The Pathophysiology, Identification and Management of Fracture Risk, Sublesional Osteoporosis and Fracture among Adults with Spinal Cord Injury.

BACKGROUND: The prevention of lower extremity fractures and fracture-related morbidity and mortality is a critical component of health services for adults living with chronic spinal cord injury (SCI). METHODS: Established best practices and guideline recommendations are articulated in recent international consensus documents from the International Society of Clinical Densitometry, the Paralyzed Veterans of America Consortium for Spinal Cord Medicine and the Orthopedic Trauma Association. RESULTS: This review is a synthesis of the aforementioned consensus documents, which highlight the pathophysiology of lower extremity bone mineral density (BMD) decline after acute SCI. The role and actions treating clinicians should take to screen, diagnose and initiate the appropriate treatment of established low bone mass/osteoporosis of the hip, distal femur or proximal tibia regions associated with moderate or high fracture risk or diagnose and manage a lower extremity fracture among adults with chronic SCI are articulated. Guidance regarding the prescription of dietary calcium, vitamin D supplements, rehabilitation interventions (passive standing, functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES)) to modify bone mass and/or anti-resorptive drug therapy (Alendronate, Denosumab, or Zoledronic Acid) is provided. In the event of lower extremity fracture, the need for timely orthopedic consultation for fracture diagnosis and interprofessional care following definitive fracture management to prevent health complications (venous thromboembolism, pressure injury, and autonomic dysreflexia) and rehabilitation interventions to return the individual to his/her pre-fracture functional abilities is emphasized. CONCLUSIONS: Interprofessional care teams should use recent consensus publications to drive sustained practice change to mitigate fracture incidence and fracture-related morbidity and mortality among adults with chronic SCI.

Postoperative management and rehabilitation after the supercharged end-to-side anterior interosseous nerve to ulnar motor nerve transfer: A report of 3 cases.

INTRODUCTION: Compressive ulnar neuropathy at the elbow is the second most common compressive neuropathy. Nerve transfers are used for severe ulnar neuropathies as a means of facilitating recovery. Hand therapy and rehabilitation after nerve transfers have not been extensively explored. PURPOSE OF THE STUDY: The aim of this repeated case study was to describe the responses, functional outcome, and neuromuscular health of three participants after the supercharged end-to-side (SETS) anterior interosseous nerve (AIN) to ulnar motor nerve transfer do describe the hand therapy and recovery of 3 cases reflecting different recovery potential mediators, trajectories, and outcomes. STUDY DESIGN: Repeated case study. METHODS: Three participants of similar age (76-80 years) that had severe ulnar neuropathy who underwent surgical treatment including a SETS AIN to ulnar motor nerve surgery were purposively selected from an ongoing clinical trial, based on their response to the surgical and the rehabilitation intervention (large, moderate, and small improvements). Clinical evaluations included measuring range of motion, strength testing, and clinical tests (ie, Egawa's sign) and, subjective assessment of rehabilitation adherence., Quick Disability of Arm, Shoulder and Hand and decomposition-based quantitative electromyography were performed at >23 months to evaluate patients. RESULTS: All the three participants completed the surgical and hand therapy interventions, demonstrating a variable course of recovery and functional outcomes. The Quick Disability of Arm, Shoulder and Hand scores (>23 months) for participants A, B, and C were 68, 30, and 18, respectively. The person with the least improvement had idiopathic Parkinson's disease, dyslipidemia, history of depression, and gout. Comparison across cases suggested that the comorbidities, longer time from neuropathy to the surgical intervention, and psychosocial barriers to exercise and rehabilitation adherence influenced the recovery process. The participants with the best outcomes demonstrated improvements in his lower motor neurons or motor unit counts (109 and 18 motor units in the abductor digiti minimi (ADM) and first dorsal interosseous, respectively) and motor unit stability (39.5% and 37.6% near-fiber jiggle in the ADM and first dorsal interosseous, respectively). The participant with moderate response to the interventions had a motor unit count of 93 for the ADM muscle. We were unable to determine motor unit counts and measurements from the participant with the poorest outcomes due to his physical limitations. CONCLUSIONS: SETS AIN to ulnar motor nerve followed by multimodal hand therapy provides measurable improvements in neurophysiology and function, although engagement in hand therapy and outcomes appear to be mediated by comorbid physical and psychosocial health.

Assessment of age-related differences in decomposition-based quantitative EMG in the intrinsic hand muscles: A multivariate approach.

OBJECTIVE: Decomposition-based quantitative electromyography (DQEMG) is one method of measuring neuromuscular physiology in human muscles. The objective of the current study is to compare the neuromuscular physiology of a typical aging population in the intrinsic hand muscles. METHODS: Measurements of DQEMG were detected with a standard concentric needle and surface EMG from the intrinsic hand muscles. DQEMG was obtained from the first dorsal interosseous (FDI), the abductor digiti minimi (ADM) and fourth dorsal interosseous (4DI). Multivariate analysis of variance (MANOVA) were performed for the surface and intramuscular EMG measures to identify age differences in motor unit properties. RESULTS: Large differences were observed between the age groups for the canonical intramuscular and surface EMG variables. Older adults demonstrated a large decrease in motor unit number estimation in the ADM and FDI. Likewise, medium to large decreases in motor unit stability were observed in the FDI, ADM and 4DI. CONCLUSIONS: With aging, there are decreases in motor unit number estimation and stability in the intrinsic hand muscles. Using a multivariate approach allows for age-related differences and the relationship between the variables to be further elucidated. SIGNIFICANCE: Multivariate analysis of DQEMG may be useful for identifying patterns of change in neuromuscular physiology with age-related changes to hand musculature. This may potentially lead to future prognostic biomarkers of age-related changes to hand muscles.

Test-retest reliability of near-fibre jiggle in the ulnar intrinsic hand muscles.

OBJECTIVE: Near-fibre (NF) jiggle is one method of measuring the shape variability of motor unit potentials (MUPs) from successive firings during voluntary contractions. MUP shape variability has been associated with neuromuscular stability and health. The purpose of this study was to analyze the test-retest reliability of NF jiggle in the ulnar nerve innervated intrinsic hand muscles of healthy subjects. METHODS: Twenty healthy adult were tested (Mean age = 23.2 ±â€¯1.9; 8 females). Measurements of NF jiggle were assessed with a standard concentric needle during mild-moderate contractions from the first dorsal interosseous (FDI), the abductor digiti minimi (ADM), and the forth dorsal interosseous (4DI) muscles. Test-retest reliability were evaluated using intraclass-correlation coefficient (ICC). RESULTS: NF jiggle showed good test-retest reliability in the FDI, ADM and 4DI muscles with ICC values of 0.86, 0.85, and 0.87, respectively. The SEM for the FDI, ADM, and 4DI were 1.9%, 2.1%, and 2.5%. Finally, the MDC of the FDI, ADM and 4DI were 4.4%, 5.0%, and 7.1%. CONCLUSION: To date, this is the first investigation to explore NF jiggle in the intrinsic hand muscles. NF Jiggle demonstrates good test-retest reliability coefficients and with low measurement error.

Validation of the QuickDASH and DASH in Patients With Distal Radius Fractures Through Agreement Analysis.

OBJECTIVE: To examine the agreement of scores between the Disabilities of the Arm, Shoulder and Hand (DASH) and QuickDASH questionnaires in patients with distal radius fractures (DRFs) and their score's concurrent validity with Patient-Rated Wrist Evaluation (PRWE) scores. DESIGN: Validity study. SETTING: Hand and upper limb clinic. PARTICIPANTS: Patients with DRFs (N=177) aged >18 years were included in this study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Measurements of the DASH, QuickDASH, and PRWE were taken at baseline and 1-year follow-up. QuickDASH scores were extracted from the DASH scores. Agreement analysis of the DASH and QuickDASH were evaluated using Bland-Altman technique. Item difficulty analysis was performed to examine the distribution of QuickDASH items among DASH items. Responsiveness of the DASH, QuickDASH, and PRWE were also evaluated by calculating standardized response means. RESULTS: QuickDASH scores were higher than DASH scores, particularly at baseline. A mean difference of 3.8 and 1.2 points were observed at baseline and 1-year follow-up, respectively. The limits of agreement were wide at baseline, with a range of 24.8 points at baseline, but decreased to 12.5 points at 1-year follow-up. Item difficulty analysis revealed that QuickDASH items were not evenly distributed at baseline. Finally, the responsiveness of the DASH, QuickDASH, and PRWE were similar from baseline to 1-year follow-up (standardized response mean of 2.13, 2.17, and 2.19, respectively). CONCLUSIONS: When changing from the DASH to the QuickDASH in the context of DRF, a systematic bias of higher scores on the QuickDASH should be considered by the user. However, the QuickDASH still demonstrated good concurrent validity and responsiveness.

Human area 5 modulates corticospinal output during movement preparation.

Neuroimaging evidence suggests that human Brodmann area 5 (BA5) within the superior parietal lobule contributes to movement planning. However, a causal role for the contribution of BA5 to preparatory processes has yet to be reported. We used paired-pulse transcranial magnetic stimulation to investigate the influence of human BA5 on corticospinal excitability during movement preparation in the context of a GO/NO-GO task. Functional connectivity between BA5 and the ipsilateral primary motor cortex (M1) was investigated by probing corticospinal output to the first dorsal interosseous muscle of the right hand. Results indicate that BA5 influences M1 during movement preparation in a task-specific manner: motor-evoked potentials are suppressed in the context of a NO-GO versus GO task. These findings provide evidence that human BA5 participates in movement preparation and differentiates between whether a movement is withheld or executed.

Rapid-rate paired associative stimulation over the primary somatosensory cortex.

Rapid-rate paired associative stimulation (rPAS) involves repeat pairing of peripheral nerve stimulation and Transcranial magnetic stimulation (TMS) pulses at a 5 Hz frequency. RPAS over primary motor cortex (M1) operates with spike-timing dependent plasticity such that increases in corticospinal excitability occur when the nerve and TMS pulse temporally coincide in cortex. The present study investigates the effects of rPAS over primary somatosensory cortex (SI) which has not been performed to date. In a series of experiments, rPAS was delivered over SI and M1 at varying timing intervals between the nerve and TMS pulse based on the latency of the N20 somatosensory evoked potential (SEP) component within each participant (intervals for SI-rPAS: N20, N20-2.5 ms, N20 + 2.5 ms, intervals for M1-rPAS: N20, N20+5 ms). Changes in SI physiology were measured via SEPs (N20, P25, N20-P25) and SEP paired-pulse inhibition, and changes in M1 physiology were measured with motor evoked potentials and short-latency afferent inhibition. Measures were obtained before rPAS and at 5, 25 and 45 minutes following stimulation. Results indicate that paired-pulse inhibition and short-latency afferent inhibition were reduced only when the SI-rPAS nerve-TMS timing interval was set to N20-2.5 ms. SI-rPAS over SI also led to remote effects on motor physiology over a wider range of nerve-TMS intervals (N20-2.5 ms - N20+2.5 ms) during which motor evoked potentials were increased. M1-rPAS increased motor evoked potentials and reduced short-latency afferent inhibition as previously reported. These data provide evidence that, similar to M1, rPAS over SI is spike-timing dependent and is capable of exerting changes in SI and M1 physiology.

Modulation of short-latency afferent inhibition depends on digit and task-relevance.

Short-latency afferent inhibition (SAI) occurs when a single transcranial magnetic stimulation (TMS) pulse delivered over the primary motor cortex is preceded by peripheral electrical nerve stimulation at a short inter-stimulus interval (∼ 20-28 ms). SAI has been extensively examined at rest, but few studies have examined how this circuit functions in the context of performing a motor task and if this circuit may contribute to surround inhibition. The present study investigated SAI in a muscle involved versus uninvolved in a motor task and specifically during three pre-movement phases; two movement preparation phases between a "warning" and "go" cue and one movement initiation phase between a "go" cue and EMG onset. SAI was tested in the first dorsal interosseous (FDI) and abductor digiti minimi (ADM) muscles in twelve individuals. In a second experiment, the origin of SAI modulation was investigated by measuring H-reflex amplitudes from FDI and ADM during the motor task. The data indicate that changes in SAI occurred predominantly in the movement initiation phase during which SAI modulation depended on the specific digit involved. Specifically, the greatest reduction in SAI occurred when FDI was involved in the task. In contrast, these effects were not present in ADM. Changes in SAI were primarily mediated via supraspinal mechanisms during movement preparation, while both supraspinal and spinal mechanisms contributed to SAI reduction during movement initiation.

Continuous theta-burst stimulation over primary somatosensory cortex modulates short-latency afferent inhibition.

OBJECTIVE: The present study investigated the effects of continuous theta-burst stimulation (cTBS) over primary somatosensory (SI) and motor (M1) cortices on motor-evoked potentials (MEPs) and short-latency afferent inhibition (SAI). METHODS: MEPs and SAI were recorded from the first dorsal interosseous (FDI) muscle of the right hand following 30Hz cTBS over left-hemisphere SI and M1 delivered to the same participants in separate sessions. Measurements were taken before and up to 60min following cTBS. RESULTS: CTBS over M1 suppressed MEPs and did not alter SAI. In contrast cTBS over SI facilitated MEPs and decreased median and digital nerve evoked SAI. CONCLUSIONS: These findings indicate that SAI amplitude is influenced by cTBS over SI but not M1, suggesting an important role for SI in the modulation of this circuit. These data provide further evidence that cTBS over SI versus M1 has opposite effects on corticospinal excitability. SIGNIFICANCE: To date, plasticity-inducing TMS protocols delivered over M1 have failed to modulate SAI, and the present research continues to support these findings. However, in young adults, cTBS over SI acts to reduce SAI and simultaneously increase corticospinal excitability. Future studies may investigate the potential to modulate SAI via targeting neural activity within SI.

30 Hz theta-burst stimulation over primary somatosensory cortex modulates corticospinal output to the hand.

BACKGROUND: The primary somatosensory cortex (SI) is important for hand function and has direct connectivity with the primary motor cortex (M1). Much of our present knowledge of this connectivity and its relevance to hand function is based on animal research. In humans, less is known about the neural mechanisms by which SI influences motor circuitry that outputs to the muscles controlling the hand. OBJECTIVE: The present study investigated the influence of SI on corticospinal excitability, and inhibitory and excitatory intracortical neural circuitry within M1 before and after continuous theta-burst stimulation (cTBS). Motor-evoked potentials (MEPs), short-latency intracortical inhibition (SICI) and intracortical facilitation (ICF) were recorded from the first dorsal interosseous (RFDI) muscle of the right hand following 30 Hz cTBS over left-hemisphere SI and M1 delivered in separate sessions. RESULTS: cTBS over SI facilitated MEPs and did not alter ICF or SICI. cTBS delivered over M1 suppressed MEPs and ICF and did not alter SICI. CONCLUSIONS: These findings indicate that SI influences corticospinal output to the hand, possibly via corticocortical projections, and may be one mechanism by which somatosensory information influences hand control.

Continuous theta-burst stimulation over the primary somatosensory cortex modulates interhemispheric inhibition.

One mechanism thought to mediate hand and upper limb control across motor cortices is called interhemispheric inhibition (IHI). Somatosensory cortices are important in the motor control of the hand, although the neural mechanisms by which somatic loci act are not fully understood. In the present study, we study the possibility that the primary somatosensory cortex (SI) influences IHI as one mechanism to modulate hand control. IHI from the motor cortices was measured before and after continuous theta-burst stimulation (cTBS) was delivered over the left-hemisphere SI. IHI was evoked using paired-pulse transcranial magnetic stimulation and measured using electromyography electrodes over the first dorsal interosseous muscles of both hands at short (10 ms) and long (40 ms) intervals to evoke short interval IHI and long interval IHI, respectively. Measures were taken before and for up to 1 h after 600 pulse cTBS was delivered over SI. Results indicate that cTBS over SI increases short interval IHI in the left hand (i.e. ipsilateral to cTBS) for 45-60 min after stimulation. These results indicate that SI is indeed able to modify IHI, and this is therefore one neural mechanism by which SI may influence hand control.

Current direction specificity of continuous θ-burst stimulation in modulating human motor cortex excitability when applied to somatosensory cortex.

The present study examines the influence of primary somatosensory cortex (SI) on corticospinal excitability within primary motor cortex (M1) using repetitive transcranial magnetic stimulation. Two groups of subjects participated and both received continuous theta-burst stimulation (cTBS) over SI. One group received cTBS oriented to induce anterior-to-posterior (AP) followed by posterior-to-anterior (PA) current flow in the cortex and the other group received cTBS in the opposite direction (PA-AP). Motor evoked potentials (MEPs) were measured from the first dorsal interosseous muscle of the left and right hand before and at three time points (5, 25, 45 min) following cTBS over left-hemisphere SI. CTBS over SI in the AP-PA direction increased contralateral MEPs at 5 and 45 min with a near significant increase at 25 min. In contrast, PA-AP cTBS decreased contralateral MEPs at 25 min. We conclude that cTBS over SI modulates neural output directed to the hand with effects that depend on the direction of induced current.

Influence of area 5 on interhemispheric inhibition.

Brodmann's area 5 is implicated in the sensorimotor control of hand movement in humans and nonhuman primates. However, little is known about the influence of area 5 on the neural circuitry within the primary motor cortex that underpins hand control. The present study investigated the neural circuitry of interhemispheric inhibition (IHI) that exists between homologous muscle representations in the motor cortex. Using paired-pulse transcranial magnetic stimulation, IHI was probed from the left-to-right hemisphere and vice versa for the first dorsal interosseous muscle of the hand at short (10 ms) and long (40 ms) latencies before and for up to 1 h after continuous θ-burst stimulation over left hemisphere area 5. The results indicate that continuous θ-burst over area 5 increases IHI at short latencies in the left hand (left-to-right inhibition) from 5-20 and 45-60 min after stimulation. Short latency inhibition in the right hand and bilateral long latency inhibition remain unaltered. The data indicate that area 5 influences the IHI that exists between the representations of the hand muscles. This effect occurs ipsilateral to the left area 5, suggesting that effects are mediated through changes in the excitability of transcallosal neurons originating in the left motor cortex.