GENERAL SESSION 4
Operative Procedures/Regeneration

Clinical Algorithm for Predicting Walking Capacity Based on the ASIA Motor Score In Acute SCI
Bjorn Zorner, M.D.1; Volker Dietz, M.D.1; Armin Curt, M.D.1,2
1Balgrist University Hospital, Zurich, Switzerland; 2University of British Columbia, Vancouver, Canada

Objective: (1) To correlate the acute ASIA motor score (AMS) and the outcome of different walking tests at the end of rehabilitation in patients with spinal cord injury (SCI). (2) To create a basic algorithm for clinical implementation to predict functional walking capacity based on AMS.

Design: Retrospective study, European Multicenter project (EM-SCI).

Participants/methods: 316 patients with SCI (90% due to trauma). Measurements: AMS was obtained between day 16 and day 40 after injury, while walking tests (WISCI II, 6min, 10m, TUG) were carried out >150 days after injury.

Results: In motor complete SCI patients only 16% achieved any walking capacity while only 2% reached a walking velocity of 0.6m/sec that is supposed to be sufficient to cross a road within the green/safety phase of pedestrian lights. In motor incomplete paraparetic patients a weak correlation could be calculated between the outcome of walking capability and AMS (0.5<|r|<0.62). About 50% with an AMS<75 reached a walking velocity of 0.6m/sec, whereas about 90% with an AMS>75 were able to achieve this walking speed. In motor incomplete tetraparetic patients all walking tests were strongly correlated to the AMS (|r|>0.78). 20% of these patients rated with an AMS<55 and 90% with an AMS>55 would have been successful to cross streets in the indicated period.

Conclusions: The AMS seems to be a useful clinical tool to predict functional walking capacity in motor incomplete tetraparetic patients, while less predictive in paraparetic patients. We propose a basic algorithm to forecast the walking capacity of SCI patients after rehabilitation.

Support: Swiss National Science Foundation and International Institute for Research in Paraplegia.

Robot-Assisted Gait Analysis for Rats after Spinal Cord Bridging
Xiaoming Deng, M.D., Ph.D.1; Yu-Shang Lee, Ph.D.1; Ian Hiso, Ph.D.1; Ximing Xiong, M.D.1; Sharon Zdunowski, B.A.2; Reggie Edgerton, Ph.D.2; Vernon Lin, M.D., Ph.D.1
1VA Long Beach Healthcare System, Long Beach, CA and University of California, Irvine, CA; 2University of California, Los Angeles, CA

Objective: We previously reported improvement in hindlimb motor recovery in adult spinal cord transected rats after receiving the bridging technique, which is consisted of peripheral nerve transplantation and local application of acidic fibroblast growth factor (aFGF). The purpose of this study was to quantify functional recovery using a robot-assisted gait analysis system (RAGAS).

Design: An animal study on functional recovery of hindlimbs after robot-assisted locomotion training in rats with complete spinal cord injury and peripheral nerve graft repair.

Participants/methods: Two groups of female Spreque-Dawley rats: 1) transection only (transection at T8; n=11), and 2) T8 transection with peripheral nerve grafts (PNG) and aFGF (n=11). For each animal, RAGAS data corresponding to the best segment of locomotor performance was analyzed 6 months after surgery. Periods of peak performance were initially identified from video footage captured during testing. The RAGAS data corresponding to these time points were subsequently examined for periodicity, repetitive trajectory patterns, and inter-limb coordination.

Results: In the group 2 animals, the rats displayed poor and brief sinusoidal step patterns with poor inter-limb coordination. In the group 3 animals, we observed considerable consistency in the negative slope of the x coordination plot in all animals, which suggested appropriate alternation between the two legs in the horizontal direction. Seven of eleven rats demonstrated significantly improved motor performance with both hindlimbs, showing consistent step trajectories with both limbs, using alternating gait, and good periodicity at both 13 and 21 cm/s treadmill rate. The other four subjects exhibited preferential stepping with the left leg stepping only.

Conclusion: The RAGAS data demonstrated spinal cord bridging using PNG and aFGF treatments facilitate recovery of hindlimb function in a T-8 transected rat model.

Support: This study was supported by a grant of Veteran Affairs Rehabilitation Research and Development Service.

Functional Motor Recovery Following Severe Contusive SCI: Human Neuronal Serotonergic Cell Transplantation.
Yerko A. Berrocal, M.D.1; Jordan S. McBroom1; Damien D. Pearse, Ph.D.1,2; Mary J. Eaton, Ph.D.1,2,3.
1The Miami Project to Cure Paralysis, 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida 33136; 3VA RR&D Center of Excellence in Functional Recovery in Chronic Spinal Cord Injury, VAMC, Miami, FL 33136.

Objective: Altered neurotransmitter status within the ventral horn a-motoneurons and loss of descending serotonergic (5HT) inputs caudal to the lesion site contributes to motor dysfunction after SCI. We have studied how to augment 5HT spinal levels with cell therapy.

Design: Randomized, controlled, blinded animal study

Participants/Methods: Sprague Dawley nude rats (n=6/group: Naïve; SCI-alone; +/- SCI, viable and non-viable cell transplants) received a severe contusion (T8, 10 g, 25.0 mm) with a mechanical weight-drop impactor (NYU device), where 1X106 hNT2.19 5HT cells (or non-viable cells) were injected bilaterally into the dorsal columns rostral (T6) and caudal (T10) to the contused area at a depth of 0.5 mm. Animals received both baseline (1 wk) and post-operative evaluations ( for 8 wks) of locomotor testing using the BBB Locomotor Rating Scale. At endpoint, we employed (i) Footprint analysis, (ii) Gridwalk Test, and (iii) immunochemistry for the human marker Nuclear matrix antigen protein (NuMA) and 5-HT in grafted cells.

Results: The SCI group with live cells grafts demonstrated a continual trend of improvement in BBB score immediately following transplantation in comparison to the other groups, as well as a trend of improving foot rotation of the hindpaws and decreased hindpaws footfall errors.

Conclusion: This study suggests that motor dysfunction after SCI can be improved employing human neuronal serotonergic cell transplantation and will allow us to provide novel insights into future therapeutic strategies to treat the injured spinal cord. These data also form the basis of preclinical efficacy studies to bring the use of these human 5HT cells to a clinical application to treat motor dysfunction after SCI.

Support: This study was supported by the Miami Project to Cure Paralysis (University of Miami Miller School of Medicine, Miami, Florida 33136).

Objective: Pressure ulcers are a significant complication for many individuals with spinal cord injury. Appropriate wound care requires frequent assessment of the wound. This assessment may be delayed or precluded by lack of access to health care providers, lack of insurance or limitations of insurance, lack of transportation, and lack of necessary pressure relieving surfaces during transport. Physical transportation may provide further risks of wound breakdown. The purpose of the study was to evaluate the use of telemedicine technologies of digital video, digital still, and 35mm camera as adjunct to the management of pressure ulcers in people with disabilities such as spinal cord injury.

Design: Prospective evaluation of wounds using digital video, digital still and 35mm camera evaluations.

Participants/methods: Digital images were sent to reviewers by e-mail, and 35mm pictures were mailed. Assessments regarding quality, ease of viewing, and usefulness of the pictures was completed by the image reviewers, a home care nurse, and a health care professional taking the images.

Results: Evaluation of 11 subjects with wounds indicated that that both 35mm and digital still were of the highest quality. Both provided information to make clinical decisions and were sufficient to be utilized to change treatment plans. 35mm was significantly more difficult to use, and generally not as easy to view. Digital video was not of sufficient quality to be useful.

Conclusion: Digital still cameras in telemedicine in wound care assessment offer a high quality, easy to use technology to provide adjunctive care for people with pressure ulcers.

Support: This project was funded as a Gaylord Rehabilitation Research Institute study.

Design: Single group pretest/posttest design.

Participants/Methods: Six subjects with SCI demonstrating spasticity with traditional manual testing participated in this study. Spasticity was assessed using the Lokomat® “L-Stiff” measure. The L-Stiff module measures resistance to passive motion of the hip and knee at pre-selected speeds (30, 60, 120 °/sec). L-Stiff measures of the knee were recorded prior to and after two randomly selected interventions: 1) walking with body weight support in the Lokomat® or 2) standing with body weight support. Interventions were performed for thirty minutes. The testing protocol was repeated with the alternate task two days later. Stiffness was recorded as the mean torque (Nm) across the joint range. Intertrial reliability of baseline L-Stiff measures was determined in one subject.

Results: Repeatability between baseline trials of L-Stiff measurements at the knee resulted in insignificant differences in mean torque (range 0.1-1.1%). There were no significant differences in L-Stiff measures of mean torque pre and post standing or walking. The resistance profile across the joint range did not represent the expected pattern of spasticity, but resembled the stiffness encountered with the rheological properties of muscle.

Conclusions: While the Lokomat® “L-Stiff” measurement module is useful in identifying resistance to passive motion of the knee joint, the application in measuring spasticity was not effective. This may be due to the limitations in testing speeds preset in the software.

Objective: To determine the validity and accuracy of three compliance monitors for assessing thoracic-lumbar-sacral orthosis (TLSO) wearing time of children with spinal cord injury (SCI).

Design: Prospective multi-center observation, using a convenience sample

Participants/methods: Fifteen children with thoracic or cervical level SCI who wore a TLSO for paralytic spine deformity were observed for four days. Two temperature sensitive, TS1 and TS2, and one pressure sensitive, PS1, compliance monitors were mounted onto the TLSO. The daily wearing time consisted of 6 hours of alternating 1.5 hour on and off periods while the subject participated in their rehabilitation program activities. The monitors’ data were compared to a wear time log recorded by a parent or therapist.

Results: The correlation coefficients with the daily log were 0.55, 0.46 and 0.38 for TS1, TS2, and PS1, respectively. Bland-Altman plots showed PS1 to have poor equivalence with the daily log by underestimating total wear time by an average of 58.9 minutes of the daily minutes recorded. TS1 and TS2 tended to overestimate wear time by an average of 1.7 and 7.4 minutes, respectively. Variances calculated between each monitor’s data and the log values demonstrated no significant difference between the TS1 and TS2 monitors. Both TS1 and TS2 variance values were statistically less than the PS1 variance (p<0.05). Observationally, TS2 is smaller and less invasive to the subject’s functional activities. Additionally, TS2 is the only monitor with a permanently attached sensor that can not be manually disconnected from the data recording unit.

Conclusion: TS1 or TS2 can be used as effective monitors for documenting TLSO compliance in children with SCI. TS2 was chosen to document brace compliance in a prospective, randomized clinical trial on TLSO efficacy due to its design advantages.

Support: This project was funded by Shriners Hospitals for Children #9155.

Objective: The control of lower limb reflexes is important for ambulation in SCI patients. We investigated whether the modulation of the H-reflex using TMS of motor cortex at different latencies in patients with an incomplete motor SCI, varies after the locomotor training with electromechanical systems (GAIT TRAINER GT 1® and LOKOMAT®).

Design: Prospective single case studies.

Participants/Methods: Ten SCI subjects received locomotor training for 8 weeks. Outcome measures were ASIA Motor Score, WISCI II scale, cadence, stride length and speed. H-reflexes were evoked in the gastrocnemius by electrical stimulation of the tibial nerve in the popliteal crease. The intensity was adjusted to obtain an H-reflex of 1 mV amplitude. TMS at intensity of 90% subtreshold was applied, preceding the electrical stimulation at 20, 50 and 80 ms.
Ten healthy subjects served as control in the modulation of the H-reflex by TMS.

Results: Control subjects exhibited an H-reflex amplitude facilitation at 20 ms (245%) and 80 ms (193%). In the SCI subjects, before the training, the early modulation was reduced compared to control (89%, p<0.05). After the training the modulation was closer to that observed in healthy individuals (143 % and 195%, respectively). All gait parameters improved after the training (chi square<0.01).

Conclusion: Gait improvement in the SCI subjects after the training was related to a tendency to normalization in the modulation of the H-reflex by TMS. The H-reflex modulation by TMS can help to asses the outcome of ambulatory capacity and contribute to the selection of the appropriate therapeutic approach.

Objective: Determine the reliability of a new measurement method for isometric peak torque using the driven gait orthosis (DGO) in healthy subjects and patients with neurological gait disorders of different etiology.

Design: Intra- and inter-rater reliability design.

Participants/methods: For the new measurement method, the orthosis (Lokomat®; Hocoma AG, Switzerland) was driven and immovably held to a well-defined position. On initiation by the therapist, the DGO measured the maximum torque (moving average, time window 1000ms) for flexion and extension movement in hip and knee joint sequentially.
Mechanical reliability was assessed by attaching different defined weights to the DGO in random order with three repetitions on each of two testing days.

For clinical reliability, 15 healthy subjects and 15 patients were tested twice on the same day by two different therapists in random order to test inter-rater reliability and on two separate days by the same therapist to test intra-rater reliability. Subjects were instructed to produce maximal force against an immovable resistance of the DGO.

Results: For the mechanical reliability, all intraclass correlation coefficients (ICC) were high (>0.999). The standard errors of measurements (SEM) were <0.45 Nm.
In healthy subjects, ICC for inter-rater reliability were >0.77 (SEM <11 Nm) and for intra-rater reliability >0.71 (SEM <11 Nm). In patients, ICC were >0.71 (SEM <18 Nm) for inter-rater and >0.65 (SEM <14 Nm) for intra-rater reliability.

Conclusion: This study has demonstrated high reproducibility of a new assessment method for maximal isometric torque in the DGO Lokomat. We suggest that this method is a valuable tool to document and control the rehabilitation process of patients.

Support: By the Swiss Commission for Technology and Innovation (CTI-Project 7497.1 LSPP-LS).

Objective: To compare the effectiveness of the pressure-relieving ability of the three most commonly prescribe wheelchair cushion (ROHO, vinyl cushion with air, and vinyl cushion with water) for a person with Spinal Cord Injury (SCI).

Design: Experimental cross-sectional study

Participants/Methods: 32 healthy adults and 36 spinal cord injured patients were participated this study. All subjects were seated at neutral position (trunk was upright, angle of hip was 90degree, angle of knee was 90 degree, and angle of ankle was 90 degree) on wheelchair without cushion and with various cushions (ROHO, vinyl cushion with air, and vinyl cushion with water). The total contact area and peak pressure of buttock and thigh were measured by X-sensor 4.2 system.

Results: In both group, total contact area was significantly increased at seating with various cushions than without cushion (p<0.05). In SCI patients group, total contact area was the higher value at seating with vinyl cushion with air than other cushions (p<0.05), but in control group, there was no significant difference of it according to types of cushion (p>0.05). In both group, peak pressure was significantly decreased at seating with various cushions than without cushion (p<0.05). There was no significant difference according to types of cushion (p>0.05).

Conclusion: Based on these findings, vinyl cushions with air or water are also effective in relieving pressure as ROHO cushion.

Objective: To provide useful data when choosing a computer mouse interface and aid a new design of interface by examining tetraplegic patients’ operation capability and preference according to the level of injury.

Design: prospective study

Participants/Methods: Total 24 subjects were consisted of eight C4 spinal cord injured, six C5, five C6, and five C7, diagnosed as motor complete injury(ASIA-A or B). The mean age was 34.5 years and the mean time since injury was 47.4 months. Through each patient’s use of 5 kinds of a computer mouse interface; head-pointer, touch-screen, big-ball-mouse, button-mouse, and touch-pad, and his motion of a mouse-curser to the target box randomly moving around on monitor, one-minute clicking frequency was measured. The preference for each mouse interface was evaluated on a five-point scale after experiments.

Results: All subjects’ one-minute clicking frequency showed 50.3±8.9 for touch-screen, 41.0±11.3 for head-pointer, 13.6±10.8 for big-ball-mouse, 9.9±7.5 for touch-pad, and 6.2±3.3 for button-mouse. In touch-screen and head-pointer, clicking frequency showed highest in every group. In big-ball-mouse, clicking frequency was low as 6.5 in the groups of C4 or C5 but relatively high as 23.5 in the groups of C6 or C7. The preference for each mouse interface showed the descending order of head-pointer, touch-screen, and mouse-pad in the groups with C4 or C5. In the groups with C6 or C7, it showed the descending order of big-ball-mouse, touch-screen, and head-pointer.

Conclusion: This result showed patients with tetraplegia would give much more emphasis on convenience of use rather than on clicking frequency when choosing a computer mouse interface.

Objective: To investigate how treating intervention by each problem can improve the function of mobile phone operation according to the level of injury in persons with tetraplegia.

Design: prospective clinical study

Participants/Methods: The subjects were 22 patients with motor complete (ASIA-A or B) Spinal Cord injury (C4 level was 4, C5 was 5, C6 was 8, and C7 was 5). The realities of mobile phone use and its problems were examined through individual interviews. Through 3-time work-treating intervention, the most proper and convenient intervention method for each individual was provided.

Results: Mobile phone operation was dependent upon others in all C4 patients. Ten out of 18 patients (C5, C6, and C7) showed difficulty in opening a mobile phone. With intervention, however, in the type of folder, 6 were able to open it because of extra space due to a ‘thick sticker’ attached within a mobile phone. In the type of slide, 2 were able to open it as an upholding motion got possible but 2 were dependent upon others. The six who showed difficulty with the upholding motion, were able to uphold a mobile phone by attaching a ‘circle ring’ for the thumb and sustaining it by the ring. After the 10 patients’ training various methods, who showed difficulty pushing buttons, it became possible to push buttons using ‘universal cuff’ in one patient, ‘both hands method’ in one and ‘their thumb’ in seven.

Conclusion: This study showed that proper treating intervention according to the level of injury would aid the tetraplegic patients’ mobile phone use.

The Effect of Four Weeks Rehabilitation in Warm Climate on Patients with Multiple Sclerosis and Pain
Lars Werhagen MD*, Elisabet Waldenlind Ass. Prof **
* Department of Rehabilitaion Medicine Danderyds hospital Stockholm
**Department of Neurology Karolinska Hospital Huddinge Stockholm

Introduction: Multiple Sclerosis(MS) is a chronic disease affecting the spinal cord
and the brain. No cure is available.

Design: Prospective study

Objective: To study the incidence of pain in MS patients selected for rehabilitation in warm climate and to study the effect on pain after four weeks rehabilitation.

Methods: Patients selected for rehabilitation were asked to participate in a study to evaluate rehabilitation in warm climate and its effect on pain. The patients who agreed had to answer a questionnaire at four occasions (before departure, after homecoming and three and six month after homecoming) Before departure and six months after homecoming they were examined by a neurologist. The patients were by drawing of lots selected into a training and a control group. The patients in the training group received standardized physiotherapy three times a week after homecoming and the control-group had no specific training but continued the same way as before the rehabilitation.
Inclusion criteria : age under 65 years, ability to walk 20 m.
Vintersol is a rehabilitation clinic situated at Tenerife, where the climate wintertime is warm
and stable. Patients with neurological diseases like MS, SCI, brain injury receive rehabilitation at Vintersol.

Result: 34 patients were included in the study. 22 patients suffered from pain before the rehabilitation. Sixtysix of them experienced pain relief on homecoming. Patients in the training-group had better painreleif six months after homecoming. Females experienced more and severe pain than males.

Conclusion: Pain is common in MS patients. Pain was relieved in 66% after rehabilitation. Physiotherapy after homecoming can prolonge the effect.

Spinal Cord Injury in Adolescents: Six Year Experience of the Rehabilitation Center for the Province of BC.
Evgeny V. Sidorov, M.D., Ph.D.1,3; Gorge Hahn M.D.2,4; Andrei Krassioukov M.D., Ph.D.1,2
1ICORD; 2Division of Phys. Med. & Rehab.; 3Dep. Healthcare and Epidem. University of British Columbia, Vancouver; 4G.F. Strong Rehabilitation Center, Vancouver, BC

Objective: To evaluate aetiology, demographic factors and severity of spinal cord injuries (SCI) in an adolescent population admitted to an urban rehabilitation center.

Design: Retrospective charts review

Participants/Methods: Individuals who sustained SCI between 14 and 18 years of age.

Results: Thirty adolescents (19 Males; 11 Females) with mean age at injury 17+0.22 years were admitted to the rehabilitation center during 2000-2005. Motor-vehicle accidents (MVA) were responsible for 15 (50%) of injuries, followed by falls 6 (20%), and sport related activities 5 (17%). Thirteen subjects (43%) sustained cervical, 4 (14%) upper thoracic and 13 (43%) lower thoracic SCI. Average length of stay for each individual was 104+12.6 days. The majority of individuals on admission had ASIA grade A 18 (60%), 4 (13%) subjects had grade B, 2 (7%) subjects had grade C and 5(17%) had grade D. Partial recovery during rehabilitation occurred in 9 (30%) of the individuals.

Conclusion: SCI is a comparatively rare injury in the adolescent population. As for adults, an MVA was the predominant cause of SCI. Adolescents showed a higher percent of neurological recovery compared to the adult population.

Support: This study was sponsored by the Rick Hansen Man in Motion Research Fund

Objective: To examine baroreflex control in men with chronic spinal cord injury (SCI) both during supine rest and an orthostatic challenge.

Design: Prospective clinical study.

Participants/Methods: We studied 8 men with cervical SCI (aged 35.0±2.4 years), 8 with thoracic SCI (aged 35.4±3.6 years), and compared their responses with those from 9 able-bodied controls (aged 33.5±4.1 years). We continuously recorded RR interval and beat-to-beat blood pressure during supine, and following the passive assumption of an upright seated posture. Cardiovascular control was assessed from time series created from the RR interval and systolic arterial pressure (SAP) waveforms, on which spectral analyses were performed. Cross spectral analyses were performed on the low frequency (LF) spectra to assess cardiac baroreceptor reflex control. Plasma noradrenaline (NA) was determined.

Results: For RR interval, the power of the LF oscillations was reduced in cervical, but not thoracic. High frequency power (HF) was decreased in thoracic SCI, but not cervical. The LF:HF ratio was low in cervical SCI. For SAP, LF power was reduced in cervical SCI; HF power was not different between groups. The LF:HF ratio was low in cervical SCI. Cross spectral analyses revealed similar transfer function gains in all groups. Phase delay was greater in cervical, but not thoracic SCI. Interestingly, the phase delay was greater in high thoracic SCI than in low. NA was lower in cervical SCI during supine and upright phases.

Conclusion: There is reduced sympathetic drive in cervical SCI (LF RR and LF SAP) and vagal outflow (HF RR) in thoracic SCI. This is accompanied by increased delay of the arterial baroreflex (phase) in both cervical and high thoracic SCI, with no change in baroreflex sensitivity (transfer function gain). These changes could partly explain the susceptibility to orthostatic instability in subjects with SCI.

Support: Rick Hansen Man In Motion Research Foundation.

Cardiovascular Control and Post-exercise Hypotension Following Arm Cycling Exercise in Subjects with SCI
Victoria E. Claydon, Ph.D.1; Adrienne T. Hol, M.Sc.1-3; Janice J. Eng, Ph.D., PT/O.T.1-3 and Andrei Krassioukov, M.D., Ph.D.1-3
1International Collaboration On Repair Discoveries (ICORD); 2School of Rehabilitation Sciences, University of British Columbia; 3GF Strong Rehabilitation Centre; Vancouver, BC, Canada.

Objective: Individuals with spinal cord injury (SCI) are prone to orthostatic hypotension. We aimed to examine the severity of post-exercise hypotension (PEH) in individuals with SCI.

Design: Prospective clinical study.

Participants/Methods: Individuals with chronic cervical (n=19; 18 male; aged 39±2 years) and thoracic (n=8, 5 male; aged 32±3 years) SCI underwent graded arm cycling until peak oxygen uptake was attained. Throughout testing we continuously recorded 12 lead ECG and breath-by-breath oxygen uptake. Before and for 5 mins after cessation of exercise we measured heart rate and blood pressure. Motor and sensory function was determined by ASIA score in all subjects, and autonomic function by sympathetic skin responses (SSR; 10 cervical; 6 thoracic).

Results: Resting blood pressures and heart rates were lower in cervical SCI than thoracic SCI (mean arterial pressure [MAP]: cervical 77±2 and thoracic 93±3 mmHg; p<0.001). Heart rate responses to exercise were greater in thoracic SCI (159±4 versus 105±4 bpm; p<0.001). MAP increased with exercise in thoracic SCI (+8±4mmHg) and decreased in cervical SCI (-9±2mmHg), p<0.001. Recovery from exercise was associated with marked PEH in cervical (MAP 67±3 mmHg) but not in thoracic SCI (MAP 102±3mmHg), p<0.001. One subject with cervical SCI (C6 ASIA B) had preserved unilateral palmar SSR; despite this he still exhibited PEH. One subject with thoracic SCI developed PEH (she declined to participate in SSR). All thoracic SCI in whom SSR were recorded showed normal palmar SSR. Interestingly, 2 subjects with cervical SCI (C7 ASIA D and C4 ASIA A) did not develop PEH, despite absent palmar SSR.

Conclusion: Cardiovascular responses to exercise were abnormal and PEH common in subjects with cervical, but not thoracic SCI. This may be related to the loss of descending sympathetic nervous control of the heart and vasculature following high SCI.

Support: Rick Hansen Man In Motion Research Foundation.

Objective: To compare the ischial pressure (IP) changes with SNRS to that with conventional gluteus surface FES.

Design: pilot, within patient control

Participants/Methods: 7 SCI (C4-T5) were recruited for non-invasive sacral functional magnetic stimulation (FMS) study; 3 of them (C4-T5) were recruited for surface FES study; 5 SCI patients (34-62yrs; T3-T10) with a sacral anterior root stimulation (SARS) implant were recruited for SARS study. FMS was delivered through a large circular coil (Medtronic Dantec MagPro) to active SNR; SARS was applied on S2 nerve root via a Finetech-Brindley SARSI. FES was provided with a 2-channel stimulator (MICROSTIM2(V2)). IP were measured by interface pressure mapping (Xsensor).

Results: Maximum 28% reduction of IP was achieved (164.7mmHg ± 13.35 vs. 117.5mmHg ± 8.40, p=0.006) in 7 SCI during optimal FMS; Maximum 25% reduction of IP was achieved (182.3mmHg ± 2.96 vs. 136.1mmHg ± 3.42, p=0.001) in 3 SCI during optimal FES. During optimal SARS, Maximum 33% reduction of IP was achieved (148.6 mmHg±10.0 vs. 99.8mmHg± 6.7, p=0.002) in 5 SCI with a SARSI; In 3 SCI who were provided FMS & FES, reduction of IP during FMS was greater than that with FES (p=0.07); In the groups as a whole, reduction of IP with FES was smaller than that with FMS & SARS (P=NS).

Conclusion: SNRS can significantly reduce ischial pressure; the magnitude of ischial pressure reduction with SNRS is greater than that with conventional surface FES.

Support: This project is funded by RNOHT.

SCI and Assistive Devices: Understanding the Challenges of Today’s Parents
Anita Kaiser, B.Sc., M.Sc.(candidate)1, 2; Kathryn A. Boschen, Ph.D. 1, 2; Denise Reid, Ph.D. 1; Fraser Shein, Ph.D., P.Eng. 1, 3
1University of Toronto, Toronto, ON; 2Toronto Rehabilitation Institute, Toronto, ON; 3Bloorview MacMillan Children's Centre, Toronto, ON

Objective: To understand the experiences of parents with SCI and the role assistive devices (ADs) play in meeting their needs as independent caregivers of young children.

Design: Mixed methods incorporating written questionnaires with semi-structured interviews.

Participants/methods: A convenience sampling technique was used to recruit parents with SCI who had had a child post-injury, currently under six years of age. ADs were classified as store bought, store bought and modified, or home-made, and they were categorized according to utility of childcare activity. Frequency counts were used to analyze the questionnaire and the interviews were analyzed using Grounded Theory.

Results: 12 parents with SCI (6 men and 6 women) participated in the study. Eleven participants had full hand function and one had limited hand function. Results confirmed that ADs and adaptive techniques play a key role in the parents’ involvement with their children. The questionnaire determined feeding to be the most important activity for parents with SCI to be involved in with their child and carrying/transporting to be the least important. Differences were found among men and women regarding use of ADs. The most commonly reported AD essential to the parents’ needs was the reacher. The activity most lacking a suitable AD was bathing. Themes identified in the interviews were 1) the significance of independence to the parents, 2) the role of the parent with SCI, and 3) parents’ fears and safety concerns. Use of ADs, and barriers and facilitators to parenting with SCI were woven throughout these themes.

Conclusions: The participants’ experiences have provided insights and recommendations for other current or future parents with SCI, healthcare providers, and AD manufacturers regarding solutions to challenges parents with SCI encounter when caring for their young children, access and availability of resources and services, and modification or development of ADs to meet their needs.

Support: Anita Kaiser was the recipient of a Studentship Award through the Ontario Neurotrauma Foundation.

Objective: The iAn increasing incidence of incompletecervica cSCI has resulted in more varying iable sensory impairments and functional consequences. making methods for sensory quantification a priority. SStandard ASIA testing is not sensitive to subtle sensory changes during recovery. Therefore, the objective of this work is the Development of a method to provide a ddevelopment of a detailed evaluation of multi-modal sensation following cervical SCI to: discriminate changes in sensorimotor recovery, measure responsiveness to interventions, and relate sensation to hand function.

Design: A A ccross- sectional study measuring multi-modal sensorimotory function was conducted in acute and individuals with chronic cervical cSCI. (n=30).

Participants/methods: PAll participants were individuals with cSCI (n=30; were medically stable (>6 weeks post- injury;). Level of injuries ranged from injury level C4-T1). All individuals were tested using Semmes Weinstein Monofilaments (SWM), Vibration Sense (VIB) and Static Two Point Discrimination (S2PD) were tested in selected test locations (SWM=-14;, VIB=-5,; S2PD-=7) on both the palmar and dorsal surfaces of the hand. Data were mapped, coded, pooled and grouped (complete injuries separateely from incomplete). according to ASIA level.

Results: Individually and collectively the new three tests were method of sensory quantification was more sensitive than ASIA sensory levelstesting. There were inter-modality differences within individuals and differences between the complete and incomplete groups. Individuals with complete injuries were found to have had sensation often one level caudal to ASIA sensory levels to the ASIA sensory level, while individuals with incomplete injuries were found to hadve sensation one to three levels either rostral or caudal to ASIA sensory levels. to the ASIA sensory level. These results suggest that a A new standard method forof sensory quantification isis required as for cSCI Understanding the sunderstanding in the changes in sensation during the recovery can phase influence level of function. The ability to quantify sensory impairment can influence informing new development of therapeutic interventions.

.Conclusions: A new method of sensory level evaluation for cervical SCI has been derived specific to the hand, and can be useful in for evaluating subtle neurological change of hand sensation in cSCI has been developed.

Support: This project was supported by the Ontario Neurotrauma Foundation and the Toronto Rehabilitation Institute Student Scholarship Foundation..

Objective: Find a neurophysiologic test to quantify the responsively of bladder detrusor muscle to Botulinum toxin injections.

Design: Case report.

Participans/methods: Three subjects affected by detrusor hyperactivity in spinal cord lesions: a) 24 year old woman, SCI with C6 level, Frankel class D; b) 59 year old woman, light spastic paraparesis due to transverse myelitis; c) 40 year old man, SCI with T1 level, Frankel class A. They were previously treated with Botulinum toxin (BTX) A injections into detrusor muscle and showed clinical resistance. To confirm the resistance to type A, and to verify the sensibility to type B toxin, the extensor digitorum brevis (edb) CMAPs elicited by stimulation of the peroneal nerve before and after BTX injections into the muscle, were recorded; the post B M-amplitude was expressed as percentage of the pre injection one. Finally, a bladder treatment with 5000 UI of BTX B was performed.

Results: With the edb test the resistance to BTX A was confirmed; after BTX B the M-amplitude decreased of 77% in case a, 70% in b and 28% in c. Finally, after the detrusor BTX B injections an increased bladder capacity was observed in the three cases, but while the effect persisted for more than six months in case a and b, in case c it disappeared after one month.

Conclusion: All the subjects were responsive to detrusor BTX B treatment as to edb injections, but case c showed a low response to the edb injection and a transitory effect on bladder. This result indicates that the edb test can predict the detrusor muscle response to Botulinum toxin injection.

Design: Randomized controlled clinical trial

Participants/methods: 12 participants (mean age = 44.4 years) with chronic paraplegia (below T7) were randomly assigned to a diet and exercise group (DE; 1000kcal+ACE 3X/wk X 12weeks, diet only group (DO; 1000kcal diet), or a control group (CG). Participants completed a graded peak exercise test at baseline, 3 and 6 months later Continuous ECG was recorded throughout the test, and expired air to measure aerobic capacity (VO2) was collected through indirect calorimetry. Participants’ height and weight were evaluated at the same 3 time points

Results: The average body mass index (kg/m2) for DE reduced from 29.1(baseline) to 27.1(3 months) to 26.8(6 months); DO = 31.2 (baseline) to 29.2(3 months) to 28.4 (6 months post) and CG = 26.9(baseline), 26.6 (3 months) and 25.6 at 6 months. The sub-maximal HR and VO2 as a percentage of peak for DE = 75%bpm [baseline], 75%bpm [3 months], 81%bpm [6 months]; DO = 82%bpm [baseline], 79%bpm [3 months] 86%bpm [6 months]; CG = 73%bpm [baseline], 73%bpm [3 months] and 75%bpm [6 months]) and VO2 for DE = 66%ml/kg [baseline], 70%ml/kg [3 months] with increased wattage, 68%ml/kg [6 months]; DO = 70%ml/kg [baseline], 71%ml/kg [3 months], 78%ml/kg [6 months] with decreased wattage; CG = 67%ml/kg [baseline], 64%ml/kg [3 months] and 72%ml/kg [6 months]).

Conclusions: There was variability in HR and VO2 that may have been due to the intensity of training and/or the effort exerted during exercise testing and training. There appears to be a benefit from both a 3 month supervised exercise and dietary intervention and a dietary intervention alone in paraplegia. Interpretation of these results is limited due to the small sample size.

Support: NIDRR Grant (#H133N000022) and the Henry H. Kessler Foundation

Objective: To determine the effect of concurrent flow respiratory resistance training (RRT) device on respiratory function and aerobic power in wheelchair athletes.

Design: A randomized pretest-posttest control group design, using matched subjects.

Participants/methods: Ten male wheelchair athletes (8 with spinal cord injuries (SCI), 1 with a neurological disorder and 1 with post-polio), were matched by lesion level and/or track rating before random assignment to either a RRT group (n=5) or a control group (CON, n=5). RRT group performed one set of breathing exercises using concurrent flow resistance device 2-3 times daily for 10 weeks. Pre/post-testing included measurement of maximum voluntary ventilation (MVV), maximum inspiratory pressure (MIP), and peak oxygen consumption (VO2peak).

Results: Repeated measures ANOVA revealed a significant group difference in change for MIP from pre to post-test (F1, 7 =6.39, p=.039). The treatment group improved by 33.0 cmH20, while the control group improved by only 0.6 cmH20. Although not significant, the MVV for the treatment group increased and decreased for the control group. The sample size could be a contributing factor to the results not being significant. There was no significant difference between VO2 for pre/ post-testing.

Conclusion: These data demonstrate that a 10-week training protocol can effectively improve MIP in wheelchair athletes. Although results were not significant with other variables, the changes reported with the MVV reinforce the possible benefits of this device. Further research and a larger sample size may be warranted to further characterize the impact of Expand-a-Lung™ on performance and other respiratory variables.

Support: This project was funded by Expand-a-Lung™

Objective: Develop an original user-friendly vibrator specifically suited to the sexual health ( and potentially fertility ) needs of men and women with spinal cord injury (SCI).

Design: Comprehensive product R&D, based on the ISO 13485 design quality system.

Participants/methods: Six males and 4 females with SCI. Two panels of structured gender-separated focus groups were employed to inform the VSD design team en route to design and development of the new prototype VSD. Eight Sexual Health clinicians also provided formal feedback throughout the VSD R&D process.

Results: Two functional VSD prototypes were created, one male, one female version.

Conclusion: A patent on the project VSDs has been applied for. Clinical ready VSD prototypes are being produced for upcoming field trials, results which we anticipate will be presented. Clinical field trials will lead to final prototype designs, and enable the project team to engage a commercial partner with the goal of bringing a new, affordable, and user-friendly VSD (targeted to SCI users) to the retail market.

Support: This project was funded by the Rick Hansen Man in Motion Research Fund / International Collaboration on Repair Discoveries (ICORD).

Objective: Develop a comprehensive program for the evaluation and treatment of children with acute spinal cord injuries.

Design: Program development and evaluation

Participants/methods: The Center for Pediatric Spinal Cord Injury is a clinical, educational and scientific collaboration between Shriners Hospitals for Children Philadelphia and Temple University Children’s Medical Center. The two individual hospitals, although one physical building, have fostered strong foundations at the administrative, medical and rehabilitative levels to promote the growth of this regional pediatric SCI program.

A child with an acute injury arrives at Temple Children’s trauma bay and is treated by a team of pediatric emergency medicine, neurosurgical and orthopaedic specialists and registered nurses. After stabilization and admission into Temple Children’s PICU, rehabilitation begins with evaluation and treatment by therapists from both facilities. Once medically stable for inpatient rehabilitation, the child is then transferred to Shiners Hospital. Upon discharge from rehab, the child is followed closely every few months until the age of 21.

The joint center addresses all medical and rehabilitative aspects of spinal cord injury, while focusing on how symptoms, sequelae and treatment of spinal cord injury can be different in the pediatric population, such as SCIWORA, hip subluxation/dislocation and neuromuscular scoliosis.

The combined center also offers access to new therapies and investigational techniques that may result in improving outcomes and advancing the field of neurological surgery, orthopaedics, urology, and spinal cord rehabilitation medicine.

Results/Conclusion: Collaborative efforts have allowed for the development of a regional program that provides rapid assessment, stabilization, innovative rehabilitation techniques and follow-up care for children and adolescents with spinal cord injuries.

Objective: To clarify relationship between types of spinal column injury according to Allen’s classification and time course of neurological injury.

Methods: A prospective analysis was performed on 78 consecutive patients (65 male, 13 female; average age:49 years) with cervical spine injury between 2001-2003. The patients were classified according to Allen’s classification into Group H-D (higher graded distractive injury: DF stage (S) 4, DES2), Group L-D (lower graded distractive injury: DFS1-3, DES1), Group H-C (higher graded compressive injury: CFS4-5, VCS3, CES4-5, LFS2) and Group L-C (lower graded compressive injury: CFS1-3, VCS1-2, CES1-3, LFS1). The time courses of neurological injury were compared between four groups.

Results: At injury, there were 15 complete tetraplegic patients (75%) in Group H-D, 5 (38.5%) in Group L-D, 23 (88.5%) in Group H-C and 9 (47.5%) in Group L-C. At the latest follow-up, there were 12 complete tetraplegic patients (60%) in Group H-D, 3 (23.1%) in Group L-D, 19 (73.1%) in Group H-C and 6 (31.6%) in Group L-C. On the other hand, the time course (at injury/1-month/2/3/4/5/at the latest follow-up) of motor score was 26/32/34/36/37/38/40 in Group H-D, 46/60/64/66/69/70/75 in Group L-D, 24/34/38/39/40/40/42 in Group H-C and 44/57/61/62/63/63/63 in Group L-C. Neurological outcomes of the lower graded distractive injury were more favorable than those of higher graded compressive or distractive injuries.

Conclusion: Time courses and outcomes of neurological injuries depended on the type and severity of spinal column injury in the cervical spine.

Effects of Elastic Abdominal Binders on Voluntary Cough in Persons with Spinal Cord Injury.
Sa’ari M.Yatim, M.D.; Nazirah Hasnan, M.D.
Rehabilitation Medicine Division, Department of Allied Health Sciences, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.

Objectives: To examine the effectiveness of two different types of elastic abdominal binders on voluntary cough in persons with spinal cord injury (SCI).

Design: Cross-sectional, experimental study.

Setting: The outpatient clinic at the Medical Rehabilitation Unit, University of Malaya Medical Centre, Kuala Lumpur, Malaysia.

Participants/methods: Twenty one (21) SCI patients with injury levels between C1 and T6. Voluntary cough was assessed by measuring the peak expiratory flow rate (PEFR) with and without an elastic abdominal binder during upright sitting. The PEFR was measured using the Assess Peak Flow Meter. Two types of commercially available single-strap and triple-strap elastic abdominal binders of the same make were used. The triple-strap abdominal binders were applied on the abdomen with graduated decrease in tension from the bottom to the top.

Results: The mean cough PEFR in all subjects without abdominal binders was 277.1 L/min, with single-strap AB 325.7 L/min and with triple-strap AB was 345.2 L/min. The abdominal binders did significantly increase cough PEFR in SCI patients especially among tetraplegic. The single-strap abdominal binders significantly increased cough PEFR by 17.5%. The triple-strap abdominal binders significantly increased cough PEFR by 24.6%.

Conclusion: These results indicate that both single-strap and triple-strap elastic abdominal binders can be used as an effective method to improve coughing ability in SCI patients especially in persons with tetraplegia.

Support: Short term research grant (Vote F) from the Ministry of Education, Malaysia.

Objective: During hurricanes the wide spread loss of electricity can cause significant problems for high spinal cord injured patients dependent on ventilators. This study demonstrates the difficulty these patients have during natural disasters associated with power loss and the benefits of the DPS system.

Design: Retrospective analysis of patients who live in hurricane ravaged areas involved or evaluated in an FDA trial of the DPS System for electrical activation of the diaphragm for ventilatory assist.

Participants/methods: Patients in effected areas were interviewed concerning their responses to hurricanes Dennis(7/05), Katrina(8/05) and Rita(9/05). Ventilator batteries last from only 1-8 hours before requiring electricity for recharging while the DPS system uses a standard disposable external battery that lasts 500 hours and patients have a stock of batteries.

Results: In summary, all patients experienced loss of electricity during the hurricanes. The problems of being on a ventilator during hurricanes included: risks and fuel shortage with external generators to power ventilators, evacuation centers not equipped for quadriplegics (a special need shelter refused entry of one patient as being too “sick”), hospitals not willing to accept patients just for ventilator power, and traveling with ventilator to areas out of the threat of loss of power is difficult, expensive and time consuming. In three patients with the DPS system the benefits included: loss of electricity alone no longer a concern, evacuation easier(less packing) and transportation simplified; less need for space or additional personnel. One patient with the DPS system who lost her home to Rita states the lack of noise and space from a ventilator simplifies living in a crowded temporary facility.

Conclusions: Hurricanes are devastating and a significant cause of anxiety in ventilator dependent quadriplegics. The DPS system improves the quality of life during these events by decreasing anxiety, easing evacuation, and simplifying temporary housing.

Introduction: Despite policy statements from the American Academy of Pediatrics against home or school use of trampolines, the occurrence of trampoline injuries continue to rise. While many trampoline injuries may not be life-changing, approximately 6% of children enrolled in the Shriners Hospital for Children(SHC) Spinal Cord Injury(SCI) database with a sports related injury, from 1990-2004, sustained SCI from trampoline accidents.

Objective: The purpose is twofold. First a review of cases of SCI due to trampoline injury with regard to neurological level, age, and severity will be presented. Secondly, the outcomes of two children with SCI secondary to trampoline use will be described.

Design: Retrospective database and chart review.

Participants/methods: Children enrolled in the SHC SCI database with SCI due to trampoline accidents from 1990-2004. Two children randomly chosen for chart review.

Results: Age range:11-16(mean age,14.15); 12(92%)boys, 1(8%)girl;
12(92%)tetraplegic, 1(8%)paraplegic; 9(69%)complete, 4(31%)incomplete.

Subject A: Sixteen-year-old, L1, complete, paraplegic, female injured at
11-years-old. Sustained fracture-dislocation of T12-L1. Modified Independent with self-care activities; utilizes manual wheelchair. Subject B: Eighteen-year-old, C3-C4, incomplete, tetraplegic, male injured at 14-years-old. Sustained acute cervical cord compression, respiratory arrest, and loss of consciousness. Dependent with self-care activities, ventilator dependent, and utilizes power wheelchair.

Conclusion: Children are at increased risk for SCI resulting in significant neurological impairment from trampoline injuries. Nurses are in a pivotal position to partner with community based programs to heighten the awareness of the risk of SCI due to trampolines.

Support: This project was supported by Shriners Hospital for Children Philadelphia, Chicago, and Northern California hospitals.

The Montecatone Rehabilitation Hospital receives spinal injuries patients coming from all around the country.
In 2003 the hospital has been organized in two departments: the Rehabilitation Medicine Department and the Reintegration Department.

The Reintegration Department coordinates, working in together with the rehabilitation team, all the actions that can be taken in order to build a life project that includes the disability.
Due to the consistent amount of patients aged 12 to 20, the Reintegration Department has activated a pathway for a school inside the hospital.

The school attendance is the quintessential rehabilitation tool: the school is the place where the young person can test his intellectual capacity, find the relation with his equals and see confirmed a functioning system that will be fundamental for the future.

The rehabilitation involves a succession of “lessons”: the school offers the learning and facilitates the activity in the gymnasium, but needs all the clinical and social information on the patient.

When a young patient is known to be admitted into hospital, the social worker activates the pathway. An “enlarged team” (teachers, rehabilitation team, reintegration workers) is organized with frequent meetings made to check the clinical situation and the compatibility between the rehabilitation work and the school pathway.
An orderly contact with the school of the area of residence of the patients arranged and also video lessons are provided.

At the discharge the patients and their families receive a folder with the activities that have been done and the activities that can possibly be undertaken at home.

Objective: Traditionally, the growth of the prostate gland and the development of prostate cancer has been regarded as mainly hormone dependent. Autopsy studies have indicated that prostate cancer may be less common in patients with high spinal cord injury (SCI) and some studies also show that the prostate glands of patients with high complete lesions are smaller than matched controls but data is conflicting. A smaller prostate size in SCI patients may indicate that factors relating to innervation play an important role in prostate growth. The objective of this study was to investigate whether patients with high SCI differ from screening population with regard to prostate size, histology and PSA levels.

Design: Single arm pilot study.

Participation/methods: 9 patients aged 50 or more with high SCI (Th1 and above) dating back at least 5 years were examined with regard to prostate volume, prostate histology, hormonal and PSA levels.

Results: Patients with SCI aged 59±7 (mean±SD) had a mean PSA of 1,1±0,9 and testosterone, SHBG, LH, FSH were within normal range. Mean prostate volume was 22±6ml. Histological examination revealed prostate intraepithelial neoplasia (PIN) in one of 8 biopsies in one patient and signs of chronic inflammation in four patients.

Conclusion: Patients with high SCI had smaller prostates and PSA levels in the lower range compared to reported values for men without SCI of the same age range in screening populations. The findings corroborate previous data indicating that high complete SCI may affect prostate growth and the normal hormonal levels indicate that factors relating to innervation may play an important role as trophic factors in the prostate. Whether prostate carcinogenesis is also affected remains to be elucidated in larger studies and in further analysis of the present material.
Support: No financial interests.

Objective: To gain a better understanding of the long term outcomes of continent urinary diversion in children with spinal cord injury (SCI).

Design: Descriptive retrospective.

Participants/methods: Individuals 5-27 years of age with SCI one year status post continent urinary diversion. Objective data collected via retrospective chart review includes: general demographics, and medical/surgical history. Subjective data collected via structured telephone interview includes: history of adverse urological events, bladder management, Functional Independence Measure (FIM) scores, patient satisfaction, and quality of life.

Results: Fifteen subjects (12 females, 3 males) with a mean age of 19 years (range 5-27) who underwent continent urinary diversion were interviewed . Mean age at urinary diversion was 15 years (range 5-20). Four (4) subjects underwent bladder augmentation with urinary diversion. Complications included: stenosis 27% (n=4) with a mean of 19 months to first occurrence of stenosis; urethral incontinence 73% (n=11); renal/bladder calculi 20% (n=3) and; stomal leakage 40% (n=6). Sixty-seven percent (67%) of subjects obtained yearly urological follow-up. Independence in bladder management revealed a mean (FIM) subscore of 2.2 before urinary diversion and 4.8 after urinary diversion. Subjects required a mean time of 11 minutes for bladder emptying pre-operatively compared to 6 minutes post urinary diversion. Subject satisfaction revealed 87% (n=13) were satisfied with the procedure while 13% (n=2) were somewhat satisfied. Eighty 80% (n= 12) of subjects also felt a change in comfort level during social outings. A thematic analysis of quality of life revealed that freedom (35%) and independence (35%) were most commonly cited. All (100%) subjects recommended continent urinary diversion.

Conclusion: While some subjects experienced complications patient satisfaction was relatively high and level of independence in bladder management was greatly improved. This study demonstrates continent urinary diversion is a beneficial option to improve independence and ease of bladder management in children with SCI.

Objective: To assess the relationship between the prevalence of pressure sores in subjects with spinal cord injury (SCI) who are taking antispasticity medications and/or alcohol.

Design/ Participants: A prospective study from data collected from three outpatient clinics. The data were collected from October 1998- January 2000.

Results: Sixty-six SCI subjects from 3 outpatient clinics participated in this study. Of these, 38 subjects were ASIA A type SCI; 10 with ASIA B; 12 with ASIA C and 6 with ASIA D. Thirty-four of the 66 subjects were on antispasticity medications; and 21 of the 34 (62%) subjects developed sores; and of the 32 subjects were not on antispasticity medications 16 (50%) developed sores. Of the total population, 5 subjects were on Diazepam; 21 subjects were on Baclofen; and 1 patient was on Tizanidine. Thirty-seven of the 66 subjects (54%) had pressure. Eighty percent of subjects on Diazepam developed sores, while 54% of subjects who were not taking Diazepam developed sores. Fifty-two percent of subjects on Baclofen developed sores, while 58% of subjects not on Baclofen developed sores. One subject on Tizanidine did not develop a sore, while 57% of subjects not on Tizanidine developed sores. Chi-Square indicated no significant correlation existed between pressure sores prevalence in subjects taking antispasticity medications. Thirty-two of the 66 subjects (48%) were drinking alcohol. As the subjects’ alcohol caloric intake increases, their risk in developing pressure sores also increases but there was no statistical difference.

Conclusion: There is an increase trend of pressure sore prevalence in subjects taking antispasticity medications and as their alcohol caloric intake increases even though there is no statistical significance shown due to the limitations of the study, which are small number of subjects and study design. Further study in this area is indicated to determine if significant correlation exists.

Objective: Compare survival after inpatient rehabilitation for cancer related myelopathy and traumatic spinal cord injury

Design: Cross-sectional cohort study

Participants/methods: IRB approved study of 314 individuals with cancer related spinal cord injury or traumatic spinal cord injury dismissed from a tertiary care inpatient rehabilitation unit from January 1, 1995 through December 31, 2003. Medical records review and a telephone survey was used to determine the survival status of the research participants. Cancer type was divided into three groups: intramedullary tumors, extramedullary tumors, or metastatic tumors. Statistical comparison using Cox proportional hazards and multivariate analysis between three groups of cancer related spinal cord injury, (metastatic, intramedullary and extramedullary) was performed for survival, and FIM change. Chi Squared or Wilcoxon Tests for non parametric data were performed to compare outcomes from cancer related myelopathy and traumatic spinal injury.

Results: 46 people had intramedullary tumors, 37 had extramedullary tumors, 41 had metastatic tumors and 190 had traumatic myelopathy. Average duration of follow-up was 4.1 ± 2.9 years. By the point of follow up 87 people had expired. Among individuals that expired, the mean survival duration was 4.6 years for people with cancer related myelopathy and 6.9 years for traumatic myelopathy (p<0.001). Significant differences existed between the mean time to death for the cancer groups (1.4 years for metastatic, 7.1 years for intramedullary and 4.8 years for extramedullary; p<0.0001). Both age and cancer group determined survival rates. However the survival of individuals with intramedullary tumors and traumatic SCI was the same.

Conclusion: After inpatient rehabilitation, the survival of people with intramedullary tumors is similar to the survival of people with traumatic SCI. Survival after rehabilitation for metastatic myelopathy is expectedly short. Individuals with extramedullary tumors have a survival duration intermediate between metastatic myelopathy and intramedullary tumor related myelopathy.

Objective: C5 palsy is a known complication of cervical decompressive procedures most commonly associated with spondylotic myelopathy or OPLL. Postoperative delayed radiculopathies developing in trauma patients with spinal cord injury are uncommon and may go undiagnosed or under-reported.

Design: Case report and literature review

Participant/methods: Postoperative trauma patient with a central cord injury

Results: A 41-year old white male with undiagnosed cervical myelopathy presented after a fall while intoxicated. Clinical exam was consistent with a severe central cord syndrome with minimal hand function and significantly weak triceps, wrist flexion, and wrist extension. The patient underwent a major spinal reconstructive surgery consisting of anterior and posterior decompression and stabilization. Approximately 48 hours following surgery, the patient developed a delayed C5-6 palsy and worsening of his C7 symptoms on the right arm. The left upper and lower extremity improved slightly in function postoperatively. The literature is reviewed with respect to postoperative delayed radiculopathies in non-traumatic and traumatic spinal cord injuries. Emphasis is given to respective reviews of the non-surgical and surgical literature as to the treatment and outcome of these delayed postoperative radiculopathies in spinal cord injury patients.

Conclusion: The management of delayed cervical radiculopathies remains controversial and, perhaps, under-reported. Further investigation is warranted.

Objective: To report five patients, who sustained cervical spinal cord injury while playing football (soccer)

Design: Retrospective review of hospital records

Methods: Five adult male patients were admitted to spinal unit in Southport between 1980 and 2005 with football
(soccer)-related spinal cord injury.

Results: Clinical details are summarised below:
Year Age when injured Findings of Medical Imaging Description of the accident Neurological level ASIA Scale Treatment provided Outcome
1980 24 X-ray: Fracture of C3-C6 Spinous processes Collided head first with team-mate while diving for a ball C-5 B Cervical collar No Recovery
1986 37 X-ray: C4/C5 Fracture Dislocation Fell, driven to the ground after tackling opposing player C-4 A Cervical traction Manipulation under anaesthesia Lesion ascended to C-0. Died of respiratory failure.
2000 18 MRI: Increased signal in the C7/T1 disc Fell down after head being pushed backwards C-8 D Cervical collar Further recovery of neurology was observed
2004 21 X-ray: C6 Burst fracture Tackled from behind, lost balance landed on its head C-6 A Anterior fusion C-5 to C-7 Improved to ASIA B
2005 53 MRI: C3-C4 high signal with expansion of the cord at this level Collided head first against a wall after being tackled from behind C-4 C Methyl prednisolone; Cervical collar Improved to ASIA D

Conclusion: These five cases illustrate that serious injury to cervical spinal cord may occur while playing football (soccer). Further, manipulation of cervical spine dislocation could result in ascent of neurological lesion with serious consequences.

Objective: To assess user satisfaction and improvement in function in spinal cord injured (SCI) persons receiving long term Intrathecal Baclofen (ITB).
Design: Audit questionnaire
Methods: A user questionnaire, consisting of 20 questions, was given to all 61 patients currently receiving ITB at Southport Spinal Unit.
Results: 42 patients returned the questionnaire. Their responses are summarised below

Q Symptoms Improved Equal Worse Not Applicable
1 Spasm severity 39 3 0 0
2 Spasm frequency 39 2 1 0
3 Stiffness/muscle tone 24 14 1 11
4 Global pain 16 15 0 11
5 Overall strength 23 12 1 6
6 Co-ordination 22 13 1 6
7 Speed of movements 21 11 2 8
8 Comfort level 33 7 0 2
9 Sleep pattern 30 10 2 0
10 Posture/Body image 19 15 5 3
Function
11 Feeding ability 14 15 1 12
12 Hygiene care 22 13 0 7
13 Dressing 27 8 1 6
14 Breathing pattern 11 22 0 9
15 Bladder & bowel 18 17 2 5
16 Sexual function 10 13 1 18
17 Transfers 25 9 1 7
18 Indoor mobility 22 13 0 7
19 Outdoor mobility 27 7 0 8
20 Recreational activities 29 9 0 4

Conclusion: These results show that ITB, although helpful in relief of spasms, adversely affected body image in a small group, did not improve indoor mobility in 13 patients, and 15 patients perceived no improvement in muscle tone.

Objective: To radiographically and clinically describe two patients with non-traumatic cervicothoracic syringomyelia and to report their outcome.

Design: Case series.

Participants/methods: Individuals who presented with progressive neurologic dysfunction who were found to harbor a cervicothoracic syringomyelia. Retrospective review of these patients’ chart was conducted. Pre- and post-operative studies, including magnetic resonance imaging (MRI), cine-MRI, post-myelography computed tomography (CT), and somatosensory evoked potential (SSEP) were obtained. Intraoperative findings and the patients’ surgical outcomes are reported. This study was approved by the institutional IRB.

Results: The patients both underwent multilevel laminectomy, lysis of adhesions, untethering of spinal cord, fenestration of syrinx, and duraplasty after preoperative imaging studies demonstrated clear evidence of CSF flow block at the level of the syrinx. Impressive arachnoiditis was found intraoperatively and the spinal cord was successfully untethered; free flow of CSF was noted to occur after fenestration of the syrinx. One patient’s neurological exam improved after surgery, while the other remained unchanged without further deterioration; both had radiographic decrease in the syrinx.

Conclusion: These two cases illustrate patients who develop a cervicothoracic syrinx in the absence of any trauma, infection, previous manipulation of the neuraxis, or malformations known to be associated with a syringomyelia. While there is no consensus on the optimal management of these patients, the patients reported here had arrest in deterioration or improvement of their neurologic exam, making the identification of this condition important as a potentially reversible cause of neurologic deficits. Long-term follow-up is required to determine the efficacy, durability, and lifestyle impact of the procedure, which is ongoing.

Stretch to Sit Protocol Following Myocutaneous Flap Repair
Julie D. Hill, PT; Cathy Koerner, RN, CWOCN, CWS
Shepherd Center, Atlanta, GA

Objective: Review of a protocol developed for post-surgical muscle flap repairs.

Design: Case study of procedures used.

Participants/methods: Spinal cord injured (SCI) individuals with recent myocutaneous flap repairs due to pressure ulcers on weight bearing bony prominences. Outlines a structured program of gradual stretching, massaging and progressive sitting.

Results: Functional range of motion of the hips, increased elasticity and strength of scar tissue, and good skin tolerance for sitting a full day.

Conclusion: Flap incisions typically remain intact for those patients who are able to begin this protocol 2- 3 weeks following surgery. Reduction in long term complications may also occur.