admitted to acute inpatient rehabilitation (AIR) facility on mechanical ventilation via tracheostomy. SETTING: AIR facility in the United States. METHODS: Eighty-four adults with SCI were divided into MVt group if maximum Vt received in AIR was <15 ml/kg predicted body weight (PBW) and HVt group if maximum Vt was >15 ml/kg PBW. Primary outcomes were incidence of pneumonia and composite pulmonary adverse events (pneumonia, weaning failure, or acute care transfers due to respiratory complications). Secondary outcomes were AIR preweaning days defined as time from AIR admission to beginning of weaning, weaning days defined as days from start to end of weaning, and AIR ventilator days calculated as days on ventilator from AIR admission to discharge. RESULTS: MVt was utilized in 50 patients and HVt was utilized in 34 patients. The risk of pneumonia in HVt group was 4.3 times higher [95% confidence interval (CI): 1.5-12] compared to MVt group. Odds of pulmonary adverse events in HVt group was 5.4 times higher (CI: 1.8-17) compared to MVt group. There was no difference in preweaning days, weaning days, or AIR ventilator days between the two groups. CONCLUSIONS: Our data suggest that HVt is associated with increased risk of pneumonia and higher odds of pulmonary adverse events in tracheostomized patients with SCI which warrants further investigation.

Observations of Autonomic Variability Following Central Neuromodulation for Chronic Neuropathic Pain in Spinal Cord Injury.

BACKGROUND: Spinal cord injury (SCI) persons with chronic neuropathic pain (NP) demonstrate maladaptive autonomic profiles compared to SCI counterparts without NP (SCI - NP) or able-bodied (AB) controls. These aberrations may be secondary to maladaptive neuroplasticity in the shared circuitry of the pain neuromatrix-central autonomic network interface (PNM-CAN). In this study, we explored the proposed PNM-CAN mechanism in SCI + NP and AB cohorts following centrally-directed neuromodulation to assess if the PNM and CAN are capable of being differentially modulated. MATERIALS AND METHODS: Central neuromodulation was administered via breathing-controlled electrical stimulation (BreEStim), previously evidenced to operate at the PNM. To quantify CAN activity, conventional heart rate variability (HRV) recordings were used to gather time and frequency domain parameters of autonomic modulation. SCI + NP (n = 10) and AB (n = 13) cohorts received null and active BreEStim randomly in crossover fashion. HRV data were gathered pretest and 30 minutes posttest. Pain modulation was quantified at both time-points by visual analog scale (VAS) for SCI + NP persons and electrical detection and pain threshold levels (EDT, EPT) for AB persons. RESULTS: Following active BreEStim only, SCI + NP persons demonstrated increased parasympathetic tone (increased NN50, p = 0.03, and pNN50, p = 0.02, HRV parameters). This parasympathetic restoration was associated with analgesia (VAS reduction, p < 0.01). Similarly, AB persons demonstrated increased noxious tolerance (increased EPT, p = 0.03, with preserved EDL, p = 0.78) only following active BreEStim. However, this increased pain threshold was not associated with autonomic changes. CONCLUSIONS: Central modulation targeting the PNM produced autonomic changes in SCI + NP persons but not AB persons. These findings suggest that AB persons exhibit intact CAN mechanisms capable of compensating for PNM aberrations or simply that SCI + NP persons exhibit altered PNM-CAN machinery altogether. Our collective findings confirm the interconnectedness and maladaptive plasticity of PNM-CAN machinery in SCI + NP persons and suggest that the PNM and CAN circuitry can be differentially modulated.

The first 24 h: opioid administration in people with spinal cord injury and neurologic recovery.

STUDY DESIGN: Retrospective chart review. OBJECTIVES: The objective of this study was to characterize opioid administration in people with acute SCI and examine the association between opioid dose and (1) changes in motor/functional scores from hospital to rehabilitation discharge, and (2) pain, depression, and quality of life (QOL) scores 1-year post injury. SETTING: Spinal Cord Injury Model System (SCIMS) inpatient acute rehabilitation facility. METHODS: Patients included in the SCIMS from 2008 to 2011 were linked to the National Trauma Registry and the electronic medical record. Three opioid dose groups (low, medium, and high) were defined based on the total morphine equivalence in milligrams at 24 h. The associations between opioid dose groups and functional/motor outcomes were assessed, as well as 1-year follow-up pain and QOL surveys. RESULTS: In all, 85/180 patients had complete medication records. By 24 h, all patients had received opioids. Patients receiving higher amounts of opioids had higher pain scores 1 year later compared with medium- and low-dose groups (pain levels 5.5 vs. 4 vs. 1, respectively, p = 0.018). There was also an 8× greater risk of depression 1 year later in the high-dose group compared with the low-dose group (OR: 8.1, 95% CI: 1.2-53.7). In analyses of motor scores, we did not find a significant interaction between opioid dose and duration of injury. CONCLUSIONS: These preliminary findings suggest that higher doses of opioids administered within 24 h of injury are associated with increased pain in the chronic phase of people with SCI.

Safety, Feasibility, and Efficacy of Transcutaneous Tibial Nerve Stimulation in Acute Spinal Cord Injury Neurogenic Bladder: A Randomized Control Pilot Trial.

OBJECTIVES: We investigated whether transcutaneous tibial nerve stimulation (TTNS) in acute spinal cord injury was safe and feasible, and could achieve neuromodulation and improve cystometrogram parameters during acute inpatient rehabilitation. MATERIALS AND METHODS: Participants were consecutive acute traumatic spinal cord injury patients admitted for acute inpatient rehabilitation, randomized to a 2-week trial of TTNS v sham stimulation. Primary outcomes were safety and feasibility of TTNS and secondary outcomes were bladder measures based on pre- and post-TTNS cystometrogram by group and within groups, including bladder capacity, detrusor hyperreflexia, pressures, and detrusor-sphincter dyssynergia, as well as filling sensations and desire to void. The principle investigator and subjects were blinded to treatment allocation. RESULTS: A total of 19 subjects consented to the study and completed the stimulation protocol. Morbidity was similar between groups and compliance was 100% to the TTNS protocol. Based on a lack of rehabilitation interruptions and comments from staff, TTNS was feasible. Post-cystometrogram parameters were significant for lower volumes until sensation in the control group and prolonged volumes until sensation in the TTNS group. The control group had significant changes of increased detrusor-sphincter dyssynergia and decreased bladder capacity. This was not significantly changed in the TTNS group. CONCLUSIONS: TTNS is a safe and feasible modality that can be performed during inpatient rehabilitation of acute traumatic spinal cord injury. Bladder capacity and episodes of detrusor-sphincter dyssynergia significantly worsened in the control group and did not significantly change in the TTNS group, suggesting that TTNS can alter the course of neurogenic bladder via neuromodulation.

Experience of Robotic Exoskeleton Use at Four Spinal Cord Injury Model Systems Centers.

BACKGROUND AND PURPOSE: Refinement of robotic exoskeletons for overground walking is progressing rapidly. We describe clinicians' experiences, evaluations, and training strategies using robotic exoskeletons in spinal cord injury rehabilitation and wellness settings and describe clinicians' perceptions of exoskeleton benefits and risks and developments that would enhance utility. METHODS: We convened focus groups at 4 spinal cord injury model system centers. A court reporter took verbatim notes and provided a transcript. Research staff used a thematic coding approach to summarize discussions. RESULTS: Thirty clinicians participated in focus groups. They reported using exoskeletons primarily in outpatient and wellness settings; 1 center used exoskeletons during inpatient rehabilitation. A typical episode of outpatient exoskeleton therapy comprises 20 to 30 sessions and at least 2 staff members are involved in each session. Treatment focuses on standing, stepping, and gait training; therapists measure progress with standardized assessments. Beyond improved gait, participants attributed physiological, psychological, and social benefits to exoskeleton use. Potential risks included falls, skin irritation, and disappointed expectations. Participants identified enhancements that would be of value including greater durability and adjustability, lighter weight, 1-hand controls, ability to navigate stairs and uneven surfaces, and ability to balance without upper extremity support. DISCUSSION AND CONCLUSIONS: Each spinal cord injury model system center had shared and distinct practices in terms of how it integrates robotic exoskeletons into physical therapy services. There is currently little evidence to guide integration of exoskeletons into rehabilitation therapy services and a pressing need to generate evidence to guide practice and to inform patients' expectations as more devices enter the market.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A231).

Intensity dependent effects of transcranial direct current stimulation on corticospinal excitability in chronic spinal cord injury.

OBJECTIVE: To investigate the effects of anodal transcranial direct current stimulation (a-tDCS) intensity on corticospinal excitability and affected muscle activation in individuals with chronic spinal cord injury (SCI). DESIGN: Single-blind, randomized, sham-controlled, crossover study. SETTING: Medical research institute and rehabilitation hospital. PARTICIPANTS: Volunteers (N = 9) with chronic SCI and motor dysfunction in wrist extensor muscles. INTERVENTIONS: Three single session exposures to 20 minutes of a-tDCS (anode over the extensor carpi radialis [ECR] muscle representation on the left primary motor cortex, cathode over the right supraorbital area) using 1 mA, 2 mA, or sham stimulation, delivered at rest, with at least 1 week between sessions. MAIN OUTCOME MEASURES: Corticospinal excitability was assessed with motor-evoked potentials (MEPs) from the ECR muscle using surface electromyography after transcranial magnetic stimulation. Changes in spinal excitability, sensory threshold, and muscle strength were also investigated. RESULTS: Mean MEP amplitude significantly increased by approximately 40% immediately after 2mA a-tDCS (pre: 0.36 ± 0.1 mV; post: 0.47 ± 0.11 mV; P = .001), but not with 1 mA or sham. Maximal voluntary contraction measures remained unaltered across all conditions. Sensory threshold significantly decreased over time after 1mA (P = .002) and 2mA (P = .039) a-tDCS and did not change with sham. F-wave persistence showed a nonsignificant trend for increase (pre: 32% ± 12%; post: 41% ± 10%; follow-up: 46% ± 12%) after 2 mA stimulation. No adverse effects were reported with any of the experimental conditions. CONCLUSIONS: The a-tDCS can transiently raise corticospinal excitability to affected muscles in patients with chronic SCI after 2 mA stimulation. Sensory perception can improve with both 1 and 2 mA stimulation. This study gives support to the safe and effective use of a-tDCS using small electrodes in patients with SCI and highlights the importance of stimulation intensity.

Spinal cord injury medicine and rehabilitation.

The rehabilitation of spinal cord injury (SCI) is a complicated process, but one in which new research is developing novel and increasingly promising methods of restorative neurology. Spinal cord injury medicine addresses not only the neurologic injury, but all the secondary complications in other organ systems whose regulation is disrupted after SCI. To some degree, the rehabilitation of SCI is focused on return to the community and functional goals are paramount, regardless of whether they can be achieved through some mechanism of compensation or due to a growing effort at engendering neurologic plasticity and recovery. The authors present a typical case of cervical incomplete SCI and discuss the medical complications and considerations for care during acute rehabilitation. They also review current methods of planning and executing rehabilitation, along with emerging methods that are leading to, in varying degrees, greater neurologic recovery. Finally, new approaches in SCI rehabilitation, namely neuromodulation, are discussed as efforts are made to further augment neural plasticity and recovery in SCI.

Proteomics in orthopedic research: Recent studies and their translational implications.

Proteomics is a growing field that offers insights into various aspects of disease processes and therapy responses. Within the field of orthopedics, there are a variety of diseases that have a poor prognosis due to a lack of targeted curative therapy or disease modifying therapy. Other diseases have been difficult to manage in part due to lack of clinical biomarkers that offer meaningful insight into disease progression or severity. As an emerging technology, proteomics has been increasingly applied in studying bone biology and an assortment of orthopedics related diseases, such as osteoarthritis, osteosarcoma and bone tumors, osteoporosis, traumatic bone injury, spinal cord injury, hip and knee arthroplasty, and fragile healing. These efforts range from mechanistic studies for elucidating novel insights in tissue activity and metabolism to identification of candidate biomarkers for diagnosis, prognosis, and targeted treatment. The knowledge gained from these proteomic and functional studies has provided unique perspectives in studying orthopedic diseases. In this review, we seek to report on the current state of the proteomic study in the field of orthopedics, overview the advances in clinically applicable discoveries, and discuss the opportunities that may guide us for future research.

Exploring 5-minute heart rate variability in spinal cord injury during acute inpatient rehabilitation.

To explore the use of 5-minute heart rate variability (HRV) during inpatient rehabilitation in the acute phase of traumatic spinal cord injury (SCI).Longitudinal observational study.Acute inpatient rehabilitation (AIR).10 patients with acute traumatic SCI.5-minute HRV supine recordings twice daily on three different days per patient.HRV values were evaluated (1) within a single day (Early versus Late); (2) across the inpatient admission (initial, mid, and discharge); (3) by SCI phenotypes and by clinical outcomes (ex. pressure injuries (PI)).Patients had an average age of 38 years, 80% male, and 40% with tetraplegia. There were no HRV differences between Early and Late recordings, across the inpatient admission, demographics, or SCI phenotype. However, improvement in neurologic exam was accompanied by increased parasympathetic tone (mean RR increased by 172 ms SD 61, P = .005). Patients with PI demonstrated lower sympathetic (SNS) activity (decreased LF by 472 ms2 SD 240, P = .049) and lower PNS activity (decreased RMSSD by 1.2 ms SD 0.5, P = .02), compared to no PI. Comparisons to uninjured reference values and chronic SCI suggest a changing autonomic nervous system (ANS) from uninjured to acute to chronic as measured by HRV. CONCLUSIONS: This preliminary evidence suggests HRV in acute SCI is stable across time and day during inpatient rehabilitation and may be correlated to clinical sequalae of ANS dysfunction and neurologic recovery. Comparisons to published work suggest that HRV may measure the progression in the ANS from acute to chronic phase after SCI.

Trends in gender, race, and ethnic diversity among prospective physical medicine and rehabilitation physicians.

BACKGROUND: As the proportion of women and individuals who are underrepresented in medicine slowly rises, disparities persist in numerous arenas and specialties. In physical medicine and rehabilitation (PM&R), there is a continued need to focus on diversity among trainees. This study aims to evaluate diversity among PM&R applicants and residents over the past 6 years. OBJECTIVE: To describe the demographic trends in PM&R over the last 6 years and compare those findings with trends in other specialties. DESIGN: Surveillance. SETTING: Analyses of national databases from self-reported questionnaires. PARTICIPANTS: The study consists of 126,833 medical school matriculants, 374,185 resident applicants, and 326,134 resident trainees over the last 6 years. MAIN OUTCOME MEASURES: Self-reported demographic data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education were analyzed for medical school matriculants, PM&R applicants, and current residents for the cycles of 2014-2015 to 2019-2020. The data were then comparatively reviewed between PM&R and other medical specialties. RESULTS: In the 6 cycles evaluated, women accounted for 36%-39% of PM&R residents, but 47%-48% in non-PM&R specialties. Women applicants to the PM&R specialty averaged 34.4% over the 6 years analyzed, which was the fourth lowest of the 11 specialties examined. Black or African American and Hispanic, Latino, or of Spanish Origin populations each accounted for only 6% of PM&R residents. PM&R demonstrated a noticeably higher proportion of White (62.1% vs. 60.3%) and an observably lower proportion of Black or African American (6.0% vs. 7.1%) and Hispanic, Latino, or of Spanish Origin (6.3% vs. 7.9%) residents compared with non-PM&R specialties. CONCLUSION: There is underrepresentation of women and multiple racial and ethnic minority groups in the field of PM&R from applicants to trainees demonstrating a need to improve recruitment efforts.

Phenol neurolysis in people with spinal cord injury: a descriptive study.

STUDY DESIGN: Descriptive study. OBJECTIVES: The study's main objective was to describe the common targets of phenol neurolysis and review the safety and efficacy of the dose used for this spasticity management procedure in people with spinal cord injury (SCI). SETTING: An acute rehabilitation hospital. METHODS: Data from people with SCI who underwent phenol neurolysis procedures for spasticity management between April 2017 and August 2018 were included in this study. We collected demographics and phenol neurolysis procedure-related information. RESULTS: A total of 66 people with SCI and spasticity underwent phenol neurolysis of 303 nerves over 102 encounters. During these encounters, 97% of procedures were performed using both electrical stimulation and ultrasound guidance. The median (IQR) total volume of 6% aqueous phenol used per encounter was 4.0 (2.0-6.0) ml with a median (IQR) of 1.5 (1.0-2.3) ml per nerve. The most frequent target was the obturator nerve (33%), followed by the pectoral nerves (23%). Immediate post-phenol neurolysis improvement or reduction in spasticity was reported for 92% of all documented encounters. There was no documentation of any post-procedure-related adverse events in this cohort during this specified time frame. CONCLUSIONS: Our findings suggest that phenol neurolysis can be safely used to manage spasticity in people with SCI under combined electrical stimulation and ultrasound guidance. Further research is required to assess the procedure's safety, efficacy, and cost-effectiveness on patient-reported outcomes compared to other spasticity interventions.

Factors Associated With Ventilator Weaning Success and Failure in People With Spinal Cord Injury in an Acute Inpatient Rehabilitation Setting: A Retrospective Study.

Objectives: To evaluate baseline characteristics, describe pulmonary outcomes, and identify weaning predictors for people with acute traumatic spinal cord injury (SCI) who are dependent on mechanical ventilation at admission to acute inpatient rehabilitation (AIR). Methods: The retrospective study was conducted at an AIR facility in the United States. It included 91 adults with acute traumatic SCI from 2015 to 2019 who were dependent on mechanical ventilation. Results: People who successfully weaned (85%) had fewer days from time of SCI to AIR admission (22 vs. 30, p = .04), higher vital capacity at admission to AIR (12 vs. 3 mL/kg predicted body weight [PBW]; p < .001), and lower (caudal) neurological injury level (p < .001) compared to those who failed weaning. The risk of pneumonia was higher in people who failed weaning compared to those who were weaned successfully (risk ratio, 5.5; 95% confidence interval [95% CI], 2.3-13). Receiver operating characteristics (ROC) curves suggest a vital capacity cutoff of 5.8 mL/kg PBW could predict weaning. The vital capacity of ≥ 5.8 mL/kg PBW is associated with 109 times higher odds (95% CI, 11-1041; p < .001) of weaning than vital capacity below that threshold. Conclusion: In this retrospective study, there was an increased risk of pneumonia in people with SCI who failed weaning at discharge from AIR. Vital capacity was a better predictor of weaning from mechanical ventilation compared to the neurological level of injury, with a cutoff of 5.8 mL/kg PBW predictive of weaning success. Further research is needed on this critical topic.

Evidence of treating spasticity before it develops: a systematic review of spasticity outcomes in acute spinal cord injury interventional trials.

INTRODUCTION: Spasticity is a common consequence of spinal cord injury (SCI), estimated to affect up to 93% of people living with SCI in the community. Problematic spasticity affects around 35% people with SCI spasticity. The early period after injury is believed to be the most opportune time for neural plasticity after SCI. We hypothesize that clinical interventions in the early period could reduce the incidence of spasticity. To address this, we evaluated the spasticity outcomes of clinical trials with interventions early after SCI. METHODS: We performed a systematic review of the literature between January 2000 and May 2021 to identify control trials, in humans and animals, that were performed early after SCI that included measures of spasticity in accordance with PRISMA guidelines. RESULTS: Our search yielded 1,463 records of which we reviewed 852 abstracts and included 8 human trial peer-reviewed publications and 9 animal studies. The 9 animal trials largely supported the hypothesis that early intervention can reduce spasticity, including evidence from electrophysiological, behavioral, and histologic measures. Of the 8 human trials, only one study measured spasticity as a primary outcome with a sample size sufficient to test the hypothesis. In this study, neuromodulation of the spinal cord using electric stimulation of the common peroneal nerve reduced spasticity in the lower extremities compared to controls. CONCLUSION: Given the prevalence of problematic spasticity, there is surprisingly little research being performed in the early period of SCI that includes spasticity measures, and even fewer studies that directly address spasticity. More research on the potential for early interventions to mitigate spasticity is needed.

Fighting for recovery on multiple fronts: The past, present, and future of clinical trials for spinal cord injury.

Through many decades of preclinical research, great progress has been achieved in understanding the complex nature of spinal cord injury (SCI). Preclinical research efforts have guided and shaped clinical trials, which are growing in number by the year. Currently, 1,149 clinical trials focused on improving outcomes after SCI are registered in the U.S. National Library of Medicine at ClinicalTrials.gov. We conducted a systematic analysis of these SCI clinical trials, using publicly accessible data downloaded from ClinicalTrials.gov. After extracting all available data for these trials, we categorized each trial according to the types of interventions being tested and the types of outcomes assessed. We then evaluated clinical trial characteristics, both globally and by year, in order to understand the areas of growth and change over time. With regard to clinical trial attributes, we found that most trials have low enrollment, only test single interventions, and have limited numbers of primary outcomes. Some gaps in reporting are apparent; for instance, over 75% of clinical trials with "Completed" status do not have results posted, and the Phase of some trials is incorrectly classified as "Not applicable" despite testing a drug or biological compound. When analyzing trials based on types of interventions assessed, we identified the largest representation in trials testing rehab/training/exercise, neuromodulation, and behavioral modifications. Most highly represented primary outcomes include motor function of the upper and lower extremities, safety, and pain. The most highly represented secondary outcomes include quality of life and pain. Over the past 15 years, we identified increased representation of neuromodulation and rehabilitation trials, and decreased representation of drug trials. Overall, the number of new clinical trials initiated each year continues to grow, signifying a hopeful future for the clinical treatment of SCI. Together, our work provides a comprehensive glimpse into the past, present, and future of SCI clinical trials, and suggests areas for improvement in clinical trial reporting.

Demographics and Durable Medical Equipment Needs of Persons With Disabilities in a Charitable Rehabilitation Clinic.

ABSTRACT: This study characterizes the demographics and durable medical equipment needs of persons with disabilities to improve utilization and management of resources at a philanthropic rehabilitation clinic. Paper charts from all encounters between 2013 and 2018 were reviewed. Data collected include sex, age, ethnicity, insurance status, diagnoses, and durable medical equipment requested/received. Paper charts that were incomplete or illegible were excluded. Among 763 individuals, there were 1157 encounters for durable medical equipment requests. Forty-six percent of individuals were uninsured. Thirty-seven percent had federal insurance such as Medicare or Medicaid, and 6% private insurance. Fifty-five percent of individuals were Hispanic, 28% African American, and 14% White. Fifty-six percent of encounters were with individuals with a neurological diagnosis, 18% medical diagnosis, 17% musculoskeletal/autoimmune diagnosis, 6% amputation diagnosis, and 3% cancer diagnosis. Of the 2680 items distributed, 34% were wheelchair parts and repair, 30% personal hygiene/incontinence supplies, 25% mobility equipment, and 11% bathroom equipment. Of the 513 unmet items requested, 49% were mobility equipment, 24% wheelchair parts and repair, 17% personal hygiene/incontinence supplies, and 11% bathroom equipment. More than a third (43%) of durable medical equipment requests were from individuals with either private insurance or federal payers, which implies lack of adequate coverage on durable medical equipment to maintain mobility and independence.

CMAP Scan Examination of the First Dorsal Interosseous Muscle After Spinal Cord Injury.

The study assessed motor unit loss in muscles paralyzed by spinal cord injury (SCI) using a novel compound muscle action potential (CMAP) scan examination. The CMAP scan of the first dorsal interosseous (FDI) muscle was applied in tetraplegia (n = 13) and neurologically intact (n = 13) subjects. MScanFit was used for estimating motor unit numbers in each subject. The D50 value of the CMAP scan was also calculated. We observed a significant decrease in both CMAP amplitude and motor unit number estimation (MUNE) in paralyzed FDI muscles, as compared with neurologically intact muscles. Across all subjects, the CMAP (negative peak) amplitude was 8.01 ± 3.97 mV for the paralyzed muscles and 16.75 ± 3.55 mV for the neurologically intact muscles (p < 0.001). The CMAP scan resulted in a MUNE of 59 ± 37 for the paralyzed muscles, much lower than 108 ± 21 for the neurologically intact muscles (p < 0.001). No significant difference in D50 was observed between the two groups (p = 0.2). For the SCI subjects, there was no significant correlation between MUNE and CMAP amplitude, or any of the clinical assessments including pinch force, grip force, the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) score, and SCI duration (p > 0.05). The findings provide an evidence of motor unit loss in the FDI muscles of individuals with tetraplegia, which may contribute to weakness and other hand function deterioration. The CMAP scan offers several practical benefits compared with the traditional MUNE techniques because it is noninvasive, automated and can be performed within several minutes.

Assessing redistribution of muscle innervation zones after spinal cord injuries.

This study aimed to examine the redistribution of neuromuscular junctions or innervation zones (IZs) after spinal cord injuries (SCI). Fifteen able-bodied subjects and 15 subjects with SCI (American Spinal Injury Association Impairment Scale A to D), participated in the study. Surface electromyography (EMG) signals were collected from the biceps brachii muscle by a customized linear electrode array when subjects generated maximal isometric voluntary contractions. The Radon transform was applied to detect the IZ locations in the multiple channel surface EMG signals which were differentiated between consecutive channels. The distribution of IZs was compared between the SCI and control groups using the student-t test. Statistical analysis disclosed a significantly wider range of IZs in the SCI group compared with the control group (SCI: 3.83 ± 1.32 IED, control: 2.83 ± 0. 87 IED, IED: inter-electrode distance, p < 0.05). No remarkable shifts of the center of the distribution were observed between the two groups (SCI: 9.23 ± 2.35 IED, control: 8.53 ± 2.33 IED, p = 0.42). Changes of IZ distribution in the paralyzed muscles could be associated with the complex neuromuscular reorganization after the SCI.