Development of an Objective Test of Upper-Limb Function in Tetraplegia

Reorganization of spinal neural circuitry and functional recovery after spinal cord injury

Purpose The purpose of this study was to translate and cross-culturally adapt the UEFI into Modern Standard Arabic language and to examine its psychometric properties among patients with upper extremity musculoskeletal disorders. Materials and Methods Translation and cross-cultural adaptation were done following Beaton’s guidelines. Internal consistency, test-retest reliability, measurement error and floor and ceiling effects for the Arabic UEFI were tested among 109 patients with upper extremity musculoskeletal disorders. Construct validity of the Arabic UEFI was also examined. Results Translation and cross-cultural adaptation processes were generally smooth with no major issues. The Arabic UEFI was considered appropriate and comprehensible by the participants. Internal consistency for Arabic UEFI was adequate (Cronbach's alpha = 0.96). Test-retest reliability for Arabic UEFI was excellent with ICC2,1=0.92. Measurement error was acceptable with a standard error of measurement of 5.5 and minimal detectable change of 12.8 points. Arabic UEFI shows no floor or ceiling effects. The results supported the majority of the construct validity predefined hypotheses (78%) supporting the construct validity of Arabic UEFI as a measure of upper extremity function. Conclusion The Arabic UEFI is an appropriate, valid and reliable outcome measure for Arabic-speaking patients with upper extremity musculoskeletal disorders. Implication for Rehabilitation: The Arabic UEFI is an acceptable, clear and comprehensible outcome measure. The Arabic UEFI has excellent internal consistency, test-retest reliability, and acceptable measurement error with no floor and ceiling effects. The Arabic UEFI is a valid measure of upper extremity activity limitation.

Loss of lower limb motor functions is among the most commonly seen effects of spinal cord injuries (SCI). Even with the current modern medical care, SCI patients require intense care at high expense. Animal models used for research on SCI may help develop better and lower cost therapies. It is well known that neonatal rats with complete SCI are capable of generating autonomous lumbar stepping, some even achieve independent weight support when tested as adults. On the contrary, rats injured at adult ages have limited recovery after a complete spinal cord injury. What can account for the difference? We hypothesized that neonatal and adult SCI animals' muscle synergy patterns were distinguished from each other and from the intacts'. Although sharing a lot of similarity, compared to the adult SCI animals, neonatal SCI animals had less synergies merging. Some xiv individual synergies of the neonatal SCIs' might resemble the intact animals more than adult SCIs'. To test the hypothesis, we examined the muscle synergy pattern using locomotor electromyography (EMG) in adult animals injured as neonates (T9/10 complete SCI, n=9), intact adult rats (n=12) and the same adult rats 10~14 days after T9/10 complete SCI (n=9). We found that adult SCI animals' synergies tended to merge post injury compared to the intact animals. The intacts also deviated from the neonatal and adult SCI animals regarding the correlation of all the synergies and individual synergy to a common synergy template. While sharing some similarity, in some individual synergies' correlation values to the common template, the neonatal animals were more similar to the adult SCIs shortly after injury than to the intacts. The neonatal synergies appeared to be preserved into adulthood and revealed after adult SCI. If given systematical training, would the synergies of adult SCI animals change with function? And if they do, would the change be the same regardless of the rehabilitation paradigms and recovery outcome? In order to answer these questions, we studied the synergy changes following robot-driven epidural stimulation combined with treadmill training (ES) and robotic assisted treadmill only (TM) systematic long-term training and we compared these to the animals resting in the cage after complete adult SCI. We hypothesized that synergies would tend to merge right after injury. As time went by after injury, the synergies' spatial structure would be simplified. However, with successful rehabilitation, the further merging and simplification of the synergies were avoided. To investigate the only (TM) systematic long-term training and we compared these to the animals resting in the cage after complete adult SCI. We hypothesized that synergies would tend to merge right after injury. As time went by after injury, the synergies' spatial structure would be simplified. However, with successful rehabilitation, the further merging and simplification of the synergies were avoided. To investigate the synergies' relationship to therapeutic methods and efficacy, we trained three groups of animals with ES training, TM training and in cage resting respectively. We examined their synergies through 8 weeks' rehabilitation period. ES and TM training showed beneficial effects on recovery after SCI. Synergy changes were linked with functional locomotion recovery. Unlike cage resting, the effective training harnessed and separated the synergies merging post injury and each synergy ended with more refined spatial patterns. However, although both ES and TM helped SCI animals recovered successfully, their underlying neural mechanisms were not the same in terms of synergy changes. Our study suggested that the TM training likely did not reverse the merging process to the extent that the ES training did.

New treatments are being investigated for spinal cord injury (SCI), and any improvement may result in incremental cost savings. The objective of this study was to determine the direct costs of care 2 years after an SCI, stratifying for completeness and level of injury. A retrospective database analysis was carried out using data from the Quebec Trauma Registry, the Quebec Medical Insurance Board, and the Quebec Automobile Insurance Corporation between 1997 and 2007. Excluding individuals sustaining moderate or severe traumatic brain injuries, 481 individuals who sustained an SCI from motor vehicle accidents were identified. Individuals were classified as complete and incomplete in the following categories: C1-C7, C8-T6, T7-L1, L2-S5. Using data from governmental public healthcare organizations makes this study comprehensive. For C1-C7 complete and incomplete spinal cord injuries, the first-year cost was $157 718 and $56 505, respectively (2009 Canadian dollars calculated per patient). Similar differences between complete and incomplete spinal cord injuries were seen for the other groups. Furthermore, for complete injuries, costs were higher for higher levels of injury during both the first and the second year after injury. For incomplete lesions, costs did not differ significantly between groups during the first or the second year. Incomplete spinal cord injuries result in lower healthcare costs compared with complete injuries across all groups during the first 2 years after injury. As less severe levels of injury result in measurably lower costs, the funds spent to reduce the severity or level of SCI could at least partially be recouped through healthcare savings.

Cross-sectional study of patients with whiplash-associated disorders investigating the internal consistency, factor structure, response rates, and presence of floor and ceiling effects of the Whiplash Disability Questionnaire (WDQ). The aim of this study was to confirm the appropriateness of the proposed WDQ items. Whiplash injuries are a common cause of pain and disability after motor vehicle accidents. Neck disability questionnaires are often used in whiplash studies to assess neck pain but lack content validity for patients with whiplash-associated disorders. The newly developed WDQ measures functional limitations associated with whiplash injury and was designed after interviews with 83 patients with whiplash in a previous study. Researchers sought expert opinion on items of the WDQ, and items were then tested on a clinical whiplash population. Data were inspected to determine floor and ceiling effects, response rates, factor structure, and internal consistency. Packages of questionnaires were distributed to 55 clinicians, whose patients with whiplash completed and returned 101 questionnaires to researchers. No substantial floor or ceiling effects were identified on inspection of data. The overall floor effect was 12%, and the overall ceiling effect was 4%. Principal component analysis identified one broad factor that accounted for 65% of the variance in responses. Internal consistency was high; Cronbach's alpha = 0.96. Results of the study supported the retention of the 13 proposed items in a whiplash-specific disability questionnaire. Dependent on the results of further psychometric testing, the WDQ is likely to be an appropriate outcome measure for patients with whiplash.

Care for patients with cerebral palsy (CP) poses significant challenges, with emphasis on the crucial role of family involvement in patients' well-being. The Family Empowerment Scale (FES) assesses parents/caregivers' perception of their ability to promote and influence their children's development in three domains: family, service system and community. The objectives of this study were to translate the FES into Brazilian Portuguese, to develop a calculator for data transformation and analysis and to evaluate the psychometric properties of the scale with Brazilian caregivers of children and adolescents with CP. Translation occurred in four stages: translation, synthesis, back-translation and review of the translated version. A calculator was then developed in the Excel program, to present data in absolute values and graphically for each subscale. Statistical analysis included Bland-Altman, Intraclass Correlation Coefficient (ICC), Internal Consistency, and Floor and Ceiling Effect. In total, 50 parents and caregivers participated to the measurement properties investigation, and the scale demonstrated good reliability for the family (ICC = 0.80) and services (ICC = 0.81) subscales, as well as for the overall scale (ICC = 0.88). The community subscale showed moderate reliability (ICC = 0.68), with an adequate Cronbach's alpha (0.89). The FES showed no ceiling or floor effects and a small limit of agreement. The data of all participants were analysed using the calculator. The FES-Brazilian Portuguese presented good reliability for assessing family empowerment in caregivers of children and adolescents with CP in Brazil, offering insights into this construct and guiding family-centred interventions. In addition, the calculator could be viable for adequate management and dissemination of data.

BACKGROUND Technology-assisted and robotic rehabilitation methods are increasingly used. Still, scarce evidence exists on their effects on upper extremity functioning after spinal cord injury. OBJECTIVE To evaluate the effects and feasibility of a 6-week intervention focusing on technology-assisted upper extremity rehabilitation in adults with incomplete cervical spinal cord injury (SCI). METHODS In this pilot randomized controlled crossover trial, 20 participants (10 men, 34–73 years of age, 1–8 years since SCI) were recruited by mail and randomized into two sequences (AB, n=10 and BA, n=10). All participants received a 6-week rehabilitation intervention during Period 1 or Period 2. The intervention was delivered 3 times a week for 6 weeks (18 sessions) by occupational therapists specialized in spinal cord injuries and neurorehabilitation. Each 1-hour rehabilitation session included a minimum of 30 minutes of technology-assisted rehabilitation using AMADEO®, DIEGO®, and/or PABLO® devices. Other occupational therapy activities were allowed to complete the session. The effects of the 6-week rehabilitation intervention were compared to 6 weeks of no-intervention. Analyses were based on paired data. Each participant served as their own control. Hand and arm function were evaluated using the Action Research Arm Test, the American Spinal Injury Association – Upper Extremity Motor Score (ASIA-UEMS), grip strength, pinch strength, and the Spinal Cord Independence Measure – Self Report, and rehabilitation goal attainment by the Goal Attainment Scale (GAS). Face-to-face assessments were conducted at baseline, after Period 1, after Period 2, and at 6 months, except for the GAS, that was used at the beginning and immediately after the rehabilitation intervention. RESULTS The rehabilitation intervention showed good feasibility and tolerability in adults with incomplete cervical spinal cord injury. Of 20 (10+10) participants (median age 62, IQR 58–66), 19 enrolled in the study, and 17 completed at least 80% of the rehabilitation sessions. Fourteen out of 16 participants included in the final analysis attained their rehabilitation goals. The goals were mainly focusing on “fine hand use”, and “hand and arm use” related to self-care and domestic life. The effects of the rehabilitation intervention did not differ from no-intervention, except for the ASIA-UEMS in participants (n=7) who received the rehabilitation during Period 2. The sum score change of participants in Sequence BA was median 0 (-2–0) after no-intervention and 1 (0–2) after the rehabilitation intervention (P=.04). CONCLUSIONS Results of this pilot study suggest that technology-assisted upper extremity rehabilitation provided by occupational therapists is safe and has potential for broader clinical use in adults with incomplete cervical spinal cord injury. The rehabilitation intervention showed good feasibility and positive outcomes, especially in rehabilitation goal attainment. Still, the results need to be confirmed in a larger randomized controlled trial. CLINICALTRIAL ClinicalTrials.gov NCT04760470

Validation of an updated patient-reported outcomes questionnaire for sacral tumors.

Individuals With Prior Chronic Pain and Long-Term Opioid Treatment May Experience Persistence of That Pain Even After Subsequent Complete Cervical Spinal Cord Injury: Suggestions From a Prospective Case-Controlled Study

Mixed methods cohort study. To develop and assess psychometric properties of the pediatric measure of participation (PMoP) short forms (SF) version 2.0. Secondary analyses of data collected from 381 children with spinal cord injury (SCI) of at least 3-month duration living in the community, and 322 parents of children with SCI at three pediatric orthopedic hospitals in the United States. Mixed methods iterative process to customize SF based on, highly relevant items, age and school analysis of item distributions; ceiling and floor effects; internal consistency and group-level reliability; correlation of SF scores with scores derived from the total item bank; and assessment of the degree to which item difficulty matched the abilities of children in the sample. PMoP SF V2.0 mean T scores ranged from 47.59 to 51.23. Overall, mean scores were somewhat higher for older children and parent respondents. Group-level reliability values ranged from 0.66 to 0.79; Cronbach's alpha values ranged from 0.79 to 0.90; ICC values ranged from 0.89 to 0.95. Pearson Correlations ranged from 0.80 to 0.95, showing good to strong correlation between scores from the SFs and total item bank for each domain. Test information function demonstrated that score estimates will be less precise at higher ends of the scale. PMoP SFs V2.0 contain items relevant to participation among children with SCI, and are tailored for four age groups and school status. They are recommended for use when computer adaptive testing (CAT) is not possible.

Background:The spinal cord injury quality-of-life questionnaire (SCIQL-23) is an instrument that has been developed for clinical follow-up as well health related quality-of-life (QOL) measurement in people with spinal cord injury (SCI). The purpose of this study was to assess the validity and reliability of the Persian version of SCIQL-23 in individuals with chronic SCI.Materials and Methods:Medical outcomes study 36 item short-form health survey (SF-36) as well as the Persian version of the SCIQL-23 questionnaires applied to be used in 52 veterans with spinal cord injuries in the Orthopedic Research Center, Mashhad University of Medical Sciences from January 2011 to August 2011. Cronbach's alpha co-efficient computed to test the reliability of the survey. In order to assess the convergent validity the correlation of each item of the SCIQL-23 done with each dimension of the SF-36 by applying the Pearson correlation co-efficient. Independent samples t-test used to test power of discrimination.Results:All of veterans were male and married. The mean age of individuals at the time of interview was 49.3 years (standard deviation = 7.9); in a range between 38 and 80 years. Most of them (88.5%) had incomplete paraplegia. Cronbach's alpha test revealed strong reliability in questions of SCI QOL (Total Cronbach's alpha = 0.764). A negative significant correlation occurred between physical function and functioning (FUNC) (r = −0.412**), bodily pain and problems related to injury (PROB) (r = −0.313*), vitality (VT) and mood state (MOOD) (r = −0.327*), social function and PROB (r = −0.309*), mental health (MH) and MOOD (r = −0.406**). Furthermore, the Mental component summary (MCS) of SF-36 had a negative significant correlation with MOOD (r = −0.312*). Similar to MCS, physical component summery (PCS) had a negative significant correlation with MOOD (r = −0.276*) in addition to FUNC (r = −0.324*) and PROB (r = −0.318*). Instead, GH (r = 0.455**), VT (r = 0.322*), MH (r = 0.276*) and PCS illustrated a positive significant correlation with global quality of life.Conclusion:The Persian version of the SCQL-23 discovered to be competent in terms of its valuable psychometric properties in assessing the QOL of SCI people by showing excellent internal consistency and no floor or ceiling effect.

This study aims to translate and cross-culturally adapt the Moroccan version of the Quebec Back Pain Disability Scale (QDS) and to investigate its reliability and validity in Moroccan patients with low back pain (LBP). The translation and cross-cultural adaptation of the QDS were developed in agreement with published guidelines. The QDS was translated by use of the forward and backward translation procedure. After pretest, it was validated in 64 Moroccan patients with LBP. The QDS was recorded twice, at baseline visit and 72h later. Reproducibility was evaluated using intraclass correlation coefficient (ICC) and Bland and Altman method. Internal consistency was measured by Cronbach α coefficient. Ceiling and floor effects were assessed. Validity was measured by correlating the scores of the Moroccan QDS with visual analogue scale (VAS) for Pain, Disability VAS, Schober test, fingertip-floor measurement and the Moroccan version of the Roland Morris Disability Questionnaire (RMDQ) by means of the Spearman rank correlation coefficient. Association with gender and education level was also studied. Reliability was excellent with an ICC (type 2.1) of 0.959 (CI 95%: 0.934-0.975). The internal consistency was high with a Cronbach α of 0.979. The Bland and Altman method showed homogenous distribution of the differences, with no systematic trend. There were no floor or ceiling effects. The correlation between QDS and RMDQ was very good (r = 0.664; p ≤ 0.001). There was no correlation between QDS and the other variables. Accordingly, the Moroccan version of QDS has good reproducibility, internal consistency and validity for the assessment of disability in Moroccan-speaking patients with LBP.

Stem cells and biomaterials transplantation hold a promising treatment for functional recovery in spinal cord injury (SCI) animal models. However, the functional recovery of complete SCI patients was still a huge challenge in clinic. Additionally, there is no clinical standard procedure available to diagnose precisely an acute patient as complete SCI. Here, two acute SCI patients, with injury at thoracic 11 (T11) and cervical 4 (C4) level respectively, were judged as complete injury by a stricter method combined with American Spinal Injury Association (ASIA) Impairment Scale, magnetic resonance imaging (MRI) and nerve electrophysiology. Collagen scaffolds, named NeuroRegen scaffolds, with human umbilical cord mesenchymal stem cells (MSCs) were transplanted into the injury site. During 1 year follow up, no obvious adverse symptoms related to the functional scaffolds implantation were found after treatment. The recovery of the sensory and motor functions was observed in the two patients. The sensory level expanded below the injury level, and the patients regained the sense function in bowel and bladder. The thoracic SCI patient could walk voluntary with the hip under the help of brace. The cervical SCI patient could raise his lower legs against the gravity in the wheelchair and shake his toes under control. The injury status of the two patients was improved from ASIA A complete injury to ASIA C incomplete injury. Furthermore, the improvement of sensory and motor functions was accompanied with the recovery of the interrupted neural conduction. These results showed that the supraspinal control of movements below the injury was regained by functional scaffolds implantation in the two patients who were judged as the complete injury with combined criteria, it suggested that functional scaffolds transplantation could serve as an effective treatment for acute complete SCI patients.

IntroductionMore knowledge of the relationships between kinematic measures and clinical assessments is required to guide clinical decision making and future research.ObjectivesTo determine which kinematic variables obtained during a drinking task were associated with clinical assessments of upper extremity functioning in people with spinal cord injury (SCI).MethodsIn total, 25 individuals with chronic cervical (n = 17) or thoracic (n = 8) complete (n = 14) or motor incomplete (n = 11) SCI (mean age 58.4, SD 13.8) were included. Kinematic data, including movement time, smoothness and joint angles was captured with a 5-camera optoelectronic system during a unimanual drinking task. Action Research Arm Test (ARAT), Sollerman Hand Function Test (SHFT) and basic hand classification of the Upper Extremity Data Set (ISCI-Hand) were used as clinical assessments. Multiple regression analysis was used to identify kinematic variables associated with clinical assessments after controlling for potential confounding factors, such as, age, severity of SCI, sensory function, and hand surgery.ResultsMovement time, smoothness and movement pattern kinematics including trunk displacement, elbow and wrist joint angles were correlated (p < 0.05) with all three clinical scales while the velocity-related kinematics and inter-joint coordination showed low correlations. Multiple regression analysis revealed that wrist angle combined with movement time or smoothness explained 82% and 77% of the total variance in ARAT and SHFT, respectively. Wrist angle alone explained 59% of the variance in ISCI-Hand. The proprioception of the hand increased the explanatory power in the models of ARAT and SHFT. Associations between kinematics and clinical assessments in the subgroup with cervical SCI were equivalent to the whole group analyses. The number of participants in the subgroup with thoracic SCI was small and only allowed limited analysis.ConclusionsWrist angle, movement time, movement smoothness are the most important kinematic variables associated with upper extremity clinical assessments in people with SCI. The results are most valid for individuals with cervical SCI. All three assessments are appropriate for SCI. Further research with larger representative sample of thoracic SCI needed.

A novel paired associative stimulation protocol with a high-frequency peripheral component: review of results in spinal cord injury rehabilitation. (Part of the symposium "Navigated TMS - based techniques in rehabilitation of motor function: diagnostics, prognostics, therapy", ID 14)