Urologic surveillance of persons with spinal cord injuries - a scoping review.

STUDY DESIGN: Scoping review - standardized according to the Equator-network and the Prisma-Statement guidelines with PRISMA-ScR. OBJECTIVES: Review the literature concerning surveillance of the urinary- and renal systems in persons with spinal cord injuries (SCI). Specifically, to assess: #1 the usability of non-invasive and non-ultrasound methods, #2 the usage of systematic ultrasound surveillance #3 patient characteristics which predispose to urinary tract abnormalities (UTA) or renal function deterioration. METHODS: The literature assessed was collected from PubMed by creating a search string comprised of three main phrases: #1 persons with SCI, #2 kidney function and #3 surveillance program. The final search resulted in 685 studies. Eligibility criteria were defined prior to the search to assess the studies systematically. RESULTS: Four studies found serum cystatin C (s-cysC) to be accurate in estimating the glomerular filtration rate in persons with SCI. One study found no difference in UTA between surveillance adherent and surveillance non-adherent persons up to 30 years post injury. UTA and especially renal function deterioration seems rare the first 15 years post-injury. Non-traumatic SCI, time since injury, high detrusor pressure, upper urinary tract dilation, vesicourethral reflux, trabeculated bladder, history of calculi removal are significant risk factors for developing UTA or renal function deterioration. CONCLUSION: Measurements of S-cysC should be considered to replace serum creatinine in most cases. Surveillance non-adherent persons are not at higher risk of developing UTA. A selective surveillance based on a baseline risk profile may be beneficial for patients and caretakers.

Implanted Peroneal Nerve Stimulator Treatment for Drop Foot Caused by Central Nervous System Lesion: A Twelve-Month Follow-up of 21 Patients.

OBJECTIVE: Drop foot is a common impairment following stroke or other causes of central pathology. We report data on patient self-perceived performance, satisfaction with performance, walking ability, and adverse effects after surgical implantation of the ActiGait® drop foot stimulator. DESIGN: Prospective case study with a 12-month follow-up. SUBJECTS: Twenty-one participants with drop foot caused by central nervous system lesion. METHODS: The patients' self-perceived performance and satisfaction with performance were evaluated using the Canadian Occupational Performance Measure (COPM). Walking ability was assessed using a 10-m walk test and a 6-min walk. Nerve conduction of the peroneal nerve was examined in 10 patients. RESULTS: At follow-up, COPM self-percieved performance from 3.2 to 6.7 points, the median increase being 2.8 (interquartile range (IQR) 2.2-5.0), p < 0.001. Likewise, the COPM satisfaction with performance increased from 2.6 to 6.9 points, the median increase being 4.2 (IQR 2.8-5.8), p < 0.001. Walking velocity increased 0.1 m/s from a baseline measurement of 0.73 m/s (95% confidence interval (95% CI) 0.03-0.2), n = 21, p < 0.01, and walking distance increased by 33 m, from a baseline measurement of 236 m (95% CI 15-51), n = 21, p < 0.001. CONCLUSION: Stimulation of the peroneal nerve by an implantable stimulator increases self-perceived performance, satisfaction with performance, and ambulation in patients with long-lasting drop foot caused by a central nervous system lesion.

Effect of pelvic laparoscopic implantation of neuroprosthesis in spinal cord injured subjects: a 1-year prospective randomized controlled study.

STUDY DESIGN: 1-year prospective RCT. OBJECTIVE: Examine the effect of implantable pulse generator and low-frequency stimulation of the pelvic nerves using laparoscopic implantation of neuroprosthesis (LION) compared with neuromuscular electrical stimulation (NMES) in SCI. METHODS: Inclusion criteria: traumatic spinal cord injury (SCI), age 18-55 years, neurological level-of-injury Th4-L1, time-since-injury >1 year, and AIS-grades A-B. Participants were randomized to (A) LION procedure or (B) control group receiving NMES. PRIMARY OUTCOME MEASURE: Walking Index for Spinal Cord Injury (WISCI-II), which is a SCI specific outcome measure assessing ability to ambulate. SECONDARY OUTCOME MEASURES: Spinal Cord Independence Measure III (SCIM III), Patient Global Impression of Change (PGIC), Penn Spasm Frequency Scale (PSFS), severity of spasticity measured by Numeric Rating Scale (NRS-11); International Spinal Cord Injury data sets-Quality of Life Basic Data Set (QoLBDS), and Brief Pain Inventory (BPI). RESULTS: Seventeen SCI individuals, AIS grade A, neurological level ranging from Th4-L1, were randomized to the study. One individual was excluded prior to intervention. Eight participants (7 males) with a mean age (SD) of 35.5 (12.4) years were allocated to the LION procedure, 8 participants (7 males) with age of 38.8 (15.1) years were allocated to NMES. Significantly, 5 LION group participants gained 1 point on the WISCI II scale, (p < 0.013; Fisher´s exact test). WISCI II scale score did not change in controls. No significant changes were observed in the secondary outcome measures. CONCLUSION: The LION procedure is a promising new treatment for individuals with SCI with significant one-year improvement in walking ability.

Feasibility and safety of 4 weeks of blood flow-restricted exercise in an individual with tetraplegia and known autonomic dysreflexia: a case report.

INTRODUCTION: Blood flow-restricted exercise (BFRE) appears to hold considerable potential in spinal cord injury (SCI) rehabilitation, due to its ability to induce beneficial functional changes and morphological alterations from low-intensity, low-load exercise. However, it remains unclear if this training approach is feasible and safe in individuals with autonomic dysreflexia (AD). CASE PRESENTATION: A 23-year-old male with traumatic, cervical (C6), motor-complete (AIS: B) SCI and diagnosed AD completed eight sessions of BFRE for the upper extremities over 4 weeks. Blood pressure and heart rate recordings and perceptual pain responses were collected repeatedly during exercise. Blood samples were drawn pre- and post-training. Training was carried out in a neurorehabilitation hospital setting with appertaining medical staff readiness, and was supervised by a physiotherapist with expertise in AD in general as well as prior knowledge of the present patient's triggers and symptoms. Four incidences of AD (defined as systolic blood pressure increase >20 mmHg) were recorded across all training sessions, of which one was symptomatic. The patient's blood profile did not change considerably from pre- to post-training sessions. Self-reported average pain during training corresponded from "mild" to "moderate". DISCUSSION: The patient was able to perform 4 weeks of BFRE, but encountered episodes of AD. Similarly, two AD episodes were registered during a single conventional, free-flow resistance training session. Evidence from clinically controlled safety studies is needed in order to establish if and how BFRE can be applied in a rehabilitation strategy in SCI individuals with neurological level of injury at or above T6 level.

Skeletal muscle fiber characteristics and oxidative capacity in hemiparetic stroke survivors.

INTRODUCTION: Skeletal muscle is changed after stroke, but conflicting data exist concerning muscle morphology and oxidative enzyme capacity. METHODS: In 36 chronic stroke patients bilateral rectus femoris muscle biopsies were analyzed, and fiber type proportions and cross-sectional areas were determined by ATPase histochemistry. Enzymatic concentrations of citrate synthase (CS) and 3-Hydroxyacyl-coenzymeA-dehydrogenase (HAD) were determined using freeze-dried muscle tissue. Findings were correlated with clinical outcomes. RESULTS: In the paretic muscles the mean fiber area was smaller (P = 0.0004), and a lower proportion of type 1 fibers (P = 0.0016) and a higher proportion of type 2X fibers (P = 0.0002) were observed. The paretic muscle had lower CS (P = 0.013) and HAD concentrations (P = 0.037). Mean fiber area correlated with muscle strength (r = 0.43; P = 0.041), and CS concentration correlated with aerobic capacity (r = 0.47; P = 0.01). CONCLUSIONS: In stroke survivors there is a phenotypic shift toward more fatigable muscle fibers with reduced oxidative enzymatic capacity that relates to clinical outcomes.

The effect of age on rehabilitation outcome after traumatic brain injury assessed by the Functional Independence Measure (FIM).

BACKGROUND: The impact of age on rehabilitation outcome after traumatic brain injury (TBI) as measured by changes in the Functional Independence Measure (FIM) has been addressed in several seemingly conflicting reports. Differences may be explained by different study populations and different ways of analyzing data. OBJECTIVE: To investigate the role of data analysis in the interpretation of the age effect on rehabilitation outcome after TBI by comparing classical analyses of the total FIM score with a new item-wise analysis that unfolds the comprehensive amount of information contained in the FIM measurement otherwise concealed by the total score. METHODS: We analyzed admission and discharge FIM data from 411 consecutive TBI patients admitted to inpatient rehabilitation during 1998-2011 by both methods. RESULTS: The classical analysis indicated similar rehabilitation outcome in the 18 to 39, 40 to 64, and 65+ years age groups, which could be explained by selection of strong elderly patients and/or methodological problems with classical data analyses, whereas the item-wise analysis demonstrated profound age effect on most FIM items throughout the age interval covered. CONCLUSIONS: The item-wise analysis meets requirements of proper data analysis, avoids concealing diversity in rehabilitation outcome behind the total FIM score, and provides a flexible, informative, and clinically relevant data analysis.

Effects of resistance training and aerobic training on ambulation in chronic stroke.

OBJECTIVE: The aim of this study was to directly compare the effects of aerobic training (AT) with progressive resistance training (RT) after stroke to determine whether AT-induced fitness gains or RT-induced strength gains translate into improved ambulation across a 12-wk intervention and whether gains are retained 1 yr after cessation of formal training. DESIGN: This study is a randomized controlled 12-wk intervention trial with a 1-yr follow-up. Forty-three community-dwelling independent walkers with a chronic ischemic hemiparetic stroke were allocated to AT using a cycle ergometer (n = 13), RT using training machines (n = 14), or low-intensity sham training of the arms (n = 16). The main outcome measures were 6-min walk distance and fast 10-m walking speed. RESULTS: Comparisons between AT, RT, and sham training revealed no clinically relevant effects on walking velocity or walking distance. Muscle strength improved after RT (P < 0.0001) and was preserved at 1-yr follow-up (P < 0.001). Aerobic capacity increased after AT (P < 0.001) but was lost during the follow-up observation period. CONCLUSIONS: Improvement of muscle strength or aerobic capacity using non-task-specific training methods does not result in improved ambulation in patients with chronic stroke. Muscle strength gains were maintained at follow-up, whereas all improvements of aerobic capacity were lost, indicating a long-lasting effect of intensive RT even without maintenance training.

Relations between 6 minute walking distance and 10 meter walking speed in patients with multiple sclerosis and stroke.

OBJECTIVE: To investigate the relationship between a short walking test and a long walking test in patients with walking disability due to multiple sclerosis (MS) or stroke. DESIGN: Cross-sectional observational study. SETTING: University hospital and sport science department. PARTICIPANTS: Patients with MS (n=38), patients with stroke (n=48), and healthy subjects (n=46). Patients were participants in other clinical trials. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Walking speed in a 10m walk test and a 6 minute walk test was compared. RESULTS: Despite differences in absolute walking speed between long and short tests, strong correlations were found between both the tests in patients with MS (r=.95) and in patients with stroke (r=.94), whereas a more moderate correlation was found in healthy controls (r=.69-.70). CONCLUSIONS: Our findings show that walking speeds of a short walking test and a long walking test are strongly correlated in both patients with MS and patients with stroke, whereas correlations in healthy subjects are weaker.

Normalized muscle strength, aerobic capacity, and walking performance in chronic stroke: a population-based study on the potential for endurance and resistance training.

OBJECTIVES: To assess muscle strength, aerobic capacity, and walking performance compared with normative values in chronic hemiparetic stroke patients and, thereby, to investigate the potential for endurance and resistance training. Second, to study the relations between muscle strength, aerobic capacity, and walking performance using normalized test values. DESIGN: Population-based, cross-sectional study. SETTING: University hospital, outpatient clinic. PARTICIPANTS: Patients (N=48) aged 50 to 80 years with reduced muscle strength and walking capacity due to an ischemic stroke 6 to 36 months prior to recruitment. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Peak oxygen consumption (Vo(2)peak) and isometric knee extensor muscle strength at the paretic knee were expressed as absolute and normalized values using normative data. The six-minute walk test (6MWT) and the habitual ten-meter walk test (10MWT) were secondary parameters. RESULTS: Peak Vo(2) was 77% (95% confidence interval [CI], 71-84) of the expected value, and the strength of the paretic knee was 71% (95% CI, 64-78), whereas walking speed (10MWT) was 59% (95% CI, 52-66) and walking distance (6MWT) was 59% (95% CI, 52-67). The normalized Vo(2)peak correlated to the normalized 6MWT (r=.58; P<.001) and normalized 10MWT (r=.53; P<.001). Normalized strength of the paretic knee correlated to normalized 6MWT (r=.40; P<.01) and normalized 10MWT (r=.31; P<.05). CONCLUSIONS: Lower extremity muscle strength and aerobic capacity are related to walking performance, which suggests a potential for endurance and resistance training in rehabilitation of walking performance in chronic hemiparesis after stroke. Correction for the influence of age, weight, and height providing normalized values improves the interpretation of severity of impairments and enables comparisons between patients.

Diabetes does not accelerate neuronal loss following nerve injury.

To determine the resistance of neuronal dorsal root ganglion (DRG) cells in experimental diabetes, we studied the neuronal cell loss after severe axonal injury in streptozotocin (STZ) diabetic rats with unilateral transection of the L5 spinal nerve for 12 weeks. Fifty 18-week-old inbred male Wistar rats were randomly allocated to three study groups. In study group 1 without spinal nerve injury, STZ diabetes was induced in 9 and 10 rats were kept as nondiabetic controls. In study group 2, spinal nerve injury was performed in 10 diabetic rats and in 10 nondiabetic controls. In study group 3, six nondiabetic control rats at 18 weeks and five nondiabetic control rats at 30 weeks were included to determine whether DRG cell changes occur without nerve injury during the study period. In group 1, the stereologically determined number of all neuronal DRG cells was unchanged after 12 weeks of diabetes. The mean perikaryal volume of neuronal DRG cells of the A and B subtypes was reduced by 10% each (p < 0.05). In group 2, spinal nerve injury led to neuronal cell loss, chromatolysis, and perikaryal shrinkage but without any acceleration of cell loss after 12 weeks of diabetes. In group 3, there were no changes indicating that the reduction of perikaryal volume in diabetic rats without nerve injury represents shrinkage. We conclude that neuronal DRG cells in rats are resistant to diabetes per se and that addition of diabetes for 12 weeks to spinal nerve injury does not further accelerate the cell loss.

Atrophy of foot muscles in diabetic patients can be detected with ultrasonography.

OBJECTIVE: To establish a bedside test with ultrasonography for evaluation of foot muscle atrophy in diabetic patients. RESEARCH DESIGN AND METHODS: Thickness and cross-sectional area (CSA) of the extensor digitorum brevis muscle (EDB) and of the muscles of the first interstitium (MILs) were determined in 26 diabetic patients and in 26 matched control subjects using ultrasonography. To estimate the validity, findings were related to the total volume of all foot muscles determined at magnetic resonance imaging (MRI-FM(vol)). Furthermore, the relations of ultrasonographic estimates to nerve conduction, sensory perception thresholds, and clinical condition were established. RESULTS: In diabetic patients, the ultrasonographic thickness of EDB (U-EDB(t)) was (means +/- SD) 6.4 +/- 2.1 vs. 9.0 +/- 1.0 mm in control subjects (P < 0.001), the thickness of MIL (U-MIL(t)) was 29.6 +/- 8.3 vs. 40.2 +/- 3.6 mm in control subjects (P < 0.001), and the CSA of EDB (U-EDB(CSA)) was 116 +/- 65 vs. 214 +/- 38 mm(2) in control subjects (P < 0.001). The MRI-FM(vol) was directly related to U-EDB(t) (r = 0.77), U-MIL(t) (r = 0.71), and U-EDB(CSA) (r = 0.74). U-EDB(t) and U-MIL(t) were thinner in neuropathic than in nonneuropathic diabetic patients (5.8 +/- 2.1 vs. 7.5 +/- 1.7 mm [P < 0.05] and 28.3 +/- 8.8 vs. 35.6 +/- 4.3 mm [P < 0.03], respectively). CONCLUSIONS: Atrophy of intrinsic foot muscles determined at ultrasonography is directly related to foot muscle volume determined by MRI and to various measures of diabetic neuropathy. Ultrasonography seems to be useful for detection of foot muscle atrophy in diabetes.

Evaluation of atrophy of foot muscles in diabetic neuropathy -- a comparative study of nerve conduction studies and ultrasonography.

OBJECTIVE: To evaluate the relation between the findings at nerve conduction studies and the size of small foot muscles determined by ultrasonography. METHODS: In 26 diabetic patients the size of the extensor digitorum brevis muscle (EDB) and of the muscles between the first and second metatarsal bone (MIL) was determined. Motor nerve conduction studies of the peroneal and tibial nerves were performed with determination of the amplitudes of the CMAPs and of the nerve conduction velocities (NCV). Further, a standardised clinical examination was performed providing a neurological impairment score. RESULTS: Seventeen patients fulfilled the criteria for diabetic neuropathy. The cross-sectional area of the EDB muscle and the thickness of the MIL muscle were 116 +/- 65 mm2 and 29.6 +/- 8.2 mm, respectively. Close relations were established between muscle size and the amplitude of the CMAP of the peroneal (r=0.77, p<0.001) and of the tibial nerve (r=0.70, p<0.01). Further there were close relations between the muscle size and the NCV of the peroneal (r=0.62, p<0.01) and of the tibial nerve (r=0.71, p<0.001). CONCLUSIONS: The amplitude of the CMAP of the peroneal and of the tibial nerves is closely related to the size of the small foot muscles as determined by ultrasonography. SIGNIFICANCE: In diabetic patients motor nerve conduction studies can reliably determine the size of small foot muscles.