Psychological or physiological

Femoral Bone Marrow Adiposity and Cortical Bone Cross‐Sectional Areas in Men With Motor Complete Spinal Cord Injury

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.

What is the central question of this study? The aim was to determine whether the reflex inhibition in the electromyographic activity of scalene muscles in response to inspiratory muscle loading is present in individuals with cervical spinal cord injury and to examine whether the intercostal muscle afferents are critical for genesis of the reflex. What is the main finding and its importance? The lack of reflex inhibition in response to inspiratory loading in individuals with complete cervical spinal cord injury suggests that the reflex critically requires input from intercostal afferents and/or an intact intersegmental neural network. In healthy individuals, transient loading of inspiratory muscles with a brief inspiratory occlusion produces a short-latency inhibitory response (IR) in the electromyographic activity of scalene muscles at ∼40 ms, followed by an excitatory response (ER). It has been argued that this reflex plays a protective role in neuromuscular control of the inspiratory muscles and that it is co-ordinated by spinal segmental or supraspinal circuits. In this study, the reflex response to airway occlusion was recorded bilaterally from scalene muscles in 14 subjects and from the right costal diaphragm in seven subjects with spinal cord injury [SCI, C4-C6; American Spinal Injury Association (ASIA) Impairment Scale (AIS) A]. The incidence, latency and size of the reflex were compared with previously published data from able-bodied subjects. Only two subjects with SCI showed an IR, and six subjects had an ER. Latencies to the onset and peak of the IR and ER were 5-50 ms longer than in able-bodied subjects. However, when reflexes were identified, their size in individuals with SCI was similar to that of control subjects. We conclude that afferents from the scalene muscles and diaphragm are insufficient in most subjects with SCI to evoke the usual inhibition to airway occlusion and that input from chest wall afferents below the spinal cord lesion may be important for genesis of the short-latency inhibition in the able-bodied subjects.

Controlled, laboratory-based analysis. To determine the impact of spinal cord injuries (SCIs) on the ability to achieve male orgasm. US academic medical center. A laboratory-based analysis of the ability of 45 men with SCIs and 16 able-bodied control subjects to achieve orgasm coupled with a detailed neurologic examination, history and physical examination, and administration of the International Index of Erectile Function. Men with SCIs were less likely than controls to achieve orgasm. Mean latency to orgasm, blood pressure and heart rates at orgasm were not significantly different between controls and SCI subjects. Men with incomplete SCIs were more likely to achieve orgasm than those with complete SCIs. A disconnect was noted between the presence of orgasm and the presence of ejaculation. Men with complete lower motor neuron dysfunction affecting their sacral segments were less likely to achieve orgasm than men with any other patterns of SCI. These results document the ability of men with complete SCIs to achieve orgasm. Characteristics of orgasm in men with SCIs as compared to able-bodied subjects are similar. Although orgasm and ejaculation are more likely to occur together, a number of men with SCIs achieve orgasm without ejaculation. Further research should explore the possibility of retraining ejaculatory and orgasmic responses in men with SCIs.

The purpose of the investigation was to examine the safety and efficacy of functional electrical stimulation (FES)-assisted hydraulic resistance training in improving cardiovascular fitness in persons with spinal cord injuries. The cardiopulmonary responses of 10 high spinal cord injured (SCI) and five able bodied (AB) subjects were assessed during three bouts of FES-assisted leg extension exercise. The protocol involved three 30-minute tests: (1) unloaded leg extension, (2) hydraulically-resisted leg extension (loaded), and (3) a reproduction of the unloaded and loaded protocols to measure cardiac output (Q). Pre-measurements were made of body mass, mean limb weight, maximal force output and maximal oxygen uptake (incremental arm ergometry). Oxygen uptake (VO2), minute ventilation (Ve), respiratory exchange ratio (RER), heart rate (HR), blood pressure (BP) were recorded before, during and after tests. There was a significant difference in VO2 max between SCI and AB subjects. Cardiac output significantly increased between the loaded and unloaded tests. The significant increases from rest to unloaded and loaded exercise pointed to the potential value of adding resistance to a leg extension training regime. Heart rate and BP of the participants with SCI consistently demonstrated a response suggestive of autonomic dysreflexia. Upon stimulation an immediate increase in (predominantly systolic) BP was observed, followed by a fall in HR. On cessation of stimulation HR exhibited a substantial rebound effect and BP returned to normal levels. This response was highly reproducible and suggests caution be exercised in the use of FES for people with SCI with lesion levels above the major splanchnic outflow (T6).

Course 510: Spinal cord injury: Severity of Sensory Impairment Determines Alterations in Cortical Moto Commands in Chronic Spinal Cord: A Case Series

To describe the kinematic gait characteristics of individuals with incomplete chronic spinal cord injury in a water environment and to compare these characteristics with those of healthy individuals. Cross-sectional study. Nineteen adults divided into 2 groups: individuals (n = 9) with incomplete chronic spinal cord injury (> 1 year), American Spinal Injury Association Impairment Scale (AIS) C or D; and a second group (n = 10) of healthy young adults. The groups were paired up according to body mass and height. Participants walked at a self-selected speed in a heated pool with water at the level of the xiphoid process. Participants with spinal cord injury were allowed to hold the researcher's hands. The body segment and joint angle coordinates in the sagittal plane were retrieved with SIMI Motion software. Temporal-spatial variables and joint ranges of motion were compared between groups. Duration of stance phase, stride length and speed differed significantly (p < 0.05) between groups. The ranges of joint motion were not significantly different (p > 0.05), and the joint angle patterns were qualitatively similar between groups. The physical properties of water provided the required time for reorganization of gait phases and allowed all individuals with spinal cord injury to walk in the water environment.

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

The optimal management of acute spinal cord injuries remains to be defined. The authors prospectively applied resuscitation principles of volume expansion and blood pressure maintenance to 77 patients who presented with acute neurological deficits as a result of spinal cord injuries occurring from C-1 through T-12 in an effort to maintain spinal cord blood flow and prevent secondary injury. According to the Intensive Care Unit protocol, all patients were managed by using Swan-Ganz and arterial blood pressure catheters and were treated with immobilization and fracture reduction as indicated. Intravenous fluids, colloid, and vasopressors were administered as necessary to maintain mean arterial blood pressure above 85 mm Hg. Surgery was performed for decompression and stabilization, and fusion in selected cases. Sixty-four patients have been followed at least 12 months postinjury by means of detailed neurological assessments and functional ability evaluations. Sixty percent of patients with complete cervical spinal cord injuries improved at least one Frankel or American Spinal Injury Association (ASIA) grade at the last follow-up review. Thirty percent regained the ability to walk and 20% had return of bladder function 1 year postinjury. Thirty-three percent of the patients with complete thoracic spinal cord injuries improved at least one Frankel or ASIA grade. Approximately 10% of the patients regained the ability to walk and had return of bladder function. As of the 12-month follow-up review, 92% of patients demonstrated clinical improvement after sustaining incomplete cervical spinal cord injuries compared to their initial neurological status. Ninety-two percent regained the ability to walk and 88% regained bladder function. Eighty-eight percent of patients with incomplete thoracic spinal cord injuries demonstrated significant improvements in neurological function 1 year postinjury. Eighty-eight percent were able to walk and 63% had return of bladder function. The authors conclude that the enhanced neurological outcome that was observed in patients after spinal cord injury in this study was in addition to, and/or distinct from, any potential benefit provided by surgery. Early and aggressive medical management (volume resuscitation and blood pressure augmentation) of patients with acute spinal cord injuries optimizes the potential for neurological recovery after sustaining trauma.

The neurorestorative effect of the parenchymal transplantation of olfactory ensheathing cells (OECs) for cord trauma remains clinically controversial. The aim of this article is to study the long-term result of OECs for patients with complete chronic spinal cord injury (SCI). One hundred and eight patients suffered from complete chronic SCI were followed up successfully within the period of 3.47 ± 1.12 years after OEC therapy. They were divided into two groups based on the quality and quantity of their rehabilitative training: group A (n = 79) in sufficient rehabilitation (or active movement-target enhancement-neurorehabilitation therapy, AMTENT) and group B (n = 29) in insufficient rehabilitation. All patients were assessed by using the American Spinal Injury Association (ASIA) standard and the International Association of Neurorestoratology Spinal Cord Injury Functional Rating Scale (IANR-SCIFRS). Thirty-one patients were evaluated by the tests of magnetic resonance imaging (MRI), electromyography (EMG), and paravertebral sensory evoked potential (PVSEP). We found the following. 1) According to ASIA and IANR-SCIFRS assessment for all 108 patients, averaged motor scores increased from 37.79 ± 18.45 to 41.25 ± 18.18 (p < 0.01), light touch scores from 50.32 ± 24.71 to 55.90 ± 24.46 (p < 0.01), pin prick scores from 50.53 ± 24.92 to 54.53 ± 24.62 (p < 0.01); IANR-SCIFRS scores increased from 19.32 ± 9.98 to 23.12 ± 10.30 (p < 0.01). 2) The score changes in terms of motor, light touch, pin prick, and IANR-SCIFRS in group A were remarkably different (all p < 0.01). The score changes in group B were remarkably different in terms of motor (p < 0.05) and IANR-SCIFRS (p < 0.01), but not light touch or pin prick (p > 0.05). 3) Comparing group A with group B, the increased scores in terms of motor, light touch, and pin prick were remarkably different (all p < 0.01), but not IANR-SCIFRS (p > 0.05). 4) Fourteen of 108 patients (12.96%) became ASIA B from ASIA A; 18 of 108 (16.67%) became ASIA C from ASIA A. Nine of them (8.33%) improved their walk ability or made them rewalk by using a walker with or without assistance; 12 of 84 men (14.29%) improved their sex function. 5) MRI examinations were taken for 31 patients; there were no neoplasm, bleeding, swelling, cysts, neural tissue destruction or infection (abscess) or any other pathological changes in or around OEC transplant sites. 6) EMG examinations were done on 31 patients; 29 showed improvement and the remaining 2 had no change. PVSEP tests were performed in 31 patients; 28 showed improvements and the remaining 3 had no change. 7) No deterioration or complications were observed in our patients within the follow-up period. Our data suggest OEC therapy is safe and can improve neurological functions for patients with complete chronic SCI and ameliorate their quality of life; the AMTENT most likely plays a critical role in enhancing functional recovery after cell-based neurorestorotherapy.

The aim of this study was to evaluate the modulation of muscle activity during locomotor-like movements by different walking speeds in subjects with a motor complete spinal cord injury (SCI) compared to actively--and passively-walking control subjects without neurological deficit. Stepping movements on a treadmill were induced and assisted by a driven gait orthosis. Electromyographic (EMG) muscle activity of one leg (rectus and biceps femoris, tibialis anterior and gastrocnemius) was recorded and analyzed at three stepping velocities with similar body weight support in both subject groups. In SCI subjects, the EMG amplitude of biceps femoris, tibialis anterior and gastrocnemius was in general similar or weaker than in passively- and actively-stepping control subjects, but that of rectus femoris was larger. The degree of co-activation between tibialis anterior and gastrocnemius was higher in SCI than in control subjects. A significant velocity-dependent EMG modulation was present in all four-leg muscles in both subject groups. In SCI subjects, this EMG modulation was similar to that in actively stepping control subjects. It is concluded that in complete spastic SCI subjects, spinal neuronal circuits underlying locomotion can to a large extent adequately respond to a change in external drive to adapt the neuronal pattern to a new locomotion speed. The application of various speeds might enhance the effect of locomotor training in incomplete SCI subjects.

Objective To investigate the clinical effect of transcranial direct current stimulation (tDCS) in treating incomplete cervical spinal cord injury, and to explore the possibility of a relationship between the expression of long chain non-coding RNA (LncRNA) and neurological recovery after such injury. Methods Forty-six patients suffering from incomplete cervical spinal cord injury were randomly divided into a tDCS group and a control group, each of 23. The American Spinal Cord Injury Association (ASIA) standard, a functional independence scale (FIM) and the modified Barthel index (MBI) were used to evaluate functional changes before and after 8 weeks of treatment. The neurophysiological evaluations of the spinal cord injury were in terms of somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs). The expression of the LncRNA-MALAT1, MIAT, GPNMB, LILRB4 and SCD1 genes was quantified before and after the intervention. The relationship between the expression of LncRNA and MBI was then further explored. Results The average central motor conduction time (CMCT) of the MEPs and the average central conduction time (CTT) of SEPs in the tDCS group were significantly lower than those before treatment and significantly faster than those of the control group after the treatment. The relative expression levels of LncRNA-MALAT1 and MIAT in the tDCS group were significantly higher than those before treatment and among the control group after the intervention. However, no significant differences were observed in the average expression of the LncRNA-GPNMB, LILRB4 or SCD1 genes. After tDCS the relative expression levels of LncRNA-MALAT1 and MIAT were positively and significantly correlated with MBI scores. Conclusions tDCS can promote the recovery of motor and sensory functions after incomplete cervical spinal cord injury. The underlying mechanism may lie in the up-regulation of LncRNA-MALAT1 and MIAT expression. Key words: Transcranial direct current stimulation; Spinal cord injury; Long chain non-coding RNA

Levels of sexual satisfaction and sexual drive in women with spinal cord injuries were examined. Eighty-four spinal cord injured (SCI) women and thirty-seven able-bodied (AB) control subjects completed the Derogatis Sexual Functioning Inventory which measured current level of sexual functioning in 10 areas: information, experience, drive, attitude, psychological symptoms, affect, gender role definition, fantasy, body image, and sexual satisfaction. When compared with AB women, SCI women had significantly lower levels of sexual satisfaction and sexual drive and significantly higher levels of psychological symptoms and negative affect. Among SCI women, sexual satisfaction decreased significantly with age. Among AB women, sexual satisfaction increased significantly with age. Married SCI women were no longer less sexually satisfied than AB women. Results support conclusions from previous self-report studies in which significant decreases in sexual satisfaction and drive were reported for SCI women. Implications for continued research on the psychological and physiological aspects of sexuality and sexual functioning in SCI women are discussed.

The reduction of motor, sensory and autonomic function below the level of an incomplete spinal cord injury (SCI) has devastating consequences. One approach to restore function is to induce neural plasticity as a means of augmenting spontaneous functional recovery. Acute intermittent hypoxia (AIH-brief exposures to reduced O2 levels alternating with normal O2 levels) elicits plasticity in respiratory and nonrespiratory somatic spinal systems, including improvements in ladder walking performance in rats with incomplete SCI. Here, we determined whether delayed treatment with AIH, with or without concomitant motor training, could improve motor recovery in a rat model of incomplete cervical SCI. In a randomized, blinded, sham-controlled study, rats were exposed to AIH for 7 days beginning at 4 weeks post-SCI, after much spontaneous recovery on a horizontal ladder-crossing task had already occurred. For up to 2 months post-treatment, AIH-treated rats made fewer footslips on the ladder task compared with sham-treated rats. Importantly, concomitant ladder-specific motor training was needed to elicit AIH-induced improvements, such that AIH-treated SCI rats receiving no motor training or nontask-specific treadmill training during the treatment week did not show improvements over sham-treated rats with SCI. AIH treatment combined with task-specific training did not improve recovery on two different reach-to-grasp tasks, however, nor on tasks involving unskilled forepaw use. In brief, our results indicate that task-specific training is needed for AIH to improve ladder performance in a rat model of incomplete cervical SCI.

Spinal cord injury (SCI) is life-altering damage for patients, their family, and society. Transplantation of olfactory ensheathing cells has demonstrated neurorestoration effects for many neurological conditions, including SCI. But voiding and sex dysfunction in patients with chronic complete SCI is still a major issue even though neurorestorative therapies can restore their partial neurological functions. Here we report a case with traumatic complete SCI at the level of C6-C7 one year ago, who received OEC transplantation with intensive neurorehabilitation. The patient started to show clinical improvements within a few days after cell treatment. Six-year follow-up demonstrated his American Spinal Injury Association (ASIA)-Impairment Scale change from ASIA A to become ASIA C. The scores of International Association of Neurorestoratology Spinal Cord Injury Functional Rating Scale changed from 14 (prior to cell therapy) to 31 + 3 (six years after cell therapy). His main improvements in activity of daily life included eating, dressing and writing by himself, standing and walking, and urine control or voiding. His sex function recovered to be normal. He married and had a son through natural sex life. His improving functions and activities of daily life stayed stable in subsequent phone call follow-up. This was one individual case report. In the future, the deep mechanisms of why he got positive results, but other patients with similar condition did not get so much benefits from OEC transplantation should be explored.