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ORAL
PRESENTATIONS
O01
Typical gait patterns in patients with incomplete spinal cord injury:
assessment with 3D gait analysis.
Author: C.Kiekens1, E.Roels1, G.Molenaers2,
F.Goditiabois1, K.Desloovere1,3
C.Kiekens (ISCOS member)
Dept. of Physical Medicine & Rehabilitation, UZ.Pellenberg, K.U.LeuvenDept.
of Orthopaedic Surgery, U.Z.Pellenberg, K.U.LeuvenDept of Rehabilitation
Sciences, FLOK, K.U.Leuven
Ten patients (6 paraplegic and 4 tetraplegic) with incomplete spinal
cord injury (ASIA D) were evaluated using a standardized set of clinical
measurements and 3D gait analysis (eight-camera VICON system, 3 AMTI
forceplates,16 channel EMG system).The aim of the study was to describe
typical gait patterns and to provide more insight in the underlying
mechanism of this pathological gait.Six patients clearly showed an
asymmetric gait pattern. Although high spasticity scores were only
found for 9/20 limbs, stiff knee gait was a common gait pattern (15/20
limbs). The majority of the patients presented with a weak ankle push-off
(18/20 limbs). The gait pattern was further characterised by increased
ankle dorsiflexion (13/20) or plantar flexion (5/20) in stance, increased
knee flexion at initial contact, decreased hip extension at terminal
stance, and increased anterior tilt of the pelvis (9/10 patients).
Knee kinematics showed a hyperextension pattern for 4/20 limbs or
a crouch pattern for 5/20 limbs. Pelvic instability was found for
7/10 patients, and was most pronounced in the transverse plane.For
10/20 limbs, clear motion synergies could be recognised by a synchronous
linkage between knee and hip flexion at terminal stance, suggesting
a lack of supra-spinal influence.
O02
DIAGNOSTIC SYMPTOMS OF SCI-PATIENTS WITH SYRINGOMYELIA
Author:
Ahoniemi
E, Alaranta H
Name of ISCoS Member (Author): Ahoniemi E
Main institution where the work was done: Käpylä
Rehabilitation Centre, Helsinki, Finland
Aim
The retrospective analysis of SCI-patients with syringomyelia during
the period 2000-2003.
Methods
In Käpylä Rehabilitation Centre 29 SCI-patients (26 traumatic
spinal cord injuries, 3 non-traumatic spinal cord injuries) having new
or increased symptoms justified MRI investigation. Neurological symptoms
and clinical findings including ASIA-classification were gathered. A
total of 14 patients were paraplegic (13 men, 1 woman, ASIA A9, B1,
C2, D2), 15 patients were tetraplegic (11 men, 4 woman, ASIA A4, B7,
C2, D2). The mean time from trauma to diagnosis of syringomyelia was
2 months - 35 years.
Results
A total of 83 % of patients with symptomatic syringomyelia revealed
increased spasticity, or spasticity was a new symptom (paraplegic 93
%, tetraplegic 73 %). One patient had only increased spasticity without
other symptoms. Spasticity was combined with pain in 19 cases, increased
sweating in 9 cases, progressive orhtostasis in 8 cases and decreased
reflex micturition in 7 cases. A total of 31 % patients revealed sensory
loss and 24 % of patients progressive motor weakness.
Conclusions
Based on the data new spasticity or increased spasticity was
the most common symptom and in many cases also the first symptom of
syringomyelia.
O03
Influence of spasticity on bone parameters of lower extremities
in spinal cord injury
Author:
Eser
P, Frotzler A, Zehnder Y, Wick L, Knecht H, Schiessl H
Main institution where the work was done: Institute
for Clinical Research, Swiss Paraplegic Centre, Nottwil, Switzerland
Aim
To assess bone decay after spinal cord injury (SCI) and the
influence of spasticity on bone parameters in paralysed extremities.
Methods
99 motor SCI subjects with paralysis duration between 0.2
and 50 years were investigated in a cross-sectional study. Bone parameters
were measured with peripheral quantitative computed tomography (pQCT)
and spasticity of the the paralysed extremities was assessed by using
the Ashworth Scale. Spearman correlations were performed between spasticity
scores and various bone parameters.
Results
Trabecular (trbBMD) and total bone mineral density (totBMD) of the
epiphyses and cortical cross sectional area (cortCSA) of the shafts
showed an exponential decrease with time after injury. New steady-states
were reached at 26% for trbBMD, 43% for totBMD and 76% for cortCSA
after 3 to 8 years compared to an able-bodied reference group.Spearman
correlation coefficients between the bone parameters in the new steady-state
and the spasticity scores were significant for trbBMD (0.352), totBMD
(0.384) and cortCSA (0.33). Subjects with the highest spasticity scores
showed a 24% and 26% higher trbBMD and totBMD, respectively, and a
29% greater cortCSA in the femur compared to flaccid subjects and
those with weak spasticity. Conclusion: Our data suggests that spasticity
reduces bone loss in the femur of people with chronic SCI. Spasticity
may hence contribute to a reduced risk of fractures in the paralysed
extremities.
O04
Active Cycling in incomplete spastic paraplegia during primary rehabilitation:
Time profile of pathological muscle activation pattern
Author:
Michaela
Obrovsky, Josef Hufgard, Karl Schrei
Name of ISCoS Member (Author): Josef Hufgard
Main institution where the work was done: Rehabilitationszentrum
Weisser Hof, 3400 Klosterneuburg/Vienna, Austria
Background and objective:
Muscle activation pattern in active cycling depends on cycling rate.
Higher rates show an advance shift in activity onset of certain muscles
(Marsh/Martin 1995). In spasticity after stroke, these patterns are
disturbed (Brown et al.1995). Little is known about alterations in
the spinal type of upper motoneuron disease. We aimed to identify
the incidence of pathological muscle patterns after incomplete spinal
cord injury.
Patients and methods:
20 Patients
with incomplete spastic paraplegia (ASIA C, ASIA D) within the first
6 months after trauma, as well as 5 healthy subjects were included.
EMG of 6 muscles was performed simultaneously (Rectus femoris, Vastus
medialis, Adductor magnus, Biceps femoris, Tibialis anterior, Gastrocnemius)
during active cycling in three rates (60, 90, and 120 cycles/min).
Results:
ASIA-D patients showed muscle activation patterns similar to that
of healthy subjects. In higher cycling rates we found inconstant perturbations.
In ASIA-C patients, however, advance shift of activity during the
faster cycling rates was hardly achieved and some patients could not
perform the faster tasks. Pathological cocontraction was present,
but showed no significant correlation with cycling rate.
Conclusion:
Typical abnormal muscle activation patterns exist in incomplete traumatic
paraplegia. Higher cycling rates produce no increase in spasticity.
O05
FUNCTIONAL OUTCOMES FOLLOWING BOTULINUM TOXIN IN SPINAL CORD INJURY
Author:
Sofia
Gonçalves, Ana Castro, Maria João Andrade
Name of ISCoS Member (Author): Maria João
Andrade
Main institution where the work was done: Physical
Medicine and Rehabilitation Department – General Hospital Santo
António
Numerous studies have demonstrated the effectiveness of the Botulinum
toxin type A in the focal treatment of spasticity secondary to different
aetiologies. However, little research was made about the interest
of Botulinum toxin on functional abilities in spinal cord injured
patients.
The aim of this study was to assess the effect of Botulinum toxin
A in the management of spasticity resulting from incomplete Spinal
Cord Injury (SCI),with emphasis on its influence over limb function.
The participants, patients with SCI of several causes and injury levels,
had Botulinum toxin type A injected into the muscles of the spastic
limb.
Assessments were made pre-injection, 1 month and 3 months post-injection,
and included clinical evaluation for muscle tone according to the
Modified Ashworth scale, joint range of motion (ROM), muscle strength,
gait parameters, and functional measure using the Functional Independence
Measure (FIM).
Main outcomes and results: a clear clinical improvement, subjective
and objective, was noted. Reduced spasticity values of the Modified
Ashworth scale, changes of the ROM and improved functional outcomes
were registered.
Based on the results, the findings in this study suggest that Botulinum
toxin may have a place in the management of spasticity following SCI,
leading to important functional benefit.
O06
ANTISPASTIC
EFFECT OF PENILE VIBRATION IN SPINAL CORD LESIONED MEN
Author:
Line
Læssøe M.D., Jens Bo Nielsen Prof., Fin Biering-Sørensen
M.D., Jens Sønksen M.D.
Name of ISCoS Member (Author): Fin Biering-Sørensen
M.D.
Main institution where the work was done: Department
of Urology and Clinic for Para- and Tetraplegic, Rigshospitalet, Copenhagen
University Hospital, Copenhagen, Denmark.
Line Læssøe M.D., Jens Bo Nielsen Prof., Fin Biering-Sørensen
M.D., Jens Sønksen M.D. Department of Urology and Clinic for
Para- and Tetraplegic, Rigshospitalet, Copenhagen University Hospital,
Copenhagen, Denmark.
Department of Neurophysiology, The Panum Institute, University
of Copenhagen, Copenhagen, Denmark.
Background:
Occasional reports have suggested a decrease in the clinically observed
frequency of leg-spasms lasting for several hours following ejaculation
induced by penile vibratory stimulation (PVS) in spinal cord lesioned
(SCL) men.
Purpose:
To evaluate the possible antispastic effect of PVS in SCL men.
Methods:
The design was an unblinded before-after trial. Nine men with spinal
cord lesions from C2 to T8 were randomly allocated into two groups.
24 hours electromyography (EMG)-recording from the quadriceps/tibialis-anterior
muscles was performed followed by PVS or “no treatment”
and then another 24 hours EMG-recording. The presence of EMG-activity
of an amplitude 4 times baseline with a duration longer than 5 sec was
taken to signify a spasm. The number of spasms per hour was calculated
before and after PVS or “no treatment” and subjectively
evaluated by the Penn Spasm Frequency Scale. Spasticity was evaluated
by the Modified Ashworth Scale (MAS).
Results:
The EMG-data showed a significant reduction in the frequency of leg-spasms
up to three hours (p<0.05). Significant decreased spasticity as evaluated
by MAS was found immediately after vibration (p<0.01). No significant
decrease in the number of spasms according to Penn was found.Conclusion:
Penile vibration may be useful as antispastic therapy.
O07
SURGICAL TREATMENT OF PAINFUL SPASTICITY AFTER SPINAL CORD INJURY
Author:
A
Livshits, M Witz, V Livshits, R Gepstein
Name of ISCoS Member (Author): A Livshits
Main institution where the work was done: Spinal Care
Unit, Meir Gen Hosp, Kfar Saba, Israel
Study Design:
There are several conservative methods of painful spasticity treatment.
However, conservative methods do not always provide long-term and complete
antispastic effects in cases of spinal cord injury with severe painful
spasticity.
Objectives:
The aim of the present study was to analyse and compare the effectiveness
of myelotomy by Bischof II and Pourpre in patients with paraplegia and
severe painful spasticity in the late period after spinal cord trauma.Setting:
Spinal Care Unit, Meir General Hospital, Kfar Saba, Israel.Methods:
Twenty patients had longitudinal T-myelotomy by the Bischof II technique
and 20 longitudinal myelotomy en croix (Pourpre). The spasticity was
determined by evaluated muscle tone and muscle spasm according to the
Ashworth and spasm-frequency scales. The pain was determined by McGill
short questionnaire. The results were calculated by the Wilcoxon signed
rank test, by Mann-Whitney U-test and Student t-test. Clinical outcomes
after myelotomy in patients with chronic spinal cord injury and painful
spasticity were evaluated after 6 months, 5 and 10 year follow-up period.
Results:
Pain was relieved in all cases. The best motor antispastic effect was
achieved after Pourpre myelotomy in 18 of the patients (90%) were evaluated
after follow-up of 6 months, 15 patients (75%) after 5 years and 11
patients (64.7%) after 10 years. Following Bischof II myelotomy results
were classified as good: in 13 patients – (65%) at 6 months; in
9 patients (45%) at 5 years and in 6 patients – (40%) at 10 years.
Statistical analysis showed no reliable relationship between the level
of spinal cord lesion (T4-T10) and the type of operation. No instability
occurred as a result of antispastic operation in any patient.
Conclusion:
A higher rate of beneficial outcome was achieved after Pourpre myelotomy.
We recommend this operation for patients with paraplegia and painful
spasticity, who do not have hope of regaining voluntary motor function.
However, transactions of basic pathways of spasticity are not always
sufficient for complete antispastic effects. Good results after the
operation may deteriorate in time. Therefore, further investigations
into the mechanism of the spasticity syndrome in the spinal cord injured
patient are required.
O08
THE EFFECT OF PENILE VIBRATORY STIMULATION ON SPASTICITY IN SPINAL CORD
INJURED MEN
Author:
Ridvan
Alaca, A. Salim Goktepe, Necmettin Yildiz, Bilge Yilmaz, Sukru Gunduz
Name of ISCoS Member (Author): Sukru Gunduz
Main institution where the work was done: Turkish Armed
Forces Rehabilitation Center (TAFRC), Gulhane Military Medical Academy
Department of Physical Medicine and Rehabilitation
Penile vibratory stimulation is the first treatment option for anejaculation
in men with spinal cord injury. It has not been studied for its antispasticity
effect to date. The purpose of this study was to determine the effect
of penile vibratory stimulation on spasticity in spinal cord injured
patients. Ten male spinal cord injury patients were included in the
study. They were examined at the baseline, and then 3, 6, 24, and 48
hours later. After their baseline examination, they performed penile
vibratory stimulation. The parameters were spasticity (Ashworth scale),
spasm frequency, spasm severity, painful spasms, plantar stimulation
response, deep tendon reflexes, clonus, and effect on function. Ashworth
grade showed a statistically significant decrease at 3rd and 6th hour
examinations (p=0.001 and p=0.03 respectively with Tukey test). The
patients showed a tendency towards having less frequent and less severe
spasms throughout the study, however, it did not reach to a significant
level. Similarly, clonus showed a nonsignificant decrease during follow-up
examinations. The other parameters did not change considerably. Penile
vibratory stimulation may contribute to the relief of the spasticity
in spinal cord injured men. Spasticity treatment should consider all
the factors that increase or decrease the tone.
O09
Managing SCI: The First 72 Hours
Author:
Belanger,
Lise, M.A., Jebson Hilary, Fenrich, Peter, & Wing , Peter
Name of ISCoS Member (Author): Wing, Peter
Main institution where the work was done: Vancouver
General Hospital Acute Spine Program
With challenging geography and weather conditions in British Columbia,
Canada, transfer of cord-injured patients to BC’s Acute Spine
Unit can be delayed by many hours. “Managing SCI: The First
72 Hours” is the second web–based program to address the
learning needs of health care providers through a collaborative effort
between Vancouver Hospital and the British Columbia Institute of Technology.
This has been produced by the same team that created the award-winning
program: “Spinal Precautions: Minimizing the Risk of Further
Spinal or Neurologic Injury” http://www.tc.bcit.ca/gait/projects/spinal.shtml
This web-based program provides health care professionals with a simple,
highly interactive and visually rich tutorial about early intervention
following SCI. Through a systems based approach, the tutorial puts
into plain language the direction and detail required to provide skilled
care for best patient outcomes. While reflecting the BC experience,
content is based on current evidence and accepted international standards
making it applicable worldwide. Germane to centers with a high volume
of SCI patients, the design makes it particularly useful to health
care providers only seeing these patients occasionally. The efficacy
and efficiency of computer-based educational technologies is far reaching.
This program has the potential to improve the standard care for patients
with acute SCI.
(Another abstract (Wing et al) presents a review of current clinical
practice guidelines for care during the first 72 hours after SCI.)
010
Prevention of venous thromboembolism in the acute phase after spinal
cord injury: a randomized multicentre trial comparing low-dose heparin
plus intermittent pneumatic compression with enoxaparin.
SCI prophylaxis investigators: Steering committee: Merli G
(PI), Geerts W, Ginzburg E, Green D. Lambert R, Leduc B. McKean J,
Wing PC. Vancouver Team: Wing PC, Dvorak MFS, Fisher CF, Boyd
MC, Benson D.
Name of ISCoS Member (Author): Peter Wing
Main institution where the work was done: Multicentre
study; Investigators based at Sunnybrook Health Sciences Centre, Toronto,
Canada, U Miami School of Medicine, Miami, Fla, USA and Jefferson
Internal Medicine, Philadelphia, PA, USA
DESIGN:
Prospective, multicentre, randomized trial comparing unfractionated
heparin (UFH) plus intermittent pneumatic compression (IPC) to enoxaparin
alone as thromboprophylaxis after acute spinal cord injury (SCI).
METHODS:
Patients age 15 or older with ASIA-A to C SCI were randomly assigned
to receive either UFH 5000 units every 8 hrs in combination with IPC
or enoxaparin 30 mgms every 12 hrs. Outcome measures were deep vein
thrombosis, pulmonary embolism, and major bleeding after two weeks
of prophylaxis.
RESULTS:
476 patients were recruited in 27 participating centers. Among 107
fully assessable patients, the incidence of VTE was 63.3% with UFH-IPC
vs 65.5% with enoxaparin (p = 1.81). The incidence of PE was 18.4%
with UFH-IPC vs 5.2% with enoxaparin (p = 0.03). Among all randomized
patients the incidence of major bleeding was 5.3% with UFH-IPC vs
2.6% with enoxaparin (p=0.14).
CONCLUSION:
In the acute treatment phase after SCI, safety and thromboprophylactic
efficacy were similar with UFH-IPC and enoxaparin.
DISCUSSION:
This study and the study of thromboprophylaxis in the rehabilitation
phase illustrate the difficulties of performing a multicentre study,
and in particular demonstrate recruitment difficulties after the publication
of clinical practise guidelines. Some general instructive comments
will be provided.
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