Reliability and Validity of S3 Pressure Sensation as an Alternative to Deep Anal Pressure in Neurologic Classification of Persons With Spinal Cord Injury.

OBJECTIVE: To determine whether pressure sensation at the S3 dermatome (a new test) could be used in place of deep anal pressure (DAP) to determine completeness of injury as part of the International Standards for Neurological Classification of Spinal Cord Injury. DESIGN: Prospective, multicenter observational study. SETTING: U.S. Spinal Cord Injury Model Systems. PARTICIPANTS: Persons (N=125) with acute traumatic spinal cord injury (SCI), neurologic levels T12 and above, were serially examined at 1 month (baseline), 3, 6, and 12 months postinjury. There were 80 subjects with tetraplegia and 45 with paraplegia. INTERVENTIONS: S3 pressure sensation at all time points, with a retest at the 1-month time point. MAIN OUTCOME MEASURES: Test-retest reliability and agreement (κ), sensitivity, specificity, positive and negative predictive values. RESULTS: Test-retest reliability of S3 pressure at 1 month was almost perfect (κ=.98). Agreement of S3 pressure with DAP was substantial both at 1 month (κ=.73) and for all time points combined (κ=.76). The positive predictive value of S3 pressure for DAP was 89.3% at baseline and 90.3% for all time points. No pattern in outcomes was seen in those cases where S3 pressure and DAP differed at 1 month. CONCLUSIONS: S3 pressure sensation is reliable and has substantial agreement with DAP in persons with SCI at least 1 month postinjury. We suggest S3 pressure as an alternative test of sensory sacral sparing for supraconus SCI, at least in cases where DAP cannot be tested. Further research is needed to determine whether S3 pressure could replace DAP for classification of SCI

Effect of Overground Training Augmented by Mental Practice on Gait Velocity in Chronic, Incomplete Spinal Cord Injury

OBJECTIVE: To compare efficacy of a regimen combining mental practice (MP) with overground training with the efficacy of a regimen comprised of overground training only on gait velocity and lower extremity motor outcomes in individuals with chronic (> 12 months post injury), incomplete, spinal cord injury (SCI). DESIGN: Randomized controlled, single blinded, study SETTING: Outpatient rehabilitation laboratories located in the Midwestern and Western United States PARTICIPANTS: 18 subjects with chronic, incomplete SCI INTERVENTIONS: Subjects were randomly assigned to receive: (a) Overground Training only (OT), occurring 3 days/week for 8 weeks; or (b) OT augmented by MP (MP + OT), during which randomly assigned subjects listened to a mental practice audio recording directly following OT sessions. MAIN OUTCOME MEASURES: Subjects were administered a test of gait velocity as well as the Tinetti Performance Oriented Mobility Assessment (POMA), Spinal Cord Injury Independence Measure (SCIM), and Satisfaction with Life Scale (SWLS) on 2 occasions before intervention, 1 week after intervention, and 12 weeks after intervention. RESULTS: A significant increase in gait velocity was exhibited across subjects at both 1 week post-therapy (p=0.0046) and at 12 weeks post-therapy (p=0.0056). However, no differences were seen in intervention response at either 1 or 12 weeks post intervention among subjects in the MP + OT versus the OT groups. CONCLUSION: Overground training was associated with significant gains in gait velocity, and that these gains were not augmented by further addition of mental practice

Motor levels in high cervical spinal cord injuries: Implications for the International Standards for Neurological Classification of Spinal Cord Injury

CONTEXT/OBJECTIVE To verify the hypothesis that motor levels (ML) inferred from sensory levels in the upper cervical segments C2-C4 according to the current version of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) are counterintuitive in cases where the most rostral myotomes C5 and C6 are graded as intact. DESIGN Prospective cohort study of ISNCSCI instructional course participants completing a post-test after the workshop to determine the MLs in two variants of a complete, high cervical spinal cord injury (SCI) case scenario. Both variants were based on the same ISNCSCI sensory and MLs of C2. In the first variant myotomes C5 and C6 were bilaterally graded as intact, while in variant 2 only active movements against gravity were possible (grade 3). SETTING Eight ISNCSCI instructional courses conducted during the study period from November 2012 until March 2015 in the framework of the European Multicenter Study on Human Spinal Cord Injury (EMSCI- http//emsci.org ). PARTICIPANTS Ninety-two clinicians from twenty-two SCI centers. Most of the attendees were physicians (58.7%) or physical therapists (33.7%) and had less than one year (44.6%) experience in SCI medicine. INTERVENTIONS Not applicable. OUTCOME MEASURE The classification performance described as percentage of correctly determined MLs by the clinicians. RESULTS Variant 2 (89.13%) was significantly (P < 0.0001) better classified than variant 1 (65.76%). In variant 1 with intact myotomes at C5 and C6, C6 was incorrectly classified as the ML by the clinicians in 33.15% of all cases, whereas in variant 2 with non-intact C5 / C6 myotomes, C6 was rarely chosen (2.17%). CONCLUSIONS Sensory level deferred MLs in the high cervical region of C2-C4 are counterintuitive whenever the most rostral cervical myotomes are intact. An adjustment of the ML definition in ISNCSCI may be needed

International standards for neurological classification of spinal cord injury: impact of the revised worksheet (revision 02/13) on classification performance

Study Design: Prospective cohort study. Objectives: Comparison of the classification performance between the worksheet revisions of 2011 and 2013 of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Settings: Ongoing ISNCSCI instructional courses of the European Multicenter Study on Human Spinal Cord Injury (EMSCI). For quality control all participants were requested to classify five ISNCSCI cases directly before (pre-test) and after (post-test) the workshop. Participants: One hundred twenty-five clinicians working in 22 SCI centers attended the instructional course between November 2011 and March 2015. Seventy-two clinicians completed the post-test with the 2011 revision of the worksheet and 53 with the 2013 revision. Interventions: Not applicable. Outcome Measures: The clinicians’ classification performance assessed by the percentage of correctly determined motor levels (ML) and sensory levels, neurological levels of injury (NLI), ASIA Impairment Scales and zones of partial preservations. Results: While no group differences were found in the pre-tests, the overall performance (rev2011: 92.2% ± 6.7%, rev2013: 94.3% ± 7.7%; P = 0.010), the percentage of correct MLs (83.2% ± 14.5% vs. 88.1% ± 15.3%; P = 0.046) and NLIs (86.1% ± 16.7% vs. 90.9% ± 18.6%; P = 0.043) improved significantly in the post-tests. Detailed ML analysis revealed the largest benefit of the 2013 revision (50.0% vs. 67.0%) in a case with a high cervical injury (NLI C2). Conclusion: The results from the EMSCI ISNCSCI post-tests show a significantly better classification performance using the revised 2013 worksheet presumably due to the body-side based grouping of myotomes and dermatomes and their correct horizontal alignment. Even with these proven advantages of the new layout, the correct determination of MLs in the segments C2–C4 remains difficult

International standards for neurological classification of spinal cord injury: impact of the revised worksheet (revision 02/13) on classification performance

Study Design: Prospective cohort study. Objectives: Comparison of the classification performance between the worksheet revisions of 2011 and 2013 of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Settings: Ongoing ISNCSCI instructional courses of the European Multicenter Study on Human Spinal Cord Injury (EMSCI). For quality control all participants were requested to classify five ISNCSCI cases directly before (pre-test) and after (post-test) the workshop. Participants: One hundred twenty-five clinicians working in 22 SCI centers attended the instructional course between November 2011 and March 2015. Seventy-two clinicians completed the post-test with the 2011 revision of the worksheet and 53 with the 2013 revision. Interventions: Not applicable. Outcome Measures: The clinicians’ classification performance assessed by the percentage of correctly determined motor levels (ML) and sensory levels, neurological levels of injury (NLI), ASIA Impairment Scales and zones of partial preservations. Results: While no group differences were found in the pre-tests, the overall performance (rev2011: 92.2% ± 6.7%, rev2013: 94.3% ± 7.7%; P = 0.010), the percentage of correct MLs (83.2% ± 14.5% vs. 88.1% ± 15.3%; P = 0.046) and NLIs (86.1% ± 16.7% vs. 90.9% ± 18.6%; P = 0.043) improved significantly in the post-tests. Detailed ML analysis revealed the largest benefit of the 2013 revision (50.0% vs. 67.0%) in a case with a high cervical injury (NLI C2). Conclusion: The results from the EMSCI ISNCSCI post-tests show a significantly better classification performance using the revised 2013 worksheet presumably due to the body-side based grouping of myotomes and dermatomes and their correct horizontal alignment. Even with these proven advantages of the new layout, the correct determination of MLs in the segments C2–C4 remains difficult

Effect of functional sympathetic nervous system impairment of the liver and abdominal visceral adipose tissue on circulating triglyceride-rich lipoproteins.

Interruption of sympathetic innervation to the liver and visceral adipose tissue (VAT) in animal models has been reported to reduce VAT lipolysis and hepatic secretion of very low density lipoprotein (VLDL) and concentrations of triglyceride-rich lipoprotein particles. Whether functional impairment of sympathetic nervous system (SNS) innervation to tissues of the abdominal cavity reduce circulating concentrations of triglyceride (TG) and VLDL particles (VLDL-P) was tested in men with spinal cord injury (SCI).One hundred-three non-ambulatory men with SCI [55 subjects with neurologic injury at or proximal to the 4th thoracic vertebrae (↑T4); 48 subjects with SCI at or distal to the 5th thoracic vertebrae (↓T5)] and 53 able-bodied (AB) subjects were studied. Fasting blood samples were obtained for determination of TG, VLDL-P concentration by NMR spectroscopy, serum glucose by autoanalyzer, and plasma insulin by radioimmunoassay. VAT volume was determined by dual energy x-ray absorptiometry imaging with calculation by a validated proprietary software package.Significant group main effects for TG and VLDL-P were present; post-hoc tests revealed that serum TG concentrations were significantly higher in ↓T5 group compared to AB and ↑T4 groups [150±9 vs. 101±8 (p<0.01) and 112±8 mg/dl (p<0.05), respectively]. VLDL-P concentration was significantly elevated in ↓T5 group compared to AB and ↑T4 groups [74±4 vs. 58±4 (p<0.05) and 55±4 μmol/l (p<0.05)]. VAT volume was significantly higher in both SCI groups than in the AB group, and HOMA-IR was higher and approached significance in the SCI groups compared to the AB group. A linear relationship between triglyceride rich lipoproteins (i.e., TG or Large VLDL-P) and VAT volume or HOMA-IR was significant only in the ↓T5 group.Despite a similar VAT volume and insulin resistance in both SCI groups, the ↓T5 group had significantly higher serum TG and VLDL-P values than that observed in the ↑T4 and the AB control groups. Thus, level of injury is an important determinate of the concentration of circulating triglyceride rich lipoproteins, which may play a role in the genesis of cardiometabolic dysfunction