Wheelchair Axle Position Effect on the Propulsion Performance of Persons With C7 Tetraplegia: A Repeated-Measures Study.

Objectives: To assess the changes in speed, stroke frequency, acceleration, and shoulder range of motion (ROM) associated with different wheelchair axle positions in people with chronic C7 tetraplegia. Methods: This repeated-measures study was conducted at the Chronic Spinal Cord Injury Unit, FLENI Escobar, Argentina. The speed, stroke frequency, acceleration, and shoulder ROM during wheelchair propulsion were measured in nine participants with C7 spinal cord injury (SCI) in four different axle positions (forward and up, forward and down, backward and down, backward and up). Two strokes performed at maximum speed were analyzed on a smooth level vinyl floor in a motion analysis laboratory. Data were analyzed for significant statistical differences using the Friedman test and the Wilcoxon signed rank test. Results: Our study showed significant differences in the speed with axle position 1 (1.57 m/s) versus 2 (1.55 m/s) and position 2 (1.55 m/s) versus 4 (1.52 m/s). The shoulder ROM showed a significant difference in the sagittal plane in position 2 (59.34 degrees) versus 3 (61.64 degrees), whereas the stroke frequency and the acceleration parameters showed no statistically significant differences with the different rear axle positions. Conclusions: Our study showed that modifying the rear axle position can improve the propulsion speed and produce changes in the shoulder ROM in the wheelchair propulsion of individuals with C7 SCI.

Prediction of Balance After Inpatient Rehabilitation in Stroke Subjects with Severe Balance Alterations at the Admission.

BACKGROUND: Patients with severe motor alterations would be those on who the prediction of the expected motor response after inpatient rehabilitation programs is most required. OBJECTIVES: To analyze if the balance progress measured by the Berg Balance Scale and the time of hospitalization could be independent predictors of the Berg Balance at the end of a post stroke rehabilitation program in patients with severe balance alteration at the admission. Secondly, to compare a Berg Balance prediction model at the time of discharge based on the Berg Balance at the time of admission (model 1) to a Berg Balance prediction model at the time of discharge based on Berg Balance progress and the time of hospitalization (model 2). METHODS: Subjects suffering a first subacute supratentorial stroke admitted for inpatient rehabilitation between 2010 through 2018 were included to develop two linear regression models of predicted Berg Balance at discharge (n=149). RESULTS: According to model 1 (p < 0.0001, R2= 0.166), the Berg Balance at the admission would be a predictor of the Berg Balance at discharge from hospitalization. According to model 2 (p < 0.0001, R2= 0.993) the Berg Balance progress (ß= 1.026; p < 0.0001) and the hospitalization time (ß=-0.006; p < 0.0001) would be independent predictors of the Berg Balance at discharge. CONCLUSIONS: The motor response to the rehabilitation programs in subacute patients with severe motor alterations could be explained on the basis of balance condition at the admission, but this explanation may be improved considering the progress on the balance the patients achieve during inpatient rehabilitation irrespective the time of hospitalization.

Demographic and clinical characteristics of individuals with traumatic spinal cord injury in Argentina from 2015 to 2019: a multicenter study.

STUDY DESIGN: Descriptive and ambispective study. OBJECTIVES: To describe the demographics, clinical characteristics, and etiologies of traumatic spinal cord injury (TSCI) in a metropolitan region of Argentina. SETTING: Five inpatient rehabilitation centers in Buenos Aires, Argentina. METHODS: We included all patients with acute TSCI who required hospital treatment at five rehabilitation facilities between 2015 and 2019. We collected data using portions of the International Spinal Cord Injury (SCI) Core Data Set. RESULTS: We registered 186 individuals as having TSCI. The males were 77% of the total sample. The mean age was 36 (SD ± 15.7) years. The distribution between paraplegia and tetraplegia was 50.3% and 49.7%, respectively. TSCI was complete in 57.3%. Including patients with motor complete SCI, the percentage reached 71.9% of the sample. Vehicular collisions were the leading cause of TSCI (47.3%), followed by falls (21.5%) and assaults (16.1%). CONCLUSIONS: We collected data about demographics, clinical characteristics, and aetiologies of TSCI for the first time in Argentina. The predominant demographic profile of the individuals with TSCI was of young males with complete SCI. We found the most important cause of TSCI was vehicular collisions. Implementation of road safety strategies in this target population might decrease the incidence of TSCI.

[Multidisciplinary rehabilitation for adult patients with stroke]. / Rehabilitación multidisciplinaria para pacientes adultos con accidente cerebrovascular.

It is estimated that two thirds of people who have suffered a stroke have sequels that condition their quality of life. The rehabilitation of the stroke is a complex process, which requires the multidisciplinary approach of specialized professionals (doctors, kinesiologists, nurses, occupational therapists, phonoaudiologists, neuropsychologists and nutritionists). Currently, the practices carried out are a consequence of the combination of evidence and consensus, most of them through international stroke rehabilitation guides. The objective of this review is to adjust the international recommendations on stroke rehabilitation to what is applied to daily practice, in order to unify the criteria of the recommendations and to reduce the variability of the practices carried out. This work is a review of the literature on stroke rehabilitation guides developed in the last 10 years. Each section was supervised by different professionals specialized in these areas. We analyze the time and organization necessary to develop rehabilitation, recommendations for motor, cognitive and visual rehabilitation, the management of dysphagia and nutrition, the approach of comorbidities (venous thrombosis, skin ulcers, pain, psychiatric disorders and osteoporosis) and the necessary tasks to favor the return to the activities of daily life.

Se estima que dos tercios de las personas que han sufrido un accidente cerebrovascular (ACV) tienen secuelas que condicionan su calidad de vida. La rehabilitación del ACV es un proceso complejo, que requiere de un equipo multidisciplinario de profesionales especializados (médicos, kinesiólogos, enfermeros, terapistas ocupacionales, fonoaudiólogos, neuropsicólogos y nutricionistas). Actualmente, las prácticas realizadas en rehabilitación son consecuencia de la combinación de evidencia y consenso, siendo la mayoría aportadas a través de guías internacionales de rehabilitación en ACV. El objetivo de esta revisión es ajustar las recomendaciones internacionales sobre rehabilitación a lo aplicado a la práctica diaria, a fin de unificar criterios en las recomendaciones y reducir la variabilidad de las prácticas empleadas. En este trabajo, se realizó una revisión de la literatura sobre las guías de rehabilitación en ACV realizadas en los últimos 10 años y cada apartado fue supervisado por distintos profesionales especializados en dichas áreas. Se analizaron los tiempos y organización necesaria para desarrollarla, las recomendaciones para la rehabilitación motora, cognitiva y visual, el tratamiento de la disfagia y nutrición, de las comorbilidades (trombosis venosa, úlceras cutáneas, dolor, trastornos psiquiátricos, osteoporosis) y las tareas necesarias para favorecer el retorno a las actividades de la vida diaria.

Rehabilitación multidisciplinaria para pacientes adultos con accidente cerebrovascular / Multidisciplinary rehabilitation for adult patients with stroke

Se estima que dos tercios de las personas que han sufrido un accidente cerebrovascular (ACV) tienen secuelas que condicionan su calidad de vida. La rehabilitación del ACV es un proceso complejo, que requiere de un equipo multidisciplinario de profesionales especializados (médicos, kinesiólogos, enfermeros, terapistas ocupacionales, fonoaudiólogos, neuropsicólogos y nutricionistas). Actualmente, las prácticas realizadas en rehabilitación son consecuencia de la combinación de evidencia y consenso, siendo la mayoría aportadas a través de guías internacionales de rehabilitación en ACV. El objetivo de esta revisión es ajustar las recomendaciones internacionales sobre rehabilitación a lo aplicado a la práctica diaria, a fin de unificar criterios en las recomendaciones y reducir la variabilidad de las prácticas empleadas. En este trabajo, se realizó una revisión de la literatura sobre las guías de rehabilitación en ACV realizadas en los últimos 10 años y cada apartado fue supervisado por distintos profesionales especializados en dichas áreas. Se analizaron los tiempos y organización necesaria para desarrollarla, las recomendaciones para la rehabilitación motora, cognitiva y visual, el tratamiento de la disfagia y nutrición, de las comorbilidades (trombosis venosa, úlceras cutáneas, dolor, trastornos psiquiátricos, osteoporosis) y las tareas necesarias para favorecer el retorno a las actividades de la vida diaria.

It is estimated that two thirds of people who have suffered a stroke have sequels that condition their quality of life. The rehabilitation of the stroke is a complex process, which requires the multidisciplinary approach of specialized professionals (doctors, kinesiologists, nurses, occupational therapists, phonoaudiologists, neuropsychologists and nutritionists). Currently, the practices carried out are a consequence of the combination of evidence and consensus, most of them through international stroke rehabilitation guides. The objective of this review is to adjust the international recommendations on stroke rehabilitation to what is applied to daily practice, in order to unify the criteria of the recommendations and to reduce the variability of the practices carried out. This work is a review of the literature on stroke rehabilitation guides developed in the last 10 years. Each section was supervised by different professionals specialized in these areas. We analyze the time and organization necessary to develop rehabilitation, recommendations for motor, cognitive and visual rehabilitation, the management of dysphagia and nutrition, the approach of comorbidities (venous thrombosis, skin ulcers, pain, psychiatric disorders and osteoporosis) and the necessary tasks to favor the return to the activities of daily life.

Reliability of the Spanish version of the wheelchair skills test 4.2 for manual wheelchair users with spinal cord injury.

Study design: Cross-sectional.Objectives: The majority of people with a spinal cord injury (SCI) are dependent on wheelchair for their mobility. Approximately, 36% of wheelchair users reported that obstacles such as curbs, uneven terrain, flooring surfaces and thresholds were barriers to mobility. Several studies have shown that assessment and training of wheelchair skills leads to improvements in those skills. The purpose of our study was to translate the Wheelchair Skill Test (4.2) and its report form into Spanish and then determine the inter-rater reliability of the WST 4.2 for manual wheelchairs operated by their users.Setting: Rehabilitation Unit, FLENI Institute, Buenos Aires, Argentina.Methods: The translation was performed by a physical therapist with advanced English language skills and specialized in the treatment of SCI subjects. We administrated and video-recorded the WST 4.2 manual Spanish version in 11 SCI subjects. Two physical therapists received specific training for administering the test and scoring the record. The reliability of the total percentage WST score were statistically quantified by intraclass correlation coefficient (ICC).Results: ICC values for Interrater were 0.998 (p < .0001). 17 out of the 32 skills had a 100 percentage of agreement. Percentage of agreement in the three skills that presented less rating agreement was 73%, 81 % and 82 %, respectively.Conclusion: The results show that the Spanish version of WST 4.2 is a reliable assessment tool to evaluate the skills capacity of spinal cord manual wheelchair users.Implications for rehabilitationWheelchair users require a proficient management of various wheelchair skills to achieve maximum independence in daily life. Determining which wheelchair skills should be addressed during the rehabilitation process is of great importance for their correct training. The WST 4.2 is an appropriate assessment tool to determine the functional capacity of wheelchair users.Making available the WST 4.2 in the Spanish language and demonstrating its reliability in this language allows its use in the Spanish-speaking world. A reliable wheelchair skills test is needed in the Spanish language.

High-technology augmentative communication for adults with post-stroke aphasia: a systematic review.

INTRODUCTION: Augmentative and alternative communication (AAC) systems were introduced into clinical practice by therapists to help compensate for persistent language deficits in people with aphasia. Although, there is currently a push towards an increased focus on compensatory approaches in an attempt to maximize communication function for social interaction, available studies including AAC systems, especially technologically advanced communication tools and systems, known as 'high-technology AAC', show key issues and obstacles for these tools to become utilized in mainstream clinical practice. Areas covered: The current review synthesizes communication intervention studies that involved the use of high-technology communication devices to enhance linguistic communication skills for adults with post-stroke aphasia. The review focuses on compensatory approaches that emphasized functional communication. It also summarizes recommendations for the report of studies evaluating high-technology devices that may be potentially relevant for other researchers working with adults with post-stroke aphasia. Expert commentary: Taken together with positive results in heterogeneous studies, high-technology devices represent a compensatory strategy to enhance communicative skills in individuals with post-stroke aphasia. Improvements in the design of studies and reporting of results may lead to better interpretation of the already existing scientific results from aphasia management.

Shoulder Functional Electrical Stimulation During Wheelchair Propulsion in Spinal Cord Injury Subjects.

Background: Subjects with spinal cord injury (SCI) propel their wheelchairs by generating a different level of muscle activity given their multiple deficits in muscle strength. Exercise training programs seem to be effective in improving wheelchair propulsion capacity. Functional electrical stimulation (FES) therapy is a complementary tool for rehabilitation programs. Objectives: To determine the accuracy of the synchronization between the FES activation and the push phase of the propulsion cycle by using hand pressure sensors that allow anterior deltoids activation when the hand is in contact with the pushrim. Methods: We analyzed 2 subjects, with injuries at C6 American Spinal Injury Association Impairment Scale (AIS) A and T12 AIS A. The stimulation parameters were set for a 30 Hz frequency symmetrical biphasic wave, 300 µs pulse width. Data were collected as participants propelled the wheelchair over a 10-m section of smooth, level vinyl floor. Subjects were evaluated in a motion analysis laboratory (ELITE; BTS, Milan, Italy). Results: Subject 1 showed synchronization between the FES activation and the push phase of 87.5% in the left hand and of 80% in the right hand. Subject 2 showed synchronization of 95.1% in the left and of hand 94.9% in the right hand. Conclusion: Our study determined a high accuracy of a novel FES therapeutic option, showing the synchronization between the electrical stimulation and the push phase of the propulsion cycle.

Efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST): a randomised, multicentre, single-blind, controlled trial.

BACKGROUND: Non-immersive virtual reality is an emerging strategy to enhance motor performance for stroke rehabilitation. There has been rapid adoption of non-immersive virtual reality as a rehabilitation strategy despite the limited evidence about its safety and effectiveness. Our aim was to compare the safety and efficacy of virtual reality with recreational therapy on motor recovery in patients after an acute ischaemic stroke. METHODS: In this randomised, controlled, single-blind, parallel-group trial we enrolled adults (aged 18-85 years) who had a first-ever ischaemic stroke and a motor deficit of the upper extremity score of 3 or more (measured with the Chedoke-McMaster scale) within 3 months of randomisation from 14 in-patient stroke rehabilitation units from four countries (Canada [11], Argentina [1], Peru [1], and Thailand [1]). Participants were randomly allocated (1:1) by a computer-generated assignment at enrolment to receive a programme of structured, task-oriented, upper extremity sessions (ten sessions, 60 min each) of either non-immersive virtual reality using the Nintendo Wii gaming system (VRWii) or simple recreational activities (playing cards, bingo, Jenga, or ball game) as add-on therapies to conventional rehabilitation over a 2 week period. All investigators assessing outcomes were masked to treatment assignment. The primary outcome was upper extremity motor performance measured by total time to complete the Wolf Motor Function Test (WMFT) at the end of the 2 week intervention period, analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NTC01406912. FINDINGS: The study was done between May 12, 2012, and Oct 1, 2015. We randomly assigned 141 patients: 71 received VRWii therapy and 70 received recreational activity. 121 (86%) patients (59 in the VRWii group and 62 in the recreational activity group) completed the final assessment and were included in the primary analysis. Each group improved WMFT performance time relative to baseline (decrease in median time from 43·7 s [IQR 26·1-68·0] to 29·7 s [21·4-45·2], 32·0% reduction for VRWii vs 38·0 s [IQR 28·0-64·1] to 27·1 s [21·2-45·5], 28·7% reduction for recreational activity). Mean time of conventional rehabilitation during the trial was similar between groups (VRWii, 373 min [SD 322] vs recreational activity, 397 min [345]; p=0·70) as was the total duration of study intervention (VRWii, 528 min [SD 155] vs recreational activity, 541 min [142]; p=0·60). Multivariable analysis adjusted for baseline WMFT score, age, sex, baseline Chedoke-McMaster, and stroke severity revealed no significant difference between groups in the primary outcome (adjusted mean estimate of difference in WMFT: 4·1 s, 95% CI -14·4 to 22·6). There were three serious adverse events during the trial, all deemed to be unrelated to the interventions (seizure after discharge and intracerebral haemorrhage in the recreational activity group and heart attack in the VRWii group). Overall incidences of adverse events and serious adverse events were similar between treatment groups. INTERPRETATION: In patients who had a stroke within the 3 months before enrolment and had mild-to-moderate upper extremity motor impairment, non-immersive virtual reality as an add-on therapy to conventional rehabilitation was not superior to a recreational activity intervention in improving motor function, as measured by WMFT. Our study suggests that the type of task used in motor rehabilitation post-stroke might be less relevant, as long as it is intensive enough and task-specific. Simple, low-cost, and widely available recreational activities might be as effective as innovative non-immersive virtual reality technologies. FUNDING: Heart and Stroke Foundation of Canada and Ontario Ministry of Health.

Modulation of the default-mode network and the attentional network by self-referential processes in patients with disorder of consciousness.

Disorders of consciousness (DOC) are related to an altered capacity of the brain to successfully integrate and segregate information. Alterations in brain functional networks structure have been found in fMRI studies, which could account for the incapability of the brain to efficiently manage internally and externally generated information. Here we assess the modulation of neural activity in areas of the networks related to active introspective or extrospective processing in 9 patients with DOC and 17 controls using fMRI. In addition, we assess the functional connectivity between those areas in resting state. Patients were experimentally studied in an early phase after the event of brain injury (3±1 months after the event) and subsequently in a second session 4±1 months after the first session. The results showed that the concerted modulation of the default mode network (DMN) and attentional network (AN) in response to the active involvement in the task improved with the level of consciousness, reflecting an integral recovery of the brain in its ability to be engaged in cognitive processes. In addition, functional connectivity decreased between the DMN and AN with recovery. Our results help to further understand the neural underpins of the disorders of consciousness.

Walking ability after stroke in patients from Argentina: predictive values of two tests in subjects with subacute hemiplegia.

[Purpose] This study aimed to determine the predictive values of the trunk control test (TCT) and functional ambulation category (FAC) for independent walking up to 6 months post stroke. [Subjects] Twenty-seven subjects with hemiplegia secondary to a unilateral hemisphere stroke were included. [Methods] The protocol was started at 45 days post stroke, with the TCT and FAC as walking predictors. At 90, 120, and 180 days post stroke, the subjects' independent walking ability was assessed by using the Wald test. [Results] The TCT was identified as an independent predictor of ambulation at 90, 120, and 180 days. Subjects who scored ≥ 49 in the initial test had 93.8% probability of achieving independent gait at 6 months. The FAC proved that 100% of the subjects who scored 2 at 45 days post stroke walked independently at 90 days, 100% of the subjects who scored 1 walked independently at 120 days, and only 33.3% of the subjects who scored 0 walked independently at 180 days. [Conclusion] The TCT and FAC can predict independent walking at 45 days post stroke. In subjects with FAC 0, the TCT should be used to predict patients who will be able to walk independently.

A Spanish validation of the Coma Recovery Scale-Revised (CRS-R).

RESEARCH DESIGN: Analysis of inter-rater reliability and concurrent validity. OBJECTIVE: To determine measurement properties of a Spanish version of The Coma Recovery Scale-Revised (CRS-R). METHODS AND PROCEDURES: A sample of 35 in-patients with severe acquired brain injury. To test concurrent validity of the translated scale, the Glasgow Coma Scale (GSC) and Disability Rating Scale (DRS) were also administered. Two experts in the field were recruited to assess inter-rater agreement. RESULTS: Inter-rater reliability was good for total CRS-R scores (Cronbach α = 0.973, p = 0.001). Sub-scale analysis showed moderate-to-high inter-rater agreement. Total CRS-R scores correlated significantly (p < 0.05) with total GCS (r = 0.74) and DRS (r = 0.54) scores, indicating acceptable concurrent validity. CONCLUSIONS: The Spanish version of CRS-R can be administered reliably by trained and experienced examiners. CRS-R appears capable of differentiating patients in Emergence from Minimally Conscious State (EMCS) or in Minimally Conscious State (MCS) from those in a Vegetative State (VS).

Effects of ankle foot orthosis in stiff knee gait in adults with hemiplegia.

Stroke survivors present a less efficient gait compared to healthy subjects due to abnormal knee flexion during the swing phase of gait, associated with spasticity of the rectus femoris muscle and overactivity of the ankle plantarflexors. It is relevant to understand the effect of the ankle foot orthosis (AFO) on gait in individuals with plantarflexor spasticity. The aim of this study was to compare the knee kinematics with an AFO/footwear combination and barefoot in post-stroke subjects with plantarflexor spasticity. Ten subjects with chronic hemiplegia were measured. Two kinematic variables were assessed during the swing phase of the paretic limb: knee flexion angle at toeoff and peak knee flexion angle. We also analyzed gait speed and step length of the non-paretic limb. All variables were obtained with and without the orthosis. Kinematic data were acquired using a motion capture system (ELITE). Subjects wearing an AFO showed significant improvements in gait speed (0.62 m/s (0.08 SD) vs. 0.47 m/s (0.13 SD) (p=0.007)), step length of the non-paretic limb (42 cm (5.9 SD) vs. 33.5 cm (6.6 SD) (p=0.005)) and peak knee flexion angle during the swing phase: 30.7° (14.1° SD) vs. 26.3° (11.7° SD) p=0.005. No significant differences were obtained in the knee flexion angle at toeoff between no AFO and AFO conditions. We described benefits with AFO/footwear use in the kinematics of the knee, the step length of the non-paretic limb, and the gait velocity in hemiplegic subjects after mild to moderate stroke. We conclude that the use of an AFO can improve the gait pattern and increase velocity in these subjects.

Early motor predictors of recovery in patients with severe traumatic brain injury.

RESEARCH DESIGN: Retrospective observational study. OBJECTIVE: To compare motor variables between patients with severe traumatic brain injury who emerge and patients who do not emerge from vegetative state, in an attempt to identify early motor manifestations associated with consistent patient improvement. METHODS AND PROCEDURES: Patients were divided into two groups: group 1, patients who emerged from vegetative state attaining at least a state of functional interactive communication and/or functional use of two different objects (n = 8); and group 2, patients who did not emerge (n = 7). Twenty-one motor variables were compared weekly between groups until the end of the treatment programme. RESULTS: Significant differences were observed in head control (p = 0.051) and head turning (p = 0.002) variables, as well as in visual fixation and pursuit (p = 0.051) after a median of 41 days of therapy; and in head control and head turning; visual fixation and pursuit; phonation; pain localization, reach and grasp, and trunk movement (p ≤ 0.051) after a median of 212 days of programme duration. CONCLUSIONS: Head turning, together with or immediately followed by visual pursuit and fixation, proved to be clinically significant variables associated with recovery from vegetative state to higher states of consciousness beyond minimally conscious state.

Wheelchair axle position effect on start-up propulsion performance of persons with tetraplegia.

This repeated measures study assessed the changes in speed, acceleration, stroke frequency, and shoulder range of motion (ROM) associated with different wheelchair axle positions in people with chronic cervical (C) 6 tetraplegia. Our main hypothesis is that the up and forward axle position is the most conducive to wheelchair propulsion, increasing speed and acceleration with a lower stroke frequency. In a chronic spinal cord injury (SCI) unit, we measured the speed, acceleration, stroke frequency, and shoulder ROM in four different axle positions in eight subjects with C6 SCI. We analyzed two start-up strokes over a smooth, level vinyl floor in the Motion Analysis Laboratory (Fleni Institute; Escobar, Argentina). We analyzed data for significant statistical differences using the Wilcoxon signed rank test and the Friedman test. Our study showed that the up and forward axle position results in an increase of speed and acceleration, with a higher stroke frequency and a decreased shoulder ROM. In addition, the down and backward axle position results in the lowest speed and acceleration, with a lower stroke frequency and an increased shoulder ROM. The up and forward axle position was the most conducive to stroke compared with other positions we analyzed.

Reconstruccion clavicular en pacientes con lesion del sistema nervioso central / Clavicular reconstruction in patients with central nervous system injuries

Introducción: El propósito de este trabajo es informarsobre los resultados del tratamiento en pacientes que sufrieron fractura diafisaria de clavícula asociada con lesión del sistema nervioso central. Materiales y métodos: Se analizaron en forma retrospectivalos resultados de 10 pacientes tratados quirúrgicamentepor fracturas diafisarias de clavícula, entre mayode 2006 y junio de 2007. Se realizó en todos los casos reducción abierta y fijación interna con placa de reconstrucción de 3,5 mm, por vía anteroinferior. El seguimiento fue de 5 meses. Para la evaluación funcional se utilizaron los puntajes de FIM y Box and Block.Resultados: Todos los pacientes evolucionaron a la consolidación a los 3 meses, en promedio. En todos los casos fue posible restaurar el offset del hombro. En la evaluación funcional se registró un promedio significativo de mejoría de la función. Conclusiones: La fijación interna en pacientes con lesión del sistema nervioso central y fractura de clavícula determinaun mejor resultado funcional y en la recuperaciónde los pacientes.